Acceptance and commitment therapy in youth with neurofibromatosis type 1 (NF1) and chronic pain and their parents: A pilot study of feasibility and preliminary efficacy

Factors influencing caregiver decisions to use complementary and integrative therapies in pediatric oncology settings: Findings from a qualitative analysis

PURPOSE

Complementary and integrative medicine (CIM) therapies (i.e., non-conventional Western medicine interventions) may reduce side-effects associated with pediatric oncology treatment. CIM therapies may also improve caregiver psychological and physical health that is exacerbated during pediatric cancer treatment. Despite known benefits, these therapies are not widely used within pediatric oncology populations in the United States. To guide and promote CIM use among this population, the aim of this project was to qualitatively explore factors that contribute to caregivers' decision to include CIM use in their own and child's care.

METHODS

Twenty caregivers of children (ages 0.5-14 years) being treated for cancer participated in this study. Each completed a demographic form and the CIM use questionnaire. Qualitative interviews followed by a card sort task were used to assess barriers and facilitators of uptake for caregivers and their child with cancer.

RESULTS

A number of predisposing (e.g., child age, beliefs) and needs factors (e.g., potential to treatment-related side-effects) provide insight into caregivers' decisions to use CIM for their child. Analyses also revealed the importance of enabling factors (e.g., resources) for caregiver use. Caregivers also reported benefiting from additional information about risk/benefit analysis of these therapies, and current research for CIM use in caregivers and children being treated for cancer.

CONCLUSION

Children may benefit from individually tailored complementary and integrative medicine consultations that explore patient history and specific needs factors to improve preference concordant care and uptake. Caregivers may benefit from support that improves enabling factors associated with care (e.g., improved accessibility).

Psychological/behavioral interventions for emerging adults with chronic pain

Background

Emerging adults, of whom significant numbers report chronic pain, are characterized as having unique needs and challenges. Psychological/behavioral treatments found to be beneficial for reducing pain outcomes in children and adults are understudied in emerging adults. Following a systematic review of the literature, our objective is to report on quantitative studies of psychological/behavioral interventions for chronic pain in emerging adults.

Method

We conducted a search of six databases (Cochrane Central Register of Controlled Trials, Google Scholar, ProQuest, PsycINFO, PubMed, and Web of Science) and reference sections in dissertations and systematic reviews to 4/29/2023. Keywords and phrases were search term combinations of "chronic/persistent pain", "emerging/young adults," and "intervention/treatment" using Boolean logic.

Results

Our review resulted in identifying 37 articles, of which 2 duplicates were removed, and 31 were further excluded by a screening process based on various inclusionary and exclusionary criteria. The search yielded four studies on psychological/behavioral interventions (yoga, acceptance and commitment therapy and relaxation), all of which positively affected the pain experience and/or pain-related outcomes. These studies presented issues in design such as not being blinded or randomized, having a small sample size, and potential confounds that were not reported or examined.

Discussion

The low number of studies reveals a large gap in the literature and is a call-to-action to further expand our understanding of effective and safer psychological/behavioral therapies for chronic pain in emerging adults. Successful pain management during this developmental phase may help young adults achieve positive trajectories for personal, occupational, relational, and health aspects of their lives.

Perspectives of adults with neurofibromatosis regarding the design of psychosocial trials: Results from an anonymous online survey

BACKGROUND/AIMS

Individuals with neurofibromatosis, including neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2)-related schwannomatosis (SWN), and other forms of SWN, often experience disease manifestations and mental health difficulties for which psychosocial interventions may help. An anonymous online survey of adults with neurofibromatosis assessed their physical, social, and emotional well-being and preferences about psychosocial interventions to inform clinical trial design.

METHODS

Neurofibromatosis clinical researchers and patient representatives from the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration developed the survey. Eligibility criteria included age ≥ 18 years, self-reported diagnosis of NF1, NF2, or SWN, and ability to read and understand English. The online survey was distributed internationally by the Neurofibromatosis Registry and other neurofibromatosis foundations from June to August 2020.

RESULTS

Surveys were completed by 630 adults (18-81 years of age; M = 45.5) with NF1 (78%), NF2 (14%), and SWN (8%) who were mostly White, not Hispanic/Latino, female, and from the United States. The majority (91%) reported that their neurofibromatosis symptoms had at least some impact on daily life. In the total sample, 51% endorsed a mental health diagnosis, and 27% without a diagnosis believed they had an undiagnosed mental health condition. Participants indicated that neurofibromatosis affected their emotional (44%), physical (38%), and social (35%) functioning to a high degree. Few reported ever having participated in a drug (6%) or psychosocial (7%) clinical trial, yet 68% reported they "probably" or "definitely" would want to participate in a psychosocial trial if it targeted a relevant concern. Top treatment targets were anxiety, healthier lifestyle, and daily stress. Top barriers to participating in psychosocial trials were distance to clinic, costs, and time commitment. Respondents preferred interventions delivered by clinicians via individual sessions or a combination of group and individual sessions, with limited in-person and mostly remote participation. There were no significant group differences by neurofibromatosis type in willingness to participate in psychosocial trials (p = 0.27). Regarding interest in intervention targets, adults with SWN were more likely to prefer psychosocial trials for pain support compared to those with NF1 (p < 0.001) and NF2 (p < 0.001).

CONCLUSION

This study conducted the largest survey assessing physical symptoms, mental health needs, and preferences for psychosocial trials in adults with neurofibromatosis. Results indicate a high prevalence of disease manifestations, psychosocial difficulties, and untreated mental health problems in adults with neurofibromatosis and a high degree of willingness to participate in psychosocial clinical trials. Patient preferences should be considered when designing and implementing psychosocial interventions to develop the most feasible and meaningful studies.

Lived experiences of neurofibromatosis type 1 patients: Social life, stigma, and intervention strategies

Neurofibromatosis type 1 (NF1) is a neurogenetic disorder associated with visual-spatial problems, executive dysfunction, and language deficits, making patients experience social isolation, stigma, anxiety, and depression. Here, we explored NF1 patients' lived experiences by conducting semi-structured, in-depth interviews with 21 NF1 patients and 16 care providers. The thematic analysis uncovered dimensions of NF1 patients' social lives at different ecological levels, including their relationships with family, friends, teachers, coworkers, providers, and society. Positive dimensions of NF1 patients' social life (e.g. familial support and sacrifice, responsibility, and self-sufficiency, supportive friends, and professors) counter negative dimensions (e.g. the vulnerability in sexual relationships, social interactions, discriminatory professors, misconceptions about abilities, appearance bias, internalized and social stigma, violence, and low self-esteem). Adaptive strategies used or suggested by NF1 patients at personal (e.g. supportive network, positive reframing, acceptance of their bodies) and social levels (e.g. psychological support, group therapy, public awareness, and governmental support) were identified.

Neurofibromatosis type 1 system-based manifestations and treatments: a review

INTRODUCTION

Neurofibromatosis type 1 (NF1) is a genetic disorder caused by a mutation in the NF1 gene. This disease presents with various system-based manifestations, including cardiac, musculoskeletal, and neuronal issues, which have been well-studied in previous research and have prompted the development of current and emerging treatments. These treatments, mainly medications targeting specific manifestations of NF1, aim to mitigate the negative impacts of the disease on patients' lives. NF1 is associated with an increased risk of malignancy and a significant decrease in life expectancy. In this paper, we review the current and emerging treatments for NF1 in relation to its system-based manifestations.

METHODS

We conducted an extensive literature search using specific keywords through databases such as PubMed, Scopus, and Cochrane. The articles we found were compiled and subjected to strict inclusion and exclusion criteria.

RESULTS

Pharmacological advances have led to the development of products that hold promise as future treatments for NF1. Given the diverse manifestations that can affect multiple organ systems in patients with NF1, it is important to consider a variety of treatment options to achieve optimal results. However, one of the major challenges in diagnosing and treating NF1 is that patients present asymptomatically, making it necessary to rely on clinical features for diagnosis.

CONCLUSION

In conclusion, NF1 is a complex disease with varying manifestations and a growing field of pharmacologic treatments. The information presented in this article synthesizes current knowledge and available therapies for NF1.

Demographic and Disease-Related Predictors of Socioemotional Development in Children with Neurofibromatosis Type 1 and Plexiform Neurofibromas: An Exploratory Study

Individuals with neurofibromatosis type 1 (NF1) and plexiform neurofibromas (PNs) have a higher risk for socioemotional problems. The current study aims to identify the socioemotional developmental pattern and its predictors across childhood and adolescence in individuals with NF1 and PNs. Participants included 88 children with NF1 and PNs (aged 6-18 years old, M = 12.05, SD = 3.62, 57% male) in a natural history study. Neuropsychological assessments were administered three times over six years. There are large variabilities in socioemotional development in the study participants. Developmental patterns varied across socioemotional domains, respondent type (parent-report [PR] vs. child-report [CR]), demographic factors, and NF1 disease-related factors. For instance, lower parental education was associated with a greater decline in internalizing problems (PR) but a greater increase in school disconnectedness (CR) over time. Non-White (vs. White) children were more likely to experience increased adaptive skills (PR) but decreased personal adjustment (CR). Children with more visible tumors experienced a greater decrease in school disconnectedness (CR). Children with more NF1 complications experienced a greater decrease in externalizing problems (PR). These findings indicate the necessity of using multi-informants and investigating subdomains of socioemotional functions. They also highlight the importance of developing individualized approaches to patient care and interventions.

Perspectives on adapting a mobile application for pain self-management in neurofibromatosis type 1: results of online focus group discussions with individuals living with neurofibromatosis type 1 and pain management experts

OBJECTIVE

Neurofibromatosis type 1 (NF1) is a genetic disorder in which chronic pain commonly occurs. The study sought to understand the needs of individuals with NF1 and pain management experts when adapting a pain self-management mobile health application (app) for individuals with NF1.

DESIGN

We conducted a series of online, audio-recorded focus groups that were then thematically analysed.

SETTING

Online focus groups with adults currently residing in the USA.

PARTICIPANTS

Two types of participants were included: individuals with NF1 (n=32 across six focus groups) and pain management experts (n=10 across three focus groups).

RESULTS

Six themes across two levels were identified. The individual level included lifestyle, reasons for using the mobile app and concerns regarding its use. The app level included desired content, desired features and format considerations. Findings included recommendations to grant free access to the app and include a community support feature for individuals to relate and validate one another's experience with pain from NF1. In addition, participants noted the importance of providing clear instructions on navigating the app, the use of an upbeat, hopeful tone and appropriate visuals.

CONCLUSIONS

Both participant groups endorsed the use of iCanCope (iCC) as an NF1 pain self-management mobile app. Differences between groups were noted, however. The NF1 group appeared interested in detailed and nuanced pain tracking capabilities; the expert group prioritised tracking information such as mood, nutrition and activity to identify potential associations with pain. In tailoring the existing iCC app for individuals with NF1, attention should be paid to creating a community support group feature and to tailoring content, features and format to potential users' specific needs.

Cutting the cord? Parenting emerging adults with chronic pain

The role of parent factors, such as distress and protective behaviors, on pain and functional outcomes of emerging adults living with chronic pain has been largely unexplored. The effects of helicopter parenting and developmental changes occurring during this transition period between adolescence and adulthood (commonly defined as the ages between 18 and 30 years) may exacerbate the pain experience and have the potential to influence chronic pain management. Clinical practice, with an additional focus on supporting the parent(s), may aid in meeting the needs of this population. In this paper, we review the available literature on (a) the socio-cultural shift in parenting over the past decade with a focus on helicopter parenting; (b) the impact of this parenting style on the pain experience and outcomes of emerging adults living with chronic pain; (c) provide recommendations for chronic pain management with a focus on the parent-emerging adult dyad; and (d) conclude with future research recommendations. This narrative review is the first to consider the impacts and outcomes of helicopter parenting on emerging adults with chronic pain.

Innovation in the treatment of persistent pain in adults with Neurofibromatosis Type 1 (NF1): Implementation of the iCanCope mobile application

Neurofibromatosis Type 1 (NF1) is a genetic disorder presenting with chronic pain symptoms that has limited treatment options for addressing the pain. The utilization of a mobile application allows for greater reach and scalability when using empirically valid psychosocial self-management treatments for pain. The iCanCope mobile application has been utilized in several different populations dealing with pain symptoms and has demonstrated initial effectiveness. To address the need for this population, we have customized the iCanCope mobile application for the NF1 population and included additional tailored features. We describe the rationale and design of a pilot randomized control study with a sample of 108 adults with NF1, in which two groups will receive access to the mobile application, of which one group will be incentivized to engage in the mobile application and the third group will treatment as usual over the course of 8-week period with a six-week follow-up. Outcomes will focus on the acceptability of the iCanCope-NF mobile application within the NF1 population and the impact of pain related activity on psychometric evaluations to determine if the contingency management will impact the engagement of mobile application, as well as to identify the participants' experiences in relationship to their treatment satisfaction and perceived support.

Measuring the Effect of Cutaneous Neurofibromas on Quality of Life in Neurofibromatosis Type 1

OBJECTIVE

In order to explore the use of Skindex scoring in patients with neurofibromatosis type 1 (NF1) across multiple clinical sites and inform design of additional quality of life measures, we analyzed correlations between Skindex, site, and clinical measures for 79 patients with NF1 from specialized clinics in Sydney, Australia (Royal North Shore Hospital [RNS]) and Minneapolis, Minnesota (University of Minnesota [UMN]).

METHODS

The relationship between clinical factors and Skindex scores were explored by clinic site and overall.

RESULTS

A total of 40 participants were recruited from RNS and 39 from UMN. Female sex, total number of cutaneous neurofibroma (cNF), and whether cNF were present on the face correlated highly with Skindex and not Riccardi scores. The UMN site had lower average scores, but these differences were almost entirely removed after adjusting for age, sex, facial cNF, and total cNF number.

CONCLUSIONS

The development of cNF in adolescence and adulthood in NF1 often leads to progressive disfigurement and discomfort and is among one of the most common reasons for patients to seek medical treatment. Skindex has been used to assess skin-related quality of life in NF1 previously but is not specific to NF1. These findings highlight the need for a low threshold for referral to dermatologists for all patients with NF1 regardless of the severity of disease. The finding that facial cNF and higher total number of cNF correlates with poorer skin-related quality of life may benefit design of more specific NF1 skin-related quality of life measures.

Neuropsychiatric Symptoms in Pediatric Chronic Pain and Outcome of Acceptance and Commitment Therapy

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy (ACT) treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children and adolescents aged 8–18 years (N = 47) were recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities (i.e., pain interference, sleep, and physical and school functioning), socioemotional functioning (i.e., depressive symptoms, emotional, and social functioning), psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key.

A systematic review of the use of acceptance and commitment therapy in supporting parents

OBJECTIVES

Acceptance and commitment therapy (ACT) has accrued a growing evidence-base for a wide variety of psychological difficulties. Given that ACT promotes broad and flexible repertoires of behaviour as well as neutralizing the ubiquitous psychological processes theorized to be responsible for much human suffering, such an approach may hold promise. The use of ACT-informed parenting interventions offers another alternative to solely behavioural approaches but it remains relatively understudied and in need of further exploration.

DESIGN

The current systematic review, which searched four databases, aimed to collate all ACT interventions that included parental therapeutic components in the treatment of various child presenting difficulties. The review also rated the methodological rigour of the ACT evidence-base for this type of treatment format.

RESULTS

Twenty-seven individual studies covering a broad spectrum of presenting problems were included, comprising of 1,155 participants. A large proportion of studies were within-group designs with a smaller number using randomized controlled trials. The majority of studies reported improvements on either parent report symptoms regarding child physical or psychological functioning as well as parent-reported measures of stress, depression, and anxiety. Similar improvements were noted on a number of ACT mechanisms of change outcomes, including mindfulness, acceptance, and cognitive fusing. These gains were evident for parents of children with neurodevelopmental disorders, chronic pain, and significant physical health difficulties. Maintenance or further treatment gains were often reported at follow-up. These positive findings are tempered by low levels of methodological rigour common in some of the studies included.

CONCLUSIONS

Despite these limitations, ACT holds promise as a transdiagnostic intervention that can help with the parenting of children with a range of psychological and physical difficulties.

PRACTITIONER POINTS

ACT has accrued a relatively strong evidence base for a range of psychological difficulties. Despite some methodological shortcomings, ACT shows promise as an intervention to help parents manage stress and difficulties especially in relation to children with autism, chronic pain, and physical health needs. Further research is required in comparing ACT to more established treatments and helping consolidate initial positive findings.

Acceptance and Commitment Therapy: A Systematic Literature Review of Prevention and Intervention Programs for Mental Health Difficulties in Children and Young People

BACKGROUND

Acceptance and commitment therapy (ACT) is increasingly being used to treat mental health difficulties, however there is a paucity of reviews concerning ACT with children.

AIM

To examine the literature about ACT interventions for child and adolescent mental well-being.

METHODS

Searches for articles reporting on ACT interventions to prevent/reduce child mental health difficulties were undertaken. Methodological quality was assessed and a narrative synthesis was used to summarize findings about mental health symptoms and psychological flexibility.

RESULTS

Ten articles were identified focusing on prevention and intervention for anxiety, depression, obsessive compulsive disorder, anorexia nervosa, and trichotillomania. Most studies found that mental health symptoms reduced following an ACT intervention and psychological flexibility increased. However, findings indicate that other active interventions also led to the same changes.

CONCLUSIONS

ACT is a promising intervention for adolescent mental health, although further research is needed to establish whether reductions in mental health symptoms are due to an increase in psychological flexibility.

Impact of mind-body treatment interventions on quality of life in neurofibromatosis patients: A systematic review and meta-analysis

Individuals with neurofibromatosis (NF) experience poorer quality of life (QoL), in part contributed by the clinical manifestations of NF, such as functional disability, chronic pain, and altered physical appearance. Mind-body therapies (MBTs) tailored to NF have been developed, and have demonstrated promising potential to improve QoL in this population. We sought to systematically review current evidence on the effectiveness of MBTs in addressing QoL deficits in NF patients. Databases were reviewed between the date of inception and June 2020, using search terms: neurofibromatosis, schwannomatosis, psychotherapy, mind-body, mindfulness, meditation, resiliency, and behavioral therapy. Quality appraisal was assessed using the Cochrane Risk of Bias Tools and National Institutes of Health Study Quality Assessment Tools. We conducted a meta-analysis of mean differences and reported aggregate effect estimates with 95% confidence intervals. A total of 10 articles, including randomized-controlled trials and pre-post studies, were identified. Meta-analytic results of randomized-controlled trial data from six citations demonstrated MBTs were associated with improved physical (MD = 13.63, 95%CI 6.95-20.30, P < .0001, I² = 24%), psychological (MD = 14.11, 95%CI 6.44-21.78, P = .0003, I² = 38%), social (MD = 9.63, 95%CI 2.93-16.33, P = .005, I² = 0%), and environmental QoL (MD = 14.14, 95%CI 8.28-20.00, P < .00001. I² = 0%) in NF patients. These associations were maintained at 6-months follow-up for physical, psychological, and environmental QoL (P < .05). Our findings suggest that NF-adapted MBT strategies are associated with improving QoL in diverse NF populations, including NF2 patients experiencing deafness and youth NF patients. Providers and caregivers for NF should be aware of the potential benefits of MBT in chronic NF management.

Mindfulness and Acceptance Interventions for Parents of Children and Adolescents Diagnosed with Chronic Medical Conditions: A Systematic Review

Background: Mindfulness and acceptance interventions (MAIs) have been identified as potentially beneficial for parents of children and adolescents diagnosed with chronic medical conditions. Objective: The objective of this review was to provide a descriptive summary of the existing literature on MAIs delivered to parents of children and adolescents diagnosed with chronic medical conditions. Data sources: Electronic searches were conducted by a Library Information Specialist familiar with the field by using EMBASE, MEDLINE, PsycINFO, EBM Reviews Databases, and Cochrane Database of Systematic Reviews. Study eligibility, participants, and interventions: Peer-reviewed journal articles of MAIs delivered to parents of children and adolescents (birth to 18 years of age) diagnosed with a chronic medical condition were eligible for inclusion. Study appraisal and synthesis methods: A total of 18 studies involving 793 parents met inclusion criteria and thus were included in this review. The majority of studies were either pre/post design (n = 8) or randomized controlled trials (n = 6). Most interventions were delivered within a group (n = 6) or individually (n = 5). Nearly all studies (n = 14) reported statistically significant outcomes following the MAI intervention. Conclusions and implications of key findings: Descriptive information yielded from this review provides promising evidence that MAIs are being delivered to parents across the world and many researchers are using similar outcome measures when assessing the psychological flexibility, acceptance, and mindfulness skills following participation in MAIs among this population of parents.

Psychotherapeutic Considerations for Patients With Terminal Illness

Dignity has gained increasing attention as a vital component of quality of life and quality of end-of-life care. This article reviews psychological, spiritual, existential, and physical issues facing patients at the end of life as well as practical considerations in providing therapy for this population. The authors reviewed several evidence-based treatments for enhancing end-of-life experience and mitigating suffering, including a primary focus on dignity therapy and an additional review of meaning-centered psychotherapy, acceptance and commitment therapy, and cognitive-behavioral therapy. Each of these therapies has an emerging evidence base, but they have not been compared to each other in trials. Thus, the choice of psychotherapy for patients at the end of life will reflect patient characteristics, therapist orientation and expertise with various approaches, and feasibility within the care context. Future research is needed to directly compare the efficacy and feasibility of these interventions to determine optimal care delivery.

Perceived fatigue in children and young adults with neurofibromatosis type 1

AIM

This study describes the prevalence and severity of perceived fatigue in a young neurofibromatosis type 1 (NF1) population.

METHODS

Ethical approval was obtained and NF1 affected Individuals aged 2-18 years from the Manchester's NF1 clinic invited along with any unaffected siblings. The PedsQL Multidimensional Fatigue Scale Parental and child report was used. This validated measure explores cognitive, physical and sleep/rest domains on a 0-100 scale. Higher scores indicate less fatigue. Fatigue scores in affected children were compared to unaffected siblings after adjusting for age, sex and Index of Multiple Deprivation and with published population standards using z-scores.

RESULTS

A total of 286 families were invited and 75 affected and 16 siblings participated. There were significant differences between NF1 and controls in the aggregated fatigue core (child report 55 ± 19 vs. 75 (14), P < 0.001; parent 54 ± 20 vs. 73 ± 18, P = 0.001) and the three sub-domains: cognitive (child 48 ± 27 vs. 75 ± 23, P < 0.001), physical (child 59 ± 19 vs. 82 ± 14, P < 0.001) and sleep/rest (child 59 ± 19 vs. 71 ± 15, P = 0.018). Similar differences were seen when compared with published controls (aggregated child z-score -1.9 ± 1.4, P < 0.001; parent -3.2 ± 1.8, P < 0.001). Prevalence of severe fatigue indicated by scores <2 standard deviation below published means for healthy controls were also higher for children with NF on both parent and child reports. Agreement between child and parent reports were limited as is frequently seen in the literature.

CONCLUSION

This study suggests that children with NF1 are affected by perceived fatigue when compared with healthy children who do not have NF1.

Resilience Factors in Children with Juvenile Idiopathic Arthritis and Their Parents: The Role of Child and Parent Psychological Flexibility

OBJECTIVE

Chronic pain is central to juvenile idiopathic arthritis (JIA) and is predictive of impaired functioning. Whereas most work has focused on identifying psychosocial risk factors for maladaptive outcomes, we explored the idea that child and parental psychological flexibility (PF) represent resilience factors for adaptive functioning of the child. We also explored differences between general vs pain-specific PF in contributing to child outcomes.

METHODS

Children with JIA (age eight to 18 years) and (one of) their parents were recruited at the Department of Pediatric Rheumatology at the Ghent University Hospital in Belgium. They completed questionnaires assessing child and parent general and pain-specific PF and child psychosocial and emotional functioning and disability.

RESULTS

The final sample consisted of 59 children and 48 parents. Multiple regression analyses revealed that child PF contributed to better psychosocial functioning and less negative affect. Child pain acceptance contributed to better psychosocial functioning, lower levels of disability, and lower negative affect, and also buffered the negative influence of pain intensity on disability. Bootstrap mediation analyses demonstrated that parental (general) PF indirectly contributed to child psychosocial functioning and affect via the child's (general) PF. Parent pain-specific PF was indirectly linked to child psychosocial functioning, disability, and negative affect via child pain acceptance.

CONCLUSIONS

Our findings indicate that child and parental PF are resilience factors and that pain acceptance buffers the negative impact of pain intensity. Implications for psychosocial interventions that target (pain-specific) PF in children and parents are discussed.

Towards a neurobiological understanding of pain in neurofibromatosis type 1: mechanisms and implications for treatment

Neurofibromatosis type 1 (NF1) is the most common of a group of rare diseases known by the term, "Neurofibromatosis," affecting 1 in 3000 to 4000 people. NF1 patients present with, among other disease complications, café au lait patches, skin fold freckling, Lisch nodules, orthopedic complications, cutaneous neurofibromas, malignant peripheral nerve sheath tumors, cognitive impairment, and chronic pain. Although NF1 patients inevitably express pain as a debilitating symptom of the disease, not much is known about its manifestation in the NF1 disease, with most current information coming from sporadic case reports. Although these reports indicate the existence of pain, the molecular signaling underlying this symptom remains underexplored, and thus, we include a synopsis of the literature surrounding NF1 pain studies in 3 animal models: mouse, rat, and miniswine. We also highlight unexplored areas of NF1 pain research. As therapy for NF1 pain remains in various clinical and preclinical stages, we present current treatments available for patients and highlight the importance of future therapeutic development. Equally important, NF1 pain is accompanied by psychological complications in comorbidities with sleep, gastrointestinal complications, and overall quality of life, lending to the importance of investigation into this understudied phenomenon of NF1. In this review, we dissect the presence of pain in NF1 in terms of psychological implication, anatomical presence, and discuss mechanisms underlying the onset and potentiation of NF1 pain to evaluate current therapies and propose implications for treatment of this severely understudied, but prevalent symptom of this rare disease.

Clinical report: one year of treatment of Proteus syndrome with miransertib (ARQ 092)

A 20-yr-old man with Proteus syndrome (PS) and somatic mosaicism of the AKT1 c.49G > A p.(E17K) variant had asymmetric overgrowth of the right frontal and facial bones, asymmetric spinal overgrowth with thoracolumbar scoliosis, dilatation of the inferior vena cava, testicular cystadenoma, bilateral knee deformities, macrodactyly, and apparent intellectual disability. Miransertib (ARQ 092) is an oral, allosteric, selective pan-AKT inhibitor initially developed for cancer therapeutics, now being evaluated for the treatment of PS. After baseline evaluation, the patient started unblinded treatment of 10 mg oral miransertib daily (∼5 mg/m²/day), escalated to 30 mg daily (∼15 mg/m²/day), and then to 50 mg daily (∼25 mg/m²/day) after 3 mo of treatment. Adverse events included dry mouth, one episode of gingivostomatitis, and loose, painful dentition due to preexisting periodontal disease, all of which resolved spontaneously. After 11 mo of treatment, the patient reported improved general well-being, increased mobility of the ankle, spine, and hands, a subjective decrease in size of the right facial bone overgrowth, and reduced areas of cerebriform connective tissue nevi on the soles. Whole-body MRI findings were stable without apparent disease progression. We conclude that 1 yr of treatment with miransertib was beneficial in this case.

Pain symptomology, functional impact, and treatment of people with Neurofibromatosis type 1

Introduction

Neurofibromatosis type 1 (NF1) is a neurogenetic disorder affecting 1 in 3000 people worldwide, where individuals are prone to develop benign and malignant tumors. In addition, many people with NF1 complain of pain that limits their daily functioning. Due to the complexity of the disorder, there are few options for treating pain symptoms besides surgery and medications. Moreover, the spectrum of pain symptomatology and treatment, as well as the mechanisms underlying NF1-associated pain, has been understudied.

Methodology

To address this knowledge gap, we conducted a survey of 255 adults with NF1, leveraging the Washington University NF1 Patient Registry Initiative (NPRI) database. Demographic and pain data were collected using a Qualtrics survey.

Results

All participants had at least one surgical procedure, with 55% reporting having at least one surgery within the last year and 17% being currently prescribed opioid medication. A positive relationship was shown (p<0.001) between those prescribed prescription pain medication, and their pain severity and interference. Moreover, there was a significant relationship (p=0.049) between the usage of complementary treatments and pain severity and interference.

Conclusion

The current study demonstrates that individuals with NF1 report a higher incidence of pain severity and interference than observed in NF1 previous studies, with pain symptoms not localized to any specific region of the body. The consideration for alternative treatments and careful monitoring of current treatments that are more conservative or have less potential adverse side effects may improve pain management and reduce the risk of developing medication dependence.

Challenges associated with parenting youth with neurofibromatosis: A qualitative investigation

Parents of children with the neurofibromatoses (NF; neurofibromatosis 1, neurofibromatosis 2, and schwannomatosis) are at an increased risk for emotional and physical health problems. This study aimed to determine parents' perceptions of stressors associated with parenting a child with NF in order to inform the development of a resiliency intervention. We conducted three live video semi structured focus groups with parents of youth with NF (N = 30), which were subsequently transcribed and coded using qualitative content analysis. Parents reported heightened stress associated with the child's educational, medical, and social needs, as well as concerns about their child's physical and mental health. They also reported stress associated with managing finances, multiple medical appointments, role challenges (i.e., being a parent or partner), and managing the uncertainty/unpredictability of their child's NF diagnosis. These stressors reportedly affected employment status (i.e., work scale backs), relationships (i.e., social, familial, with partner, other children), and the parents' physical and mental health. All participants expressed interest in a mind body program aimed at improving resiliency by teaching coping skills (e.g., mindfulness, adaptive thinking, positive psychology skills) and enhancing social support. Results show parents' enthusiasm for a resiliency intervention targeting stress associated with parenting a child with NF, and provide valuable information for the content of the intervention and its delivery modality.

Mindfulness and Acceptance as Potential Protective Factors for Mothers of Children With Fragile X Syndrome

Women with an FMR1 premutation may be at increased genetic risk for stress vulnerability. This increased vulnerability, when combined with stressful parenting that can result from raising children with fragile X syndrome (FXS), may result in negative physical and emotional outcomes. Mindfulness and acceptance have been found to be protective factors for parents of children with similar behavioral challenges, but these traits have not previously been explored among mothers with a child with FXS. This study explored the associations of child disability severity with maternal stress, anxiety, depression, and physical health symptoms in 155 biological mothers of children with FXS. Women completed an online survey using standardized measures of stress, mindfulness, and acceptance. General mindfulness, mindfulness in the parenting role, and general acceptance were explored as potential protective factors between the child disability severity and maternal outcomes. Trait mindfulness and acceptance were significant predictors of lower stress, anxiety, depression, and daily health symptoms, while mindful parenting was associated with lower stress, anxiety, and depression. Acceptance was found to attenuate the effects of child severity on maternal stress and depression. These findings suggest that interventions focused on improving mindfulness and acceptance may promote health and well-being for mothers of children with FXS and have important health implications for all individuals with an FMR1 premutation.

The Relationship Between Heart Rate Variability, Psychological Flexibility, and Pain in Neurofibromatosis Type 1

Individuals with neurofibromatosis type 1 (NF1) and plexiform neurofibromas (PNs) can experience chronic pain. Previous research has examined the relationship between heart rate variability (HRV) and persistent pain. HRV is an index of autonomic nervous system functioning, and reflects the variability in time elapsed between heartbeats. Patients with chronic pain tend to exhibit lower HRV, which has been associated with poor adaptability, or psychological flexibility, to stress. The aim of the current study was to examine relationships between HRV, psychological flexibility, and pain in a sample of adolescents and young adults (AYAs) with NF1 and PNs. AYA participants (n = 40) 16 to 34 years of age with NF1 completed baseline measures of pain and psychological functioning, and underwent a 5-minute electrocardiogram (ECG). A subset of 20 participants completed follow-up questionnaires and a second ECG 8 weeks later. Spectral analyses of ECGs yielded a measure of high-frequency heart rate variability (HF-HRV). Baseline correlations revealed that lower HF-HRV is related to greater inflexibility and more pain interference, but not pain intensity. Moreover, psychological inflexibility significantly mediated the relationship between HF-HRV and pain interference. Finally, regression models indicated that baseline psychological inflexibility is a significant predictor of HF-HRV at follow-up and, separately, that baseline HF-HRV significantly predicted pain intensity at follow-up. These findings suggest complex mind-body processes in the experience of pain in NF1, which have not been studied previously. Implications for pain-related interventions and future research are discussed.

Online cognitive-behavioral based group interventions for adolescents with chronic illness and parents: study protocol of two multicenter randomized controlled trials

BACKGROUND

Adolescents with chronic illness (CI) and parents of a child with CI are at risk for psychosocial problems. Psychosocial group interventions may prevent these problems. With the use of cognitive-behavioral therapy, active coping strategies can be learned. Offering an intervention online eliminates logistic barriers (travel time and distance) and improves accessibility for participants. Aim of this study is to examine the effectiveness of two cognitive-behavioral based online group interventions, one for adolescents and one for parents: Op Koers Online. The approach is generic, which makes it easier for patients with rare illnesses to participate.

METHODS/DESIGN

This study conducts two separate multicenter randomized controlled trials. Participants are adolescents (12 to 18 years of age) with CI and parents of children (0 to 18 years of age) with CI. Participants are randomly allocated to the intervention group or the waitlist control group. Outcomes are measured with standardized questionnaires at baseline, after 8 (adolescents) or 6 (parents) weeks of treatment, and at 6- and 12-month follow-up period. Primary outcomes are psychosocial functioning (emotional and behavioral problems) and disease-related coping skills. Secondary outcomes for adolescents are self-esteem and quality of life. Secondary outcomes for parents are impact of the illness on family functioning, parental distress, social involvement and illness cognitions. The analyses will be performed according to the intention-to-treat principle. Primary and secondary outcomes will be assessed with linear mixed model analyses using SPSS.

DISCUSSION

These randomized controlled trials evaluate the effectiveness of two online group interventions improving psychosocial functioning in adolescents with CI and parents of children with CI. If proven effective, the intervention will be optimized and implemented in clinical practice.

TRIAL REGISTRATION

ISRCTN ISRCTN83623452 . Registered 30 November 2017. Retrospectively registered.

Psychosocial Features of Neurofibromatosis Type 1 in Children and Adolescents

Neurofibromatosis type 1 (NF1) is a common neurologic condition associated with a wide variety of developmental deficits that have an important impact on children and adolescents.

OBJECTIVE

This article aims to document the psychosocial features of NF1 and to report the interventions described to address the needs of pediatric patients with NF1.

METHODS

A literature review was conducted concerning the social life, mental health, and quality of life (QOL) of children and adolescents with NF1 as well as the psychosocial interventions addressed to this population.

RESULTS

Compared to unaffected children and adolescents of the general population, pediatric patients with NF1 have an increased risk of having social difficulties, mental health disorders, behavioral and emotional problems, as well as diminished QOL. Only 3 articles describe interventions within the NF1 population to address these difficulties.

CONCLUSION

There is a need to develop and assess psychosocial interventions for patients with NF1.

Pain Assessment Methods and Interventions Used by Pediatric Psychologists: A Survey by the Pain Special Interest Group of the Society of Pediatric Psychology

Although many valid pain-related assessment instruments and interventions exist, little is known about which are actually utilized in practice and the factors that contribute to pediatric psychologist's decisions about their use. The aim of this survey study was to present a summary of current clinical practice among pediatric psychologists in the area of pediatric pain and to identify the needs and possible resources that would enable practitioners to better implement evidence-based assessments and interventions. To accomplish this aim, the Pain Special Interest Group of the Society of Pediatric Psychology (SPP) constructed an online survey that was sent electronically to current members of the SPP list serve. Results indicated the majority of participants are guided by a theoretical model and are using evidence-based assessments and interventions, although they are not always familiar with the literature supporting their use. Providers noted evidence-based pain intervention is facilitated by assessment tools, intervention resources, and appreciation of pain interventions by multidisciplinary team members. Barriers are both logistical (clinic space and time constraints) and knowledge-based (lack of familiarity with assessments/interventions). Thus, while pediatric psychologists are progressing towards better translation of research to practice, continued educational efforts and communication among practitioners about available resources are warranted.

Neuropathies in the setting of Neurofibromatosis tumor syndromes: Complexities and opportunities

The term 'Neurofibromatosis' (NF) comprises a group of rare diseases with related clinical presentations but distinct genetic conditions. All currently known types - NF1, NF2 and Schwannomatosis - predispose afflicted individuals to the development of glial cell-derived (gliogenic) tumors. Furthermore, the occurrence of neuropathic symptoms, which add to the overall neurologic disability of patients, has been described in all disease entities. We show that neuropathic symptoms are a common and clinically important, yet infrequently studied feature in the NF spectrum. However, the clinical relevance and respective underlying pathogenesis, varies greatly among the different NF types. In this review, we summarize and interpret the latest basic research findings, as well as clinical observations, in respect of Neurofibromatosis-associated neuropathies.

Patient-reported outcomes of pain and physical functioning in neurofibromatosis clinical trials

OBJECTIVE

Tumors and other disease complications of neurofibromatosis (NF) can cause pain and negatively affect physical functioning. To document the clinical benefit of treatment in NF trials targeting these manifestations, patient-reported outcomes (PROs) assessing pain and physical functioning should be included as study endpoints. Currently, there is no consensus on the selection and use of such measures in the NF population. This article presents the recommendations of the PRO group of the Response Evaluation in Neurofibromatosis and Schwannomatosis (REiNS) International Collaboration for assessing the domains of pain and physical functioning for NF clinical trials.

METHODS

The REiNS PRO group reviewed and rated existing PRO measures assessing pain intensity, pain interference, and physical functioning using their systematic method. Final recommendations are based primarily on 4 main criteria: patient characteristics, item content, psychometric properties, and feasibility for clinical trials.

RESULTS

The REiNS PRO group chose the Numeric Rating Scale-11 (≥8 years) to assess pain intensity, the Pain Interference Index (6-24 years) and the Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference Scale (≥18 years) to evaluate pain interference, and the PROMIS Physical Functioning Scale to measure upper extremity function and mobility (≥5 years) for NF clinical trials.

CONCLUSIONS

The REiNS Collaboration currently recommends these PRO measures to assess the domains of pain and physical functioning for NF clinical trials; however, further research is needed to evaluate their use in individuals with NF. A final consensus recommendation for the pain interference measure will be disseminated in a future publication based on findings from additional published research.

Neurofibromatosis type 1

Neurofibromatosis type 1 is a complex autosomal dominant disorder caused by germline mutations in the NF1 tumour suppressor gene. Nearly all individuals with neurofibromatosis type 1 develop pigmentary lesions (café-au-lait macules, skinfold freckling and Lisch nodules) and dermal neurofibromas. Some individuals develop skeletal abnormalities (scoliosis, tibial pseudarthrosis and orbital dysplasia), brain tumours (optic pathway gliomas and glioblastoma), peripheral nerve tumours (spinal neurofibromas, plexiform neurofibromas and malignant peripheral nerve sheath tumours), learning disabilities, attention deficits, and social and behavioural problems, which can negatively affect quality of life. With the identification of NF1 and the generation of accurate preclinical mouse strains that model some of these clinical features, therapies that target the underlying molecular and cellular pathophysiology for neurofibromatosis type 1 are becoming available. Although no single treatment exists, current clinical management strategies include early detection of disease phenotypes (risk assessment) and biologically targeted therapies. Similarly, new medical and behavioural interventions are emerging to improve the quality of life of patients. Although considerable progress has been made in understanding this condition, numerous challenges remain; a collaborative and interdisciplinary approach is required to manage individuals with neurofibromatosis type1 and to develop effective treatments.

Evidence-Based Psychological Interventions for the Management of Pediatric Chronic Pain: New Directions in Research and Clinical Practice

Over the past 20 years our knowledge about evidence-based psychological interventions for pediatric chronic pain has dramatically increased. Overall, the evidence in support of psychological interventions for pediatric chronic pain is strong, demonstrating positive psychological and behavioral effects for a variety of children with a range of pain conditions. However, wide scale access to effective psychologically-based pain management treatments remains a challenge for many children who suffer with pain. Increasing access to care and reducing persistent biomedical biases that inhibit attainment of psychological services are a central focus of current pain treatment interventions. Additionally, as the number of evidence-based treatments increase, tailoring treatments to a child or family’s particular needs is increasingly possible. This article will (1) discuss the theoretical frameworks as well as the specific psychological skills and strategies that currently hold promise as effective agents of change; (2) review and summarize trends in the development of well-researched outpatient interventions over the past ten years; and (3) discuss future directions for intervention research on pediatric chronic pain.

Acceptance and Commitment Therapy for Pediatric Chronic Pain: Theory and Application

Acceptance and Commitment Therapy (ACT) is a third wave behavior therapy approach which aims to increase engagement in activities that bring meaning, vitality, and value to the lives of individuals experiencing persistent pain, discomfort, or distress. This goal is particularly relevant when these aversive experiences cannot be effectively avoided or when avoidance efforts risk their exacerbation, all of which may be common experiences in children and adolescents with chronic pain conditions. The primary aim of the present paper is to review and summarize the extant literature on the application, utility, and evidence for using ACT with pediatric chronic pain populations by: (1) defining the theoretical assumptions of the ACT model; (2) summarizing research study findings and relevant measures from the published literature; and (3) critically discussing the strengths, limitations and areas in need of further development.

Psychological Neuromodulatory Treatments for Young People with Chronic Pain

The treatment of young people with chronic pain is a complex endeavor. Many of these youth do not obtain adequate relief from available interventions. Psychological neuromodulatory treatments have been shown to have potential benefit for adults with chronic pain. Here, we review and summarize the available information about the efficacy of three promising psychological neuromodulatory treatments-neurofeedback, meditation and hypnosis-when provided to young people with chronic pain. A total of 16 articles were identified and reviewed. The findings from these studies show that hypnotic treatments are effective in reducing pain intensity for a variety of pediatric chronic pain problems, although research suggests variability in outcomes as a function of the specific pain problem treated. There are too few studies evaluating the efficacy of neurofeedback or meditation training in young people with chronic pain to draw firm conclusions regarding their efficacy. However, preliminary data indicate that these treatments could potentially have positive effects on a variety of outcomes (e.g., pain intensity, frequency of pain episodes, physical and psychological function), at least in the short term. Clinical trials are needed to evaluate the effects of neurofeedback and meditation training, and research is needed to identify the moderators of treatment benefits as well as better understand the mechanisms underlying the efficacy of all three of these treatments. The findings from such research could enhance overall treatment efficacy by: (1) providing an empirical basis for better patient-treatment matching; and (2) identifying specific mechanisms that could be targeted with treatment.

A Clinical Pilot Study of Individual and Group Treatment for Adolescents with Chronic Pain and Their Parents: Effects of Acceptance and Commitment Therapy on Functioning

Pediatric chronic pain is common and can result in substantial long-term disability. Previous studies on acceptance and commitment therapy (ACT) have shown promising results in improving functioning in affected children, but more research is still urgently needed. In the current clinical pilot study, we evaluated an ACT-based interdisciplinary outpatient intervention (14 sessions), including a parent support program (four sessions). Adolescents were referred to the clinic if they experienced disabling chronic pain. They were then randomized, along with their parents, to receive group (n = 12) or individual (n = 18) treatment. Adolescent pain interference, pain reactivity, depression, functional disability, pain intensity and psychological flexibility, along with parent anxiety, depression, pain reactivity and psychological flexibility were assessed using self-reported questionnaires. There were no significant differences in outcomes between individual and group treatment. Analyses illustrated significant (p < 0.01) improvements (medium to large effects) in pain interference, depression, pain reactivity and psychological flexibility post-treatment. Additionally, analyses showed significant (p < 0.01) improvements (large effects) in parent pain reactivity and psychological flexibility post-treatment. On all significant outcomes, clinically-significant changes were observed for 21%–63% of the adolescents across the different outcome measures and in 54%–76% of the parents. These results support previous findings and thus warrant the need for larger, randomized clinical trials evaluating the relative utility of individual and group treatment and the effects of parental interventions.