Clinical Assistant Professor, Anesthesiology, Perioperative and Pain Medicine
Fellowship: Stanford University School of Medicine (2017) CA
Internship: Semel Institute for Neuroscience and Human Behavior (UCLA) (2014) CA
PhD Training: Georgia State University Registrar (2014) GA
M.S., Drexel University, Psychology (2008)
Ph.D., Georgia State University, Clinical Psychology (2014)
Clinical Internship, UCLA, Semel Institute for Neuroscience and Human Behavior, Pediatric Psychology (2014)
Postdoctoral Fellowship, Stanford University School of Medicine, Pediatric Pain Psychology (2017)
Current Research and Scholarly Interests
Pediatric Pain Management:
-Descriptive cross sectional research utilizing Peds-CHOIR
-Psychosocial interventions within an interdisciplinary outpatient and intensive rehabilitation setting (i.e., Pediatric Rehabilitation Program, PReP)
Risk and Resilience in Pediatric Pain
-Risk factors in pediatric pain including pain catastrophizing, particularly across developmental phases
-Resilience factors in pediatric pain such as acceptance of pain and mindfulness
-Mindfulness-based intervention for youth with pain and their parents/caregivers
-Photovoice with Pediatric Rehabilitation Program
-Adolescents and Young Adults (AYA) with chronic pain: exploring the needs of this population, developing and implementing interventions to promote psychosocial functioning and resilience
Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study.
JMIR rehabilitation and assistive technologies
2020; 7 (2): e22620
BACKGROUND: In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements.OBJECTIVE: We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain.METHODS: We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires.RESULTS: This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs.CONCLUSIONS: The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun.
View details for DOI 10.2196/22620
View details for PubMedID 33226346
Risk and Resilience in Pediatric Pain: The Roles of Parent and Adolescent Catastrophizing and Acceptance.
The Clinical journal of pain
OBJECTIVES: Both pediatric and parent pain catastrophizing and pain acceptance are key factors associated with pediatric pain outcomes; however, the interactive effects of these factors within the parent-child dyad have yet to be tested. The aims of this study were to examine: (1) the mediating role of child catastrophizing between parent catastrophizing and child outcomes (pain interference and mobility), (2) the mediating role of child acceptance between parent acceptance and child outcomes, and (3) whether child acceptance buffers the relation between parent catastrophizing and child catastrophizing, which in turn impacts child outcomes.METHODS: Cross-sectional data from 324 youth with chronic pain ages 10 to 17 years (M age=14.72, (SD=2.12); 73.1% female; 59% Caucasian) and their parents were collected. Participants completed measures assessing pediatric PROMIS domains (mobility and pain interference), pain catastrophizing, pain acceptance, and child pain intensity. Mediation was conducted via 1000-draw bootstrap-adjusted analyses in Mplus.RESULTS: Parent pain catastrophizing was indirectly associated with child pain interference via child catastrophizing but was not associated with mobility difficulties in the mediation model. Parent pain acceptance was indirectly associated with both child pain interference and mobility via child acceptance. We did not find evidence of child acceptance buffering parent and child pain catastrophizing.DISCUSSION: The findings of this study highlight the need for caregiver involvement in multidisciplinary treatments to mitigate risk and enhance resilience in youth with chronic pain.
View details for PubMedID 30028367
A Pilot Study of Mindfulness Meditation for Pediatric Chronic Pain.
Children (Basel, Switzerland)
2017; 4 (5)
Despite advances in psychological interventions for pediatric chronic pain, there has been little research examining mindfulness meditation for these conditions. This study presents data from a pilot clinical trial of a six-week manualized mindfulness meditation intervention offered to 20 adolescents aged 13-17 years. Measures of pain intensity, functional disability, depression and parent worry about their child's pain were obtained at baseline and post-treatment. Results indicated no significant changes in pain or depression, however functional disability and frequency of pain functioning complaints improved with small effect sizes. Parents' worry about child's pain significantly decreased with a large effect size. Participants rated intervention components positively and most teens suggested that the number of sessions be increased. Three case examples illustrate mindfulness meditation effects and precautions. Mindfulness meditation shows promise as a feasible and acceptable intervention for youth with chronic pain. Future research should optimize intervention components and determine treatment efficacy.
View details for DOI 10.3390/children4050032
View details for PubMedID 28445406
The Effect of Pain Catastrophizing on Outcomes: A Developmental Perspective Across Children, Adolescents, and Young Adults With Chronic Pain.
journal of pain
2017; 18 (2): 144-154
Pain catastrophizing is one of the most powerful predictors of poor outcomes in youth and adults with pain; however, little is known about differential effects of pain catastrophizing on outcomes as a function of age. The current study examined the predictive value of pain catastrophizing on pain interference and pain intensity across children, adolescents, and 2 age groups of young adults with chronic pain. Cross-sectional data are presented from the adult and pediatric Collaborative Health Outcomes Information Registry (CHOIR), including measures of pain catastrophizing, pain intensity, pain interference, and emotional distress from 1,028 individuals with chronic pain. Results revealed that age moderated the relation between pain catastrophizing and pain interference, with the strength of these effects declining with age. The effect of pain catastrophizing on pain interference was strongest in adolescents and relatively weak in all 3 other groups. Emotional distress was the strongest predictor of pain interference for children, whereas pain intensity was the strongest predictor for both adult groups. Pain catastrophizing was found to predict pain intensity and, although age was a significant moderator, statistical findings were weak. Developmental considerations and clinical implications regarding the utility of the construct of pain catastrophizing across age groups are discussed.This article explores differences in pain catastrophizing as predictors of pain interference and pain intensity across cohorts of children, adolescents, and 2 age groups of young adults. This work may stimulate further research on chronic pain from a developmental perceptive and inform developmentally tailored treatment interventions that target catastrophizing, emotional distress, and pain intensity.
View details for DOI 10.1016/j.jpain.2016.10.009
View details for PubMedID 27825857
Pediatric-Collaborative Health Outcomes Information Registry (Peds-CHOIR): a learning health system to guide pediatric pain research and treatment.
2016; 157 (9): 2033-2044
The pediatric adaptation of the Collaborative Health Outcomes Information Registry (Peds-CHOIR) is a free, open-source, flexible learning health care system (LHS) that meets the call by the Institute of Medicine for the development of national registries to guide research and precision pain medicine. This report is a technical account of the first application of Peds-CHOIR with 3 aims: (1) to describe the design and implementation process of the LHS; (2) to highlight how the clinical system concurrently cultivates a research platform rich in breadth (eg, clinic characteristics) and depth (eg, unique patient- and caregiver-reporting patterns); and (3) to demonstrate the utility of capturing patient-caregiver dyad data in real time, with dynamic outcomes tracking that informs clinical decisions and delivery of treatments. Technical, financial, and systems-based considerations of Peds-CHOIR are discussed. Cross-sectional retrospective data from patients with chronic pain (N = 352; range, 8-17 years; mean, 13.9 years) and their caregivers are reported, including National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) domains (mobility, pain interference, fatigue, peer relations, anxiety, and depression) and the Pain Catastrophizing Scale. Consistent with the literature, analyses of initial visits revealed impairments across physical, psychological, and social domains. Patients and caregivers evidenced agreement in observable variables (mobility); however, caregivers consistently endorsed greater impairment regarding internal experiences (pain interference, fatigue, peer relations, anxiety, and depression) than patients' self-report. A platform like Peds-CHOIR highlights predictors of chronic pain outcomes on a group level and facilitates individually tailored treatment(s). Challenges of implementation and future directions are discussed.
View details for DOI 10.1097/j.pain.0000000000000609
View details for PubMedID 27280328
Pain Intensity, Psychological Inflexibility, and Acceptance of Pain as Predictors of Functioning in Adolescents with Juvenile Idiopathic Arthritis: A Preliminary Investigation
JOURNAL OF CLINICAL PSYCHOLOGY IN MEDICAL SETTINGS
2011; 18 (3): 291-298
Juvenile Idiopathic Arthritis (JIA) is a chronic rheumatic disease associated with pain and maladjustment. This study investigated whether pain, acceptance of pain, and psychological inflexibility uniquely predicted functional disability, anxiety, general quality of life (QOL), and health-related quality of life (HQOL) among adolescents with JIA. Twenty-three adolescents with JIA and pain were recruited from a pediatric rheumatology clinic. Participants completed self-report measures pertaining to the key study variables. A series of multiple regression analyses demonstrated that higher pain uniquely predicted higher functional disability. Greater psychological inflexibility uniquely predicted higher anxiety, lower general QOL, and lower HQOL. Increases in acceptance of pain were found to be uniquely related to increases in general QOL. These data confirm prior findings that pain impacts functioning, and provide preliminary findings that psychological inflexibility and acceptance may be important targets of psychological intervention for youth with JIA and pain to improve functioning and QOL.
View details for DOI 10.1007/s10880-011-9243-6
View details for Web of Science ID 000294361000007
View details for PubMedID 21630002
Parent physical and mental health contributions to interpersonal fear avoidance processes in pediatric chronic pain.
Theoretical models and evidence increasingly identify chronic pain as a family issue. To date, much of this work has focused on risk conferred by parental chronic pain status despite evidence suggesting parent mental illness and non-pain-related chronic illness may also contribute to poorer chronic pain outcomes in children. This study is the first to test interpersonal fear avoidance processes as possible mechanisms through which parent health (mental and physical) influences pediatric chronic pain functioning. We used structural equation models (SEM) to test such an integrative model using cross-sectional data from a large clinical registry of 448 dyads of patients 8-18 years old (M=14.57 years; SD=2.38; 327 females) with mixed chronic pain and their parents (403 mothers). As expected, poorer parent global health was indirectly related to greater child pain interference via higher parent pain catastrophizing, and then via greater parent protective behaviors, and child pain catastrophizing. The model demonstrated excellent fit to the data (chi = 5.04, ns; chi/df = 1.01; CFI = 1.00, RMSEA = .004 [90% confidence interval (CI) = .000-.066]). Exploratory multiple-group comparison SEM revealed moderation of specific model paths based on child age group (8- to 12-year-olds versus 13- to 18-year-olds) and parent pain status (present versus absent). This study integrates family models of pain with the interpersonal fear avoidance model to extend our mechanistic understanding of parental physical and mental health contributors to pediatric chronic pain.
View details for DOI 10.1097/j.pain.0000000000001820
View details for PubMedID 32011420
Yoga Intervention for an Adolescent With Juvenile Idiopathic Arthritis: A Case Study.
Advances in mind-body medicine
; 32 (1): 13–20
Juvenile idiopathic arthritis (JIA) is a chronic rheumatic disease associated with pain, stiffness, and psychosocial difficulties. The purpose of this case study was to investigate the impact of a yoga intervention on pain and morning stiffness in an adolescent female with JIA. A secondary aim was to assess the impact of this intervention on self-efficacy, mindfulness, health-related quality of life, and disease activity. A 17-y-old female with JIA participated in 3 yoga groups and home yoga practice with a digital video disc. She engaged in daily self-monitoring of pain and stiffness and completed questionnaires assessing psychosocial functioning and disease activity at pre- and postintervention, and psychosocial functioning at 3-mo follow-up. Primary outcomes were evaluated using quasi-experimental single-case design structure (ie, ABAB), with emphasis on the report of means. Results suggested that yoga reduced pain intensity, stiffness intensity, and duration of morning stiffness. Outcomes for disease activity also suggested improvements. Modest changes were revealed on psychosocial outcome measures, however not consistently in the direction of hypotheses. Anecdotal reports from the participant indicated acceptability of the intervention and improvements in pain and stiffness attributed to engaging in the yoga intervention. More research is warranted to further explore the impact of yoga for youth with JIA as an adjunctive component of multidisciplinary treatment targeting pain, stiffness, disease activity, and psychosocial factors.
View details for PubMedID 29406303
Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids.
Children (Basel, Switzerland)
2019; 6 (2)
Opioid therapy is the cornerstone of treatment for acute procedural and postoperative pain and is regularly prescribed for severe and debilitating chronic pain conditions. Although beneficial for many patients, opioid therapy may have side effects, limited efficacy, and potential negative outcomes. Multidisciplinary pain management treatments incorporating pharmacological and integrative non-pharmacological therapies have been shown to be effective in acute and chronic pain management for pediatric populations. A multidisciplinary approach can also benefit psychological functioning and quality of life, and may have the potential to reduce reliance on opioids. The aims of this paper are to: (1) provide a brief overview of a multidisciplinary pain management approach for pediatric patients with acute and chronic pain, (2) highlight the mechanisms of action and evidence base of commonly utilized integrative non-pharmacological therapies in pediatric multidisciplinary pain management, and (3) explore the opioid sparing effects of multidisciplinary treatment for pediatric pain.
View details for PubMedID 30795645
The role of fatigue in functional outcomes for youth with chronic pain.
European journal of pain (London, England)
As a complex multidimensional construct, fatigue may play an important role in the physical and psychosocial functioning of youth with chronic pain. Based on a model previously tested in adults, the current study similarly utilized patient-reported outcomes measurement system (PROMIS) to examine how fatigue contributes to functional outcomes for youth with chronic pain. The model tested self-reported ratings of pain intensity, depressive symptoms and sleep disturbance as predictors of outcomes (mobility, pain-related interference and school functioning) as mediated by ratings of fatigue.Two hundred and eighty-five youth with chronic pain ages 8-17 years and their caregivers, completed surveys as part of their initial clinical evaluation at a tertiary paediatric pain clinic. Study measures included: paediatric PROMIS domains (mobility, pain interference, sleep disturbance, fatigue and depressive symptoms), Paediatric Quality of Life school functioning and pain intensity. All mediated effects were calculated via a 1,000-draw bootstrap estimation method in Mplus.Fatigue was found to be a statistically significant mediator of the effects of pain intensity, sleep disturbance and depressive symptoms on outcomes of pain interference, mobility and school functioning. While pain intensity was found to independently contribute to mobility and pain interference, depressive symptoms did not show significant effects on any outcome beyond its association with fatigue. Sleep disturbance predicted pain interference while fatigue predicted school functioning.Findings suggest that fatigue is an important intervening factor for functional outcomes among youth with chronic pain. Targeting fatigue may be effective in optimizing school functioning and reducing the deleterious effects of depressive symptoms.This cross-sectional study highlights fatigue as a potential clinical target by applying a path analytic model to understand its possible significance and distinction from overlapping constructs such as pain intensity, depression and sleep disturbance. Further study of fatigue may be important in understanding its importance in treatment of paediatric chronic pain.
View details for DOI 10.1002/ejp.1431
View details for PubMedID 31131940
Social Risk and Resilience Factors in Adolescent Chronic Pain: Examining the Role of Parents and Peers.
Journal of pediatric psychology
The current study focuses on social risk and resilience in an adolescent population with chronic pain. Prior research identifies parental cognitions and behaviors as influential in youths' experiences of chronic pain and pain-related disability. Adolescent development is characterized by greater autonomy from parents and an increased emphasis on peer relationships. Study aims explore the potential protective effect of high-quality adolescent peer relationships on associations between parent and adolescent cognitive and behavioral responses to pain.238 adolescents with mixed-etiology chronic pain and their parents completed Pediatric Collaborative Health Outcomes Information Registry (Peds-CHOIR) electronic questionnaires prior to their initial visit to a tertiary pediatric pain clinic. Variables in this study include parent catastrophizing, parent protective behavior, adolescent peer relationship quality, adolescent catastrophizing, adolescent functional impairment, and demographic and pain characteristics.As expected, associations between parent and adolescent cognitive and behavioral pain responses were moderated by peer relationship quality. Contrary to expectations, for adolescents endorsing low-quality peer relationships, maladaptive adolescent outcomes were elevated across levels of parental cognitions and behaviors. For adolescents endorsing high-quality peer relationships, adolescent and parent pain responses were linearly related.This study highlights the salience of both family and peer processes in functional outcomes among adolescents with chronic pain. Results suggest that adolescents' adaptive responses to chronic pain may be best supported by the simultaneous presence of adaptive parenting and high-quality peer relationships. Understanding the larger social context in which an adolescent exists is informative in specifying models that predict adaptive outcomes or magnify risks.
View details for PubMedID 29048554
- Gender differences in the relation between functioning and values-based living in youth with sickle cell disease Clinical Practice in Pediatric Psychology 2016; 4 (1): 11-22
Single-Case Research Design in Pediatric Psychology: Considerations Regarding Data Analysis
JOURNAL OF PEDIATRIC PSYCHOLOGY
2014; 39 (2): 124-137
Single-case research allows for an examination of behavior and can demonstrate the functional relation between intervention and outcome in pediatric psychology. This review highlights key assumptions, methodological and design considerations, and options for data analysis.Single-case methodology and guidelines are reviewed with an in-depth focus on visual and statistical analyses.Guidelines allow for the careful evaluation of design quality and visual analysis. A number of statistical techniques have been introduced to supplement visual analysis, but to date, there is no consensus on their recommended use in single-case research design.Single-case methodology is invaluable for advancing pediatric psychology science and practice, and guidelines have been introduced to enhance the consistency, validity, and reliability of these studies. Experts generally agree that visual inspection is the optimal method of analysis in single-case design; however, statistical approaches are becoming increasingly evaluated and used to augment data interpretation.
View details for DOI 10.1093/jpepsy/jst065
View details for Web of Science ID 000332344000002
View details for PubMedID 24003176
Ecological system influences in the treatment of pediatric chronic pain
PAIN RESEARCH & MANAGEMENT
2012; 17 (6): 407-411
Family, school and the peer network each shape the chronic pain experience of the individual child, and each of these contexts also represents a domain of functioning often impaired by chronic pain. The goal of the present article is to summarize what is known about these bidirectional influences between children with pain and the social systems that surround them. Case reports that illustrate these complex, transactional forces and their ultimate impact on the child's pain-related functioning are included. A case involving siblings participating in an intensive interdisciplinary program for functional restoration and pain rehabilitation highlights how parents change through this treatment approach and how this change is vital to the child's outcomes. Another case involving a child undergoing intensive interdisciplinary treatment illustrates how school avoidance can be treated in the context of pain rehabilitation, resulting in successful return to the regular school environment. Finally, an acceptance and commitment therapy-focused group intervention for children with sickle cell disease and their parents demonstrates the benefits of peer contact as an element of the therapeutic intervention.
View details for Web of Science ID 000315572000007
View details for PubMedID 23248814
The Influence of Parent Preprocedural Anxiety on Child Procedural Pain: Mediation by Child Procedural Anxiety
JOURNAL OF PEDIATRIC PSYCHOLOGY
2012; 37 (6): 680-686
Data suggest parents' preprocedural anxiety is related to children's acute procedural anxiety and pain. This study examined the temporal relations among these constructs to determine whether children's anxiety mediates the relation between parents' anticipatory anxiety and children's procedural pain.A total of 90 preschoolers receiving immunizations, their parents, and the nurses rated children's procedural anxiety and pain. Parents provided ratings of their own preprocedural anxiety.Bootstrapping analyses revealed that children's procedural anxiety mediated the relation between parents' preprocedural anxiety and children's procedural pain according to parents' report and nurses' report but not children's self-report of anxiety and pain.Analyses suggest that children's procedural anxiety mediates the relation between parents' anticipatory anxiety and children's procedural pain. Thus, targeting parents' preprocedural anxiety might be beneficial to the parents as well as the children undergoing a distressing medical procedure.
View details for DOI 10.1093/jpepsy/jss041
View details for Web of Science ID 000305827600010
View details for PubMedID 22623729
- The use of distraction, acceptance and mindfulness-based techniques in the treatment of pediatric pain Pediatric Pain Letter 2012; 14: 1-9
- Managing pain in older adults: the benefits of yoga postures, meditation and mindfulness Topics in Geriatric Rehabilitation 2011; 27: 1-6
Cognitive Defusion Versus Thought Distraction: A Clinical Rationale, Training, and Experiential Exercise in Altering Psychological Impacts of Negative Self-Referential Thoughts
2010; 34 (6): 520-538
Using two modes of intervention delivery, the present study compared the effects of a cognitive defusion strategy with a thought distraction strategy on the emotional discomfort and believability of negative self-referential thoughts. One mode of intervention delivery consisted of a clinical rationale and training (i.e., Partial condition). The other mode contained a condition-specific experiential exercise with the negative self-referential thought in addition to the clinical rationale and training (i.e., Full condition). Nonclinical undergraduates were randomly assigned to one of five protocols: Partial-Defusion, Full-Defusion, Partial-Distraction, Full-Distraction, and a distraction-based experimental control task. The Full-Defusion condition reduced the emotional discomfort and believability of negative self-referential thoughts significantly more than other comparison conditions. The positive results of the Full-Defusion condition were also found among participants with elevated depressive symptoms.
View details for DOI 10.1177/0145445510379632
View details for Web of Science ID 000282686100003
View details for PubMedID 20689153
- The effects of cognitive defusion and thought distraction on emotional discomfort and believability of negative self-referential thoughts JOURNAL OF BEHAVIOR THERAPY AND EXPERIMENTAL PSYCHIATRY 2010; 41 (1): 11-17