Child Emotion Regulation Capacity Moderates the Association Between Parent Behaviors and Child Distress During Pediatric Venipuncture.

OBJECTIVES: Medical needle procedures are a common source of pain, distress, and fear for children, which can worsen over time and lead to needle noncompliance and avoidance, if unaddressed. Children's pain experience is multiply determined by external (e.g., parent behaviors) and internal (e.g., cognitive and affective) factors. Some parent behaviors (e.g., reassurance, giving control to child, empathy, apologies, criticism) have related to poor child pain experiences. No research has examined how children's internal emotion regulation, commonly measured via heart rate variability (HRV), may buffer, or strengthen this association. This study is the first to examine child HRV in relation to pain experiences, and as a moderator between a constellation of parent behaviors (reassurance, giving control, empathy) and child pain, fear, and distress. METHODS: Sixty-one children aged 7-12 years undergoing venipuncture and a parent participated. Child HRV was measured before the procedure. After venipuncture, children rated their pain and fear. Parent and child behaviors during venipuncture were coded using the "distress promoting" and "distress" composites of the Child-Adult Medical Procedure Interaction Scale-Revised. RESULTS: Children with lower HRV displayed greater distress. Child HRV moderated the positive association between parent behaviors (reassurance, giving control, empathy) and child distress such that the association was strongest among children with low HRV. CONCLUSIONS: Findings suggest children with lower HRV, indicative of lower emotion regulation capacity, may be at risk of experiencing higher levels of distress and may be more vulnerable to distress when facing parent reassurance, giving control, and empathy verbalizations during venipuncture.

A Brief Mindfulness Intervention for Parents and Children before Pediatric Venipuncture: A Randomized Controlled Trial.

BACKGROUND: Routine needle procedures can be distressing for parents and children. Mindfulness interventions may be helpful for parents and children but have not been examined for pediatric needle procedures despite showing benefits in the context of pediatric chronic pain and in lab-based pain tasks. METHODS: This preregistered (NCT03941717) two-arm, parallel-group randomized controlled trial examined the effects of a 5 min mindfulness intervention before pediatric venipuncture for parents and children (aged 7-12) compared to a control group on primary outcomes of child pain and fear, secondary outcomes of parent distress, and tertiary outcomes of parent ratings of child pain and fear. Moderators of parent and children's responses to the intervention were examined: state catastrophizing, trait mindfulness, and experiential avoidance. RESULTS: Sixty-one parent-child dyads were randomized (31 mindfulness; 30 control). Parents and children completed measures, listened to a 5 min audio recording (mindfulness or control), and parents accompanied their child during routine venipuncture. The mindfulness intervention involved breathing and encouraging nonjudgmental attention to one's experiences, while the control condition involved an unfocused attention task. Three between-subject MANCOVAs assessed for group differences. Child pain and fear rated by children and their parents did not differ between groups. Parents in the mindfulness group were less distressed during the venipuncture than the controls. Parent state catastrophizing may have moderated the intervention effects, such that parents with moderate and high catastrophizing levels had lower distress following the mindfulness intervention versus control. CONCLUSIONS: The intervention did not reduce child pain or fear but reduced parent distress. It appeared most helpful for parents catastrophizing about their child's pain, which is noteworthy as these children are prone to worse outcomes.

Prevalence of pain and fear as barriers to vaccination in children - Systematic review and meta-analysis.

BACKGROUND: Injection-related pain and fear are common adverse reactions in children undergoing vaccination and influence vaccine acceptance. Despite the large body of literature on sources of vaccine non-compliance, there is no estimate of the prevalence of pain and fear as contributing factors. The objective was to estimate the prevalence of injection pain or fear of needles as barriers to childhood (i.e., 0-18 years) vaccination. METHODS: Four databases were searched from inception for relevant English and French articles until August 2021. In addition, the references of recent systematic reviews and all articles included in the review were hand searched. Article screening and data extractions were performed in duplicate. Studies were included if they reported on injection-related pain or fear of needles in children (0-18 years) using a checklist/closed-ended question(s). Results were stratified by respondent (parents or children), type of pediatric population (general or under-vaccinated), and relative importance of barrier (pain or needle fear as primary reason or any reason for under-vaccination). Prevalence rates of pain or needle fear were combined using a random effects model. Quality of included studies was assessed using the Joanna Briggs Institute critical appraisal checklist for prevalence data. Quality across studies was assessed using GRADE. RESULTS: There were 26 studies with 45 prevalence estimates published between 1995 and 2021. For parent reports (of children) and children self-reported reasons for non-compliance, prevalence rates of pain or needle fear ranged from 5 to 13% in a general population and 8 to 28% in an under-vaccinated population, with a substantial variation in the prevalence estimates. There was no difference between category of respondent or relative importance on pain or needle fear prevalence rate. A regression model demonstrated an overall prevalence rate of pain or needle fear as an obstacle to vaccination of 8% in the general population and 18.3% in the under-vaccinated population. All evidence was very low in quality. CONCLUSION: This is the first review to systematically quantify the prevalence and therefore, importance, of pain and needle fear as obstacles to vaccination in children around the world. Pain from injection or fear of needles were demonstrated to be sufficiently prevalent as barriers to vaccination in children to warrant attention. Addressing pain and fear has the potential to significantly improve vaccination acceptance.

Biopsychosocial Contributors to Parent Behaviors during Child Venipuncture.

Children's needle-related distress is strongly related to parental verbal behaviors. Yet, empirical data supporting theorized contributors to parent behaviors in this context remain limited. This is the first study to collectively measure biological (heart rate variability; HRV), psychological (catastrophizing, anxiety), and social (child behaviors) contributors to parent verbal behaviors throughout pediatric venipuncture. HRV was used as a measure of emotion regulation capacity and examined as a moderator in the associations between parent psychological factors and their behaviors, and between child and parent behaviors. Sixty-one children aged 7 to 12 years who presented at an outpatient blood lab for venipuncture and a parent participated. Parent baseline HRV, state catastrophizing, and anxiety were measured prior to venipuncture. The procedure was video-recorded for later coding of pairs' verbal behaviors. Strong associations emerged between child behaviors and parent behaviors. Baseline HRV moderated the association between parent catastrophizing and behavior. Social factors remain a strong influence related to parent behaviors. Psychologically, parent negative cognitions differentially related to parent behaviors based on their emotion regulation capacity. Biologically, low baseline HRV may increase the risk that certain parents engage in a constellation of behaviors that simultaneously direct their child's attention toward the procedure and inadvertently communicate parental worry, fear, or concern.

Parent and child self- and co-regulation during pediatric venipuncture: Exploring heart rate variability and the effects of a mindfulness intervention.

Needle procedures are common throughout childhood and often elicit distress in children and parents. Heart rate variability (HRV), as an index of emotion regulation, can inform both self-regulatory and co-regulatory processes. Mindfulness may serve to regulate distress; however, no research has studied mindfulness or parent and child regulatory responding concurrently during venipuncture. Stemming from a randomized controlled trial investigating a mindfulness intervention, this study sought to describe regulatory responding (via HRV) throughout pediatric venipuncture and the role of cognitive-affective factors (mindfulness, parent anxiety, catastrophizing) in 61 parent-child dyads (7-12 years). We examined (1) patterns of parent and child HRV throughout venipuncture and whether a brief, randomly assigned audio-guided mindfulness versus control exercise affected this pattern and (2) the extent to which changes in parent and child HRV were synchronized throughout venipuncture, and whether parent catastrophizing and anxiety moderated this association. HRV differed as a function of procedural phase. Practicing the mindfulness versus control exercise did not consistently affect HRV in dyads. Positive synchrony was observed during the end of the intervention in dyads with high parental catastrophizing. Otherwise, a pattern of nonsynchrony emerged. Results provide foundational knowledge regarding children's internal (self) and external (parent) regulation mechanisms. RCT registration: NCT03941717.

Study protocol for a randomized controlled trial of a child and parent mindfulness intervention for pediatric venipuncture.

Children commonly undergo painful needle procedures. Unmanaged procedural pain can have short- and long-term consequences, including longer procedure times, greater distress at future procedures, and vaccine hesitancy. While parent behaviors are one of the strongest predictors of children's response to acute pain, pediatric procedural pain management interventions focus almost exclusively on the child. Further, existing parent-involved pediatric pain management interventions typically fail to improve child self-reported pain during painful procedures. The current protocol offers the first randomized controlled trial involving a mindfulness intervention for pediatric acute pain that includes children and their parents. This study aims to conduct a single-site, two-arm, parallel-group RCT to examine the effects of a mindfulness intervention for parents and children before child venipuncture compared to a control group on primary (child self-report of pain and fear), secondary (parent self-report and child report of parent distress), and tertiary outcomes (parent report of child pain and fear). Parent-child dyads (n = 150) will be recruited from the McMaster Children's Hospital outpatient blood laboratory. Dyads will be randomly assigned to either a mindfulness group guided through a mindfulness intervention or control group guided through an unfocused attention task. Parents will accompany their child for their venipuncture. Postvenipuncture measures will be collected (eg, child pain-related outcomes as reported by parents and children). The first enrollment occurred in October 2019. We offer a novel intervention that aims to facilitate both parent and child coping during child venipuncture.

A systematic review of the effectiveness of behavioural treatments for pica in youths.

Pica is the persistent consumption of non-nutritive, nonfood substances and is associated with adverse health complications. However, there is limited research on interventions for pica in youth. The objective of this study is to systematically review the empirical evidence for the effectiveness of behavioural interventions for pica in children and adolescents and to generate treatment recommendations. A systematic search yielded 823 articles extracted from five databases: CINALH, Family and Society Studies Worldwide, Medline, PsycINFO, and Web of Science. Two reviewers completed initial sorting based on article titles and abstracts. Five reviewers completed sorting based on full article review. Thirty articles were included and double coded for demographic information, co-morbid conditions, and intervention characteristics. These studies were case studies involving behavioural treatments for pica. Seventeen behavioural interventions were categorized into four treatment approaches: reinforcement-based, response interruption, "other" interventions, and punishment-based procedures. Interventions that resulted in near-zero rates of pica were deemed effective. Findings showed support for contingent reinforcement, discrimination training as part of a combination treatment, physical restraint, time out, and contingent aversive stimulus. No evidence supported the effectiveness of response interruption procedures, including response blocking and visual facial screen. Other coded procedures did not appear effective. We recommend that the least restrictive procedures are implemented first, including a combination treatment with contingent reinforcement and discrimination training. As needed, more restrictive procedures can be added to the treatment package. This review will facilitate future empirical work and assist clinicians with treatment options for pica in youth. High-quality trials are needed.

SUPER scale to the rescue: reconciling what parents say and what they communicate during their child's pain.

Aim: Fully illuminating mechanisms relating parent behaviors to child pain require examining both verbal and nonverbal communication. We conducted a multimethod investigation into parent nonverbal communication and physiology, and investigated the psychometric properties of the Scheme for Understanding Parent Emotive Responses Scale to assess parent nonverbals accompanying reassurance and distraction. Materials & methods: 23 children (7-12 years of age) completed the cold pressor task with their parent (predominately mothers). Parent heart rate and heart rate variability were monitored and assessed. The Scheme for Understanding Parent Emotive Responses Scale coding of parent nonverbal behaviors (i.e., vocal cues, facial expressions, posture) was used to detect levels of fear, warmth, disengagement and humor. Results & conclusion: Preliminary evidence for the psychometric properties of the scale are offered. Parent reassurance was associated with more fear, less warmth and less humor compared with distraction.

Teaching the Teacher: The Impact of a Workshop Developed for Radiation Therapists.

INTRODUCTION: Enhancing the teaching skills of radiation therapists is of benefit to both students and therapists and is ultimately important for patient outcomes. However, there is a paucity of evidence-based interventions for improving the teaching skills of radiation therapists. An intervention was developed to tackle this initiative. In accordance with a local, quality improvement initiative, a two-part workshop was developed for radiation therapists to improve their ability to (1) effectively communicate with students, (2) provide meaningful feedback to students, (3) increase consistency in conducting competency assessments, and (4) increase an understanding of cultural competency as it pertains to both teaching and health care more broadly. METHODS: Participants included 67 radiation therapists (18 males and 49 females) currently working at an urban, tertiary care center in Ontario. Not all therapists attended both the workshops (48 attended both workshops, 67 attended A only, and 49 attended B only). The sessions were divided into workshop A, targeting communication and evaluation, and workshop B, targeting competency assessment and cultural competency. Self-report questionnaires assessing clinician ratings of their confidence in these skills were administered before workshop A and B, after workshop A and B, and at a follow-up after 75 days. For radiation therapists who completed the questionnaire at all three time points, changes in their confidence ratings were analyzed using repeated measures analysis of variance (ANOVA) before workshop, after workshop, and at follow-up (for workshop A: n = 29 and for workshop B: n = 24). It was hypothesized that teaching skills of communication and evaluation would improve after workshop A. Similarly, teaching skills of competency assessment and cultural competency would both improve after workshop B. RESULTS: All four repeated measures ANOVAs indicated significant improvements in clinician self-assessment in the four teaching skills targeted in the workshops. DISCUSSION: Radiation therapists reported being significantly more confident in their teaching skills after the intervention. CONCLUSION: There is preliminary evidence for the efficacy of this teaching intervention in improving the confidence of radiation therapists in the assessed skills.

Parent Cardiac Response in the Context of Their Child's Completion of the Cold Pressor Task: A Pilot Study.

Parents' ability to regulate their emotions is essential to providing supportive caregiving behaviours when their child is in pain. Extant research focuses on parent self-reported experience or observable behavioural responses. Physiological responding, such as heart rate (HR) and heart rate variability (HRV), is critical to the experience and regulation of emotions and provides a complementary perspective on parent experience; yet, it is scarcely assessed. This pilot study examined parent (n = 25) cardiac response (HR, HRV) at rest (neutral film clip), immediately before the cold pressor task (pre-CPT), and following the CPT (post-CPT). Further, variables that may influence changes in HR and HRV in the context of pediatric pain were investigated, including (1) initial HRV, and (2) parent perception of their child's typical response to needle procedures. Time-domain (root mean square of successive differences; RMSSD) and frequency-domain (high-frequency heart rate variability; HF-HRV) parameters of HRV were computed. HR and HF-HRV varied as a function of time block. Typical negative responses to needle pain related to higher parental HR and lower HRV at rest. Parents with higher HRV at baseline experienced the greatest decreases in HRV after the CPT. Consequently, considering previous experience with pain and resting HRV levels are relevant to understanding parent physiological responses before and after child pain.