Master of Science, University of Oxford, Experimental Psychology (2011)
Doctor of Philosophy, University of Oxford (2017)
Laura Simons, Postdoctoral Faculty Sponsor
Wellbeing after successful cancer treatment depends on more than merely reducing the risk of disease recurrence. Cancer survival can be characterised by uncertainty, fear, and the interpretation of bodily sensations as potentially symptomatic of cancer recurrence. This fear can lead to over-vigilance about bodily sensations and precautionary visits to the doctor, both of which can increase the chance of early detection but can also increase anxiety and decrease quality of life. In this Personal View, we consider the medical, psychological, and ethical issues related to the practice of self-directed symptom monitoring after completion of cancer treatment, focusing on the role of doctor-patient communication. We ask how clinicians can account for the plurality of values that patients might have when it comes to deciding on how to manage and respond to experiences of post-cancer symptoms. We advocate a shared decision-making approach that incorporates the assessment of an individual's cancer recurrence risks as well as psychosocial considerations regarding fear of cancer recurrence and mental health. We aim to raise awareness of the potential quality-of-life implications of symptom-monitoring practices, emphasising the need for a balance between physical and psychological health in people living beyond cancer.
View details for Web of Science ID 000446052800029
View details for PubMedID 30303128
Introduction: The epidemiology of chronic pain in youth has been increasingly documented over the past decade. However, the precipitating events associated with the onset of pediatric chronic pain are not well studied.Objectives: Understanding the events that precede the onset of pain, and are reported by patients as germane to the early stages of their pain, may add one piece to the puzzle of the causal etiology of pediatric chronic pain disorders.Methods: We conducted a retrospective chart review of 320 young people attending a tertiary care chronic pain clinic with musculoskeletal chronic pain.Results: Approximately two-thirds of patients reported a precipitating event for their pain; injury was the most commonly reported event, followed by a chronic disease, then an infection or illness. Surgery was the least commonly reported event. About one-third of patients did not report any precipitating event for their pain. Patients with neuropathic pain were even more likely to report a precipitating event compared to those with localized and diffuse musculoskeletal pain. Patients with localized musculoskeletal pain and neuropathic pain were most likely to report an injury, whereas patients with diffuse musculoskeletal pain were most likely to report a chronic disease. We found little to no evidence that the presence or type of precipitating event was associated with patients' psychological or physical functioning.Conclusion: This study adds to the epidemiological evidence base for pediatric chronic pain disorders.
View details for DOI 10.1097/PR9.0000000000000665
View details for PubMedID 30324167
How parents attribute cause to their child’s physical symptoms is likely important in understanding how the parent responds to the child, as well as the child’s health outcomes, especially within the context of chronic illness. Here, we adapt the Symptom Interpretation Questionnaire for parent report (SIQ-PR) and provide preliminary validation in a sample of parents of children with chronic pain (N = 311). Confirmatory factor analysis revealed that the SIQ-PR structure is consistent with the original measure, with three distinct attribution types: psychological (emotional/affective), somatic (illness/disease), and environmental (situational/transient) causes. All three subscales demonstrated satisfactory to good internal consistency, and temporal stability. Parents typically endorsed more than one attribution for each symptom, indicating that parents of children with chronic pain have a multidimensional interpretation of physical symptoms in their children. Further, parent psychological and somatic attributions, but not environmental attributions, were significantly associated with (i) parent protective responses towards their child, and (ii) the child’s self-reported somatic and psychological symptoms, indicating convergent and divergent validity. The SIQ-PR may be a useful measure for future studies investigating intergenerational and interpersonal models of pediatric chronic pain, and more broadly, to examine parent attributions of children’s ambiguous symptoms within the context of childhood chronic illness.
View details for DOI 10.3390/children5060076
View details for PubMedID 29899299
Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain by facilitating fear and avoidance. Whereas extensive research has established attention, interpretation, and memory biases in adults with chronic pain, far less is known about these same biases in children and adolescents with pain. Studying cognitive biases in attention, interpretation, and memory in relation to pain occurring in youth is important because youth is a time when pain can first become chronic, and when relationships between cognitive biases and pain outcomes emerge and stabilize. Thus, youth potentially offers a time window for the prevention of chronic pain problems. In this article, we summarize the growing corpus of data that have measured cognitive biases in relation to pediatric pain. We conclude that although biases in attention, interpretation, and memory characterize children and adolescents with varying pain experiences, questions regarding the direction, magnitude, nature, and role of these biases remain. We call for independent extension of cognitive bias research in children and adolescents, using well powered longitudinal studies with wide age ranges and psychometrically sound experimental measures to clarify these findings and any developmental trends in the links between cognitive biases and pain outcomes.This article provides a rationale for the theoretical and practical importance of studying the role of cognitive biases in children and adolescents with chronic pain, which has to date, been relatively understudied. Existing findings are reviewed critically, and recommendations for future research are offered.
View details for DOI 10.1016/j.jpain.2018.01.005
View details for Web of Science ID 000434750800002
View details for PubMedID 29374535
The current study examined the application of a screening tool to identify biopsychosocial risk factors and derive prognostic risk groups in children and adolescents with headache pain.Youth (n = 242, 8-17 years, 75.6% female) presenting for evaluation at a tertiary pediatric headache clinic completed the nine-item Pediatric Pain Screening Tool (PPST) as well as measures of functional disability, pain catastrophizing, fear of pain, anxiety, and depressive symptoms. In addition, 119 patients reported on functional disability at 2-month follow-up.The PPST demonstrated discriminant validity that ranged from fair to good for identifying significant disability and high emotional distress. Receiver operating characteristic curve analyses indicated that established cutoff scores were appropriate for the current sample, and thus participants were classified into low-risk (21%), medium-risk (31%), and high-risk (48%) groups. Only 1-6% of patients who met reference standard case status for disability and emotional distress were classified as low risk, whereas 64-90% of patients who met reference standard case status were classified as high risk, suggesting robust stratification.The nine-item PPST may be a useful tool for efficiently identifying young patients with headache who are at risk of poor outcomes, and effectively classifying them into risk groups that could drive stratified treatment directly targeting patient needs.
View details for DOI 10.1093/jpepsy/jsx123
View details for Web of Science ID 000429285300005
View details for PubMedID 29048551
To apply a biopsychosocial framework to understand factors influencing pain in survivors of pediatric cancer to inform pain prevention efforts and highlight the need for interdisciplinary care.This topical review draws from both pediatric cancer survivorship research and chronic noncancer pain research to illustrate how components of a preventative model can be applied to pain in survivorship.Pain is a common experience among long-term survivors of pediatric cancer. The pain experience in survivorship can be conceptualized in terms of biological disease and treatment factors, cognitive and affective factors, and social and contextual factors. We review literature pertinent to each of these biopsychosocial factors and tailor an existing public health prevention framework for pain in survivors of pediatric cancer.Classifying survivors of pediatric cancer into pain risk categories based on their daily experiences of pain, pain-related functional impairment, and distress could help guide the implementation of pain-related prevention and intervention strategies in this population. Future research is needed to establish the efficacy of screening measures to identify patients in need of psychosocial pain and pain-related fear management services, and interdisciplinary pediatric chronic pain management programs in survivors of pediatric cancer.
View details for DOI 10.1093/jpepsy/jsx114
View details for Web of Science ID 000429285300004
View details for PubMedID 29048571
To conduct a systematic review of pain anxiety, pain catastrophizing, and fear of pain measures psychometrically established in youth with chronic pain. The review addresses three specific aims: (1) to identify measures used in youth with chronic pain, summarizing their content, psychometric properties, and use; (2) to use evidence-based assessment criteria to rate each measure according to the Society of Pediatric Psychology (SPP) guidelines; (3) to pool data across studies for meta-analysis of shared variance in psychometric performance in relation to the primary outcomes of pain intensity, disability, generalized anxiety, and depression.We searched Medline, Embase, PsycINFO, and relevant literature for possible studies to include. We identified measures studied in youth with chronic pain that assessed pain anxiety, pain catastrophizing, or fear of pain and extracted the item-level content. Study and participant characteristics, and correlation data were extracted for summary and meta-analysis, and measures were rated using the SPP evidence-based assessment criteria.Fifty-four studies (84 papers) met the inclusion criteria, including seven relevant measures: one assessed pain anxiety, three pain catastrophizing, and three fear of pain. Overall, five measures were rated as "well established." We conducted meta-analyses on four measures with available data. We found significant positive correlations with the variables pain intensity, disability, generalized anxiety, and depression.Seven measures are available to assess pain anxiety, pain catastrophizing, and fear of pain in young people with chronic pain, and most are well established. We present implications for practice and directions for future research.
View details for DOI 10.1093/jpepsy/jsx103
View details for Web of Science ID 000429285300012
View details for PubMedID 29049813
Complex human behaviour can only be understood within its social environment. However, disentangling the causal links between individual outcomes and social network position is empirically challenging. We present a research design in a closed real-world setting with high-resolution temporal data to understand this interplay within a fundamental human experience - physical pain. Study participants completed an isolated 3-week hiking expedition in the Arctic Circle during which they were subject to the same variation in environmental conditions and only interacted amongst themselves. Adolescents provided daily ratings of pain and social interaction partners. Using longitudinal network models, we analyze the interplay between social network position and the experience of pain. Specifically, we test whether experiencing pain is linked to decreasing popularity (increasing isolation), whether adolescents prefer to interact with others experiencing similar pain (homophily), and whether participants are increasingly likely to report similar pain as their interaction partners (contagion). We find that reporting pain is associated with decreasing popularity - interestingly, this effect holds for males only. Further exploratory analyses suggest this is at least partly driven by males withdrawing from contact with females when in pain, enhancing our understanding of pain and masculinity. Contrary to recent experimental and clinical studies, we found no evidence of pain homophily or contagion in the expedition group.
View details for DOI 10.1016/j.socscimed.2017.10.028
View details for Web of Science ID 000424721300006
View details for PubMedID 29127852
Adult patients with chronic pain are consistently shown to interpret ambiguous health and bodily information in a pain-related and threatening way. This interpretation bias may play a role in the development and maintenance of pain and disability. However, no studies have yet investigated the role of interpretation bias in adolescent patients with pain, despite that pain often first becomes chronic in youth. We administered the Adolescent Interpretations of Bodily Threat (AIBT) task to adolescents with chronic pain (N = 66) and adolescents without chronic pain (N = 74). Adolescents were 10 to 18 years old and completed the study procedures either at the clinic (patient group) or at school (control group). We found that adolescents with chronic pain were less likely to endorse benign interpretations of ambiguous pain and bodily threat information than adolescents without chronic pain, particularly when reporting on the strength of belief in those interpretations being true. These differences between patients and controls were not evident for ambiguous social situations, and they could not be explained by differences in anxious or depressive symptoms. Furthermore, this interpretation pattern was associated with increased levels of disability among adolescent patients, even after controlling for severity of chronic pain and pain catastrophizing. The current findings extend our understanding of the role and nature of cognition in adolescent pain, and provide justification for using the AIBT task in longitudinal and training studies to further investigate causal associations between interpretation bias and chronic pain.
View details for DOI 10.1097/j.pain.0000000000000781
View details for PubMedID 28067692
View details for DOI 10.1002/14651858.CD012535
View details for DOI 10.1097/j.pain.0000000000000781
View details for DOI 10.1097/j.pain.0000000000000872
View details for DOI 10.1002/14651858.CD012536
View details for DOI 10.1002/ejp.920
View details for DOI 10.1002/14651858.CD012563
Chronic pain is a widespread problem in the field of pediatrics. Many interventions to ameliorate pain-related dysfunction have a biobehavioral focus. As treatments for chronic pain (e.g., increased movement) often stand in stark contrast to treatments for an acute injury (e.g., rest), providing a solid rationale for treatment is necessary to gain patient and parent buy-in. Most pain treatment interventions incorporate psychoeducation, or pain neuroscience education (PNE), as an essential component, and in some cases, as a stand-alone approach. The current topical review focuses on the state of pain neuroscience education and its application to pediatric chronic pain. As very little research has examined pain neuroscience education in pediatrics, we aim to describe this emerging area and catalyze further work on this important topic. As the present literature has generally focused on adults with chronic pain, pain neuroscience education merits further attention in the realm of pediatric pain in order to be tailored and implemented in this population.
View details for DOI 10.3390/children3040043
View details for PubMedID 28009822
View details for PubMedCentralID PMC5184818
Negative interpretation bias, the tendency to appraise ambiguous situations in a negative or threatening way, has been suggested to be important for the development of adult chronic pain. To our knowledge, this is the first study to examine the role of a negative interpretation bias in adolescent pain. We first developed and piloted a novel task that measures the tendency for adolescents to interpret ambiguous situations as indicative of pain and bodily threat. Using this task in a separate community sample of adolescents (N = 115), we then found that adolescents who catastrophize about pain, as well as those who reported more pain issues in the preceding 3 months, were more likely to endorse negative interpretations, and less likely to endorse benign interpretations, of ambiguous situations. This interpretation pattern was not, however, specific for situations regarding pain and bodily threat, but generalized across social situations as well. We also found that a negative interpretation bias, specifically in ambiguous situations that could indicate pain and bodily threat, mediated the association between pain catastrophizing and recent pain experiences. Findings may support one potential cognitive mechanism explaining why adolescents who catastrophize about pain often report more pain.This article presents a new adolescent measure of interpretation bias. We found that the tendency to interpret ambiguous situations as indicative of pain and bodily threat may be one potential cognitive mechanism explaining why adolescents who catastrophize about pain report more pain, thus indicating a potential novel intervention target.
View details for DOI 10.1016/j.jpain.2016.05.009
View details for Web of Science ID 000382796000003
View details for PubMedID 27263991
View details for DOI 10.3390/children3040043
Persistent adult anxiety disorders often begin in adolescence. As emphasis on early treatment grows, we need a better understanding of how adolescent anxiety develops. In the current study, we used a fear conditioning paradigm to identify disruptions in cue and context threat-learning in 19 high anxious (HA) and 24 low anxious (LA) adolescents (12-17years). We presented three neutral female faces (conditioned stimulus, CS) in three contingent relations with an unconditioned stimulus (UCS, a shrieking female scream) in three virtual room contexts. The degree of contingency between the CSs and the UCSs varied across the rooms: in the predictable scream condition, the scream followed the face on 100% of trials; in the unpredictable scream condition, the scream and face appeared randomly and independently of each other; in the no-scream condition the CS was presented in the absence of any UCS. We found that the LA adolescents showed higher levels of fear-potentiated startle to the faces relative to the rooms. This difference was independent of the contingency condition. The HA adolescents showed non-differential startle between the CSs, but, in contrast to previous adult data, across both cue types displayed lowest startle to the unpredictable condition and highest startle to the no-scream condition. Our study is the first to examine context conditioning in adolescents, and our results suggest that high trait anxiety early in development may be associated with an inability to disambiguate the signalling roles of cues and contexts, and a mislabelling of safety or ambiguous signals.
View details for DOI 10.1016/j.nlm.2015.05.002
View details for Web of Science ID 000359510900007
View details for PubMedID 25982943
This study considered the attentional functioning of adolescents with varying levels of pain catastrophizing. Specifically, we investigated the relationship between pain catastrophizing and attention bias to pain facial expressions. Furthermore, drawing on dual process models in the context of pain, we investigated the moderating role of attention control on this relationship. Adolescents (N = 73; age, 16-18 years) performed a dot-probe task in which facial expressions of pain and neutral expressions were presented for 100 milliseconds and 1250 milliseconds. Participants also completed self-report pain catastrophizing and attention control measures. We found that although there was no main effect of pain catastrophizing on attention bias towards pain faces, attention control did significantly moderate this relationship. Further analysis revealed that lower levels of attention control were significantly associated with increasing attentional vigilance towards pain faces only within high catastrophizing adolescents. In addition, we found that poorer attention control was related to increased attention bias for pain faces (regardless of pain catastrophizing level) when these faces were presented for relatively longer durations (ie, 1250 milliseconds) but not for short durations (ie, 100 milliseconds). This study supports a dual process model of attentional processes in pain, thus replicating previous findings within the psychopathology literature but extending them to the study of pain. Theoretical and clinical implications of our findings are discussed.
View details for DOI 10.1097/j.pain.0000000000000174
View details for Web of Science ID 000357426200020
View details for PubMedID 25830926
This systematic review and meta-analysis examined the effects of psychological therapies for management of chronic pain in children. Randomized controlled trials of psychological interventions treating children (<18 years) with chronic pain conditions including headache, abdominal, musculoskeletal, or neuropathic pain were searched for. Pain symptoms, disability, depression, anxiety, and sleep outcomes were extracted. Risk of bias was assessed and quality of the evidence was rated using GRADE. 35 included studies revealed that across all chronic pain conditions, psychological interventions reduced pain symptoms and disability posttreatment. Individual pain conditions were analyzed separately. Sleep outcomes were not reported in any trials. Optimal dose of treatment was explored. For headache pain, higher treatment dose led to greater reductions in pain. No effect of dosage was found for other chronic pain conditions. Evidence for psychological therapies treating chronic pain is promising. Recommendations for clinical practice and research are presented.
View details for DOI 10.1093/jpepsy/jsu008
View details for Web of Science ID 000343398100002
View details for PubMedID 24602890
This study set out to establish the novel use of the go/no-go Overlap task for investigating the role of attentional control capacities in the processing of emotional expressions across different age-groups within adolescence: at the onset of adolescence (11-12 year-olds) and toward the end of adolescence (17-18 year-olds). We also looked at how attentional control in the processing of fearful, happy, and neutral expressions relates to individual differences in trait anxiety in these adolescent groups. We were able to show that younger adolescents, but not older adolescents had more difficulties with attention control in the presence of all faces, but particularly in the presence of fearful faces. Moreover, we found that across all groups, adolescents with higher trait anxiety exhibited attentional avoidance of all faces, which facilitated relatively better performance on the primary task. These differences in reaction time emerged in the context of comparable accuracy level in the primary task across age-groups. Our results contribute to our understanding of how attentional control abilities to faces but in particular fearful expressions may mature across adolescence. This may affect learning about the environment and the acquisition of behavioral response patterns in the social world.
View details for DOI 10.3389/fpsyg.2014.00111
View details for PubMedID 24575077