Cynthia W. Karlson

Family and parent influences on pediatric chronic pain: a developmental perspective.

Pain that recurs or persists is unfortunately a common experience for children. One of the unique considerations in pediatric chronic pain management is the bidirectional influences of childrens pain experiences and parental and family factors. In this review we present a developmental perspective on understanding pediatric chronic pain and disability, highlighting factors relevant from infancy to adolescence, and family and parent influences. Preliminary evidence indicates that developmental processes are influenced and may also shape the pediatric pain experience. Parent emotions, behaviors, and health also play a role in childrens pain experiences, where overly protective parent behaviors, increased distress, and history of chronic pain are important parent-level influences. Research on family-level influences has revealed that families of children with chronic pain have poorer family functioning (e.g., more conflict, less cohesion) than families of healthy children. Several important gaps exist in this research, such as in understanding basic developmental processes in children with chronic pain and how they influence childrens perception of and responses to pain. Also, there is a lack of longitudinal data on family relationships and individual adjustment to allow for understanding of whether changes occur in parenting over the course of the childs chronic pain experience. Although parent interventions have been successfully incorporated into many cognitive-behavioral treatments for children with chronic pain conditions, little guidance exists for adapting intervention strategies to be developmentally appropriate. Additional research is needed to examine whether parent interventions are effective at different developmental stages and the best way to incorporate developmental goals into treatment.

Fibromyalgia : The Role of Sleep in Affect and in Negative Event Reactivity and Recovery

OBJECTIVE Fibromyalgia (FM) syndrome is a chronic pain condition characterized by diffuse muscle pain, increased negative mood, and sleep disturbance. Until recently, sleep disturbance in persons with FM has been modeled as the result of the disease process or its associated pain. The current study examined sleep disturbance (i.e., sleep duration and sleep quality) as a predictor of daily affect, stress reactivity, and stress recovery. DESIGN AND MEASURES A hybrid of daily diary and ecological momentary assessment methodology was used to evaluate the psychosocial functioning of 89 women with FM. Participants recorded numeric ratings of pain, fatigue, and positive and negative affect 3 times throughout the day for 30 consecutive days. At the end of each day, participants completed daily diary records of positive and negative life events. In addition, participants reported on their sleep duration and sleep quality each morning. RESULTS After accounting for the effects of positive events, negative events, and pain on daily affect scores, it was found that sleep duration and quality were prospectively related to affect and fatigue. Furthermore, the effects of inadequate sleep on negative affect were cumulative. In addition, an inadequate amount of sleep prevented affective recovery from days with a high number of negative events. CONCLUSIONS These results lend support to the hypothesis that sleep is a component of allostatic load and has an upstream role in daily functioning.

Sleep and the affective response to stress and pain.

OBJECTIVE The current study examined sleep disturbance (i.e., sleep duration, sleep quality) as a correlate of stress reactivity and pain reactivity. DESIGN AND OUTCOME MEASURES An ecological momentary assessment design was used to evaluate the psychosocial functioning of men and women with fibromyalgia or rheumatoid arthritis (N=49). Participants recorded numeric ratings of pain, the occurrence of a stressful event, as well as positive and negative affect 7 times throughout the day for 2 consecutive days. In addition, participants reported on their sleep duration and sleep quality each morning. RESULTS Sleep disruption was not found to be an independent predictor of affect. However, sleep was found to buffer the relationship between stress and negative affect and the relationship between pain and both positive and negative affect. CONCLUSION These results are consistent with a model in which good-quality sleep acts as a biobehavioral resource that minimizes allostatic load.

Attrition in Randomized Controlled Trials for Pediatric Chronic Conditions

OBJECTIVE To examine attrition variables in randomized controlled trials of cognitive behavioral interventions for children with chronic illnesses. METHODS We examined attrition rates reported on 40 randomized cognitive behavioral interventions published in six pediatric research journals, during the years 2002-2007. Intervention focus was limited to children with a chronic medical condition, such as asthma, obesity, arthritis, diabetes, cancer, sickle cell disease, and cystic fibrosis. RESULTS Mean rate of enrollment refusal was 37% (range 0-75%). Mean attrition rate was 20% (range 0-54%) for initial follow-up and 32% (range 0-59%) for extended follow-up. Of the reviewed articles, 40% included a CONSORT diagram. CONCLUSIONS Strategies that can be used to limit attrition include tailoring recruitment to the study population, providing personalized feedback, maintaining consistent study procedures, providing incentives, and using intensive tracking measures. There is a need for standardized definitions and reporting of attrition rates in randomized cognitive behavioral intervention studies.

Insomnia and Well-Being

Most Americans have occasional problems with insomnia. The relationship of insomnia to illness is well known. However, insomnia may also relate to lower levels of well-being. Although there are various definitions of well-being, one of the most clearly articulated and comprehensive models identifies 2 overarching constructs, psychological well-being and subjective well-being. The purpose in the present study was to assess the relationship between insomnia symptoms and the dimensions of psychological and subjective well-being, adjusting for the potential confound of comorbid physical and psychological illness. The data for the present study came from the National Survey of Midlife Development in the United States, a survey of community-dwelling adults. After adjustment for demographic characteristics and a wide range of chronic mental and physical health conditions, insomnia symptoms were found to have a significant relationship with both psychological and subjective well-being but a stronger relationship to subjective well-being. These data suggest that insomnia symptoms have a stronger relationship to enjoying life than to the perception that one has a meaningful life.

Insomnia symptoms and well-being: Longitudinal follow-up.

OBJECTIVE Most Americans have occasional problems with symptoms of insomnia. Insomnia symptoms have been linked to psychological distress, but few studies have examined the relationship between insomnia symptoms and well-being. The purpose of the present study was to assess the relationship between insomnia symptoms reported in a 10-year longitudinal study and the dimensions of subjective well-being and eudaimonic well-being, adjusting for the potential confounds of age, gender, and comorbid physical illness. METHOD The data for the present study came from the National Survey of Midlife Development in the United States. Participants were 4,014 community dwelling adults (M age = 56.27 years, SD = 12.4; 55.4% female; 91.6% White). RESULTS After adjusting for demographic characteristics and a wide range of chronic physical health conditions, we found that insomnia symptoms had a significant relationship with both subjective and eudaimonic well-being. Furthermore, the report of insomnia symptoms at 2 time points 10 years apart was found to have an additional impact on subjective and eudaimonic well-being. CONCLUSIONS Results of this study suggest that insomnia symptoms have a strong relationship to individuals enjoying life and perceiving that one has a meaningful life. In addition, these data suggest that the experience of recurrent insomnia symptoms at 2 time points is particularly detrimental to ones well-being.

Bidirectional associations between pain and physical activity in adolescents

Objectives:The objectives were to: (1) examine temporal relationships between pain and activity in youth, specifically, whether physical activity affects pain intensity and whether intensity of pain affects subsequent physical activity levels on a daily basis, and (2) examine clinical predictors of this relationship. Methods:Participants were 119 adolescents (59 with chronic pain and 60 healthy) aged 12 to 18 years, 71% female. Adolescents completed 10 days of actigraphic monitoring of physical activity and daily electronic diary recordings of pain intensity, medication use, sleep quality, and mood. Linear mixed models assessed daily associations among physical activity and pain. Daily mean (average count/min) and peak (highest daily level) activity were used for analyses. Medication use, sleep quality, and mood ratings were included as covariates, and age, sex, and body mass index percentile were adjusted for. Results:Higher pain intensity was associated with lower peak physical activity levels on the next day (t641=−2.25, P=0.03) and greater medication use predicted lower mean physical activity levels the same day (t641=−2.10, P=0.04). Higher mean physical activity levels predicted lower pain intensity ratings at the end of the day (t705=−2.92, P=0.004), but only in adolescents with chronic pain. Discussion:Youth experiencing high pain intensity limit their physical activity level on a day-to-day basis. Activity was related to subsequent pain intensity, and may represent an important focus in chronic pain treatment. Further study of the effect of medications on subsequent activity is needed.

The Assessment of Emotion Regulation in Cognitive Context: The Emotion Amplification and Reduction Scales

The purpose of this study was to provide initial psychometric evidence for the reliability and validity of The Emotion Amplification and Reduction Scales (TEARS), a questionnaire designed to assess perceived ability to change the trajectory of an emotional response. Items were formulated to assess perceived ability to amplify an emotionally response by either prolonging or intensifying an existing emotion. Additional items were selected to measure processes related to emotion reduction, selecting an emotional response or altering an existing emotion by softening, stopping, or shortening it. Both subscales, Emotion Amplification and Emotion Reduction, were found to have good internal consistency. Confirmatory Factor Analysis was used to document the two-factor structure of the measure and to assess evidence for construct validity. The latent Emotion Reduction variable was found to correlate inversely with negative affect and symptoms of depression. The latent Emotion Amplification variable was found to correlate with higher positive affect and also fatigue. As expected, TEARS is correlated with tonic measures of emotionality.

Relationship Between Daily Mood and Migraine in Children

Retrospective and cross‐sectional studies have suggested a bidirectional relationship between migraine and mood disturbance.

The Role of Sleep and Attention in the Etiology and Maintenance of Fibromyalgia

Fibromyalgia (FM) is a prevalent, debilitating condition characterized by widespread, intense pain experienced as emanating from in the muscles, tendons, and ligaments. Other symptoms include disabling fatigue, poor sleep quality, gastrointestinal complaints, cognitive difficulties and often depression. Lack of apparent muscle pathology or other obvious physiological causes of FM pain make the etiology of FM unclear. This manuscript reviews extant FM literature and integrates research on sleep and the burgeoning literature from the domain of cognitive neuroscience to formulate the Sleep and Pain Diatheses (SAPD) model of FM. This model proposes that a wide range of biopsychosocial stressors can set the stage for FM by activating diatheses for sleep disruption and pain sensitivity. Sleep disruption in those most sensitive to pain initiates a cascade of symptoms that are codified as FM. Once this process is initiated, the symptoms of FM are perpetuated and aggravated by increased vigilance to a broad range of threat-related biopsychosocial stimuli. Thus, it is proposed that sleep is integral to the etiology of FM and also energizes a cognitive feedback loop that maintains or amplifies symptom severity over time.