Parent communication and child pain and distress during painful pediatric cancer treatments

"You Look Perfectly Healthy to Me": Living With Postural Orthostatic Tachycardia Syndrome Through Adolescents' and Parents' Eyes

Postural orthostatic tachycardia syndrome (POTS) is an autonomic dysfunction that impairs quality of life (QoL). Increased familiarity with the lived experiences of youth with POTS better informs our understanding of this condition and its impact on QoL, provides context and depth to existing research, and improves patient-centered care. Thus, this qualitative study seeks to develop a more robust understanding of QoL in this understudied population. Youth with POTS (N = 6) and their parents (N = 8) participated in semi-structured interviews. Following saturation, data were analyzed via conventional content analysis, including code/theme identification and member-checking. Four themes were identified (1) negative changes in functioning, (2) invalidation and difficulties living with an invisible condition, (3) trust and advocacy, and (4) need for increased resources and understanding. Findings suggest POTS negatively impacts adolescents' QoL across domains. Based on participants' responses, developing POTS-specific resources and integrating mental health services into interdisciplinary POTS treatment may improve youth's QoL.

Perceived emotion invalidation predicts daily affect and stressors

BACKGROUND AND OBJECTIVES

Perceived emotion invalidation is linked to the development or worsening of a variety of emotional and physical health conditions. However, prior studies are largely cross-sectional and whether there are day-to-day effects of generally feeling invalidated is unknown.

DESIGN

We examined the relations between perceived emotion invalidation and momentary affect, average daily affect, and the experience of daily stressors among a sample of young adults using ecological momentary assessment (EMA).

METHODS

Participants (n = 86) completed measures of perceived emotion invalidation and emotional reactivity at baseline then completed one week of EMA including: (1) 7x/day reports of current affect and social context and (2) 1x/day index of experienced stressors and their intensity.

RESULTS

Higher perceived emotion invalidation predicted lower momentary positive affect. Perceived invalidation also interacted with social context such that higher emotion invalidation predicted greater negative affect when participants were with non-close others (i.e., co-workers, acquaintances). Only participants with high perceived emotional invalidation experienced increased stress alongside heightened daily negative affect.

CONCLUSIONS

These results provide preliminary evidence that feeling emotionally invalidated may predict affective experiences, including how emotions are momentarily experienced and how life stressors are interpreted when they are later reflected on.

Communication within families about advanced pediatric cancer: A qualitative study

OBJECTIVES

This qualitative study examined how families share information and feelings about advanced pediatric cancer from the perspective of both parents and children, as well as how these perspectives vary by child developmental stage.

METHODS

Participants (24 mothers, 20 fathers, 23 youth [children and adolescents]) were from a larger longitudinal study at an academic pediatric hospital. Eligible youth had advanced cancer (physician-estimated prognosis of <60%, relapse, or refractory disease), were aged 5-19 years (>8 years old to participate independently), had an English-speaking parent, and lived within 140 miles of the hospital. Interviews were completed at enrollment and asked how families share information and emotions about the child's cancer as a family.

RESULTS

Saturation was reached at 20 interviews for mothers, fathers, and youth. Analyses revealed 4 major themes: (A) parents managing cancer-related information based on child age/developmental stage and processing styles of family members; (B) parents withholding poor prognosis information and emotions to maintain positivity; (C) lack of personal and familial emotion sharing; and (D) emotion sharing among their family and externally. Both parents and youth endorsed themes A, C, and D, but only parents endorsed theme B. Adolescents endorsed more themes than children. Parents of children (as opposed to adolescents) endorsed theme A more.

SIGNIFICANCE OF RESULTS

Although both parents and youth with advanced cancer were generally willing to talk about treatment, emotions were not consistently shared. Perspectives varied depending on the child's developmental stage. Clinicians should assess parent and child information and emotion-sharing needs and provide individualized support to families regarding communication about advanced cancer.

Reframe the pain: Divided attention and positive memory reframing to reduce needle pain and distress in children-A feasibility randomized controlled trial

BACKGROUND

Negative experiences of needle procedures in childhood can lead to medical avoidance and vaccine hesitancy into adulthood. We evaluated the feasibility of two new interventions provided by clinical nurses to reduce the negative impact of vaccinations: divided attention (DA) and positive memory reframing (PMR).

METHODS

Children (8-12 years) were randomized into four groups: usual care (UC), DA, PMR or combined (DA + PMR). To evaluate feasibility, we undertook in-depth analysis of video-recorded interventions, nurse experiences (phone interviews) and child/parent memory recall of interventions (phone interviews at 2 weeks post-vaccination). Key clinical outcomes included child and parent ratings of needle-related pain intensity and fear assessed at baseline, immediately post-vaccination and 2 weeks post-vaccination (recalled).

RESULTS

A total of 54 child-parent dyads were screened, with 41 included (10/group, except PMR [n = 11]). The interventions were not always completed as intended: 10%-22% of participants received complete interventions and two had adverse events related to protocol breach. Preliminary within-group analyses showed no effects on child/parent pain ratings. However, children in DA + PMR had reduced recalled fear (p = 0.008), and PMR (p = 0.025) and DA + PMR (p = 0.003) had reduced fear of future needles. Parent ratings of child fear were also reduced immediately post-vaccination for UC (p = 0.035) and PMR (p = 0.035).

CONCLUSIONS

The interventions were feasible, although enhanced nurse training is required to improve fidelity. Preliminary clinical results appear promising, particularly for reducing needle-related fear.

PROTOCOL REGISTRATION

Protocol number ACTRN12618000687291 at ANZCTR.org.au SIGNIFICANCE: Two new nurse-led interventions to reduce negative impacts of vaccinations in children, divided attention and positive memory reframing, were feasible and may reduce needle-related fear. Nurses were able to deliver the interventions in various environments including non-clinical settings (schools). These interventions have potential to facilitate broader dissemination of vaccinations for children in a manner that minimizes distress.

Pain coping strategies in paediatric patients newly diagnosed with leukaemia compared with healthy peers

Objective

Children with leukaemia experience special difficulties adapting to stressful medical procedures and to the adverse effects of chemotherapy, though they can implement their coping strategies.

The aims of the study were to assess whether the coping‐with‐pain strategies could be influenced by a child's personal and illness factors and to render possible comparisons between children with leukaemia and healthy peers. Another aim was to compare parents' and children's reports on coping strategies.

Methods

A total of 125 patients (average age = 6.79 years; SD = 3.40) with acute leukaemia (lymphocytic leukaemia 90.4% and myeloid leukaemia 9.6%) and age‐matched healthy children with their parents were enrolled in the study. A socio‐demographic questionnaire and the Waldon–Varni Pediatric Pain Coping Inventory, parent and self‐report versions, were administered 1 month after diagnosis. Data regarding the therapy's side effects were recorded.

Results

The comparison between proxy‐reports of the two groups of parents found significant differences in terms of social support, self‐cognitive instructions and catastrophising strategies. Children aged 6–10 years relied more heavily on distraction than children of other ages, using more problem‐solving and self‐cognitive instructions. The results indicated moderate parent–child agreement.

Conclusion

Health professionals could help paediatric leukaemic patients in adopting more efficiently pain coping strategies applicable for different ages.

Pain Coping Strategies in Pediatric Patients with Acute Leukemias in the First Month of Therapy: Effects of Treatments and Implications on Procedural Analgesia

Simple Summary

Children with leukemia have to adapt to several pain episodes related to medical procedures and to the treatment effects. This is one of the first multi-disciplinary studies involving different perspectives of pediatric hematologists, anesthetists, and psychologists. The aim of this study is to understand how specific coping strategies could be associated with the treatments’ factors and with the dosage of sedation analgesic drugs during bone marrow aspirates. Results underlined that patients’ coping with pain, such as distraction, could be influenced by treatment factors and by their age. The use of particular pain coping strategies (especially the request for social support) was associated with a lower demand for hypnotic sedative drugs during sedation for bone marrow aspirate. Contrarily, the catastrophic attitude was recognized as a negative factor that influenced a major dosage of propofol for the bone morrow sedations. Health professionals should strengthen these useful coping strategies and dampen the catastrophizing one.

Abstract

Children with leukemia experience difficulties adapting to medical procedures and to the chemotherapy’s adverse effects. Study’s objectives were to identify which coping strategies could be associated with the treatments’ factors and with the dosage of sedation analgesic drugs during bone marrow aspirates. A total of 125 patients (mean = 6.79 years; standard deviation = 3.40), majority with acute lymphoblastic leukemia (90.4%) and their parents received, one month after diagnosis, the Pediatric Pain Coping Inventory. Data on the severe treatment effects and on the dosage of drugs in sedation-analgesia were also collected. An ANCOVA model (R² = 0.25) showed that, weighing the age factor (F = 3.47; df = 3; p = 0.02), the number of episodes of fever (F = 4.78; df = 1; p = 0.03), nausea (F = 4.71; df = 1; p = 0.03) and mucositis (F = 5.81; df = 1; p = 0.02) influenced the use of distraction. Cognitive self-instructions (R² = 0.22) were influenced by the number of hospitalizations (F = 5.14; df = 1; p = 0.03) and mucositis (F = 8.48; df = 3; p = 0.004) and by child’s age (F = 3.76; df = 3; p = 0.01). Children who sought parental support more frequently (F = 9.7; df = 2; p = 0.0001) and who tended not to succumb to a catastrophic attitude (F = 13.33; df = 2; p = 0.001) during the induction treatment phase required lower drug dosages, especially propofol. The clinical application of these results could be to encourage the use of cognitive self-instructions and search for social support.

Effect of time on quality of parent-child communication in pediatric cancer

BACKGROUND

A diagnosis of childhood cancer results in new parent-child communication challenges. Little is known about how communication changes over time after diagnosis or relapse. The objective of this study was to determine the effect of time since diagnosis and relapse on quality of parent-child communication. We hypothesized that there would be a positive correlation between time and quality of parent-child communication.

METHODS

Cross-sectional study in children (7-17 years) with relapsed/refractory cancer and their caregivers, who spoke English, were not cognitively impaired, and had internet access. Parents were recruited through Facebook ads. Parents and children completed the Parent-Adolescent Communication Scale (PACS), a 20-item measure of communication quality, with openness and problem subscales. Spearman's rho (r_s ) coefficients assessed correlations between PACS scores and time since diagnosis/relapse.

RESULTS

There was a statistically significant negative correlation between parent PACS scores and time since child's cancer diagnosis (r_s  = -0.21, p = .02), indicating a tendency for overall worsening communication as time since diagnosis increased. There was a positive correlation between the parent PACS problem scores and time since diagnosis (r_s  = +0.22, p = .01), indicating more problematic communication as time since diagnosis increased. Correlations of time since relapse and PACS scores were small and not statistically significant.

CONCLUSION

Parent-child communication worsens over time following a child's cancer diagnosis with more communication problems, contrary to our hypothesis. Future studies are needed to evaluate intervention timing to best support parent-child communication beyond the new-diagnosis period.

How Do I Help My Partner in Pain? Partners' Helping Behaviors Are Linked to Lower Pain and Greater Perceived Validation During an Experimental Pain Task

BACKGROUND

Observers' responses to people with illness are important predictors of quality of life, yet findings are mixed regarding the types of responses that affect illness-related suffering.

PURPOSE

The purpose of this study was to examine whether perspective taking positively affects observers' responses to their romantic partner experiencing experimentally induced pain and whether responses based in Self-Determination Theory and communication models of illness are related to perceived validation and pain outcomes.

METHODS

Undergraduate romantic couples (N = 122) completed baseline questionnaires; then one partner was randomly assigned to complete the cold pressor task, whereas the other partner observed. Couples were randomly assigned to one of two groups: a perspective-taking group in which observers were privately instructed to take the perspective of the pain participant or a control group. Afterward, both partners completed surveys, and pain participants completed a video recall task in which they recalled partner behaviors that were coded by trained raters using a theoretically derived manual.

RESULTS

Pain participants in the perspective-taking group identified significantly less invalidating communication from their partners, fewer behaviors that thwarted their competence, and more behaviors that supported their autonomy. Across groups, pain participants who received more normalizing communication that supported their competence felt more validated by their partners, had lower pain intensity, and exhibited greater pain tolerance, whereas those who received more invalidation showed worse outcomes.

CONCLUSIONS

The results from this study suggest that attention to different types of partner behaviors is essential when developing behavioral medicine treatments for pain and illness.

Concerns and Needs of Support Among Guardians of Children on Cancer Treatment in Dar es Salaam: A Qualitative Study

BACKGROUND

Cancer in children in Tanzania is a concerning health issue, yet there is a shortage of information about the experiences of the guardians of children who receive cancer treatment.

OBJECTIVE

To explore concerns and needs of support among guardians of children on cancer treatment in Dar es Salaam, Tanzania.

METHOD

Using a qualitative design, 3 focus group discussions were held with 22 guardians of children aged 9 to 17 years. Guardians were recruited from Muhimbili National Hospital, Dar es Salaam, where their children were receiving cancer treatment. Data were analyzed using thematic content analysis.

RESULTS

Guardians experienced several issues during the initial stages of their child's cancer treatment, including the process of seeking a diagnosis, and experiences with care at the peripheral (regional) hospitals and national hospital. They also shared what they felt would lessen their difficult experiences. Seven themes emerged in this study: financial concerns, emotional concerns, barriers to cancer care, need for improved cancer care, need for information, need for tangible support, and gratitude and hope.

CONCLUSION

Guardians of children with cancer experience challenges during initial stages when seeking a diagnosis and have concerns and needs related to cancer care and treatment.

IMPLICATIONS FOR PRACTICE

Improvements are needed regarding care at regional hospitals, the cancer diagnosis, and the recognition of early signs of cancer and quick referral to diagnostic centers, compassionate caring behaviors by healthcare workers, budgetary support from the government to meet the medication supply demands, and meeting stakeholders' support needs.

Communicating with Youth about Pain: Developmental Considerations

BACKGROUND

Pain experiences can negatively impact children and adolescents, leading to trauma symptoms and nonadherence to important health behaviors. Developmentally-tailored communication strategies may mitigate this risk.

METHODS

This article reviews cognitive and linguistic developmental factors, within the familial and cultural context, that are important to consider when communicating with youth about acute, procedural, and/or chronic pain.

RESULTS

Youth undergoing acute or procedural pain benefit from pain education, truthful information about the procedure, and advance preparation. The use of analogies may be particularly helpful for patient understanding of chronic pain development, maintenance, and treatment. Youth with developmental disabilities may express pain differently than their normative peers, requiring adaptation of communication strategies.

CONCLUSION

Developmentally-tailored pain communication is an important tool for caregivers and healthcare providers that may foster adaptive functioning in youth who experience pain.

Role of maternal affect and regulatory strategies in toddlers' emotion and behavior regulation

Using a moment-to-moment multilevel approach, we examined the relative effectiveness of (a) toddlers' lagged (i.e., previous-interval) regulatory strategies and toddlers' lagged expression of negative emotion, as moderated by maternal affect, and (b) maternal lagged regulatory strategies, on toddlers' current-interval (1) expression of negative emotion, and, (2) ability to delay gratification during a wait task. Two-level random coefficient models, with twelve repeated-measurement occasions (10 s-intervals) of observed behaviors (N = 1571) nested within 134 mother-toddler dyads from low-income families (67 girls; M_age = 25.77 months, SD_age = 1.60) were examined. Cross-level interactions revealed that maternal positive affect buffered severity of toddlers' expression of negative emotion between lagged and current-intervals, while maternal negative affect disrupted toddlers' effective utilization of lagged regulatory strategies on current-interval expression of negative emotion. However, regardless of maternal affect, toddlers who displayed higher expression of negative emotion and utilized more regulatory strategies in lagged-intervals displayed greater delay of gratification in current-intervals. Also, as mothers displayed greater minimization of toddlers' emotional distress, higher physical restraint, and used fewer distractions, toddlers displayed more intense expression of negative emotion in subsequent intervals. Similarly, as mothers used higher physical restraint and fewer distractions, toddlers were less able to wait in subsequent intervals. Results illustrate the disruptive roles of maternal negative affect and unsupportive regulatory strategies on toddlers' emotion and behavior regulation. Together, these findings point to targeting maternal positive affect in combination with supportive regulatory strategies to promote toddlers' transition from external- to internal-regulation.

Effects of (in)validation and plain versus technical language on the experience of experimentally induced pain: A computer controlled simulation paradigm

BACKGROUND AND OBJECTIVES

Amongst social contextual influences on pain, the manner in which pain and painful procedures are communicated to patients is considered an important contributor to the subjective experience of pain. Threatening information, e.g., by the use of technical language, is suggested to increase pain reports. Validation, or communicating understanding towards another person reporting personal experiences, is suggested to reduce pain. The current study examines effects of both information language (technical vs. plain language) and validation (validation vs. invalidation) on the subjective experience of experimentally induced pain.

METHODS

Pain-free participants (N = 132) were randomly assigned to one of four groups as formed by manipulations of validation and information language. After reading a description concerning the upcoming thermal stimulus formulated in technical or plain language, participants engaged in a computer controlled simulation (CCS; based on virtual reality technology). Participants received three thermal stimuli while interacting with an avatar who either validated or invalidated their experience during the CCS. Pain intensity and pain unpleasantness were assessed after each stimulus.

RESULTS

The validation manipulation showed to be effective, but the information language manipulation did not induce differential threat expectancies. Results show no effect of validation or information language on subjective pain reports.

LIMITATIONS

Suboptimality of the information language manipulation and shortcomings of the CCS procedure might account for current findings.

CONCLUSIONS

The study offers an interesting model for the further experimental study of isolated and combined effects of (social) contextual factors on pain. Diverse future research avenues are discussed.

SUPER scale to the rescue: reconciling what parents say and what they communicate during their child's pain

Aim: Fully illuminating mechanisms relating parent behaviors to child pain require examining both verbal and nonverbal communication. We conducted a multimethod investigation into parent nonverbal communication and physiology, and investigated the psychometric properties of the Scheme for Understanding Parent Emotive Responses Scale to assess parent nonverbals accompanying reassurance and distraction. Materials & methods: 23 children (7-12 years of age) completed the cold pressor task with their parent (predominately mothers). Parent heart rate and heart rate variability were monitored and assessed. The Scheme for Understanding Parent Emotive Responses Scale coding of parent nonverbal behaviors (i.e., vocal cues, facial expressions, posture) was used to detect levels of fear, warmth, disengagement and humor. Results & conclusion: Preliminary evidence for the psychometric properties of the scale are offered. Parent reassurance was associated with more fear, less warmth and less humor compared with distraction.

When "a headache is not just a headache": A qualitative examination of parent and child experiences of pain after childhood cancer

OBJECTIVE

Today, more than 80% of children diagnosed with cancer are expected to survive. Despite the high prevalence of pain associated with the diagnosis and treatment of childhood cancer, there is a limited understanding of how having cancer shapes children's experience and meaning of pain after treatment has ended. This study addresses this gap by exploring childhood cancer survivors' (CCS') experiences of pain from their perspective and the perspective of their parents.

METHODS

Twenty semi-structured interviews were completed with CCS (50% female; mean age = 13.20 y, range = 8-17 y) and their parents (90% mothers). Data were analyzed using interpretive phenomenological analysis.

RESULTS

Analyses revealed three superordinate themes present in the data: (a) pain is a changed experience after childhood cancer; (b) new or ambiguous pains may be interpreted by CCS and parents as a threat of disease recurrence, late effects, or a secondary cancer; and (c) pain interpretation occurs within the broader context of how CCS and parents appraise their cancer experience. Parents generally appraised their child's cancer and pain as more threatening and were influential in guiding their child's interpretations.

CONCLUSIONS

The cancer experience played an important role in shaping CCS' and their parents' experience and interpretation of pain in survivorship. This study provides novel data to inform the development and refinement of new and existing conceptual models of pain and symptom perception after cancer. The results also point to key areas for future investigation and clinical intervention to address the issue of pain in cancer survivorship.

Evidence-Based Recommendations for the Appropriate Level of Sedation to Manage Pain in Pediatric Oncology Patients Requiring Procedures: A Systematic Review From the Children's Oncology Group [Formula: see text]

Repeated invasive and painful procedures are often necessary components of pediatric cancer treatment. Adequate pain control during procedures is essential; however, procedure-related pain may be underestimated and undertreated. Currently, there is not a standard approach for the appropriate level of sedation to manage procedure-related pain in children with cancer. A team was assembled to review the evidence and develop recommendations to determine the appropriate level of sedation necessary for pain control in patients undergoing pediatric oncology procedures. After a systematic search of the literature, 15 research-based articles were synthesized and critically appraised. A recommendation was made related to the level of sedation utilized for bone marrow aspirates and bone marrow biopsies. There is a need for further research related to the necessary level of sedation for patients undergoing pediatric oncology procedures.

Parents' emotion socialization beliefs moderate relations between parent and patient coping, but not sibling coping, with pediatric cancer

OBJECTIVE

This study evaluated (a) differences in parents' emotion socialization (ES) beliefs for patients/siblings, (b) whether parents' ES beliefs predict patient/sibling coping, and (c) whether parents' ES beliefs moderate links between parent and patient/sibling coping with pediatric cancer.

METHOD

This was a cross-sectional, questionnaire-based study of 134 pediatric cancer patients, their caregiver, and their nearest-age sibling. Participants could complete measures themselves via paper-and-pencil or telephone, or researchers could read questions aloud.

RESULTS

Parents' ES beliefs differed for patients/siblings. ES beliefs did not directly predict patient/sibling coping but did moderate relations between parent and patient coping.

CONCLUSIONS

Despite extent literature promoting universal emotion coaching ES, our study indicates that ES beliefs might have a complex relation with parent coping in predicting patient coping.

Perspectives on Cancer Pain Assessment and Management in Children

OBJECTIVE

To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management.

IMPLICATIONS FOR NURSING PRACTICE

Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.

Are we meeting the informational needs of cancer patients and families? Perception of physician communication in pediatric oncology

BACKGROUND

High-quality oncology care is marked by skillful communication, yet little is known about patient and family communication perceptions or content preferences. Our study sought to elicit pediatric oncology patient and parent perceptions of early cancer communication to establish whether informational needs were met and identify opportunities for enhanced communication throughout cancer care.

METHOD

An original survey instrument was developed, pretested, and administered to 129 patients, age 10-18 years, and their parents at 3 cancer centers between 2011 and 2015. Statistical analysis of survey items about perceived communication, related associations, and patient/parent concordance was performed.

RESULTS

A greater percentage of participants reported "a lot" of discussion about the physical impact of cancer (patients, 58.1% [n = 75]; parents, 69.8% [n = 90]) compared with impact on quality of life (QOL) (patients, 44.2% [n = 57]; parents, 55.8% [n = 72]) or emotional impact (patients, 31.8% [n = 41]; parents, 43.4% [n = 56]). One fifth of patients (20.9% [n = 27]) reported they had no up-front discussion about the emotional impact of cancer treatment. Parents indicated a desire for increased discussion regarding impact on family life (27.9% [n = 36]), long-term QOL (27.9% [n = 36]), and daily activities (20.2% [n = 26]). Patients more frequently than parents indicated a desire for increased physician/patient discussion around the impact on daily activities (patients, 40.3% [n = 52]; parents, 21.7% [n = 28]; P < .001), long-term QOL (patients, 34.9% [n = 45]; parents, 16.3% [n = 21]; P < .001), pain management (patients, 23.3% [n = 30]; parents, 7% [n = 9]; P < .001), physical symptom management (patients, 24% [n = 31]; parents, 7.8% [n = 10]; P < .001), short-term QOL (patients, 23.3% [n = 30]; parents, 9.3% [n = 12]; P = .001), and curative potential (patients, 21.7% [n = 28]; parents, 8.5% [n = 11]; P = .002, P values calculated using McNemar's test).

CONCLUSION

Oncologists may not be meeting the informational needs of many patients and some parents/caregivers. Communication could be enhanced through increased direct physician-patient communication, as well as proactive discussion of emotional symptoms and impact of cancer on QOL.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents.

OBJECTIVES

To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013.

SELECTION CRITERIA

We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention.

AUTHORS' CONCLUSIONS

We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

Neurodevelopmental consequences of pediatric cancer and its treatment: applying an early adversity framework to understanding cognitive, behavioral, and emotional outcomes

Today, children are surviving pediatric cancer at unprecedented rates, making it one of modern medicine's true success stories. However, we are increasingly becoming aware of several deleterious effects of cancer and the subsequent "cure" that extend beyond physical sequelae. Indeed, survivors of childhood cancer commonly report cognitive, emotional, and psychological difficulties, including attentional difficulties, anxiety, and posttraumatic stress symptoms (PTSS). Cognitive late- and long-term effects have been largely attributed to neurotoxic effects of cancer treatments (e.g., chemotherapy, cranial irradiation, surgery) on brain development. The role of childhood adversity in pediatric cancer - namely, the presence of a life-threatening disease and endurance of invasive medical procedures - has been largely ignored in the existing neuroscientific literature, despite compelling research by our group and others showing that exposure to more commonly studied adverse childhood experiences (i.e., domestic and community violence, physical, sexual, and emotional abuse) strongly imprints on neural development. While these adverse childhood experiences are different in many ways from the experience of childhood cancer (e.g., context, nature, source), they do share a common element of exposure to threat (i.e., threat to life or physical integrity). Therefore, we argue that the double hit of early threat and cancer treatments likely alters neural development, and ultimately, cognitive, behavioral, and emotional outcomes. In this paper, we (1) review the existing neuroimaging research on child, adolescent, and adult survivors of childhood cancer, (2) summarize gaps in our current understanding, (3) propose a novel neurobiological framework that characterizes childhood cancer as a type of childhood adversity, particularly a form of early threat, focusing on development of the hippocampus and the salience and emotion network (SEN), and (4) outline future directions for research.

A Multi-Informant Multi-Method Investigation of Family Functioning and Parent-Child Coping During Children's Acute Pain

Objective

To explore relations between family functioning and child acute pain, including pain ratings, coping, and parent–child behaviors.

Methods

Community sample of 171 dyads including one child aged 8–12 years (52% girls) and one parent (79% mothers). Family functioning was assessed via child and parent self-report, and observation during a conflict discussion task. Children and parents rated pain catastrophizing at baseline, and child pain and distress following a cold pressor task (CPT). Parent–child interactions during the CPT were coded for observed behaviors during child pain.

Results

Self-report of poorer family functioning predicted greater child and parent pain catastrophizing, and parent distress. Less observed family negativity/conflict and cohesiveness, and greater family focus of problems and parent emotional support predicted more child symptom complaints. Family functioning was not associated with child pain or distress.

Conclusions

Family functioning influenced parent and child coping and child behavioral responses, but not the experience, of acute pain.

Developmental considerations of young people with cancer transitioning to adulthood

The literature concerning the impact of having cancer during adolescence and emerging adulthood has been widely discussed in relation to the unique nature of psychosocial challenges. The current study presents these findings within the context of developmental literature to further our understanding on how their developmental transitioning can be affected by having cancer. Specifically, two developmental milestones considered to be the pre-requisites for acquiring an adult status were focused on: forming identity and establishing independence. Several traditions of developmental literature were incorporated, including the psychosocial, sociological and psychoanalytical perspectives. The study discusses challenges to these developmental processes and suggests measures to foster young people's normative development.

Longitudinal Analysis of Parent Communication Behaviors and Child Distress during Cancer Port Start Procedures

BACKGROUND

The roles parents play in supporting their child during painful cancer procedures have been studied as communication strategies versus a broader caring framework and from a cross-sectional versus longitudinal perspective.

OBJECTIVES

To examine the longitudinal change in parent communication behaviors over repeated cancer port start procedures experienced by their children.

METHODS

This study used a longitudinal design. Two trained raters coded 104 recorded videos of port starts from 43 children being treated for cancer. This included 25 children with two video-recorded port starts and 18 children with three (T1, T2, T3). The Parent Caring Response Scoring System derived from Swanson's Caring Theory was used to code parent communication behaviors as caring responses during their children's port starts. Three 3- to 5-minute slices (pre-port start, during, and post-port start) were coded for each video. Mixed modeling with generalized estimating equations and Friedman test were used to analyze longitudinal change in parent behaviors.

RESULTS

Significant differences were found between T1 versus T3 in eye contact (β = -1.05, p = .02), distance-close-enough-to-touch (β = -0.81, p = .03), nonverbal comforting (β = -1.34, p = .04), and availability (β = -0.92, p = .036), suggesting that more parents used communication behaviors at T3 compared with T1. Parent burdensome or intrusive questions (e.g., Why do you cry? β = -1.11, p = .03) and nonverbal comforting (β = -1.52, p = .047) increased from T2 to T3. The median values of parent communication behaviors overall had no significant changes from T1 to T3.

CONCLUSION

Parents adjusted to use more nonverbal caring behaviors as their child experienced additional port starts. Experimental studies should be designed to help parents use caring behaviors to better support their children during cancer procedures.

Play and optimal welfare: Does play indicate the presence of positive affective states?

Play is commonly used to assess affective states in both humans and non-human animals. Play appears to be most common when animals are well-fed and not under any direct threats to fitness. Could play and playfulness therefore indicate pre-existing positive emotions, and thence optimal animal welfare? We examine this question by surveying the internal and external conditions that promote or suppress play in a variety of species, starting with humans. We find that negative affective states and poor welfare usually do suppress play (although there are notable exceptions where the opposite occurs). Furthermore, research in children suggests that beyond the frequency or total duration of play, poor welfare may additionally be reflected in qualitative aspects of this heterogeneous behaviour (e.g. display of solitary over social play; and the 'fragmentation' of play bouts) that are often overlooked in animals. There are surprisingly few studies of play in subjects with pre-existing optimal welfare or in unambiguously highly positive affective states, making it currently impossible to determine whether play can distinguish optimal or good welfare from merely neutral welfare. This therefore represents an important and exciting area for future research.

Parents' Verbal and Nonverbal Caring Behaviors and Child Distress During Cancer-Related Port Access Procedures: A Time-Window Sequential Analysis

PURPOSE/OBJECTIVES

To study the relationship between parental verbal and nonverbal caring behaviors and child distress during cancer-related port access placement using correlational and time-window sequential analyses.
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DESIGN

Longitudinal, observational design.
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SETTING

Children's Hospital of Michigan and St. Jude Children's Research Hospital.
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SAMPLE

43 child-parent dyads, each with two or three video recordings of the child undergoing cancer-related port placement.
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METHODS

Two trained raters coded parent interaction behaviors and child distress using the Parent Caring Response Scoring System and Karmanos Child Coping and Distress Scale, respectively. Mixed modeling with generalized estimating equations examined the associations between parent interaction behaviors and parent distress, child distress, and child cooperation reported by multiple raters. Time-window sequential analyses were performed to investigate the temporal relationships in parent-child interactions within a five-second window.
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MAIN RESEARCH VARIABLES

Parent caring behaviors, child distress, and child cooperation.
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FINDINGS

Parent caring interaction behaviors were significantly correlated with parent distress, child distress, and child cooperation during repeated cancer port accessing. Sequential analyses showed that children were significantly less likely to display behavioral and verbal distress following parent caring behaviors than at any other time. If a child is already distressed, parent verbal and nonverbal caring behaviors can significantly reduce child behavioral and verbal distress.
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CONCLUSIONS

Parent caring behaviors, particularly the rarely studied nonverbal behaviors (e.g., eye contact, distance close to touch, supporting/allowing), can reduce the child's distress during cancer port accessing procedures.
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IMPLICATIONS FOR NURSING

Studying parent-child interactions during painful cancer-related procedures can provide evidence to develop nursing interventions to support parents in caring for their child during painful procedures.

Parent Caring Response Scoring System: development and psychometric evaluation in the context of childhood cancer-related port starts

RATIONALE

Multiple observational coding systems have been developed and validated to assess parent-child interactions during painful procedures. Most of these coding systems are neither theory-based nor do they well represent parent nonverbal behaviours.

AIMS

Develop the Parent Caring Response Scoring System (P-CaReSS) based on Swanson's Theory of Caring and test its psychometric properties in children in cancer port starts.

METHODS

A hybrid approach of inductive and deductive coding was used to formulate the preliminary observational codes for the P-CaReSS. Twenty-nine children, each with one video-recording of port start available, were selected from the parent study (R01CA138981) to refine the P-CaReSS, train coders and test inter-rater reliability. Videos of another 43 children were used to evaluate the construct validity of P-CaReSS. Per cent agreement and Cohen's kappa were used to present the inter-rater reliability. Spearman rank-order correlations were used to report the construct validity.

RESULTS

The 18-item P-CaReSS includes three types of parent behaviours: verbal, nonverbal and emotional behaviours. These parent interaction behaviours comprise five caring domains - knowing, being with, doing for, enabling, and maintaining belief - and one noncaring domain. On average the per cent agreement was 0.82 for the P-CaReSS overall, with average per cent agreements above 0.80 for both verbal and nonverbal behaviours. Kappa coefficient was 0.81 for the emotional behaviour. The behavioural codes in the P-CaReSS showed significant correlations with independent ratings of parent distress, child distress and child cooperation.

CONCLUSIONS

The P-CaReSS is a promising tool that can be used to evaluate parent verbal, nonverbal and emotional behaviours during cancer-related port starts. This observational tool can be used to guide the development of nursing interventions to help parents caring for their child during cancer procedures.

Supporting Parents' Pain Care Involvement With Their Children With Acute Lymphoblastic Leukemia: A Qualitative Interpretive Description

Children with acute lymphoblastic leukemia experience pain from the disease, treatment, and procedures. Parents can be effective in managing their child's pain, but little is systematically known about how they do this. Appreciative inquiry was used to frame the study within a strengths-based lens and interpretive descriptive methods were used to describe pain sources, parents' pain care role, and key structures supporting parents pain care involvement. Eight paediatric oncology clinic nurses and 10 parents participated. Six key themes per group were identified. Parent themes included establishing therapeutic relationships, relearning how to care for my child, overcoming challenges and recognizing pain, learning parent specific strategies, empowering to take active pain care role, and maintaining relationships. Nurse themes included establishing therapeutic relationships, preparing parents to care for their child, facilitating pain assessment, teaching parents best pain care, empowering parents, and maintaining relationships. These findings can be used to guide clinical practice and future research.

Observational Coding Systems of Parent-Child Interactions During Painful Procedures: A Systematic Review

BACKGROUND

Parent interactions with their child can influence the child's pain and distress during painful procedures. Reliable and valid interaction analysis systems (IASs) are valuable tools for capturing these interactions. The extent to which IASs are used in observational research of parent-child interactions is unknown in pediatric populations.

OBJECTIVES

To identify and evaluate studies that focus on assessing psychometric properties of initial iterations/publications of observational coding systems of parent-child interactions during painful procedures.

METHODS

To identify and evaluate studies that focus on assessing psychometric properties of initial iterations/publications of observational coding systems of parent-child interactions during painful procedures. Computerized databases searched included PubMed, CINAHL, PsycINFO, Health and Psychosocial Instruments, and Scopus. Timeframes covered from inception of the database to January 2017. Studies were included if they reported use or psychometrics of parent-child IASs. First assessment was whether the parent-child IASs were theory-based; next, using the Society of Pediatric Psychology Assessment Task Force criteria IASs were assigned to one of three categories: well-established, approaching well-established, or promising.

RESULTS

A total of 795 studies were identified through computerized searches. Eighteen studies were ultimately determined to be eligible for inclusion in the review and 17 parent-child IASs were identified from these 18 studies. Among the 17 coding systems, 14 were suitable for use in children age 3 years or more; two were theory-based; and 11 included verbal and nonverbal parent behaviors that promoted either child coping or child distress. Four IASs were assessed as well-established; seven approached well-established; and six were promising.

CONCLUSIONS

Findings indicate a need for the development of theory-based parent-child IASs that consider both verbal and nonverbal parent behaviors during painful procedures. Findings also suggest a need for further testing of those parent-child IASs deemed "approaching well-established" or "promising".

Attachment orientations and psychological adjustment of parents of children with cancer: A matched-group comparison

OBJECTIVE

To investigate the impact of childhood cancer on parents' adult attachment, social support, marital adjustment, anxiety, and depression.

METHODS

30 parents of children with childhood cancer and 30 matched controls completed the following questionnaires: Experiences in Close Relationships-Revised, Dyadic Adjustment Scale-4, Multidimensional Scale of Perceived Social Support, State-Trait Anxiety Inventory - form Y, and Beck Depression Inventory.

RESULTS

Parents of children with childhood cancer had a significantly lower dyadic adjustment than controls, and higher levels of insecure-avoidant attachment, state anxiety, and depression.

CONCLUSION

It is important for health-care personnel to take into account these parents' propensity to show increased levels of avoidant attachment during children's treatment to foster effective communication and supportive relationships between clinicians, pediatric patients, and parents.

Peaches for Lunch: Creating and Using Visual Variables

In this article, I describe the process of systematically including nonverbal data in medical anthropology research. I demonstrate the process of visualizing and coding videotaped moments of life and show how we can analyze what is being done along with what is being said. I ground my discussion in toddler language socialization and then expand my observations to the realm of language pathologies. Aphasia from strokes, speech difficulties in neurologically based illnesses like Lou Gehrig's disease, and the variety of communication challenges that face those on the autism spectrum can all be studied in interesting ways by including precise descriptions of nonverbal actions. I discuss the process of recording and coding the data with the software Observer XT 11.5 by Noldus. This method of collecting and analyzing video data can be used for many anthropological questions, in addition to those concerned with communication.

How to Increase the Quality of a Suffering Experience: Lessons Derived From the Diary Narratives of a Dying Adolescent Girl

Personal narratives are assumed to be primary sources of the essential meaning of lived experiences of dying. In this study, I analyzed the personal diary of Miraç Fidan, a terminally ill adolescent with advanced cancer who kept a diary until her death at the age of 15. Miraç’s Diary, also published as a book, was subjected to hermeneutic phenomenological narrative analysis. Inferences were drawn regarding the following basic elements: (a) The dynamics in which Miraç lived and (2) her perceptions of herself, her immediate environment, and her experiences. Suffering seems to be the main experience dominating Miraç’s life, which I examined with regard to two dimensions: suffering caused by inevitable factors and suffering caused by preventable/changeable factors. The results suggest that if various causes among contextual factors are neutralized, then the quality of the existential experience determined by the inevitable factors would increase.

Procedural Preparation and Support as a Standard of Care in Pediatric Oncology

Youth with cancer undergo many repeated and invasive medical procedures that are often painful and highly distressing. A systematic review of published research since 1995 identified 65 papers (11 review articles and 54 empirical studies) that investigated preparatory information and psychological interventions for a variety of medical procedures in pediatric cancer. Distraction, combined cognitive-behavioral strategies, and hypnosis were identified as effective for reducing child pain and increasing child coping. Low- to high-quality evidence informed strong recommendations for all youth with cancer to receive developmentally appropriate preparatory information and psychological intervention for invasive medical procedures.

Maternal Coping and Depressive Symptoms as Predictors of Mother-Child Communication About a Child's Cancer

OBJECTIVE

This study sought to identify possible associations between maternal coping and depression and subsequent mother-child communication about cancer following the child's diagnosis. 

METHOD

Mothers (N = 100) reported on coping and depressive symptoms shortly after the child's diagnosis (M = 1.9 months). Subsequently, we observed children (age 5-17 years; M = 10.2 years; 48% female; 81% White) and mothers discussing cancer and coded maternal communication. 

RESULTS

Higher primary and secondary control coping, and lower depressive symptoms, were generally correlated with more positive, and less harsh and withdrawn communication. In regression models, higher primary control coping (i.e., coping efforts to change the stressor or one's emotional reaction to the stressor) independently predicted less withdrawn communication, and depressive symptoms mediated relations between coping and harsh communication. 

CONCLUSIONS

Maternal primary control coping and depressive symptoms predict mothers' subsequent harsh and withdrawn communication about cancer.

Self-distancing Buffers High Trait Anxious Pediatric Cancer Caregivers against Short- and Longer-term Distress

Pediatric cancer caregivers are typically present at their child's frequent, invasive treatments, and such treatments elicit substantial distress. Yet, variability exists in how even the most anxious caregivers cope. Here we examined one potential source of this variability: caregivers' tendencies to self-distance when reflecting on their feelings surrounding their child's treatments. We measured caregivers' self-distancing and trait anxiety at baseline, anticipatory anxiety during their child's treatment procedures, and psychological distress and avoidance three months later. Self-distancing buffered high (but not low) trait anxious caregivers against short- and long-term distress without promoting avoidance. These findings held when controlling for other buffers, highlighting the unique benefits of self-distancing. These results identify a coping process that buffers vulnerable caregivers against a chronic life stressor while also demonstrating the ecological validly of laboratory research on self-distancing. Future research is needed to explicate causality and the cognitive and physiological processes that mediate these results.

Cancer-Related Pain and Pain Management: Sources, Prevalence, and the Experiences of Children and Parents

Advances in treatment mean children are increasingly cared for by their parents at home, leading to a shift in responsibility from health care professionals to parents. Little is known about parents' pain management experiences and the etiology of pain experienced by children with cancer especially when at home. A rapid review of the literature was undertaken investigating children's cancer-related pain, with emphasis on the management of pain outside the health care setting. Electronic databases were searched and a quality assessment was conducted. Forty-two articles were included. Despite advances in pain management techniques, children with cancer regularly cite pain as the most prevalent symptom throughout the cancer trajectory. The source of pain is usually treatment side effects or painful procedures. Parents find dealing with their child's pain distressing and demanding and may hold misconceptions about pain management. Findings indicate a need for more robust research into parental pain management leading to the development of effective pain management resources for parents.

Using Colors to Assess Pain in Toddlers

Self-report, when available, is considered the ideal way to assess the intensity and other aspects of pain in children. However, self-report scales are often too complex cognitively for preschool-aged children (2-4 years). The Rainbow Pain Scale (RPS) was developed to provide individualized self-reported pain ratings for preschool-aged children. The psychometric properties of this scale have yet to be evaluated. To ensure validity, our first step was to compare RPS scores to a well-validated scale in older children who were able to self-report their pain. The purpose of this study was to assess the concurrent validity of the RPS in children aged 5 to 10 years as proof of principle. We compared ratings of 49 children’s pain using the RPS with those on the Faces Pain Scale–Revised (FPS-R). Participants suffering from pain related to cancer and cancer treatment were recruited to complete both scales at 3 time points, during both inpatient and outpatient clinic visits. Pearson’s r and Cohen’s κ were used to evaluate the level of association between the scales. The association between RPS and the FPS-R was greater than .7 at all 3 visits; r = .96 between the scales at the first clinic visit, .97 at the second visit, and .93 at the third visit. Cohen’s κ between scales was 1.0 at the first clinic visit, .95 at the second visit, and .87 at the third visit. The RPS shows excellent concurrent validity with the FPS-R in school-aged children. The next step will be to examine the psychometric properties of the RPS in preschool-aged children.

The behaviour of preschool children receiving fluoride varnish application in a community setting

BACKGROUND

The behaviour of young children receiving mildly invasive dental preventive procedures in a community setting warrants more extensive research due to limitations in the literature.Objectives To document the behavioural profile of preschool children undergoing a preventive oral health intervention (fluoride varnish application) and to investigate this behaviour across children with different previous experience of the procedure, ages and initial anxiety states.

METHOD

Nurse-child interactions were video recorded and child behaviours coded and analysed using a specially developed coding scheme (SABICS). Behaviour frequency was measured and presented diagrammatically, followed by independent sample non-parametric tests to distinguish behavioural group differences.

RESULTS

Three hundred and three interactions were coded out of 456 recorded application sessions. 'Nonverbal agreement' behaviour was observed most frequently compared to disruptive behaviours. Younger preschool children tended to exhibit 'interact with instrument' behaviour more frequently than older children regardless of whether they had had previous application experience. Children who showed signs of initial anxiety were likely to display more disruptive behaviours during the later stage of the procedure compared with non-anxious children.

CONCLUSIONS

Dental staff working with preschool children are recommended to use encouragement-centred strategies to promote nonverbal cooperative behaviours in children. In addition, procedure instruments could be considered as a tool to gain child cooperation. Evidence of an autocorrelation effect of child behaviour was found, indicating that the early presentation of child behaviour predicted the behaviour of the child at later stages.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This review is an updated version of the original Cochrane review published in Issue 4, 2006. Needle-related procedures are a common source of pain and distress for children. Our previous review on this topic indicated that a number of psychological interventions were efficacious in managing pediatric needle pain, including distraction, hypnosis, and combined cognitive behavioural interventions. Considerable additional research in the area has been published since that time.

OBJECTIVES

To provide an update to our 2006 review assessing the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

Searches of the following databases were conducted for relevant randomized controlled trials (RCTs): Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; PsycINFO; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Web of Science. Requests for relevant studies were also posted on various electronic list servers. We ran an updated search in March 2012, and again in March 2013.

SELECTION CRITERIA

Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only RCTs with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed trial quality and a third author helped with data extraction and coding for one non-English study. Included studies were coded for quality using the Cochrane Risk of bias tool. Standardized mean differences with 95% confidence intervals were computed for all analyses using Review Manager 5.2 software.

MAIN RESULTS

Thirty-nine trials with 3394 participants were included. The most commonly studied needle procedures were venipuncture, intravenous (IV) line insertion, and immunization. Studies included children aged two to 19 years, with the most evidence available for children under 12 years of age. Consistent with the original review, the most commonly studied psychological interventions for needle procedures were distraction, hypnosis, and cognitive behavioural therapy (CBT). The majority of included studies (19 of 39) examined distraction only. The additional studies from this review update continued to provide strong evidence for the efficacy of distraction and hypnosis. No evidence was available to support the efficacy of preparation and information, combined CBT (at least two or more cognitive or behavioural strategies combined), parent coaching plus distraction, suggestion, or virtual reality for reducing children's pain and distress. No conclusions could be drawn about interventions of memory alteration, parent positioning plus distraction, blowing out air, or distraction plus suggestion, as evidence was available from single studies only. In addition, the Risk of bias scores indicated several domains with high or unclear bias scores (for example, selection, detection, and performance bias) suggesting that the methodological rigour and reporting of RCTs of psychological interventions continue to have considerable room for improvement.

AUTHORS' CONCLUSIONS

Overall, there is strong evidence supporting the efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents, with no evidence currently available for preparation and information or both, combined CBT, parent coaching plus distraction, suggestion, or virtual reality. Additional research is needed to further assess interventions that have only been investigated in one RCT to date (that is, memory alteration, parent positioning plus distraction, blowing out air, and distraction plus suggestion). There are continuing issues with the quality of trials examining psychological interventions for needle-related pain and distress.

Mother-child communication and maternal depressive symptoms in families of children with cancer: integrating macro and micro levels of analysis

OBJECTIVES

This study examines associations between maternal depressive symptoms and macro- and micro-level aspects of mothers' communication about their children's cancer.

METHODS

Mothers reported depressive symptoms after diagnosis or relapse (child mean age = 10.4 years; 53% male). Mother-child dyads (N = 94) were subsequently observed discussing the child's cancer and maternal communication was coded.

RESULTS

Macro-level indicators (positive and negative communication) were associated with certain micro-level indicators of communication (topic maintenance, reflections, reframes, and imperatives). Higher depressive symptoms predicted lower positive communication and higher negative communication. Maternal reflections and imperatives predicted positive communication, and topic maintenance and reframes predicted negative communication, beyond child age, family income, and depressive symptoms.

CONCLUSIONS

Findings suggest concrete targets for improving communication in families after diagnosis or relapse.

The effect of validating and invalidating communication on satisfaction, pain and affect in nurses suffering from low back pain during a semi-structured interview

When physicians interview patients with ambiguous or nonspecific symptoms, they often try to reassure them with the purpose of explaining that no dangerous illness or disease is causing the symptoms. Unfortunately the evidence suggests that patients with benign (back) pain instead feel misunderstood, frustrated and unsatisfied with the consultation. Validation is a communication method that focuses on understanding and empathy as a platform for problem solving and it may be applicable for interviews in medical settings. The aim of this study was to examine the effects of validation on patient satisfaction, pain and affect. To this end 28 nurses with (re)current back pain were recruited and randomly assigned to be interviewed in a validating or invalidating condition. Patient satisfaction, affect, pain, disability, pain catastrophizing, and fear of movement were assessed immediately after the interview. The results show that the participants in the validated group were more satisfied with the interview than participants in the invalidating condition. Moreover, they showed a significant decrease on all measures of negative affect as well as for pain. For example, there was a significant between group difference in frustration where frustration decreased in the validation group, while it increased in the invalidation condition. A validating communication style seems to be beneficial for enhancing patient satisfaction, as well as diminishing negative affect and pain intensity ratings. Our results suggest that validation might be a viable technique to use in clinical examinations of patients suffering pain.

Children's positive dispositional attributes, parents' empathic responses, and children's responses to painful pediatric oncology treatment procedures

Pain/distress during pediatric cancer treatments has substantial psychosocial consequences for children and families. The authors examined relationships between children's positive dispositional attributes, parents' empathic responses, and children's pain/distress responses to treatment procedures. Participants were 41 pediatric cancer patients and parents. Several weeks before treatment, parents rated children's resilience and positive dimensions of temperament. Parents' pretreatment empathic affective responses to their children were assessed. Children's pain/distress during treatments was rated by multiple independent raters. Children's resilience was significantly and positively associated with parents' empathic affective responses and negatively associated with children's pain/distress. Children's adaptability and attention focusing also showed positive relationships (p < 0.10) with parents' empathic responses. Parents' empathic responses mediated effects of children's resilience on children's pain/distress. Children's positive dispositional attributes influence their pain/distress during cancer treatments; however, these effects may be mediated by parents' empathic responses. These relationships provide critical understanding of the influence of parent-child relationships on coping with treatment.

Relief of pain and anxiety in pediatric patients in emergency medical systems

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child's and family's reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction.

Main Caregivers’ Experiences of Managing Pain for Children With Neuroblastoma in Taiwan

Neuroblastoma is a common malignant tumor among children. Seventy percent of children with neuroblastoma have metastatic disease when the diagnosis is established. The aim of this study was to understand the main caregivers’ lived experiences in managing pain for children with neuroblastoma. A descriptive qualitative design was used. Twelve main caregivers of children with neuroblastoma were interviewed. Two themes evolved: experiences of pain and coping with pain. Three subthemes were found under the theme “experience of pain”: pain assessment based on language expressions and behavioral observations, tendency of misdiagnosing tumor metastasis–related pain, and unique manifestations of pain at various phases. Four subthemes evolved under the theme “coping with pain”: utilization of pharmacological and nonpharmacological modalities for pain management, learning to confront pain, seeking mental and emotional support, and adjustment of family lifestyle. The results provide a description regarding the expression of pain in children with neuroblastoma and the pain management modalities used by the main caregivers. The findings serve as a reference for health care providers in Taiwan as they manage pain for children with neuroblastoma and seek to understand the needs of the main caregivers.