Parental narrative style moderates the relation between pain-related attention and memory biases in youth with chronic pain

ABSTRACT

Negatively biased pain memories robustly predict maladaptive pain outcomes in children. Both attention bias to pain and parental narrative style have been linked with the development of these negative biases, with previous studies indicating that how parents talk to their child about the pain might buffer the influence of children's attention bias to pain on the development of such negatively biased pain memories. This study investigated the moderating role of parental narrative style in the relation between pain-related attention and memory biases in a pediatric chronic pain sample who underwent a cold pressor task. Participants were 85 youth-parent dyads who reminisced about youth's painful event. Eye-tracking technology was used to assess youth's attention bias to pain information, whereas youth's pain-related memories were elicited 1 month later through telephone interview. Results indicated that a parental narrative style using less repetitive yes-no questions, more emotion words, and less fear words buffered the influence of high levels of youth's attention bias to pain in the development of negatively biased pain memories. Opposite effects were observed for youth with low levels of attention bias to pain. Current findings corroborate earlier results on parental reminiscing in the context of pain (memories) but stress the importance of matching narrative style with child characteristics, such as child attention bias to pain, in the development of negatively biased pain memories. Future avenues for parent-child reminiscing and clinical implications for pediatric chronic pain are discussed.

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

Exploring the family experience of children aged 2-4 years receiving daily vosoritide injections: A qualitative study

PURPOSE

Vosoritide is administered as a daily subcutaneous injection in children with achondroplasia. In clinical trials, families of children aged 2-4 years reported difficulty with drug administration due to child fear, pain, and distress. Study aims were to gain a better understanding of the current vosoritide administration experience in this cohort and to investigate whether topical anaesthesia and ice application prior to injections improved the child and family experience.

DESIGN AND METHODS

A qualitative descriptive study design ensured in-depth understanding of family experience. Parents were interviewed to explore experience of vosoritide administration for their child at two time points, before (Phase 1) and after (Phase 2) the introduction of topical anaesthesia and ice application prior to injections. Interviews were analysed using thematic analysis.

RESULTS

Seven families participated. Children's ages ranged from 2 years 2 months to 3 years 11 months. Five themes emerged from data analysis: (1) The reality of the burden of care; (2) Child experience as the greatest obstacle; (3) Parents juggle multiple emotional considerations; (4) Many factors may impact experience; and (5) Short-term and long-term impacts.

CONCLUSIONS

Administration of vosoritide in this cohort presents multiple challenges for families. Factors which influenced experience differed between families. Responses to topical anaesthesia and ice application also varied between children, improving administration experience for some children and worsening experience for others.

PRACTICE IMPLICATIONS

This study highlights the need for individualised care for young children receiving daily injections. Support should be provided to families to identify factors that improve experience.

Picturing Bravery: A Rapid Review of Needle Procedures Depicted in Children's Picture Books

Existing research has identified evidence-based strategies for mitigating fear and pain during needle procedures; yet, families often experience limited access to health professionals who deliver these interventions. Children may benefit from learning about such strategies in a developmentally appropriate and accessible format such as a picture book. This review aimed to summarize content related to needle procedures represented in picture books for 5- to 8-year-old children. Key terms were searched on Amazon, and the website was used to screen for relevant eligibility criteria. Three levels of screening and exclusions resulted in a final sample of 48 books. Quantitative content analysis was used to apply a coding scheme developed based on relevant Clinical Practice Guidelines and systematic reviews. Cohen's Kappa indicated strong reliability, and frequencies were calculated to summarize the content. The books were published between 1981 and 2022. All 48 books included at least one evidence-based coping strategy. Distressing aspects such as scary visuals were often included (27.1%), as well as specific expressions of fear (52.1%) and pain (16.7%). Overall, this study paves the way for researchers interested in evaluating the effectiveness of picture books on children's knowledge and self-efficacy, as well as creating interventions for coping.

A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention to Reduce Distress and Pain Associated with Vaccine Injections in Young Children

Children remember their memories of pain long after the painful experience is over. Those memories predict higher levels of future pain intensity. Young children's memories can be reframed to be less distressing. Parents and the way they reminisce about past events with their children play a key role in the formation of pain memories. A novel parent-led memory-reframing intervention changed children's memories of post-surgical pain to be less distressing. The intervention efficacy in the context of vaccine injections is unclear. This registered randomized controlled trial (NCT05217563) aimed to fill this gap. Seventy-four children aged 4.49 years (SD = 1.05) and scheduled to obtain two COVID-19 vaccine injections and one of their parents were randomized to receive: (1) standard care; (2) standard care and memory-reframing information; and (3) standard care and memory-reframing information with verbal instructions. Children reported their pain after vaccine injections. One week after the first vaccination, children reported memory of pain. Parents reported their use of memory-reframing strategies and intervention feasibility and acceptability. The intervention did not result in significant differences in children's recalled or future pain. Parents rated the intervention as acceptable and feasible.

Virtually Augmented Self-Hypnosis in Peripheral Vascular Intervention: A Randomized Controlled Trial

PURPOSE

Hypnosis is useful for diminishing distress during medical procedures. This study investigated the efficacy of virtually augmented self-hypnosis as an adjunctive non-pharmacological method for procedural pain and anxiety relief during endovascular interventions (EVI).

METHODS

We compared an immersive distraction experience (clinicaltrials.gov identifier NCT04561596) featuring virtual reality (VR) using a head-mounted display versus treatment as usual (TAU). Patients followed the "Aqua" module (Oncomfort™) consisting of a scuba dive and breathing exercises. They experienced a self-induced dissociative state similar to clinical hypnosis without direct intervention of a professional. Enrollment followed a 1:1 randomized open study (VR or TAU). Patients' feelings were evaluated just before and after the procedure, and 3 months following intervention. Anxiety was evaluated using the State Trait Anxiety Inventory (STAI) and pain (sensory, emotional, and memory) with a visual analogue scale (VAS).

RESULTS

This study included 100 patients. Mean anxiety (pre-post) was significantly reduced within groups and between groups (difference of 4.2 points, p = 0.016). The percentage of responders to anxiety lowering were 76 and 46% for VR and TAU, respectively (p = 0.004). The two groups did not significantly differ in mean sensory-intensity and affective emotional pain (pre-post) using VAS, in negative memories concerning remembered pain at 3 months (difference > 1 from immediate post-procedural reported pain intensity), mean procedural time, or the need for analgesic or sedative drugs.

CONCLUSIONS

VR self-hypnosis has the potential to improve the management of patients' distress during radiological procedures. It is safe and effective for reducing anxiety during EVI.

The relation between children's attention bias to pain and children's pain-related memory biases is moderated by parental narrative style

Children's heightened attention to pain and parental narrative style have been linked to the development of negatively-biased pain memories in children (i.e., recalling higher levels of pain and fear than initially reported, which robustly predicts maladaptive pain outcomes). However, the interplay between child attention bias and parental narrative style remains to be assessed. This study aims to fill this gap using enhanced paradigms assessing children's cognitive biases for cues signaling actual pain. Healthy school children (N = 63; 9-15 years old) received painful heat stimuli while performing a spatial cueing task measuring attention bias to cues signaling actual pain. Parent-child interaction upon completion of the painful task, was coded for parental narrative style (i.e., elaboration, repetition and evaluation). Children's pain-related memories were elicited two weeks later. Findings indicated that children showed an attention bias to cues signaling pain. Furthermore, children who were hypervigilant to pain cues benefitted from parents elaborating more about the pain experience, while children who avoided pain cues developed more negatively-biased pain memories if parents had a more elaborative style compared to a more evaluative parental style. In conclusion, this study suggests that optimal ways to talk about children's pain depend upon child characteristics (i.e., children's attention bias to pain).

Biofeedback assisted relaxation training and distraction therapy for pain in children undergoing botulinum neurotoxin A injections: A crossover randomized controlled trial

AIM

To compare biofeedback assisted relaxation training (BART) with distraction therapy for pain during botulinum neurotoxin A (BoNT-A) treatment.

METHOD

This was a crossover randomized controlled trial. Eligible participants were 7 years and older with neurological conditions. Participants were randomized to receive BART or distraction during their first BoNT-A treatment, followed by the alternative intervention in their subsequent BoNT-A treatment. BART was delivered via BrightHearts, an interactive heart-rate-responsive application. Outcomes were pain (Faces Pain Scale - Revised), fear (Children's Fear Scale), and anxiety (numerical rating scale, State-Trait Anxiety Inventory). Demographics, paired t-tests, and linear mixed models were used to compare outcomes.

RESULTS

Thirty-eight participants (mean [SD] age 13 years 5 months [3 years 4 months], 20 males, 34 with cerebral palsy) completed both interventions. There were non-significant differences in overall pain (mean difference - 0.05, 95% confidence interval [CI] -0.91 to 0.80, p = 0.902) and worst pain (mean difference 0.37, 95% CI -0.39 to 1.13, p = 0.334) when using BART and distraction therapy. There were non-significant differences in fear and anxiety between interventions. Younger age, heightened pre-procedural state anxiety, and Gross Motor Function Classification System levels III and IV were associated with poorer outcomes (p < 0.05). Participants who received BART before distraction therapy reported lower pain and anxiety scores during both BoNT-A treatments (p < 0.05).

INTERPRETATION

Children reported similar pain when using BART and distraction therapy. Those who used BART before distraction therapy reported lower pain and anxiety during both treatments.

WHAT THIS PAPER ADDS

Children reported similar pain (overall; worst) when using biofeedback assisted relaxation training (BART) and distraction therapy. Children who used BART before distraction therapy reported lower pain and anxiety over both botulinum neurotoxin A treatments. Younger age, pre-procedural state anxiety, and Gross Motor Function Classification System levels III and IV predicted a worse pain experience. Distraction therapy and BART were acceptable non-pharmacological interventions for procedural pain management.

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.

The Effect of a Pain Educational Video Upon Child Pain-Related Memory and the Moderating Role of Parental Pain- and Non-Pain-Attending Verbalizations: An Experimental Lab-Based Study

OBJECTIVES

Early memories of pain contribute to fear and may underlie the maintenance and development of chronic pain into adulthood. Accordingly, understanding determinants that may impact children's pain memory development is key. This study examined (a) the effect of a brief engaging pain educational video in healthy children before undergoing an experimental pain task upon children's recalled pain intensity and pain-related fear and (b) the moderating role of parental pain- and non-pain-attending verbalizations before and after the pain task.

METHODS

Seventy-seven children (8-15 years old) participated in an experimental heat pain task, including actual heat pain stimuli delivered through a thermode on their forearm. Children were randomized to the experimental group (i.e., watching a pain educational video) or the control group (i.e., no video). Children's recalled pain intensity and pain-related fear were elicited 2 weeks later.

RESULTS

Findings showed that recalled pain intensity (but not recalled pain-related fear) of children who watched the pain educational video was significantly lower compared to the control group (p = .028). Further, parental pain-attending verbalizations before the pain task moderated the impact of the video upon children's recalled pain intensity (p = .038). Specifically, children in the control group, but not the experimental group, whose parents used less pain-attending verbalizations recalled higher pain intensity, whereas children whose parents used more pain-attending verbalizations recalled lower pain intensity.

CONCLUSIONS

As children's pain memories have important implications for pain assessment, treatment, and health across the lifespan, these findings might have important implications for the prevention of development or maintenance of maladaptive pain-related outcomes.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

Preference of Dental Practitioners toward the Use of Local and Topical Anesthetics for Pediatric Patients in Saudi Arabia: A Cross-Sectional Survey

Background: Local anesthesia administration techniques are slightly challenging to perform and master on the basis of experience. It is always delicate to adjust to the first patient injection, especially in children. This study investigated dental practitioners’ preferences toward topical and local anesthetics for children in Saudi Arabia. Materials and methods: A questionnaire was sent through google forms to the participants, including sociodemographic characteristics, as well as perceptions of local anesthesia and topical anesthesia. The details for each demographic variable were based the gender, occupation, and experience years. Descriptive statistics were carried out using SPSS (version 24.0), where a p-value of 0.05 at a 95% confidence interval was considered significant. Result: A total of 274 responses were received from Saudi Arabian dental practitioners, whereby 92.3% preferred lidocaine, and, while choosing local anesthesia, most participants (57.7%) considered precise bodyweight. The majority of the participants selected 27 gauge needles for infiltrations (46.3%) and blocks (63.9%). Short needles were preferred by the majority (93.4%) of the dental practitioners for infiltration, while long needles (83.9%) were chosen for nerve blocks. Benzocaine (68.2%) was preferred by the majority of the dental practitioners for topical anesthesia, and 55.8% of them were not aware of the brand of the topical anesthesia. The majority of dental practitioners felt that topical anesthesia was effective prior to administration of local anesthesia, and 83.6% of the Arabian dental practitioners expressed that patients complained regarding the taste of topical anesthesia. There were mixed opinions observed among the genders and occupations of dental practitioners regarding anesthetics used. Conclusion: The dental practitioners’ perceptions and preferences demonstrate that the most commonly preferred type of local anesthetic was lidocaine, whereas the most preferred type of topical anesthetic was benzocaine in gel form. Moreover, the most widely used factor in deciding the dosage of local anesthesia was precise body weight among Saudi dentists. The majority of participants preferred short needles for infiltrations and long needles for nerve blocks. The 27 gauge needle was chosen by the majority of the participants for both infiltration and nerve blocks.

The Moderating Role of Attention Control in the Relationship Between Pain Catastrophizing and Negatively-Biased Pain Memories in Youth With Chronic Pain

The present study examined the role of attention control in understanding the development of negatively-biased pain memories as well as its moderating role in the relationship between pain catastrophizing and negatively-biased pain memories. Youth with chronic pain (N = 105) performed a cold pressor task (CPT) and completed self-report measures of state/trait pain catastrophizing and attention control, with the latter comprising both attention focusing and attention shifting. Two weeks after the CPT, youth's pain-related memories were elicited via telephone allowing to compute pain and anxiety memory bias indices (ie, recalling pain intensity or pain-related anxiety, respectively, as higher than initially reported). Results indicated no main effects of attention control and pain catastrophizing on pain memories. However, both components of attention control (ie, attention focusing and attention shifting) moderated the impact of pain catastrophizing on youth's memory bias, with opposite interaction effects. Specifically, whereas high levels of attention shifting buffered the influence of high pain catastrophizing on the development of pain memory bias, high levels of attention focusing strengthened the influence of high pain catastrophizing on the development of anxiety memory bias. Interaction effects were confined to trait catastrophizing (ie, not state catastrophizing). Theoretical and clinical implications are discussed. PERSPECTIVE: This article investigates the role of attention control in the development of negatively-biased pain memories in children with chronic pain. Findings underscore the importance of targeting differential components of attention control and can inform intervention efforts to minimize the development of negatively biased pain memories in youth with chronic pain.

Reframe the Pain: A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention

Negatively-biased pain memories (ie, recalling more pain as compared to earlier reports) are a robust predictor of future pain experiences. This randomized controlled trial examined the efficacy of a memory-reframing intervention to reframe children's pain memories. Sixty-five children (54% girls, M_age=5.35 years) underwent a tonsillectomy and reported their levels of post-surgical pain intensity and pain-related fear. 2 weeks post-surgery, children and 1 of their parents were randomized to the memory-reframing intervention or control group. Following control/intervention instructions, parents and children reminisced about the past surgery as they normally would (control) or using the memory-reframing strategies (intervention). Children recalled their post-surgical pain intensity and pain-related fear one week later. Parents reported the intervention's acceptability. Recruitment statistics were used to assess feasibility. Controlling for initial pain intensity ratings and using the Faces Pain Scale Revised, children in the intervention group reported more accurate/positively-biased memories for day 1 post-surgery pain intensity (M = 2.60/10; 95% CI, 1.62 to 3.68), compared to children in the control group (M = 4.11/10; 95% CI, 3.12 to 5.03), η_p² = .07, p = .040. The intervention was acceptable and feasible. Optimal parent-child reminiscing about a past pain experience resulted in children remembering their pain more accurately/positively. Clinicaltrials.gov:NCT03538730. PERSPECTIVE: This article presents results of the first randomized controlled trial examining the efficacy of parent-led memory-reframing intervention to change children's memories for pain. Children of parents who were taught and engaged in optimal reminiscing about a past surgery experience remembered their pain intensity more accurately/positively.

Retrospective Comparison of Intranasal Fentanyl and Inhaled Nitrous Oxide to Intravenous Ketamine and Midazolam for Painful Orthopedic Procedures in a Pediatric Emergency Department

OBJECTIVES

To compare the efficacy and adverse events of 2 pharmacological strategies: intranasal fentanyl and nitrous oxide (FN) inhaled against intravenous ketamine and midazolam (KM) as procedural sedation and analgesia (PSA) in painful orthopedic procedures in the pediatric emergency department (ED).

METHODS

This is an observational retrospective cohort study. Patients were included that submitted to PSA for carrying out a painful orthopedic procedure in the ED of a tertiary hospital over a period of 2 years. The main outcome variable was efficacy and adverse events of the PSA procedure.

RESULTS

Eighty-three patients were included. Fifty-two patients received FN and 31 KM. The PSA strategy was considered efficacious in 82.7% of the patients in the KM group and 80.6% in the FN cohort. No differences between both strategies were found (P = 0.815). Seventeen children showed early adverse events, 2 in the FN cohort and 15 in the KM group (relative risk of the KM strategy, 23.48; 95% confidence interval (CI), 3.24-169.99). The average of satisfaction obtained by the families was of 10 (CI, 10-10) in the KM cohort and of 9 (CI, 8-9.5) in the FN group (P = 0.152). The length of stay in the ED was longer in the KM cohort (P < 0.001). Hospital admission rate differences were not statistically different (9.6% vs 22.6%, P = 0.144) in the KM versus FN cohort.

CONCLUSIONS

Both PSA strategies presented similar efficacy. The FN strategy was associated with a lower risk of adverse events and shorter ED length of stay than KM in this ED setting.

Parent-Child Reminiscing about Past Pain as a Preparatory Technique in the Context of Children's Pain: A Narrative Review and Call for Future Research

Pain permeates childhood and remains inadequately and/or inconsistently managed. Existing research and clinical practice guidelines have largely focused on factors influencing the immediate experience of pain. The need for and benefits of preparing children for future pain (e.g., painful procedures) has been well established. Despite being a robust predictor of future pain and distress, memories of past painful experiences remain overlooked in pediatric pain management. Just as autobiographical memories prepare us for the future, children’s memories for past pain can be harnessed to prepare children for future painful experiences. Children’s pain memories are malleable and can be reframed to be less distressing, thus reducing anticipatory distress and promoting self-efficacy. Parents are powerful agents of change in the context of pediatric pain and valuable historians of children’s past painful experiences. They can alter children’s pain memories to be less distressing simply by talking, or reminiscing, about past pain. This narrative review summarizes existing research on parent–child reminiscing in the context of acute and chronic pediatric pain and argues for incorporation of parent–child reminiscing elements into preparatory interventions for painful procedures.

Role of anxiety in young children's pain memory development after surgery

Pediatric pain is common, and memory for it may be distressing and have long-lasting effects. Children who develop more negatively biased memories for pain (ie, recalled pain is higher than initial pain report) are at risk of worse future pain outcomes. In adolescent samples, higher child and parent catastrophic thinking about pain was associated with negatively biased memories for postsurgical pain. This study examined the influence of child and parent anxiety on the development of younger children's postsurgical pain memories. Seventy-eight children undergoing a tonsillectomy and one of their parents participated. Parents reported on their anxiety (state and trait) before surgery, and trained researchers observationally coded children's anxiety at anaesthesia induction. Children reported on their postsurgical pain intensity and pain-related fear for 3 days after discharge. One month after surgery, children recalled their pain intensity and pain-related fear using the same scales previously administered. Results revealed that higher levels of postsurgical pain and higher parent trait anxiety predicted more negatively biased memories for pain-related fear. Parent state anxiety and child preoperative anxiety were not associated with children's recall. Children who developed negatively biased pain memories had worse postsurgical pain several days after surgery. These findings underscore the importance of reducing parental anxiety and effective postsurgical pain management to potentially buffer against the development of negatively biased pain memories in young children.

The Experience of Pain and Pain Tool Preferences of Hospitalized Youth

BACKGROUND

An accurate holistic pediatric pain assessment is necessary for quality pain management. Evidence continues to be published indicating inadequacies in pediatric pain management. It is important for clinicians to consider the pain assessment process while caring for youth.

AIM

The purpose of this study was to understand the pain experience through focused interviews and to explore how youth use, interpret and understand self-report pain assessment tools including their tool preferences.

DESIGN

A qualitative descriptive study using a research developed semi-structured interview guide was conducted with 40 hospitalized youth, 10-17 years (M: 13yr; S.D. 2.4); 21 (52.5%) female on a medical inpatient unit. Interview questions focused on: current pain experience; pain related symptoms; evaluation of pain treatment and preferences for select pain assessment tools: 0-10 Numeric Rating Scale, The Oucher, Faces Pain Scale-Revised, and Adolescent Pediatric Pain Tool (APPT).

SETTING

Large tertiary and quaternary care pediatric hospital located in northeastern United States.

PARTICIPANTS/SUBJECTS

Hospitalized youth, 10-17 years of age.

RESULTS

Analysis of transcribed interviews yielded 3 themes: My Pain Now, Pain Treatment Expectations, and Telling Healthcare Providers about My Pain. Additionally, pain tools preference, assessment frequency, and discussion of how behavior, activity level, and pain expression was different for each youth. APPT was the preferred pain assessment tool. Descriptive words such as sharp, throbbing, and aching were identified most often. Youth identified that activity and pain level often do not match.

CONCLUSIONS

Because pain is multi-dimensional, assessing each dimension (quality, location, intensity, and meaning) is key to thorough assessment. Results provide insight into youth preferences influencing clinical practice such as offering options for interventions and having a voice in the pain management process. All nurses caring for children should discuss available pain tools preferably before the child is in pain and assure the child knows how to use the tool.

Using the MEDiPORT humanoid robot to reduce procedural pain and distress in children with cancer: A pilot randomized controlled trial

BACKGROUND

Subcutaneous port needle insertions are painful and distressing for children with cancer. The interactive MEDiPORT robot has been programmed to implement psychological strategies to decrease pain and distress during this procedure. This study assessed the feasibility of a future MEDiPORT trial. The secondary aim was to determine the preliminary effectiveness of MEDiPORT in reducing child pain and distress during subcutaneous port accesses.

METHODS

This 5-month pilot randomized controlled trial used a web-based service to randomize 4- to 9-year-olds with cancer to the MEDiPORT cognitive-behavioral arm (robot using evidence-based cognitive-behavioral interventions) or active distraction arm (robot dancing and singing) while a nurse conducted a needle insertion. We assessed accrual and retention; technical difficulties; outcome measure completion by children, parents, and nurses; time taken to complete the study and clinical procedure; and child-, parent-, and nurse-rated acceptability. Descriptive analyses, with exploratory inferential testing of child pain and distress data, were used to address study aims.

RESULTS

Forty children were randomized across study arms. Most (85%) eligible children participated and no children withdrew. Technical difficulties were more common in the cognitive-behavioral arm. Completion times for the study and needle insertion were acceptable and >96% of outcome measure items were completed. Overall, MEDiPORT and the study were acceptable to participants. There was no difference in pain between arms, but distress during the procedure was less pronounced in the active distraction arm.

CONCLUSION

The MEDiPORT study appears feasible to implement as an adequately-powered effectiveness-assessing trial following modifications to the intervention and study protocol. ClinicalTrials.gov NCT02611739.

The influence of pain memories on children's and adolescents' post-surgical pain experience: A longitudinal dyadic analysis

OBJECTIVE

Although children's pain memories have been shown to be a powerful predictor of subsequent pain experiences in acute procedural and experimental pain settings, little is known about the influence of children's and parents' pain memories on children's future pain experiences in other painful contexts. This study used a dyadic approach to examine the roles of children's and parents' memories of pain on their subsequent reporting of postsurgical pain several months after the child underwent a major surgical procedure.

METHOD

The sample included 66 parent-child dyads (Mage youth = 14.73 years, SD = 2.01) recruited from 2 tertiary level pediatric hospitals. At baseline, children and parents reported on their catastrophic thinking about the child's pain. Parent and child reports of child pain were collected at approximately 1 month and 5 months postsurgery. At 2-4 months postsurgery, children's and parents' memories for postsurgical pain were assessed.

RESULTS

Results revealed that children's, but not parents', pain memories were a strong predictor of subsequent pain experienced at 5 months postsurgery. Children's and parents' memories for pain did not influence each others' subsequent pain reporting.

CONCLUSIONS

Findings suggest that children's pain memories influence their continued recovery from postsurgical pain and may contribute to pain persistence. Implications for intervention and prevention are discussed. (PsycINFO Database Record

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.

Ethics of research for patients in pain

PURPOSE OF REVIEW

This review describes advances in rising and continuing ethical issues in research in patients in pain. Although some of the issues focus directly on pain research, such as research in neonatal pain management, others focus on widespread ethical issues that are relevant to pain research, such as scientific misconduct, deception, placebo use and genomics.

RECENT FINDINGS

Scientific misconduct is more widespread than realized and requires greater awareness of the markers of misconduct like irreproducibility. More education about what qualifies as misconduct, such as consent violations, plagiarism and inappropriate patient recruitment along with data falsification needs to be implemented. Wayward researchers may attend a rehabilitation conference to improve their practices. Studies in neonatal pain management do not require comparing an intervention with the inadequate analgesia of a placebo; comparing with a standard approach is sufficient. Deception of research patients may be acceptable under narrow circumstances. The legitimacy of using broad informed consent for biobanking and genomic studies are being challenged as changes to the Common Rule are being considered.

SUMMARY

Increasing complexity and the desire to further medical knowledge complicates research methods and informed consent. The ethical issues surrounding these and offshoot areas will continue to develop.

Accuracy and bias in retrospective symptom reporting

PURPOSE OF REVIEW

Self-reported bodily symptoms are of primary importance in healthcare and in health-related research. Typically, they are assessed in clinical interviews or by means of traditional questionnaire formats that require the respondent to provide retrospective symptom estimates rated along intuitive frequency and/or intensity standards and aggregated across varying or unspecified time windows.

RECENT FINDINGS

Retrospective symptom assessments are often biased when compared to (averaged) momentary assessments of symptoms. A variety of factors and conditions have been identified to influence the amount of bias in symptom reporting. Recent research has focused on the underlying mechanisms for the discrepancy between memory and experience. It is suggested that different types of questions and formats assess different types of information, and each may be relevant for different purposes. Knowledge of these underlying mechanisms also provides a relevant framework to better understand individual differences in symptom reporting, including somatoform and somatic symptom disorder.

SUMMARY

Accuracy of self-reported bodily symptoms is important for the clinician and the researcher. Understanding the mechanisms underlying bias may provide an interesting window to understand how symptom episodes are processed, encoded, and consolidated in memory and may also provide clues to modify symptom experiences.

Post-traumatic stress symptoms in children and adolescents with chronic pain: A topical review of the literature and a proposed framework for future research

BACKGROUND AND OBJECTIVE

The co-occurrence of chronic pain and post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) has gained increasing research attention. Studies on associations among pain and PTSS or PTSD in youth have largely been conducted in the context of acute injury or trauma. Less is known about the risk for co-occurrence with paediatric chronic pain. In this review, we (1) propose a conceptual framework to outline factors salient during childhood that may be associated with symptom severity, co-occurrence and mutual maintenance, (2) present relevant literature on PTSS in youth with acute and chronic pain and identify research gaps and (3) provide recommendations to guide paediatric research examining shared symptomatology.

DATABASES AND DATA TREATMENT

Electronic databases (PubMed and Google Scholar) were used to identify relevant articles using the search terms 'child, adolescent, paediatric, chronic pain, acute pain, post-traumatic stress symptoms and post-traumatic stress disorder'. Studies were retrieved and reviewed based on relevance to the topic.

RESULTS

Our findings revealed that existing biobehavioural and ecological models of paediatric chronic pain lack attention to traumatic events or the potential development of PTSS. Paediatric studies are also limited by lack of a conceptual framework for understanding the prevalence, risk and trajectories of PTSS in youth with chronic pain.

CONCLUSIONS

Our new developmentally informed framework highlights individual symptoms and shared contextual factors that are important when examining potential associations among paediatric chronic pain and PTSS. Future studies should consider bidirectional and mutually maintaining associations, which will be aided by prospective, longitudinal designs. WHAT DOES THIS REVIEW ADD?: This review presents relevant literature on pain and PTSS in youth and proposes a conceptual framework to examine factors salient during childhood that may be associated with symptom severity, comorbidity and mutual maintenance of chronic pain and PTSS in paediatric populations. We highlight dynamic factors that may change across children's development and provide recommendations to guide paediatric research examining potential associations among PTSS and chronic pain.

Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall

Children's memories for pain play a powerful role in their pain experiences. Parents' memories may also influence children's pain experiences, by influencing parent-child interactions about pain and children's cognitions and behaviors. Pain catastrophizing of children and parents has been implicated as a factor underlying memory biases; however, this has not been empirically examined. The current longitudinal study is the first to examine the role of pain catastrophizing of children and parents in the development of their pain memories after surgery. Participants were 49 youth (32 girls) aged 10 to 18 years undergoing major surgery and their parents. One week before surgery, children and parents completed measures of pain catastrophizing. Two weeks after surgery (the acute recovery period), children and parents completed measures of child pain intensity and affect. Two to 4 months after surgery, children's and parents' memories of child pain intensity and affect were elicited. Hierarchical linear regression models revealed that over and above covariates, parent catastrophizing about their child's pain (magnification, rumination) accounted for a significant portion of variance in children's affective and parents' sensory pain memories. Although parent catastrophizing had a direct effect on pain memories, mediation analyses revealed that child catastrophizing (helplessness) indirectly influenced children's and parents' pain memories through the child's postoperative pain experience. Findings highlight that aspects of catastrophic thinking about child pain before surgery are linked to distressing pain memories several months later. Although both child and parent catastrophizing influence pain memory development, parent catastrophizing is most influential to both children's and parents' evolving cognitions about child pain.

The Music Attentiveness Screening Assessment, Revised (MASA-R): A Study of Technical Adequacy

BACKGROUND

Evidence suggests that attention is an important consideration when designing procedural support interventions for children undergoing distressing medical procedures. As such, the extent to which children can attend to musical stimuli used during music-based procedural support interventions would seem important. The Music Attentiveness Screening Assessment (MASA) was designed to assess a child's ability to attend to musical stimuli, but further revisions were deemed necessary to improve administration, test-retest reliability, and interobserver agreement for the measure's items.

OBJECTIVE

This study investigated the technical adequacy of the Music Attentiveness Screening Assessment, Revised (MASA-R), with a non-clinical sample of children aged 4 to 9 years by examining (a) Construct validity using comparator instruments measuring auditory attention; (b) Test-retest reliability following a two-week delay; and (c) Interobserver agreement when administered by two independent examiners.

METHODS

This non-clinical sample included 69 children who were administered both items from MASA-R and two comparator instruments: the Auditory Attention subtest from the NEPSY-II (NII-AA) for children aged 5 to 9 years (n = 47); and the Auditory Attention subtest from the Woodcock-Johnson Tests of Cognitive Abilities, 3rd ed. (WJIII-AA), for children aged 4 years (n = 22).

RESULTS

A significant proportion of score variance was shared by both MASA-R items and the comparator measures: R (2) = .16, F(2, 66) = 6.30, p = .003. MASA-R score estimates with regard to test-retest reliability (Item I, intra-class correlation [ICC] = .88; Item II, ICC = .91) and interobserver agreement (Item I, ICC = .99; Item II, ICC = .98) also fell into acceptable ranges.

CONCLUSIONS

Estimates of MASA-R score construct validity, test-retest reliability, and interobserver agreement appear improved over its predecessor, MASA. While findings are promising, additional investigation of its use with a clinical sample is needed before it can be confidently used in pediatrics.

Neonatal pain and developmental outcomes in children born preterm: a systematic review

BACKGROUND

Neonates cared for in neonatal intensive care units are exposed to many painful and stressful procedures that, cumulatively, could impact later neurodevelopmental outcomes. However, a systematic analysis of these effects is yet to be reported.

OBJECTIVES

The aim of this research was to review empirical studies examining the association between early neonatal pain experiences of preterm infants and the subsequent developmental outcomes of these children across different ages.

METHODS

The literature search was performed using the PubMed, PsycINFO, Lilacs, and SciELO databases and included the following key words: "pain," "preterm," and "development." In addition, a complementary search was performed in online journals that published pain and developmental studies to ensure all of the target studies had been found. The data were extracted according to predefined inclusion and exclusion criteria.

RESULTS

Thirteen studies were analyzed. In infants born extremely preterm (gestational age ≤29 wk) greater numbers of painful procedures were associated with delayed postnatal growth, with poor early neurodevelopment, high cortical activation, and with altered brain development. In toddlers born very preterm (gestational age ≤32 wk) biobehavioral pain reactivity-recovery scores were associated with negative affectivity temperament. Furthermore, greater numbers of neonatal painful experiences were associated with a poor quality of cognitive and motor development at 1 year of age and changes in cortical rhythmicity and cortical thickness in children at 7 years of age.

CONCLUSIONS

For infants born preterm, neonatal pain-related stress was associated with alterations in both early and in later developmental outcomes. Few longitudinal studies examined the impact of neonatal pain in the long-term development of children born preterm.

Far From "Just a Poke": Common Painful Needle Procedures and the Development of Needle Fear

BACKGROUND

Vaccine injections are the most common painful needle procedure experienced throughout the lifespan. Many strategies are available to mitigate this pain; however, they are uncommonly utilized, leading to unnecessary pain and suffering. Some individuals develop a high level of fear and subsequent needle procedures are associated with significant distress.

OBJECTIVE

The present work is part of an update and expansion of a 2009 knowledge synthesis to include the management of vaccine-related pain across the lifespan and the treatment of individuals with high levels of needle fear. This article will provide a conceptual foundation for understanding: (a) painful procedures and their role in the development and maintenance of high levels of fear; (b) treatment strategies for preventing or reducing the experience of pain and the development of fear; and (c) interventions for mitigating high levels of fear once they are established.

RESULTS

First, the general definitions, lifespan development and functionality, needle procedure-related considerations, and assessment of the following constructs are provided: pain, fear, anxiety, phobia, distress, and vasovagal syncope. Second, the importance of unmitigated pain from needle procedures is highlighted from a developmental perspective. Third, the prevalence, course, etiology, and consequences of high levels of needle fear are described. Finally, the management of needle-related pain and fear are outlined to provide an introduction to the series of systematic reviews in this issue.

DISCUSSION

Through the body of work in this supplement, the authors aim to provide guidance in how to treat vaccination-related pain and its sequelae, including high levels of needle fear.

Reappraisal mitigates overestimation of remembered pain in anxious individuals

Anxiety sensitivity, a trait characterised by fear of anxiety-related body sensations, has been linked to heightened attention to pain, appraising body sensations as threatening, and remembering threat-related information. We assessed whether individuals with greater anxiety sensitivity overestimate in remembering pain. We also assessed whether emotion regulation strategies that direct attention away from pain (distraction), or alter appraisals of pain (reappraisal), alleviate memory bias. Participants (N = 137) were randomly assigned to one of two emotion regulation conditions or to a control condition before taking part in a cold pressor task. Greater anxiety sensitivity was associated with overestimation in remembering pain. Engaging in reappraisal mitigated this memory bias but engaging in distraction did not. This is the first study to examine the relations among anxiety sensitivity, emotion regulation and memory for pain. The findings suggest that health-care practitioners can encourage reappraisal to promote more positive memories of procedural pain, particularly in patients high in anxiety sensitivity.

Impact of Threat Level, Task Instruction, and Individual Characteristics on Cold Pressor Pain and Fear among Children and Their Parents

The cold pressor task (CPT) is increasingly used to induce experimental pain in children, but the specific methodology of the CPT is quite variable across pediatric studies. This study examined how subtle variations in CPT methodology (eg. provision of low- or high-threat information regarding the task; provision or omission of maximum immersion time) may influence children's and parents' perceptions of the pain experience. Forty-eight children (8 to 14 years) and their parents were randomly assigned to receive information about the CPT that varied on 2 dimensions, prior to completing the task: (i) threat level: high-threat (task described as very painful, high pain expressions depicted) or low-threat (standard CPT instructions provided, low pain expressions depicted); (ii) ceiling: informed (provided maximum immersion time) or uninformed (information about maximum immersion time omitted). Parents and children in the high-threat condition expected greater child pain, and these children reported higher perceived threat of pain and state pain catastrophizing. For children in the low-threat condition, an informed ceiling was associated with less state pain catastrophizing during the CPT. Pain intensity, tolerance, and fear during the CPT did not differ by experimental group, but were predicted by child characteristics. Findings suggest that provision of threatening information may impact anticipatory outcomes, but experienced pain was better explained by individual child variables.

Acceptability by parents and children of deception in pediatric research

OBJECTIVE

Deception has been used to investigate the role of developmental and behavioral factors in child health; however, its acceptability for use in pediatric research has received little empirical attention. This study examined the acceptability of deception in a pediatric pain research study as assessed through participating children's and parents' long-term perceptions of its use.

METHOD

Ninety-four children (52 boys; mean age = 12.77 yr) and their parents (86 mothers, 8 fathers) completed a structured interview that assessed perceptions of various aspects of deception in a pediatric pain study, 2.5 years after participating.

RESULTS

A minority of parents (25.5%) and children (13.8%) spontaneously recalled that deception was used. Overall, parents and children reported positive experiences with research participation, felt comfortable with the debriefing process, and deemed the research to be of societal importance. Opinions about researchers and psychologists were not negatively impacted, and most reported willingness to participate in research involving deception again.

CONCLUSION

When thoughtfully planned and disclosed, deception in pediatric research seems to be acceptable to parents and children. Future research should further examine the acceptability of deception and alternatives (e.g., authorized deception) among pediatric samples.

Is top-down vs bottom-up radiological evaluation after febrile urinary tract infection really less stressful for the child and family? Challenging the dogma

PURPOSE

We evaluated whether stress levels in children and parents during radiological evaluation after febrile urinary tract infection are really lower using the top-down approach, where (99m)technetium dimercaptosuccinic acid renal scintigraphy is used initially, than the bottom-up approach, where voiding cystourethrography is initially performed and repeated examinations are easier for all.

MATERIALS AND METHODS

We prospectively evaluated 120 children 3 to 8 years old. Pain ratings were obtained using the Faces Pain Scale-Revised, and conversation during the procedure was evaluated using the Child-Adult Medical Procedure Interaction Scale-Revised by 2 independent observers. To evaluate parental anxiety, the State-Trait Anxiety Inventory form was also completed. Following a documented febrile urinary tract infection children were randomized to the top-down or bottom-up group. A third group of 44 children undergoing repeat voiding cystourethrography and their parents were also evaluated.

RESULTS

Child ratings of pain using the Faces Pain Scale-Revised were not significantly different between the top-down group following (99m)technetium dimercaptosuccinic acid renal scintigraphy (2.99 on a scale of 10) and the bottom-up group following voiding cystourethrography (3.21). Also the Faces Pain Scale-Revised was not significantly different in the repeat voiding cystourethrography group (3.35). On the Child-Adult Medical Procedure Interaction Scale-Revised there was negative correlation between child coping and child distress, as well as rate of child distress and adult coping promoting behavior. Parental state anxiety scores were significantly less in the top-down and repeat voiding cystourethrography groups than in the bottom-up group.

CONCLUSIONS

Although the top-down approach and repeat voiding cystourethrography cause less anxiety for caregivers, these values do not correlate to pain scale in children. This finding might be due to lack of appropriate evaluation tools of pediatric pain and anxiety. However, the theory that the top-down approach is less invasive, and thus less stressful, requires further research. The Child-Adult Medical Procedure Interaction Scale-Revised data indicate that influences in adult-child interaction are bidirectional.

The facial affective scale as a predictor for pain unpleasantness when children undergo immunizations

Needle fear is a common problem in children undergoing immunization. To ensure that the individual child's needs are met during a painful procedure it would be beneficial to be able to predict whether there is a need for extra support. The self-reporting instrument facial affective scale (FAS) could have potential for this purpose. The aim of this study was to evaluate whether the FAS can predict pain unpleasantness in girls undergoing immunization. Girls, aged 11-12 years, reported their expected pain unpleasantness on the FAS at least two weeks before and then experienced pain unpleasantness immediately before each vaccination. The experienced pain unpleasantness during the vaccination was also reported immediately after each immunization. The level of anxiety was similarly assessed during each vaccination and supplemented with stress measures in relation to the procedure in order to assess and evaluate concurrent validity. The results show that the FAS is valid to predict pain unpleasantness in 11-12-year-old girls who undergo immunizations and that it has the potential to be a feasible instrument to identify children who are in need of extra support to cope with immunization. In conclusion, the FAS measurement can facilitate caring interventions.

Analysis of an intervention to reduce parental anxiety prior to voiding cystourethrogram

PURPOSE

The voiding cystourethrogram (VCUG) is a common imaging test in pediatric urology that can be associated with anxiety in the child and parent. We hypothesized that education by mailed brochure would decrease pre-procedure parental anxiety.

METHODS

Families of children scheduled for VCUG were randomized into an experimental group that was mailed an educational brochure about the VCUG and a control group. Immediately prior to the procedure, parental anxiety was assessed with the self-administered State-Trait Anxiety Inventory (STAI). The parent repeated the STAI at home after the VCUG and answered brief questions about educational resources used to prepare for the VUCG.

RESULTS

We enrolled 105 families (47 experimental, 58 control). Parental state anxiety was higher before the procedure than after the procedure (p < 0.001). Younger parents had greater pre-procedure state anxiety (p = 0.007). Contrary to our expectations, pre-procedure state anxiety did not differ between control and experimental groups. However, parents in the experimental group demonstrated less anxiety with some individual items in the questionnaire.

CONCLUSION

An educational brochure mailed to families prior to VCUG did not decrease pre-procedure parental state anxiety. However, the educational brochure can ensure accurate dissemination of information to help families prepare for this potentially distressing procedure.

Functional somatic symptoms in childhood and adolescence

PURPOSE OF REVIEW

Functional somatic symptoms (FSS) are common in children and adolescents, but explanatory models that synthesize research findings are lacking. This article reviews the studies published from January 2012 to March 2013 that investigate the neurophysiological mechanisms that may underlie FSS.

RECENT FINDINGS

Studies from diverse medical disciplines suggest that FSS are associated with functional differences in hypothalamic-pituitary-adrenal function, imbalances in vagal-sympathetic tone, upregulation of immune-inflammatory function, and primed cognitive-emotional responses that serve to amplify reactivity to threatening stimuli, thereby contributing to the subjective experience of somatic symptoms.

SUMMARY

FSS appear to reflect dysregulations of the stress system. When seemingly disparate research findings are interpreted together within an overarching 'stress-system' framework, a coherent explanatory model begins to emerge.