Adaptation of the State-Trait Inventory for Cognitive and Somatic Anxiety for Use in Children: A Preliminary Analysis

Implementation of a teen sleep app in Canadian high schools: Preliminary evidence of acceptability, engagement, and capacity for supporting healthy sleep habits

High school students suffer from mental health challenges and poorer academic performance resulting from sleep disturbances. Unfortunately, approaches to this problem sometimes focus on increasing sleep duration by going to bed early; a strategy with limited success because teens experience a phase delay in bedtimes. There is a need for approaches that leverage behavioural sleep science and are accessible, scalable, and easily disseminated to students. DOZE (Delivering Online Zzz's with Empirical Support) is a self-management app that is grounded in sleep and circadian basic science. Although initial testing supports it as a feasible and acceptable app in a research context, it has not been tested as a strategy to use in schools. The present study tested DOZE in private high schools in Canada. Two-hundred and twenty-three students downloaded the app and completed daily sleep diaries over 4 weeks. Students reported a more regularised routine for bedtime, Mdiff = -0.43 h, p < 0.001, 95% CI [-0.65, -0.21], and rise time, Mdiff = -0.61 h, p < 0.001, 95% CI [-0.84, -0.38], in addition to a higher total sleep time, Mdiff = 0.18 h, p < 0.008, 95% CI [0.05, 0.31]. Students also rated DOZE to be highly acceptable. The evidence suggests that students find DOZE to be acceptable and engagement in this nonclinical population was reasonably high under minimal researcher supervision. This makes DOZE an attractive option and a step towards broad-based sleep health services. High powered replications with control groups are needed to increase empirical rigour.

A Pilot Study of Ketotifen in Patients Aged 8-17 Years with Functional Dyspepsia Associated with Mucosal Eosinophilia

BACKGROUND AND OBJECTIVE

Mast cells have been implicated in abdominal pain-associated disorders of gut-brain interaction, such as functional dyspepsia. As such, ketotifen, a second-generation antihistamine and mast cell stabilizer, could represent a viable treatment option in these conditions. The primary aim of the current pilot study was to assess clinical response to ketotifen and assess pharmacokinetics in youth with functional dyspepsia.

METHODS

We conducted a pilot randomized, double-blind, placebo-controlled, cross-over trial of ketotifen in 11 youth with functional dyspepsia and duodenal mucosal eosinophilia with 4 weeks of active treatment at a dose of 1 mg twice daily. Global clinical response was graded on a 5-point Likert Scale. A single plasma sample was obtained at steady state for pharmacokinetic analysis.

RESULTS

Ketotifen was not superior to placebo with regard to global clinical response. Only 18% of patients demonstrated a complete or near-complete clinical response. The estimated half-life was 3.3 h.

CONCLUSIONS

While ketotifen was not superior to placebo, this study highlights several important challenges for developing drug trials for youth with chronic abdominal pain. Recommendations are made for designing a larger treatment trial for ketotifen in this patient group.

CLINICAL TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov: NCT02484248.

Percutaneous electrical nerve field stimulation improves comorbidities in children with cyclic vomiting syndrome

Introduction

Children with cyclic vomiting syndrome (CVS) frequently suffer from disabling abdominal pain and comorbidities that impair quality of life. A noninvasive, auricular percutaneous electrical nerve field stimulation (PENFS) device is shown to be effective for abdominal pain in children with disorders of gut-brain interaction. We aimed to determine the effects of PENFS on pain, common comorbidities, and quality of life in pediatric CVS.

Methods

Children aged 8-18 years with drug-refractory CVS were enrolled in a prospective, open-label study receiving 6 consecutive weeks of PENFS. Subjects completed the following surveys at baseline, during/after therapy (week 6), and at extended follow-up approximately 4-6 months later: Abdominal Pain Index (API), State-Trait Anxiety Inventory for Children (STAI-C), Pittsburgh Sleep Quality Index (PSQI), and Patient Reported Outcome Measurement Information System (PROMIS) Pediatric Profile-37.

Results

Thirty subjects were included. Median (interquartile range, IQR) age was 10.5 (8.5-15.5) years; 60% were female. Median API scores decreased from baseline to week 6 (p = 0.003) and to extended follow-up (p < 0.0001). State anxiety scores decreased from baseline to week 6 (p < 0.0001) and to extended follow-up (p < 0.0001). There were short-term improvements in sleep at 6 weeks (p = 0.031) but not at extended follow-up (p = 0.22). Quality of life measures of physical function, anxiety, fatigue, and pain interference improved short-term, while there were long-term benefits for anxiety. No serious side effects were reported.

Conclusions

This is the first study to demonstrate the efficacy of auricular neurostimulation using PENFS for pain and several disabling comorbidities in pediatric CVS. PENFS improves anxiety, sleep, and several aspects of quality of life with long-term benefits for anxiety.Clinical trial registration: ClinicalTrials.gov, identifier NCT03434652.

A Transdiagnostic Self-management Web-Based App for Sleep Disturbance in Adolescents and Young Adults: Feasibility and Acceptability Study

Background

Sleep disturbance and its daytime sequelae, which comprise complex, transdiagnostic sleep problems, are pervasive problems in adolescents and young adults (AYAs) and are associated with negative outcomes. Effective interventions must be both evidence based and individually tailored. Some AYAs prefer self-management and digital approaches. Leveraging these preferences is helpful, given the dearth of AYA treatment providers trained in behavioral sleep medicine. We involved AYAs in the co-design of a behavioral, self-management, transdiagnostic sleep app called DOZE (Delivering Online Zzz’s with Empirical Support).

Objective

This study tests the feasibility and acceptability of DOZE in a community AYA sample aged 15-24 years. The secondary objective is to evaluate sleep and related outcomes in this nonclinical sample.

Methods

Participants used DOZE for 4 weeks (2 periods of 2 weeks). They completed sleep diaries, received feedback on their sleep, set goals in identified target areas, and accessed tips to help them achieve their goals. Measures of acceptability and credibility were completed at baseline and end point. Google Analytics was used to understand the patterns of app use to assess feasibility. Participants completed questionnaires assessing fatigue, sleepiness, chronotype, depression, anxiety, and quality of life at baseline and end point.

Results

In total, 83 participants created a DOZE account, and 51 completed the study. During the study, 2659 app sessions took place with an average duration of 3:02 minutes. AYAs tracked most days in period 1 (mean 10.52, SD 4.87) and period 2 (mean 9.81, SD 6.65), with a modal time of 9 AM (within 2 hours of waking). DOZE was appraised as highly acceptable (mode≥4) on the items “easy to use,” “easy to understand,” “time commitment,” and “overall satisfaction” and was rated as credible (mode≥4) at baseline and end point across all items (logic, confident it would work, confident recommending it to a friend, willingness to undergo, and perceived success in treating others). The most common goals set were decreasing schedule variability (34/83, 41% of participants), naps (17/83, 20%), and morning lingering in bed (16/83, 19%). AYAs accessed tips on difficulty winding down (24/83, 29% of participants), being a night owl (17/83, 20%), difficulty getting up (13/83, 16%), and fatigue (13/83, 16%). There were significant improvements in morning lingering in bed (P=.03); total wake time (P=.02); sleep efficiency (P=.002); total sleep time (P=.03); and self-reported insomnia severity (P=.001), anxiety (P=.002), depression (P=.004), and energy (P=.01).

Conclusions

Our results support the feasibility, acceptability, credibility, and preliminary efficacy of DOZE. AYAs are able to set and achieve goals based on tailored feedback on their sleep habits, which is consistent with research suggesting that AYAs prefer autonomy in their health care choices and produce good results when given tools that support their autonomy.

Trial Registration

ClinicalTrials.gov NCT03960294; https://clinicaltrials.gov/ct2/show/NCT03960294

Comparing Three Music Therapy Interventions for Anxiety and Relaxation in Youth With Amplified Pain

Research in pediatric hospitals has shown that active music engagement, preferred music listening, and music-assisted relaxation can decrease anxiety and increase relaxation responses. However, there is little research on the use of music therapy with pediatric chronic pain conditions such as amplified pain syndromes. The purpose of the current study was to examine the effects of 3 specific music therapy interventions (active music engagement, live patient-selected music, and music-assisted relaxation) on anxiety and relaxation levels in youth (ages 10-18) participating in a 40 hr per week hospital-based intensive interdisciplinary pain treatment program. A sample of 48 patients participated in this study which utilized a 3-period, 3-treatment cross-over design with 3 interventions delivered in a quasi-randomized order determined by when the patients started the treatment program. State anxiety was measured via the state form of the State-Trait Inventory for Cognitive and Somatic Anxiety for Children and relaxation scores were assessed with a Visual Analog Scale. Statistically significant changes were found in anxiety and relaxation outcomes across all interventions provided. Results suggest that music therapy services (using active music engagement, live patient-selected music, and music-assisted relaxation) may be an effective modality to decrease anxiety and increase relaxation levels in pediatric patients with amplified pain syndromes.

Dimensionality of the State-Trait Inventory of Cognitive and Somatic Anxiety

The State-Trait Inventory of Cognitive and Somatic Anxiety (STICSA) is a commonly administered self-report instrument of state-trait cognitive and somatic anxiety. Extant research has consistently supported the intended oblique two-factor scoring structure for the STICSA. However, this model assumes that population-level data have (or approximate) a simple structure and that item-level variance is unidimensional. These assumptions may not be tenable and have unintended consequences for STICSA subscore interpretation. Consequently, we tested these assumptions by fitting confirmatory and exploratory structural equation models to STICSA scores for a diverse sample of college students enrolled at a large Southwestern university in the United States (n = 635). Results indicated that cognitive and somatic factors are not equally robust and that STICSA items appear to measure a nonnegligible mixture of both latent cognitive and somatic anxiety. It is recommended that future research use exploratory structural equation model in tandem with CFA to directly model data complexity.

Systematic Symptom Reporting by Pediatric Palliative Care Patients with Cancer: A Preliminary Report

Background: Systematic symptom assessment is not a standard of care in children with cancer. Many well-known symptom assessment tools are lengthy or difficult to integrate into a daily pediatric palliative care practice. We created a series of brief and simple questions to be systematically given to children and their caregivers. Objective: The primary objective was to determine the percentage of eligible children and caregivers exposed to the questions that were able to complete the assessment. Secondary objectives included documenting the symptom burden at the time of consultation, evaluating the level of agreement in symptom reporting between children and caregivers, as well as between children/caregivers and the referring medical team. Design: A series of systematic questions were presented to all caregivers (if present) and children who were seven years of age or older at the time of initial consultation with pediatric palliative care. Results: One hundred twenty-two consecutive children/caregiver dyads were given the survey. One hundred seven of 108 (99%) eligible caregivers and 83 of 97 (86%) eligible children completed the survey. Lack of appetite (child-72/83, 87%; caregiver-89/107, 83%) and pain (child-71/83, 86%; caregiver-86/107, 80%) were the most commonly reported symptoms. Caregivers reported irritability (p = 0.005) and nervousness (p < 0.001) more frequently than children. Referring medical teams significantly underdiagnosed psychological and other less clinically evident symptoms such as lack of appetite, fatigue, and sleep disturbance (p < 0.001). Conclusions: Our series of questions is easy to complete by children and caregivers. Systematic symptom assessment of children with cancer referred to palliative care should become a true standard of care.

Dimensions of Anxiety, Age, and Gender: Assessing Dimensionality and Measurement Invariance of the State-Trait for Cognitive and Somatic Anxiety (STICSA) in an Italian Sample

The State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA) is a widely used measure of state and trait anxiety that permits a specific assessment of cognitive and somatic anxiety. Previous research provided inconsistent findings about its factor structure in non-clinical samples (e.g., hierarchical or bi-factor structure). To date, no psychometric validation of the Italian version of the STICSA has been conducted. Our study aimed to determine the psychometric functioning of the Italian version of the STICSA, including its dimensionality, gender and age measurement equivalence, and convergent/divergent validity in a large sample of community-dwelling participants (N = 2,938; 55.9% female). Through confirmatory factor analysis, the multidimensional structure of both State and Trait STICSA scales, with each including Cognitive and Somatic dimensions, was supported. Factor structure invariance was tested and established at configural, metric, and scalar levels for males and females. Additionally, full factorial measurement invariance was supported for the State scale across young, middle age, and old adult groups whereas the Trait scale was partially invariant across age groups. The STICSA also showed good convergent validity with concurrent anxiety measures (State-Trait Anxiety Inventory and Beck Anxiety Inventory), and satisfactory internal discriminant validity with two depression measures (Teate Depression Inventory and Beck Depression Inventory-II). Results provided support for the multidimensionality of the STICSA, as well as the generalizability of the State and Trait scales as independent measures of Cognitive and Somatic symptomatology across gender in the general population. Implications for research and personality and clinical assessment are discussed.