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

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

Individual Differences in the Relationship Between Pain Fear, Avoidance, and Pain Severity in a Chronic Abdominal Pain Sample and the Moderating Effect of Child Age.

BACKGROUND/PURPOSE: Most studies examining the components of the fear-avoidance model have examined processes at the group level. The current study used ecological momentary assessments to: (a) investigate the group and intraindividual relationships between pain fear, avoidance, and pain severity, (b) identify any heterogeneity between these relationships, and (c) explore the role of moderators to explain such heterogeneity. METHODS: Seventy-one pediatric patients with chronic abdominal pain (M = 13.34 years, standard deviation = 2.67 years) reported pain fear, avoidance, and pain severity four times per day over 14 days. RESULTS: Results indicated significant individual differences in the relationship between pain fear and pain avoidance predicting pain severity. Child age helped explain the heterogeneity in the relationships between pain avoidance and pain severity such that older children had a stronger and more positive relationship between these variables. The random effect between pain fear and pain severity also indicated a moderator trend of child age such that older children were likely to have a stronger and more positive relationship. CONCLUSIONS: The present study extends the fear-avoidance model by highlighting the importance of identifying potential individual differences when examining pain fear, avoidance, and pain severity. Furthermore, the current study suggests that child development should be considered in the model. However, future randomized control designs are necessary to explore the causal relationships between pain fear and avoidance on pain severity and potential developmental differences.

Tailoring Individualized Evaluation of Pediatric Abdominal Pain Using Ecological Momentary Assessment (EMA): A Pilot Study Testing Feasibility and Acceptability.

OBJECTIVE: The current study aimed to determine if it was feasible and acceptable to use ecological momentary assessment to assess individual associations between biopsychosocial contributors to chronic abdominal pain with 2 objective sensors and a mobile application. Specifically, we aimed to determine if it was possible to identify individualized associations between idiopathic pain associations. The goal was to determine if idiographic profiles have clinical value while the field works torward consensus about nomothetic trends. MATERIALS AND METHODS: Participants included 30 pediatric chronic abdominal pain patients, aged 8 to 17, who wore a physiological monitor and accelerometer that measured sleep and physical activity and answered 4 surveys per day on an app over the course of a 14-day study period. RESULTS: Results indicated that participants were 96.2% and 95.5% compliant to the wrist-worn accelerometer measuring sleep and physical activity, respectively. Participants completed 76.3% of expected surveys and were least adherent to the physiological monitor (37.9%). In addition, it was possible to generate 24 (80%) personalized reports describing unique associations with pain for participants in the study. DISCUSSION: Findings provide initial support for the use of ecological momentary assessment over a 2-week period to inform and create personalized profiles for improved clinical care in this population.

Associations Between Physical Activity and Chronic Pain Severity in Youth With Chronic Abdominal Pain.

OBJECTIVES: The present study aimed to: (1) better understand physical activity levels in youth with chronic abdominal pain and (2) investigate the relationship between day-level physical activity related to next day pain intensity to identify any intraindividual heterogeneity. METHODS: Seventy-one youth (M=13.34 y, SD=2.67 y) with chronic abdominal pain provided reports of pain severity and continuous objective reports of sedentary behavior, moderate-to-vigorous physical activity (MVPA), and total sleep time using accelerometers over 14 days. RESULTS: Findings revealed that youth with chronic abdominal pain do not meet recommended levels of MVPA per day (M=34.64 min, SD=33.31 min). Further, results indicated a random effect of the previous day's MVPA predicting pain severity. There was a small significant negative effect of within-person total sleep time as a predictor of pain severity. DISCUSSION: The current study highlights the importance of separating between-person and within-person differences when examining the relationship between physical activity and pain severity. Future studies should explore moderating factors that may help to explain random effects to better understand the types of individuals with positive or negative relationships between physical activity and pain severity.

Parents' Perspectives on the Theoretical Domains Framework Elements Needed in a Pediatric Health Behavior App: A Crowdsourced Social Validity Study.

BACKGROUND: Most pediatric studies do not include parent stakeholders in the design of the intervention itself and many pediatric mobile health (mHealth) interventions are not meaningfully disseminated after the trial period ends. Consequently, the consumer desire for mobile apps targeting pediatric health behavior is likely to be met by commercial products that are not based in theory or evidence and may not take stakeholder preferences into account. OBJECTIVE: The aim was to assess parent preference for mobile app features that map onto specific Theoretical Domains Framework (TDF) elements. METHODS: This study was a crowdsourced social validity study of 183 parents who were asked to rate their preferences for mobile app features that correspond to elements of the TDF. The TDF organizes a large number of theoretical models and constructs into three components: (1) capability, (2) motivation, and (3) opportunity. Parents of children were recruited through Amazon Mechanical Turk. RESULTS: The majority of participants were Caucasian and mean age was 36.9 (SD 8.0) years. Results revealed broad acceptability of communication, motivation, and opportunity domains. However, the degree to which each domain was valued varied within behavioral category. Parents demonstrated a preference for increasing procedural knowledge for physical activity and diet behaviors over sleep (F2,545=5.18, P=.006). Similarly, parents valued self-monitoring as more important for physical activity than sleep (F2,546=4.04, P=.02). When asked about the value of features to help children develop skills, parents preferred those features for dietary behavior over sleep (F2,546=3.57, P=.03). Parents perceived that goal-setting features would be most useful for physical activity over sleep and diet (F2,545=5.30, P=.005). Incentive features within the app were seen as most useful for physical activity over sleep (F2,546=4.34, P=.01). CONCLUSIONS: This study presents a low-cost strategy for involving a large number of stakeholders in the discussion of how health behavior theory should be applied in a mHealth intervention. Our approach is innovative in that it took a scientific framework (ie, TDF) and made it digestible to parents so that they could then provide their opinions about features that might appear in a future app. Our survey items discriminated between various health behaviors allowing stakeholders to communicate the different health behaviors that they would like a TDF feature to change. Moreover, we were able to develop a set of consumer opinions about features that were directly linked to elements of the TDF.

An assessment of meaning in life-threatening illness: development of the Healing Experience in All Life Stressors (HEALS).

CONTEXT: Patients with life-threatening or chronic illness report an experience of increased positive psychological, social, and/or spiritual change during diagnosis and/or treatment of their illness, even in the face of unfavorable prognosis. This transformation begins through the ability to make their life meaningful by forming meaningful connections that emerge through self-introspection and relationships with a divine entity, nature, and other people. The Healing Experience in All Life Stressors (HEALS) assessment provides a way to identify distress-causing changes that may interfere with the development of meaning and psycho-social-spiritual homeostasis. OBJECTIVE: Preliminary examination of responses to items on the HEALS and examination of the factor structure. METHOD: The 48-item HEALS questionnaire was developed using a multistep process: literature review for concept development, item generation from qualitative data, and face and content validity by expert panel. In the current study, HEALS was completed by 100 patients diagnosed with life-limiting disease and seen by the palliative care team at a large research institution in the US. Exploratory factor analysis techniques were used to determine scale structure of the instrument. RESULTS: Outcome testing of sample adequacy using Kaiser-Meyer-Olkin statistic was 0.75, which exceeds the recommended value of 0.60. The HEALS show very good internal consistency with a Cronbach's a of 0.94. Overall results of the exploratory factor analysis established a four-factor questionnaire: 1) religion; 2) spirituality, demonstrated by a) interaction with a religious community and b) belief in higher power; 3) intrapersonal; and 4) interpersonal relationships expressed through psychological changes resulting in enhanced outlook and improvement in relationships with family and friends. CONCLUSION: This study involved the initial step to commence the process of scale validation, with promising outcomes identifying subscales as an effective way to assess the construct of healing. These findings support further examination using cognitive appraisal and confirmatory factor analysis.