This is the first in a three-part series of interviews with young investigators who were recognized for their work at the 8-11 May 2013 Annual Scientific Meeting of the American Pain Society in New Orleans, Louisiana, US. See Part 2 and Part 3.
Laura Simons, PhD, is a staff psychologist at the Pain Treatment Service at Boston Children's Hospital, and an assistant professor of psychology in the Department of Psychiatry at Harvard Medical School, Boston, US. She earned her PhD in clinical psychology in 2006 from the University of Georgia in Athens, US, and also completed an internship in child clinical/pediatric psychology at the University of Florida Health Science Center in Gainesville, US, and a postdoctoral fellowship at Boston Children’s Hospital.
Simons developed the Fear of Pain Questionnaire, the first assessment tool to measure pain-related fear in children. For her work in that area, the American Pain Society (APS) awarded her the 2013 John C. Liebeskind Early Career Scholar Award which, according to the APS, “was named in 1998 to honor the memory of John C. Liebeskind, PhD, a past president of APS who was a noted pain researcher, scientist, and teacher. The Early Career Scholar Award recognizes early career achievements that have made outstanding contributions to pain scholarship.”
Neil Andrews, PRF co-executive editor, recently spoke with Simons at the APS Annual Scientific Meeting to learn about the genesis of her interest in pain research, how she developed the Fear of Pain Questionnaire, and her new interest in bringing neuroimaging to bear on her work in pain psychology. The following is an edited transcript of their conversation.
PRF: What was your route to pain research?
LS: It has been an interesting journey. My undergraduate honors thesis advisor at Ohio University was Christopher France, who has done a lot of research looking at vasovagal syncope, blood and injury phobia, and pain. I was fascinated by the psychophysiological research in his lab, and that drew me to pediatric psychology—the intersection of child clinical psychology and pediatrics. Then I went for graduate training at the University of Georgia with Ronald Blount, who was looking at acute pain and behavioral distress in the interactions between children and their parents. I got involved from day one doing some really intensive behavioral coding of infant immunizations—watching hundreds of hours of tape, and coding parent and child interactions sequentially, as well as nurse behaviors.
But I did not actually start doing my own pain research until my postdoctoral fellowship at Boston Children’s Hospital. My research in graduate school was focused on cardiology, gastrointestinal disorders, and transplantation—the beauty of pediatric psychology is that you can be in all of those disciplines and still have a coherent line of research and focus. But what I was really drawn to was pediatric pain and pediatric pain patients. When I was on internship at the University of Florida, I sought out chronic pain patients to treat in therapy, and when I was looking for postdoctoral fellowships, I saw that Boston Children’s Hospital would give me the opportunity to really focus on pain. I went there to work with Deirdre Logan and Lisa Scharff, started doing pain treatment and research, and have never looked back. I love it.
Much of your work has focused on pain-related fear in children. Why did you concentrate on that specific area?
When I was on fellowship and treating children with persistent pain, what I noticed was that there were kids who were not responding to our traditional biobehavioral pain coping strategies of relaxation, biofeedback, and cognitive restructuring. They also were not making gains in physical therapy, and what I noticed was that there was a lot of fear around that. These kids didn’t necessarily meet criteria for an anxiety disorder, but they clearly had some fear avoidance around re-engaging in activities that they used to do before their injury and before they had pain. I looked to the literature to ask: How can we assess this? What I found was that there were no measures looking at pain-related fear in children. That’s when I started my work on the Fear of Pain Questionnaire.
How did you develop that assessment tool?
I first looked at the literature to see what was out there, and, in fact, there are several measures of pain-related fear and anxiety in adults. I compiled all of those measures into a questionnaire, invited an expert panel to review it for its relevance to kids, and made adaptations to make it more pediatric focused. After the expert panel review, I had parents and kids review the questionnaire, and I made further changes based on their feedback. I then administered the questionnaire to 300 kids with chronic pain and was able to do a validation study.
I found that the questionnaire was a pretty robust predictor of outcomes—it was highly associated with disability and catastrophizing. I also looked at predictive outcomes and found that it was associated with disability one month later, and that, in fact, decreases in fear were associated with improvements in functioning [Simons et al., 2011].
I then did a study that looked at fear of pain in the context of our pain rehabilitation program at Boston Children’s Hospital. In children and adolescents with neuropathic pain, we found not only that a decrease in fear was associated with concurrent improvements in disability and depression, but that high levels of fear at baseline were actually predictive of worse treatment outcomes [Simons et al., 2012]. What that told me was that we need to be doing more treatments that target pain-related fear, and I have been working on adapting graded in-vivo exposure, which has been used to treat pain-related fear in adults with chronic pain, for use in kids.
How do parental responses fit into the equation of children’s pain?
I recently coauthored, with Liesbet Goubert, a chapter in the Oxford Textbook of Paediatric Pain where we put forth an interpersonal model of fear avoidance. In this model, parent thoughts, feelings, and behaviors feed into each step of the child’s fear avoidance cycle. Right now I am in the process of collecting data to validate parent fear of pain measures, to get at how pain-related fear that parents experience may contribute to their child’s functioning, and to their own functioning.
There has been a lot of great psychological research looking at parent responses as they relate to child outcomes, and so we know parents are a key component of this model. And with our treatment that we are putting together at the Pain Treatment Service at Boston Children’s Hospital, there is a very defined parent component working directly with parents on how they encourage, support, and validate their children exposing themselves to increasingly more difficult activities. The parents will be present while the kids are doing many of these exposures so that they can see what their children are capable of doing and be able to help them practice the skills at home.
We have been talking about psychology, but you are now taking the next step by integrating neuroimaging into your work. What is the focus of that research?
That is another piece of the pie that has been really fascinating, and actually is where I spend most of my energy and my time, learning and working with David Borsook, Lino Becerra, and others in the PAIN Group at Boston Children’s Hospital. The neuroimaging work looks at the neural correlates of pain-related fear in children—at how the brain patterns of kids with high levels of fear may look different compared to other kids in chronic pain but with lower levels of fear, as well as whether those brain patterns predict how they respond to treatment in our rehab program. We are doing cross-sectional brain imaging studies as well as brief longitudinal studies.
There is a lot of really great animal work and human brain imaging work that is coming out right now on fear and fear learning that illuminates how the fear extinction circuitry is not working correctly for chronic pain patients. Herta Flor and Irene Tracey have been writing about it, and it is really fascinating. I am in the process of learning it and also trying to figure out how I can apply it to my own program of research.
What is most exciting to you about the neuroimaging research?
I am really passionate about helping to legitimize psychological treatment for chronic pain. I think it is very difficult for patients to seek out psychological care for pain because of the stigma associated with mental health treatment. I think that brain imaging has the opportunity to really legitimize psychological therapies and the impact those therapies can have on brain circuitry. To be able to verify that something is changing at the brain circuit level, and that it is potentially changing in relation to psychological treatment, is really exciting. There have already been a few studies looking at this, but we are really just scratching the surface.
Thank you very much for speaking to PRF about your work.
Thank you.
