Parents' Empathic Responses and Pain and Distress in Pediatric Patients

Life engagement and anxiety-depressive symptoms in adolescents and young adults with or without a cancer history and their mothers: A dyadic analytic approach

OBJECTIVE

The aim of the present study was to examine the dyadic relationships between symptoms of anxiety and depression and life engagement in mother-adolescent and young adult (AYA) dyads with and without a history of cancer.

METHODS

One hundred mother-AYA dyads and 50 mother-AYA cancer survivor dyads self-reported anxiety and depressive symptoms and life engagement. Multilevel modelling analyses were used to test actor-partner interdependence models.

RESULTS

Significant actor effects of depressive symptoms on life engagement were found for AYAs and their mothers in both groups. But this effect was significantly attenuated downward in AYAs with a history of cancer. In addition, only AYAs' depressive symptoms exerted a significant effect on mothers' life engagement, indicating the presence of significant partner effects for mothers.

CONCLUSION

AYAs' and mothers' depressive symptoms are related to life engagement. Mothers' perception of depressive symptoms relates not only to their own perception of life engagement but also to that of their AYAs. These findings show the complex relationships that exist between AYAs and their mothers and point to the mechanisms through which AYAs-related variables affect mother outcomes, in the two groups of AYAs.

Parents' Empathic Accuracy: Associations With Type 1 Diabetes Management and Familism

OBJECTIVE

To (1) test associations between parents' empathic accuracy for their adolescents' positive and negative emotions and adolescents' physical and mental health (HbA1c, diabetes self-care, and depressive symptoms) in a predominantly Latinx sample of adolescents with type 1 diabetes and their parents, and (2) explore how familism values were associated with parent empathic accuracy and adolescent physical and mental health in this population.

METHODS

Parents and adolescents engaged in a discussion about a topic of frequent conflict related to the adolescents' diabetes management. Parents and adolescents subsequently completed a video recall task in which they rated their own and their partner's emotions once per minute; parents' empathic accuracy was calculated from an average discrepancy between parent and adolescent ratings of the adolescent's emotions. Adolescents reported on their depressive symptoms and both parents and adolescents reported on adolescents' diabetes self-care and their own familism values; HbA1c was obtained from medical records.

RESULTS

Results from structural equation modeling revealed that parents' empathic accuracy for adolescents' negative (but not positive) emotions was uniquely associated with adolescents' HbA1c, self-care, and depressive symptoms. There was limited evidence that familism was related to parent empathic accuracy or adolescent physical and mental health.

CONCLUSIONS

Promoting parents' empathic accuracy for adolescents' negative emotions in the context of type 1 diabetes management may have important implications for adolescents' mental and physical health.

Understanding differences in the long-term psychosocial adjustment of pediatric cancer patients and their parents: an individual differences resources model

The experience of childhood cancer is a major life stressor for children and their parents. There is substantial variability among pediatric cancer patients and their parents in their ability to cope with the cancer. Although other models typically focus on the psychological resources families use to broadly cope with a diagnosis of pediatric cancer, we present a model that focuses specifically how parents and children cope with the stress of invasive and often painful treatment episodes. Our resources model is further distinct with its focus on individual differences in personal (e.g., personality traits) and social (e.g., social support) resources and the role these differences may play in psychosocial adjustment of families confronting pediatric cancer. We use findings from the broader pediatric cancer research literature and our own 15-year program of research on individual differences in psychological resources and parents and children's responses to treatment episodes to provide empirical support for our model. Support was found for the six premises of the model: (a) parent resources influence their longer-term psychosocial adjustment, (b) parent resources influence children's responses to treatment episodes, (c) parent resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes, (d) children's personal resources influence how parent responses to treatment episodes, (e) children's resources influence their longer-term psychosocial adjustment, and (f) children's resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes. Understanding how the availability of resources influences parents and children confronting cancer provides a foundation for future research on individual differences in resources and offers other avenues through which clinicians can assess and treat families at risk for poor psychosocial adjustment during treatment and in their life beyond cancer treatments.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Family Functioning and Depressive Symptoms in Adolescent and Young Adult Cancer Survivors and Their Families: A Dyadic Analytic Approach

Background

To examine dyadic relationships between depressive symptoms and family functioning in families of pediatric cancer survivors. Methods Sixty-four adolescent and young adult (AYA) cancer survivors and their caregivers self-reported on depressive symptoms and family functioning. Multilevel modeling analyses were used to test actor–partner interdependence models.

Results

Significant actor effects of depressive symptoms on domains of family functioning were found for AYAs and their caregivers. Only caregivers’ depressive symptoms exerted a significant effect on AYAs’ report of family cohesion, indicating the presence of significant partner effects for AYAs.

Conclusions

AYAs’ and caregivers’ depressive symptoms are related to poorer family functioning. Caregivers’ perceptions of depressive symptoms relate not only to their own perceptions of family functioning but also to that of their children. These findings begin to map the complex relationships that exist between AYAs and their caregivers and elucidate some of the mechanisms through which caregiver-related variables affect AYA outcomes.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Parenting behaviors and the well-being of children with a chronic physical condition

INTRODUCTION

Numerous studies have identified the importance of parenting behaviors to the well-being of children with chronic physical conditions. Synthesizing the findings of these studies has potential to identify which parenting behaviors are associated with specific aspects of child well-being.

METHOD

We retrieved research reports addressing the relationship between parenting behaviors and well-being in children with chronic physical conditions, and categorized parenting behaviors based on Skinner, Johnson, and Snyder's (2005) core dimensions of parenting (warmth, rejection, structure, chaos, autonomy support, and coercion) Through meta-analysis, we examined relationships between parenting dimension and child well-being variables.

RESULTS

Fifty-four reports from 47 unique studies met inclusion criteria. Parent warmth was associated with less child depression, better quality of life, better physical functioning, and fewer externalizing behavior problems. Parent rejection was associated with more child depression, internalizing/externalizing behavior problems, and poorer physical functioning. Parent structure was associated with better child physical functioning. Parent chaos was associated with poorer child physical functioning. Parent autonomy support was associated with better quality of life and fewer externalizing behavior problems. Parent coercion was associated with more child depression, poorer quality of life, poorer physical function, and more internalizing behavior problems.

CONCLUSION

The results identify multiple, potentially modifiable parenting dimensions associated with well-being in children with a chronic condition, which could be targeted in developing family-focused interventions. They also provide evidence that research using Skinner's core dimensions could lead to conceptualization and study of parenting behaviors in ways that would enable comparison of parenting in a variety of health and sociocultural contexts. (PsycINFO Database Record

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

PURPOSE/OBJECTIVES

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

Longitudinal, observational design.
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SETTING

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

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

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

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

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

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

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

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

RATIONALE

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal Anxiety and Children's Laboratory Pain: The Mediating Role of Solicitousness

There has been limited empirical examination of how parent variables such as anxiety and solicitousness collectively impact child pain response. We sought to examine the relationships among maternal anxiety, solicitous parenting, and children’s laboratory anxiety and pain intensity in children with chronic pain. Participants included 80 children and adolescents (ages 8–18) with chronic pain and their mothers. Children completed questionnaires and lab pain tasks measuring their parents’ solicitous parenting, pressure, cold and heat pain anticipatory anxiety and pain intensity. Using bootstrapping analysis, maternal anxiety predicted child anticipatory anxiety and pain intensity in girls with chronic pain, which was mediated by the child’s report of parental solicitousness. For boys with chronic pain, maternal anxiety predicted boys’ anticipatory anxiety and pain intensity, with no support for mediation. This study adds to the growing literature demonstrating the impact of maternal anxiety on children’s pain. The study highlights the importance of considering parents in treatment designed to reduce children’s pain.

Circles of engagement: Childhood pain and parent brain

Social interaction can have a profound effect on individual behavior, perhaps most salient in interactions between sick suffering children and their parents. Chronic pain is a difficult condition that can produce considerable changes in children's behaviors that can secondarily have profound effects on their parents. It may create a functionally disabling negative feedback loop. Research supports the notion of alterations in the brain of individuals who observe and empathize with loved ones in acute pain. However, neural activity in relation to empathic responses in the context of chronic pain has not been examined. Ongoing suffering with chronic pain in a child can result in child's brain circuit alterations. Moreover, prolonged suffering jointly experienced by the parent may putatively produce maladaptive changes in their neural networks and consequently in parental behaviors. Here we put forth the conceptual framework for 'Chronic pain contagion' (CPC). We review the underlying processes in CPC and discuss implications for devising and implementing treatments for children in chronic pain and their parents.

Pediatric Cancer Patients' Treatment-Related Distress and Longer-Term Anxiety: An Individual Differences Perspective

OBJECTIVE

Although distress during treatment procedures and longer-term treatment-related anxiety are among the most common cancer-related stressors for children and their families, they are not invariant. This study examined whether individual differences in temperament and personality play a role in how children respond to treatment procedures. Attention control, a facet of the effortful control dimension of temperament, and the personality attribute ego-resilience were hypothesized to predict lower levels of distress during procedures. Moreover, ego-resilience and distress during procedures were hypothesized to account for indirect associations between attention control and longer-term treatment-related anxiety. Child gender was examined as a potential moderator of these relationships.

METHOD

Participants were 147 children undergoing treatment for pediatric cancer and their parents. At baseline, parents reported on children's effortful control and ego-resilience. Multiple raters assessed children's distress during multiple cancer-related procedures. Treatment-related anxiety was measured 3 and 9 months after the last assessed treatment procedure.

RESULTS

Attention control was linked to ego-resilience and lower levels of distress, and these variables, in turn, accounted for indirect associations between attention control and treatment-related anxiety. Associations involving ego-resilience were stronger for boys than girls.

CONCLUSION

Attention control plays an important role in children's immediate and longer-term responses to cancer-related medical procedures. Medical staff should consider individual differences in child temperament and personality when considering the nature and extent of support to provide to pediatric cancer patients and their families.

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

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

Parent caregiver self-efficacy and child reactions to pediatric cancer treatment procedures

This study examined how parents' sense of self-efficacy specific to caregiving for their child during cancer treatment procedures affected children's distress and cooperation during procedures. Potential correlates of caregiver self-efficacy (ie, demographics, child clinical characteristics, parent dispositional attributes, and social support) were also examined. Participants were 119 children undergoing cancer treatment procedures and their parents. Parents' self-efficacy about 6 procedure-specific caregiver tasks was measured. Parents, children, nurses, and observers rated child distress and parents, nurses and observers rated child cooperation during procedures. Higher parent self-efficacy about keeping children calm during procedures predicted lower child distress and higher child cooperation during procedures. Parent dispositional attributes (eg, enduring positive mood, empathy) and social support predicted self-efficacy. Parent caregiver self-efficacy influences child distress and cooperation during procedures and is associated with certain parent attributes. Findings suggest the utility of identifying parents who would benefit from targeted interventions to increase self-efficacy about caregiving during treatment procedures.

The social modulation of pain: others as predictive signals of salience - a systematic review

Several studies in cognitive neuroscience have investigated the cognitive and affective modulation of pain. By contrast, fewer studies have focused on the social modulation of pain, despite a plethora of relevant clinical findings. Here we present the first review of experimental studies addressing how interpersonal factors, such as the presence, behavior, and spatial proximity of an observer, modulate pain. Based on a systematic literature search, we identified 26 studies on experimentally induced pain that manipulated different interpersonal variables and measured behavioral, physiological, and neural pain-related responses. We observed that the modulation of pain by interpersonal factors depended on (1) the degree to which the social partners were active or were perceived by the participants to possess possibility for action; (2) the degree to which participants could perceive the specific intentions of the social partners; (3) the type of pre-existing relationship between the social partner and the person in pain, and lastly, (4) individual differences in relating to others and coping styles. Based on these findings, we propose that the modulation of pain by social factors can be fruitfully understood in relation to a recent predictive coding model, the free energy framework, particularly as applied to interoception and social cognition. Specifically, we argue that interpersonal interactions during pain may function as social, predictive signals of contextual threat or safety and as such influence the salience of noxious stimuli. The perception of such interpersonal interactions may in turn depend on (a) prior beliefs about interpersonal relating and (b) the certainty or precision by which an interpersonal interaction may predict environmental threat or safety.

Postural correlates with painful situations

Background: Emotional context may play a crucial role in movement production. According to simulation theories, emotional states affect motor systems. The aim of this study was to compare postural responses assessed by posturography and electromyography when subjects were instructed to imagine themselves in a painful or a non-painful situation.

Methods: Twenty-nine subjects (22.3 ± 3.7 years) participated in this study. While standing quietly on a posturographic platform, they were instructed to imagine themselves in a painful or non-painful situation. Displacement of the center of pressure (COP), leg muscle electromyographic activity, heart rate, and electrodermal activity were assessed in response to painful and non-painful situations.

Results: The anteroposterior path was shorter (p < 0.05) when subjects imagined themselves in a painful situation (M = 148.0 ± 33.4 mm) compared to a non-painful situation (158.2 ± 38.7 mm). Higher tibialis anterior (TA) activity (RMS-TA = 3.38 ± 1.95% vs. 3.24 ± 1.85%; p < 0.001) and higher variability of soleus (SO) activity (variation coefficient of RMS-SO = 13.5 ± 16.2% vs. M = 9.0 ± 7.2%; p < 0.05) were also observed in painful compared to non-painful situations. No significant changes were observed for other physiological data.

Conclusion: This study demonstrates that simulation of painful situations induces changes in postural control and leg muscle activation compared to non-painful situations, as increased stiffness was demonstrated in response to aversive pictures in accordance with previous results.

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

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

Child's and parents' catastrophizing about pain is associated with procedural fear in children: a study in children with diabetes and their mothers

The contribution of the child's and parents' catastrophizing about pain was explored in explaining procedural pain and fear in children. Procedural fear and pain were investigated in 44 children with Type I diabetes undergoing a finger prick. The relationships between parents' catastrophizing and parents' own fear and estimates of their child's pain were also investigated. The children and their mothers completed questionnaires prior to a routine consultation with the diabetes physician. Children completed a situation-specific measure of the Pain Catastrophizing Scale for Children (PCS-C) and provided ratings of their experienced pain and fear on a 0-10 numerical rating scale (NRS). Parents completed a situation-specific measure of the Pain Catastrophizing Scale For Parents (PCS-P) d provided estimates of their child's pain and their own experienced fear on a 0-10 NRS. Analyses indicated that higher catastrophizing by children was associated with more fear and pain during the finger prick. Scores for parents' catastrophzing about their children's pain were positively related to parents' scores for their own fear, estimates of their children's pain, and child-reported fear, but not the amount of pain reported by the child. The findings attest to the importance of assessing for and targeting child and parents' catastrophizing about pain. Addressing catastrophizing and related fears and concerns of both parents and children may be necessary to assure appropriate self-management. Further investigation of the mechanisms relating catastrophizing to deleterious outcomes is warranted.

Motivational Processes Underlying Both Prejudice and Helping

Examined at the behavioral level, prejudice and helping appear as qualitatively different and perhaps mutually incompatible social behaviors. As a result, the literatures on prejudice and helping evolved largely independent of each other. When they are examined at the process level, however, underlying similarities appear. Furthermore, when anomalies are examined within each of these two separate literatures, similarities become more apparent. Finally, the personality dimension of agreeableness is systematically related to both prejudice and helping. The authors propose that many forms of prejudice and helping are expressions of underlying processes of self-regulation and social accommodation. After discussing several other social-cognitive approaches to self-correction, the authors offer a novel opponent process model of motivation that integrates the apparently exclusive processes of prejudice and helping into a single system.

Studying the process of clinical communication: issues of context, concepts, and research directions

Much cancer-related health communication research has involved studies of the effects of media campaigns and strategies on secondary prevention. Cancer diagnosis rates, however, continue to affect millions of people. The need exists for communication studies to address the quality of the clinical interaction, the point of actual care delivery in addressing diagnosis, treatment, and survivorship. Using examples from a 6-year communication and behavioral oncology research program established at the Karmanos Cancer Institute (KCI) in Detroit, Michigan, we describe selected empirical issues; models, particularly the "convergence model" (adapted from Rogers & Kincaid, 1981); and associated constructs that are relevant and promising foundations for building future research in cancer clinical settings. Two examples from our empirical research program are described.