Family and parent influences on pediatric chronic pain: a developmental perspective

Perceived injustice and pain-related outcomes in children with pain conditions: A systematic review

OBJECTIVE

Research indicates that perceived injustice significantly influences pain-related outcomes and is associated with delayed recovery in adults. This systematic review examines the relationship between perceived injustice and pain-related outcomes in children with pain conditions.

METHODS

A search of published studies in English in PubMed, PsychInfo, and Cochrane Database of Systematic Reviews from database inception through December 2022 were performed. The search criteria focused on studies that measured perceived injustice and pain-related outcomes in children with pain conditions. Out of 56 articles screened, 8 met the inclusion criteria, providing data on 1240 children with pain conditions.

RESULTS

The average age of participants across all studies was 14.12 years (SD = 2.25), with 68.2% being female. There was strong evidence that higher perceived injustice is associated with worse pain intensity, functional disability, mental health outcomes, and emotional, social, and school functioning.

CONCLUSION

The results of this study underscore how perceptions of injustice are associated various pain-related outcomes across different domains of children's lives. The findings highlight the need for screening and treatments targeting injustice appraisals in pediatric populations with pain conditions. The discussion addresses possible determinants and mechanisms of perceived injustice, along with implications for research and clinical practice.

Contents and delivery methods of pain neuroscience education in pediatrics: A scoping review

BACKGROUND

Pain is prevalent among children and adolescents. The development and implementation of Pain Neuroscience Education (PNE) strategies tailored to this population remains overlooked in contrast to the adult population.

OBJECTIVE

This study sought to identify the content, delivery methods, and dosage of PNE for children and adolescents available in the literature.

METHOD

We systematically searched PubMed, EMBASE, Physiotherapy Evidence Database, Scopus, Web of Science, Cochrane Library, PsycINFO, and clinical trial registration databases. Inclusion criteria consisted of studies that involved children submitted to a PNE program in community, school, clinics, hospitals or child development centers. We considered studies that included children with and without pain who received PNE strategies associated or not with self-motivational interventions. Studies focusing on psychological interventions were excluded. We extracted data on authors, publication year, country, sample characteristics, health condition, PNE content, study design, context, outcomes, duration, follow-up, main results, dropout, and adverse effects. Data extracted were qualitatively organized.

RESULTS

A total of 805 studies were initially reviewed. The final sample comprised 17 studies. Common PNE topics included pain neurophysiology, biopsychosocial influences, pain concepts, self-management, and coping strategies. Delivery methods ranged from slideshows and videos to booklets, with sessions lasting 8-60 min. Schools were the most common setting for these interventions.

CONCLUSION

Our review demonstrates the diversity in PNE content, delivery methods, and intervention dosages among the included studies. Most studies occurred in school settings, potentially limiting its generalizability for clinical contexts.

Co-creation in healthcare and research to improve service delivery for young people with chronic pain

Introduction

The process of co-creation can enable more effective, agile and integrated healthcare solutions achieving outcomes that effectively translate to healthcare delivery. Collaborative knowledge generation is particularly important in fields such as pediatric chronic pain where there is a complex interplay between biological, social, environmental, emotional, familial and school factors. The co-creation initiative described here was designed to amplify the voices of youth with chronic pain and their families and a variety of key stakeholders and generate novel approaches to the management of chronic pediatric pain in the setting of the South Australian Pediatric Chronic Pain Service.

Methods

Stakeholders who were identified as influential in this ecosystem were allocated to 6 groups. A skilled facilitator co-prepared and delivered the workshop, engaging participants in three structured activities. Firstly, the challenges to service delivery were outlined, followed by the groups discussing what is currently working. The second activity involved lateral thinking without restrictions on time, resources or system to generate solutions to the key challenges presented. Finally, stakeholders were asked to agree on a generated solution from Activity 2 and build a case for actionable implementation of this solution. Data were summarised by the workshop facilitator and reflexive thematic analysis was used for coding and generating themes.

Results

From Activity 1, six themes collectively demonstrated that stakeholders valued many of the existing strengths of the service delivery, but some areas such as pain education was undervalued. Activity 2 generated solutions from high-level ideas to more day-to- day management strategies. Each of six groups generated unique solutions to an identified challenge for Activity 3.

Discussion

Engaging a wide variety of stakeholders in collaborative knowledge generation successfully provided the South Australian Pediatric Chronic Pain Service with a variety of novel, scalable solution across the healthcare continuum. Equally important is that this initiative helped to raise awareness about the complex issues faced in pediatric chronic pain care and helped to establish new partnerships that have led to enhanced service delivery.

The Effectiveness of Pain Science Education on Caregiver and Children's Knowledge, Beliefs, Attitudes, and Behaviors-A Systematic Review and Meta-Analysis

Pain science education (PSE) can be used as part of treatment and prevention for chronic pain in children. We assessed the effectiveness of PSE on knowledge, beliefs, attitudes, and behaviors in children and the people that care for children. We set a minimum criterion for education to address pain biology knowledge. We included studies aimed at both treatment and prevention of chronic pain. We conducted searches using 5 databases. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool. Data were pooled using a random-effects meta-analysis or assessed using a narrative synthesis. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. We screened 14,505 records and included 7 studies involving 351 caregivers and 1,285 children. Four studies were included in meta-analyses. We found low-certainty evidence that PSE has a large beneficial effect on caregiver knowledge and beliefs compared with alternative education (standardized mean difference = 1.14 [95% confidence interval: .88-1.42]; I2 = 0%). We found no difference in functional disability in children with chronic pain after PSE (Functional Disability Inventory score mean difference = .73 [95% confidence interval: -.81 to 2.27; I = 0%]). Narrative syntheses showed low-certainty evidence for improved knowledge and beliefs in children with preventative and treatment effects. Overall, we found few studies, and along with high risk of bias, this significantly contributed to the low certainty of findings. The effect of learning pain science for both preventative and treatment effects in children, carers, and the child/carer dyad remains mostly unknown. This review was prospectively registered with The international Prospective register of systematic reviews (CRD42022344382) on July 22, 2022. PERSPECTIVE: This review examines the effect of PSE on pain-related knowledge, beliefs, attitudes, and behaviors in children and the people that care for children (0-18). The findings contribute to knowledge about pain treatments and health promotion for caregivers and their children with and without chronic pain.

Children with Cerebral Palsy and Their Parents Have Different Experiences of Pain Management: A Qualitative Study

Aim: The aim of this study is to explore and compare experiences of pain management strategies for children with CP from the perspectives of children themselves and their parents. Methods: A secondary inductive analysis of previously collected qualitative data was performed. Fourteen children with CP and one parent of each child were interviewed separately about the management of the child's pain. A dyadic data analysis was used to compare parents' and children's perspectives. Findings: The main thematic categories of pain management identified were self-care, psychological strategies, physical interventions and professional treatment. Experiences described by the child and parent differed within all participating dyads but to different degrees. On a group level, children described more use of psychological strategies than parents did. Parents described more professional treatment strategies. Conclusions: Parents and children described different experiences of pain management strategies, and both perspectives are needed to understand the child's situation.

Who develops chronic pain after an acute lower limb injury? A longitudinal study of children and adolescents

ABSTRACT

Prevention of chronic pain is a major challenge in this area of clinical practice. To do this, we must be able to understand who is most at risk of developing chronic pain after an injury. In this study, we aimed to identify risk factors of chronic pain onset, disability, and pain interference after a lower limb musculoskeletal injury in children and adolescents between 8 to 16 years of age. We assessed biopsychosocial factors including age, sex, pubertal status, anxiety, depression, fear of pain, pain worry, adverse life events, and sleep in children. We also assessed risk factors in parents including parent anxiety, depression, parent pain catastrophising, and protective behaviours. Logistic and hierarchical linear regressions identified risk factors assessed immediately postinjury for outcomes assessed at 3 months postinjury. Fourteen percent (17/118 children) reported chronic pain 3 months after injury. There were significant between-group differences in children with and without chronic pain at baseline. Children with chronic pain reported higher pain intensity, disability, pain interference, child depression, fear of pain, and catastrophic thinking about their pain. Regressions showed child depression and fear of pain at baseline independently predicted chronic pain onset at 3 months, parent protectiveness predicted child pain interference at 3 months, and child depression, poor sleep, parent anxiety and pain catastrophising predicted disability. Most children recover after a lower limb injury, but a minority develop chronic pain predicted by important psychosocial risk factors, which could be addressed to prevent the onset of treatment-resistant chronic pain and disability.

Agreement between child self-report and parent-proxy report for functioning in pediatric chronic pain

PURPOSE

Accurate assessment of chronic pain and functional disability in children and adolescents is imperative for guiding pain management interventions. Parents have multifaceted roles in their child's pain experience and frequently provide parent-proxy reports of pain-related functioning. However, cross-informant variance is often observed with limited understanding of contributing factors. This study aims to examine the degree of alignment between child and parent-proxy reports for Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference domain among children with chronic pain and to identify factors associated with improved child-parent agreement.

METHODS

This study includes a sample of 127 youth (66.1% female) with mixed etiology chronic pain, ranging in age from 8 to 17 (M = 12.24; SD = 1.598), and their parent. Data was collected at an interdisciplinary pediatric pain clinic and online peer support groups. Measures of demographic, pain intensity, and functioning were collected.

RESULTS

Means of parent-proxy reports were significantly lower than child self-reports on the PROMIS (p < 0.05). A statistically significant association between child's pain intensity (β = 0.953, P < 0.05) and the difference between child self-reported and parent-proxy reported PROMIS functional interference scores was found.

CONCLUSION

Parents underestimated pain-related functional disability relative to children's self-reports. The difference between the paired child self-report and parent-proxy report of functional disability was significantly associated with greater child self-reported pain intensity. Although parent-proxy reports in pediatric chronic pain is often used in research and practice, findings underscore the importance of incorporating child and adolescent self-report, when possible, to comprehensively capture the child's pain experience and best inform clinical interventions.

Parent Anxiety, Depression, Protective Responses, and Parenting Stress in the Context of Parent and Child Chronic Pain: A Daily Diary Study of Parent Variability

Parents with (vs without) chronic pain report poorer psychosocial functioning (eg, worse mental health, parenting difficulties), which has been linked to poorer child outcomes (eg, child pain). However, emerging research suggests that individuals vary in their functioning from day-to-day, particularly those with chronic pain. This study used daily diaries to compare parents with (versus without) chronic pain on variability in their anxiety, mood, protective responses, and parenting stress. We also examined parent chronic pain status as a moderator of the associations between parent variability and youth daily pain and interference. Participants were 76 youth with chronic pain (Mage = 14.26; 71.1% female) and one of their parents (89.5% mothers; n = 38 or 50.0% endorsing chronic pain). Parents and youth completed self-report questionnaires and 7 days of diaries. Parent variability was calculated to reflect the frequency and size of day-to-day changes. Multilevel models revealed that parents with (vs without) chronic pain were significantly more variable in their parenting stress, but not in their anxiety, mood, or protective responses. Contrary to hypotheses, parent variability was not significantly related to youth daily pain intensity or interference and parent chronic pain did not moderate any associations. Instead, mean levels of parent anxiety, protective responses, and parenting stress across the week significantly predicted youth daily pain interference. Findings suggest that while variability was observed among parents (with and without chronic pain) of youth with chronic pain, it did not significantly predict youth's daily pain-related functioning. Further research is needed to confirm these initial findings. PERSPECTIVE: Parents with chronic pain have expressed concerns that the variable nature of their pain negatively impacts their children. Our results found that parents (with and without chronic pain) were variable in their anxiety, mood, protective responses, and parenting stress, but this variability did not significantly predict youth's chronic pain-related functioning.

Development and Evaluation of the Abdominal Pain Knowledge Questionnaire (A-PKQ) for Children and Their Parents

BACKGROUND

Abdominal pain is a common and often debilitating issue for children and adolescents. In many cases, it is not caused by a specific somatic condition but rather emerges from a complex interplay of bio-psycho-social factors, leading to functional abdominal pain (FAP). Given the complex nature of FAP, understanding its origins and how to effectively manage this condition is crucial. Until now, however, no questionnaire exists that targets knowledge in this specific domain. To address this, the Abdominal Pain Knowledge Questionnaire (A-PKQ) was developed.

METHODS

Two versions were created (one for children and one for parents) and tested in four gastroenterology clinics and one specialized pain clinic in Germany between November 2021 and February 2024. Children between 8 and 17 years of age (N = 128) and their accompanying parents (N = 131) participated in the study. Rasch analysis was used to test the performance of both versions of the questionnaire.

RESULTS

The original questionnaires exhibited good model and item fit. Subsequently, both questionnaires were refined to improve usability, resulting in final versions containing 10 items each. These final versions also demonstrated good model and item fit, with items assessing a variety of relevant domains.

CONCLUSION

The A-PKQ is an important contribution to improving assessment in clinical trials focused on pediatric functional abdominal pain.

Understanding how children and young people with chronic non-cancer pain and their families experience living with pain, pain management and services: a meta-ethnography

Background

Childhood chronic pain is a widespread public health issue. We need to understand how children with chronic pain and their families experience chronic pain and its management.

Objectives

To conduct a meta-ethnography on the experiences and perceptions of children with chronic pain and their families of chronic pain, treatments and services. We investigated how children and their families conceptualise and live with chronic pain; what they think of and want from health and social care services; and what they conceptualise as 'good' pain management.

Design

Meta-ethnography with stakeholder and patient and public involvement in the design, search and sampling strategies, analysis and dissemination. Review strategy: comprehensive searches of 12 bibliographic databases and supplementary searches in September 2022, to identify qualitative studies with children aged 3 months to 18 years with chronic non-cancer pain and their families. We included studies with rich explanatory data; appraised methodological limitations using the Critical Appraisal Skills Programme tool; and extracted, analysed and synthesised studies' findings. We used Grading of Recommendations Assessment, Development and Evaluation-confidence in the evidence from reviews of qualitative research to assess confidence in review findings. We integrated findings with 14 Cochrane treatment effectiveness reviews on children's chronic non-cancer pain.

Results

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Studies had minor (n = 24) or moderate (n = 19) methodological limitations. Grading of Recommendations Assessment, Development and Evaluation-confidence in the evidence from reviews of qualitative research assessments of review findings were high (n = 22), moderate (n = 13) or very low confidence (n = 1). Moderate and severe chronic pain had profound adverse impacts on family members' well-being, autonomy and self-identity; family dynamics; parenting approaches; friendships and socialising; children's education and parental paid employment. Most children and families sought a biomedical cure for pain. They experienced difficulties seeking and receiving support from health services to manage pain and its impacts. Consequently, some families repeatedly visited health services. Cochrane reviews of intervention effects and trials did not measure some outcomes important to children and families, for example effects of pain on the family and resolution of pain. Reviews have mainly neglected a biopsychosocial approach when considering how interventions work.

Limitations

There were limited data on common pain conditions like migraine/headache, abdominal pain; some rarer conditions; children with learning disabilities and under-fives; siblings; fathers and experiences of treatments/services. We excluded studies on cancer, end-of-life pain and experiences of healthcare professionals.

Conclusions

We developed the family-centred theory of children's chronic pain management, integrating health and social care with community support.

Future work

Future research should explore families' experiences of services and treatments, including opioids, and social care services; experiences of children with autism and learning disabilities, under 5 years old and with certain common pain conditions. We need development and testing of family-centred interventions and services.

Study registration

This study is registered as PROSPERO (CRD42019161455) and Cochrane Pain, Palliative and Supportive Care (623).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128671) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 17. See the NIHR Funding and Awards website for further award information.

Assessing parental comprehension of online resources on childhood pain

We aimed to examine the patient education materials (PEMs) on the internet about "Child Pain" in terms of readability, reliability, quality and content. For our observational study, a search was made on February 28, 2024, using the keywords "Child Pain," "Pediatric Pain," and "Children Pain" in the Google search engine. The readability of PEMs was assessed using computer-based readability formulas (Flesch Reading Ease Score [FRES], Flesch-Kincaid Grade Level [FKGL], Automated readability index (ARI), Gunning Fog [GFOG], Coleman-Liau score [CL], Linsear Write [LW], Simple Measure of Gobbledygook [SMOG]). The reliability and quality of websites were determined using the Journal of American Medical Association (JAMA) score, Global Quality Score (GQS), and DISCERN score. 96 PEM websites included in our study. We determined that the FRES was 64 (32-84), the FKGL was 8.24 (4.01-15.19), ARI was 8.95 (4.67-17.38), GFOG was 11 (7.1-19.2), CL was 10.1 (6.95-15.64), LW was 8.08 (3.94-19.0) and SMOG was 8.1 (4.98-13.93). The scores of readability formulas showed that, the readability level of PEMs was statistically higher than sixth-grade level with all formulas (P = .011 for FRES, P < .001 for GFOG, P < .001 for ARI, P < .001 for FKGL, P < .001 for CL and P < .001 for SMOG), except LW formula (P = .112). The websites had moderate-to-low reliability and quality. Health-related websites had the highest quality with JAMA score. We found a weak negative correlation between Blexb score and JAMA score (P = .013). Compared to the sixth-grade level recommended by the American Medical Association and the National Institutes of Health, the readability grade level of child pain-related internet-based PEMs is quite high. On the other hand, the reliability and quality of PEMs were determined as moderate-to-low. The low readability and quality of PEMs could cause an anxious parent and unnecessary hospital admissions. PEMs on issues threatening public health should be prepared with attention to the recommendations on readability.

A dyadic perspective on parent-child dyadic coping in children with a chronic condition

OBJECTIVE

In this study, we examined the extent to which parents and their children with a chronic condition communicate their stress to one another and whether stress communication is associated with different forms of dyadic coping.

METHODS

In a sample of 239 parent-child dyads, self-reported stress communication and different forms of perceived dyadic coping (i.e., emotion-oriented, problem-oriented, and negative dyadic coping) were assessed using a cross-sectional design.

RESULTS

We first found that children's stress communication was positively associated with more positive (r = 0.28, p < .001) and less negative dyadic coping responses by children (r = -0.22, p < .001). Children's stress communication was also associated with more positive (r = 0.52, r = 0.45, p's < 0.001), and less negative dyadic coping responses by parents (r = -0.19, p < .001). Using dyadic data of children with a chronic condition and their parents, we found that more stress communication of children was associated with healthier coping responses of both children (perceived emotion-oriented dyadic coping: β = 0.23, p < .001) and parents (perceived emotion-oriented dyadic coping: β = 0.33, p < .001; perceived problem-oriented dyadic coping: β = 0.22, p < .001).

CONCLUSION

This underscores the importance of communication and adaptive coping strategies of parents and children in the context of a child's chronic condition. These findings may help us find ways to support children and their parents to optimally communicate about and deal with their stress.

Psychosocial Functioning of Parents of Youth Receiving Intensive Interdisciplinary Pain Treatment

OBJECTIVE

Parents of youth with chronic pain report psychosocial difficulties, yet treatment often focuses on improving their child's functioning and pain. This study evaluated changes in parents' social and emotional functioning and explored predictors of change, as they completed a parent-focused intervention while their child was enrolled in an intensive interdisciplinary pain treatment (IIPT) program.

METHODS

Parents (n = 69) completed questionnaires at baseline and weekly (average duration of 4 weeks) during their child's participation in IIPT. Parents engaged in 3 groups per week providing education, therapeutic art, and psychotherapy (3 hr/week total).

RESULTS

At baseline, 38% of parents reported scores in the clinically elevated range for at least 1 psychosocial variable. Linear mixed modeling for the full sample indicated reduced parent anxiety (t = -2.72, p <.01) and depression (t = -3.59, p <.001), but not increased emotional support (t = 1.86, p >. 05) or reduced social isolation (t = -1.20, p >.05). For parents with at least moderately elevated psychosocial concerns, statistically significant improvements were observed for all 4 outcomes (all p's<.01). Psychological flexibility, cognitive reappraisal, and emotional suppression were found to be related to changes in parent outcomes (anxiety, depression, isolation, and support).

CONCLUSIONS

Findings support the benefit of parent-focused interventions in addition to child-focused interventions. Many parents of youth participating in IIPT had elevated scores for at least 1 psychosocial concern at baseline. Brief, parent-focused intervention including psychoeducation, therapeutic art, and psychotherapy targeting mindfulness, acceptance, and values had a significant impact on these parents, particularly those with greater struggles at baseline.

Association of Neighborhood Characteristics and Chronic Pain in Children and Adolescents in the United States

OBJECTIVE

To determine the associations between neighborhood characteristics and chronic pain during childhood and adolescence in the United States, 2020-2021.

METHODS

Cross-sectional analysis of the 2020 and 2021 National Survey of Children's Health. National Survey of Children's Health grouped parents' responses to questions about neighborhood characteristics into 5 categories: neighborhood support, neighborhood safety, school support, neighborhood amenities, and the presence of detracting neighborhood elements. Chronic pain was defined as parents reporting their children had "frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain during the past 12 months." Multivariable Poisson regression analyses estimated associations between neighborhood characteristics and chronic pain, adjusted for sociodemographic characteristics.

RESULTS

The sample contained 55,387 children (6 to 17 years), weighted to represent 44 million nationally. Children had significantly increased rates of chronic pain if they lived in neighborhoods that were unsupportive, unsafe, had unsafe schools, fewer amenities, and greater numbers of detracting elements ( P <0.0001). After adjusting for covariates, children had significantly increased chronic pain if they lived in neighborhoods that were not supportive (adjusted prevalence rate ratio=1.7 (95% CI: 1.5-1.9, P <0.0001), with similar patterns observed for living in neighborhoods characterized as not safe, that did not have safe schools, with fewer amenities, and/or more detracting elements.

DISCUSSION

Disadvantageous neighborhood characteristics are associated with pediatric chronic pain prevalence. Future research should investigate the underlying mechanisms of this association and guide neighborhood interventions aimed at preventing and decreasing childhood chronic pain and its associated burdens.

Caregiver Burden Associated With Pediatric Chronic Pain: A Retrospective Study Using the Pediatric Electronic Persistent Pain Outcomes Collaboration Database

OBJECTIVES

This retrospective, cross-sectional study investigated the nature and extent of burden experienced by caregivers of children and adolescents with chronic pain, and factors associated with increased caregiver burden.

METHODS

The Pediatric Electronic Persistent Pain Outcomes Collaboration database provided prospectively collected data from 1929 families attending 9 pediatric chronic pain services across Australia and New Zealand. Data included demographic information, responses to child pain and functioning measures, caregiver work impairment, and psychosocial functioning.

RESULTS

Caregivers of children with chronic pain reported work impairment associated with their child's pain (mean: 15% ± SD 25 absenteeism; 38% ± SD 29 productivity lost), significantly worse than published international population norms (large-scale community survey data), most other caregiver samples of adults and children with other chronic conditions, and adult samples with various pain conditions. Caregivers reported considerable burden in multiple psychosocial functioning domains, particularly leisure functioning, pain-related catastrophizing, and adverse parenting behaviors (with greater pain-related avoidance). Caregiver psychosocial burden was significantly associated with child psychosocial functioning (β = -0.308, P < 0.01), school absenteeism (β = 0.161, P < 0.01), physical disability (β = 0.096, P < 0.05), and pain duration (β = 0.084, P < 0.05), but not pain intensity. Caregiver work productivity loss was significantly associated with school absenteeism (β = 0.290, P < 0.01), child physical disability (β = 0.148, P < 0.01), child health care utilization (β = 0.118, P < 0.05), and worst pain intensity (β = 0.101, P < 0.05).

DISCUSSION

These results highlight the significant and varied impacts experienced by caregivers of children with chronic pain. This work is novel in reporting significant work impairment and confirms psychosocial burden in a larger sample than previous studies.

Longitudinal Pain Outcomes Following an Intensive Pediatric Pain Rehabilitation Program: Testing Potential Treatment Mechanisms

OBJECTIVES

This study tested performance measures of physical functioning and pain-related psychosocial measures as potential mechanisms of improvements in outcomes following intensive outpatient interdisciplinary pain rehabilitation for adolescents. We hypothesized that improvements in performance measures of physical functioning, fear of pain, pain catastrophizing, and self-efficacy during treatment would be related to improvements in pain, functional disability, and depressive symptoms.

METHODS

Seventy-seven adolescents, 10 to 18 years old, completed self-report measures before treatment, after the first week, at discharge, and at the 3-month follow-up. Participants completed physical performance measures of physical and exercise capacity and core strength on day 1, after the first week, and at discharge. Linear mixed models were used to examine the association between changes in potential mechanisms and changes in outcomes, adjusting for age, sex, pain duration, and baseline functional disability.

RESULTS

Statistically significant improvement in functional disability, pain, and depressive symptoms was demonstrated across the 4 time points. Improvements were also demonstrated in physical performance measures, fear of pain, pain catastrophizing, and self-efficacy. Improvements in pain catastrophizing predicted improvements in functional disability, pain, and depressive symptoms. Improvements in self-efficacy predicted improvements in all outcome variables except depression. Improvements in physical performance measures predicted improvements in some aspects of functional disability and pain, but not depressive symptoms.

DISCUSSION

This study contributes to the growing literature on the effectiveness of pediatric intensive interdisciplinary pain rehabilitation programs and mechanisms that influence improvements in outcomes, an area that is currently underexplored. Results are important to guide future research and inform clinical practice.

Attrition from Face-to-Face Pediatric Outpatient Chronic Pain Interventions: A Narrative Review and Theoretical Model

There is limited understanding of attrition (premature treatment withdrawal and non-completion) from pediatric chronic pain services. This narrative review aimed to summarize attrition prevalence from face-to-face pediatric outpatient chronic pain interventions, identify associated factors and develop a theoretical model to account for attrition in this setting. A comprehensive search of the published literature revealed massive variability (0-100%) in the reported attrition rates from pediatric chronic pain interventions that varied in type and format (individual vs. group, single discipline vs. interdisciplinary, psychological only vs. multiple combined interventions, of different durations). The factors associated with attrition from pediatric chronic pain programs varied between the studies: some have assessed patient sex, psychological and other comorbidities, avoidance strategies, missed schooling, family composition/tensions, caregiver catastrophizing, scheduling, caregiver leave and clinic access. A theoretical model is presented depicting youth, caregiver and service factors that may impact attrition from pediatric chronic pain interventions. Where available, literature is drawn from the pediatric chronic pain context, but also from adult chronic pain and pediatric weight management fields. The implications for research and clinical practice are discussed, including improved reporting, patient screening and targeted supports to promote intervention completion. This review contributes to a better understanding of attrition, which is crucial for optimizing pediatric chronic pain service outcomes.

Impact of Musculoskeletal Pain on Functioning and Disability in Children with Juvenile Idiopathic Arthritis in Iceland

AIMS

1) to map questions of pain from a survey to the International Classification of Functioning, Disability and Health (ICF) 2) to compare the impact of musculoskeletal pain on functioning based on the different components of the ICF in children with juvenile idiopathic arthritis (JIA) and age-matched peers.

METHOD

A cross-sectional case-control survey. A total of 28 children with JIA and 36 age-matched children participated. The survey included questions on the child's sex and age, about pain experienced, number of painful body areas, pain frequency and three short forms of Patient-Reported Outcome Measurement Information System (PROMIS) pain questionnaires. Sixteen children with JIA (57%) and 10 peers (28%) reported pain during past seven days. Their responses were used in the description of impact of pain.

RESULTS

After the mapping of the questions to ICF, a comparison between the two groups indicated that a higher number of children with JIA described effects of pain on mental function, mobility, general tasks and demands, than their peers. More children with JIA expressed to others that they had pain, non-verbally and verbally.

CONCLUSION

The findings provide important information about the impacts of pain on daily life in children with JIA and about their intervention needs.

Comparing the prevalence of chronic pain in school-aged children in the United States from 2019 to 2020: a nationally representative study examining differences associated with the COVID-19 pandemic

ABSTRACT

The coronavirus disease 19 (COVID-19) pandemic negatively affected children's health in the United States (US), with more severe disruption for marginalized groups. However, potential impact on pediatric chronic pain has not been assessed at the population level. This study aimed to (1) estimate differences in the US national prevalence of pediatric chronic pain during the first year of the COVID-19 pandemic (2020), relative to one year earlier (2019); (2) determine whether differences in prevalence varied across sociodemographic groups; and (3) explore changes in child, caregiver, and family factors associated with chronic pain prevalence. Using data of children 6 to 17 years from the National Survey of Children's Health 2019 and 2020 (n = 50,518), we compared weighted percentages of sample characteristics by year and conducted a series of directed-acyclic graph-informed survey-weighted Poisson regressions. The estimated national prevalence (95% CI) of pediatric chronic pain was 10.8% (9.9, 11.9%) in 2019, decreasing to 7.6% (6.9, 8.3%) in 2020. Contrary to hypotheses, the adjusted prevalence of chronic pain was 31% lower in 2020 than in 2019 (aPR = 0.69, 95% CI: 0.61, 0.79), adjusting for child age, sex, race or ethnicity, caregiver education, neighborhood park or playground, and census region. The 2019 to 2020 change in chronic pain prevalence was similar by age ( P = 0.34), sex ( P = 0.94), race or ethnicity ( P = 0.41), caregiver education ( P = 0.49), neighborhood park or playground ( P = 0.22), and census region ( P = 0.20). Exploratory analyses identified 3 potential contributors to the unexpected decrease in the national prevalence of pediatric chronic pain: lower prevalence of bullying, more frequent family meals, and higher family resilience.

Pain in Adolescence: Maternal and Paternal Factors Affecting Adolescents' Pain in Norway-A Cross-Sectional Study

BACKGROUND

Pain in adolescence is considered a worldwide concern. Adolescents' pain affects family functioning. However, bidirectional associations should be considered as parental determinates such as pain, stress, and sociodemographic factors are also shown to influence pain in adolescence.

OBJECTIVES

This study explored the associations between maternal and paternal sociodemographic factors, pain, and stress and adolescents' pain, and stress on adolescents' pain.

METHODS

In total, 508 school-based Norwegian adolescents with a corresponding parent were included. All adolescents completed an electronic survey during school hours, and their respective parents responded electronically. The survey included sociodemographic data, the Perceived Stress Questionnaire, and the Brief Pain Inventory.

RESULTS

Herein, 385 adolescents reported an average pain of 2.1 (SD, 1.9), and 308 of the participating parents reported an average pain of 1.6 (SD, 1.8). Regressions stratified by parental gender revealed nonsignificant associations in fathers' study variables predicting adolescents' pain. However, having the highest maternal educational level (p ≤ 0.01) and working part-time (p ≤ 0.01) were associated with lower pain in adolescents.

CONCLUSIONS

The findings of this study demonstrated that sociodemographic factors such as high educational status in mothers and mothers working part-time were associated with lower pain in Norwegian adolescents. These findings highlight the importance of a holistic approach to pain management in adolescence.

"My gut feeling is…": An Ethnographic Study Exploring Interprofessional Communication About Children and Adolescents With Chronic Musculoskeletal Pain in Paediatric Rheumatology

Interprofessional communication about inflammatory and non-inflammatory musculoskeletal conditions is an important component of assessment and management in paediatric rheumatology. Chronic pain is a feature of some of these conditions which likely influences the extent and type of communication about pain. Research investigating interprofessional communication about paediatric pain is limited but has found that communication is inclusive of the biopsychosocial context of children/adolescents as well as their families. The aim of this ethnographic study was to explore interprofessional communication about children and adolescents with chronic musculoskeletal pain in paediatric rheumatology. We observed forty-five healthcare professionals recruited from 3 UK paediatric rheumatology teams during thirty multi-disciplinary team meetings. Contemporaneous field notes created during observations were analysed using grounded theory procedures. Core processes identified in interprofessional communication involved describing, making sense of, and managing children/adolescents with pain and their families. Topic areas discussed within these core processes included healthcare professional perceptions about children's and parents' personality characteristics, as well as healthcare professionals' familiarity with families. Underlying diagnoses and possible attributions of pain aetiology were also discussed. Interprofessional narratives included consideration of the potential anxieties and uncertainties about pain within families. Healthcare professionals communicated about strategies for managing expectations about pain. These findings characterise the nuances in interprofessional communication about pain and can be used to inform future work aimed at understanding and optimising the impact of interprofessional communication on clinical decisions and pain outcomes. PERSPECTIVE: This study characterises the processes (series of actions), the function (purpose) and the content (topic areas) of interprofessional communication about paediatric pain in rheumatology settings. These findings should be used to inform interventions targeting both the appropriateness and effectiveness of this communication.

Pubertal development and pain incidence and characteristics in children: a 1-year prospective cohort study of a national sample

ABSTRACT

Sex differences in pain become apparent during puberty. However, the influence of key pubertal characteristics and pubertal hormones on pain is largely unknown. We examined the prospective associations between self-reported and hormone-indicated pubertal characteristics and pain incidence and severity in 10- to 11-year-old pain-free youth in the Adolescent Brain Cognitive Development (ABCD) Study over 1 year. Puberty was measured at baseline and follow-up with self-report (Pubertal Development Scale [PDS]) and hormonal assessment (salivary dehydroepiandrosterone [DHEA], testosterone, and estradiol). Pain status (yes/no), intensity, and interference (0-10 numerical rating scale) in the past month were self-reported at follow-up. Pubertal maturity, progression, and asynchrony were examined in relation to pain onset and severity through confounder-adjusted generalized estimating equations modified Poisson and linear mixed regression models. Among 6631 pain-free youth at baseline, 1-year incident pain was 30.7%. In both sexes, higher PDS scores were associated with greater risk of pain onset (relative risk [RR] = 1.10 to 1.27, P s < 0.01). In boys, higher PDS item variance was associated with greater pain incidence (RR = 1.11, 95% CI, 1.03-1.20) and interference (beta = 0.40, 95% CI, 0.03-0.76); higher PDS overall and gonadal scores were associated with higher pain intensity ( P s < 0.05). Associations with hormones were seen in boys only, with each 10-fold higher testosterone levels associated with a 40% lower risk of pain incidence (95% CI, -55% to -22%) and 1.30-point lower (95% CI, -2.12 to -0.48) pain intensity, and higher DHEA levels were associated with lower pain intensity ( P = 0.020). Relationships between pubertal development and pain in peripubertal adolescents are sex specific and puberty measurement specific and warrant further investigation.

Learning, Hope, and Empowerment: A Reflexive Thematic Analysis of Feedback on a Group Intervention for Parents of Youth With Chronic Pain

OBJECTIVES

Limited research has investigated parent-targeted interventions in pediatric chronic pain, though these interventions may be an important part of family-centered care. Further, parent perspectives and feedback regarding these interventions are scant in the literature, even though they are crucial for developing, refining, and optimizing treatment options. This study aimed to understand how parents experience and perceive their participation in a cognitive-behavioral therapy-based, parent-targeted group intervention that was delivered either in-person or virtually, with a focus on the treatment components they found most important.

METHODS

Data from semistructured focus groups/interviews within 1week post-treatment with 32 parents (n=11 in-person, n=21 virtual) were analyzed using an inductive reflexive thematic analysis.

RESULTS

Three overarching themes were generated from the thematic analysis: building a foundation of knowledge, finding normalization and hope through connection and lived experiences, and sharing collective responsibility for pain management.

DISCUSSION

Parents perceived a range of benefits from participating in a cognitive-behavioral therapy-based, parent-targeted group intervention, both on themselves and for their youth. Overall, parent perceptions across in-person and virtual intervention delivery were consistent, except for a drawback of virtual participation for developing a deeper social connection among parents. Thus, a relatively brief parent-targeted group intervention was perceived to be a positive experience for parents, though considerations for adapting to virtual delivery and facilitating social connection among parents seem to be important.

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments

BACKGROUND

Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them.

OBJECTIVES

1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services?

SEARCH METHODS

Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022.

SELECTION CRITERIA

To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families.

DATA COLLECTION AND ANALYSIS

We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain.

MAIN RESULTS

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

Predictors of parental anxiety in a paediatric emergency department

BACKGROUND

Children experience significant anxiety in the paediatric ED. Although research from preoperative and primary care samples indicates that parents experience anxiety surrounding their children's medical procedures, less is known about parental anxiety and factors that contribute to higher parental anxiety in the ED. This study aimed to assess parental anxiety in families presenting to a paediatric ED with a variety of presenting concerns and examine demographic and psychological factors associated with parental anxiety.

METHODS

This cross-sectional study included parents of children <18 years old presenting to a paediatric ED in Orange County, California, USA, for a non-psychiatric complaint between 20 January 2021 and 26 March 2021. Parents were, on average, 34.76±9.10 years old, 87.5% were mothers, 59.2% identified as non-Latinx and parents reported average levels of mental health (T-score=51.21±9.84). Parent state anxiety was assessed via the State-Trait Anxiety Inventory and validated instruments were used to measure child temperament (ie, emotionality, activity, sociability, shyness), previous medical anxiety, and parent physical and mental health. Data were analysed using multiple linear regression models.

RESULTS

Out of 201 families screened, 150 were eligible, and 120 enrolled. In the sample, 42.5% of parents endorsed clinically significant levels of anxiety in the ED. Regression analyses indicated that lower child activity temperament (ie, tendency to be less active/energetic; B=-3.20, 95% CI -5.70 to -0.70, p=0.012) and poorer parent mental health (B=-0.31, 95% CI -0.52 to -0.09, p=0.006) were independently associated with higher parent anxiety (F(5, 99)=6.77, p=0.004).

CONCLUSION

Over 40% of parents sampled endorsed clinically significant anxiety in the paediatric ED. Child temperament, specifically lower activity temperament, and poorer parental mental health were identified as contributors to parent anxiety, whereas clinical condition or severity did not influence parent anxiety. Current results may help identify families in need of additional intervention and may improve patient outcomes.

Caregiver Psychological Burden in Pediatric Chronic Pain: A Systematic Review and Meta-Analysis of Associations with Caregiver Sociodemographic and Biopsychosocial Variables

OBJECTIVE

To investigate, via systematic review and meta-analysis, caregiver sociodemographic and biopsychosocial factors associated with anxiety, depression, posttraumatic stress symptoms, and stress of caregivers in the pediatric chronic pain context.

METHODS

EMBASE, Medline, and PsycINFO databases were searched from their inception to the search date (April 4, 2022). Studies were included if they examined caregivers of youth with chronic pain, were published in a peer-reviewed journal and assessed at least one quantitative association between relevant variables. Qualitative and intervention studies were excluded. A total of 3,052 articles were screened. Risk of bias was assessed using the JBI Checklist for analytical cross-sectional studies. Meta-analyses were conducted using robust variance estimation for associations reported in at least three studies, as well as a narrative synthesis of the evidence.

RESULTS

Fourteen studies assessing 1,908 caregivers were included in this review. Meta-analytic results showed a positive pooled correlation coefficient between caregiver catastrophizing about their child's pain and caregiver anxiety (r = 0.51; 95% CI: 0.35-0.65; p<.01) and depression (r = 0.45; 95% CI: 0.29-0.58; p < .01). Self-blame and helplessness were related to increased caregiver anxiety (r = 0.55; 95% CI: 0.40-0.67; p<.01), but not depression. No significant relationship was found for pain-promoting behavior and anxiety or depression. The qualitative synthesis of all other eligible studies showed associations between relevant psychological burden variables and various caregiver factors, which were mainly psychosocial.

CONCLUSION

Results should be interpreted with caution due to the small number of studies. Further research is needed to get a better understanding of these relationships and to examine the causal direction of effects.

Pain Management in Pediatric Burns: A Review of the Science behind It

Pediatric burns are a significant medical issue that can have long-term effects on various aspects of a child's health and well-being. Pain management in pediatric burns is a crucial aspect of treatment to ensure the comfort and well-being of young patients. The causes and risk factors for pediatric burns vary depending on various factors, such as geographical location, socioeconomic status, and cultural practices. Assessing pain in pediatric patients, especially during burn injury treatment, poses several challenges. These challenges stem from various factors, including the age and developmental stage of the child, the nature of burn injuries, and the limitations of pain assessment tools. In pediatric pain management, various pain assessment tools and scales are used to evaluate and measure pain in children. These tools are designed to account for the unique challenges of assessing pain in pediatric patients, including their age, developmental stage, and ability to communicate effectively. Pain can have significant physical, emotional, and psychological consequences for pediatric patients. It can interfere with their ability to engage in daily activities, disrupt sleep patterns, and negatively affect their mood and behavior. Untreated pain can also lead to increased stress, anxiety, and fear, which can further exacerbate the pain experience. Acute pain, which is short-term and typically associated with injury or illness, can disrupt a child's ability to engage in physical activities and impede their overall recovery process. On the other hand, chronic pain, which persists for an extended period, can have long-lasting effects on physical functioning and quality of life in children. The psychological consequences of burns can persist long after the physical wounds have healed, leading to ongoing emotional distress and impaired functioning. Multimodal pain management, which involves the use of multiple interventions or medications targeting different aspects of the pain pathway, has gained recognition as an effective approach for managing pain in both children and adults. However, it is important to consider the specific needs and considerations of pediatric patients when developing evidence-based guidelines for multimodal pain management in this population. Over the years, there have been significant advances in pediatric pain research and technology, leading to a better understanding of pain mechanisms and the development of innovative approaches to assess and treat pain in children. Overall, pain management in pediatric burns requires a multidisciplinary approach that combines pharmacologic and nonpharmacologic interventions.

Are We Any Closer to Understanding How Chronic Pain Develops? A Systematic Search and Critical Narrative Review of Existing Chronic Pain Vulnerability Models

Identifying biopsychosocial factors underlying chronic pain vulnerability is essential for the design of preventative efforts. Multiple chronic pain vulnerability models exist, however, there is a lack of comprehensive evaluation of these models in the literature, potentially due to the lack of guidelines that specify the criteria by which these types of work should be assessed. In this work, we created evaluation criteria (based on the general goals of conceptual models), and we then used them to critically review the chronic pain vulnerability models available in the current peer-reviewed literature (identified through a systematic search). Particularly, we evaluated the models on the basis of conceptual clarity/specificity of measures, depth of description of aetiological and mechanistic factors, use of a whole system approach, and quality of the evidence associated with the models. We found nine conceptual models that have been explored in detail (eg, fear avoidance model, diathesis-stress model). These models excel at clarity and are supported mostly by self-report evidence of a psychological nature (anxiety sensitivity, pain catastrophizing, etc.), but provide little explanation of mechanistic and aetiological factors. In the future, models could be improved by complementing them with proposals from other models and exploring potential causal factors and mechanisms maintaining the condition. This task could be carried out through prospective cohort studies, and computational approaches, amongst others.

Physical symptoms and brain morphology: a population neuroimaging study in 12,286 pre-adolescents

Physical symptoms, also known as somatic symptoms, are those for which medical examinations do not reveal a sufficient underlying root cause (e.g., pain and fatigue). The extant literature of the neurobiological underpinnings of physical symptoms is largely inconsistent and primarily comprises of (clinical) case-control studies with small sample sizes. In this cross-sectional study, we studied the association between dimensionally measured physical symptoms and brain morphology in pre-adolescents from two population-based cohorts; the Generation R Study (n = 2649, 10.1 ± 0.6 years old) and ABCD Study (n = 9637, 9.9 ± 0.6 years old). Physical symptoms were evaluated using continuous scores from the somatic complaints syndrome scale from the parent-reported Child Behavior Checklist (CBCL). High-resolution structural magnetic resonance imaging (MRI) was collected using 3-Tesla MRI systems. Linear regression models were fitted for global brain metrics (cortical and subcortical grey matter and total white matter volume) and surface-based vertex-wise measures (surface area and cortical thickness). Results were meta-analysed. Symptoms of anxiety/depression were studied as a contrasting comorbidity. In the meta-analyses across cohorts, we found negative associations between physical symptoms and surface area in the (i) left hemisphere; in the lateral orbitofrontal cortex and pars triangularis and (ii) right hemisphere; in the pars triangularis, the pars orbitalis, insula, middle temporal gyrus and caudal anterior cingulate cortex. However, only a subset of regions (left lateral orbitofrontal cortex and right pars triangularis) were specifically associated with physical symptoms, while others were also related to symptoms of anxiety/depression. No significant associations were observed for cortical thickness. This study in preadolescents, the most representative and well-powered to date, showed that more physical symptoms are modestly related to less surface area of the prefrontal cortex mostly. While these effects are subtle, future prospective research is warranted to understand the longitudinal relationship of physical symptoms and brain changes over time. Particularly, to elucidate whether physical symptoms are a potential cause or consequence of distinct neurodevelopmental trajectories.

Factors associated with health-related quality of life in children with sickle cell disease

BACKGROUND

Sickle cell disease is an inherited haematological condition with life-threatening consequences. It can affect all aspects of the lives of children with the condition, including biopsychosocial and cognitive aspects. These children tend to have a low health-related quality of life (HRQoL).

AIM

To identify factors associated with HRQoL in Omani children with sickle cell disease.

METHOD

The study was a secondary analysis of data from a randomised controlled trial conducted with 72 parent-and-child dyads who were recruited from two tertiary hospitals in Oman. The aim of the original study was to examine the effects of an educational programme on the knowledge and self-efficacy of parents of children with sickle cell disease. As part of that study, parents and children completed two questionnaires on HRQoL, one generic and one specific to sickle cell disease.

RESULTS

Parents' knowledge of sickle cell disease, parents' self-efficacy in managing their child's symptoms, parents' age, children's age and treatment with hydroxyurea were found to affect children's HRQoL.

CONCLUSION

Healthcare providers need to include biopsychosocial and cognitive aspects of HRQoL in their assessments of children with sickle cell disease. Programmes designed to enhance parents' and children's knowledge and self-efficacy, as well as measures designed to ensure that children receive treatment with hydroxyurea, are likely to improve the HRQoL of children with sickle cell disease.

A dyadic analysis of parent and child pain catastrophizing and health-related quality of life in pediatric sickle cell disease

ABSTRACT

The purpose of this study was to examine the dyadic and individual level effects of parent and child pain catastrophizing on child health-related quality of life (HRQOL) in pediatric sickle cell disease. Questionnaires assessing child pain frequency, child and parent pain catastrophizing, and child HRQOL were completed by youth and their primary caregiver. A Common Fate Model was estimated to test the dyadic level relationship between parent and child pain catastrophizing and child HRQOL. An Actor-Partner-Common Fate Model hybrid was estimated to test the relationship between child HRQOL and individual-level child pain catastrophizing and parent pain catastrophizing, respectively. In each model, child HRQOL was modelled as a dyadic variable by factoring parent and child ratings. Patients (N = 100, M age = 13.5 years, 61% female) and their caregivers (M age = 41.8 years, 86% mothers) participated. Dyad-level pain catastrophizing was negatively associated with child HRQOL, demonstrating a large effect (β = -0.809). Individual-level parent and child pain catastrophizing were each uniquely negatively associated with child HRQOL, demonstrating small to medium effects (β = -0.309, β = -0.270). Individual level effects were net of same-rater bias, which was significant for both parents and children. Both the unique and the overlapping aspects of parent and child pain catastrophizing are significant contributors to associations with child HRQOL, such that higher levels of pain catastrophizing are associated with worse child HRQOL. Findings suggest the need for multipronged intervention targeting factors common to parent-child dyads and factors unique to parents and children, respectively.

Distress and Resilience Narratives within Pain Memories of Adolescents and Young Adults with Complex Regional Pain Syndrome: A Multi-Method Study

A comprehensive understanding of pain memories requires consideration of risk and resilience factors across biopsychosocial domains. Previous research has typically focused on pain-related outcomes, largely ignoring the nature and context of pain memories. Using a multiple-method approach, this study explores the content and context of pain memories in adolescents and young adults with complex regional pain syndrome (CRPS). Recruited via social media and pain-related organizations, participants completed an autobiographical pain memory task. Two-step cluster analysis was conducted on the pain memory narratives of adolescents and young adults with CRPS (n=50) using a modified version of the Pain Narrative Coding Scheme. Narrative profiles generated from the cluster analysis subsequently guided a deductive thematic analysis. Cluster analysis identified two narrative profiles of Distress and Resilience, with the role of coping and positive affect emerging as important profile predictors across pain memories. Subsequent deductive thematic analysis, utilizing Distress and Resilience codes, demonstrated the complex interplay between affect, social, and coping domains. Findings highlight the importance of applying a biopsychosocial framework to pain memory research, accounting for both risk and resilience perspectives and encourage the use of multiple method approaches to improve understanding of autobiographic pain memories. Clinical implications of reframing and recontextualizing pain memories and narratives are discussed, and the importance of exploring the origins of pain and possible application to developing resilience-based, preventative interventions is highlighted. PERSPECTIVE: Using multiple methods, this paper presents a comprehensive account of pain memories in adolescents and young adults with CRPS. Study findings promote the importance of adopting a biopsychosocial approach to examining both risk and resilience factors in understanding autobiographical pain memories in the context of pediatric pain.

A systematic review of the psychosocial factors associated with pain in children with juvenile idiopathic arthritis

BACKGROUND

Pain is one of the most frequently reported experiences amongst children with Juvenile Idiopathic Arthritis (JIA); however, the management of JIA pain remains challenging. As pain is a multidimensional experience that is influenced by biological, psychological, and social factors, the key to effective pain management lies in understanding these complex relationships. The objective of this study is to systematically review the literature on psychosocial factors of children with JIA and their caregivers 1) associated with and 2) predictive of later JIA pain intensity, frequency, and sensitivity in children 0-17 years of age.

METHODS

The Joanna Briggs Institute methodology for etiology and risk and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement guided the conduct and reporting of this review. Terms related to pain and JIA were searched in English without date restrictions across various databases (PubMed, CINAHL, PsycINFO, Embase, Scopus, and the Cochrane Central Register of Controlled Trials) in September 2021. Two independent reviewers identified, extracted data from, and critically appraised the included studies. Conflicts were resolved via consensus.

RESULTS

Of the 9,929 unique studies identified, 61 were included in this review and reported on 516 associations. Results were heterogeneous, likely due to methodological differences and moderate study quality. Results identified predominantly significant associations between pain and primary and secondary appraisals (e.g., more child pain beliefs, lower parent/child self-efficacy, lower child social functioning), parent/child internalizing symptoms, and lower child well-being and health-related quality of life. Prognostically, studies had 1-to-60-month follow-up periods. Fewer beliefs of harm, disability, and no control were associated with lower pain at follow-up, whereas internalizing symptoms and lower well-being were predictive of higher pain at follow-up (bidirectional relationships were also identified).

CONCLUSIONS

Despite the heterogeneous results, this review highlights important associations between psychosocial factors and JIA pain. Clinically, this information supports an interdisciplinary approach to pain management, informs the role of psychosocial supports, and provides information to better optimize JIA pain assessments and interventions. It also identifies a need for high quality studies with larger samples and more complex and longitudinal analyses to understand factors that impact the pain experience in children with JIA.

TRIAL REGISTRATION

PROSPERO CRD42021266716.

Chronic pain in children and adolescents diagnosed with cancer: the challenge of mitigating the pain and the potential of integrating exercise into pain management

BACKGROUND

Pain is one of the most common and distressing symptoms experienced by children and adolescents diagnosed with cancer. It is vital that children and adolescents receive adequate pain management early on in their cancer treatments to mitigate pain and cancer-related symptoms. Exercise training shows particular promise in the management of acute and chronic pain among children and adolescents diagnosed with cancer.

METHODS

This position paper comes to outline the challenge of mitigating pain in children and adolescents diagnosed with cancer, and the potential benefits of integrating exercise training to the management of chronic pain in this population in need.

RESULTS

Integrating exercise training into the care and pain management of children and adolescents diagnosed with cancer who have chronic pain would have the advantage of addressing several shortcomings of pain medication. Pain medication aims to temporarily manage or reduce pain; it does not have the potential to directly improve a patient's physical condition in the way that exercise training can. The current paucity of data available on the use of exercise training as a complementary treatment to pain medications to reduce chronic pain in children and adolescents diagnosed with cancer allows only for hypotheses on the effectiveness of this pain management modality.

CONCLUSION

More research on this important topic is necessary and mitigating pain effectively while also reducing the use of opioid pain medication is an important goal shared by patients, their families, clinicians, and researchers alike. Future research in this area has great potential to inform clinical care, clinical care guidelines, and policy-making decisions for pain management in children and adolescents diagnosed with cancer who experience chronic pain.

Caregiving burden and special needs of parents in the care of their short-statured children - a qualitative approach

Purpose

To explore caregiving burden, health-related quality of life (HRQOL), stress, and individual resources of parents in the care of children with isolated growth hormone deficiency (IGHD) or idiopathic short stature (ISS).

Methods

Focused interview analysis of previously, within the Quality of Life in Short Stature Youth (QoLISSY) project, conducted structured focus group discussions (n=7) with parents (n=33) of children with IGHD/ISS aged 4 to 18 years were performed.

Results

26 out of the 33 parents reported mental stress due to their child's growth disorder. Social pressure and stigmatization were also mentioned as being demanding. Some parents reported having trouble with human growth hormone (hGH) treatment. Several parents wished for parent support groups with other like-minded parents of short-statured children.

Conclusion

For physicians, it is essential to understand the parents' caregiving burden, stress, and individual resources in caring for IGHD/ISS children. If an impaired HRQOL is detected, psychological intervention for these parents may be scheduled, and coping mechanisms may be discussed. Furthermore, it seems essential for parents to be educated by their healthcare provider about the possible side effects of hGH treatment or to know where to find evidence-based information about it.

A Parent-Targeted Group Intervention for Pediatric Pain Delivered In-Person or Virtually: Feasibility, Acceptability, and Effectiveness

OBJECTIVES

Parents play integral roles in their youth's chronic pain and can experience elevated distress related to caregiving. This study examined a cognitive-behavior therapy-based parent-targeted group intervention, including understudied/novel resilience/risk (eg, distress, parenting self-regulation), and compared the effect of in-person versus virtual delivery format.

HYPOTHESES

(1) Adequate feasibility and acceptability (enrolment>33%, attendance >60%, attrition <25%, satisfaction ratings >90%), with higher indicators of feasibility in the virtual groups; (2) Significant improvements in parent psychological flexibility, protectiveness, distress, and parenting self-regulation at posttreatment that were maintained at follow-up, with no difference between delivery type.

METHODS

Parents were enroled from an outpatient pediatric chronic pain clinic and participated in the group intervention in-person or virtually; questionnaires were completed at baseline, posttreatment, and 3-month follow-up.

RESULTS

Enrolment (55% in-person, 65% virtual) and attendance (86% in-person, 93% virtual) were higher, and attrition was lower than expected (4% in-person, 7% virtual). Satisfaction was high (4.95/5 in-person, 4.85/5 virtual); on written feedback, parents enjoyed connecting with other parents (27/56, 48%) the most. The least preferred were the virtual format (5/36, 14%) and timing of the group (6/52, 12%). There were no differences between delivery formats in feasibility/acceptability. The intervention significantly improved parents' psychological flexibility, protectiveness, distress, and parenting self-regulation over time. A small group difference favored the in-person format for psychological flexibility, and an interaction effect for parenting self-regulation was found.

DISCUSSION

This standalone parent-targeted group intervention had positive effects on parent outcomes delivered either in-person or virtually.

"We survived the pandemic together": The impact of the COVID-19 pandemic on Canadian families living with chronic pain

Introduction

Pediatric chronic pain is a significant problem in Canada, affecting one in five youth. This study describes the impact of the pandemic on the experiences of Canadian families living with chronic pain through interviews with youth living with chronic pain, parents, and siblings.

Methods

Employing a qualitative descriptive design, in-depth semistructured interviews were completed with Canadian youth living with pain, as well as parents and siblings. Participants were not required to be related. Interviews were analyzed using a reflexive thematic analysis approach.

Results

Forty-four interviews were completed with 14 parents, 19 youth with chronic pain, and 11 siblings from across the country. Three key themes were developed: (1) absorbing and shifting: the toll of the pandemic on the family system (e.g., loss of coping mechanisms, shifting roles to respond to the pandemic), (2) social ambiguity and abandonment (e.g., social sacrifice and abandonment by the health care system), and (3) building community resilience: familial adaptation to the pandemic (e.g., family cohesion, confidence, and self-management).

Discussion/Conclusions

Youth, parents, and siblings reported that the pandemic impacted coping strategies across the family system. These results outline the challenges youth experienced managing their pain and overall health throughout the pandemic and the resilience built within families during this time. Going forward, it would be relevant to examine how racialized and structurally marginalized youth with chronic pain and their families experienced the pandemic. Future research should examine how unexpected benefits of the pandemic (e.g., increased confidence and self-management) may be sustained into the future.

Children and pain: Assessment and management according to parents' perspective

Pain in children is frequent. Parents evaluate their children's pain to decide how to manage it or to share information with caregivers. This qualitative descriptive study aims to identify elements influencing the evaluation and management of pain in children from a parent's perspective. Participants were recruited through a pediatric center and university family medicine clinic. Participants had to have used medication for their child that was prescribed "as needed" to manage their child's pain in the month preceding the interview, whether it was a prescription-strength medication or an over-the-counter strength prescription. Semi-directed interviews 30-45 min in duration were conducted with 16 parents in the Outaouais region of Quebec (Canada), either at the participant's home or by phone (after the declaration of the COVID-19 pandemic). A thematic analysis was completed to identify themes in the data from these individual interviews. The evaluation of children's pain by their parents is influenced by the parents' experience with pain and the expression of the pain by the children, whereas the actions to relieve the pain are based on the beliefs surrounding pain management in children. Evaluation of pain is complex since many parents' beliefs influence this evaluation and the subsequent pain management. The study results raise healthcare professionals' awareness regarding several elements which influence the evaluation of children's pain and its management by their parents.

The effect domains, measures, and methods reported in pediatric-specialized multidisciplinary outpatient rehabilitation programs: An integrated review

OBJECTIVES

Specialized pain rehabilitation is recognized as the treatment of choice for youth with pain-related disability. Appropriate outcomes for program evaluation are critical. This study aimed to summarize the effect domains and methods used to evaluate pediatric-specialized outpatient pain rehabilition programs, map them to the PedIMMPACT statement, and highlight future directions.

METHODS

An integrated review framework, incorporating stakeholders, was used. Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar were searched for studies published in 1999-2021 featuring the treatment effects of specialized outpatient pain rehabilitation on youth with pain-related disability and their parents. Selected studies were critically appraised using the Quality Assessment Tool for Studies of Diverse Design, organized by study characteristics, and analyzed using constant comparison.

RESULTS

From the 1951 potentially relevant titles, 37 studies were selected. Twenty-five effects targeted youth and 24 focused on parents, with a maximum of 15 youth and 11 parent effect domains (median = 5 domains per study). Although most studies measured a combination of effect domains and were inclusive of some recommended in the PedIMMPACT statement, no effect was measured consistently across studies. Youth physical functioning and parent emotional functioning were measured most often. Eighty-five instruments were used to assess youth outcomes and 59 for parents, with self-report questionnaires dominating.

DISCUSSION

A lack of standardization exists associated with the domains and methods used to evaluate the effects of pediatric-specialized outpatient pain rehabilitation programs, hindering comparisons. Future program evaluations should be founded on their theory, aim, and anticipated outcomes.

Preschool Pain Management Program for Young Children with Sickle Cell Disease: A Pre-Post Feasibility Study

OBJECTIVE

Vaso-occlusive pain crises in sickle cell disease (SCD) often begin in early childhood. We developed an online pain management intervention to teach caregivers of preschool-aged children with SCD behavioral pain management strategies. The feasibility study goals were to examine response to recruitment, barriers to participation, engagement, acceptability and perceived usefulness of the intervention, and suitability of outcome measures.

METHODS

Caregivers of children aged 2.0-5.9 years with access to text messaging and a device to access online videos were recruited from a Southeastern outpatient hematology clinic for a 12-week intervention consisting of pain management videos. Videos taught caregivers behavioral pain management strategies and adaptive responses to pain. Workbook activities helped tailor strategies to their child. Caregivers completed process measures as well as baseline and follow-up measures of pain catastrophizing (Pain Catastrophizing Scale-Parent Report) and responses to their child's pain (Adult Response to Children's Symptoms).

RESULTS

Fifty percent (10 of 20) of eligible parents enrolled. Caregivers partially completed (N = 6), completed (N = 3), or did not engage (N = 1) in the intervention. Caregivers who engaged in the program reported implementing the pain management strategies. The intervention was rated as high quality, relevant, and useful. Measures of pain catastrophizing and responses to their child's pain appeared sensitive to change.

CONCLUSIONS

The intervention to promote adaptive coping to pain was acceptable and feasible for caregivers though we found barriers to delivering the intervention to parents. Evaluation of a modified version of the program is indicated to assess implementation issues and effectiveness.

Symptom perceptions in functional disorders, major health conditions, and healthy controls: A general population study

Background

The present study investigated differences in symptom perceptions between individuals with functional disorders (FD), major health conditions, and FDs + major health conditions, respectively, and a group of healthy individuals. Furthermore, it investigated the relevance of FDs among other health-related and psychological correlates of symptom perceptions in the framework of the Common Sense Model of Self-Regulation (CMS).

Method

This cross-sectional study used epidemiological data from the Danish Study of Functional Disorders part two (N = 7,459 participants, 54% female, 51.99 ± 13.4 years). Symptom perceptions were assessed using the Brief Illness Perception Questionnaire (B-IPQ) and compared between the four health condition groups. Multiple regression analyses were performed to examine associations between symptom perceptions, FDs, and other health-related and psychological correlates from the CMS framework.

Results

Individuals with FDs (n = 976) and those with FDs + major health conditions (n = 162) reported less favorable symptom perceptions compared to the other two groups, particularly regarding perceived consequences, timeline, and emotional representations (effect size range Cohen’s d = 0.12-0.66). The presence of a FD was significantly associated with all B-IPQ items, even in the context of 16 other relevant health-related and psychological correlates from the CMS framework, whereas symptom presence last year or last week was not.

Conclusion

In the general population, symptom perceptions seem to play a more salient role in FD than in individuals with well-defined physical illness. Symptom perceptions should therefore be targeted in both primary and secondary interventions for FDs.

Impacts of paediatric chronic pain on parents: A qualitative study

BACKGROUND

Paediatric chronic pain adversely impacts the child's functioning, health-related quality of life and development. However, there is a need for a holistic assessment of parental impacts of caring for a child with chronic pain. This qualitative study aimed to investigate the possible psychosocial, functional and work impacts of caring for a child with chronic pain on parents, including any positive effects of the experience.

METHODS

Ten parents (eight mothers and two fathers), whose child attended the Sydney Children's Hospital Interdisciplinary Chronic and Complex Pain Clinic, participated in semi-structured interviews exploring the impact of caring for a child with chronic pain. Interviews were audio-recorded, transcribed, coded (with good inter-coder agreement) and analysed using thematic analysis.

RESULTS

The parental experience of caring for a child with chronic pain was encapsulated by four overarching themes: (1) 'the constant and all-consuming nature of pain' - parents described the unpredictable, yet constant nature of chronic pain, contributing to wide-reaching impacts in various areas of their life; (2) 'dealing with uncertainty' - their experience was commonly characterized by a sense of uncertainty, stress, hopelessness and fear; (3) 'importance of support and self-care' - strong support networks and prioritizing self-care were crucial in alleviating the negative effects of paediatric chronic pain; and (4) 'a revitalized and optimistic view on life and relationships' - some parents identified unique and positive effects, such as stronger relationships, personal growth and a reformed view on life.

CONCLUSIONS

This study provided rich data on the various impacts of caring for a child with chronic pain, highlighting the need for the development of holistic, family-centred interventions addressing both child and parental functioning.

Biopsychosocial Attributes of Single-region and Multi-region Body Pain During Early Adolescence: Analysis of the ABCD Cohort

OBJECTIVES

Multi-region pain during adolescence is associated with a higher symptom burden and lower quality of life. The purpose of this study was to describe and compare the biopsychosocial attributes of single-region and multi-region pain among healthy young adolescents.

MATERIALS AND METHODS

We analyzed data from 10,320 children aged 10.6 to 14 years who self-reported pain in the Adolescent Brain and Cognitive Development Study. Pain was coded as single-region or multi-region based on body map data.

RESULTS

One in 5 young adolescents indicated recent multi-region pain. Sequential regression supported improved model fit when psychological and sociocultural factors were added to a biological model of pain; however, these models improved the classification of multi-region but not single-region pain. A significant interaction effect of sex and puberty remained constant across models with increased odds of pain at each advancing pubertal stage for both sexes compared with prepuberty, but no difference between girls and boys at late puberty (adjusted odds ratio [OR]=2.45 [1.72, 3.49] and adjusted OR=1.63 [1.20, 2.23], respectively). Psychological factors improved the classification of multi-region pain with significant effects of anxiety, somatic symptoms, and somnolence. Finally, compared with White and non-Hispanic children, Black and Hispanic children were less likely to report pain (adjusted OR=0.70 [0.61, 0.80]; adjusted OR=0.88 [0.78, 0.99], respectively) but had significantly higher pain interference when pain was present (adjusted OR=1.49 [1.29, 1.73] and adjusted OR=1.20 [1.06, 1.35], respectively).

DISCUSSION

Pain is a biopsychosocial phenomenon, but psychological and sociocultural features may be more relevant for multi-region compared with single-region pain during early adolescence.

Will This Treatment Help My Child?: How Parent/Caregiver Treatment Expectations Relate to Intensive Pain Rehabilitation Outcomes for Youth With Chronic Pain

OBJECTIVE

An extensive body of research has highlighted the impact that parent/caregiver factors have on functioning and treatment outcomes among youth with chronic pain. However, parent/caregiver expectations in pain treatment have been largely understudied, despite strong evidence that treatment expectations are associated with treatment engagement and overall outcomes in nonpain populations. Accordingly, the primary aim of this investigation was to preliminarily examine the manifestation and measurement of parent/caregiver treatment expectations in an intensive interdisciplinary pediatric pain treatment (IIPT) setting.

METHODS

Participants in this study (N=328) included children and adolescents who attended an IIPT program for chronic pain between August 2013 and March 2020 and their parent/caregiver(s). Outcomes examined include parent/caregiver self-report of treatment expectations for their child upon admission to the IIPT in addition to pain-related and psychosocial factors at admission and discharge.

RESULTS

Findings revealed a high level of expectations (ie, belief that the treatment will be helpful) on average, with higher parent/caregiver expectations associated with poorer functioning at admission to and discharge from the IIPT program.

CONCLUSION

Extremely high treatment expectations among parents of more disabled youth may be indicative of unrealistic hopes or the "need" for IIPT to help their child; tempering parental expectations with psychoeducation about IIPT goals and realistic outcomes may indirectly improve treatment outcomes for their children. Future research should examine the potentially unique and important role that treatment expectations, of both parent/caregivers and their children, may have in overall IIPT outcomes.

Long COVID symptoms in exposed and infected children, adolescents and their parents one year after SARS-CoV-2 infection: A prospective observational cohort study

BACKGROUND

Long COVID in children and adolescents remains poorly understood due to a lack of well-controlled studies with long-term follow-up. In particular, the impact of the family context on persistent symptoms following SARS-CoV-2 infection remains unknown. We examined long COVID symptoms in a cohort of infected children, adolescents, and adults and their exposed but non-infected household members approximately 1 year after infection and investigated clustering of persistent symptoms within households.

METHODS

1267 members of 341 households (404 children aged <14 years, 140 adolescents aged 14-18 years and 723 adults) were categorized as having had either a SARS-CoV-2 infection or household exposure to SARS-CoV-2 without infection, based on three serological assays and history of laboratory-confirmed infection. Participants completed questionnaires assessing the presence of long COVID symptoms 11-12 months after infection in the household using online questionnaires.

FINDINGS

The prevalence of moderate or severe persistent symptoms was statistically significantly higher in infected than in exposed women (36.4% [95% CI: 30.7-42.4%] vs 14.2% [95% CI: 8.7-21.5%]), infected men (22.9% [95% CI: 17.9-28.5%] vs 10.3% [95% CI: 5.8-16.9%]) and infected adolescent girls (32.1% 95% CI: 17.2-50.5%] vs 8.9% [95%CI: 3.1-19.8%]). However, moderate or severe persistent symptoms were not statistically more common in infected adolescent boys aged 14-18 (9.7% [95% CI: 2.8-23.6%] or in infected children <14 years (girls: 4.3% [95% CI: 1.2-11.0%]; boys: 3.7% [95% CI: 1.1-9.6%]) than in their exposed counterparts (adolescent boys: 0.0% [95% CI: 0.0-6.7%]; girls < 14 years: 2.3% [95% CI: 0·7-6·1%]; boys < 14 years: 0.0% [95% CI: 0.0-2.0%]). The number of persistent symptoms reported by individuals was associated with the number of persistent symptoms reported by their household members (IRR=1·11, p=·005, 95% CI [1.03-1.20]).

INTERPRETATION

In this controlled, multi-centre study, infected men, women and adolescent girls were at increased risk of negative outcomes 11-12 months after SARS-CoV-2 infection. Amongst non-infected adults, prevalence of negative outcomes was also high. Prolonged symptoms tended to cluster within families, suggesting family-level interventions for long COVID could prove useful.

FUNDING

Ministry of Science, Research and the Arts, Baden-Württemberg, Germany.

The sands of time: Adolescents' temporal perceptions of peer relationships and autonomy in the context of living with chronic pain

The incidence of chronic and recurrent pain increases in adolescence. Prevalence of adolescent chronic pain is estimated to be 11%-44%, with approximately 5% adolescents experiencing moderate-to-severe chronic pain. Adolescents with chronic pain also report unwanted changes in emotional, social, and developmental functioning. Very little is known about how adolescents with chronic pain make sense of their development, the role of pain in that development, and how such developmental trajectories progress over time. A multi-methods qualitative study was designed to explore how adolescents make sense of their experience of chronic pain in the context of development. Nine adolescents (8 girls) aged 12-22 years old (Mean = 15.7, SD = 2.8) were recruited from a UK national pain service. Adolescents completed an interview on entering the service, and a follow-up interview 12 months later. They also completed monthly diaries in this 12-month period. Data comprised 18 interviews and 60 diary entries, which were analyzed using inductive reflexive thematic analysis. Analyses generated one overarching theme entitled "tug of war: push and pull," demonstrating developmental tension related to pain, and the cumulative impact these had over time. This overarching theme comprised two subthemes which capture these tensions across the developmental domains of peer relationships and autonomy. The first subtheme, "the shifting sands of peer relationships," explores the ever-changing closeness between self and peers. The second subtheme referred to "restricted choices" and how pain limited the participants' autonomy but that this, over time could push development forward. These results extend previous cross-sectional research on the developmental consequences of chronic pain, showing the dynamic fluctuations and alterations to developmental trajectories over time.

Cutting the cord? Parenting emerging adults with chronic pain

The role of parent factors, such as distress and protective behaviors, on pain and functional outcomes of emerging adults living with chronic pain has been largely unexplored. The effects of helicopter parenting and developmental changes occurring during this transition period between adolescence and adulthood (commonly defined as the ages between 18 and 30 years) may exacerbate the pain experience and have the potential to influence chronic pain management. Clinical practice, with an additional focus on supporting the parent(s), may aid in meeting the needs of this population. In this paper, we review the available literature on (a) the socio-cultural shift in parenting over the past decade with a focus on helicopter parenting; (b) the impact of this parenting style on the pain experience and outcomes of emerging adults living with chronic pain; (c) provide recommendations for chronic pain management with a focus on the parent-emerging adult dyad; and (d) conclude with future research recommendations. This narrative review is the first to consider the impacts and outcomes of helicopter parenting on emerging adults with chronic pain.