Do parent protective responses mediate the relation between parent distress and child functional disability among children with chronic pain?

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

ABSTRACT

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

The association between parent mental health and pediatric chronic pain: a systematic review and meta-analysis

ABSTRACT

Mental health problems are common among parents of children with chronic pain and associated with worse outcomes for the child with chronic pain. However, the effect sizes of these associations between parent mental health and pediatric chronic pain vary widely across studies. The aim of this systematic review and meta-analysis was to generate pooled estimates of the (1) prevalence of mental health problems among parents of children with chronic pain and (2) associations between parent mental health and the (2a) presence of child chronic pain and (2b) functioning of children with chronic pain. Embase, MEDLINE, PsycINFO, Web of Science, and CINAHL were searched up to November 2022. Observational studies that examined symptoms or diagnoses of parent anxiety, depression, or general distress and the presence of child chronic pain and/or related functioning were included. From 32,848 records, 2 coders identified 49 studies to include in random-effects meta-analyses. The results revealed that mental health problems among parents of children with chronic pain were common (anxiety: 28.8% [95% CI 20.3-39.1]; depression: 20.0% [15.7-25.2]; general distress: 32.4% [22.7-44.0]). Poorer parent mental health was significantly associated with the presence of chronic pain (anxiety: OR = 1.91 [1.51-2.41]; depression: OR = 1.90 [1.51-2.38]; general distress: OR = 1.74 [1.47-2.05]) and worse related functioning (ie, pain intensity, physical functioning, anxiety and depression symptoms; r s = 0.10-0.25, all P s < 0.05) in children. Moderator analyses were generally nonsignificant or could not be conducted because of insufficient data. Findings support the importance of addressing parent mental health in the prevention and treatment of pediatric chronic pain.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

HYPOTHESES

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

METHODS

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

RESULTS

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

DISCUSSION

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

Aligning with Patients and Families: Exploring Youth and Caregiver Openness to Pediatric Headache Interventions

Primary headache disorders are common yet underestimated in youth, resulting in functional disability, decreased quality of life, and caregiver burden. Despite the ubiquity of options, adherence remains challenging for families. One potential factor impacting willingness to engage in recommended treatments is openness. This study explored openness to multidisciplinary headache interventions and the relationships with demographic, pain-related, and psychological variables, among youth and their caregivers. Participants (n = 1087) were youth/caregiver dyads presenting for initial headache evaluation. They completed assessments of openness to headache treatments, medical information, functional disability, and pain-related distress. Overall openness was moderately high for youth and caregivers, and highly correlated between them (r = 0.70). Relationships between youth/caregiver openness to specific interventions were moderate-high (r = 0.42-0.73). These were stronger for interventional techniques but weaker for lifestyle changes. In hierarchical regression models predicting youth and caregiver openness, we found that counterpart openness accounted for the largest portion of variance in their own openness (31-32%), beyond demographic (3%), pain-related (10%), and psychological variables (2-3%). Our findings highlight the importance of involving caregivers in pediatric headache management, given their influence on youth openness and potential involvement in adherence. Awareness of youth/caregiver openness may guide clinicians providing recommendations.

Spreading the word: pediatric pain education from treatment to prevention

Pain affects everyone hence one can argue that it is in each individual’s interest to understand pain in order to hold correct and adaptive beliefs and attitudes about pain. In addition, chronic pain is reaching pandemic proportions and it is now well known that people living with chronic pain have a reduced life expectancy. To address and to prevent the growth of this public health disaster, we must start looking beyond adulthood. How children view pain has an impact on their behavioral coping responses which in turn predict persistent pain early in the lifespan. In addition, children who suffer from chronic pain and who are not (properly) treated for it before adolescence have an increased risk of having chronic pain during their adult life. Explaining pain to children and youth may have a tremendous impact not only on the individual child suffering from chronic pain but also on society, since the key to stop the pain pandemic may well lie in the first two decades of life. In order to facilitate the acquisition of adaptive behavioral coping responses, pain education aims to shift people’s view on pain from being an apparent threat towards being a compelling perceptual experience generated by the brain that will only arise whenever the conceivable proof of danger to the body is greater than the conceivable proof of safety to the body. Nowadays a lot of pain education material is available for adults, but it is not adapted to children’s developmental stage and therefore little or not suitable for them. An overview of the state-of-the-art pain education material for children and youth is provided here, along with its current and future areas of application as well as challenges to its development and delivery. Research on pediatric pain education is still in its infancy and many questions remain to be answered within this emerging field of investigation.

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.

Cutting the cord? Parenting emerging adults with chronic pain

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

"I just want to be normal": A qualitative investigation of adolescents' coping goals when dealing with pain related to arthritis and the underlying parent-adolescent personal models

The aim of the current study was to examine adolescents' goals when coping with pain and map these goals to the cognitive and emotional profiles of both adolescent and their parent. 17 adolescents (11-16 years) and their parents participated in a cohort study of Juvenile Idiopathic Arthritis (JIA); the adolescents, took part in a two-part interview (about their pain perceptions and about a recent pain experience) and the parents completed an open-ended qualitative survey. The three datasets were analysed following a qualitative framework approach. A coping framework was developed and cognitive and emotional profiles for both adolescent and parent were mapped back to the framework. The overall goal of adolescents was to preserve social identity, by either focusing on maintaining a "normal" lifestyle (sub-coping goal one) or managing the pain (sub-coping goal two). Across these two sub-coping goals, the adolescents held similar cognitive profiles (beliefs about timeline, consequences, control) but different emotional profiles such as feeling fine/happy compared with feeling angry and frustrated. Conversely, the parents' cognitive and emotional profiles were mapped back to the two groups and found that their beliefs were different across the two sub-coping goals but had similar emotional profiles across the two groups such as worry. Both the adolescents' emotional representations and parental cognitive profiles seem to be related to how the adolescent perceives a pain event, deals with the pain, and the overall coping goal of the adolescent. Findings are suggestive that parental pain beliefs influence the adolescents' pain representations and their coping goals but are also driven by adolescents' emotions. Further work on these potential pathways is needed. Family interventions should be designed, targeting coping goals taking into consideration the importance of emotions for adolescents and parental pain beliefs.

Pain science education for children living with and beyond cancer: Challenges and research agenda

Pain in children living with and beyond cancer is understudied and undertreated. Pain science education (PSE) is a conceptual change strategy facilitating patients' understanding of the biopsychosocial aspects of pain. Preliminary studies on the adaptation of PSE interventions to adults with and beyond cancer provide a foundation for pediatric research. PSE could help childhood cancer survivors experiencing persistent pain and pain-related worry after active treatment. PSE may also help children receiving cancer treatment, providing them with a foundation of adaptive pain beliefs and cognitions, and preparing them for procedural and treatment-related pain. We direct this paper toward pediatric oncology clinicians, policy makers, and researchers working with children living with and beyond cancer. We aim to (a) identify challenges in adapting PSE for children living with and beyond cancer, (b) offer possible solutions, and (c) propose research questions to guide the implementation of PSE for children living with and beyond cancer.

Pain and Fear of Cancer Recurrence in Survivors of Childhood Cancer

OBJECTIVES

Theoretical models suggest that anxiety, pain intensity, and pain catastrophizing are implicated in a cycle that leads to heightened fear of cancer recurrence (FCR). However, these relationships have not been empirically examined. The objective of this study was to examine the relationships between anxiety symptoms, pain intensity, pain catastrophizing, and FCR in childhood cancer survivors and their parents and to examine whether pain catastrophizing predicts increased FCR beyond anxiety symptoms and pain intensity.

METHODS

The participants were 54 survivors of various childhood cancers (Mage=13.1 y, range=8.4 to 17.9 y, 50% female) and their parents (94% mothers). Children reported on their pain intensity in the past 7 days. Children and parents separately completed measures of anxiety symptoms, pain catastrophizing, and FCR.

RESULTS

Higher anxiety symptoms were associated with increased pain intensity, pain catastrophizing, and FCR in childhood cancer survivors. Higher anxiety symptoms and pain catastrophizing, but not child pain intensity, were associated with FCR in parents. Hierarchical linear regression models revealed that pain catastrophizing explained unique variance in both parent (ΔR2=0.11, P<0.01) and child (ΔR2=0.07, P<0.05) FCR over and above the effects of their own anxiety symptoms and child pain.

DISCUSSION

The results of this study provides novel data on the association between pain and FCR and suggests that a catastrophic style of thinking about pain is more closely related to heightened FCR than one's anxiety symptoms or the sensory pain experience in both childhood cancer survivors and their parents. Pain catastrophizing may be a novel intervention target for survivors and parents struggling with fears of recurrence.

What about parents? A systematic review of paediatric intensive interdisciplinary pain treatment on parent outcomes

BACKGROUND AND OBJECTIVE

Intensive interdisciplinary pain treatment (IIPT) for youth with high impact chronic pain has been found to be effective in improving child symptoms and functioning. However, it remains unclear how these interventions impact the parents' own well-being, as well as cognitions and behaviours which are known to influence child pain and functioning. Thus, the current study sought to determine the effect of IIPT on parent mental health, cognitions and behaviours in parents of youth attending IIPT with their child.

DATABASES AND DATA TREATMENT

A search of the electronic databases CINAHL, Ovid EBM Reviews, Embase, Medline, APA PsychINFO, Scopus and web of Science was conducted. Studies were included if they comprised at least 10 parents of patients aged 9-22 with nonmalignant chronic pain attending an IIPT and were written in English.

RESULTS

A random-effects model was used to pool the standardized mean change (SMC) across seven prepost studies. At discharge, IIPT participation was associated with small to moderate improvements in direct parental outcomes (general mental health, anxiety, depression and parenting stress), a moderate improvement in pain catastrophizing and large improvements in psychological flexibility and parenting behaviours. Most improvements were maintained at follow-up. The risk of bias of all studies was rated as serious and the certainty of the evidence as low, suggesting limited confidence in the estimates.

CONCLUSIONS

Although parents appear to benefit from attending an IIPT with their child, RCTs are needed to substantiate the effect of these interventions on important aspects of parent well-being and functioning.

Child-Focused Cognitive Behavioral Therapy for Pediatric Abdominal Pain Disorders Reduces Caregiver Anxiety in Randomized Clinical Trial

Pediatric functional abdominal pain disorders (FAPD) are associated with elevated anxiety in youth and their caregivers, both contributing to an adverse impact on functioning in youth with FAPD. While a CBT approach (ie, Aim to Decrease Anxiety and Pain Treatment [ADAPT]) is known to improve health outcomes for youth, it is unknown if child-focused treatment improves caregiver anxiety. This secondary analysis of a larger randomized clinical trial examined if child-focused CBT (ADAPT) for pain and anxiety also impacts caregiver anxiety and explored the relation between caregiver anxiety and child symptoms (ie, pain, disability, anxiety) after treatment. A total of 79 caregiver-child dyads were randomized to ADAPT plus treatment as usual (TAU) or TAU only. Caregiver anxiety and child outcomes (pain, disability, anxiety) were assessed at baseline and approximately 8 weeks later. Caregivers of children who completed ADAPT+TAU demonstrated lower anxiety compared to those who only received TAU. Moreover, regardless of treatment assignment, caregivers with greater anxiety had children who reported more pain and anxiety, but not functional disability at post-assessment. Results suggest a brief, child-focused intervention targeting pain and anxiety may also improve caregiver anxiety. As such, suggestions to improve future treatments are offered. PERSPECTIVE: Caregiver anxiety symptoms diminished after their child with functional abdominal pain completed a course of child-focused CBT targeting pain and anxiety. Further, caregiver anxiety was related to child-reported symptoms (pain and anxiety) after treatment. Therefore, improved caregiver mental health via a child-focused CBT may also improve pediatric outcomes.

Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective

A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child's quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.

Treatment for Pediatric Functional Abdominal Pain: An Initial Examination of Reciprocal Associations Between Pain, Functional Impairment, and Parental Distress

OBJECTIVE

While cross-sectional studies underline that child and parent factors in pediatric chronic pain are reciprocally related, so far, little is known on their prospective relationship, especially in treatment contexts. This study aims to analyze directions of influence between child and parental outcomes using data from an intervention study.

METHODS

The sample covered 109 families with children aged 7-13 years diagnosed with functional abdominal pain (FAP). Child outcomes included pain and impairment, and parental outcomes covered caregiver-specific distress including both parental personal time burden (i.e., less time available for personal needs) and emotional burden due to child's pain (i.e., increased worries). Cross-lagged panel analyses examined the directions of the relations between child and parental outcomes across time (pretreatment T1, post-treatment T2, and 3-month follow-up and 12-month follow-up T3/T4).

RESULTS

First, a significant improvement over time in all measures was observed. Cross-lagged effects were found for less parental personal time burden at T2, predicting both less pain (β = -0.254, p = .004) and less impairment (β = -0.150, p = .039) at T3. Higher baseline pain was predictive for higher parental emotional burden after treatment (β = -0.130, p = .049) and, reversely, for less emotional burden at 12-month follow-up (β = 0.261, p = .004).

CONCLUSIONS

Addressing parental personal time burden in FAP treatment might possibly support the improvement on the child level. Replication of results in larger samples is warranted to gain more insight into the directions of influence and, in that way, to optimize treatment for pediatric FAP.

Examining Parent Adverse Childhood Experiences as a Distal Risk Factor in Pediatric Chronic Pain

OBJECTIVES

Adverse childhood experiences (ACEs; ie, exposure to abuse, neglect, household dysfunction in childhood) are associated with poor mental and physical health outcomes across the lifespan. Emerging research suggests parent ACEs also confer risk for poor child outcomes. The relation between parent ACEs and child pain in youth with chronic pain has not yet been examined. The aim of the current longitudinal study was to examine the associations among parent ACEs, parent health, and child pain, in a clinical sample of youth with chronic pain.

METHODS

In total, 192 youth (75.5% female, 10 to 18 y old) and one of their parents (92.2% female) were recruited from tertiary pediatric chronic pain clinics in Canada. At baseline, parents completed self-report measures of ACEs, chronic pain status, anxiety and depressive symptoms, and posttraumatic stress disorder symptoms. At a 3-month follow-up, youth completed self-report measures of pain intensity and pain interference.

RESULTS

Regression and mediation analyses revealed that parent ACEs significantly predicted parent chronic pain status and depressive symptoms, but not parent anxiety or posttraumatic stress disorder symptoms. Moreover, parent ACEs were not significantly related to youth pain, either directly or indirectly through parent health variables.

DISCUSSION

Findings suggest that an intergenerational cascade from parent ACEs to parent health to child pain was not present in the current sample. Further research that examines the role of parent ACEs in the development of child chronic pain, as well as other risk and resiliency factors that may mediate or moderate the association between parent ACEs and child chronic pain, is needed.

The Impact of Parental Pain-attending and Non-pain-attending Responses on Child Pain Behavior in the Context of Cancer-related Painful Procedures: The Moderating Role of Parental Self-oriented Distress

OBJECTIVES

Literature has demonstrated inconsistent findings regarding the impact of parental responses on child pain-related outcomes. Yet, research into factors that may underlie inconsistent findings regarding the variable impact of parental responses is lacking. The current study investigated the moderating role of parental distress in understanding the impact of parental pain-attending (eg, reassuring the child) and non-pain-attending (eg, distracting the child with humor) responses on child pain behavior (eg, crying).

METHODS

Children (18 y and younger) with leukemia, undergoing a lumbar puncture (LP) and/or bone marrow aspiration procedure, and one of their parents, were recruited from the Pediatric Ghent University Hospital. Parent-child interactions were videotaped after the procedure allowing coding of parental responses and child pain behavior. Parents self-reported on experienced personal distress.

RESULTS

Participants consisted of 42 children (24 boys, 18 girls) with leukemia and one of their parents. Children were 0.6 to 15 (7.08±4.39) years old. Findings indicated a positive association between parental pain-attending and child pain behavior, but only when parents reported high levels of distress (β=0.56, P=0.001). No association was observed for parents reporting low levels of distress (β=-0.09, ns). Parental non-pain-attending responses contributed to lower child pain behavior (β=-0.24, P=0.045), independently of parental distress (β=-0.07, ns).

DISCUSSION

The current findings point to the moderating role of parental distress in understanding the impact of parental responses on child pain behavior and highlight the importance of interventions targeting parental emotion regulation to promote optimal child pain outcomes.

Parental Response to Only Children: Breaking the Stereotypes

While much has been written about the relationship between only child status and parents' behavior toward children, and consequent personality and intelligence, little is known about the relationship between only child status, parental response to illness, and subsequent child illness behavior. In this study, 227 mothers of 342 children completed measures designed to assess: (a) their children's school attendance, (b) their own psychological status, and (c) their own responses to their children's expressions of stomach pain. Parents of only children were more likely to minimize their children's gastrointestinal symptoms than were parents of children with at least one sibling. In addition, only children were less likely to miss school. Parental protectiveness did not differ as a function of only child status. These findings are somewhat discrepant with commonly held beliefs about parents' patterns of responding to only children.

Parental Catastrophizing and Goal Pursuit in the Context of Child Chronic Pain: A Daily Diary Study

Background: Despite daily variability in children's chronic pain experiences, little is known about how parents' emotions and goals toward their child's pain are influenced by these daily changes. This diary study examined how daily child pain intensity (as perceived by parents) moderates the associations between parental catastrophic thoughts about child pain on the one hand, and daily parental distress and parents' goals with regard to their child's pain (pain control vs. activity engagement) on the other hand.

Method: Participants were 25 parents of 20 different children (N = 18; 90% girls). Children, aged 8–14 years (M = 9.5, SD = 2.09), experienced either chronic headache or functional abdominal pain with an average pain duration of 22.5 months (SD = 24.5 months). Daily parental responses (i.e., perceived child pain intensity, distress and goal endorsement) were collected through a 3-week daily diary (resulting in 413 valid diary reports). Parents completed the Pain Catastrophizing Scale for Parents prior to starting the diary (PCS-P general) and a daily measure (PCS-P daily) included in the diary. To account for the interdependence of the data, the data were analyzed using multilevel modeling.

Results: Perceived daily child pain intensity moderated the impact of parental general and daily catastrophic thoughts on parents' daily distress. Only for parents experiencing low general catastrophic thoughts an increase in distress was observed on days when they perceived their child's pain intensity as high. For all parents, high levels of perceived child pain intensity were related to more distress on days where parents reported high levels of catastrophic thinking (i.e., PCS-P daily). Perceived daily child pain intensity also moderated the impact of parental general catastrophic thinking on parents' daily endorsement of goals. Parents with high levels of general catastrophic thinking reported a lower focus on child pain control on days when child pain intensity was perceived to be low. Parents with low general catastrophic thinking reported lower endorsement of the activity engagement goal on days where the child's pain intensity was perceived to be low.

Conclusion: These findings highlight the complexity of daily fluctuations in parental distress and goals regarding their child's pain. Clinical implications and future directions are critically assessed.

The Parent Version of the Sensitivity to Pain Traumatization Scale (SPTS-P): A Preliminary Validation

Sensitivity to pain traumatization (SPT) is defined as the propensity to develop responses to pain that resemble a traumatic stress reaction. To date, SPT has been assessed in adults with a self-report measure (Sensitivity to Pain Traumatization Scale (SPTS-12)). SPT may also be relevant in the context of parenting a child with chronic pain, as many of these parents report clinically elevated posttraumatic stress symptoms (PTSS). This study aimed to develop and validate a measure of parent SPT by adapting the SPTS-12 and evaluating its psychometric properties in a sample of parents whose children have chronic pain. In total, 170 parents (90.6% female) and children (aged 10–18 years, 71.2% female) were recruited from a tertiary chronic pain program. Parents completed the parent version of the SPTS-12 (SPTS-P) and measures of PTSS, depression, anxiety and anxiety-related constructs, and parenting behaviors. Youth completed measures of pain. Consistent with the SPTS-12, the SPTS-P demonstrated a one-factor structure that accounted for 45% of the variance, adequate to good reliability and moderate construct validity. Parent SPT was positively related to their protective and monitoring behaviors but was unrelated to youth pain intensity, unpleasantness, and interference. These results provide preliminary evidence for the psychometric properties of the SPTS-P and highlight the interaction between parent distress about child pain and parent responses to child pain.

Parental accommodation of symptoms in adolescents with chronic pain

Chronic pain in adolescents can be highly impairing. Parental reactions to their child's pain are important factors influencing pain perception and pain-related impairment in children and adolescents. The present study aimed to examine parental accommodation of pain symptoms using the Inventory of Parent Accommodations of Children's Symptoms (IPACS) to provide empirical support for the utility of this measure in parents of adolescents with chronic pain. We examined the prevalence, nature, and correlates of accommodation behaviors in 66 adolescents with chronic pain and their parents using the IPACS. All parents reported some level of accommodation of their child's pain symptoms. After controlling for pain severity, parental accommodation was associated with functional impairment. In addition, parental accommodation mediated the link between parental catastrophizing reactions to pain and child impairment and between child anxiety and depressive symptoms and child impairment. The IPACS appears to be a useful measure of parental accommodation of pain. Parental accommodation should be included as an intervention target when necessary. It is important to educate families about the negative consequences that can be related to excessive accommodation of pain symptoms and to provide effective resources to manage the impact of chronic pain and replace accommodation with more adaptive pain coping strategies.

Intergenerational transmission of chronic pain-related disability: the explanatory effects of depressive symptoms

ABSTRACT

Parents with chronic pain have a higher likelihood of having depression and anxiety and more often have children with these conditions. Depressive and anxious symptoms in children worsen pain-related disability and may be derived from exposure to their parents' symptoms. We assessed a model of intergenerational chronic pain-related disability that relies upon depressive and anxious symptoms of a mother and their child. Adolescents in grades 5 to 10 from 5 schools, and their mothers, completed standardized electronic questionnaires about pain. In maternal-offspring dyads (n = 1179), the mean offspring age was 12.7 years (SD = 1.7, range = 10-17) and 51% were girls. Logistic regression was used to investigate mother-offspring associations of chronic pain presence, and mediation models using multiple linear regression were used to investigate the proposed model. Adolescents of mothers with chronic pain had 1.67 (95% confidence interval [CI] = 1.29-2.16) times increased odds of chronic pain, with each year of exposure to maternal chronic pain associated with a 5% (odds ratio 95% CI = 1.01-1.10) increased likelihood of offspring chronic pain. Worse maternal pain-related disability was associated with worse offspring pain-related disability (β = 0.20, 95% CI = 0.06-0.34). The mediation model indicated maternal and adolescent offspring symptoms of depression explained 36% of the relationship between maternal and offspring pain-related disability, with 11% explained by the intergenerational transmission of depression (serial mediation). We conclude that worse pain-related disability is associated between parent and child, and that depressive symptoms common to both mother and child play a key role in this relationship.

Longitudinal Impact of Parental Catastrophizing on Child Functional Disability in Pediatric Amplified Pain

Objective

Children with amplified musculoskeletal pain (AMPS) experience significant functional disability, with impairment in their ability to participate in age-appropriate activities of daily living. Parental factors play an important role in a child’s pain symptoms and treatment outcomes, with parental pain catastrophizing and protective behaviors linked to several maladaptive outcomes for children. Aims of the current study were to examine how parental pain catastrophizing, child pain catastrophizing, and parental protective behaviors longitudinally impacted functional disability for children with AMPS.

Methods

Archival data were examined from parent-child dyads presenting to a tertiary pain clinic for treatment of AMPS. Over 1 year, parents completed measures assessing the level of pain catastrophizing, common behavioral responses to child pain, and child functional disability. Children completed measures of pain catastrophizing and functional disability. Measures were collected at initial evaluation, 6-months, and 12-months. Latent growth models (LGM) were conducted to examine how to study variables longitudinally impacted the rate of change in child functional disability.

Results

Examining a comprehensive LGM of study variables, parental catastrophizing emerged as the sole contributing factor to slower improvement in functional disability.

Conclusions

The strong influence of parental pain catastrophizing on functional disability may relate to parents limiting behaviors that promote adaptive coping in children with pain. As such, parents who catastrophize may benefit from specific interventions to increase their use of adaptive behavioral responses, such as redirecting children to complete functional activities and encouraging the use of positive coping skills for pain-related distress.

The Co-occurrence of Pediatric Chronic Pain and Anxiety: A Theoretical Review of a Developmentally Informed Shared Vulnerability Model

The development and maintenance of pediatric chronic pain and anxiety are complex, underscoring the need to better understand the interactive forces contributing to their co-occurrence. The shared vulnerability model (SVM) was developed to explain the co-occurrence of chronic pain and posttraumatic stress disorder in adults. Although many core tenets have been well supported by pediatric research, the SVM has yet to be extended to pediatric pain populations. We propose a developmentally informed pediatric SVM for advancing our understanding of the co-occurrence of pediatric chronic pain and anxiety disorders. The proposed SVM postulates that youth at increased risk for the development of chronic pain and/or anxiety share predisposing vulnerabilities, including anxiety sensitivity, and that these shared vulnerabilities give rise to negative emotional responses (child and parent) in the context of stressful events. Consequences of fear and anxiety, including avoidance behavior, further contribute to the development of chronic pain, anxiety, and their co-occurrence. The parental, school, and peer contexts in which these problems develop and are maintained in youth are pertinent to integrate into a SVM, as pediatric chronic pain and anxiety disorders share several social-contextual risk and maintenance factors. We also highlight new areas of inquiry.

The Co-occurrence of Pediatric Chronic Pain and Depression: A Narrative Review and Conceptualization of Mutual Maintenance

OBJECTIVES

Internalizing mental health issues co-occur with pediatric chronic pain at high rates and are linked to worse pain and functioning. Although the field has prioritized anxiety and posttraumatic stress disorder, little is known about co-occurring depression and chronic pain in youth, despite its high prevalence. The purpose of this narrative review was to examine the existing literature on the co-occurrence of pediatric chronic pain and depressive disorders and symptoms and propose a conceptual model of mutual maintenance to guide future research.

METHODS

The literature from both fields of pediatric pain and developmental psychology were searched to review the evidence for the co-occurrence of pediatric chronic pain and depression. Conceptual models of co-occurring mental health issues and chronic pain, as well as child depression, were reviewed. From both literatures, we provide evidence for a number of proposed child, parent, and neurobiological factors that may serve to mutually maintain both conditions over time. On the basis of this evidence, we propose a conceptual model of mutual maintenance and highlight several areas for future research in this area.

RESULTS

Evidence was found for the prevalence of depression in pediatric chronic pain as well as the co-occurrence of both conditions. The key mutually maintaining factors identified and proposed included neurobiological, intrapersonal (eg, cognitive biases, sleep disturbances, emotion regulation, and behavioral inactivation), and interpersonal (eg, parent mental health and pain, genes, and parenting) factors.

DISCUSSION

Given the dearth of research on mutual maintenance in this area, this review and conceptual model could drive future research in this area. We argue for the development of tailored treatments for this unique population of youth to improve outcomes.

Parent Factors are Associated With Pain and Activity Limitations in Youth With Acute Musculoskeletal Pain: A Cohort Study

OBJECTIVES

Biopsychosocial models emphasize the influence of parent/family factors on pediatric chronic pain. Little is known about how parent factors differ across the acute to chronic pain continuum, or contribute to youths' pain experience in the acute pain period. The purpose of the study was to describe parent factors in youth with acute musculoskeletal pain (n=84) compared with youth with chronic pain (n=60) and youth without pain (n=61). Further, within the acute pain sample, we tested parent factors as predictors of child pain characteristics, as well as the moderating role of child sex on associations.

METHODS

Participants were 205 youth (age, 10 to 17) and one biological parent per child. Children reported on their own pain and activity limitations. Parents reported on their own chronic pain, somatization, and protective pain responses.

RESULTS

Parents of youth with acute pain had higher prevalence of chronic pain and greater somatization than parents of youth without pain. Parents of youth with acute and chronic pain did not differ. Linear regressions within the acute pain sample revealed presence of parent chronic pain and protective behavior were associated with child pain. Moreover, parent somatization was associated with child activity limitations. Within the acute pain sample, associations between parent protectiveness and child pain were moderated by child sex, with relationships stronger for female children.

DISCUSSION

Findings highlight the importance of parent factors on pain experiences of youth with acute musculoskeletal pain. Future longitudinal research can elucidate temporal associations that underlie how parent factors may impact transition from acute to chronic pain.

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.

Parent Responses to Their Child's Pain: Systematic Review and Meta-Analysis of Measures

Objective

Parent responses can have a major impact on their child’s pain. The purpose of this systematic review is to (a) identify and describe measures assessing pain-related cognitive, affective, and behavioral responses in parents of children with chronic pain and (b) meta-analyze reported correlations between parent constructs and child outcomes (i.e., pain intensity, functional disability, and school functioning). Prospero protocol registration ID: CRD42019125496.

Methods

We conducted a systematic search of studies including a measure of parent/caregiver responses to their child’s chronic pain. Study characteristics and correlations between parent measures and child outcomes were extracted. Data were summarized and meta-analyzed.

Results

Seventy-nine met inclusion criteria using 18 different measures of cognitive/affective (n = 3), behavioral (n = 5), and multidimensional responses (n = 10). Measures were used a median of three times (range 1–48), predominantly completed by mothers (88%), and primarily in mixed pain samples. Psychometrics of measures were generally adequate. Meta-analyses were based on 42 papers across five measures. Results showed that each of the cognitive, affective, and behavioral parent constructs we examined was significantly associated with pain-related functional disability. A small number of measures assessing parent cognitions and affective functioning were associated with higher child pain intensity; however, the majority were not.

Conclusion

Findings demonstrate that there is a wealth of measures available, with adequate reliability overall but a lack of psychometrics on temporal stability. Synthesizing data across studies revealed small effects between parent responses and child functioning, and even smaller and/or absent effects on child pain intensity.

Parental stress, anxiety and trait mindfulness: associations with parent-child mealtime interactions in children with type 1 diabetes

Introduction This study examined how maternal and paternal stress, anxiety, and trait mindfulness, and child glycemic control are related to real-life parent-child interactions in families confronted with type 1 diabetes (T1D). Methods Parents reported on trait mindfulness, illness-related parenting stress, general stress, and state anxiety. Parent-child mealtime interactions were videotaped and scored in 33 families (31 mothers and 20 fathers) of children with T1D (5-12y., mean HbA1c = 7.22%). Results Parental stress and anxiety were related to more maladaptive and less adaptive parent-child interactions. For mothers, mindfulness was related to less observed discomfort of the child during injection. For fathers, more emotional involvement was related to better child glycemic control. Discussion Results indicate that parental stress and anxiety may be risk factors for maladaptive parent-child interactions.

Quality of Life in Youth With Chronic Pain: An Examination of Youth and Parent Resilience and Risk Factors

OBJECTIVES

Pediatric chronic pain has often been examined from a risk perspective, and relatively less is known about the individual and family-level resilience factors that help youth with chronic pain maintain their quality of life (QOL). This cross-sectional study: (1) examined the relations among purported youth and parent resilience (youth pain acceptance and pain self-efficacy, parent psychological flexibility) and risk (youth pain intensity and parent protectiveness) factors with youth QOL, and (2) tested exploratory statistical mechanisms that may explain relations between parent and youth variables.

METHODS

Participants included 122 youth (10 to 17 y; M=14.26, SD=2.19) seen in an interdisciplinary pediatric chronic pain program and a parent. Youth completed measures of their average pain, QOL, pain acceptance, and pain self-efficacy. Parents completed measures of their pain-related psychological flexibility and behavioral responses to pain (ie, protectiveness, distraction, monitoring, minimizing).

RESULTS

Youth pain acceptance, pain self-efficacy, and parent psychological flexibility were highly positively correlated with each other, and with overall youth QOL. Evidence for a buffering effect of pain acceptance and pain self-efficacy on the association between pain intensity and QOL was not found. Protectiveness was found to be a significant mediator of the relation between parental psychological flexibility and youth QOL.

DISCUSSION

The results are discussed in the context of the resilience-risk framework and current understandings of the role of parental factors for pediatric chronic pain.

"Placebo by Proxy" and "Nocebo by Proxy" in Children: A Review of Parents' Role in Treatment Outcomes

The "placebo (effect) by proxy" (PbP) concept, introduced by Grelotti and Kaptchuk (1), describes a positive effect of a patient's treatment on persons in their surrounding such as family members or healthcare providers, who feel better because the patient is being treated. The PbP effect is a complex dynamic phenomenon which attempts to explain a change in treatment outcome arising from an interaction between a patient and an effect from proxies such as parents, caregivers, physicians or even the media. By extension the effect of the proxy can also have a negative or adverse effect whereby a proxy feels worse when a patient is treated, giving rise to the possibility of a "nocebo (effect) by proxy" (NbP), and by extension can influence a patient's treatment response. While this has yet to be systematically investigated, such an effect could occur when a proxy observes that a treatment is ineffective or is perceived as causing adverse effects leading the patient to experience side effects. In this narrative review, we take these definitions one step further to include the impact of PbP/NbP as they transform to affect the treatment outcome for the patient or child being treated, not just the people surrounding the individual being treated. Following a systematic search of literature on the subject using the Journal of Interdisciplinary Placebo Studies (JIPS) database (https://jips.online) and PubMed (NCBI) resulted in very few relevant studies, especially in children. The effect of PbP per se has been studied in parents and their children for temper tantrums, acupuncture for postoperative symptoms, as well as for neuroprotection in very preterm-born infants. This paper will review the PbP/NbP concepts, show evidence for its presence in children's treatment outcome and introduce clinical implications. We will also offer suggestions for future research to further our understanding of the role of the proxy in promoting or distracting from treatment benefit in children. Increasing an appreciation of the PbP and NbP phenomena and the role of the proxy in children's treatment should improve research study design and ultimately harness them to improve clinical child healthcare.

Maternal Protective Parenting Accounts for the Relationship Between Pain Behaviors and Functional Disability in Adolescents

INTRODUCTION

A variety of factors influence parent responses to pain behaviors they observe in their adolescents with chronic pain. Certain parental responses to pain, such as attention or overprotection, can adversely impact adolescent adaptive functioning and correspond to poor clinical outcomes.

OBJECTIVES

It was hypothesized that the relationship between adolescent pain behaviors and functional disability was mediated by maladaptive parenting (protective, monitoring, solicitousness) responses.

MATERIALS AND METHODS

Participants were 303 adolescents and their mothers presenting to a pain clinic. Adolescents completed measures of functional disability and pain intensity; mothers completed measures assessing adolescent pain behaviors, their own catastrophizing about their adolescent's pain, and responses to pain. A path model tested the direct and indirect associations between pain behaviors and disability via 3 parenting responses, controlling for average pain intensity and parent pain catastrophizing.

RESULTS

Greater pain behavior was associated with increased protective responses (α path, P<0.001); greater protective behavior was associated with increased disability (β path, P=0.002). Including parenting responses in the model, the path between pain behaviors and disability remained significant (c' path, P<0.001). The indirect path between pain behaviors and disability via parenting responses was significant for protective responses (P<0.02), controlling for pain intensity and parent pain catastrophizing. The indirect effect of protective responses explained 18% of the variance between pain behaviors and disability.

DISCUSSION

Observing adolescent pain behaviors may prompt parents to engage in increased protective behavior that negatively impacts adolescents' functioning, even after controlling for the effects of parental pain catastrophizing.

Graded exposure treatment for adolescents with chronic pain (GET Living): Protocol for a randomized controlled trial enhanced with single case experimental design

Chronic musculoskeletal pain in adolescence is a significant public health concern with 3-5% of adolescents suffering from significant pain-related disability. Pain-related fear and avoidance of activities has been found to have a significant influence on pain outcomes in children and adolescents and is a risk factor for less favorable response to treatment. To address this need, we developed graded exposure treatment for youth with chronic pain (GET Living). We describe the rationale, design, and implementation of a two-group randomized controlled trial (RCT) enhanced with single-case experimental design (SCED) methodology with a sample of 74 adolescents with chronic musculosketal pain and their parent caregivers. GET Living includes education, behavioral exposures, and parent intervention jointly delivered by pain psychology and physical therapy providers. The multidisciplinary pain management control group includes pain psychology delivered education and pain self-management skills training (e.g., relaxation, cognitive skills) and separate physical therapy. Assessments include brief daily diaries (baseline to discharge, 7-days at 3-month and 6-month follow-up), comprehensive in-person evaluations at baseline and discharge, and questionnaire across all time points (baseline, discharge, 3-month and 6-month follow-up). Primary outcome is pain-related fear avoidance. Secondary outcome is functional disability. We also outline all additional outcomes, exploratory outcomes, covariates, and implementation measures. The objective is to offer a mechanism-based, targeted intervention to youth with musculoskeletal pain to enhance likelihood of return to function.

Social learning pathways in the relation between parental chronic pain and daily pain severity and functional impairment in adolescents with functional abdominal pain

Having a parent with chronic pain (CP) may confer greater risk of persistence of CP from childhood into young adulthood. Social learning, such as parental modeling and reinforcement, represents one plausible mechanism for the transmission of risk of CP from parents to offspring. Based on a 7-day pain diary in 154 pediatric patients with functional abdominal CP, we tested a model in which parental CP predicted adolescents' daily average CP severity and functional impairment (distal outcomes) via parental modeling of pain behaviors and parental reinforcement of adolescent's pain behaviors (mediators) and adolescents' cognitive appraisals of pain threat (proximal outcome representing adolescents' encoding of parents' behaviors). Results indicated significant indirect pathways from parental CP status to adolescent average daily pain severity (b = 0.18, SE = 0.08, 95% confidence interval: 0.04-0.31, P = 0.03) and functional impairment (b = 0.08, SE = 0.04, 95% confidence interval: 0.02-0.15, P = 0.03) over the 7-day diary period via adolescents' observations of parent pain behaviors and adolescent pain threat appraisal. The indirect pathway through parental reinforcing responses to adolescents' pain did not reach significance for either adolescent pain severity or functional impairment. Identifying mechanisms of increased risk of pain and functional impairment in children of parents with CP ultimately could lead to targeted interventions aimed at improving functioning and quality of life in families with CP. Parental modeling of pain behaviors represents a potentially promising target for family-based interventions to ameliorate pediatric CP.

The (Parental) Whole Is Greater Than the Sum of Its Parts: A Multifactorial Model of Parent Factors in Pediatric Chronic Pain

Parents play a critical role in children's experience of, and recovery from, chronic pain. Although several parental factors have been linked to child pain and functioning, these factors are typically examined in isolation or as moderators or mediators. Structural equation modeling affords the opportunity to examine the extent to which parental factors are interrelated, and if there are differential associations among parental factors and child outcomes. Based on extant literature, a unified model of parental factors, including chronic pain status, physical functioning, responses to child pain, and psychological factors, and their effect on child pain and functioning, was conceptualized. This model was evaluated using structural equation modeling based on data from 146 dyads recruited from a multidisciplinary pain clinic. Modifications to model iterations were made based on theoretical and statistical justification. The final model revealed associations among all parental factors, with significant loadings on child pain and functioning. Findings indicated the conceptual model was supported, with the exception of parent responses to child pain. Findings support the inclusion of parent chronic pain status and physical and psychological functioning as part of a comprehensive assessment of youth with chronic pain and may inform new parental intervention targets to improve child outcomes. PERSPECTIVE: A unified structural equation model indicated parents' own chronic pain characteristics and physical and psychological functioning represent important factors associated with child pain and functioning. Current family-based interventions that often primarily focus on parent responses to child pain may need to be adapted to more comprehensively address parental factors.

Executive Functioning in Pediatric Chronic Pain: Do Deficits Exist?

Objective

Despite ample research documenting deficits in executive functioning for adults with chronic pain, the literature on pediatric patients with chronic pain is limited and provides mixed results. The current study sought to further investigate the nature of executive dysfunction in this population and also examine the relationships between pain intensity, duration, and catastrophizing with sustained attention, working memory, and self- and parent-report of executive functioning.

Settings

Pediatric pain clinic and rehabilitation program.

Participants

Forty adolescents with chronic pain and their parents participated in this study.

Methods

Participants completed neuropsychological measures and standardized self-report questionnaires during a 45- to 60-minute testing session.

Results

Fifty percent of this sample of adolescents with chronic pain demonstrated significant difficulties on at least one measure, with nine participants indicating difficulties on multiple measures. Pain significantly increased during the testing session. Pain variables of intensity, duration, and catastrophizing are related to sustained attention and working memory.

Conclusions

This study adds support to previous findings suggesting subclinical struggles with executive functioning for adolescents with chronic pain. One-half of the sample indicated difficulties in either sustained attention and/or working memory. Future studies that would more thoroughly examine more complex executive functioning skills in this population would be helpful to further guide multidisciplinary treatment of these patients, particularly regarding whether or not school accommodations are warranted.

Topical Review: Basic Psychological Needs in Adolescents with Chronic Pain-A Self-Determination Perspective

This topical review outlines the resilience pathway to adaptive functioning in pediatric pain within a developmental perspective. Self-Determination Theory proposes that the satisfaction of one's basic psychological needs (for autonomy, relatedness, and competence) is crucial for understanding human flourishing and healthy development. However, the role of the basic psychological needs received little attention in a pediatric-pain population. Yet, we propose that need satisfaction may be a resilience factor and need frustration a risk factor, for living with chronic pain. In this topical review, we first discuss two major models that have been developed to understand pain-related disability: the fear-avoidance model of pain and the ecological resilience-risk model in pediatric chronic pain. Both models have been used with children and adolescents but do not include a developmental perspective. Therefore, we introduce Self-Determination Theory and highlight the potentially moderating and mediating role of the basic needs on pain-related disability in children and adolescents. Taken together, we believe that Self-Determination Theory is compatible with the fear-avoidance model of pain and the ecological resilience-risk model in pediatric chronic pain and may deepen our understanding of why some adolescents are able to live adaptively in spite of chronic pain.

Parent Attributions of Ambiguous Symptoms in Their Children: A Preliminary Measure Validation in Parents of Children with Chronic Pain

How parents attribute cause to their child’s physical symptoms is likely important in understanding how the parent responds to the child, as well as the child’s health outcomes, especially within the context of chronic illness. Here, we adapt the Symptom Interpretation Questionnaire for parent report (SIQ-PR) and provide preliminary validation in a sample of parents of children with chronic pain (N = 311). Confirmatory factor analysis revealed that the SIQ-PR structure is consistent with the original measure, with three distinct attribution types: psychological (emotional/affective), somatic (illness/disease), and environmental (situational/transient) causes. All three subscales demonstrated satisfactory to good internal consistency, and temporal stability. Parents typically endorsed more than one attribution for each symptom, indicating that parents of children with chronic pain have a multidimensional interpretation of physical symptoms in their children. Further, parent psychological and somatic attributions, but not environmental attributions, were significantly associated with (i) parent protective responses towards their child, and (ii) the child’s self-reported somatic and psychological symptoms, indicating convergent and divergent validity. The SIQ-PR may be a useful measure for future studies investigating intergenerational and interpersonal models of pediatric chronic pain, and more broadly, to examine parent attributions of children’s ambiguous symptoms within the context of childhood chronic illness.

Changes in Maternal and Paternal Pain-Related Attitudes, Behaviors, and Perceptions across Pediatric Pain Rehabilitation Treatment: A Multilevel Modeling Approach

Objectives

This prospective study compared paternal versus maternal factors and their impact on child outcomes in the context of an intensive pediatric pain rehabilitation program.

Methods

One hundred four youth with treatment refractory chronic pain and their parents enrolled in an intensive pediatric pain rehabilitation program completed measures of pain, functional disability, and parent pain-related attitudes, perceptions, and behaviors at admission and discharge.

Results

Linear mixed models were used. Controlling for significant demographic and clinical characteristics, mothers and fathers who were present for the program typically demonstrated significantly better improvement from admission to discharge compared with nonpresent fathers. Mothers made the most significant gains in protective parent responses. Children also had significant decreases in pain and improvements in functioning over time.

Conclusions

Results indicate the efficacy of this treatment model for both children with chronic pain and their parents and highlights the importance of parental presence in treatment.

Assessment of Pain Anxiety, Pain Catastrophizing, and Fear of Pain in Children and Adolescents With Chronic Pain: A Systematic Review and Meta-Analysis

Objective

To conduct a systematic review of pain anxiety, pain catastrophizing, and fear of pain measures psychometrically established in youth with chronic pain. The review addresses three specific aims: (1) to identify measures used in youth with chronic pain, summarizing their content, psychometric properties, and use; (2) to use evidence-based assessment criteria to rate each measure according to the Society of Pediatric Psychology (SPP) guidelines; (3) to pool data across studies for meta-analysis of shared variance in psychometric performance in relation to the primary outcomes of pain intensity, disability, generalized anxiety, and depression.

Methods

We searched Medline, Embase, PsycINFO, and relevant literature for possible studies to include. We identified measures studied in youth with chronic pain that assessed pain anxiety, pain catastrophizing, or fear of pain and extracted the item-level content. Study and participant characteristics, and correlation data were extracted for summary and meta-analysis, and measures were rated using the SPP evidence-based assessment criteria.

Results

Fifty-four studies (84 papers) met the inclusion criteria, including seven relevant measures: one assessed pain anxiety, three pain catastrophizing, and three fear of pain. Overall, five measures were rated as "well established." We conducted meta-analyses on four measures with available data. We found significant positive correlations with the variables pain intensity, disability, generalized anxiety, and depression.

Conclusion

Seven measures are available to assess pain anxiety, pain catastrophizing, and fear of pain in young people with chronic pain, and most are well established. We present implications for practice and directions for future research.

The role of avoidance behavior in the treatment of adolescents with irritable bowel syndrome: A mediation analysis

Irritable bowel syndrome (IBS) is common in adolescents with a pronounced negative impact on quality of life. A pattern of avoidance behavior is commonly seen in the IBS population, which is associated with more gastrointestinal (GI) symptoms. Exposure-based cognitive behavior therapy (CBT) targets the avoidance behavior to reduce symptoms, but it is unknown whether reduced avoidance is a mediator of symptom improvement in adolescent IBS. Stress has been suggested to play a key role in worsening GI symptoms and is also a potential mediator of the treatment effect in IBS. This study was based on data from a randomized controlled trial (N = 101) that evaluated exposure-based internet-delivered CBT (Internet-CBT) compared with a wait-list for adolescents with IBS. We investigated whether avoidance behavior and perceived stress mediated the improvement in global GI symptoms due to treatment. We found that a change in avoidance behavior, but not perceived stress, mediated the effect of exposure-based Internet-CBT on GI symptoms. The decrease in avoidance behavior explained a large portion (67%) of the total treatment effect. Moreover, a unidirectional relationship over time was observed between avoidance behavior and GI symptoms. Our conclusion is that exposure-based CBT in adolescent IBS reduces avoidance and, consequently, reduces GI symptoms.

Interdisciplinary Treatment of Maladaptive Behaviors Associated with Postural Orthostatic Tachycardia Syndrome (POTS): A Case Report

The prevalence of postural orthostatic tachycardia syndrome (POTS) in adolescents and young adults has been increasing during the past decade. Despite this increase, documentation regarding treatment of these patients is just beginning to emerge. In addition, despite a call for a multidisciplinary or interdisciplinary approach, no studies have examined the efficacy of such an approach to treatment. This paper describes a case study of a 19-year-old male with debilitating POTS seen at a tertiary clinic for evaluation and subsequent intensive interdisciplinary treatment. The treatment approach is described and outcomes are presented.

[Consequences of chronic pain in childhood and adolescence]

OBJECTIVE

Our aim was to examine and map the consequences of chronic pain in children and adolescents.

METHOD

A scoping review was carried out in the international databases (PubMed, SCOPUS, WOS and CINAHL, Cochrane Library) and gray literature. We included documents that addressed psychosocial aspects that influence chronic pain, published in English between 2010 and 2016. We excluded the documents that dealt with pharmacological treatments, chronic pain derived from surgical interventions or where there was no access to full text. 34 of the 716 documents reviewed were included.

RESULTS

Studies show that pain is associated with high rates of functional disability, sleep disorders and spectrum depression-anxiety. Young people experience higher rates of victimization and stigmatization, contributing to social isolation, difficulty in meeting academic demands and less opportunity to consume illegal substances. With respect to the family, chronic pain has been associated with poorer family functioning and considerable investment of economic resources.

CONCLUSIONS

This Scoping Review shows that functional capacity, sleep, personal development, peer support and family functioning are interesting lines in published works. However, gaps in knowledge are detected in areas such as risk behaviours, the consequences that pain can cause in adulthood and gender inequalities.

Transmission of risk from parents with chronic pain to offspring: an integrative conceptual model

Offspring of parents with chronic pain are at increased risk for pain and adverse mental and physical health outcomes (Higgins et al, 2015). Although the association between chronic pain in parents and offspring has been established, few studies have addressed why or how this relation occurs. Identifying mechanisms for the transmission of risk that leads to the development of chronic pain in offspring is important for developing preventive interventions targeted to decrease risk for chronic pain and related outcomes (eg, disability and internalizing symptoms). This review presents a conceptual model for the intergenerational transmission of chronic pain from parents to offspring with the goal of setting an agenda for future research and the development of preventive interventions. Our proposed model highlights 5 potential mechanisms for the relation between parental chronic pain and pediatric chronic pain and related adverse outcomes: (1) genetics, (2) alterations in early neurobiological development, (3) pain-specific social learning, (4), general parenting and family health, and (5) exposure to stressful environment. In addition, the model presents 3 potential moderators for the relation between parent and child chronic pain: (1) the presence of chronic pain in a second parent, (2) timing, course, and location of parental chronic pain, and (3) offspring's characteristics (ie, sex, developmental stage, race or ethnicity, and temperament). Such a framework highlights chronic pain as inherently familial and intergenerational, opening up avenues for new models of intervention and prevention that can be family centered and include at-risk children.

Maternal distress in the context of their child's type 1 diabetes: exploring the role of adaptive maternal emotion regulation on child outcomes

Parents of children with Type 1 diabetes (T1D) experience high levels of distress, which may negatively impact child functioning. However, little is known about mechanisms that may buffer the adverse impact of parental distress. The current study explored the possible buffering role of maternal adaptive cognitive emotion regulation (CER) for the relationship between maternal distress and child psychological functioning. Forty-three children with T1D (8-15 years) completed measures assessing trait anxiety and depressive symptoms. Their mothers reported on general distress, illness-related parenting stress, and adaptive CER. Maternal illness-related parenting stress (but not general distress) was significantly associated with child psychological functioning. No buffering role for maternal adaptive CER was observed. As the current study is rather preliminary, future research using other methods to examine maternal adaptive CER, and examining other parental variables that may buffer against the negative impact of parental distress is warranted.