Maggie H. Bromberg

A systematic review of sleep in pediatric pain populations

Objective: The primary aim of this systematic review was to examine the evidence for a pain-sleep relationship in children with persistent pain by reviewing studies using single and mixed pediatric persistent pain samples. Methods: Electronic searches of Medline, PubMed, the Cochrane Database of Systematic Reviews, and PsycINFO were conducted to identify all relevant empirical studies. Studies were included in the review if the majority of participants were between 0 and 17 years and from one of the following pediatric pain populations: juvenile idiopathic arthritis, sickle cell disease, migraine/headache, functional abdominal pain, juvenile fibromyalgia syndrome, chronic musculoskeletal pain, or mixed populations including the aforementioned conditions. Results: Research from single and mixed sample studies support the hypothesis that children and adolescents with persistent pain suffer from sleep impairment. Literature addressing factors that may influence or mediate the pain-sleep relationship and the functional outcomes of the pain-sleep relationship was reviewed, and a model of the interrelationships with pain and sleep was developed. Conclusion: Findings from this review highlight the need to assess and treat sleep problems in children presenting with persistent pain. Health care providers should consider conducting routine sleep screenings, including a comprehensive description of sleep patterns and behaviors obtained through clinical interview, sleep diaries, and/or the use of standardized measures of sleep. Future research focusing on investigating the mechanisms associating sleep and pediatric persistent pain and on functional outcomes of poor sleep in pediatric pain populations is needed.

Emotion Regulation Predicts Pain and Functioning in Children With Juvenile Idiopathic Arthritis: An Electronic Diary Study

OBJECTIVES This study utilized e-diaries to evaluate whether components of emotion regulation predict daily pain and function in children with juvenile idiopathic arthritis (JIA). METHODS 43 children ages 8-17 years and their caregivers provided baseline reports of child emotion regulation. Children then completed thrice daily e-diary assessments of emotion, pain, and activity involvement for 28 days. E-diary ratings of negative and positive emotions were used to calculate emotion variability and to infer adaptive emotion modulation following periods of high or low emotion intensity. Hierarchical linear models were used to evaluate how emotion regulation related to pain and function. RESULTS The attenuation of negative emotion following a period of high negative emotion predicted reduced pain; greater variability of negative emotion predicted higher pain and increased activity limitation. Indices of positive emotion regulation also significantly predicted pain. CONCLUSIONS Components of emotion regulation as captured by e-diaries predict important health outcomes in children with JIA.

Self-Reported Pain and Disease Symptoms Persist in Juvenile Idiopathic Arthritis Despite Treatment Advances: An Electronic Diary Study

To use electronic diaries (e‐diaries) to determine whether pain, stiffness, and fatigue continue to be common, disabling symptoms in children with juvenile idiopathic arthritis (JIA) despite the use of aggressive treatments in contemporary medical management.

Parental Perceptions of Child Vulnerability and Parent Stress as Predictors of Pain and Adjustment in Children With Chronic Arthritis

Parental predictors of child psychological adjustment and pain were investigated in 51 children with arthritis. Children rated depressive symptoms, anxiety, and pain. Disease severity was determined by a physician provided active joint count, as well as a physicians global assessment. Parents rated their own depressive symptoms, stress, and perceptions of child vulnerability. Regression analyses indicated that higher parental perceptions of child vulnerability predicted increased child depressive symptoms and anxiety. Parent stress predicted both child anxiety and pain. Thus, the important role parent variables play in child health outcomes was reinforced, thereby strengthening the indication to assess parent functioning when performing clinical evaluations of adjustment to juvenile arthritis.

Prospective Mediation Models of Sleep, Pain, and Daily Function in Children With Arthritis Using Ecological Momentary Assessment.

Objectives:Sleep is an emerging area of concern in children with juvenile idiopathic arthritis (JIA). Research shows the presence of poor sleep quality and related adverse outcomes in pediatric pain populations, including JIA, but few studies have examined the prospective patterns of association between sleep and associated outcomes. This prospective study evaluated the direction and magnitude of associations between subjective sleep characteristics (sleep quality, difficulty initiating sleep, and sleep duration), pain intensity, and functional limitations in children with JIA. We hypothesized that pain intensity would partially mediate the relationship between sleep and functional limitations. Methods:Children and adolescents with JIA (n=59; age range, 8 to 18 y) recruited during clinic visits, completed smartphone-based diaries for 1 month. Subjective sleep characteristics were reported each morning; pain and functioning were assessed 3 times daily. Results:As hypothesized, the associations between sleep quality and functional limitations and between difficulty initiating sleep and functional limitations were partially mediated by pain intensity, at any given moment (z=−3.27, P=0.001, z=2.70, P<0.05). Mediation was not detected in a model testing the association between sleep duration, pain intensity, and functional limitations (z=−0.58, P=0.56). Discussion:Results suggest that sleep is integral to understanding the momentary association between pain intensity and functioning in children with JIA.

A Single Arm Pilot Trial of Brief Cognitive Behavioral Therapy for Insomnia in Adolescents with Physical and Psychiatric Comorbidities

STUDY OBJECTIVES The majority of adolescents with chronic insomnia have physical health or psychiatric comorbidities; insomnia is also associated with greater negative daytime symptoms (e.g., depressive symptoms) and reduced overall health-related quality of life (HRQOL). However, to date, there has been limited attention to treatment of insomnia in this population. The purpose of this study was to determine the preliminary efficacy of a brief cognitive behavioral therapy for insomnia (CBT-I) intervention on sleep, psychological symptoms, and HRQOL outcomes in adolescents with insomnia and co-occurring physical or psychiatric comorbidities. METHODS We conducted a single arm pilot trial in which 40 youth (mean age = 14.93, standard deviation = 1.89) with insomnia and physical or psychiatric comorbidities (e.g., depression, chronic pain, anxiety, gastrointestinal problems) received CBT-I in four individual treatment sessions over 4 to 6 w. Adolescents completed 7 days of wrist actigraphy and self-report measures of insomnia, sleep quality and behaviors, psychological symptoms, and HRQOL outcomes at pretreatment, immediate posttreatment, and 3-mo follow-up. RESULTS CBT-I was associated with improvements in self-reported measures of sleep including insomnia symptoms, sleep quality, sleep hygiene, pre-sleep arousal, and sleep onset latency. Psychological symptoms and HRQOL also improved. Effects were generally sustained at 3-mo follow-up. CONCLUSIONS CBT-I may be efficacious for adolescents with co-occurring physical and mental health comorbidities; future randomized controlled trials are needed to test the effect of CBT-I on sleep, psychological symptoms, and HRQOL and to evaluate maintenance of treatment effects over longer time periods.

Persistent pain in chronically ill children without detectable disease activity

Children with organic diseases may experience persistent pain in the presence of controlled disease, as evidenced by little or no measurable disease activity or inflammation. Historically, dualistic definitions of pain have informed standard diagnostic approaches to persistent pain; aggressive investigation and treatment targeting underlying disease, even in the absence of evidence indicating disease escalation. Evidence across disease populations, in children with inflammatory bowel disease, sickle cell disease, and juvenile idiopathic arthritis indicates that persistent pain in these conditions may be better conceptualized as functional in nature, potentially resulting from disordered somatosensory processing including central sensitization. Applying a biopsychosocial understanding of persistent pain and multidisciplinary functional pain management strategies may lead to improved health outcomes.

Use of smartphones to prospectively evaluate predictors and outcomes of caregiver responses to pain in youth with chronic disease

Abstract This study examined outcomes and predictors of different types of responses to child pain used by caregivers of youth with chronic disease. Sixty-six children and adolescents (age 7-18 years) with juvenile idiopathic arthritis answered questions about pain, pain interference in activities, and mood on a smartphone 3 times per day for one month, while a caregiver contemporaneously answered questions about their own mood and use of protecting, monitoring, minimizing, or distracting responses to their childs pain. Multilevel models were used to evaluate (1) how a childs pain and pain interference changes after a caregiver uses different types of pain responses; (2) the extent to which caregiver responses to pain vary across days; and (3) whether variability in caregiver responses to pain is predicted by changes in child pain characteristics, child mood, and/or caregiver mood. Results showed that childrens pain intensity and pain interference increased after moments when caregivers used more protective responses, whereas childrens pain interference decreased after times when caregivers responded with minimizing responses. Caregiver pain responses varied considerably across days, with caregivers responding with more protecting and monitoring responses and fewer minimizing responses at moments when their child reported high levels of pain unpleasantness and pain interference. Caregivers also were found to respond with fewer protective responses at moments when they themselves were in a more positive mood. Implications for clinical recommendations and future studies are discussed.

Parent and Child Report of Pain and Fatigue in JIA: Does Disagreement between Parent and Child Predict Functional Outcomes?

While previous research in juvenile idiopathic arthritis (JIA) has identified discrepancy between parent and child perception of disease-related symptoms such as pain, the significance and impact of this disagreement has not been characterized. We examined the extent to which parent-child discordance in JIA symptom ratings are associated with child functional outcomes. Linear regression and mixed effects models were used to test the effects of discrepancy in pain and fatigue ratings on functional outcomes in 65 dyads, consisting of youth with JIA and one parent. Results suggested that children reported increased activity limitations and negative mood when parent and child pain ratings were discrepant, with parent rated child pain much lower. Greater discrepancy in fatigue ratings was also associated with more negative mood, whereas children whose parent rated child fatigue as moderately lower than the child experienced decreased activity limitations relative to dyads who agreed closely on fatigue level. Implications of these results for the quality of life and treatment of children with JIA are discussed.