Kirsten Hanrahan

Normative salivary cortisol values and responsivity in children

This was a descriptive study on normative salivary cortisol values and responsivity to a hospital clinic visit and an intravenous (IV) procedure in children. The study presented was a subproject of a primary research study that examined parents coaching their children requiring an IV placement in the use of distraction. One measure of child response in the primary study, salivary cortisol, was included to further our understanding of childrens physiologic response to stressful and painful stimuli. Salivary cortisol samples were obtained from 384 children aged between 4 and 10 years upon arrival to the clinic and 20 minutes after their IV insertion. Baseline samples were collected at home on a typical day for the children. Data from baseline samples were used to establish normative values between 8:00 a.m. and 3:00 p.m. on a nonprocedural day. Results demonstrate that normative cortisol levels in children follow a pattern similar to the circadian pattern in adults, decreasing from early morning to mid afternoon. Matched samples from control group children were used to evaluate group responsivity. Salivary cortisol levels on the baseline day were lower than those obtained during the day of the procedure and tapered over time as expected (-8.7% +/- 6.7%, p = .431). Cortisol levels on the clinic day increased from baseline and increased further in response to IV placement (15.7% +/- 6.7%, p = .023). A Location x Time interaction was significant (p = .019). Findings demonstrate that salivary cortisol is a useful measure of stress response that can be used to evaluate intervention effectiveness.

Impact of parent-provided distraction on child responses to an IV insertion

This study evaluates the impact of parent-provided distraction on childrens responses (behavioral, physiological, parent, and self-report) during an IV insertion. Participants were 542 children, 4 to 10 years old, randomized to an experimental group that received a parent distraction coaching intervention or to routine care. Experimental group children had significantly less cortisol responsivity (p = .026). Children that received the highest level of distraction coaching had the lowest distress on behavioral, parent report, and cortisol measures. When parents provide a higher frequency and quality of distraction, children have lower distress responses on most measures.

Salivary Cortisol Responsivity to an Intravenous Catheter Insertion in Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE To compare salivary cortisol baseline levels and responsivity as well as behavioral distress to intravenous (IV) catheter insertions in 4- to 10-year-old children with (n = 29) and without (n = 339) attention-deficit/hyperactivity disorder (ADHD). METHODS This is a secondary data analysis from a sample of 542 children who participated in a multisite study on distraction. Data included were demographic variables, Pediatric Behavior Scale-30, Observational Scale of Behavioral Distress-Revised, and four salivary cortisol samples. RESULTS Home samples from the ADHD group revealed nonsignificant but higher cortisol levels than the non-ADHD group. However, on the clinic day, the ADHD group had significantly lower cortisol levels before (0.184 vs. 0.261, p = .040) and 20-30 min after IV insertion (0.186 vs. 0.299, p = .014) compared with the non-ADHD group. CONCLUSIONS Cortisol levels in children with and without ADHD differ in response to the stress of an IV insertion.

Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial.

BackgroundParents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training. ObjectiveThe aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress. MethodsChildren undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress. ResultsA total of 574 children, ages 4–10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels. DiscussionSome parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.

Validation of a clinically useful measure of children's state anxiety before medical procedures

PURPOSE Assessment of childrens anxiety in busy clinic settings is an important step in developing tailored interventions. This article describes the construct validation of the Childrens Anxiety Meter-State (CAM-S), a brief measure of state anxiety. DESIGN AND METHODS Existing data were used to investigate the associations between child self-reports of anxiety, parent reports of child anxiety, and observed child distress during an intravenous procedure. RESULTS Childrens (n = 421) CAM-S scores were significantly associated with all parent measures and observed distress ratings. PRACTICE IMPLICATIONS Findings support the use of the CAM-S for assessment of child anxiety in clinical settings.

Integrating molecular genetics analyses into clinical research

The integration of molecular genetics approaches into the study of complex health phenomena is an increasingly important and available strategy for researchers across the health science disciplines. Pain sensation and response to painful stimuli are examples of complex health phenomena that are particularly amenable to molecular genetics approaches. Both human and animal model research suggests that differences in these responses may be related, in part, to variation in the genes that modulate sensation and behavior. The authors are currently managing a large cross-disciplinary research effort to identify child characteristics, including genotypes, that predict the degree of distress displayed by children following a painful medical procedure (i.e., IV insertion). The purpose of this article is to describe the strategies used to integrate molecular genetics methods into this project. The authors discuss the steps needed to complete this process, including (a) establishing a collaboration with genetics researchers and laboratory facilities, (b) developing and implementing a plan to manage biologic samples, and (c) incorporating genetics into the informed consent process.

Relationship of Genetic Variants With Procedural Pain, Anxiety, and Distress in Children:

Objective: This study used a candidate gene approach to examine genomic variation associated with pain, anxiety, and distress in children undergoing a medical procedure. Study Design: Children aged 4–10 years having an IV catheter insertion were recruited from three Midwestern children’s hospitals. Self-report measures of pain, anxiety, and distress were obtained as well as an observed measure of distress. Samples were collected from children and biological parents for analysis of genomic variation. Genotyped variants had known or suspected association with phenotypes of interest. Analyses included child-only association and family-based transmission disequilibrium tests. Results: Genotype and phenotype data were available from 828 children and 376 family trios. Children were 50% male, had a mean age of 7.2 years, and were 84% White/non-Hispanic. In family-based analysis, one single-nucleotide polymorphism (SNP; rs1143629, interleukin (IL1B) 1β) was associated with observed child distress at Bonferroni-corrected levels of significance (p = .00013), while two approached significance for association with high state anxiety (rs6330 Nerve Growth Factor, Beta Subunit, [NGFB]) and high trait anxiety (rs6265 brain-derived neurotrophic factor [BDNF]). In the child-only analysis, multiple SNPs showed nominal evidence of relationships with phenotypes of interest. rs6265 BDNF and rs2941026 cholecystokinin B receptor had possible relationships with trait anxiety in child-only and family-based analyses. Conclusions: Exploring genomic variation furthers our understanding of pain, anxiety, and distress and facilitates genomic screening to identify children at high risk of procedural pain, anxiety, and distress. Combined with clinical observations and knowledge, such explorations could help guide tailoring of interventions to limit procedure-related distress and identify genes and pathways of interest for future genotype–phenotype studies.

Building a Computer Program To Support Children, Parents, and Distraction During Healthcare Procedures

This secondary data analysis used data mining methods to develop predictive models of child risk for distress during a healthcare procedure. Data used came from a study that predicted factors associated with children’s responses to an intravenous catheter insertion while parents provided distraction coaching. From the 255 items used in the primary study, 44 predictive items were identified through automatic feature selection and used to build support vector machine regression models. Models were validated using multiple cross-validation tests and by comparing variables identified as explanatory in the traditional versus support vector machine regression. Rule-based approaches were applied to the model outputs to identify overall risk for distress. A decision tree was then applied to evidence-based instructions for tailoring distraction to characteristics and preferences of the parent and child. The resulting decision support computer application, titled Children, Parents and Distraction, is being used in research. Future use will support practitioners in deciding the level and type of distraction intervention needed by a child undergoing a healthcare procedure.

The Distraction in Action Tool©: Feasibility and Usability in Clinical Settings

Purpose: Distraction is a relatively simple, evidence‐based intervention to minimize child distress during medical procedures. Timely on‐site interventions that instruct parents on distraction coaching are needed. The purpose of this study was to test the feasibility and usability of the Distraction in Action Tool© (DAT©), which 1) predicts child risk for distress with a needle stick and 2) provides individualized instructions for parents on how to be a distraction coach for their child in clinical settings. Design and Methods: A mixed‐methods descriptive design was used to test feasibility and usability of DAT in the Emergency Department and a Phlebotomy Lab at a large Midwest Academic Medical Center. Twenty parents of children ages 4–10 years requiring venipuncture and clinicians performing 13 of those procedures participated. Participants completed an evaluation and participated in a brief interview. Results: The average age of the children was 6.8 years, and 80% of parent participants were mothers. Most parents reported the DAT was not difficult to use (84.2%), understandable (100%), and they had a positive experience (89.5%). Clinicians thought DAT was helpful (100%) and did not cause a meaningful delay in workflow (92%). Conclusion: DAT can be used by parents and clinicians to assess their childrens risk for procedure related distress and learn distraction techniques to help their children during needle stick procedures. Practice Implications: DAT for parents is being disseminated via social media and an open‐access website. Further research is needed to disseminate and implement DAT in community healthcare settings. HighlightsParents can use distraction to help their children during needle stick procedures.The Distraction in Action Tool (DAT) generates evidence‐based instructions.A DistrEstimate is the DAT prediction of a childs risk for procedural distress.The DAT is research‐based, feasible and easy to use.For open‐access to the DAT go to https://uichildrens.org/distraction.

Validation of a clinically useful measure of children's state anxiety before medical procedures: Validation of a Clinically Useful Measure of Children's State Anxiety Before Medical Procedures

PURPOSE Assessment of childrens anxiety in busy clinic settings is an important step in developing tailored interventions. This article describes the construct validation of the Childrens Anxiety Meter-State (CAM-S), a brief measure of state anxiety. DESIGN AND METHODS Existing data were used to investigate the associations between child self-reports of anxiety, parent reports of child anxiety, and observed child distress during an intravenous procedure. RESULTS Childrens (n = 421) CAM-S scores were significantly associated with all parent measures and observed distress ratings. PRACTICE IMPLICATIONS Findings support the use of the CAM-S for assessment of child anxiety in clinical settings.