THE EFFECTS OF PARENTAL ANXIETY AND MEDICATION ATTITUDES ON THE USE OF PAIN MEDICATION IN PEDIATRIC CANCER PATIENTS

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1 THE EFFECTS OF PARENTAL ANXIETY AND MEDICATION ATTITUDES ON THE USE OF PAIN MEDICATION IN PEDIATRIC CANCER PATIENTS Narvaez, Vincent Reginald F. Deartment of Anesthesiology Michelle A. Fortier, Ph.D. Parents of ediatric cancer atients exerience uncertainty with regards to cancer-related ain. Parental ain management at home is very imortant in managing the overall symtoms of ediatric cancer atients. It is very imortant to investigate the relationshi between arental anxiety and ain medication use. Studies have suggested that more anxious arents tend to exerience more symtoms of acute stress comared to less anxious arents. Studies in ostoerative children have also found that arental attitudes can be a barrier in ain management. In this study, I hyothesized that arents having more favorable attitudes to medication will administer more analgesics to their children. I also hyothesized that increased levels of anxiety in arents will lead to a greater use of analgesic medication in the management of ediatric cancer ain. The study found that arents who have less misconcetions about medication Avoidance ( = 0.09) and Aroriate use ( = 0.03) administered more medication to their children. Parental attitudes regarding Fear of Side Effects did not significantly imact the administration of medication. In terms of anxiety, only child-trait anxiety showed a significant relationshi with the administration of medication ( = 0.04). The imlications of this study may include arental counseling and intervention by the healthcare roviders on medication administration. The healthcare roviders must address questions regarding how much medication, how often, and what signs to look for. This way, ediatric cancer atients are adequately and aroriately treated for ain at home. Cancer conjures fear and anxiety in the afflicted individual, as well as the eole close to them. The arents of ediatric cancer atients exerience extreme distress when dealing with the diagnosis, treatment, and ost-treatment conditions of their children. lays a big role in the exerience of the arents as it brings forth a feeling of uncertainty and threat (Jantien Vrijmoet-Wiersma et al, 2008). There is a marked difference in levels of anxiety between arents

2 whose child was recently diagnosed with cancer, arents of children undergoing treatment, and arents of children who are off-treatment (Brown et al, 1992). The general stigma associated with cancer, couled with the arent s lack of information can contribute to the shock brought about by the initial diagnosis. Even after the diagnosis, arents go through intense distress when their child is undergoing cancer treatment This might be due to watching their children suffer through ainful rocedures and having difficulty in dealing with interrutions in their normal daily lives (Best, 2001). Parental distress may be artly due to the ain symtoms that are commonly exerienced by ediatric cancer atients. Although ain is only one of the many symtoms cancer atients exerience, it is one of the most distressing symtom that atients and caregivers fear (Collins, 2002). Pain in cancer atients is enhanced due to the increased sensitivity of nocicetors after exosure to roducts of tumor cells or tissue injury (Collins et al, 2006). Although harmacological and non-harmacological theraies are available to manage ain in cancer atients, its multidimensional nature makes cancer ain comlicated to control. Drug theray is the main tool used in managing ediatric cancer ain (Jacox et al, 1994). The World Health Organization analgesic ladder, divided according to the drug s usefulness in dealing with mild, moderate, and severe ain, is used in determining the tye of analgesic medication administered in ediatric cancer atients (WHO, 1998). On the other hand, non-harmacological treatments may include hysical and behavioral interventions such as massage, acuuncture, dee breathing, and meditation. Due to the increase in outatient treatment of ediatric cancer atients, arents are largely resonsible for ain management in the home setting; yet, arents may not have enough information and exertise to manage their children s ain. Furthermore, the arent s emotional 2

3 behavior and state may influence how arents manage children s ain symtoms. Past studies have indicated that arents showing a greater level of anxiety tend to exerience increased symtoms of acute stress comared to less anxious atients (Patiño et al, 2008). This added acute stress may cause arents to overcomensate with their child s ain management and unintentionally give too much ain medication in order to alleviate their children s symtoms. This is very imortant as changes in the healthcare system focus on outatient treatment of children, thus utting more care resonsibilities in the hands of the arents. Overuse of ain medications can result in unwanted side effects such as nausea, vomiting, constiation, and diarrhea. More imortantly, these medications, when used indiscriminately, may cause liver and renal toxicities. Acetaminohen, a drug commonly used to manage ediatric cancer ain, can cause injury to liver cells that can gradually rogress into acute liver failure (Lee, 2003). Due to its imortance and otential risks, medication use in ediatric cancer atients at home should be examined more closely. The rimary hyothesis of this study is that increased levels of arental anxiety will lead to a greater use of ain medications to control the child s ain symtoms at home. In addition, although untested in the ediatric cancer oulation, ast studies involving ostoerative children show that arent s attitudes may be a barrier to the child s ostoerative ain assessment and ain management (Zisk-Rony et al, 2010). This may be alicable to arental ain assessment and management of ediatric cancer ain at home. In connection to this, the study hyothesized that arents having more favorable attitudes towards the use of ain medications will use analgesics to a greater extent than those who have less favorable attitudes. MATERIALS AND METHODS 3

4 All exeriments were carried out in accordance with the Institutional Review Board and the University of California, Irvine, and were consistent with Federal guidelines. Study Particiants Children ages 4-17 and their arents were recruited to articiate in this study, which was art of a larger cross-sectional study examining revalence of ain and analgesic administration in children undergoing outatient treatment for cancer. Recruited children were currently undergoing cancer treatment and were routinely seen in the outatient infusion center at the Children s Hosital of Orange County (CHOC). Exclusion criteria included: a) Children with develoment delays or secial needs, and b) children whose arents did not seak English. Background information about the study was rovided to rosective articiants by mail. Trained research assistants met the rosective articiants at CHOC s outatient infusion center to answer questions and consent their articiation. Study Procedures Particiants were rovided the questionnaires and were given instructions on comleting them. Parents were required to log whether or not they administered medication to their child on a daily basis for 14 days. Additionally, arents were asked to log the secific times during the day when the medication was administered, as well as the tye and amount of medication. Parents who did not administer medication on a secific day were asked to indicate the reason for not giving any medication to their child. Parents and children also rovided daily reorts of child ain severity for the 14 days. Measures 4

5 Demograhic Information. Parents comleted a demograhic form that included information about their child s gender, race, age, diagnosis, and ethnicity. Additionally, the arents gender, race, age, and education levels were also collected. Medication Attitude Questionnaire (MAQ). The MAQ (Zisk et al, 2007; Forward et al, 1996) was develoed to examine attitudes about the use of ain medication in treating children s ain. The instrument consists of 27 items each rated on a seven-oint Likert-tye scale that ranges from strongly disagree to strongly agree. Parents are instructed to consider analgesia as any medication rescribed for a secific event or over-the-counter analgesia any time. Internal consistency (Cronbach s Alha) for the overall scale is reorted between 0.68 and 0.73 (Forward et al, 1996). Three factors exist within the measure, including; Aroriate-use (relates to the roer use of drugs in children), Fear of Side-effects (relates to the worries brought about by ossible drug-side effects), and Avoidance (relates to the avoidance of medication until absolutely necessary). State-Trait Inventory (STAI). The STAI is a widely used self-reort anxiety assessment instrument for adults (Sielberger, 1983). The questionnaire contains two searate, 20-item, 4- oint self-reort rating scales for measuring trait and state anxiety. Higher overall scores denote higher levels of anxiety. Test-retest correlations for the STAI trait are high and range from 0.73 to 0.86 (Sielberger, 1983). Parents comleted the STAI at baseline. Faces Pain Scale-Revised (FPS-R). This self-reort ain scale consists of a series of six faces ranging from a neutral exression ( no ain ) to an exression reresenting the most ain ossible (Hicks et al, 2001). The well-validated scale has been recommended for use in children ages 4-18 (Stinson et al, 2006). The FPS-R has demonstrated good convergent validity with visual analog scale and observational scale ratings of ain (Hicks et al, 2001). 5

6 Pain Medication Record. This is a form comleted by arents on their analgesic medication administration to children in the home setting for 14 consecutive days. Parents reorted what ain medication was used, time of administration, and dosage for each dose of medication given for the entire 14 days. If no medication was given, arents were asked to indicate the reason from the following resonse otions: no medication was rescribed, child was not in ain, child refused medication, and other. Analysis IBM SPSS version 20 was used to analyze descritive statistics for the whole samle and conduct tests of grou differences between arents who administered ain medication, and arents who did not through the entire 14 days. In addition, descritive statistics were used to analyze daily face ain scores, and their correlation to the administration of medication for that articular day. The sum of the Medication Attitude Questionnaire (MAQ) scores for avoidance, fear of side effects, and aroriate use were examined for their relationshi with the use of medication using analysis of variance (ANOVA). ANOVA was also used to examine the relationshi between the use of medication comared to the total scores for state and trait anxiety for both arent and children. The total number of medication administrations across the 14 days was summed and a bivariate correlation test was erformed between the total number of administrations and MAQ as well as STAI scores. RESULTS Demograhics Table 1 details the ertinent demograhic information obtained for the study. The majority of the articiants were Table 1. Child demograhics Child Age (years) Mean SD Child Gender (%) Male Female Child Race (%) Hisanic/Latino African American Asian White More than one race % 37.3% 35.3% 2.0% 11.8% 47.1% 3.9% 6

7 male, average age was 8.31±4.09 years, and most were Caucasian. The mean arental education levels for arents who comleted the questionnaires are detailed in table 2. ANOVA revealed a significant difference in arental education levels between arents who administered medication and those who did not ( = 0.01). Table 2. Parental education and use of ain medication Parental education levels (years) Used analgesic medication No analgesic medication used Mean SD ** Reasons why arents did not administer medication Out the total study oulation (n=51), 17 arents administered medication at least once while 34 arents did not for the entire14-day eriod. Parents were asked to rovide reasons for each day that no medication was administered to their child. Parents reasoned that no medication was rovided because the child was not in ain 79% of the time. Daily-face ain scale scores were cross-matched with the reasons why no medication was given to the child. It was found that 57% of the time (8 out of 14 days), medication administration was withheld even when at least one child reorted clinically significant ain (face-ain scale scores 3). and the use of ain medication ANOVA was used to determine differences in anxiety (arent STAI and child STAIC) were resent between the medication and non-medication grou. The means Table 3. and use of medication mean differences Parent State Parent Trait Child State Child Trait Used Analgesic Medication of the scores for both grous are shown in Table 3. There were no significant relationshis No Analgesic Medication Used Mean SD Mean SD Mean SD Mean SD ** 7

8 Table 4. STAI and frequency of medication administration bivariate correlation Note. STAI State-Trait Inventory ** denotes 0.05 R Parental State Parental Trait Child State Child Trait ** between arental state-anxiety, arental trait-anxiety, and child state-anxiety and the use of ain medication. On the other hand, ANOVA showed that child trait-anxiety scores between the medication and nonmedication grou were significantly different. Bivariate correlations were also run between child and arent anxiety and the total number of doses of medication administered to children across the 14 days (Table 4). Parent anxiety (STAIs and STAIt), and child state anxiety (STAICs) were not correlated with total medication doses. However, child trait anxiety (STAICt) showed a ositive significant relationshi with the number of times medication was administered ( = 0.002). Attitudes and the use of ain medication ANOVA was used to determine if MAQ mean score differences were resent between arents who administered medication and those who did not. Table 5 shows the calculated MAQ scores for all three of its factors: avoidance, fear of side effects, and aroriate use. MAQ Aroriate use showed significant differences between the Table 5. MAQ and use of medication mean differences Note. MAQ Medication Attitude Questionnaire Medication Attitude Questionnaire Subscale Avoidance Fear of Side Effects Aroriate Use Used Analgesic Medication No Analgesic Medication Used Mean SD * Mean SD Mean SD ** medication and non-medication grous. Avoidance showed a relationshi with the use of medication trending towards significant differences, while the mean differences for the Fear of side effects subscale were insignificant. Bivariate correlations were run between MAQ scores 8

9 and the total number of times the arent administered medication to their child, which revealed no significant relationshis ( 0.05). DISCUSSION The urose of this study was to determine the relationshi between arental anxiety and the use of and administration of ain medication in ediatric cancer atients. The study intended to determine if more anxious arents administer medication more or less frequently than less anxious arents. The study also aimed to determine if there is a significant relationshi between arental attitudes toward medications and its administration. Findings showed that arental education levels and the administration of medication were significantly related. In terms of state and trait anxiety, only child trait anxiety showed significant mean differences and correlations between the medication and non-medication grous. In addition, differences in arental attitudes about ain medication were different significant between arents who administered medication and those who did not. However, there was no correlation between medication attitudes and the number of times medication was administered. More educated arents were more likely to administer ain medication to control their children s ain symtoms. It is likely that the more educated the arents are, the more aware they become of when their child is in ain. Less educated arents may not be aware of the signs to look for regarding their child s ain. Furthermore, the study suggested that arents may not be roviding adequate ain medication to treat their child. No medication was administered 57% of the time even though the face-ain scale suggested that at least one child was exeriencing clinically significant ain. Children may not have been exressing their ain enough for the arents to recognize it. In addition, arents may have different ercetions on what constitutes significant ain. 9

10 The study results did not suort the hyothesis that more anxious arents will medicate their child more. Parental anxiety did not show a significant relationshi with the use of ain medication. Although the medication and non-medication grous did show a difference in their corresonding STAI scores, ANOVA showed that the mean differences were insignificant. Child trait anxiety was significantly related to the administration of medication. The more anxious child may show increased stress resonse that arents may interret as ain. This is imortant to note, as less anxious children may show decreased verbalization of ain, leading to the ossibility of undermedication. Parental attitudes toward ain medication also affected the administration of medication to children. Parents who administered medication showed significantly lower Medication Attitude Questionnaire Avoidance and higher Aroriate use scores. Thus arents who administered medications were more likely to believe that ain medication can be used in children without develoing deendence. Additionally, arents who administered medication felt that the situations when they gave medication to their children was timely and aroriate for the amount of ain that the child was exeriencing. The findings of the study were consistent with its hyothesis that more favorable medication attitudes lead to the use of medication. However, the number of medication doses administered did not have a significant relationshi with attitudes towards medications. Parents from the medication grou may have less reservations and misconcetions in using ain medication to control their child s ain, but they still may not have adequately managed it. In a study conducted to examine ain management at home after undergoing a tonsillectomy, Sutters and Miaskowski discussed that the child may achieve temorary ain relief after the arent administers analgesic medication. However, if the arent fails to sustain treatment, the ain relief may be insignificant to the overall ain intensity 10

11 reduction (Sutters and Miaskowski, 1997). Thus, attitudes towards ain medication may not accurately redict whether or not the child s ain is adequately treated. There was not much difference seen between the medication and non-medication grous in terms of their Fear of side effects scores. This may be exlained by the risk-reward ercetion of arents resonsible for managing their children s ain. The medication grou may have been comosed of arents who feel that the rewards of ain relief outweigh the ossible side effects. The significance of this study lies in its clinical imlications. Firstly, less educated arents may not have access to adequate information regarding their child s care. This deficiency is something that health care roviders can address and sulement with interventions at the clinical setting. Health care rofessionals can counsel arents and rovide information on the imortant signs to look out for regarding their child s ain. Secondly, hysiological ain redictors sulemental to self-reort may be used to better ascertain the child s ain. Parents may be trained in simle rocedures such as obtaining the child s heart rate and skin conductance in order to better quantify their child s ain (Howard, 2004). Admittedly, there would be difficulty imlementing such measures to accurately know the child s ain level. However combining sychological and hysiological signs of ain may rovide arents a better idea on how much ain their child is really in. Lastly, a similar study using a larger samle size can be done in order to obtain better statistical ower. Most of the factors in the study were trending to significance, and may have achieved significance given a bigger study oulation. ACKNOWLEDGEMENTS I want to thank Dr. Michelle A. Fortier, the faculty advisor for the lab, for her suort, atience, and time she sent heling me throughout the entire Excellence in Research rocess. I also want to thank Dr. Fortier for all the knowledge regarding the writing rocess and statistical analysis that she has imarted to me. I wanted to thank her further for heling me write and edit my aer. Secondly, I wanted to thank Aditi Wahi for training me in managing the databases, as 11

12 well as teaching me the basics of statistical analysis. Lastly, I would like to acknowledge Eva Maurer, Sulay Gomez, and Libby Bunzli for suorting and encouraging me to ursue this toic, and training me with the basic lab tasks I needed to comlete my roject. Literature Cited Best M, Streisand R, Catania L, Kazak AE Parental distress during ediatric leukemia and osttraumatic stress symtoms (PTSS) after treatment ends. Journal of Pediatric Psychology 26: Brown RT, Kaslow NJ, Hazzard AP, Mdana-Swain A, Sexson SB, Lambert R, Baldwin K Psychiatric and family functioning in children with leukemia and their arents. J Am Acad Child Adolesce Psychiatry 31: Collins JJ Palliative care and the child with cancer. Hematol Oncol Clin North Am 16: Collins JJ, Stevens MM, Berde CB Pediatric cancer ain. In: Sykes N, Bennet MI, Yung KK, editors. Cancer Pain. 2 nd ed. London: Hodder and Stroughton ress Forward S, Brown TL, McGrath PJ Mothers attitudes and behavior toward medicating children s ain. Pain 67: Hicks CL, von Baeyer CL, Safford PA, van Korlaar I, Goodenough B The faces ain scale revised: toward a common metric in ediatric ain measurement. Pain 93: Howard RF Current status of ain management in children. Journal of the American Medical Association 18: Jacox A, Carr DB, Payne R New clinical-ractice guidelines for the management of ain in atients with cancer. N Engl J Med 330: Jantien Vrijmoet-Wiersma CM, van Klink JMM, Kolk AM, Kooman HM, Ball LM, Egeler RM Assessment of arental sychological stress in ediatric cancer: a review. Journal of Pediatric Psychology 33: Lee WM Drug-induced heatotoxicity. N Engl J Med 349: Pain relief and alliative care in children with cancer Geneva: WHO. Patiño-Fernandez AM, Pai AL, Alderfer M, Hwang WT, Reily A, Kazak AE Acute stress in arents of children newly diagnosed with cancer. Pediatric Blood Cancer 50: Sielberger CD: Manual for the State-Trait Inventory (STAI: Form Y) Consulting Psychologists Press Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B Systematic review of the sychometric roerties, interretability and feasibility of self-reort ain intensity measures for use in clinical trials in children and adolescents. Pain 125: Sutters KA, Miaskowski C Inadequate ain management and associated morbidity in children at home after tonsillectomy. Journal of Pediatric Nursing 12: Zisk RY, Grey M, MacLaren JE, Kain ZN Exloring sociodemograhic and ersonality characteristic redictors of arental ain ercetions. Anesthesia and Analgesia 104: Zisk-Rony RY, Fortier MA, MacLaren Chorny J, Perret D, Kain ZN Parental ostoerative ain management: attitudes, assessment, and management. Pediatrics 125: e1372-e

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