Stress Responses in Children with Chronic Pain and Anxiety

Madeleine Jackson, Lynette Dufton, M.S., & Bruce E. Compas, Ph.D.

Introduction

Method

Conclusions

References

•Children with RAP and anxious children may be more similar than different in reactivity to stress.•RAP (n = 21): 11 (52%) also met criteria for a DSM-IV anxiety disorder•Anxious (n = 21): 5 (24%) also met criteria for RAP

•The results of this study provide support for the theory that the commonality between the clinical groups is stress reactivity.•Implications for intervention include focusing on altering automatic stress responses both by bringing physiological reactivity under control and focusing on the cognitive and behavioral factors on stress reactivity (e.g. intrusive thoughts, rumination, and impulsive action).

ResultsParticipants:

•63 participants (29 male, 34 female):•21 RAP, 21 anxious, 21 healthy•Ages 8 to 16 (M = 11.64)•Groups matched for age and gender

•Ethnic makeup of the sample:•71% white 19% African American, 3%Asian, 6% other, and 2% Hispanic

•Participants excluded pair-wise for analyses

Measures:

•Heart rate monitors•Psychological Stress Tasks

•Serial Subtraction Task•Social Stress Interview

•Physical Stress Task: Cold Pressor•Recovery Period•Questionnaires

•Youth Self Report (YSR) •112-item questionnaire provides information on the participants’ perceptions of their psychological and somatic symptoms as well as level of functioning

•Child Behavior Checklist (CBCL)•112-item parent-version of the YSR•assesses the parent’s perception of the child’s internalizing and externalizing problems in the past six months

•Responses to Stress Questionnaire (RSQ) •57-item RSQ assess coping mechanisms in reference to age-appropriate social stressors •One scale of the RSQ is involuntary engagement, which includes physiological reactivity, emotional reactivity, intrusive thoughts, rumination, and impulsive action

STRESS REACTIVITY

•Chronic stress plays a role in the maintenance of RAP and anxiety disorders (Walker, Garber, Smith, Van Slyke, & Claar, 2001)

•RAP could be similar to anxiety in that they both involve an overall maladaptive reactivity to stress

•Automatic stress responses play a role in both clinical populations: biological, psychological, and emotional reactions to perceived stressors

•Stress reactivity is associated with more somatic symptoms and symptoms of anxiety and depression (Thomsen & Compas, 2002)

RECURRENT ABDOMINAL PAIN

•Recurrent abdominal pain (RAP) is the most common chronic pain complaint among children---between 10 and 20% of children experience RAP

•To qualify for a classification of RAP, a child must have experienced at least 3 pain episodes in 3 months that impaired an activity (Apley, 1975)

Hypotheses

•(1) Physiological stress responses:

•Children with RAP and anxious children will react similarly to stress, reflected in their similar mean heart rates. These two groups will have higher mean heart rates than the healthy controls.

•(2) Self-reported Stress reactivity:

•Children with RAP will self-report being more stress reactive than the other two groups, as measured by the Involuntary Engagement scale of the RSQ.

•(3) Relations among the variables?:

•Physiological reactivity will be positively correlated with psychological and somatic symptoms, and self-reported stress reactivity.

•We will be able to predict the variance in self-reported psychological and somatic symptoms from physiological and self-reported stress reactivity beyond what group label tells us.

Future Directions

•Future studies should use a larger sample size to determine presence of differences in physiological reactivity, namely with the RAP group.•Future research should investigate parent perceptions of child difficulties to address the difference in parent and child reports of psychological and somatic symptoms.•Future analyses with the current sample will divide the groups based solely on the presence vs. absence of RAP and/or an anxiety disorder.•Future analyses with the current sample will also use additional physiological measures that were collected, including Galvanic Skin Response and Respiratory Sinus Arrhythmia.

Acknowledgments

•Dr. Bruce E. Compas, for his constant encouragement and untiring attention and care to both this thesis and my learning experience. I attribute to him my love of psychology and research. •Lynette Dufton, M.S., the graduate supervisor of the project. I thank her for her extensive role in teaching me about research methods and data analysis, and for her generous nature as a consultant for so many questions.•Supported by a National Research Service Award from NIMH to Lynette Dufton.

56.8

63.3

56.5

61.8

60.1

63.8

56.056.8

53.453.6

54.6

52.4

50.0

54.0

58.0

62.0

66.0

70.0

YSRAnx/Dep

YSRSomatic

Complaints

CBCLAnx/Dep

CBCLSomatic

Complaints

T-S

core

s RAPAnxiousHealthy

Descriptive Statistics:Psychological Symptoms

0.26

0.220.23

0.2

0.22

0.24

0.26

0.28

0.3

Involuntary Engagement Responses to Stress

Prop

ortio

n Sc

ores

from

the

RSQ

RAP

Anxious

Healthy

Self-reported Stress Reactivity

0.440.47

0.44

0.54

0.380.35

0.26

0.4

0.3

0.47

0.35

0.3

0.44

0

0.2

0.4

0.6

Baseline:Mean

Heart Rate

StressTasks:Mean

Heart Rate

ColdPressor:

MeanHeart Rate

Recovery:Mean

Heart Rate

PainIntensity

Co

rre

lati

on

Co

eff

icie

nts

(r

= ) YSR

Anx/Dep

CBCLSomatic

Inv.Engage.

YSRSomatic

Correlational Data

YSR Anxious/DepressedSymptoms

Group Label (RAP, Anxious, Healthy)

β = .35*

Mean Heart Rate(beats per minute)

β = .36*

Involuntary EngagementProportion Scores (RSQ)

β = .32

Regression Equation Predicting

YSR Anxious/Depressed Symptoms

YSR SomaticComplaints

Group Label (RAP, Anxious, Healthy)

β = .17

Mean Heart Rate(beats per minute)

β = -.16

Involuntary EngagementProportion Scores (RSQ)

β = .51*

Regression Equation Predicting

YSR Somatic Complaints

Mean Heart Rate Across Time for Groups

82.00

85.00

88.00

91.00

94.00

97.00

100.00

Baseline Stress Tasks Cold Pressor Recovery

Time Intervals

Mea

n H

eart

Rat

e (b

pm

)

Well

RAP

ANX

PAIN AND ANXIETY

•RAP is comorbid with symptoms of anxiety and anxiety disorders (Blanchard & Scharff, 2002)

•Underlying mechanisms could be the same in these two clinical populations, but children present with different primary complaints

•Children with RAP and anxious children are hypervigilant to perceived environmental threats (Boyer & Compas, 2006)

Physiological Stress Reactivity

•Apley, J. (1975). The Child with Abdominal Pain (2nd edition) (2nd ed.). Oxford: Blackwell Scientific Publications.•Blanchard, E. B., & Scharff, L. (2002). Psychosocial aspects of assessment and treatment of irritable bowel syndrome in adults and recurrent abdominal pain in children. Journal of Consulting and Clinical Psychology, 70, 725-738.•Boyer, M. C., Compas, B. E., Stanger, C., Colletti, R. B., Konik, B. S., Morrow, S. B., et al. (2006). Attentional biases to pain and social threat in children with recurrent abdominal pain. Journal of Pediatric Psychology, 31(2), 209-220.•Thomsen, A.H., Compas, B.E., Colletti, R.B., Stanger, C., Boyer, M., & Konik, B. (2002). Parent reports of coping and stress responses in children with recurrent abdominal pain. Journal of Pediatric Psychology, 27, 215-226.

At the final step: F (3, 28) = 6.44, p =.002, Final R2 = .41

* p < .05At the final step: F (3, 28) = 2.43, p =.09, Final R2 = .21

* p < .05

*

*

*

YSR Som: F (2, 34) = 7.30, p = .002CBCL Anx/Dep: F (2, 60) = 12.1, p < .001 CBCL Som: F (2, 60) = 7.5, p = .001

Main Effect for Time: Wilks’ Lambda: F (3, 49) = 12.64, p < .001Quadratic Effect for Time: F (1, 51) = 20.65, p < .001

**p < .01, F (2, 54) = 5.59, p = .006

**

*p < .05, **p< .01, +p = .06

*

*

**

**

**

** *

*

+

**

****

*