To evaluate the feasibility and preliminary effectiveness of an Internet-delivered cognitive-beha... more To evaluate the feasibility and preliminary effectiveness of an Internet-delivered cognitive-behavioral therapy (CBT) intervention for adolescents with chronic headache. Headache is among the most common pain complaints of childhood. Cognitive-behavioral interventions are efficacious for improving pain among youth with headache. However, many youth do not receive psychological treatment for headache due to poor access, which has led to consideration of alternative delivery modalities such as the Internet. We used a parallel arm randomized controlled trial design to evaluate the feasibility and preliminary effectiveness of an Internet-delivered family-based CBT intervention, Web-based management of adolescent pain. Adolescents were eligible for the trial if they were a new patient being evaluated in a specialized headache clinic, between 11 and 17 years of age, and had recurrent headache for 3 months or more as diagnosed by a pediatric neurologist. Eighty-three youths were enrolled i...
Around 4 million children undergo inpatient surgery in the U.S. each year, however little is know... more Around 4 million children undergo inpatient surgery in the U.S. each year, however little is known about the impact of surgery and postoperative pain on children's health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2-18 years (Mean=9.6 years), 50% male, 56% white, admitted to surgical services at a children's hospital enrolled in the study.
Internet-delivered interventions are emerging as a strategy to address barriers to care for indiv... more Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included 273 adolescents (205 females, 68 males), ages 11 to 17 years with mixed chronic pain conditions and their parents, randomly assigned in a parallel-group design to Internet-delivered CBT (n=138) or Internet-delivered Education (n=135). Assessments were completed at pre-treatment, immediate post-treatment and at 6-month follow up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to six-month follow-up for Internet CBT compared to Internet Education (b = -1.13, p = 0.03). On secondary outcomes, significant beneficial effects of Inter...
The purpose of the present study was to compare the health-related quality of life (HRQOL) of chi... more The purpose of the present study was to compare the health-related quality of life (HRQOL) of children with epilepsy with that of healthy controls and to examine predictors of HRQOL, including current treatment, seizure severity, and comorbid neurological impairments. The epilepsy group consisted of 41 children, aged 4-19 years. The control group consisted of 41 age-matched healthy children seen for well child care in a community pediatric practice. Results demonstrated that the HRQOL of the epilepsy group was significantly more limited than that of the control group. For children with epilepsy, comorbid neurological impairments and number of antiepileptic medications were associated with diminished HRQOL. Duration of illness, age of onset, seizure severity, and treatment type were not predictive of diminished HRQOL. The present findings suggest that presence of comorbid neurological impairments and number of medications are the best predictors of reduced HRQOL in children with epilepsy and may present a subgroup of patients with additional treatment needs.
Physical function and functional recovery are important aspects of the acute pain experience in c... more Physical function and functional recovery are important aspects of the acute pain experience in children and adolescents in hospitalized settings. Measures of function related to pediatric acute pain do not exist currently, limiting understanding of recovery in youth undergoing acute and procedural pain. To address this gap, we developed and assessed the clinical utility and preliminary validity of the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ). We evaluated psychometric properties of this measure in 159 patients with sickle cell disease, ages 7 to 21 years, who were hospitalized for vaso-occlusive episodes at 4 urban children's hospitals. The YAPFAQ demonstrated strong internal reliability and test-retest reliability. An exploratory factor analysis was conducted to examine the preliminary factor structure and to help reduce the number of items for the final scale. Evidence for moderate construct validity was demonstrated among validated measures of pain burden, motor function, functional ability, and quality of life. The YAPFAQ is a new measure of youth functional ability in the acute pain setting. Further evaluation of this measure in additional pediatric populations is needed to understand applicability across a spectrum of youth experiencing acute pain related to illness, trauma, and medical/surgical procedures.
The journal of pain : official journal of the American Pain Society, 2014
Physical function and functional recovery are important aspects of the acute pain experience in c... more Physical function and functional recovery are important aspects of the acute pain experience in children and adolescents in hospitalized settings. Measures of function related to pediatric acute pain do not exist currently, limiting understanding of recovery in youth undergoing acute and procedural pain. To address this gap, we developed and assessed the clinical utility and preliminary validity of the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ). We evaluated psychometric properties of this measure in 159 patients with sickle cell disease, ages 7 to 21Â years, who were hospitalized for vaso-occlusive episodes at 4 urban children's hospitals. The YAPFAQ demonstrated strong internal reliability and test-retest reliability. An exploratory factor analysis was conducted to examine the preliminary factor structure and to help reduce the number of items for the final scale. Evidence for moderate construct validity was demonstrated among validated measures of pain burden, ...
This study examined the factor structure of the Adolescent Sleep-Wake Scale (ASWS) among 491 adol... more This study examined the factor structure of the Adolescent Sleep-Wake Scale (ASWS) among 491 adolescents (12-18 years) with and without pediatric health conditions. Exploratory factor analyses were conducted using iterated principal axis factoring with varimax rotation. Highly cross-loading items were systematically removed and analyses were rerun until a clean solution was attained. The final solution explained 57.1% of the total model variance, including 10 items and three factors: Falling Asleep and Reinitiating Sleep-Revised, returning to Wakefulness-Revised, and Going to Bed-Revised. Internal consistency reliability scores were acceptable to good, with the exception of the Going to Bed-Revised subscale for the healthy sample. Adolescents with chronic pain reported significantly poorer overall sleep quality and more problems in falling asleep, reinitiating sleep, and returning to wakefulness as compared to healthy adolescents, providing preliminary evidence for construct validit...
The fear-avoidance model of chronic pain posits that fear of pain is associated with fear and avo... more The fear-avoidance model of chronic pain posits that fear of pain is associated with fear and avoidance of activity, which can lead to deconditioning and persistence of pain and disability. Despite being well supported in adults, little is known about the role of fear-avoidance beliefs regarding physical activity in children. Research has shown that parental protectiveness contributes to activity limitations in children; however, no studies have examined relationships between protectiveness, and fear and avoidance. To conduct a cross-sectional study to provide additional information regarding the reliability and validity of the Fear-Avoidance Beliefs Questionnaire physical activity subscale among adolescents with chronic pain; examine fear-avoidance beliefs and depressive symptoms as concurrent predictors of physical activity limitations; and test competing models using fear-avoidance beliefs as mediators and moderators of the association between parental protectiveness and activity...
To examine the incidence and nature of disagreements about pain and functional disability between... more To examine the incidence and nature of disagreements about pain and functional disability between parents and their children with juvenile idiopathic arthritis (JIA) and to identify demographic and psychosocial predictors of parent-child disagreement about pain and functional disability. Participants comprised 63 children 8-16 years of age (mean 12.36 +/- 2.61) and their parents, followed as part of a longitudinal study of pain in children. During routine rheumatology clinic visits, children and their parents completed validated measures of pain, depressive symptoms, and functional disability. Parents and children often disagreed as to the frequency and intensity of pain and to the degree of disability caused by arthritis. Child depressive symptoms (p < 0.01) and parental perceptions of child limitations (p < 0.02) predicted parent-child disagreement about the frequency of the child's pain. Parental perceptions of child limitations also predicted parent-child disagreement ...
There is increased recognition that sleep problems may develop in children and adolescents after ... more There is increased recognition that sleep problems may develop in children and adolescents after mild traumatic brain injury (mTBI). However, few studies have utilized both subjective and objective measures to comprehensively assess sleep problems in the pediatric population following the acute post-TBI period. The aims of this study were to compare sleep in adolescents with mTBI to healthy adolescents using subjective and objective measures, and to identify the clinical correlates associated with sleep problems. One hundred adolescents (50 adolescents with mTBI recruited from 3 to 12 months post-injury) and 50 healthy adolescents completed questionnaires assessing sleep quality, depression, and pain symptoms, and underwent 10-day actigraphic assessment of sleep patterns. Adolescents with mTBI reported poorer sleep quality, and demonstrated significantly shorter actigraphic-measured sleep duration, poorer sleep efficiency, and more wake time during the night compared to healthy adolescents (p&amp;amp;#39;s &amp;amp;lt; 0.05). For both groups of adolescents, poorer self-reported sleep quality was predicted by greater depressive symptoms. Poorer actigraphic sleep efficiency was predicted by membership in the mTBI group after controlling for age, sex, depressive symptoms and presence of pain. Our findings suggest that adolescents may experience subjective and objective sleep disturbances up to one year following mTBI. These findings require further replication in larger samples. Additionally, research is needed to identify possible mechanisms for poor sleep in youth with mTBI.
We appreciate the thoughtful commentaries by Cohen and by Steele, Borner, and Roberts on our reco... more We appreciate the thoughtful commentaries by Cohen and by Steele, Borner, and Roberts on our recommendations for competencies in pediatric psychology . This type of dialogue is exactly what we hoped to see and we encourage continued discussion concerning training in competency development in pediatric psychology.
Research on the experience of parents caring for a child with chronic pain indicates that high le... more Research on the experience of parents caring for a child with chronic pain indicates that high levels of parental role stress, feelings of frustration over an inability to help, and psychological distress are common. Moreover, parental distress adversely influences child adjustment to chronic pain. Therefore, intervening with parents of youth with chronic pain may, in turn, result in positive outcomes for children in their ability to engage in positive coping strategies, reduce their own distress, and to function competently in their normal daily lives. Our aim was to adapt an intervention, Problem-Solving Skills Training, previously proven effective in reducing parental distress in other pediatric illness conditions to the population of caregivers of youth with chronic pain. In the first phase, the intervention was adapted based on expert review of the literature and review of parent responses on a measure of pain-related family impact. In the second phase, the intervention was tested in a small group of parents to evaluate feasibility, determined by response to treatment content, ratings of acceptability, and ability to enroll and deliver the treatment visits. This phase included piloting the PSST intervention and all outcome measures at pre-treatment and immediately post-treatment. In an exploratory manner we examined change in parent distress and child physical function and depression from pre-to post-treatment. Findings from this feasibility study suggest that PSST can be implemented with parents of youth with chronic pain, and they find the treatment acceptable.
Sleep is intricately connected to health and well-being. Over the past decade, research has incre... more Sleep is intricately connected to health and well-being. Over the past decade, research has increasingly recognized the importance of sleep and the adverse daytime consequences and health outcomes of untreated sleep disturbances and sleep disorders. Studies have shown associations among sleep problems and key physiologic health parameters, including immune system functioning and metabolic/ endocrine regulation. 1 In children, specifically, short duration of nighttime sleep has been associated with increased risk of subsequent overweight or obesity. Sleep disturbances are especially prevalent in children with both acute and chronic disease states (eg, juvenile rheumatoid arthritis, asthma, cancer). Studies have shown that both acute and chronic medical conditions increase the risk of sleep disruptions, 3-6 and there is some evidence that sleep problems are more often chronic and persistent in youth with chronic conditions compared with those without chronic conditions. 7 The association between sleep problems and medical conditions may be related to underlying disease-related mechanisms (eg, airway restriction, inflammation), treatment regimens (including medications), or hospitalization. Some medical
The primary objective of this study was to assess the impact of pediatric pain-related conditions... more The primary objective of this study was to assess the impact of pediatric pain-related conditions on healthcare expenditures. We analyzed data from a nationally representative sample of 6-17
Current Therapeutic Research-clinical and Experimental, 2002
No widely accepted, optimal intervention is currently available for sleep disturbances in pediatr... more No widely accepted, optimal intervention is currently available for sleep disturbances in pediatric patients. This paper reviews data establishing the need for an effective, tolerated treatment and sets forth characteristics and applications of the ideal therapeutic approach. These points are considered with the aim of stimulating thought and furthering research to improve therapy for childhood sleep disturbances. The ideal pediatric
To evaluate the feasibility and preliminary effectiveness of an Internet-delivered cognitive-beha... more To evaluate the feasibility and preliminary effectiveness of an Internet-delivered cognitive-behavioral therapy (CBT) intervention for adolescents with chronic headache. Headache is among the most common pain complaints of childhood. Cognitive-behavioral interventions are efficacious for improving pain among youth with headache. However, many youth do not receive psychological treatment for headache due to poor access, which has led to consideration of alternative delivery modalities such as the Internet. We used a parallel arm randomized controlled trial design to evaluate the feasibility and preliminary effectiveness of an Internet-delivered family-based CBT intervention, Web-based management of adolescent pain. Adolescents were eligible for the trial if they were a new patient being evaluated in a specialized headache clinic, between 11 and 17 years of age, and had recurrent headache for 3 months or more as diagnosed by a pediatric neurologist. Eighty-three youths were enrolled i...
Around 4 million children undergo inpatient surgery in the U.S. each year, however little is know... more Around 4 million children undergo inpatient surgery in the U.S. each year, however little is known about the impact of surgery and postoperative pain on children's health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2-18 years (Mean=9.6 years), 50% male, 56% white, admitted to surgical services at a children's hospital enrolled in the study.
Internet-delivered interventions are emerging as a strategy to address barriers to care for indiv... more Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included 273 adolescents (205 females, 68 males), ages 11 to 17 years with mixed chronic pain conditions and their parents, randomly assigned in a parallel-group design to Internet-delivered CBT (n=138) or Internet-delivered Education (n=135). Assessments were completed at pre-treatment, immediate post-treatment and at 6-month follow up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to six-month follow-up for Internet CBT compared to Internet Education (b = -1.13, p = 0.03). On secondary outcomes, significant beneficial effects of Inter...
The purpose of the present study was to compare the health-related quality of life (HRQOL) of chi... more The purpose of the present study was to compare the health-related quality of life (HRQOL) of children with epilepsy with that of healthy controls and to examine predictors of HRQOL, including current treatment, seizure severity, and comorbid neurological impairments. The epilepsy group consisted of 41 children, aged 4-19 years. The control group consisted of 41 age-matched healthy children seen for well child care in a community pediatric practice. Results demonstrated that the HRQOL of the epilepsy group was significantly more limited than that of the control group. For children with epilepsy, comorbid neurological impairments and number of antiepileptic medications were associated with diminished HRQOL. Duration of illness, age of onset, seizure severity, and treatment type were not predictive of diminished HRQOL. The present findings suggest that presence of comorbid neurological impairments and number of medications are the best predictors of reduced HRQOL in children with epilepsy and may present a subgroup of patients with additional treatment needs.
Physical function and functional recovery are important aspects of the acute pain experience in c... more Physical function and functional recovery are important aspects of the acute pain experience in children and adolescents in hospitalized settings. Measures of function related to pediatric acute pain do not exist currently, limiting understanding of recovery in youth undergoing acute and procedural pain. To address this gap, we developed and assessed the clinical utility and preliminary validity of the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ). We evaluated psychometric properties of this measure in 159 patients with sickle cell disease, ages 7 to 21 years, who were hospitalized for vaso-occlusive episodes at 4 urban children's hospitals. The YAPFAQ demonstrated strong internal reliability and test-retest reliability. An exploratory factor analysis was conducted to examine the preliminary factor structure and to help reduce the number of items for the final scale. Evidence for moderate construct validity was demonstrated among validated measures of pain burden, motor function, functional ability, and quality of life. The YAPFAQ is a new measure of youth functional ability in the acute pain setting. Further evaluation of this measure in additional pediatric populations is needed to understand applicability across a spectrum of youth experiencing acute pain related to illness, trauma, and medical/surgical procedures.
The journal of pain : official journal of the American Pain Society, 2014
Physical function and functional recovery are important aspects of the acute pain experience in c... more Physical function and functional recovery are important aspects of the acute pain experience in children and adolescents in hospitalized settings. Measures of function related to pediatric acute pain do not exist currently, limiting understanding of recovery in youth undergoing acute and procedural pain. To address this gap, we developed and assessed the clinical utility and preliminary validity of the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ). We evaluated psychometric properties of this measure in 159 patients with sickle cell disease, ages 7 to 21Â years, who were hospitalized for vaso-occlusive episodes at 4 urban children's hospitals. The YAPFAQ demonstrated strong internal reliability and test-retest reliability. An exploratory factor analysis was conducted to examine the preliminary factor structure and to help reduce the number of items for the final scale. Evidence for moderate construct validity was demonstrated among validated measures of pain burden, ...
This study examined the factor structure of the Adolescent Sleep-Wake Scale (ASWS) among 491 adol... more This study examined the factor structure of the Adolescent Sleep-Wake Scale (ASWS) among 491 adolescents (12-18 years) with and without pediatric health conditions. Exploratory factor analyses were conducted using iterated principal axis factoring with varimax rotation. Highly cross-loading items were systematically removed and analyses were rerun until a clean solution was attained. The final solution explained 57.1% of the total model variance, including 10 items and three factors: Falling Asleep and Reinitiating Sleep-Revised, returning to Wakefulness-Revised, and Going to Bed-Revised. Internal consistency reliability scores were acceptable to good, with the exception of the Going to Bed-Revised subscale for the healthy sample. Adolescents with chronic pain reported significantly poorer overall sleep quality and more problems in falling asleep, reinitiating sleep, and returning to wakefulness as compared to healthy adolescents, providing preliminary evidence for construct validit...
The fear-avoidance model of chronic pain posits that fear of pain is associated with fear and avo... more The fear-avoidance model of chronic pain posits that fear of pain is associated with fear and avoidance of activity, which can lead to deconditioning and persistence of pain and disability. Despite being well supported in adults, little is known about the role of fear-avoidance beliefs regarding physical activity in children. Research has shown that parental protectiveness contributes to activity limitations in children; however, no studies have examined relationships between protectiveness, and fear and avoidance. To conduct a cross-sectional study to provide additional information regarding the reliability and validity of the Fear-Avoidance Beliefs Questionnaire physical activity subscale among adolescents with chronic pain; examine fear-avoidance beliefs and depressive symptoms as concurrent predictors of physical activity limitations; and test competing models using fear-avoidance beliefs as mediators and moderators of the association between parental protectiveness and activity...
To examine the incidence and nature of disagreements about pain and functional disability between... more To examine the incidence and nature of disagreements about pain and functional disability between parents and their children with juvenile idiopathic arthritis (JIA) and to identify demographic and psychosocial predictors of parent-child disagreement about pain and functional disability. Participants comprised 63 children 8-16 years of age (mean 12.36 +/- 2.61) and their parents, followed as part of a longitudinal study of pain in children. During routine rheumatology clinic visits, children and their parents completed validated measures of pain, depressive symptoms, and functional disability. Parents and children often disagreed as to the frequency and intensity of pain and to the degree of disability caused by arthritis. Child depressive symptoms (p < 0.01) and parental perceptions of child limitations (p < 0.02) predicted parent-child disagreement about the frequency of the child's pain. Parental perceptions of child limitations also predicted parent-child disagreement ...
There is increased recognition that sleep problems may develop in children and adolescents after ... more There is increased recognition that sleep problems may develop in children and adolescents after mild traumatic brain injury (mTBI). However, few studies have utilized both subjective and objective measures to comprehensively assess sleep problems in the pediatric population following the acute post-TBI period. The aims of this study were to compare sleep in adolescents with mTBI to healthy adolescents using subjective and objective measures, and to identify the clinical correlates associated with sleep problems. One hundred adolescents (50 adolescents with mTBI recruited from 3 to 12 months post-injury) and 50 healthy adolescents completed questionnaires assessing sleep quality, depression, and pain symptoms, and underwent 10-day actigraphic assessment of sleep patterns. Adolescents with mTBI reported poorer sleep quality, and demonstrated significantly shorter actigraphic-measured sleep duration, poorer sleep efficiency, and more wake time during the night compared to healthy adolescents (p&amp;amp;#39;s &amp;amp;lt; 0.05). For both groups of adolescents, poorer self-reported sleep quality was predicted by greater depressive symptoms. Poorer actigraphic sleep efficiency was predicted by membership in the mTBI group after controlling for age, sex, depressive symptoms and presence of pain. Our findings suggest that adolescents may experience subjective and objective sleep disturbances up to one year following mTBI. These findings require further replication in larger samples. Additionally, research is needed to identify possible mechanisms for poor sleep in youth with mTBI.
We appreciate the thoughtful commentaries by Cohen and by Steele, Borner, and Roberts on our reco... more We appreciate the thoughtful commentaries by Cohen and by Steele, Borner, and Roberts on our recommendations for competencies in pediatric psychology . This type of dialogue is exactly what we hoped to see and we encourage continued discussion concerning training in competency development in pediatric psychology.
Research on the experience of parents caring for a child with chronic pain indicates that high le... more Research on the experience of parents caring for a child with chronic pain indicates that high levels of parental role stress, feelings of frustration over an inability to help, and psychological distress are common. Moreover, parental distress adversely influences child adjustment to chronic pain. Therefore, intervening with parents of youth with chronic pain may, in turn, result in positive outcomes for children in their ability to engage in positive coping strategies, reduce their own distress, and to function competently in their normal daily lives. Our aim was to adapt an intervention, Problem-Solving Skills Training, previously proven effective in reducing parental distress in other pediatric illness conditions to the population of caregivers of youth with chronic pain. In the first phase, the intervention was adapted based on expert review of the literature and review of parent responses on a measure of pain-related family impact. In the second phase, the intervention was tested in a small group of parents to evaluate feasibility, determined by response to treatment content, ratings of acceptability, and ability to enroll and deliver the treatment visits. This phase included piloting the PSST intervention and all outcome measures at pre-treatment and immediately post-treatment. In an exploratory manner we examined change in parent distress and child physical function and depression from pre-to post-treatment. Findings from this feasibility study suggest that PSST can be implemented with parents of youth with chronic pain, and they find the treatment acceptable.
Sleep is intricately connected to health and well-being. Over the past decade, research has incre... more Sleep is intricately connected to health and well-being. Over the past decade, research has increasingly recognized the importance of sleep and the adverse daytime consequences and health outcomes of untreated sleep disturbances and sleep disorders. Studies have shown associations among sleep problems and key physiologic health parameters, including immune system functioning and metabolic/ endocrine regulation. 1 In children, specifically, short duration of nighttime sleep has been associated with increased risk of subsequent overweight or obesity. Sleep disturbances are especially prevalent in children with both acute and chronic disease states (eg, juvenile rheumatoid arthritis, asthma, cancer). Studies have shown that both acute and chronic medical conditions increase the risk of sleep disruptions, 3-6 and there is some evidence that sleep problems are more often chronic and persistent in youth with chronic conditions compared with those without chronic conditions. 7 The association between sleep problems and medical conditions may be related to underlying disease-related mechanisms (eg, airway restriction, inflammation), treatment regimens (including medications), or hospitalization. Some medical
The primary objective of this study was to assess the impact of pediatric pain-related conditions... more The primary objective of this study was to assess the impact of pediatric pain-related conditions on healthcare expenditures. We analyzed data from a nationally representative sample of 6-17
Current Therapeutic Research-clinical and Experimental, 2002
No widely accepted, optimal intervention is currently available for sleep disturbances in pediatr... more No widely accepted, optimal intervention is currently available for sleep disturbances in pediatric patients. This paper reviews data establishing the need for an effective, tolerated treatment and sets forth characteristics and applications of the ideal therapeutic approach. These points are considered with the aim of stimulating thought and furthering research to improve therapy for childhood sleep disturbances. The ideal pediatric
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Papers by Tonya Palermo