Neuropsychological Functioning of Youth Receiving Intensive Interdisciplinary Pain Treatment

Topical Review: Getting into the head of youth with chronic pain: how theory of mind deficits may relate to the development and maintenance of pediatric pain

OBJECTIVE

Theory of mind (ToM) is the ability to understand the thoughts, feelings, and mental states of others and is critical for effective social and psychological functioning. ToM deficits have been associated with various psychological disorders and identified in adult pain populations. For youth with chronic pain, ToM deficits may underlie the biological, psychological, and social factors that contribute to their experience of pain, but this remains poorly understood.

METHODS

This topical review explored the extant literature in the areas of ToM and chronic pain, particularly for pediatric populations, with respect to biological, psychological, and social elements of the biopsychosocial model of pain.

RESULTS

ToM deficits may be present alongside previously identified biological, psychological, and social correlates of pediatric pain, as a vulnerability, mechanism, and/or consequence. Biologically, ToM deficits may relate to cortisol abnormalities and neurobiological substrates of pain processing. Psychologically, ToM deficits may stem from pain-focused cognitions, thus impacting relationships and fueling impairment. Socially, chronic pain may preclude normative development of ToM abilities through social withdrawal, thereby exacerbating the experience of pain.

CONCLUSION

Taken together, ToM deficits may be associated with increased risk for the development and/or maintenance of pediatric chronic pain, and pediatric chronic pain may similarly confer risk for ToM deficits. Future research should investigate the nature of ToM abilities in youth with chronic pain to test these hypotheses and ultimately inform ToM-focused and pain-based interventions, as this ability has been demonstrated to be modifiable.

Chronic Pain in Autistic Youth: Clinical Prevalence and Reflections on Tailoring Evidence-Based Interventions from an Interdisciplinary Treatment Team

Though there is growing awareness of the overrepresentation of autistic patients in chronic pain clinics, potential adaptations for the assessment and treatment of chronic pain in this population have not yet been established. To address this gap, a retrospective review of electronic medical records and discussions by an interdisciplinary pain treatment team were summarized to inform potential biopsychosocial factors affecting the presentation, assessment, and treatment of chronic pain in autistic youth. Our sample included a record review of 95 patients receiving treatment in an interdisciplinary outpatient pediatric pain clinic. Results indicated that 9% (n = 9) of the patients presented to the clinic with a prior diagnosis of autism, but an additional 21% (n = 20) were identified as likely meeting criteria for autism based on the clinical assessment of the developmental history, behaviors observed during the clinical encounter(s), and expert clinical judgment, suggesting that the prevalence rate of autism may be closer to 30% in our outpatient pediatric pain clinic. Over half (52%) of the autistic youth presented to the clinic with widespread pain, 60% identified as female, and 6% identified as gender expansive or transgender. Qualitative insights revealed that most of the autistic patients had co-occurring sensory-processing challenges and difficulty in describing their pain, emotions, and somatic experiences and exhibited cognitive inflexibility and social challenges. We summarize our team's clinical reflections on how autism-relevant biopsychosocial vulnerability factors may contribute to the experience of pain in autistic youth and propose treatment targets and adaptations for the assessment and treatment of pain in this population. Finally, we recommend the need for interventions focused on sensorimotor integration, especially for autistic youth, and describe how pain clinics may be particularly helpful for identifying and supporting autistic females, for whom the potential role of autism in pain experiences had not been considered until receiving treatment in our clinic.

A developmental framework for understanding the influence of sex and gender on health: Pediatric pain as an exemplar

Sex differences are a robust finding in many areas of adult health, including cardiovascular disease, psychiatric disorders, and chronic pain. However, many sex differences are not consistently observed until after the onset of puberty. This has led to the hypothesis that hormones are primary contributors to sex differences in health outcomes, largely ignoring the relative contributions of early developmental influences, emerging psychosocial factors, gender, and the interaction between these variables. In this paper, we argue that a comprehensive understanding of sex and gender contributions to health outcomes should start as early as conception and take an iterative biopsychosocial-developmental perspective that considers intersecting social positions. We present a conceptual framework, informed by a review of the literature in basic, clinical, and social science that captures how critical developmental stages for both sex and gender can affect children's health and longer-term outcomes. The literature on pediatric chronic pain is used as a worked example of how the framework can be applied to understanding different chronic conditions.

Pediatric Neural Changes to Physical and Emotional Pain After Intensive Interdisciplinary Pain Treatment: A Pilot Study

Brain areas activated during pain can contribute to enhancing or reducing the pain experience, showing a potential connection between chronic pain and the neural response to pain in adolescents and youth. This study examined changes in brain activation associated with experiencing physical pain, and the observation of physical and emotional pain in others, by using functional magnetic resonance imaging (fMRI) before and after intensive interdisciplinary pain treatment (IIPT). Eighteen youth (age 14 to 18) with widespread chronic pain completed fMRI testing before and after IIPT to assess changes in brain activation in response to physical and emotional pain. Broadly, brain activation changes were observed in frontal, somatosensory, and limbic regions. These changes suggest improvements in descending pain modulation via thalamus and caudate, and the different pattern of brain activation after treatment suggests better discrimination between physical and emotional pain. Brain activation changes were also correlated with improvements in clinical outcomes of catastrophizing (reduced activation in right caudate, right mid-cingulate, and postcentral gyrus) and pain-related disability (increased activation in precentral gyrus, left hippocampus, right middle occipital cortex, and left superior frontal gyrus). These changes support interpretation that reduced brain protective responses to pain were associated with treatment-related improvements. This pilot study highlights the need for larger trials designed to better understand the brain mechanisms involved in pediatric widespread pain treatment.

Associations between Chronic Pain and Attention-Deficit Hyperactivity Disorder (ADHD) in Youth: A Scoping Review

Background: Chronic pain and ADHD are common conditions among youth that negatively impact functioning. This review fills a critical gap by summarizing current research on chronic pain and ADHD comorbidity, and it proposes a conceptual model of shared associations and underlying mechanisms. Objective: The aims of the current study were to: (1) review the extant literature and present estimates of the prevalence of comorbid non-headache chronic pain and ADHD in youth and (2) describe potential shared mechanisms for ADHD and chronic non-headache pain in youth. We also outline future directions to inform future research and interventions directed to youth with comorbid pain and ADHD. Design: A scoping review of the literature was performed in MEDLINE, PsycInfo, and Cochrane Database of Systematic Reviews using a wide range of search terms related to pain, Attention Deficit-Hyperactivity Disorder, childhood, adolescence, and young adulthood. Results: Eleven published studies were included in the review. These studies examined the prevalence of chronic pain among youth with ADHD, the prevalence of ADHD in chronic pain samples, and the association between chronic pain and ADHD among youth. Findings revealed results from studies indicating a higher prevalence of ADHD among youth with chronic pain and a higher prevalence of chronic pain in samples of youth with ADHD. Conclusions: Findings from this scoping review suggest an association between chronic pain and ADHD among youth. Little research was found to examine the etiology of this association. Future studies should examine underlying mechanisms of comorbid chronic pain and ADHD.

Neuropathic pain and neurocognitive functioning in children treated for acute lymphoblastic leukemia

ABSTRACT

Children with acute lymphoblastic leukemia (ALL) often experience treatment-related neurocognitive deficits and significant pain. Pain may exacerbate these cognitive impairments. This study examined neuropathic pain and neurocognitive outcomes in survivors of childhood ALL treated with contemporary therapy on a clinical trial (NCT00137111). There were 345 survivors (45% female, M = 6.9 years at diagnosis) who completed neurocognitive assessments including measures of sustained attention, learning and memory, and parent ratings of attention during at least one of 4 time points: on-therapy (Induction and Reinduction), end of therapy, and 2 years post-therapy. At-risk performance was defined as a score at least 1SD below the age-adjusted mean. Data on neuropathic pain (events, duration, and severity according NCI Common Toxicity Criteria) and pharmacologic pain management (opioids and gabapentin) were ascertained. Results showed that 135 survivors (39%) experienced neuropathic pain during treatment. Compared with those without pain, survivors with pain had greater memory impairments at end of therapy (California Verbal Learning Test [CVLT]-Total, 24% vs 12%, P = 0.046). Within the pain group, survivors who experienced a greater number of pain events (CVLT-Total = -0.88, P = 0.023) and those who were treated with opioids (versus gabapentin) had poorer learning and memory performance (CVLT-Total = -0.73, P = 0.011; Short Delay = -0.57, P = 0.024; Long Delay = -0.62, P = 0.012; and Learning Slope = -0.45, P = 0.042) across time points. These are considered medium-to-large effects (SD = 0.45-0.88). Neuropathic pain may be a risk factor for learning problems after therapy completion, and treatment for pain with opioids may also adversely affect neurocognitive performance. Therefore, patients who experience pain may require closer monitoring and additional intervention for neurocognitive impairment.

A Systematic Review of the Validity and Realiability of Assessment Tools for Executive Function and Adaptive Function Following Brain Pathology among Children and Adolescents in Low- and Middle-Income Countries

Minimal but increasing number of assessment instruments for Executive functions (EFs) and adaptive functioning (AF) have either been developed for or adapted and validated for use among children in low and middle income countries (LAMICs). However, the suitability of these tools for this context is unclear. A systematic review of such instruments was thus undertaken. The Systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist (Liberati et al., in BMJ (Clinical Research Ed.), 339, 2009). A search was made for primary research papers reporting psychometric properties for development or adaptation of either EF or AF tools among children in LAMICs, with no date or language restrictions. 14 bibliographic databases were searched, including grey literature. Risk of bias assessment was done following the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) guidelines (Mokkink et al., in Quality of Life Research,63, 32, 2014). For EF, the Behaviour Rating Inventory of Executive Functioning (BRIEF- multiple versions), Wisconsin Card Sorting Test (WCST), Go/No-go and the Rey-Osterrieth complex figure (ROCF) were the most rigorously validated. For AFs, the Vineland Adaptive Behaviour Scales (VABS- multiple versions) and the Child Function Impairment Rating Scale (CFIRS- first edition) were most validated. Most of these tools showed adequate internal consistency and structural validity. However, none of these tools showed acceptable quality of evidence for sufficient psychometric properties across all the measured domains, particularly so for content validity and cross-cultural validity in LAMICs. There is a great need for adequate adaptation of the most popular EF and AF instruments, or alternatively the development of purpose-made instruments for assessing children in LAMICs.

Systematic Review Registration numbers: CRD42020202190 (EF tools systematic review) and CRD42020203968 (AF tools systematic review) registered on PROSPERO website (https://www.crd.york.ac.uk/prospero/).

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

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

Beyond Amitriptyline: A Pediatric and Adolescent Oriented Narrative Review of the Analgesic Properties of Psychotropic Medications for the Treatment of Complex Pain and Headache Disorders

Children and adolescents with recurrent or chronic pain and headache are a complex and heterogenous population. Patients are best served by multi-specialty, multidisciplinary teams to assess and create tailored, individualized pain treatment and rehabilitation plans. Due to the complex nature of pain, generalizing pharmacologic treatment recommendations in children with recurrent or chronic pains is challenging. This is particularly true of complicated patients with co-existing painful and psychiatric conditions. There is an unfortunate dearth of evidence to support many pharmacologic therapies to treat children with chronic pain and headache. This narrative review hopes to supplement the available treatment options for this complex population by reviewing the pediatric and adult literature for analgesic properties of medications that also have psychiatric indication. The medications reviewed belong to medication classes typically described as antidepressants, alpha 2 delta ligands, mood stabilizers, anti-psychotics, anti-sympathetic agents, and stimulants.

Neurocognitive Difficulties Among Youth with POTS within an Intensive Pain Rehabilitation Program

OBJECTIVE

Adolescents and young adults (AYAs) with postural orthostatic tachycardia syndrome (POTS) commonly report cognitive difficulties, though there is limited information regarding the objective measurement of neurocognitive deficits in this population. This study described the rates of subjectively experienced and objectively measured neurocognitive difficulties and explored effects of medications on neurocognitive functioning among AYAs with POTS admitted to an intensive outpatient pain rehabilitation program.

METHODS

Participants in a pain rehabilitation program diagnosed with POTS (N = 96; ages 12-22) were included in the study. Medical characteristics, reported cognitive complaints, and neurocognitive assessment results were collected through retrospective medical record review. We calculated descriptive statistics and Pearson's χ2 or Fisher's exact tests, where appropriate.

RESULTS

While 96% of this sample reported subjective cognitive complaints, as a group, they performed in the Average range on standardized measures of intellectual functioning, attention, and memory. The majority did not demonstrate any normative (73%) or relative (54%) weaknesses in attention or memory. Those prescribed an antiepileptic (n = 19) were less likely to have visual-spatial memory weaknesses but more likely to have attention weaknesses.

CONCLUSIONS

Despite a high frequency of reported cognitive difficulties, most AYAs with POTS did not demonstrate neurocognitive impairment on standardized, one-on-one assessment. Suggestions for further study of biopsychosocial contributors to neurocognitive difficulties and for clinical use of neurocognitive assessments in this population were provided.

Recurrent Pain and Academic Achievement in School-Aged Children: A Systematic Review

Recurrent pain and school failures are common problems in children visiting the school nurses office. The overall aim of the current study was to investigate the relationship between recurrent pain and academic achievement in school-aged children. Literature was searched in seven electronic databases and in relevant bibliographies. Study selection, data extraction, and study and evidence quality assessments were performed systematically with standardized tools. Twenty-one studies met the inclusion criteria and 13 verified an association between recurrent pain (headache, stomachache, and musculoskeletal pain) and negative academic achievement. Two longitudinal studies indicated a likely causal effect of pain on academic achievement. All studies had substantial methodological drawbacks and the overall quality of the evidence for the identified associations was low. Thus, children’s lack of success in school may be partly attributed to recurrent pain problems. However, more high-quality studies are needed, including on the direction of the association and its moderators and mediators.

Prevalence of autism traits and attention-deficit hyperactivity disorder symptoms in a clinical sample of children and adolescents with chronic pain

Purpose

Recent research has suggested that autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) may be comorbid to pediatric chronic pain, but the empirical support is yet scarce. Therefore, the current study aimed to investigate the occurrence of traits and symptoms consistent with clinically significant ASD and ADHD in a group of children and adolescents with chronic debilitating pain and examine potential differences in pain and demographic variables between children with and without clinically significant traits and symptoms of ASD and ADHD.

Patients and methods

This cross-sectional study included 146 parent–child dyads (102 girls, 111 mothers, children 8–17 years) consecutively referred to a tertiary pain clinic. Parents completed the Social Responsiveness Scale to assess autistic traits, and Conners-3 to measure symptoms of ADHD in their children. Children completed the Lübeck Pain Questionnaire to evaluate experienced pain.

Results

Among children, 20 (13.7%) received scores consistent with clinically significant ASD and 29 (19.9%) received scores consistent with clinically significant ADHD, with a combined prevalence of clinically significant ASD/ADHD traits and symptoms of 26% of the total sample. Only 4.8% of children were previously diagnosed with either disorder. Among children with clinically significant ASD traits, girls were more prevalent, parents reported lower health, and the pain was more likely triggered by being in school. Among children with clinically significant ADHD symptoms, there were no gender differences and pain was more likely triggered by the family situation and new situations. No differences regarding pain intensity, duration, or frequency were found between children with and without clinically significant ASD traits or ADHD symptoms.

Conclusion

Children with debilitating chronic pain, particularly girls, may present with an elevated risk of having a comorbid, possibly high-functioning, neurodevelopmental disorder. Results suggest that clinical assessment of pediatric chronic pain should include screening for neurodevelopmental disorders.