Reliability and validity of the Child Pain Anxiety Symptoms Scale (CPASS) in a clinical sample of children and adolescents with acute postsurgical pain

Lived Experiences of Adolescents Living With Primary Chronic Pain

BACKGROUND

Primary chronic pain (PCP), a relatively new classification, characterizes pain that is not a secondary response to an underlying primary condition such as trauma or cancer. This study explored the lived experience of adolescents with a diagnosis of PCP.

METHOD

A qualitative methodology, Interpretative Description (ID), was used to guide our study. ID uses a constructivist approach and allows for clinician experience to guide a theoretical scaffold of inquiry, which can be refined as the data collection progresses. We interviewed fifteen adolescents (n = 15) living with PCP.

RESULTS

All participants in this sample reported struggling with diagnostic uncertainty, depression, and anxiety. Adding to their distress was the fact that our participants perceived that health care professionals did not believe them when they described their pain and its intensity.

CONCLUSIONS

While significant research is being conducted on PCP, participants believe there is a lack of knowledge about PCP as a diagnosis and thus there are limited resources and a lack of empathy and understanding for these adolescents.

The Sensitivity to Pain Traumatization Scale-Child Version (SPTS-C): Development and preliminary validation

Background

Sensitivity to pain traumatization is defined as the propensity to develop cognitive, affective, and behavioral responses to pain that resemble a traumatic stress reaction. To date, sensitivity to pain traumatization has been assessed in adults (Sensitivity to Pain Traumatization Scale [SPTS-12]) and parents of youth with chronic pain (Sensitivity to Pain Traumatization Scale-Parent version [SPTS-P]). SPT may be relevant in the context of pediatric chronic pain given the substantial comorbidity between posttraumatic stress symptoms and pain.

Aims

This prospective study aimed to adapt the SPTS-12 for use in youth and to evaluate the psychometric properties of the new scale.

Methods

Participants included 175 youth with chronic pain (Mage = 14.31 years, 73% girls) referred to outpatient chronic pain programs. At baseline, youth self-reported the levels of their sensitivity to pain traumatization (Sensitivity to Pain Traumatization Scale-Child version [SPTS-C]), as well as their pain symptoms, pain-related anxiety, posttraumatic stress symptoms, and attentional control. Three months later, youth self-reported their pain symptoms and completed the SPTS-C.

Results

The SPTS-C had a one-factor structure that explained 48% of variance and demonstrated good reliability and construct validity. SPTS-C baseline scores predicted follow-up levels of pain interference but not pain intensity or pain unpleasantness.

Conclusions

The results provide preliminary evidence for the psychometric properties of the SPTS-C and the potential role of SPT in pediatric chronic pain outcomes.

Cross-cultural adaptation and psychometric properties of Spanish Child Pain Anxiety Symptoms Scale

INTRODUCTION

Pain anxiety is a psychological component that can regulate and modulate the experience of pain in children and adolescents. It can also have an impact on the outcomes of surgical procedures, chronic pain management and psychological interventions. The aim of our study was to translate the Child Pain Anxiety Symptoms Scale (CPASS) into Spanish and assess the psychometric properties of the Spanish version.

PATIENTS AND METHODS

First, the CPASS was translated according to international guidelines. Secondly, to assess the psychometric properties of the translated version, we conducted an analysis in a paediatric sample. A total of 160 children, 49.37% female, with a mean age of 14.5 years (SD, 2.3; range, 8-18 years) completed pain catastrophising, health-related quality of life, pain interference and pain intensity scales. We assessed the following psychometric properties: construct validity (exploratory and confirmatory factor analysis), internal consistency, floor and ceiling effects and convergent validity (correlation of CPASS to the other completed questionnaires completed and with objective aspects of the health history).

RESULTS

In the exploratory factor analysis, the final 18-item version (having excluded items 18 and 19) of the CPASS was the best fit, with all items included in the hypothetical construct and exhibiting optimal factor loadings. The confirmatory factor analysis showed that the final 18-item, 4-factor model was adequate for the scale structure. We did not detect any floor or ceiling effects in the final version. Lastly, the results confirmed that the Spanish version has good internal consistency (Cronbach  α, 0.88) and an adequate convergent validity.

CONCLUSION

The Spanish CPASS exhibits good psychometric proprieties and it can be used to assess pain anxiety in the paediatric population.

The Relationship Between Chronic Pain, Depression, Psychosocial Factors, and Suicidality in Adolescents

BACKGROUND

Chronic pain in youth is often associated with social conflict, depression, and suicidality. The interpersonal theory of suicide posits that there are psychosocial factors, such as peer victimization and lack of fear of pain, that may also influence suicidality.

OBJECTIVES

The objective of this study was to determine whether depressive symptoms, peer victimization, and lack of fear of pain predict suicidality in adolescents with chronic pain. It was hypothesized that higher levels of depressive symptoms and peer victimization, and lower levels of fear of pain, would predict a higher lifetime prevalence of suicidality.

METHODS

Participants consisted of 184 youth with primary chronic pain conditions (10 to 18 y, M = 14.27 y). Measures included diagnostic clinical interviews assessing suicidality and self-report questionnaires assessing depressive symptoms, peer victimization, and fear of pain.

RESULTS

Forty-two (22.8%) participants reported suicidality. Regression analyses demonstrated that the occurrence of suicidality was associated with higher rates of depressive symptoms (β = 1.03, P = 0.020, 95% CI: 1.01, 1.06) and peer victimization (β = 2.23, P < 0.05, 95% CI: 1.07, 4.63), though there was no association between lower fear of pain and suicidality.

DISCUSSION

These results suggest that depressive symptoms and peer victimization are significant predictors of suicidality in adolescents with chronic pain; however, lower fear of pain was not shown to be a significant predictor. Given these findings, depression and peer victimization should be further explored and considered in the design and implementation of prevention and early intervention strategies that target chronic pain and suicidality in youth.

Psychometric properties of the Persian version of the pain anxiety symptom scale (PASS-20) in chronic non-specific neck pain patients

OBJECTIVES

Pain-related anxiety has been linked to avoidance behaviour, maintenance of pain and disability. A valid and reliable tool is required to evaluate pain-related anxiety among Persian speaking adults with chronic non-specific neck pain (CNSNP). This study aimed to evaluate psychometric properties of the Persian pain anxiety symptom scale-20 (PASS-20) according to the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist in Iranian adults with CNSNP.

METHODS

198 individuals with CNSNP completed the PASS-20. The factorial structure (confirmatory factor analysis (CFA), exploratory factor analysis (EFA)), test-retest reliability (intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC)), internal consistency (Cronbach's alpha), and construct validity (convergent and known-group validity) were assessed. The correlation between PASS-20 with pain catastrophizing scale (PCS), Tampa Scale for Kinesiophobia (TSK), neck disability index (NDI), Beck Depression Inventory (BDI), visual analog scale (VAS) (Spearman's rank correlation) were examined. Known-group validity of PASS-20 was evaluated by comparing the difference between the PASS-20 scores of the known groups based on level of disability, pain intensity and gender using non-parametric tests.

RESULTS

The CFA showed almost the best fit with the original version. The subscales and total score demonstrated good internal consistency (Cronbach's α: 0.70-0.92) and high test-retest reliability (ICC: 0.94-0.97). PASS-20 had significant moderate correlations with PCS, TSK, NDI, VAS and a significant low correlation with BDI. Regarding known-group validity, the total score of Persian PASS-20 was higher in CNSNP with higher levels of pain and disability and in the female gender.

CONCLUSIONS

The Persian PASS-20 has acceptable psychometric properties in adults with CNSNP. The results of the factor analysis supported the four-factor structure comparable to the original version.

ETHICAL COMMITTEE NUMBER

921672004.

An Exploration of the Psychometric Properties of the PASS-20 in Older Adults with Chronic Pain: Preliminary Development and Validity

OBJECTIVES

The Pain Anxiety Symptoms Scale (PASS-20) is well validated in adults and younger populations, but not in older adults. This study aimed to analyze the psychometric properties of the PASS-20 in Spanish older adults who experience chronic pain.

METHODS

Participants were 111 older adults with chronic pain living in nursing homes (mean age = 83.36; SD = 6.53; 78.6% female). Face-to-face interviews were conducted which included assessment of pain anxiety (PASS-20), chronic pain acceptance (CPAQ), depression symptoms (GDS), catastrophizing beliefs (PCS), pain severity, and sociodemographic information. An Exploratory Structural Equation Modeling (ESEM) approach was used to refine the scale.

RESULTS

The final scale was composed of seven items, measuring two factors that could be labeled "Internal experiences" and "Escape/Avoidance behaviors". The two factors explained 60.98% of the total variance. PASS-7 version fit properly: χ²/df = 14.57/13, CMIN/df = 1.121, CFI = 0.99, RMSEA = 0.033, TLI = 0.98, GFI = 0.96, AGFI = 0.92. Good validity indices were found and acceptable reliability results in the scale and its subscales (Chronbach´s α; Internal Experiences = 0.70; Escape/Avoidance Behaviors= 0.73; Total Scale = 0.77).

CONCLUSIONS

The short version of the PASS-7 has good psychometric properties.

CLINICAL IMPLICATIONS

The brevity of the PASS-7 increases the feasibility of this instrument which could potentially be utilized in a variety of clinical settings and research studies with older people with chronic pain samples, specially institutionalized older adults.

Guided Relaxation-Based Virtual Reality for Acute Postoperative Pain and Anxiety in a Pediatric Population: Pilot Observational Study

BACKGROUND

Distraction-based therapies, such as virtual reality (VR), have been used to reduce pain during acutely painful procedures. However, distraction alone cannot produce prolonged pain reduction to manage sustained postoperative pain. Therefore, the integration of VR with other pain-reducing therapies, like guided relaxation, may enhance its clinical impact.

OBJECTIVE

The goal of this pilot study was to assess the impact of a single guided relaxation-based VR (VR-GR) session on postoperative pain and anxiety reduction in children. We also explored the influence of pain catastrophizing and anxiety sensitivity on this association.

METHODS

A total of 51 children and adolescents (7-21 years) with postoperative pain and followed by the Acute Pain Service at Cincinnati Children's Hospital were recruited over an 8-month period to undergo a single VR-GR session. Prior to VR, the patients completed 2 questionnaires: Pain Catastrophizing Scale for Children (PCS-C) and the Child Anxiety Sensitivity Index (CASI). The primary outcome was a change in pain intensity following the VR-GR session (immediately, 15 minutes, and 30 minutes). The secondary outcomes included changes in pain unpleasantness and anxiety.

RESULTS

The VR-GR decreased pain intensity immediately (P<.001) and at 30 minutes (P=.04) after the VR session, but not at 15 minutes (P=.16) postsession. Reductions in pain unpleasantness were observed at all time intervals (P<.001 at all intervals). Anxiety was reduced immediately (P=.02) but not at 15 minutes (P=.08) or 30 minutes (P=.30) following VR-GR. Patients with higher CASI scores reported greater reductions in pain intensity (P=.04) and unpleasantness (P=.01) following VR-GR. Pain catastrophizing was not associated with changes in pain and anxiety.

CONCLUSIONS

A single, short VR-GR session showed transient reductions in pain intensity, pain unpleasantness, and anxiety in children and adolescents with acute postoperative pain. The results call for a future randomized controlled trial to assess the efficacy of VR-GR.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04556747; https://clinicaltrials.gov/ct2/show/NCT04556747.

Transient Reductions in Postoperative Pain and Anxiety using Virtual Reality in Children

OBJECTIVE

Virtual reality (VR) is a promising method to manage pain. Distraction-based VR (VR-D) is thought to reduce pain by redirecting attention. While VR-D can reduce pain associated with acutely painful procedures, it is unclear if VR-D can reduce pain after surgery. We assessed the ability of a single VR-D session to decrease postoperative pain and anxiety and explored if pain catastrophizing and anxiety sensitivity influenced these outcomes in children following surgery.

DESIGN

Single-center, prospective, pilot study.

SETTING

Cincinnati Children's Hospital Medical Center (CCHMC).

SUBJECTS

50 children (7-21 years) with postoperative pain followed by the Acute Pain Service.

METHODS

Patients received one VR-D session following surgery. Prior to the session, patients completed pain catastrophizing (PCS-C) and anxiety sensitivity (CASI) questionnaires. Primary outcome consisted of changes in pain intensity following VR-D (immediately, 15, and 30 minutes). Secondary outcomes included changes in pain unpleasantness and anxiety.

RESULTS

VR-D use was associated with a decrease in pain intensity immediately and 15-minutes after VR-D. Reductions in pain unpleasantness were observed up to 30 minutes following VR-D. VR-D was also associated with a reduction in anxiety immediately and at 15-minutes. While patients with higher pain catastrophizing had higher baseline pain intensity and unpleasantness, they did not show larger pain reductions following VR-D compared to those with lower pain catastrophizing.

CONCLUSIONS

VR-D may be beneficial in transiently reducing pain intensity, unpleasantness, and anxiety in children with postoperative pain. This study informs design of larger, randomized, controlled study assessing VR-D for acute postoperative pain and anxiety management.

Differential Risk Factor Profiles in the Prediction of General and Pain-Specific Functional Limitations 12 Months after Major Pediatric Surgery

Pediatric chronic post-surgical pain is a surgical complication associated with various levels of functional limitation. Two commonly used measures of functional limitations in youth are the Functional Disability Inventory (FDI) and the PROMIS Pediatric Pain Interference Scale (PPIS), where the former is general, and the latter, pain specific. The aim of the present study was to prospectively compare pre-surgical youth and parent risk factors for youth functional limitations, assessed by the FDI and PPIS, 12 months after major pediatric surgery. Risk factors for the FDI and PPIS were compared in 79 dyads consisting of youth (58% female, M = 14.56 years; SD = 2.31) undergoing major surgery and one of their parents. The FDI and PPIS were highly correlated prior to surgery (r = 0.698, p < 0.001) and even more so 12 months after surgery (r = 0.807, p < 0.001). Parent pre-surgical anxiety sensitivity and youth pre-surgical functional disability significantly predicted 12-month FDI (F(6,56) = 4.443, p = 0.001, Adjusted R² = 0.25), whereas parent pre-surgical anxiety sensitivity, trait anxiety, pain anxiety, as well as youth pain-related anxiety and worry significantly predicted 12-month PPIS (F(6,45) = 4.104, p = 0.002, Adjusted R² = 0.27). Risk factors for 12-month general and pain-specific functional limitations differ by dyad member and type. Functional limitations in youth after surgery are predicted by youth and parent factors, however the risk factors differ between the FDI and the PPIS.

Individual Differences in the Relationship Between Pain Fear, Avoidance, and Pain Severity in a Chronic Abdominal Pain Sample and the Moderating Effect of Child Age

BACKGROUND/PURPOSE

Most studies examining the components of the fear-avoidance model have examined processes at the group level. The current study used ecological momentary assessments to: (a) investigate the group and intraindividual relationships between pain fear, avoidance, and pain severity, (b) identify any heterogeneity between these relationships, and (c) explore the role of moderators to explain such heterogeneity.

METHODS

Seventy-one pediatric patients with chronic abdominal pain (M = 13.34 years, standard deviation = 2.67 years) reported pain fear, avoidance, and pain severity four times per day over 14 days.

RESULTS

Results indicated significant individual differences in the relationship between pain fear and pain avoidance predicting pain severity. Child age helped explain the heterogeneity in the relationships between pain avoidance and pain severity such that older children had a stronger and more positive relationship between these variables. The random effect between pain fear and pain severity also indicated a moderator trend of child age such that older children were likely to have a stronger and more positive relationship.

CONCLUSIONS

The present study extends the fear-avoidance model by highlighting the importance of identifying potential individual differences when examining pain fear, avoidance, and pain severity. Furthermore, the current study suggests that child development should be considered in the model. However, future randomized control designs are necessary to explore the causal relationships between pain fear and avoidance on pain severity and potential developmental differences.

The Predictors of Postoperative Pain Among Children Based on the Theory of Unpleasant Symptoms: A Descriptive-Correlational Study

PURPOSE

Postoperative pain (POP) is a common outcome of surgical interventions among children. Identifying POP contributing factors can help identify children who are at risk for POP and facilitate POP management. The aim of the study was to determine the predictors of POP based on the Theory of Unpleasant Symptoms.

DESIGN AND METHODS

This descriptive-correlational study was conducted in 2018-2019 on 153 children purposively recruited. Data were collected using a personal characteristics questionnaire, the Coping Strategies Questionnaire, the Child Pain Anxiety Symptoms Scale, and a Visual Analogue Scale for Pain. The SPSS software (v. 21.0) was used for data analysis.

RESULTS

Twelve participants were excluded and final data analysis was done on the data obtained from 141 participants. Most of participants were male (65.2%), underwent abdominal surgery (53.2%), and experienced POP (86.5%). Their age mean was 8.58±2.23. Linear regression analysis revealed that the physiological factors of heart rate, preoperative pain, and surgery duration as well as the psychological factors of anxiety and coping strategies were significant predictors of POP among children. All these factors collectively explained 34% of the total variance of POP. Situational factors (such as age, gender, and ethnicity) had no significant effects on POP.

CONCLUSIONS

Heart rate, preoperative pain, surgery duration, anxiety and coping as predictive factors of POP can be considered when designing effective POP management strategies.

PRACTICE IMPLICATIONS

The findings provide a better understanding about the predictors of POP and can be used to develop pain management among children.

Fear of movement in children and adolescents undergoing major surgery: A psychometric evaluation of the Tampa Scale for Kinesiophobia

BACKGROUND

The objective of this study was to evaluate the psychometric properties of the 17-item Tampa Scale for Kinesiophobia (TSK) in youth.

METHODS

Participants were 264 children and adolescents (58.7% female, M_age  = 14.1 years, SD_age  = 2.51) scheduled for major surgery who were assessed before surgery, while in hospital postoperatively, and at 6 and 12 months after surgery. Exploratory factor analyses (EFA) were conducted to determine the factor structure of pre-operative TSK scores. Reliability, and convergent, discriminant, and predictive validity were examined.

RESULTS

EFA on the 17-item TSK revealed a two-factor model distinguishing the 13 positively scored items from the 4 reverse scored items, but the fit was poor. A second EFA was conducted on the 13 positively scored items (TSK-13) revealing a three-factor model: Fear of injury, bodily vulnerability, and activity avoidance. The TSK-13 showed adequate internal consistency (Ω = 0.82) and weak convergent validity. The TSK-13 was not correlated with postoperative, in-hospital physical activity (actigraphy; r (179) = -0.10, p = 0.18) and showed adequate discriminant validity, that is correlations less than 0.70, with measures of depression (r (225) = 0.41, p < 0.001) and general anxiety (r (224)=0.35, p < 0.001). Predictive validity for pain-related disability at 12 months (r (70) = 0.34, p < 0.001) was adequate.

CONCLUSIONS

The original TSK-17 does not appear to be a meaningful measure of kinesiophobia in youth after surgery possibly because of the syntactic structure of the reverse scored items. In contrast, a modified TSK-13, comprised of only the positively scored items, revealed a 3-factor structure that is reliable and demonstrates adequate convergent, discriminant, and predictive validity.

SIGNIFICANCE

Kinesiophobia is an important construct to evaluate in the transition from acute to chronic pain among children and adolescents. The 17 item Tampa Scale for Kinesiophobia (TSK) does not show adequate validity or reliability in youth undergoing major surgery, however, the psychometric properties of a 13-item modified scale (TSK-13) are promising.

Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery

BACKGROUND

Chronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability.

METHODS

This study followed 265 children aged 8-17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy.

RESULTS AND DISCUSSION

The incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability.

CONCLUSION

Pre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.

Multicenter assessment of quantitative sensory testing (QST) for the detection of neuropathic-like pain responses using the topical capsaicin model

Background

The use of quantitative sensory testing (QST) in multicenter studies has been quite limited, due in part to lack of standardized procedures among centers.

Aim

The aim of this study was to assess the application of the capsaicin pain model as a surrogate experimental human model of neuropathic pain in different centers and verify the variation in reports of QST measures across centers.

Methods

A multicenter study conducted by the Quebec Pain Research Network in six laboratories allowed the evaluation of nine QST parameters in 60 healthy subjects treated with topical capsaicin to model unilateral pain and allodynia. The same measurements (without capsaicin) were taken in 20 patients with chronic neuropathic pain recruited from an independent pain clinic.

Results

Results revealed that six parameters detected a significant difference between the capsaicin-treated and the control skin areas: (1) cold detection threshold (CDT) and (2) cold pain threshold (CPT) are lower on the capsaicin-treated side, indicating a decreased in cold sensitivity; (3) heat pain threshold (HPT) was lower on the capsaicin-treated side in healthy subjects, suggesting an increased heat pain sensitivity; (4) dynamic mechanical allodynia (DMA); (5) mechanical pain after two stimulations (MPS2); and (6) mechanical pain summation after ten stimulations (MPS10), are increased on the capsaicin-treated side, suggesting an increased in mechanical pain (P < 0.002). CDT, CPT and HPT showed comparable effects across all six centers, with CPT and HPT demonstrating the best sensitivity. Data from the patients showed significant difference between affected and unaffected body side but only with CDT.

Conclusion

These results provide further support for the application of QST in multicenter studies examining normal and pathological pain responses.

Individuals with sickle cell disease have a significantly greater vasoconstriction response to thermal pain than controls and have significant vasoconstriction in response to anticipation of pain

The painful vaso-occlusive crises (VOC) that characterize sickle cell disease (SCD) progress over hours from the asymptomatic steady-state. SCD patients report that VOC can be triggered by stress, cold exposure, and, pain itself. We anticipated that pain could cause neural-mediated vasoconstriction, decreasing regional blood flow and promoting entrapment of sickle cells in the microvasculature. Therefore, we measured microvascular blood flow in the fingers of both hands using plethysmography and laser-Doppler flowmetry while applying a series of painful thermal stimuli on the right forearm in 23 SCD patients and 25 controls. Heat pain applied to one arm caused bilateral decrease in microvascular perfusion. The vasoconstriction response started before administration of the thermal pain stimulus in all subjects, suggesting that pain anticipation also causes significant vasoconstriction. The time delay between thermal pain application and global vasoconstriction ranged from 5 to 15.5 seconds and increased with age (P < .01). Although subjective measures, pain threshold and pain tolerance were not different between SCD subjects and controls, but the vaso-reactivity index characterizing the microvascular blood flow response to painful stimuli was significantly higher in SCD patients (P = .0028). This global vasoconstriction increases microvascular transit time, and may promote entrapment of sickle cells in the microvasculature, making vaso-occlusion more likely. The rapidity of the global vasoconstriction response indicates a neural origin that may play a part in the transition from steady-state to VOC, and may also contribute to the variability in VOC frequency observed in SCD patients.

Children's and adolescents' relationship to pain during cancer treatment: a preliminary validation of the Pain Flexibility Scale for Children

OBJECTIVES

Children with cancer often suffer from pain. Pain is associated with psychological distress, which may amplify the pain experience. In chronic pain, it has been shown that psychological acceptance is helpful for both adults and children. For experimentally induced pain, interventions fostering psychological acceptance have been shown to predict increases in pain tolerance and reductions in pain intensity and discomfort of pain. A single subject study aiming to nurture psychological acceptance for children with cancer experiencing pain has shown promising results. No instruments measuring psychological acceptance in acute pain are yet available. The aim of the current study was to develop and preliminarily evaluate an instrument to measure psychological acceptance in children experiencing pain during cancer treatment.

METHODS

A test version of the Pain Flexibility Scale for Children was sent to all children aged 7-18 years undergoing cancer treatment in Sweden at the time of the study. Exploratory factor analysis was used. Internal consistency, test-retest reliability, and convergent validity were examined.

RESULTS

Sixty-one children participated in the study. A two-factor solution with Promax rotation was found to best represent the data. Internal consistency was good to excellent (a =0.87-0.91). The total scale and the subscales demonstrated temporal stability (Intraclass correlation coefficient =0.56-0.61) and satisfactory convergent validity (r=-0.27 to -0.68).

DISCUSSION

The Pain Flexibility Scale for Children measuring psychological acceptance in children with cancer experiencing pain is now available for use. This enables the evaluation of acceptance as a mediator for treatment change in the context of acute pain in children with cancer, which in turn is a step forward in the development of psychological treatments to help children cope with the pain during these difficult circumstances. The scale shows good psychometric properties but needs further validation, particularly considering the small sample size.

Photographs of Daily Activities-Youth English: validating a targeted assessment of worry and anticipated pain

PHODA is an electronic measure that individualizes and guides treatment for individuals with chronic pain. Implicit in its design is recognition that pain-related fear is a driving force that impedes treatment progress. With this tool, patients visually rate their expectations about the harmful consequences of specific movements. This study aimed to (1) develop and validate PHODA-Youth English (PHODA-YE) and (2) evaluate the potential impact of PHODA-YE assessment on treatment outcomes. Participants were 195 youth, age 8 to 20 years, who presented to an outpatient pain clinic for evaluation (n = 99), or enrolled at the Pediatric Pain Rehabilitation Center (PPRC) intensive program (PPRC; n = 96). All patients completed the PHODA-YE along with measures of emotional functioning and disability. Patients in the PPRC completed the measure at both admission and discharge. After eliminating infrequently endorsed and poorly loading items, factor analytic procedures yielded a 4-subscale, 50-item measure with strong internal consistency (from 0.92 to 0.97 across subscales). Fear, avoidance, and functional disability were strongly associated with PHODA-YE scores, supporting construct validity. Within the PPRC sample, PHODA-YE was sensitive to changes over time in relation to functional improvements. Across the PPRC sample, patients found it helpful to complete the PHODA and target feared activities. Altogether, the PHODA-YE is a valid and concrete assessment tool that rapidly identifies specific activities and movements that elicit fearful responses from patients.

Validations and psychological properties of a simplified Chinese version of pain anxiety symptoms scale (SC-PASS)

The Pain Anxiety Symptoms Scale (PASS) has been developed to evaluate pain anxiety, which leads to avoidance of daily activities and normal movements. However, a simplified Chinese version of PASS is still not available. Physicians are not aware of which patients are prone to anxiety, and what the risk factors are.To cross-culturally adapt the PASS into a simplified Chinese version and test the reliability and validity. Factors affecting pain anxiety were also explored.The PASS was first translated into a simplified Chinese version according to a forward-backward method. Then, validations were tested including content validity, construct validity, and reliability. Content validity was analyzed by response trend. Construct validity was analyzed by confirmatory factor analysis (CFA), exploratory factor analysis, and priori hypotheses testing. Reliability was analyzed by internal consistency and test-retest reliability. Risk factors of catastrophizing were analyzed by performing multivariate liner regression.A total of 219 patients were included in the study. The scores of items were well distributed. Both CFA and exploratory factor analysis suggested a 2nd-order, 4-factor model, accounting for 65.42% of the total variance according to principle component analysis. SC-PASS obtained good reliability with a Cronbach α = 0.92 and ICC = 0.90. College education, long pain duration, and both married and divorced status were risk factors. Factors reduced pain-related anxiety were no medication assumption, female sex, widowed status, non-Han ethnicity, and having no religious belief.The SC-PASS was applicable in Chinese patients and it was suitable for the clinical uses in mainland China.

Dyadic analysis of child and parent trait and state pain catastrophizing in the process of children's pain communication

When explored separately, child and parent catastrophic thoughts about child pain show robust negative relations with child pain. The objective of this study was to conduct a dyadic analysis to elucidate intrapersonal and interpersonal influences of child and parent pain catastrophizing on aspects of pain communication, including observed behaviours and perceptions of child pain. A community sample of 171 dyads including children aged 8 to 12 years (89 girls) and parents (135 mothers) rated pain catastrophizing (trait and state versions) and child pain intensity and unpleasantness following a cold pressor task. Child pain tolerance was also assessed. Parent-child interactions during the cold pressor task were coded for parent attending, nonattending, and other talk, and child symptom complaints and other talk. Data were analyzed using the actor-partner interdependence model and hierarchical multiple regressions. Children reporting higher state pain catastrophizing had greater symptom complaints regardless of level of parent state pain catastrophizing. Children reporting low state pain catastrophizing had similar high levels of symptom complaints, but only when parents reported high state pain catastrophizing. Higher child and parent state and/or trait pain catastrophizing predicted their own ratings of higher child pain intensity and unpleasantness, with child state pain catastrophizing additionally predicting parent ratings. Higher pain tolerance was predicted by older child age and lower child state pain catastrophizing. These newly identified interpersonal effects highlight the relevance of the social context to children's pain expressions and parent perceptions of child pain. Both child and parent pain catastrophizing warrant consideration when managing child pain.

Fear of pain in children and adolescents with neuropathic pain and complex regional pain syndrome

A significant proportion of children and adolescents with chronic pain endorse elevated pain-related fear. Pain-related fear is associated with high levels of disability, depressive symptoms, and school impairment. Because of faulty nerve signaling, individuals with neuropathic pain and complex regional pain syndrome may be more prone to develop pain-related fear as they avoid use of and neglect the affected body area(s), resulting in exacerbated symptoms, muscle atrophy, maintenance of pain signaling, and ongoing pain-related disability. Not surprisingly, effective treatments for elevated pain-related fears involve exposure to previously avoided activities to downregulate incorrect pain signaling. In the context of intensive interdisciplinary pain treatment of youth with neuropathic pain, decreasing pain-related fear is associated with improved physical and psychological functioning, whereas high initial pain-related fear is a risk factor for less treatment responsiveness. An innovative approach to targeting pain-related fear and evidence of a neural response to treatment involving decoupling of the amygdala with key fear circuits in youth with complex regional pain syndrome suggest breakthroughs in our ability to ameliorate these issues.

Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer

We evaluated the construct validity (including responsiveness), reliability, and feasibility of the Pain Squad multidimensional smartphone-based pain assessment application (app) in children and adolescents with cancer, using 2 descriptive studies with repeated measures. Participants (8-18 years) undergoing cancer treatment were drawn from 4 pediatric cancer centers. In study 1, 92 participants self-reported their level of pain twice daily for 2 weeks using the Pain Squad app to assess app construct validity and reliability. In study 2, 14 participants recorded their level of pain twice a day for 1 week before and 2 weeks after cancer-related surgery to determine app responsiveness. Participants in both studies completed multiple measures to determine the construct validity and feasibility of the Pain Squad app. Correlations between average weekly pain ratings on the Pain Squad app and recalled least, average, and worst weekly pain were moderate to high (0.43-0.68). Correlations with health-related quality of life and pain coping (measured with PedsQL Inventory 4.0, PedsQL Cancer Module, and Pain Coping Questionnaire) were -0.46 to 0.29. The app showed excellent internal consistency (α = 0.96). Pain ratings changed because of surgery with large effect sizes between baseline and the first week postsurgery (>0.85) and small effect sizes between baseline and the second week postsurgery (0.13-0.32). These findings provide evidence of the construct validity, reliability, and feasibility of the Pain Squad app in children and adolescents with cancer. Use of real-time data capture approaches should be considered in future studies of childhood cancer pain. A video accompanying this abstract is available online as Supplemental Digital Content at http://links.lww.com/PAIN/A169.

Parental risk factors for the development of pediatric acute and chronic postsurgical pain: a longitudinal study

Background

The goal of this longitudinal study was to examine the associations among psychological factors and pain reports of children and their parents over the 12 month period after pediatric surgery.

Materials and methods

Included in the study were 83 children aged 8–18 years undergoing major surgery. In each case, the child and one of their parents completed measures of pain intensity and unpleasantness, psychological function, and functional disability at 48–72 hours, 2 weeks (child only), 6 months, and 12 months after surgery.

Results

The strength of the correlation coefficients between the psychological measures of the parent and their child increased significantly over time. There was a fair level of agreement between parent ratings of child acute and chronic pain (6 months after surgery) and the child’s actual ratings. Parent and child pain anxiety scores 48–72 hours after surgery interacted significantly to predict pain intensity, pain unpleasantness, and functional disability levels 2 weeks after discharge from hospital. Parent pain catastrophizing scores 48–72 hours after surgery predicted child pain intensity reports 12 months later.

Conclusion

These results raise the possibility that as time from surgery increases, parents exert greater and greater influence over the pain response of their children, so that by 12 months postsurgery mark, parent pain catastrophizing (measured in the days after surgery) is the main risk factor for the development of postsurgical pain chronicity.

Identification of pain-related psychological risk factors for the development and maintenance of pediatric chronic postsurgical pain

Background

The goals of this study were to examine the trajectory of pediatric chronic postsurgical pain (CPSP) over the first year after surgery and to identify acute postsurgical predictors of CPSP.

Methods

Eighty-three children aged 8–18 years (mean 13.8, standard deviation 2.4) who underwent major orthopedic or general surgery completed pain and pain-related psychological measures at 48–72 hours, 2 weeks (pain anxiety and pain measures only), and 6 and 12 months after surgery.

Results

Results showed that 1 year after surgery, 22% of children developed moderate to severe CPSP with minimal functional disability. Children who reported a Numeric Rating Scale pain-intensity score ≥ 3 out of 10 two weeks after discharge were more than three times as likely to develop moderate/severe CPSP at 6 months and more than twice as likely to develop moderate/severe CPSP at 12 months than those who reported a Numeric Rating Scale pain score < 3 (6-month relative risk 3.3, 95% confidence interval 1.2–9.0 and 12-month relative risk 2.5, 95% confidence interval 0.9–7.5). Pain unpleasantness predicted the transition from acute to moderate/severe CPSP, whereas anxiety sensitivity predicted the maintenance of moderate/severe CPSP from 6 to 12 months after surgery.

Conclusions

This study highlights the prevalence of pediatric CPSP and the role played by psychological variables in its development/maintenance. Risk factors that are associated with the development of CPSP are different from those that maintain it.

Pediatric fear-avoidance model of chronic pain: foundation, application and future directions

The fear-avoidance model of chronic musculoskeletal pain has become an increasingly popular conceptualization of the processes and mechanisms through which acute pain can become chronic. Despite rapidly growing interest and research regarding the influence of fear-avoidance constructs on pain-related disability in children and adolescents, there have been no amendments to the model to account for unique aspects of pediatric chronic pain. A comprehensive understanding of the role of fear-avoidance in pediatric chronic pain necessitates understanding of both child⁄adolescent and parent factors implicated in its development and maintenance. The primary purpose of the present article is to propose an empirically-based pediatric fear-avoidance model of chronic pain that accounts for both child⁄adolescent and parent factors as well as their potential interactive effects. To accomplish this goal, the present article will define important fear-avoidance constructs, provide a summary of the general fear-avoidance model and review the growing empirical literature regarding the role of fear-avoidance constructs in pediatric chronic pain. Assessment and treatment options for children with chronic pain will also be described in the context of the proposed pediatric fear-avoidance model of chronic pain. Finally, avenues for future investigation will be proposed.

Pain-related psychological correlates of pediatric acute post-surgical pain

Background

Post-surgical pain is prevalent in children, yet is significantly understudied. The goals of this study were to examine gender differences in pain outcomes and pain-related psychological constructs postoperatively and to identify pain-related psychological correlates of acute post-surgical pain (APSP) and predictors of functional disability 2 weeks after hospital discharge.

Methods

Eighty-three children aged 8–18 (mean 13.8 ± 2.4) years who underwent major orthopedic or general surgery completed pain and pain-related psychological measures 48–72 hours and 2 weeks after surgery.

Results

Girls reported higher levels of acute postoperative anxiety and pain unpleasantness compared with boys. In addition, pain anxiety was significantly associated with APSP intensity and functional disability 2 weeks after discharge, whereas pain catastrophizing was associated with APSP unpleasantness.

Conclusion

These results highlight the important role played by pain-related psychological factors in the experience of pediatric APSP by children and adolescents.

Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response

Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment.

PERSPECTIVE

This paper presents results underscoring the importance of pain-related fear in relation to treatment response for children and adolescents with chronic pain. These findings support the need to develop and implement interventions that target reductions in pain-related fear.

Pain is not over when the needle ends: a review and preliminary model of acute pain memory development in childhood

SUMMARY Over the past several decades, the field of pediatric pain has made impressive advances in our understanding of the pain experience of the developing child, as well as the devastating impact of inadequately managed pain early in life. It is now well recognized that, from infancy, children are capable of developing implicit memories of pain that can influence their subsequent reactions to pain. The present review provides a synthesis of selected studies that made a significant impact on this field of inquiry, with particular emphasis on recent clinical and laboratory-based experimental research examining children’s explicit autobiographical memories for acute pain. Research has begun to move towards improving the precision with which children at risk for developing negatively estimated pain memories can be identified, given the adverse influence these memories can have on subsequent pain experiences. As such, several fear- and anxiety-related child and parent variables implicated in this process are discussed, and avenues for future research and clinical intervention are identified throughout. Finally, a preliminary empirically and theoretically derived model of acute pain memory development in childhood is presented to parsimoniously summarize the evidence accumulated to date and guide future investigation in this area.

The Fear Avoidance model of chronic pain: examination for pediatric application

The current study examined the Fear Avoidance (FA) model of chronic pain in pediatric chronic pain patients. Multiple structural equation models were tested in the current study with pairwise parameter comparisons made between younger children (8-12 years) and adolescents (13-17 years). Within a sample of 350 children and adolescents, we examined functional disability and depressive symptoms in separate models with the following predictor variables-pain, pain catastrophizing, fear of pain, and avoidance of activities-after controlling for duration of pain. For a subset of patients (n = 151), we also tested a brief prospective outcome model with baseline predictor variables and functional disability at 1-month follow-up. The FA models predicting functional disability concurrently and prospectively were an excellent fit to the data. The theorized FA model for depression was a poor fit. When the model was modified to include direct pathways from the cognitive processes of pain catastrophizing and fear of pain to depressive symptoms, the model fit was significantly improved. In the examination of developmental differences between younger children and adolescent patients, duration of pain contributed to the model for younger children, whereas pain-related fears were more influential for adolescent patients.

PERSPECTIVE

The FA model of chronic pain appears to be applicable for pediatric patients with some modification to account for developmental differences across childhood. We discuss the developmental, theoretical, and clinical implications of these results.