Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – A randomized controlled trial

Evaluating an acceptance-based lifestyle modification program to address cardiovascular disease risk among adolescent girls with overweight and obesity: Protocol for a randomized controlled trial

BACKGROUND

Behavioral weight loss interventions achieve only limited weight loss in adolescent samples and weight regain is common. This limited intervention success may be attributed, in part, to adolescents' lack of self-regulation skills essential for lifestyle modification and use of a one-size fits-all approach to produce weight loss in boys and girls. Interventions which teach self-regulation skills, such as Acceptance-Based Therapy (ABT), and are tailored to meet gender-specific concerns, are critical to help adolescents adapt to pervasive biological and environmental influences toward weight gain.

OBJECTIVE

This trial tests the effect of an ABT intervention on cardiometabolic health, health-related behaviors, and psychological factors among adolescent girls with overweight or obesity (OW/OB).

METHODS

Girls 14-19 years (N = 148; ≥ 40% racial/ethnic minorities) with OW/OB (BMI: ≥ 85th percentile) will be enrolled in the study. Participants will be randomized to one of two 6-month interventions, consisting of either 18 sessions of ABT or 9 sessions of a health education control, an augmented version of standard care for adolescent OW/OB, both led by bachelor's level interventionists.

RESULTS

Recruitment is taking place in Philadelphia, USA, from January 2024 to January 2028. Cardiometabolic health markers (adiposity; blood pressure; blood lipids), health-related behaviors (dietary intake; physical activity; sleep), and psychological factors (quality of life; depression; disordered eating; psychological flexibility) will be measured at baseline, mid-treatment, post-treatment, 6-month follow-up, and 12-month follow-up.

CONCLUSIONS

This study will provide valuable information on a novel intervention tailored to the needs of adolescent girls with OW/OB to address self-regulation and cardiometabolic health.

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.

Meaningful Clinical Outcomes for Young People and Parents When Treated for Chronic Musculoskeletal Pain in the UK: Q Set Development

Previous studies have established a core outcome set for pediatric chronic pain clinical trials. The aim of this research was to establish which outcomes young people and parents considered important to measure during treatment for chronic musculoskeletal pain. To the best of our knowledge, this is the first study to explore which outcomes could be used to tailor interventions within a clinical setting. Twenty-one young people (aged 11-18 years) and 21 parents were recruited from 2 UK hospital sites and took part in semi-structured interviews that incorporated drawing a timeline of their treatment. They identified positive and negative outcomes showing the perceived effectiveness of treatment. Informed by Q methodology, the words and phases of young people and parents were developed into 101 statements that were mapped onto the core outcome set and represented wide-ranging opinions regarding the outcomes they considered important (Q set). This approach helped identify additional statements related to "parent and family functioning" not routinely considered. Outcomes related to the treatment experience and adverse effects were highlighted as important, yet are not routinely prioritized in clinical research. Parents prioritized outcomes related to the treatment experience, whereas young people prioritized their overall well-being. Over the course of treatment, outcome focus changed, with some outcomes only deemed relevant at a specific time point. Overall, the research highlighted the need for clinical guidance on which outcome domains to measure during the treatment course to gauge treatment effectiveness and optimally tailor interventions. PERSPECTIVE: This study established the range of outcomes that were important to young people and their parents during treatment for chronic musculoskeletal pain. The findings show how young people and parents have different outcome preferences and how their outcome focus changes during the treatment course.

Psychological predictors of performance-based physical functioning among pediatric pain program participants

PURPOSE

The purpose of the present study was to evaluate changes in performance-based physical functioning and investigate psychological predictors of physical functioning over time in pediatric patients with chronic pain who completed an interdisciplinary rehabilitation intensive outpatient program (IOP).

METHODS

Participants (N = 55; mean age = 14.92 years; 12.7% male, 87.3% female; 83.6% White, 5.6% African-American/Black; 9.1% Latinx) completed baseline measures assessing pain intensity and modifiable psychological factors (i.e., pain catastrophizing, kinesiophobia, anxiety and depressive symptoms). Participants were administered performance-based assessments of physical functioning (i.e., physical endurance, high-level motor abilities) before and after IOP completion.

RESULTS

Pain intensity was not significantly associated with physical functioning at either timepoint. There was significant improvement on measures of physical functioning after completion of the IOP when controlling for the effects of sex, race, and ethnicity. Depressive symptoms were associated with baseline physical endurance, β = - .28, p = .047, while pain catastrophizing was associated with baseline gross motor abilities, β = - .28, p = .032.

CONCLUSION

Participation in an IOP led to significant improvement in physical endurance and high-level motor ability. Depressive symptoms and pain catastrophizing were associated with physical functioning at baseline but not post-program completion. Integration of pain psychology and physical therapy in an IOP can help address the interrelated psychological and physical factors impacting physical functioning to improve outcomes for children with chronic pain.

A randomized controlled trial of graded exposure treatment (GET living) for adolescents with chronic pain

ABSTRACT

Graded exposure treatment (GET) is a theory-driven pain treatment that aims to improve functioning by exposing patients to activities previously feared and avoided. Combining key elements of GET with acceptance-based exposure, GET Living (GL) was developed for adolescents with chronic pain (GL). Based on robust treatment effects observed in our single-case experimental design pilot trial of GL (NCT01974791), we conducted a 2-arm randomized clinical trial comparing GL with multidisciplinary pain management (MPM) comprised of cognitive behavioral therapy and physical therapy for pain management (NCT03699007). A cohort of 68 youth with chronic musculoskeletal pain (M age 14.2 years; 81% female) were randomized to GL or MPM. Owing to COVID-19 restrictions, 54% of participants received zoom video delivered care. Assessments were collected at baseline, discharge, as well as at 3-month and 6-month follow-up. Primary outcomes were self-reported pain-related fear and avoidance. Secondary outcomes were child functional disability and parent protective responses to child pain. As hypothesized, GL improved in primary and secondary outcomes at 3-month follow-up. Contrary to our superiority hypothesis, there was no significant difference between GL and MPM. Patients reported both GL and MPM (in person and video) as credible and were highly satisfied with the treatment experience. Next steps will involve examining the single-case experimental design data embedded in this trial to facilitate an understanding of individual differences in treatment responses (eg, when effects occurred, what processes changed during treatment within the treatment arm). The current findings support GET Living and MPM for youth with chronic pain.

Wellness Achieved Through Changing Habits: A Randomized Controlled Trial of an Acceptance-Based Intervention for Adolescent Girls With Overweight or Obesity

Background: Obesity prevalence among adolescent girls continues to rise. Acceptance-based therapy (ABT) is effective for weight loss in adults and feasible and acceptable for weight loss among adolescents. This pilot randomized controlled trial (RCT) assessed effectiveness of an adolescent-tailored ABT intervention on decreasing weight-related outcomes and improving psychological outcomes compared with enhanced care. Methods: In this 6-month, two-arm pilot RCT, participants were randomized to the ABT intervention or to enhanced care. The ABT intervention condition attended 15 virtual, 90-minute group sessions. The enhanced care comparison received 15 healthy lifestyle handouts and virtually met twice with a registered dietitian. The primary outcome assessed was change in BMI expressed as a percentage of the 95th percentile (%BMIp95). Results: Participants included 40 girls (ages 14-19) assigned to ABT (n = 20) or enhanced care (n = 20). A decrease in %BMIp95 was observed within the ABT intervention [d = -0.19, 95% confidence interval, CI: (-0.36 to -0.02)], however, not within the enhanced care comparison [d = -0.01, 95% CI: (-0.09 to 0.07)]. The ABT group showed slight changes in psychological flexibility [d = -0.34, 95% CI: (-0.62 to -0.06)] over enhanced care [d = -0.11, 95% CI: (-0.58 to 0.37)]. There was no significant intervention effect noted between groups. Conclusion: In this pilot RCT, the ABT intervention was as effective as enhanced care for weight loss. However, previous ABT studies occurred in person, and this study was conducted virtually due to COVID-19. Thus, future research investigating the potential effectiveness of ABT in-person among adolescents and optimization of virtual interventions is needed.

Psychological flexibility and global health in young adults with and without a self-reported functional somatic syndrome: a preliminary investigation

Functional somatic syndromes (FSS) are associated with functional impairments and distress. FSSs are common among young adults, and psychological flexibility may be a transdiagnostic process appropriate for treatment of FSS in this population. The objective of the current study was to compare physical and mental health in young adults with and without a self-reported FSS and examine which psychological flexibility processes are associated with better physical and mental health in the FSS subset. A total of 447 young adults participated in the current study. Individuals who reported an FSS diagnosis were coded as having a self-reported FSS. Physical and mental health and psychological flexibility were measured via self-report. FSS and non-FSS groups were compared regarding demographic characteristics and on the primary outcomes. Hierarchical regression analyses were conducted to examine the role of the psychological flexibility processes in physical and mental health in the FSS subset. Findings revealed that the FSS group scored significantly lower on measures of physical health and demonstrated less behavioral awareness than the non-FSS group. No differences regarding mental health were found. All three psychological flexibility processes were associated with physical and mental health, accounting for 26-49% of the variance in these outcomes. In conclusion, young adults with FSS experience more physical health difficulties than those without FSS. Psychological flexibility processes were related to better physical and mental health in those with FSS. These findings add to the literature and provide preliminary support for psychological flexibility as a future target for intervention development and implementation aimed at young adults with FSS.

Improved pain acceptance and interference following outpatient interdisciplinary pediatric chronic pain treatment

OBJECTIVES

Intensive interdisciplinary chronic pain treatment programs have demonstrated that pain acceptance predicts positive treatment outcomes, but limited research has focused on less-intensive programs. This study aimed to examine associations between changes in pain acceptance and pain interference among youth participating in an outpatient interdisciplinary chronic pain treatment program.

DESIGN

Youth presenting to an evaluation within an interdisciplinary outpatient pediatric chronic pain program completed questionnaires at initial program evaluation (T1) and three months later (T2).

MAIN OUTCOME MEASURES

Youth (N = 94, Mage = 14.59 years, 74% female) completed the Chronic Pain Acceptance Questionnaire, Adolescent Version (CPAQ-A) and PROMIS Pediatric Pain Interference scale.

RESULTS

Pain acceptance increased significantly from T1 to T2 (p=.001), driven primarily by activity engagement (p=.001). Pain interference decreased from T1 to T2 (p<.001). Improvements in acceptance were strongly associated with reductions in interference (p<.001). An exploratory cross-lagged structural equation model revealed a number of direct and indirect effects between pain acceptance and pain interference at T1 and T2.

CONCLUSION

Pain acceptance and interference improved after three months in an outpatient chronic pain treatment program. Improvements in acceptance were strongly related to reductions in interference. Future research should examine these relationships over longer periods, in larger samples.

Rapid Mobilization of an Evidence-Based Psychological Intervention for Pediatric Pain during COVID-19: The Development and Deployment of the Comfort Ability® Program Virtual Intervention (CAP-V)

BACKGROUND

The gold standard of treatment for chronic pain is a multidisciplinary approach in which psychology plays a leading role, but many children and caregivers do not gain access to this treatment. The Comfort Ability® Program (CAP) developed a CBT-oriented group intervention for adolescents and caregivers designed expressly to address access to evidence-based psychological care for pediatric chronic pain. Before the COVID-19 disruption of in-person services, the CAP workshop had been disseminated to a network of 21 children's hospitals across three countries. In March 2020, a virtual (telehealth) format was needed to ensure that children with chronic pain could continue to access this clinical service throughout the CAP Network.

METHODS

A model of knowledge mobilization was used to adapt the CAP workshop to a virtual format (CAP-V) and disseminate it to network sites. A pilot study assessing participant and clinician perceptions of acceptability, feasibility, and treatment satisfaction included baseline, post-sessions, and post-program questionnaires.

RESULTS

A knowledge mobilization framework informed the rapid development, refinement, and mobilization of CAP-V. Data from a pilot study demonstrated feasibility and high acceptability across participants and clinicians.

CONCLUSIONS

A knowledge mobilizationframework provided a roadmap to successfully develop and deploy a virtual behavioral health intervention for adolescents with chronic pain and their caregivers during a worldwide pandemic. While CAP-V has demonstrated preliminary clinical feasibility and acceptability at the CAP hub, ongoing research is needed.

Animal-Assisted Psychotherapy for Pediatric Chronic Pain: Case Series of an Open Pilot Study to Test Initial Feasibility and Potential Efficacy

Objective

Chronic pain is a common complaint in children and adolescents, placing an enormous burden on individuals, their families, and the healthcare system. New innovative approaches for the treatment of pediatric chronic pain (PCP) are clearly warranted, as drop-out rates in intervention studies are high and it can be difficult to engage patients with PCP in therapy. Here, animal-assisted interventions (AAIs) might be promising, since there is preliminary evidence for the approach in adults with chronic pain, and AAIs are generally known to foster the therapeutic motivation of patients. To date, however, AAIs have not been examined in pediatric chronic pain.

Methods

The aim of this open pilot study was to examine the initial feasibility of recruitment and potential efficacy of an animal-assisted group psychotherapy (including horses, rabbits, chickens, goats, and a dog), providing case reports of three children with chronic pain. We applied a mixed-methods approach, including the conductance of semi-structured interviews and assessment of quantitative pre-post data with a focus on pain severity, avoidance behavior, pain acceptance, and ability to defocus from the pain.

Results

The three participating girls (age: 9-12 years) reported chronic pain in the head and abdomen. The process of recruitment turned out to be challenging. All three children reported reduced pain-related disability and pain-related distress, as well as an increased ability to accept pain and to defocus from the pain. The qualitative data revealed that patients and their parents had a positive attitude towards AAIs.

Conclusion

Our initial open pilot study is the first to investigate AAIs in the context of pediatric chronic pain. Notably, we had difficulties in the recruitment procedure, mostly due to the Covid-19 situation. Based on three case reports, we found some first indication that AAI approaches might be associated with symptom changes. Future randomized-control studies with larger sample sizes are clearly warranted.

Clinicaltrialsgov Identifier

NCT04171336.

Effects of acceptance and commitment therapy on cognitive function: A systematic review

Cognitive function is essential for daily activities. Acceptance and commitment therapy (ACT) may improve cognitive function by enhancing psychological flexibility, but the underlying mechanism is unknown. This systematic review evaluated the effectiveness of ACT on cognitive function. Seven research databases (PubMed, ProQuest Dissertations and Theses, Web of Science, EBSCOhost, CNKI, Scopus, Wanfang) were searched to collect articles with trials published in English and Chinese. After applying inclusion and exclusion criteria, we identified 12 studies published between 1994 and 2022 that included a combined total of 904 participants. Among the included studies were within-group (N = 3) and randomized controlled trial (RCT, N = 9) study designs. Outcome measures included cognitive scales and behavioral measurements. Of the 12 articles, 10 studies showed improvements in certain domains of cognitive function due indirectly to ACT intervention. We found that the ability of ACT intervention to promote psychological flexibility is due to its transdiagnostic nature. Also, the effects of the ACT intervention were observed in multiple cognitive domains: attention, subjective cognitive function, executive function, and memory. In conclusion, cognitive trainers could consider practicing ACT as part of their strategy to enhance an individual's psychological flexibility and cognitive function.

The effectiveness of third wave cognitive behavioural therapies for children and adolescents: A systematic review and meta-analysis

OBJECTIVES

Third wave cognitive behavioural therapies are increasingly used with children and adolescents. This meta-analysis aimed to determine the effectiveness of four third-wave interventions (acceptance and commitment therapy, compassion focused therapy, mindfulness-based cognitive therapy, and metacognitive therapy) for youth.

METHODS

Four electronic databases were used to identify randomized controlled trials, which tested effects related to health, well-being and functioning. Sensitivity analyses considering study quality were conducted and moderators were explored.

RESULTS

The results based on 50 RCTs meeting inclusion criteria indicated emotional symptoms/internalizing problems (g = -.68, 95% CI -.98 to -.37, k = 43, N = 3265), behavioural difficulties/externalizing problems (g = -.62, 95% CI -1.01 to -.22, k = 23, N = 1659), interference from difficulties (g = -.46, 95% CI -.87 to -.05, k = 21, N = 1786), third wave processes (g = .39, 95% CI .17 to .62, k = 22, N = 1900), wellbeing/flourishing (g = .76, 95% CI .35 to 1.17, k = 21, N = 1303) and physical health/pain (g = .72, 95% CI .01 to 1.44, k = 9, N = 1171) yielded significant effects. Effect for quality of life (g = .62, 95% CI -.08 to 1.31, k = 12, N = 1271) was non-significant. When analysing only those studies rated moderate-high quality, third wave interventions yielded significant superiority effects compared to controls for emotional symptoms/internalizing problems (g = -.55, 95% CI -.82 to -.27, k = 28, N = 2110), interference from difficulties (g = -.48, 95% CI -.90 to -.05, k = 21, N = 1605), third wave processes (g = .27, 95% CI .11 to .43, k = 18, N = 1692), well-being/flourishing (g = .50, 95% CI .18 to .81, k = 16, N = 1063), and quality of life (g = .32, 95% CI .04 to .60, k = 10, N = 1212). Behavioural difficulties/externalizing problems (g = -.38, 95% CI -.86 to .10, k = 15, N = 1351) and physical health/pain (g = .52, 95% CI -.14 to 1.17, k = 8, N = 1139) ceased to be significant. Widespread heterogeneity raised concerns about generalizability and follow-up data was relatively sparse.

CONCLUSIONS

This meta-analysis finds promising results for use of third wave CBT with youth, though the review has limitations.

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.

The effectiveness and cost-effectiveness of Acceptance and Commitment Therapy as a transdiagnostic intervention for transitional-age youth: study protocol of a randomized controlled trial

BACKGROUND

Although the prevalence of psychological problems in transitional-age youth (i.e., youth aged 15 to 25; TAY) is high, TAY are much less likely to receive age-appropriate treatments for their psychological problems compared to younger adolescents or older adults. Hence, effective interventions for TAY seem warranted. ACT your way is a transdiagnostic treatment, specifically developed for TAY, based on the principles of Acceptance and Commitment Therapy (ACT). ACT your way is not directed primarily at symptom reduction, but mainly aims to change the underlying mechanism of psychopathology, namely increasing TAY's psychological flexibility. Meta-analyses show that ACT is an effective treatment for adults with diverse types of psychopathology. Less is known about the effectiveness of ACT for TAY. Therefore, the goal of this study is to examine the effectiveness and cost-effectiveness of ACT your way. In addition, we will investigate for whom and under what circumstances (i.e., moderators) and how (i.e., mediators) the intervention is (most) effective.

METHOD

The study is designed as a multi-centre, randomized controlled trial. In total, 140 TAY diagnosed with any psychological disorder will be randomly assigned to either the ACT your way or treatment as usual (TAU) condition. In total, six assessments will be conducted: at baseline, after 3, 6 and 9 sessions, at post-intervention and at 6-month follow-up, using multiple informants (TAY, parents/caregivers, therapists). Assessments will include diagnostic interviews and questionnaires. The primary outcomes are psychological flexibility and number of DSM-5 diagnoses; the secondary outcomes are the presence of the primary DSM-5 diagnosis, psychopathology, personality problems, global, individual and societal functioning, quality of life, stress, treatment satisfaction, treatment drop-out and therapeutic alliance. We will also assess costs and various moderators (i.e., demographic characteristics, type and severity of problems, psychopathology of parents/caregivers, treatment expectancy and previous treatments) and mediators (i.e., psychological flexibility, emotion regulation, self-compassion, autonomy, perfectionism, self-esteem and group cohesion).

DISCUSSION

To our knowledge, this is the first study investigating the (cost-)effectiveness of ACT compared to TAU in clinically referred TAY with various types of psychopathology, using a rigorous design.

TRIAL REGISTRATION

The research project is registered in the Dutch Trial Register (Trial NL9642).

Investigating the Relationship between Empowerment and Chronic Pain Acceptance and the Resulting Limitations in the Elderly with Diabetes living Southwest of Iran

BACKGROUND AIM

Considering the importance of pain acceptance in adjusting to chronic pain among diabetic patients, this study was conducted to determine the relationship between the empowerment scale and the level of chronic pain acceptance among the elderly with diabetes and the resulting limitations.

METHOD

This is a descriptive-analytical study on 250 older patients (65 years and older) with diabetes. The samples were selected through random convenience sampling, performed during 2019 to 2020 in the health centers of Ahvaz, Iran. The data were collected using the demographic information checklist and standard questionnaires including chronic pain acceptance questionnaire (CPAQ), the scale of chronic pain-related limitations, and the diabetes empowerment scale-short form (DES-SF). The data were analyzed using SPSS V24.

RESULTS

The majority of the samples were male (56%) and the mean age of the participants was 70.96 ± 8.95 years. The results showed that the mean and standard deviation were reported to be 20.04 ± 4.63 for pain acceptance, 46.16 ± 10.85 for chronic pain-related limitations, and 27.24 ± 9.65 for the empowerment scale. According to regression coefficients, the mean score of empowerments of patients with diabetes has no significant relationship with pain acceptance (p = .199, b = -0.327) and pain-related limitations (p = .925, b = 0.004).

CONCLUSIONS

Based on the results of this study, the level of empowerment, pain acceptance, and pain-related limitations in the older patients with diabetes was moderate and there was no significant relationship between them. Identifying vulnerable groups in the field of chronic pain and preventive, educational and therapeutic interventions will help increase patients' self-care capacity and reduce the limitations and the disability caused by pain.

Demographics, Diagnoses, Drugs, and Adjuvants in Patients on Chronic Opioid Therapy vs. Intermittent Use in a Tertiary Pediatric Chronic Pain Clinic

Anywhere from 11.6% to 20% of pediatric and adolescent patients treated for chronic pain are prescribed opioids, but little is known about these patients. The purpose of this study was to determine the characteristics of patients on chronic opioid therapy (COT) and what therapies had been utilized prior to or in conjunction with COT. The study was a retrospective chart review of all chronic pain patients seen during 2020 with those patients on COT separated for analysis. A total of 346 unique patients were seen of which 257 were female (74.3%). The average age was 15.5 years. A total of 48 patients (13.9%) were identified as being on COT with an average age of 18.1 years. Of these, 23 (47.9%) were male which was significantly more than expected. The most common reason for patients to be receiving COT was palliative (13/48), and the second most common was sickle cell anemia (10/48). Patients on COT were significantly more likely to be male, be older, and to be concurrently prescribed benzodiazepines. Concurrent opioid and benzodiazepine therapy is a risk factor for respiratory depression and overdose. Further investigation into the increased proportion of males and benzodiazepine usage in patients on COT is warranted.

Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design

BACKGROUND

Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain.

OBJECTIVE

This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design.

METHODS

This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice.

RESULTS

The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.

CONCLUSIONS

Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40705.

The missing mechanistic link: Improving behavioral treatment efficacy for pediatric chronic pain

Pediatric chronic pain is a significant global issue, with biopsychosocial factors contributing to the complexity of the condition. Studies have explored behavioral treatments for pediatric chronic pain, but these treatments have mixed efficacy for improving functional and psychological outcomes. Furthermore, the literature lacks an understanding of the biobehavioral mechanisms contributing to pediatric chronic pain treatment response. In this mini review, we focus on how neuroimaging has been used to identify biobehavioral mechanisms of different conditions and how this modality can be used in mechanistic clinical trials to identify markers of treatment response for pediatric chronic pain. We propose that mechanistic clinical trials, utilizing neuroimaging, are warranted to investigate how to optimize the efficacy of behavioral treatments for pediatric chronic pain patients across pain types and ages.

Pain, depressive symptoms, and health-related quality of life among survivors of pediatric hematopoietic stem cell transplant

OBJECTIVE

Pediatric hematopoietic stem cell transplant (HCT) is an intensive medical procedure associated with significant late effects, of which pain is a prominent example. While pain is associated with increased depressive symptoms and health-related quality-of-life (HRQoL) impairments in other pediatric chronic illness populations, associations between these variables are not well understood in pediatric HCT. Clarifying these associations may inform clinical interventions to improve health outcomes following pediatric HCT. This study aimed to investigate the relations between pain intensity, depressive symptoms, and HRQoL in survivors of pediatric HCT.

METHOD

Fifty-one survivors of pediatric HCT (Mage  = 14.3 years, standard deviation [SD] = 4.3; 58.8% male; 80.4% White) completed self-report measures of pain intensity, depressive symptoms, and HRQoL. Demographic and disease information was collected via demographic forms and medical record review. Path analysis was used to examine hypothesized associations between pain intensity, depressive symptoms, and HRQoL.

RESULTS

Analyses revealed direct effects of pain intensity on depressive symptoms (estimate [Est.] = .23, p < .001) and HRQoL (Est. = -.2, p = .04), and direct effects of depressive symptoms on HRQoL (Est. = -.68, p < .001). Depressive symptoms also mediated the relationship between pain intensity and HRQoL (Est. = -.16, p = .006).

CONCLUSIONS

Greater pain intensity was associated directly with increased depressive symptoms and indirectly with HRQoL through depressive symptoms. Results of this study suggest that multitargeted cognitive behavioral interventions that address pain and depressive symptoms may improve HRQoL ratings in survivors of pediatric HCT.

Child and adolescent psychiatry staff's knowledge on pain management

OBJECTIVE

To assess the level of child and adolescent psychiatric staff's knowledge regarding pain management, to determine group differences between the medically more educated (physicians, nurses) and the less educated (psychologists, educators, special therapists) and to investigate the influence of gender, age, or professional experience as well as staff's own pain experiences.

METHODS

A total of 193 staff members from different professional backgrounds from three independent child and adolescent psychiatry clinics in Northern Germany were tested using the German version of the Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain Shriner's revision (PNKAS-Sr).

RESULTS

In total, the staff scored correctly 66% of the inventory questions. There was no difference between medically more educated and less educated staff members regarding the knowledge of pain management. The main factors influencing PNKAS score were age, profession, and pain education training.

CONCLUSIONS

Although chronic pain is not one of the main aspects of continuing education in child and adolescent psychiatry, the resulting level of knowledge was comparable to results of similar surveys with paediatric staffs. Nevertheless, further education is needed to enhance knowledge and understanding of children's pain in child psychiatry staff in order to professionally treat patients with chronic somatic and mental illnesses.

A unified Internet-delivered exposure treatment for undifferentiated somatic symptom disorder: single-group prospective feasibility trial

BACKGROUND

Exposure-based psychological treatment appears to have beneficial effects for several patient groups that commonly report distress related to persistent somatic symptoms. Yet exposure-based treatment is rarely offered in routine care. This may be because existing treatment protocols have been developed for specific symptom clusters or specific unwanted responses to somatic symptoms, and many clinics do not have the resources to offer all these specialised treatments in parallel. In preparation for a randomised controlled trial, we investigated the feasibility of a new and unified Internet-delivered exposure treatment (OSF.io: cnbwj) for somatic symptom disorder regardless of somatic symptom domain (e.g. cardiopulmonary, fatigue, gastrointestinal, pain), combination of unwanted emotions (e.g. anger, anxiety, fear, shame) and whether somatic symptoms are medically explained or not. We hypothesised that a wide spectrum of subgroups would show interest, that the treatment would be rated as credible, that adherence would be adequate, that the measurement strategy would be acceptable and that there would be no serious adverse events.

METHODS

Single-group prospective cohort study where 33 self-referred adults with undifferentiated DSM-5 somatic symptom disorder took part in 8 weeks of unified Internet-delivered exposure treatment delivered via a web platform hosted by a medical university. Self-report questionnaires were administered online before treatment, each week during treatment, post treatment and 3 months after treatment.

RESULTS

Participants reported a broad spectrum of symptoms. The Credibility/Expectancy mean score was 34.5 (SD = 7.0, range: 18-47). Participants completed 91% (150/165) of all modules and 97% of the participants (32/33) completed at least two exposure exercises. The average participant rated the adequacy of the rationale as 8.4 (SD = 1.5) on a scale from 0 to 10. The post-treatment assessment was completed by 97% (32/33), and 84% (27/32) rated the measurement strategy as acceptable. The Client Satisfaction Questionnaire mean score was 25.3 (SD = 4.7, range: 17-32) and no serious adverse events were reported. Reductions in subjective somatic symptom burden (the Patient Health Questionnaire 15; d = 0.90) and symptom preoccupation (the somatic symptom disorder 12; d = 1.17) were large and sustained.

CONCLUSIONS

Delivering a unified Internet-delivered exposure-based treatment protocol for individuals with undifferentiated somatic symptom disorder appears to be feasible.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04511286 . Registered on August 13, 2020.

Chronic Pain and Emotional Stroop: A Systematic Review

Chronic pain is an unpleasant sensory and emotional experience that persists for more than 3 months and is often accompanied by symptoms such as depression, fatigue, sleep disturbances, and cognitive impairment. Emotional dysregulation may also be involved in its etiology. Emotions are known to modulate the experience of pain by influencing cognition and behavior (emotional awareness, emotional expression and experience, and verbalizations). A useful task to explore emotional processing and emotional dysregulation is the emotional Stroop task. Despite the large number of studies using this task, their objectives are diverse; it is necessary to integrate them. The main objective of the present systematic review was to determine the extent of the abnormalities in behavioral performance (including attentional biases) and/or brain alterations in patients with chronic pain during the emotional Stroop task. This systematic review was conducted in accordance with the Cochrane Collaboration guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The protocol was previously registered in the Prospective Register of Systematic Reviews (PROSPERO) international database. The selected articles were extracted from the PubMed, Scopus, and Web of Science databases. Fifteen studies were identified as eligible for systematic review. The studies reported alterations in brain regions related to pain and emotional regulation, as well as attentional bias and higher response time latencies (related to the words’ emotional load) in patients with chronic pain. The results confirm the validity of the emotional Stroop task to measure emotions and selective attention. As attentional bias towards negative information is often seen in chronic pain patients, and given the relation between selective attention and greater activation of the brain areas associated with pain and emotional processing, this type of task plays a crucial role in research on emotional and attentional processes among chronic pain patients. Further, attentional bias towards negative information has been associated with higher levels of pain. Taken together, the results suggest the need for cognitive training and an emotional approach to chronic pain therapies, especially targeting attentional biases and negative mood.

Evaluating the performance of the Pain Interference Index and the Short Form McGill Pain Questionnaire among Chilean injured working adults

Background

Chronic pain can lead to economic instability, decreased job productivity, and poor mental health. Therefore, reliable identification and quantification of chronic pain is important for clinical diagnosis and treatment.

Objective

To determine the psychometric properties of the Spanish language versions of the Pain Interference Index (PII) and the Short Form McGill Pain Questionnaire (SF-MPG) among a population of working adults who experienced injury in Santiago, Chile.

Methods

A total of 1,975 participants with work-related injuries were interviewed to collect sociodemographic, occupational, and chronic pain characteristics. Construct validity and factorial structure of the PII and SF-MPG were assessed through exploratory factor analyses (EFA). Cronbach’s alpha was used to evaluate internal consistency.

Results

The PII mean score was 3.84 ± 1.43 among all participants. The SF-MPG median score was 11 [IQR: 6–16] in this study population. Cronbach’s alpha for the PII was 0.90 and 0.87 for the SF-MP. EFA resulted in a one factor solution for the PII. A two-factor solution was found for the SF-MPG. The two-factors for SF-MPG were sensory and affective subscales with Cronbach’s alpha of 0.82 and 0.714, respectively. When the two scales were combined, an EFA analysis confirmed the PII and SF-MPG measure different aspects of chronic pain.

Conclusions

The PII and SF-MPG had good construct validity and reliability for assessing different aspects of chronic pain among working Chilean adults.

Tailored internet-based cognitive behavioral therapy for individuals with chronic pain and comorbid psychological distress: a randomized controlled trial

Comorbid psychological problems are commonly related to chronic pain but addressing heterogeneous comorbidities in traditional settings is often difficult. Delivering individually tailored treatment using the internet could be a viable alternative. The present study investigates whether a guided, individually tailored and internet-delivered cognitive behavioral therapy (ICBT) could improve mood and reduce disability in individuals suffering from chronic pain and comorbid psychological distress.Participants were recruited from a pain clinic and randomized to either ICBT or waiting list. The participants (n = 187) individually tailored treatments included 6-13 modules targeting different types of psychological distress. Modules were designed to be completed weekly, and feedback was provided by clinicians. Participants completed an average of 5.1 (49.7%) modules, with 22.9% completing all assigned modules. Intention-to-treat analyses showed significantly larger improvements in depression, disability, pain acceptance, catastrophizing, and quality of life in the ICBT-group compared to the control group. Between-group effect sizes were very small or small at post for the primary outcomes depression (d = 0.18) and pain interference (d = 0.22). Other effect sizes ranged from very small to small, with the largest effect being improvements in pain acceptance (d = 0.3). All significant changes were stable at 12-month follow up.

Preventing pediatric chronic postsurgical pain: Time for increased rigor

Chronic postsurgical pain (CPSP) results from a cascade of events in the peripheral and central nervous systems following surgery. Several clinical predictors, including the prior pain state, premorbid psychological state (e.g., anxiety, catastrophizing), intraoperative surgical load (establishment of peripheral and central sensitization), and acute postoperative pain management, may contribute to the patient's risk of developing CPSP. However, research on the neurobiological and biobehavioral mechanisms contributing to pediatric CPSP and effective preemptive/treatment strategies are still lacking. Here we evaluate the perisurgical process by identifying key problems and propose potential solutions for the pre-, intra-, and postoperative pain states to both prevent and manage the transition of acute to chronic pain. We propose an eight-step process involving preemptive and preventative analgesia, behavioral interventions, and the use of biomarkers (brain-based, inflammatory, or genetic) to facilitate timely evaluation and treatment of premorbid psychological factors, ongoing surgical pain, and postoperative pain to provide an overall improved outcome. By achieving this, we can begin to establish personalized precision medicine for children and adolescents presenting to surgery and subsequent treatment selection.

Associations Between Six Core Processes of Psychological Flexibility and Functioning for Chronic Pain Patients: A Three-Level Meta-Analysis

The previous research showed contradictions in the relationships between psychological flexibility processes and functioning. This meta-analysis is the first to provide a comprehensive meta-analysis of the associations between six core processes of psychological flexibility and functioning among chronic pain patients. Four databases were searched (PsycINFO; PubMed; CINAHL; Web of Science) along with reference lists. Thirty-six cross-sectional studies were included (7,812 chronic pain patients). A three-level meta-analytic model was used to examine the associations. The publication bias was assessed with the Egger test, funnel plot, and p-curve analysis. Significant associations were found between functioning and six processes of psychological flexibility (i.e., acceptance, defusion, present moment, committed action, self as context, and values). Except for the relationship between defusion and functioning, the relationships between the other five psychological flexibility processes and functioning were all moderated by domains of functioning. No moderators were found regarding age, percentage of females, country, or type of instrument used to measure functioning. These findings may carry significant implications for chronic pain patients and clinical workers. It might be more effective to focus on functioning-related psychological flexibility processes rather than all therapy packages if the relationships between functioning and specific processes of psychological flexibility were better informed. Limitations were also discussed.

Pain assessment tools in paediatric palliative care: A systematic review of psychometric properties and recommendations for clinical practice

BACKGROUND

Assessing pain in infants, children and young people with life-limiting conditions remains a challenge due to diverse patient conditions, types of pain and often a reduced ability or inability of patients to communicate verbally.

AIM

To systematically identify pain assessment tools that are currently used in paediatric palliative care and examine their psychometric properties and feasibility and make recommendations for clinical practice.

DESIGN

A systematic literature review and evaluation of psychometric properties of pain assessment tools of original peer-reviewed research published from inception of data sources to April 2021.

DATA SOURCES

PsycINFO via ProQuest, Web of Science Core, Medline via Ovid, EMBASE, BIOSIS and CINAHL were searched from inception to April 2021. Hand searches of reference lists of included studies and relevant reviews were performed.

RESULTS

From 1168 articles identified, 201 papers were selected for full-text assessment. Thirty-four articles met the eligibility criteria and we examined the psychometric properties of 22 pain assessment tools. Overall, the Faces Pain Scale-Revised (FPS-R) had high cross-cultural validity, construct validity (hypothesis testing) and responsiveness; while the Faces, Legs, Activity, Cry and Consolability (FLACC) scale and Paediatric Pain Profile (PPP) had high internal consistency, criterion validity, reliability and responsiveness. The number of studies per psychometric property of each pain assessment tool was limited and the methodological quality of included studies was low.

CONCLUSION

Balancing aspects of feasibility and psychometric properties, the FPS-R is recommended for self-assessment, and the FLACC scale/FLACC Revised and PPP are the recommended observational tools in their respective age groups.

Mental Health in Pediatric Rheumatology: An Opportunity to Improve Outcomes

Mental health problems are more common in children with pediatric rheumatologic diseases (PRDs) than healthy peers. Mental health problems affect disease-related outcomes and health-related quality of life (HRQOL), so addressing these problems can improve clinical and psychosocial outcomes. Mental health screening tools are available, and there are resources available to aid in integrating mental health care into the clinical setting. By implementing these tools, mental health problems can be recognized and addressed.

Autistic Traits and Attention-Deficit Hyperactivity Disorder Symptoms Associated With Greater Pain Interference and Depression, and Reduced Health-Related Quality of Life in Children With Chronic Pain

Previous research indicates elevated levels of clinically significant traits and symptoms of autism spectrum disorder and attention-deficit hyperactivity disorder (ADHD) in children with chronic pain, but associations with functioning and depression are yet unclear. The current study examined the relationships of autistic traits and ADHD symptoms with pain interference, depression, and health-related quality of life, as well as the mediating roles of insomnia and psychological inflexibility, in children with chronic pain (n = 146, 8–17 years, 102 girls) presenting at a tertiary pain clinic. Children completed measures of pain intensity, depression, pain interference, health-related quality of life, insomnia, and psychological inflexibility. Parents (n = 146, 111 mothers) completed measures to assess autistic traits and ADHD symptoms in their children. Children with clinically significant autistic traits and ADHD symptoms presented with significantly higher levels of depressive symptoms and pain interference, and significantly lower health-related quality of life, than did the other children. Autistic traits and ADHD symptoms contributed significantly to the prediction of pain interference and depressive symptoms, as well as health-related quality of life. Psychological inflexibility mediated the relationships between ADHD symptoms and autistic traits on the one hand and depression, pain interference, and health-related quality of life on the other, while insomnia mediated the relationships between ADHD symptoms and depression, pain interference, and health-related quality of life. All analyses were adjusted for demographics and pain intensity. Results suggest the utility of screening for neurodevelopmental disorders in children with chronic pain. Furthermore, the findings may indicate insomnia and skills related to psychological flexibility as potential treatment targets in interventions aiming at improving functioning and health-related quality of life in children with chronic pain and co-occurring symptoms of neurodevelopmental disorders.

Optimal application of compressive palatal stents following mesiodens removal in pediatric patients: A Randomized Controlled Trial

Background

There is no scientific evidence supporting the choice of a palatal stent in patients who underwent removal of an impacted supernumerary tooth. We aimed to investigate the effects of palatal stents in patients who underwent supernumerary tooth removal through a palatal approach and to suggest the optimal stent thickness and material.

Material and Methods

We recruited 144 patients who underwent extraction of a supernumerary tooth between the maxillary anterior teeth. Subjects were assigned to a control group (CG) or one of four compressive palatal stent groups (CPSGs) classified by the thickness and material of the thermoplastic acrylic stent used. Palatal gingival swelling and objective indices (healing, oral hygiene, gingival, and plaque) were evaluated before surgery and on postoperative days (PODs) 3, 7, and 14; pain/discomfort and the Child Oral Health Impact Profile (COHIP) were assessed as subjective indices of the effects of the stent.

Results

The CPSGs showed faster healing than did the CG on PODs 7 (P<0.001) and 14 (P=0.043); swelling was measured by 1.64±0.88 mm and 4.52±0.39 mm, respectively. Although swelling was least in the 4-mm hard group (0.92±0.33 mm), the difference compared with that in the 2-mm hard group (1.01±0.18 mm) was not significant (P=0.077). The CPSGs showed better COHIP (P<0.001-0.036) and pain scores (P<0.001) than did the CG on PODs 1-3.

Conclusions

Compressive palatal stents reduce discomfort by decreasing pain and alleviating swelling. Although a stent is effective regardless of its thickness and material, 2-mm hard stents maximized such positive effects with minimal discomfort.

Key words:Supernumerary tooth, tooth Extraction, postoperative care, oral Health, pediatric dentistry.

Qualitative study of the acceptability and feasibility of acceptance and commitment therapy for adolescents with chronic fatigue syndrome

Background

Paediatric chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is disabling and relatively common. Although evidenced-based treatments are available, at least 15% of children remain symptomatic after one year of treatment. Acceptance and commitment therapy (ACT) is an alternative therapy option; however, little is known about whether it is an acceptable treatment approach. Our aim was to find out if adolescents who remain symptomatic with CFS/ME after 12 months of treatment would find ACT acceptable, to inform a randomised controlled trial (RCT) of ACT.

Methods

We recruited adolescents (diagnosed with CFS/ME; not recovered after one year of treatment; aged 11-17 years), their parent/carer and healthcare professionals (HCPs) from one specialist UK paediatric CFS/ME service. We conducted semi-structured interviews to explore barriers to recovery; views on current treatments; acceptability of ACT; and feasibility of an effectiveness RCT. Thematic analysis was used to identify patterns in data.

Results

Twelve adolescents, eleven parents and seven HCPs were interviewed. All participants thought ACT was acceptable. Participants identified reasons why ACT might be efficacious: pragmatism, acceptance and compassion are valued in chronic illness; values-focussed treatment provides motivation and direction; psychological and physical needs are addressed; normalising difficulties is a useful life-skill. Some adolescents preferred ACT to cognitive behavioural therapy as it encouraged accepting (rather than challenging) thoughts. Most adolescents would consent to an RCT of ACT but a barrier to recruitment was reluctance to randomisation. All HCPs deemed ACT feasible to deliver. Some were concerned patients might confuse 'acceptance' with 'giving up' and called for clear explanations. All participants thought the timing of ACT should be individualised.

Conclusions

All adolescents with CFS/ME, parents and HCPs thought ACT was acceptable, and most adolescents were willing to try ACT. An RCT needs to solve issues around randomisation and timing of the intervention.

Health-related quality of life in youth with abdominal pain: An examination of optimism and pain self-efficacy

OBJECTIVES

Abdominal pain adversely impacts children with functional gastrointestinal disorders (FGIDs) or organic gastrointestinal disorders (OGIDs); findings are inconsistent regarding diagnosis and health-related quality of life (HRQoL). This study utilizes a positive psychology framework to understand the experience of youth with abdominal pain (i.e., do positive psychological factors, such as optimism and pain self-efficacy, relate to higher HRQoL?). Consistent with a protective factor model of resilience, in which personal assets may serve as buffers between risk factors and negative outcomes, optimism and pain self-efficacy were examined as they relate to HRQoL in youth with abdominal pain. Specifically, exploratory moderational analyses examined a) if optimism and pain self-efficacy moderate the relation between pain and HRQoL, and b) whether diagnostic status moderated the relation between optimism/pain self-efficacy and HRQoL.

METHODS

In a cross-sectional, observational study, youth (n = 98; M_age = 13, SD = 3) experiencing abdominal pain related to FGIDs or OGIDs and one of their parents participated. Measures included pain intensity, optimism, pain self-efficacy, and HRQoL. Analyses controlled for diagnosis, age, and gender.

RESULTS

Higher pain and age related to lower HRQoL. Higher levels of optimism and pain self-efficacy associated with HRQoL beyond demographics. Optimism and pain self-efficacy did not moderate the relation between pain and HRQoL. Diagnostic status did not moderate the relation between optimism or pain self-efficacy and HRQoL.

DISCUSSION

Our results suggest positive relations between positive psychological factors (optimism, pain self-efficacy) and HRQoL in youth with abdominal pain. Such factors could be further examined in intervention studies.

Trends in Gabapentin and Pregabalin Prescribing in a Tertiary Pediatric Medical Center

OBJECTIVES

Analgesic medications are commonly prescribed in pediatrics, with prescribing practices frequently extrapolated from adult trials. Gabapentinoids (gabapentin and pregabalin) are widely used as analgesics but are labeled in pediatrics only for epilepsy. We aim to (1) define trends in pediatric gabapentinoid prescribing (label and off-label) over 7 years, and (2) evaluate use in chronic pain clinic (CPC) patients during 2018.

METHODS

Retrospective data from a tertiary-care pediatric hospital were collected between 2013 and 2019. Annual numbers of gabapentinoid prescriptions were stratified by prescriber specialty. Additional information about gabapentinoid prescribing in the CPC was manually collected from initial clinic notes in 2018.

RESULTS

There were 15 808 outpatient prescriptions for gabapentinoids among 5172 patients over 7 years. Of these, 93% were gabapentin and 7% were pregabalin. Numbers of patients receiving gabapentin and pregabalin prescriptions increased by 1.4- and 1.3-fold, respectively, between 2013 and 2019. Few prescriptions were done for patients with a previous epilepsy diagnosis (in 2019, 16% for gabapentin and 13% for pregabalin). Approximately 28% of 650 CPC new patients were prescribed gabapentin or pregabalin before referral. Among those, 44% had discontinued the medication because of adverse events (35%), inefficacy (46%), or both (5%). Most side effects reported were mild to moderate. Diagnoses at first visit were diverse, not limited to neuropathic pain conditions, and did not differ between patients receiving or not receiving gabapentinoid prescriptions.

CONCLUSIONS

In our hospital, gabapentinoids are commonly prescribed off-label for diverse indications, including chronic pain. Future research is needed to evaluate gabapentinoid efficacy in these indications.

Usage activity, perceived usefulness, and satisfaction in a web-based acceptance and commitment therapy program among Finnish ninth-grade adolescents

Understanding adolescent usage activity and experiences in web-based psychological intervention programs helps in developing universal programs that can be adopted for promotion of adolescent well-being and prevention of mental health problems. This study examined the usage activity, perceived usefulness (i.e., learning of mindfulness, acceptance and value-related skills), and program satisfaction of 157 Finnish ninth-grade adolescents, who participated in a school-based five-week universal acceptance and commitment therapy web intervention called Youth Compass. Individual and growth environment-related antecedents were measured before the five-week intervention, adolescents' usage activity during the intervention, and perceived usefulness and satisfaction after the intervention. The results showed that female adolescents and adolescents with high self-regulation were more active program users and had more positive experiences of the program. Most of the adolescents used the program on at least a moderate level and perceived it to be moderately or highly useful and satisfactory. Four subgroups of adolescents were identified based on their usage activity, perceived usefulness, and satisfaction: adolescents in the satisfied group (41%) had average activity and high perceived usefulness and intervention satisfaction, the dissatisfied group (18%) had low activity and very low perceived usefulness and intervention satisfaction, the active group (8%) had very high activity and average perceived usefulness and intervention satisfaction, and the moderate group (33%) had average activity, perceived usefulness and intervention satisfaction. Gender, academic achievement, closeness to mother and teacher, and conflict with teacher were significantly related to subgroup membership. The results suggested that adolescent usage activity, perceived usefulness, and satisfaction with the Youth Compass program may to some extent be predicted based on different factors.

Pain and QOL in Pediatric Sickle Cell Disease: Buffering by Resilience Processes

OBJECTIVE

Sickle cell disease (SCD) is a group of inherited blood disorders. The central feature of this chronic condition is pain. Several identified risk factors exacerbate the impact of pain on quality of life (QOL) in SCD; however, there are relatively fewer investigations of strengths-based resilience variables that might buffer the influence of pain on living with SCD. The purpose of this study was to examine strength-based resilience processes in youth with SCD and their parents. Grounded in an ecological resilience-risk model, we evaluated whether adolescent and parent protective factors (pain acceptance, mindfulness, and psychological flexibility) moderated the relation between adolescent-reported pain burden and QOL.

METHODS

Ninety-three 12- to 18-year-old adolescents with SCD and their parents participated. Adolescents completed assessments of pain characteristics, pain acceptance, mindfulness, and QOL. Parents completed instruments measuring demographic and disease variables and parent psychological flexibility.

RESULTS

Pain variables were associated with protective factors in predicted directions. Adolescent acceptance and mindfulness were positively correlated with QOL. Parent psychological flexibility and adolescent QOL were not related. After controlling for demographic, pain, and disease variables, moderation analyses indicated that adolescent pain acceptance buffered the relation between SCD pain burden and QOL. Moderation analyses were not significant for adolescent mindfulness or parent psychological flexibility.

CONCLUSIONS

Results suggest that strengths-based factors may play an important role for adolescents' QOL within the context of SCD pain. Interventions that enhance teenagers' ability to accept pain might be particularly useful to improve QOL in adolescents living with SCD pain.

"A journey to learn about pain": the development and validation of a comic book about pain neuroscience education for children

BACKGROUND

Pain education resources for children using appropriate language and illustrations remain scarce.

OBJECTIVES

We aimed to summarize the development process and testing for face and content validity of a structured comic book about pain education for children.

METHODS

A first draft of a comic book was developed (Portuguese and English) based on pain education concepts. Experts in pediatric pain from different countries analyzed content, objectives, language, illustrations, layout, motivation, and cultural adjustment. A third draft developed in Portuguese considering experts' suggestions was presented to children and parents in Brazil. The total adequacy score was calculated from the sum of the scores obtained in each domain, divided by the maximum total score. Descriptive analysis is presented.

RESULTS

The expert panel was composed of 11 (64.7%) physical therapists, and 6 (35.3%) psychologists. The total adequacy score (0-100%) was 87.74%. The third draft version of the comic book was presented to 28 children and the final version was presented to 16 children with a mean age of 9.6 years. Children were totally satisfied (n=4; 26.7%) or satisfied (n=9; 56.2%) with the story of the comic book. The readability of the comic book was considered suitable for grades 4 to 6 educational level.

CONCLUSION

The comic book "A Journey to Learn about Pain" was validated for face and content validity by the expert panel and the Brazilian target population. This comic book is available in Portuguese and English and can be a potentially useful resource for children.

Finnish diabetes-related quality of life questionnaire for children and adolescents: Reliability and validity

AIM

To study the psychometric properties, reliability and validity of the FinDiab quality-of-life questionnaire (FDQL), a strength-oriented quality-of-life (QOL) questionnaire for children and adolescents with type 1 diabetes (T1D).

METHODS

Participants were 215 youths with T1D (aged 10-17 years). They completed FDQL and comparison questionnaires (KINDL-R and SDQ). Demographic and disease measures were collected from the participants' medical records. The questionnaire's psychometric properties were investigated. Construct validity was studied through principal component analysis using Promax rotation, reliability with alphas, and criterion and convergent validity with correlations between sum scale, subscales, demographic and disease factors, and comparison measures.

RESULTS

FDQL demonstrated an adequate range of measurement and feasibility. The four-factor solution was found to be optimal, resulting in the subscales of flexibility with diabetes, well-being, social relations and health behaviour. The sum scale correlated significantly with glycaemic control and the psychosocial and QOL comparison measures. Construct, criterion and convergent validity of the subscales was also good. Children under 14 years of age reported better QOL than older adolescents.

CONCLUSION

FDQL is a practical QOL assessment method focusing on strengths. The questionnaire has good validity and reliability and is easy to use as a clinical tool.

Neuropsychiatric Symptoms in Pediatric Chronic Pain and Outcome of Acceptance and Commitment Therapy

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy (ACT) treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children and adolescents aged 8–18 years (N = 47) were recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities (i.e., pain interference, sleep, and physical and school functioning), socioemotional functioning (i.e., depressive symptoms, emotional, and social functioning), psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key.

A systematic review of the use of acceptance and commitment therapy in supporting parents

OBJECTIVES

Acceptance and commitment therapy (ACT) has accrued a growing evidence-base for a wide variety of psychological difficulties. Given that ACT promotes broad and flexible repertoires of behaviour as well as neutralizing the ubiquitous psychological processes theorized to be responsible for much human suffering, such an approach may hold promise. The use of ACT-informed parenting interventions offers another alternative to solely behavioural approaches but it remains relatively understudied and in need of further exploration.

DESIGN

The current systematic review, which searched four databases, aimed to collate all ACT interventions that included parental therapeutic components in the treatment of various child presenting difficulties. The review also rated the methodological rigour of the ACT evidence-base for this type of treatment format.

RESULTS

Twenty-seven individual studies covering a broad spectrum of presenting problems were included, comprising of 1,155 participants. A large proportion of studies were within-group designs with a smaller number using randomized controlled trials. The majority of studies reported improvements on either parent report symptoms regarding child physical or psychological functioning as well as parent-reported measures of stress, depression, and anxiety. Similar improvements were noted on a number of ACT mechanisms of change outcomes, including mindfulness, acceptance, and cognitive fusing. These gains were evident for parents of children with neurodevelopmental disorders, chronic pain, and significant physical health difficulties. Maintenance or further treatment gains were often reported at follow-up. These positive findings are tempered by low levels of methodological rigour common in some of the studies included.

CONCLUSIONS

Despite these limitations, ACT holds promise as a transdiagnostic intervention that can help with the parenting of children with a range of psychological and physical difficulties.

PRACTITIONER POINTS

ACT has accrued a relatively strong evidence base for a range of psychological difficulties. Despite some methodological shortcomings, ACT shows promise as an intervention to help parents manage stress and difficulties especially in relation to children with autism, chronic pain, and physical health needs. Further research is required in comparing ACT to more established treatments and helping consolidate initial positive findings.

myPainPal: Co-creation of a mHealth app for the management of chronic pain in young people

Chronic pain is common in young people aged 10-14 years. Interdisciplinary, clinician-delivered treatments, while effective, are often criticized for failing to be readily accessible. Mobile health applications (mHealth apps) have been proposed as effective treatment adjuncts that address these challenges, while meeting the needs of tech-savvy young people. The objectives of this study were to co-create a mHealth app with consumers and health care professionals and evaluate the acceptability and feasibility of the resulting mHealth app (myPainPal). A phased, qualitative approach within a consumer engagement framework was employed. Interviews with young people (n = 14), parents (n = 12) and health care professionals (n = 8) identified key health needs that formed the underlying structure of the myPainPal app. Testing showed that the app is an acceptable and feasible platform to facilitate young people's self-management of chronic pain. The myPainPal app has the potential to positively influence young people's experiences of chronic pain. Further testing in controlled settings is required.

Understanding How Perfectionism Impacts Intensive Interdisciplinary Pain Treatment Outcomes: A Nonrandomized Trial

OBJECTIVE

Several factors are known to impact response to the intensive interdisciplinary pain treatment (IIPT) program described in this study, yet no research has explored the role of perfectionism. This secondary data analysis explored direct and indirect relations between perfectionism and functional disability (primary outcome) and pain severity (secondary outcome) after IIPT, with pain catastrophizing and fear of pain as mediators.

METHODS

Youth (N = 253) aged 8-21 with chronic pain and associated disability completed pre- and post-IIPT measures of self-oriented perfectionism (SOP), socially prescribed perfectionism (SPP), pain catastrophizing, fear of pain, functional disability, and pain characteristics for routine clinical care and this nonrandomized trial. Eight mediated models were run for the two predictors, two mediators, and two outcomes.

RESULTS

Pretreatment perfectionism (SOP and SPP) led to greater reductions in pain catastrophizing over the course of IIPT, which resulted in lower pain severity (β = -.02 [CI = -0.07, -0.01] for SOP and β = -.02 [CI = -0.06, -0.003] for SPP) and less functional disability (β = -.06 [CI = -0.13, -0.01] for SOP and β = -.06 [CI = -0.14, -0.01] for SPP). Independent of pain catastrophizing, pretreatment SPP was directly associated with more posttreatment functional disability (β = .16 [CI = 0.05, 0.27]). Fear of pain was not a mediator.

CONCLUSIONS

Findings suggest perfectionism has the potential to negatively impact IIPT outcomes. However, when perfectionistic youth with chronic pain learn to manage pain-related distress, they benefit. Results highlight the importance of assessing for and treating perfectionism and pain-related distress in youth with chronic pain.

ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain-A Pilot Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is a behavioral health intervention with strong empirical support for chronic pain but, to date, widespread dissemination is limited. Digital solutions improve access to care and can be integrated into patients' everyday lives.

OBJECTIVE

ACTsmart, a guided smartphone-delivered ACT intervention, was developed to improve the accessibility of an evidence-based behavioral treatment for chronic pain. In the present study, we evaluated the preliminary efficacy of ACTsmart in adults with chronic pain.

METHODS

The study was an open-label pilot trial. The treatment lasted for 8 weeks, and participants completed all outcome measures at pretreatment and posttreatment and at 3-, 6-, and 12-month follow-ups, with weekly assessments of selected measures during treatment. The primary outcome was pain interference. The secondary outcomes were psychological flexibility, values, insomnia, anxiety, depressive symptoms, health-related quality of life, and pain intensity. All outcomes were analyzed using linear mixed-effects models.

RESULTS

The sample consisted of 34 adults (88% women) with long-standing chronic pain (M=20.4 years, SD=11.7). Compliance to treatment was high, and at the end of treatment, we observed a significant improvement in the primary outcome of pain interference (d = -1.01). All secondary outcomes significantly improved from pretreatment to posttreatment with small to large effect sizes. Improvements were maintained throughout 12 months of follow-up.

CONCLUSION

The results of this pilot study provide preliminary support for ACTsmart as an accessible and effective behavioral health treatment for adults with chronic pain and warrant a randomized controlled trial to further evaluate the efficacy of the intervention.

Internet-Delivered Acceptance and Commitment Therapy for Adolescents with Chronic Pain and Their Parents: A Nonrandomized Pilot Trial

BACKGROUND

Acceptance and Commitment Therapy (ACT) is an empirically supported treatment for chronic pain in adults. There is also a small but growing evidence base of ACT for pediatric chronic pain. However, because of limited access to psychological treatment for pain, and geographical distances from pain facilities, many patients will not receive such treatment.

OBJECTIVE

The aim of the study was to evaluate the feasibility and preliminary effects of an internet-delivered ACT for adolescents with chronic pain, and their parents.

METHODS

In this nonrandomized pilot study 28 self-recruited adolescents, aged 13-17 years, received 8 weeks of internet-delivered ACT, while outcomes were assessed at pre-, posttreatment, and at follow-up (17-25 weeks). Parents of the adolescents received an 8-week internet-delivered parental program, and their outcomes were assessed at the same timepoints. Both treatments were guided by a therapist experienced in ACT and chronic pain.

RESULTS

Some threats to feasibility were identified such as slow recruitment rate, low compliance and a delay in completion of follow-up assessments. Preliminary outcome evaluation showed that adolescents showed a large significant improvement on their main outcome (pain interference, d = 1.09), and parents a medium improvement on their main outcome, pain reactivity (d = 0.70). Improvements were also seen in adolescents' depressive symptoms and insomnia severity.

CONCLUSION

The preliminary results of internet-delivered ACT are promising with regards to improvements in adolescent and parent outcome. Measures to improve feasibility are needed prior to conducting a larger randomized trial.

Avoid or engage? Outcomes of graded exposure in youth with chronic pain using a sequential replicated single-case randomized design

Pain-related fear is typically associated with avoidance behavior and pain-related disability in youth with chronic pain. Youth with elevated pain-related fear have attenuated treatment responses; thus, targeted treatment is highly warranted. Evidence supporting graded in vivo exposure treatment (GET) for adults with chronic pain is considerable, but just emerging for youth. The current investigation represents the first sequential replicated and randomized single-case experimental phase design with multiple measures evaluating GET for youth with chronic pain, entitled GET Living. A cohort of 27 youth (81% female) with mixed chronic pain completed GET Living. For each participant, a no-treatment randomized baseline period was compared with GET Living and 3- and 6-month follow-ups. Daily changes in primary outcomes fear and avoidance and secondary outcomes pain catastrophizing, pain intensity, and pain acceptance were assessed using electronic diaries and subjected to descriptive and model-based inference analyses. Based on individual effect size calculations, a third of participants significantly improved by the end of treatment on fear, avoidance, and pain acceptance. By follow-up, over 80% of participants had improved across all primary and secondary outcomes. Model-based inference analysis results to examine the series of replicated cases were generally consistent. Improvements during GET Living was superior to the no-treatment randomized baseline period for avoidance, pain acceptance, and pain intensity, whereas fear and pain catastrophizing did not improve. All 5 outcomes emerged as significantly improved at 3- and 6-month follow-ups. The results of this replicated single-case experimental phase design support the effectiveness of graded exposure for youth with chronic pain and elevated pain-related fear avoidance.

A Network Analysis of Potential Antecedents and Consequences of Pain-Related Activity Avoidance and Activity Engagement in Adolescents

OBJECTIVE

This study sets out to identify potential daily antecedents and consequences of pain-related activity avoidance and engagement behavior in adolescents with chronic pain.

METHODS

Adolescents (N = 65, Mage = 14.41) completed baseline self-reports and a diary for 14 days. Afternoon and evening reports were used to infer a network structure of within-day associations between pain intensity, pain-related fear, pain catastrophizing, affect, and pain-related activity avoidance and engagement behavior. Baseline psychological flexibility was examined as a potential resilience factor.

RESULTS

Activity avoidance in the evening was predicted by pain-related fear and avoidance earlier that afternoon. Activity engagement was predicted by positive affect and activity engagement in the afternoon. Pain-related behavior in the afternoon was not related to subsequent changes in pain intensity, pain-related fear, pain catastrophizing, or affect. Pain-related fear in the afternoon was predictive of increased levels of pain and pain catastrophizing in the evening. Both pain-related fear and pain catastrophizing in the evening were predicted by negative affect in the afternoon. Psychological flexibility was associated with lower levels of daily activity avoidance and buffered the negative association between pain intensity and subsequent activity engagement.

CONCLUSIONS

This study provides insight into unique factors that trigger and maintain activity avoidance and engagement and into the role of psychological flexibility in pediatric pain. Future work should focus on both risk and resilience factors and examine the role of psychological flexibility in chronic pediatric pain in greater detail.