Publications

Relationship of exposure to clinically irrelevant emotion cues and obsessive-compulsive symptoms.

Behavior Modification, (In Press) Authors: Allen, L. B., & Barlow, D. H. Research has highlighted the role of emotion regulation as a common factor underlying emotional disorders. The current study examined the relationship of emotion regulation skills to obsessive-compulsive disorder (OCD) symptoms. Seven participants with a principal diagnosis of OCD in a multiple baseline across subjects design were taught the skill of prevention of emotional avoidance in the context of emotion provocation procedures to clinically irrelevant (nonspecific) cues prior to practicing this skill with clinically relevant (OCD-specific) cues. Results suggested successful acquisition of emotion regulation skills (as evidenced by reduced thought suppression and increased acceptance of thoughts and feelings) in clinically irrelevant contexts. Acquisition of this skill was associated with reduction in obsessive-compulsive symptoms, even though clinically relevant cues were not introduced during this phase. Implementation of skills in clinically relevant contexts was associated with greater reductions in OCD symptoms. Discussion focuses on implications for emotion regulatory processes in the maintenance and treatment of emotional disorders.

Psychologically-based treatments for medical conditions.

M. A. Bray and T. J. Kehle (Eds.), Oxford Handbook of School Psychology, (In Press) Authors: Allen, L. B., Tsao, J. C. I., Freeman, C., & Zeltzer, L. K. This chapter describes and reviews the evidence for a range of psychological treatments to assist children with medical problems. The interventions discussed in this chapter are designed to address the distress associated with a range of medical problems in children by reducing stress and anxiety, improving patients’ abilities to cope with their illness, and by encouraging developmentally appropriate behaviors to promote social, academic and family functioning. The focus of this chapter is on the treatment of chronic, non-malignant pain, since this condition involves the complex interaction of biological, social and psychological aspects and is thus well-suited to psychosocial intervention. This biopsychosocial model is at the core of psychological interventions for chronic medical problems in children which aim to promote active, adaptive coping with symptoms and illness-related disability.

Cognitive-behavior therapy (CBT) for panic disorder: Relationship of anxiety and depression comorbidity with treatment outcome.

Journal of Psychopathology and Behavioral Assessment., (In Press) Authors: Allen, L. B., White, K. S., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.

“I can’t be what I want to be”: Children’s narratives of Chronic Pain Experiences and Treatment Outcomes.

Pain Medicine, (In Press) Authors: Meldrum, M.L., Tsao, J.C.I., & Zeltzer, L.K. Background. Chronic or recurrent nonmalignant pain is a significant problem for many children and adolescents and often limits the child's participation in normal physical, academic, and social activities.
Objective. To better understand the impact of chronic or recurrent pain on children within the context of their own lives and experiences, using qualitative analysis, and to suggest the applications of the narrative method to clinical practice.
Design. Grounded theory and narrative analysis of in-depth semi-structured interviews conducted at baseline and 6-12 months following clinic intake.
Setting. Subject homes.
Patients. Fifty-three children ages 10-17 presenting with recurrent pain to a university-based pain clinic. This sample did not differ significantly from the overall clinic population during the study period.
Results. Five common themes were identified; these suggested that isolation, changed self-perception, activity limitations, concerns about barriers to future goals, and lack of medical validation were important to the children's perceived impact of pain on their lives. Five narratives were identified, each of which provided a coherent, integrated description of the factors and perspectives presented by a specific subset of children at baseline. These narratives were then compared against the children's reports of improvement in pain and functioning at 6-12 months; from this comparison, a sixth narrative of therapeutic change emerged for some of the children. Conclusions. The authors suggest that physicians and parents who take the initiative to elicit the child's narrative can help the child to rewrite the story to promote therapeutic change, a better outcome, and higher satisfaction.

Sex differences in associations between cortisol and laboratory pain responses in children.

Gender Medicine, New 6, 193-207, (2009-2021) Authors: Allen, L. B., Lu, Q., Tsao, J. C. I., Worthman, C., & Zeltzer, L. K. Background: Research in adult populations has highlighted sex differences in cortisol concentrations and laboratory pain responses, with men exhibiting higher cortisol concentrations and reduced pain responses compared with women. Yet, less is known about the relationship of cortisol concentrations to pain in children.
Objective: This study examined associations between sex, cortisol, and pain responses to laboratory pain tasks in children.
Methods: Salivary cortisol samples from subjects aged 8 to 18 years were obtained at baseline after entering the laboratory (SCb), after the completion of all pain tasks (SC1), and at the end of the session (SC2), 20 minutes later. Blood cortisol samples were also taken after completion of the pain tasks (BC1) and at the end of the session (BC2), 20 minutes later. Subjects completed 3 counterbalanced laboratory pain tasks: pressure, heat, and cold pressor tasks. Pain measures included pain tolerance, and self-reported pain intensity and unpleasantness for all 3 tasks.
Results: The study included 235 healthy children and adolescents (119 boys, 116 girls; mean age, 12.7 years; range, 8–18 years; 109 [46.4%] were in early puberty; 94 [40.0%] white). Salivary and blood cortisol levels were highly correlated with each other. Salivary cortisol levels for the total sample and for boys and girls declined significantly from SCb to SC1 (P < 0.01), although there were no significant changes from SC1 to SC2. No significant sex differences in salivary or blood cortisol levels were evident at any assessment point. Separate examination of the cortisol-laboratory pain response relationships by sex (controlling for age and time of day) suggested different sex-specific patterns. Higher cortisol levels were associated with lower pain reactivity (ie, increased pressure tolerance) among boys compared with girls at SC1, SC2, and BC1 (SC1: r = 0.338, P = 0.003; SC2: r = 0.271, P = 0.020; and BC1: r = 0.261, P = 0.026). However, higher cortisol levels were related to higher pain response (ie, increased cold intensity [BC2: r = 0.229, P = 0.048] and unpleasantness [BC1: r = 0.237, P = 0.041]) in girls compared with boys.
Conclusions: These findings suggest important sex differences in cortisol-pain relationships in children and adolescents. Cortisol levels were positively associated with increased pain tolerance in boys and increased pain sensitivity in girls.

Cognitive-behavioral therapy (CBT) for adolescents with chronic pain and comorbid anxiety/depression.

Poster session presented at the 28th annual scientific meeting of the American Pain Society, San Diego, CA., (2009-2021) Authors: Allen, L. B., Tsao, J. C. I, & Zeltzer, L. Z. Chronic, functional pain disorders in children are prevalent, difficult to treat, and can have a profound impact on social, physical, and academic functioning with potential long-term reduction in quality of life. Chronic pain, i.e., pain lasting 3 months or more, has been estimated to afflict between 25 to 45% of children under the age of 18 years. Despite significant advances over the past decade, standard medical therapies are not sufficient to manage chronic pain syndromes, and often additional therapies including psychotherapy are needed, and recent research emphasizing a biopsychosocial pain model has sparked interest in empirically-supported psychological treatments, such as cognitive-behavioral therapy (CBT) for addressing pain. However, one potential difficulty with treating pediatric pain syndromes is the high rate of comorbid anxiety and mood disorders that can exacerbate and complicate pain presentation. Between 50 to 64% of pediatric chronic pain patients meet criteria for a psychological disorder. Without sufficient attention to comorbid psychological symptoms, pain patients may be less likely to respond to pain therapies and may have greater risk of relapse. The current study evaluated the efficacy and feasibility of a new CBT protocol in children with chronic functional pain disorders with comorbid anxiety and/or unipolar depression symptoms. This unified protocol, based in cognitive-behavioral foundations, targets the emotional dysregulation that plays a fundamental role in anxiety and mood disorders, and likely pain disorders as well. We will present data on eight children and adolescents, ages 13-17, who participated in a nonconcurrent, multiple-baseline across subjects design. Pain and anxiety/depression symptoms were monitored weekly during baseline and throughout treatment. Post-intervention symptoms were compared to this baseline assessment of anxiety, depression, pain, and functioning. Initial results indicate significant improvement in pain and symptoms of anxiety and depression by posttreatment.

Sex differences in the relationship between maternal negative life events and children’s laboratory pain responsivity.

Journal of Developmental & Behavioral Pediatrics, 30(4); 279-288., (2009-2021) Authors: Evans, S., Tsao, J. C. I., Lu, Q., Kim, S. C., Turk, N., Myers, C. D., & Zeltzer, L. K Objectives: Previous research has demonstrated links between psychosocial factors, including negative life events (NLE) and pain in children. This study examined sex differences in the relationship among mother-reported NLE, child NLE, mother somatization, and children's laboratory pain responses for heat, cold, and pressure pain tasks. We predicted that maternal NLE would be moderately associated with girls' pain responses but would not be associated with boys' pain responses. METHOD: Participants were 176 nonclinical children (89 boys) aged 8 to 18 years (mean = 12.2, SD = 2.7) and their mothers. Mothers and children completed questionnaires assessing their perceptions of NLE experienced in the previous 12 months. RESULTS: Contrary to predictions, maternal NLE were related to pain responses in both boys and girls, although in opposite directions. Thus, increased maternal stress was associated with increased pain responses in girls but with decreased pain responses in boys. In addition, the impact of maternal NLE was only apparent for heat and pain tasks, indicating differential effects for various types of pain. CONCLUSION: The current findings underscore the importance of family variables in understanding sex differences in children's pain. Future research is needed to examine the mechanisms within the parent-child relationship that contribute to sex-differentiated pain outcomes, particularly under conditions of exacerbated parental stress.

Pediatric Pain Management: using Complementary and Alternative Medicine.

Reviews in Pain, 2(1); 14-20., (2009-2021) Authors: Evans, S., Tsao, J., & Zeltzer, L. Summary points
Children undergo acute painful procedures and many also experience chronic pain.
Due to their developing systems, infants and children may be at greater risk than adults for protracted pain sensitivity.
There is a need to manage acute and chronic paediatric pain to reduce children’s suffering and to prevent future pain problems.
Consistent with a biopsychosocial perspective, complementary and alternative medicine (CAM) should be considered in management of acute and chronic paediatric pain.
Although research is limited for paediatric pain, CAM interventions receiving the most empirical attention include hypnotherapy, acupuncture and music therapy. Evidence also exists for the therapeutic benefits of yoga, massage, humor therapy and the use of certain biological based therapies.

Iyengar yoga for pediatric chronic pain.

Pediatric Pain Letter, 11 (2); 12-16., (2009-2021) Authors: Evans, S., Tsao, J. C. I., Zeltzer, L. K.

Using the biopsychosocial model to understand the health benefits of yoga.

Journal of Complementary and Integrative Medicine, 6(1), Article 15., (2009-2021) Authors: Evans, S., Tsao, J., Sternlieb, B., & Zeltzer, L. Yoga is widely practiced as a means to promote physical, psychological and spiritual wellbeing. While a number of studies have documented the efficacy of yoga for functioning in healthy individuals and those experiencing illness or pain, biopsychosocial effects have not been detailed. We propose an analogue between the physical, psychological and spiritual effects of practice as espoused in yoga traditions, and the biopsychosocial model of health. To this end, we present a review and conceptual model of the potential biopsychosocial benefits of yoga, which may provide clues regarding the possible mechanisms of action of yoga upon well-being. Physical systems activated through yoga practice include musculoskeletal, cardiopulmonary, autonomic nervous system and endocrine functioning. Psychological benefits include enhanced coping, self-efficacy and positive mood. Spiritual mechanisms that can be understood within a Western medical model include acceptance and mindful awareness. We present empirical evidence that supports the involvement of these domains. However, additional well-conducted research is required to further establish the efficacy of yoga for health states, and to understand how posture, breath and meditative activity affect the body, mind and spirit.