A comparative effectiveness trial of functional behavioral assessment methods.

Clinicians report primarily using functional behavioral assessment (FBA) methods that do not include functional analyses. However, studies examining the correspondence between functional analyses and other types of FBAs have produced inconsistent results. In addition, although functional analyses are considered the gold standard, their contribution toward successful treatment compared with other FBA methods remains unclear. This comparative effectiveness study, conducted with 57 young children with autism spectrum disorder, evaluated the results of FBAs that did (n = 26) and did not (n = 31) include a functional analysis. Results of FBAs with and without functional analyses showed modest correspondence. All participants who completed functional communication training achieved successful outcomes regardless of the type of FBA conducted.

Microtemporal Relationships in the Fear Avoidance Model: An Ecological Momentary Assessment Study.

OBJECTIVES: Current literature in pediatric pain evaluates the Fear Avoidance model (FAM) pathways at the trait (or macrotemporal) level, but it is unknown if these pathways also occur at the state (or microtemporal) level. Identifying microtemporal processes can improve our understanding of how the relationships within the Fear Avoidance constructs vary when specific Fear Avoidance variables wax and wane. We hypothesized that changes in FAM constructs would be associated with changes in the next variable in the sequence on a microtemporal level, including: (1) higher pain when there is more pain-related fear, (2) higher pain-related fear when there is more avoidance, and (3) higher avoidance when there is more reported disability. METHODS: 71 pediatric patients with chronic abdominal pain ( M =13.34 y, SD=2.67 y) reported pain severity, pain-related fear, and avoidance via ecological momentary assessments over 14 days. RESULTS: Our results indicated significant microtemporal relationships between Fear Avoidance constructs for pain predicting pain-related fear, pain-related fear predicting avoidance, and avoidance predicting disability. DISCUSSION: The current study suggests that the ways in which the FAM is related to various aspects of pain functioning differs on a state-level, which adds new clinical and research opportunities.

Suicide Risk in Adolescents During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic created high levels of psychological distress and may have increased suicide risk. METHODS: We used the 4-item Ask Suicide-Screening Questions (ASQ) to assess suicide risk among all patients 12 to 24 years of age at a children's hospital. We compared demographics, encounter type (telehealth or face-to-face [F2F]), and screening results from April to June 2020 (T2) to those from April to June 2019 (T1). RESULTS: Fewer patients were seen at T2 than T1 (17 986 vs 24 863). A greater proportion of visits at T2 were by telehealth (0% vs 43%). The rate of positive suicide screens was higher in T2 than in T1 (12.2% vs 11.1%, adjusted odds ration [aOR], 1.24; 95% confidence interval [CI], 1.15-1.35). The odds of a positive screen were greater for older patients (aOR of 1.12 for age in years; 95% CI, 1.10-1.14), female patients (aOR, 2.23; 95% CI, 2.00-2.48), patients with public versus private insurance (aOR, 1.88; 95% CI, 1.72-2.07), and lower for Black versus White patients (aOR, 0.85; 95% CI, 0.77-0.95). Rates of positive screens were highest among inpatients (20.0%), intermediate for emergency department patients (14.4%), and lowest in outpatient clinics (9.9%) (P < .05). CONCLUSIONS: Rates of positive suicide risk screens among adolescents rose in the pandemic's early months with differences related to sociodemographics and visit type. Changes in health care delivery highlight the complexities of assessing and responding to mental health needs of adolescents. Additional research might determine the effects of screening methods and patient populations on screening results.

Development and Assessment of an Abbreviated Acupuncture Curriculum for Pediatricians.

OBJECTIVE: Acupuncture has been shown to improve pain and other health outcomes in children and is well tolerated. However, use of acupuncture by pediatric medical providers is rare, in part due to the cost and time associated with formal training. We aimed to develop an abbreviated acupuncture curriculum and assess its impact and acceptability with academic pediatricians. METHODS: In this pilot study, pediatricians received instruction in 2 acupuncture protocols for treating acute and chronic pain (Battlefield Acupuncture and Four Gates) during a 10-hour course developed by board-certified medical acupuncturists. Learning methods included an online module with videos and articles, 2 live workshops, and additional home practice. Participants completed a skills-based exam and pre- and post-tests measuring knowledge and attitudes about acupuncture treatment. RESULTS: Forty-five physicians (divided among 3 cohorts) began the acupuncture training course, and 38 (84.4%) completed all components. The course significantly increased participants' perceived efficacy of acupuncture for acute and chronic pain. Participants showed significant improvement in acupuncture knowledge. All participants agreed that the course would influence their current medical practice, and all participants felt confident utilizing basic acupuncture. Additionally, all participants indicated that they would recommend the abbreviated acupuncture curriculum to a colleague. CONCLUSIONS: Pediatricians became proficient in 2 acupuncture protocols with a 10-hour curriculum and found the format and content highly acceptable. Future plans include studying acupuncture implementation and expanding the course to other departments and institutions.

Models of Care for addressing chronic musculoskeletal pain and health in children and adolescents.

Chronic musculoskeletal pain among children and adolescents is common and can negatively affect quality of life. It also represents a high burden on the health system. Effective models of care for addressing the prevention and management of pediatric musculoskeletal pain are imperative. This chapter will address the following key questions: (1) Why are pediatric-specific models of pain care needed? (2) What is the burden of chronic musculoskeletal pain among children and adolescents? (3) What are the best practice approaches for early identification and prevention of chronic musculoskeletal pain in children and adolescents? (4) What are the recommended strategies for clinical management of chronic pain, including pharmacological, physical, psychological and complementary, and alternative approaches? (5) What are the most effective strategies for implementing models of pain care across different care settings? (6) What are the research priorities to improve models of care for children and adolescents with chronic musculoskeletal pain?

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

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

Parent Attitudes Toward Pain Management for Childhood Immunizations.

OBJECTIVES: Evidence-based pain-limiting strategies for pediatric immunizations remain underutilized, with barriers identified to date mostly pertaining to health care providers and systems of care. The present study sought to quantify and investigate parent attitudes toward pain management as another potential barrier to the routine use of pain-mitigating strategies during immunizations. MATERIALS AND METHODS: Questionnaires measuring parent attitudes, willingness to pay, and perceived barriers for using pain management for immunizations were completed by 259 parent/guardians of children ages 0 to 5 years attending appointments at an urban primary care clinic in the Midwestern United States. RESULTS: Parent attitudes toward pain management for immunization were relatively normally distributed and varied from strongly positive to negative, with 33% of parents disagreeing that they were concerned about the pain their child may experience and 50% agreeing that there are no lasting negative effects from immunization pain. Negative parent attitudes were associated with willingness to spend less in money or time for pain management and with greater perceived significance of cost, time, and other barriers for using pain-mitigating strategies. DISCUSSION: Some parents perceive limited value in trying to reduce pain during immunizations such that they may be hesitant to invest much time or effort in interventions. Greater success of translating evidence-based pain management into practice therefore may require accounting for differences in parent attitudes by tailoring educational efforts and pain management options accordingly.

Pupillometry: a non-invasive technique for pain assessment in paediatric patients.

OBJECTIVE: Pupillometry has been used to assess pain intensity and response to analgesic medications in adults. The aim of this observational study was to explore proof of concept for the use of this technique in paediatric patients. Changes in pupil parameters before and after opioid exposure also were evaluated. DESIGN AND SETTING: This was a single-centre, prospective study conducted at an academic paediatric medical centre. PATIENTS: Children 9-17 years of age undergoing elective surgical correction of pectus excavatum were enrolled into a protocol approved by the human ethical committee (institutional review board). INTERVENTIONS: Pupil size and reactivity were measured using a handheld pupillometer. Pain was assessed using age-appropriate, validated pain self-report scales. RESULTS: Thirty patients were enrolled. Each point change on a 10 cm visual analogue pain intensity scale was associated with a statistically significant mean change of 0.11 mm/s in maximum pupil constriction velocity, and of approximately 0.4% in pupil diameter. As expected, there was an association between total opioid dose (expressed as morphine equivalents) and pupil diameter. Age, sex and baseline anxiety scores did not correlate significantly with pupillary response. CONCLUSIONS: The association of maximum pupillary constriction velocity and diameter with pain scores illustrates the potential for using pupillometry as a non-invasive method to objectively quantitate pain response/intensity in children. The technique holds promise as a pharmacodynamic 'tool' to assess opioid response in paediatric patients.

Developing a standardized approach to the assessment of pain in children and youth presenting to pediatric rheumatology providers: a Delphi survey and consensus conference process followed by feasibility testing.

BACKGROUND: Pain in children with rheumatic conditions such as arthritis is common. However, there is currently no standardized method for the assessment of this pain in children presenting to pediatric rheumatologists. A more consistent and comprehensive approach is needed to effectively assess, treat and monitor pain outcomes in the pediatric rheumatology population. The objectives of this study were to: (a) develop consensus regarding a standardized pain assessment tool for use in pediatric rheumatology practice and (b) test the feasibility of three mediums (paper, laptop, and handheld-based applications) for administration. METHODS: In Phase 1, a 2-stage Delphi technique (pediatric rheumatologists and allied professionals) and consensus meeting (pediatric pain and rheumatology experts) were used to develop the self- and proxy-report pain measures. In Phase 2, 24 children aged 4-7 years (and their parents), and 77 youth, aged 8-18 years, with pain, were recruited during routine rheumatology clinic appointments and completed the pain measure using each medium (order randomly assigned). The participant's rheumatologist received a summary report prior to clinical assessment. Satisfaction surveys were completed by all participants. Descriptive statistics were used to describe the participant characteristics using means and standard deviations (for continuous variables) and frequencies and proportions (for categorical variables) RESULTS: Completing the measure using the handheld device took significantly longer for youth (M = 5.90 minutes) and parents (M = 7.00 minutes) compared to paper (M = 3.08 and 2.28 minutes respectively p = 0.001) and computer (M = 3.40 and 4.00 minutes respectively; p < 0.001). There was no difference in the number of missed responses between mediums for children or parents. For youth, the number of missed responses varied across mediums (p = 0.047) with the greatest number of missed responses occurring with the handheld device. Most children preferred the computer (65%, p = 0.008) and youth reported no preference between mediums (p = 0.307). Most physicians (60%) would recommend the computer summary over the paper questionnaire to a colleague. CONCLUSIONS: It is clinically feasible to implement a newly developed consensus-driven pain measure in pediatric rheumatology clinics using electronic or paper administration. Computer-based administration was most efficient for most users, but the medium employed in practice may depend on child age and economic and administrative factors.

Parent perceptions of child vulnerability are associated with functioning and health care use in children with chronic pain.

CONTEXT: The extent to which parent variables are associated with the level of disability experienced by children with persistent pain has been an area of increasing research. OBJECTIVES: To evaluate the extent to which parent perceptions of their child's vulnerability are associated with functioning and health care utilization among children with persistent pain. We also evaluated whether perceptions of child vulnerability contribute to an indirect relationship between parent distress and child functioning and/or child health care utilization. METHODS: The study sample comprised 87 patients aged 6-18 years and a parent attending a chronic pain clinic. Children completed questionnaires on functional limitations, and parents completed questionnaires on parent distress, perceptions of child vulnerability, and extent of the child's pain-related health care utilization. Hierarchical regression and bootstrapping mediation analyses were used to test study hypotheses. RESULTS: Perceptions of child vulnerability were found to be clinically elevated in nearly half (46%) of parents/caregivers, and average child functional ability for the sample was substantially lower than healthy norms. Parent perceptions of greater child vulnerability were significantly associated with poorer child functioning and more child pain-related health care utilization regardless of child age, sex, and duration of persistent pain. Parent distress was found to be indirectly related to child health care utilization through parent perceptions of child vulnerability but directly related to child functioning. CONCLUSION: Parent perceptions of child vulnerability appear important for understanding levels of child functional limitations and health care utilization among children with chronic pain.

Electronic momentary assessment of weather changes as a trigger of headaches in children.

BACKGROUND: Variables that are thought to precipitate migraine or tension-type headache episodes in children hitherto have only been studied using retrospective reports. As such, there is little empirical evidence to support the actual predictive association between presumed headache triggers and actual headache occurrence in children. OBJECTIVE: The present study sought to determine if fluctuations in weather, a commonly reported headache trigger in children, predict increased likelihood of headache occurrence when evaluated using rigorous prospective methodology ("electronic momentary assessment"). METHODS: Twenty-five children (21 girls, 4 boys) between the ages of 8-17 years attending a new patient neurology clinic appointment and having a diagnosis of chronic migraine, chronic tension-type, or episodic migraine headache (with or without aura) participated in the study. Children completed baseline measures on headache characteristics, presumed headache triggers, and mood and subsequently were trained in the use of electronic diaries to record information on headaches. Children then completed thrice daily diaries on handheld computers for a 2-week time period (42 assessments per child) while data on weather variables (temperature, dew point temperature, barometric pressure, humidity, precipitation, and sunlight) in the child's geographic location were recorded each time a diary was completed. Data were analyzed using multilevel models. RESULTS: Of the weather variables, relative humidity and presence of precipitation were significantly predictive of new headache onset, with nearly a 3-fold increase in probability of headache occurrence during times of precipitation or elevated humidity in the child's area, b = 0.38, t(821) = 2.10, P = .04, and b = 0.02, t(821) = 2.81, P = .01, respectively. These associations remained after accounting for fluctuations in mood, and associations were not significantly stronger in children who at baseline thought that weather was a headache trigger for them. Changes in temperature, dew point temperature, barometric pressure, and sunlight were not significantly predictive of new headache episode occurrence in this sample. CONCLUSIONS: Results of the present study lend some support to the belief commonly held by children with recurrent headaches that weather changes may contribute to headache onset. Although electronic momentary assessment methodology was found to be feasible in this population and to have the potential to identify specific headache triggers for children, it remains to be determined how best (or even whether) to incorporate this information into treatment recommendations.

Latest developments in the assessment and management of chronic musculoskeletal pain syndromes in children.

PURPOSE OF REVIEW: As many as 25% of new patients in pediatric rheumatology clinics present with idiopathic chronic pain and recent data suggest the prevalence of these conditions is increasing. Knowledge of the latest developments in assessment and treatment is critical for providing optimal clinical care. This review summarizes advances published in the past year forwarding our understanding of chronic musculoskeletal pain syndromes in children. RECENT FINDINGS: Research has recently focused on the impairment associated with chronic pain syndromes in children, issues impacting the diagnosis of these conditions, and the efficacy of pharmacological and psychosocial treatments. No diagnostic criteria have been developed for specific chronic pain syndromes in children; however, data from several studies substantiate the need for thorough assessment of the child and family in multiple domains. In addition, studies have expanded both pharmacologic and psychosocial treatment options for children with these syndromes. SUMMARY: Despite a growing body of research on chronic pain syndromes in children, there are no established standards of care. Data continues to support an interdisciplinary approach for effectively assessing and managing these conditions.