Personal and Contextual Factors Affecting the Functional Ability of Children and Adolescents with Chronic Pain: A Systematic Review

Pain and depressive symptoms among adolescents: prevalence and associations with achievement pressure and coping in the Norwegian Ungdata study

BACKGROUND

This study investigated the prevalence of pain, depressive symptoms, and their co-occurrence in Norwegian adolescents. Additionally, we investigated if perceived achievement pressure and coping with pressure were associated with pain, depressive symptoms and co-occurrent pain and depressive symptoms.

METHODS

Cross-sectional data from the Norwegian Ungdata Survey (2017-2019) were analysed. Adolescents from across Norway completed an electronic questionnaire including questions on perceived achievement pressure, coping with pressure, pain, and depressive symptoms. Descriptive statistics presented prevalence rates, and multinominal regression reported in relative risk ratios (RR) was employed to estimate associations, adjusted for gender (boys/girls), school level, and socioeconomic status.

RESULTS

The analyses included 209,826 adolescents. The prevalence of pain was 33%, 3% for depressive symptoms, and 14% reported co-occurring pain and depressive symptoms. The prevalence of co-occurring symptoms was higher in girls (22%) than boys (6%). Significant associations were found between perceived achievement pressure and pain (RR 1.11, 95% CI 1.10-1.11), depressive symptoms (RR 1.27, 95% CI 1.27-1.28), and co-occurring symptoms (RR 1.34, 95% CI 1.33-1.34). Struggling to cope with pressure was associated with pain (RR 2.67 95% CI 2.53-2.81), depressive symptoms (RR 16.68, 95% CI 15.60-17.83), and co-occurring symptoms (RR 27.95, 95% CI 26.64-29.33).

CONCLUSION

The prevalence of co-occurring pain and depressive symptoms is high among Norwegian adolescents. Perceived achievement pressure and struggling to cope with pressure were associated with isolated and, more strongly, co-occurring pain and depressive symptoms. Enhancing adolescents' ability to cope with pressure could be a crucial target in treating pain and depressive symptoms.

Fear of movement and competence frustration mediate the relationship between pain catastrophising and physical function in people living with axSpA: an online cross-sectional survey

The objective of this study is to examine the contribution of pain catastrophising to Axial Spondyloarthritis (axSpA) patient's physical function and to test the mediating role of fear of movement, and uniquely, the contribution of competence frustration to the fear-avoidance model. Participants (N = 98, 70% female, M age = 45.62, SD 12.16) completed an online survey (December 2020-May 2021) distributed in the United Kingdom via the National Axial Spondyloarthritis Society (n ≈ 3500; NASS, 2019). The PROCESS SPSS macro was used to test three mediation models using percentile bootstrap 95% confidence intervals (PBCI). A significant indirect effect on the relationship between pain and physical function via fear of movement (β = 0.10, 95% PBCI = 0.030-0.183) was observed (Model 1). Model 2 showed the relationship between pain catastrophising and physical function to be significantly mediated by fear of movement (β = 0.16, 95% PBCI = 0.005-0.322). Finally, Model 3 showed a significant indirect effect on the relationship between pain catastrophising and physical function via competence frustration (β = 0.15, 95% PBCI = 0.014-0.309) but not through fear of movement (β = 0.062, 95% PBCI = - 0.134 to 0.248). To our knowledge, this is the first study to examine and demonstrate the unique contribution of competence need frustration to the Fear-avoidance model in people that live with axSpA. Identifying modifiable factors that contribute to disease outcomes such as physical function can improve the care and quality of life for people living with a disease currently without a cure.

Co-occurring chronic pain and primary psychological disorders in adolescents: A scoping review

Long-term health conditions, whether mental or physical, often co-occur in adolescents. For instance, adolescents with chronic pain may experience co-occurring primary psychological disorders. In this scoping review, we determine the influence of co-occurring chronic pain and primary psychological disorders on adolescents' functioning. A systematic search of six databases was conducted to identify articles if they were: (1) peer-reviewed; (2) reported original findings; (3) included participants aged 11-19 years, who experienced chronic pain (i.e., pain lasting 3 months or more) and had a co-occurring diagnosis of a primary psychological disorder; and (4) assessed functioning. Searches returned 9864 articles after the removal of duplicates. A two-phase abstract and full-text screening process identified two eligible articles which compared emotional functioning (n = 1) and social functioning (n = 2) between groups of adolescents with co-occurring chronic pain and primary psychological disorders with adolescents only reporting chronic pain. Overall findings revealed no differences in social functioning, but adolescents with co-occurring chronic pain and a primary psychological disorder (depression and anxiety) reported worse emotional functioning compared with adolescents with chronic pain alone. This review confirms the limited research on the co-occurrence of primary psychological disorders and chronic pain in adolescents by only identifying two eligible articles exploring the co-occurrence of chronic pain with depression, anxiety, and/or attentional disorders.

Pain and insomnia as risk factors for first lifetime onsets of anxiety, depression, and suicidality in adolescence

ABSTRACT

Chronic pain and mental health problems have both been identified as public health emergencies and co-occur at high rates. This prospective, longitudinal investigation examined whether chronic pain status, pain-related symptoms (intensity, interference), pain catastrophizing, and insomnia severity predicted first lifetime onset of depressive and/or anxiety disorders as well as suicidality in a cohort of youth with a parental history of mood and/or anxiety disorders. Participants included 145 youth (Mage = 13.74 years; 64% female) who completed structured diagnostic interviews at baseline and at 9- and 18-month follow-up to assess depressive and anxiety disorders as well as suicidality. Participants completed baseline questionnaires assessing depressive and anxiety symptoms, pain symptoms and characteristics, pain interference, pain catastrophizing, and insomnia severity. Approximately 25% of youth reported having chronic pain at baseline. Nearly half (47.3%) developed a depressive disorder (21.3%), anxiety disorder (15.7%), or both (10.3%), and 34% endorsed experiencing suicidality at follow-up. Increased pain interference, intensity, catastrophizing, and insomnia severity predicted increased likelihood of first lifetime onset of a depressive disorder at follow-up, over and above sex and baseline symptoms. Chronic pain at baseline was associated with the increased likelihood of onset of suicidality at follow-up. Increased pain intensity and interference at baseline predicted increased severity of suicidality at follow-up. Insomnia severity predicted increased likelihood of anxiety disorder onset. The presence of chronic pain and elevated pain-related symptoms and insomnia are premorbid risk factors for the development of significant mental health disorders and issues in youth.

The association between childhood trauma and pain symptoms in depressed adults: The moderating role of anxious attachment

Studies have previously demonstrated that anxious attachment shapes the association between childhood traumatic experiences and somatic pain; however, it remains unclear how this relationship is influenced by anxious attachment in patients with depression. This study investigated how anxious attachment influences the relationship between childhood traumatic experiences and pain symptoms in depressed patients from a social psychological perspective. A total of 139 adult patients with depression participated in this study; the level of depression was assessed by a psychiatric professional. Childhood trauma, pain symptoms, and attachment dimensions were tested by various questionnaires. The moderating role of anxious attachment in the trauma-pain association was examined using the PROCESS Model 1. Our findings showed that in depressed patients, childhood maltreatment had a significant positive impact on the severity of pain ratings. Moreover, anxious attachment influenced the relationship between childhood trauma and pain symptoms. Our study indicated that anxious attachment is not necessarily a negative outcome for depressed patients; moderate levels of anxious attachment alleviate childhood trauma-related pain symptoms in individuals with highly traumatic experiences. Understanding the traumatic experiences and attachment styles of depressed patients with pain complaints can help to develop intervention strategies.

Intolerance of Uncertainty in Pediatric Chronic Pain: Dyadic Relationships Between Youth and Parents

The current study used a dyadic analytic approach (actor-partner interdependence models) to assess the stability and interrelationships of intolerance of uncertainty (IU) among a cohort of youth with chronic pain and their parents (n = 156 dyads). Relationships between parent and youth IU, parent and youth pain interference, and parent and youth internalizing mental health symptoms were examined. At baseline and follow-up, youth and parents completed psychometrically-sound questionnaires to assess their respective IU, pain characteristics, and clinical outcomes (pain interference, anxiety, depressive, and posttraumatic stress symptoms). Our findings support the construct stability of IU over time, as well as intrapersonal (ie, actor) effects of IU on follow-up youth pain interference and mental health symptoms and parents' mental health symptoms (but not parent pain interference). There were no interpersonal (ie, partner) effects over time between youth and parent IU or between youth and parent IU and pain interference or mental health symptoms. These findings align with previous research evidencing IU as a transdiagnostic risk factor for a range of mental health concerns and extend previous findings by showing the stability of parent and youth IU over time and its potential predictive relevance to outcomes in a clinical sample of youth with chronic pain. PERSPECTIVE: This article presents dyadic analyses assessing intrapersonal and interpersonal associations between intolerance of uncertainty (IU) and pain and mental health symptoms in youth with chronic pain and their parents. Analyses evidenced short-term construct stability of IU and intrapersonal (but not interpersonal) effects of IU on pain and mental health symptoms.

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

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

Predictors and Consequences of Pediatric Pain Symptom Trajectories: A 14-Year Longitudinal Study

OBJECTIVE

The present study had three primary objectives. First, pain trajectory from early childhood to early adolescence were modeled. Second, we examined how early childhood individual-, parental-, and family-level factors predict pain trajectories. Third, we evaluated consequences of pain trajectories in terms of anxiety and depressive symptoms, and substance use at age 16 years.

DESIGN

The current paper is a secondary data analysis of a multisite longitudinal study. A total of 731 children and their families were followed from ages 2 to 16 years.

METHODS

A growth mixture model (GMM) was used to identify pain trajectories from ages 2 to 14 years.

RESULTS

The GMM revealed three distinct pain trajectories: (1) Low Pain Symptom (n = 572); (2) Increasing Pain Symptom (n = 106); and (3) U-shaped Pain Symptom (n = 53). Children who experienced greater harsh parenting and sleep disturbances in early childhood were more likely to belong to the Increasing Pain Symptom group, and those with greater anxious-depressed symptoms at age 2 years were more likely to belong to the U-shaped Pain Symptom group than the Low Pain Symptom group. Additionally, those youth in the Increasing Pain Symptom group, compared to the Low and U-shaped Pain Symptom groups, showed elevated anxiety symptoms at age 16 years.

CONCLUSIONS

Reducing harsh parenting and children's sleep disturbances could be important targets for preventing pediatric pain problems. Children with increasing pain symptoms may also benefit from learning adaptive pain management skills to lower the risk of developing anxiety problems in late adolescence.

Cross-Sectional Associations among Components of Injustice Appraisals and Functioning in Adolescents With Chronic Pain

OBJECTIVE

Pain-related appraisals, including pain-related injustice, impact the development and maintenance of chronic pain. This cross-sectional study aimed to examine the relationship between the cognitive-emotional components of pain-related injustice-blame/unfairness and severity/irreparability of loss-and functioning in a mixed sample of adolescents with chronic pain.

METHODS

Pediatric patients age 11-18 years (N = 408) completed forms assessing pain-related injustice, pain intensity, and physical and psychosocial functioning as part of their routine assessment in a pediatric chronic pain clinic between January 2014 and January 2019. A series of hierarchical regressions were used to evaluate the relationships among the separate components of pain-related injustice appraisals and functioning.

RESULTS

Pain intensity and blame/unfairness appraisals were significantly associated with emotional functioning with blame/unfairness being the stronger association (β = -.27). Blame/unfairness appraisals, severity/irreparability appraisals, and pain intensity were significantly associated with physical functioning with pain intensity being the strongest association (β = .36). Pain intensity, blame/unfairness appraisals, and severity/irreparability appraisals were significantly associated with social functioning with blame/unfairness being the strongest association (β = -.34). Pain intensity and severity/irreparability appraisals were significantly associated with school functioning with severity/irreparability being the stronger association (β = -.19).

CONCLUSIONS

These results lend further support to incorporating pain-related injustice appraisals in standard clinical pain assessments. Treatment practices should target the specific injustice appraisals and domains of functioning impacted for each pediatric patient with chronic pain.

Battle of the Appraisals: Pain-Related Injustice Versus Catastrophizing as Mediators in the Relationship Between Pain Intensity and 3-Month Outcomes in Adolescents with Chronic Pain

Pain appraisals are closely tied to pain and functional outcomes. Pain-related injustice and pain catastrophizing appraisals have both been identified as important cognitive-emotional factors in the pain experience of youth. Although pain-related injustice and catastrophizing have been linked to worse pain outcomes - as primary predictors and intermediary variables - little is known about whether they operate as independent or parallel mediators of the relationship between pain and functioning in youth. We tested pain-related injustice and catastrophizing appraisals as candidate mediators of the relationship between baseline pain intensity and 3-month functional outcomes in adolescents. Youth with chronic pain (N = 89, 76% female, 89% White, average age = 15 years) completed measures assessing pain intensity, pain-related injustice, and catastrophizing at baseline, as well as measures assessing functional disability and overall quality of life 3 months later. Multiple mediation analyses indicated that injustice mediated the relationship between pain intensity and 3 month quality of life. Exploratory analyses of specific quality of life domains indicated that injustice mediated the relationship between pain intensity and 3 month emotional functioning, whereas catastrophizing mediated the relationship between pain intensity and 3 month social functioning. The findings suggest these pain-related appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes. PERSPECTIVE: Pain-related injustice and catastrophizing appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes in youth with chronic pain. Treatments targeting pain-related injustice appraisals in pediatric populations are needed to complement existing treatments for catastrophizing.

Viewpoint: An Information Extraction Framework for Disability Determination Using a Mental Functioning Use-Case (Preprint)

Natural language processing (NLP) in health care enables transformation of complex narrative information into high value products such as clinical decision support and adverse event monitoring in real time via the electronic health record (EHR). However, information technologies for mental health have consistently lagged because of the complexity of measuring and modeling mental health and illness. The use of NLP to support management of mental health conditions is a viable topic that has not been explored in depth. This paper provides a framework for the advanced application of NLP methods to identify, extract, and organize information on mental health and functioning to inform the decision-making process applied to assessing mental health. We present a use-case related to work disability, guided by the disability determination process of the US Social Security Administration (SSA). From this perspective, the following questions must be addressed about each problem that leads to a disability benefits claim: When did the problem occur and how long has it existed? How severe is it? Does it affect the person’s ability to work? and What is the source of the evidence about the problem? Our framework includes 4 dimensions of medical information that are central to assessing disability—temporal sequence and duration, severity, context, and information source. We describe key aspects of each dimension and promising approaches for application in mental functioning. For example, to address temporality, a complete functional timeline must be created with all relevant aspects of functioning such as intermittence, persistence, and recurrence. Severity of mental health symptoms can be successfully identified and extracted on a 4-level ordinal scale from absent to severe. Some NLP work has been reported on the extraction of context for specific cases of wheelchair use in clinical settings. We discuss the links between the task of information source assessment and work on source attribution, coreference resolution, event extraction, and rule-based methods. Gaps were identified in NLP applications that directly applied to the framework and in existing relevant annotated data sets. We highlighted NLP methods with the potential for advanced application in the field of mental functioning. Findings of this work will inform the development of instruments for supporting SSA adjudicators in their disability determination process. The 4 dimensions of medical information may have relevance for a broad array of individuals and organizations responsible for assessing mental health function and ability. Further, our framework with 4 specific dimensions presents significant opportunity for the application of NLP in the realm of mental health and functioning beyond the SSA setting, and it may support the development of robust tools and methods for decision-making related to clinical care, program implementation, and other outcomes.

Chronic non-cancer pain in adolescents: a narrative review

Introduction

Chronic pain is defined as a pain lasting more than 3–6 months. It is estimated that 25% of the pediatric population may experience some kind of pain in this context. Adolescence, corresponding to a particular period of development, seems to present the ideal territory for the appearance of maladaptive mechanisms that can trigger episodes of persistent or recurrent pain.

Methods

A narrative review, in the PubMed/Medline database, in order to synthetize the available evidence in the approach to chronic pain in adolescents, highlighting its etiology, pathophysiology, diagnosis, and treatment.

Results

Pain is seen as a result from the interaction of biological, psychological, individual, social, and environmental factors. Headache, abdominal pain, and musculoskeletal pain are frequent causes of chronic pain in adolescents. Pain not only has implications on adolescents, but also on family, society, and how they interact. It has implications on daily activities, physical capacity, school performance, and sleep, and is associated with psychiatric comorbidities, such as anxiety and depression. The therapeutic approach of pain must be multimodal and multidisciplinary, involving adolescents, their families, and environment, using pharmacological and non-pharmacological strategies.

Discussion and conclusion

The acknowledgment, prevention, diagnosis, and treatment of chronic pain in adolescent patients seem not to be ideal. The development of evidence-based forms of treatment, and the training of health professionals at all levels of care are essential for the diagnosis, treatment, and early referral of these patients.

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.

A Review on the Triggers of Pediatric Migraine with the Aim of Improving Headache Education

Although migraines are common in children and adolescents, they have a robustly negative impact on the quality of life of individuals and their families. The current treatment guidelines outline the behavioral and lifestyle interventions to correct common causative factors, such as negative emotional states, lack of exercise and sleep, and obesity; however, the evidence of their effectiveness is insufficient. To create a plan for disseminating optimal pediatric headache education, we reviewed the current evidence for factors correlated with migraine. We assessed three triggers or risk factors for migraines in children and adolescents: stress, sleep poverty, and alimentation (including diet and obesity). While there is a gradual uptick in research supporting the association between migraine, stress, and sleep, the evidence for diet-related migraines is very limited. Unless obvious dietary triggers are defined, clinicians should counsel patients to eat a balanced diet and avoid skipping meals rather than randomly limiting certain foods. We concluded that there is not enough evidence to establish a headache education plan regarding behavioral and lifestyle interventions. Clinicians should advise patients to avoid certain triggers, such as stress and sleep disorders, and make a few conservative dietary changes.

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.

Testing the intergenerational model of transmission of risk for chronic pain from parents to their children: an empirical investigation of social transmission pathways

Children of parents with chronic pain have higher rates of pain and internalizing (eg, anxiety and depressive) symptoms than children of parents without chronic pain. Parental modeling of pain behaviour and reinforcement of child pain have been hypothesized to underlie these relationships. These mechanisms were tested in a sample of 72 parents with chronic pain and their children (aged 8-15 years). Standardized measures were completed by parents (pain characteristics, pain interference, and child internalizing) and children (pain catastrophizing, pain over previous 3 months, and internalizing). In a laboratory session, children completed the cold pressor task in the presence of their parent, and parent-child verbalizations were coded. Significant indirect effects of parental pain interference on child self-reported (B = 0.12, 95% confidence interval [CI]: 0.01-0.29) and parent-reported (B = 0.16, 95% CI: 0.03-0.40) internalizing symptoms through child pain catastrophizing were found (parental modeling mechanism), and were not moderated by child chronic pain status. Significant indirect effects were found between parent pain-attending verbalizations and child self-reported (B = 2.58, 95% CI: 1.03-5.31) and parent-reported (B = 2.18, 95% CI: 0.93-4.27) cold pressor task pain intensity and tolerance (B = -1.02, 95% CI: -1.92 to -0.42) through child pain-attending verbalizations (parental reinforcement mechanism). Although further understanding of the temporal relationships between these variables is needed, the current study identifies constructs (eg, parent pain interference, child pain catastrophizing, and parent reinforcement of child pain) that should be further examined as potential targets for prevention and intervention of pain and internalizing symptoms in children of parents with chronic pain.

Clinical relevance of attentional biases in pediatric chronic pain: an eye-tracking study

ABSTRACT

Attentional biases have been posited as one of the key mechanisms underlying the development and maintenance of chronic pain and co-occurring internalizing mental health symptoms. Despite this theoretical prominence, a comprehensive understanding of the nature of biased attentional processing in chronic pain and its relationship to theorized antecedents and clinical outcomes is lacking, particularly in youth. This study used eye-tracking to assess attentional bias for painful facial expressions and its relationship to theorized antecedents of chronic pain and clinical outcomes. Youth with chronic pain (n = 125) and without chronic pain (n = 52) viewed face images of varying levels of pain expressiveness while their eye gaze was tracked and recorded. At baseline, youth completed questionnaires to assess pain characteristics, theorized antecedents (pain catastrophizing, fear of pain, and anxiety sensitivity), and clinical outcomes (pain intensity, interference, anxiety, depression, and posttraumatic stress). For youth with chronic pain, clinical outcomes were reassessed at 3 months to assess for relationships with attentional bias while controlling for baseline symptoms. In both groups, youth exhibited an attentional bias for painful facial expressions. For youth with chronic pain, attentional bias was not significantly associated with theorized antecedents or clinical outcomes at baseline or 3-month follow-up. These findings call into question the posited relationships between attentional bias and clinical outcomes. Additional studies using more comprehensive and contextual paradigms for the assessment of attentional bias are required to clarify the ways in which such biases may manifest and relate to clinical outcomes.

Daily Peer Victimization Experiences of Adolescents With and Without Chronic Pain: Associations With Mood, Sleep, Pain, and Activity Limitations

This study aims to 1) examine the temporal influence of peer victimization on mood, sleep quality, pain, and activity limitations in clinical and community samples of youth, and 2) test mood and sleep as mediators of peer victimization-pain pathways. One hundred fifty-six adolescents (n = 74 chronic pain group) completed a week of online diary monitoring assessing their daily peer victimization experiences, negative mood, sleep quality, pain intensity, and pain-related activity limitations. In multilevel models controlling for group status, person-mean peer victimization (averaged across days) significantly predicted worse mood, pain, and activity limitations (all Ps < .01) while daily victimization predicted worse mood (P < .05). Results from within-person mediation indicated a significant indirect effect of daily peer victimization on next-day activity limitations, through daily negative mood. Results from between-person mediation indicated that negative mood significantly mediated the relation between peer victimization and pain and the relation between peer victimization and activity limitations. Peer victimization is associated with negative health indicators in clinical and community samples of youth and may exert its influence on pain and pain-related activity limitations through negative mood. PERSPECTIVE: This article examines the temporal influence of peer victimization on pain in adolescents with and without chronic pain, and examines mood and sleep quality as mechanisms linking victimization to pain. This information may be useful for pain prevention researchers as well as providers who assess and treat pain in childhood.

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.

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.

Association between Pain Sensitivity, Central Sensitization, and Functional Disability in Adolescents With Joint Hypermobility

PURPOSE

The purpose of this study was to examine the association between pain sensitivity, central sensitization, and functional disability in adolescents with joint hypermobility.

DESIGN AND METHODS

A cross-sectional descriptive design was utilized for this study. A sample of 40 adolescents being evaluated for chronic pain and autonomic nervous system dysfunction were recruited. Subjects were evaluated for pain, function, central sensitization, and sensitivity on pain and touch sensory nerve fiber types. Data were analyzed to detect associations between variables.

RESULTS

Joint hypermobility had a moderately significant correlation with central sensitization measured by the Central Sensitization Inventory, as well as increased pain sensitivity as evidenced by hypersensitivity of Aδ sensory nerve fibers. The presence of central sensitization was also positively associated with level of functional disability.

CONCLUSIONS

Findings implicate joint hypermobility as a possible antecedent to pain hypersensitivity and central sensitization syndromes that when recognized and addressed effectively may reduce functional disability in those affected.

PRACTICE IMPLICATIONS

It is important for pediatric nurses that work with adolescents that have chronic pain to understand variables that may impact pain and functional disability in order to develop methods to increase function, reduce pain, and increase perceived quality of life.

[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.

Improved health-related quality of life, participation, and autonomy in patients with treatment-resistant chronic pain after an intensive social cognitive intervention with the participation of support partners

Despite the availability of various specific treatments, most patients with chronic pain (CP) consider their pain problem as undertreated. Recently, multiple sclerosis (MS) patients who were given an intensive 3-day social cognitive treatment with the participation of support partners experienced lasting improvements in health-related quality of life (HRQoL) and self-efficacy. In this study, a similar intervention was given to treatment-resistant CP patients with stressors, relational problems with support partner, and distress, anxiety or depression. Before and 1, 3, and 6 months after the intervention, patients completed the Euro-Qol 5 Dimensions 5 Levels (EQ-5D-5L) and Impact on Participation and Autonomy (IPA) questionnaires (primary outcomes), and the Survey Of Pain Attitudes (SOPA), the Four-Dimensional Symptom Questionnaire (4DSQ) (distress, depression, anxiety, and somatization), and Visual Analog Scale for pain intensity, whereas the support partners completed the Caregiver Strain Index (CSI) questionnaire. Differences between baseline and post-treatment were tested via paired t-tests (significance level 0.05). Of the 39 patients who were included, 34 (87.2%) completed the 3-day treatment. At 1, 3, and 6 months, improvements were seen in EQ-5D-5L-Index (+40.6%; +22.4%; +31.7%), Health Today (+61.8%; +36.3%; +46.8%), Control attitude (+45.8%; not significant [NS]; +55.0%) and decreases in IPA-Problems (−14.8%; NS; −20.4%), Harm attitude (−18.9%; −15.0%; −17.7%), Distress (−17.7%; −31.8%; −37.1%), and Depression (−37.4%; −31.4%; −35.7%) scores. The CSI score had decreased by −29.0%, −21.4%, and −25.9%, respectively. In conclusion, after an intensive 3-day social cognitive intervention, treatment-resistant CP patients experienced substantial and lasting improvements in HRQoL and in problematic limitations to participation and autonomy, in association with improvements in pain attitudes, depression, and distress. To assess whether this innovative approach may be an effective treatment for this subgroup of CP patients, future randomized controlled studies are needed.

Gender differences in the experience of pain dismissal in adolescence

This study examined physician-generated pain dismissal experiences in adolescence between males and females. Young adults (ages 18-24, N = 178) with chronic or recurrent pain reported at least one pain dismissal experience in adolescence and answered a series of questions regarding the experience during this time period. Females were significantly more likely to report pain dismissal and a physician as the dismisser. Males were more likely to report that the dismisser expressed hostility toward them, feeling ambivalent regarding the dismissal experience, and a desire to avoid the dismisser. Females were more likely to report a desire to plead for understanding with the dismisser. Results suggest that female adolescents are more likely to report a pain dismissal experience with physicians, raising concerns that adolescent females may receive, or at least perceive, differential treatment for their chronic pain.

The role of perceived family social support and parental solicitous responses in adjustment to bothersome pain in young people with physical disabilities

PURPOSE

Family social support and parental solicitous responses have been hypothesised to play an important role in paediatric pain. However, research testing the hypothesised associations between these social domains and measures of adjustment to pain in youths with disabilities and chronic pain is non-existent.

METHODS

About 111 youths with physical disabilities and bothersome pain were interviewed and asked to complete measures of average pain intensity, pain interference, family social support, parent solicitous responding, and catastrophising.

RESULTS

Children's perceptions of pain-related solicitous responses from their parent/guardian were associated both with more pain interference and greater pain-related catastrophising; perceived social support was negatively associated with pain interference.

CONCLUSIONS

The findings provide new information regarding the role that psychosocial factors have in predicting function and adjustment, and have important implications as to how youth with physical disabilities with pain might be most effectively treated. Implications for rehabilitation Little is known about the role of perceived family social support or parental solicitous responses in the adjustment to chronic pain in young people with physical disabilities. This study provides new and important findings that have significant theoretical and practical implications that could help to understand and manage function in these patients. Results show that it matters how parents respond to their children with disabilities who have pain, and raise the possibility that interventions which target these responses may result in significant benefits for the children.

Predictors of chronic neuropathic pain after scoliosis surgery in children

Background

Numerous publications describe chronic pain following surgery in both adults and children. However, data in the paediatric population are still sparse and both prevalence of chronic pain after surgery and risk factors of this complication still undetermined.

Methods

We prospectively evaluated the prevalence of chronic pain and its neuropathic pain component at 1 year following correction of idiopathic scoliosis in children less than 18 years of age. Pain was defined as the presence of pain (numerical rating scale – NRS ≥4), the presence of signs of neurologic damage within the area of surgery and the presence of the neuropathic symptoms as a DN4 (Douleur Neuropathique 4) questionnaire ≥4. Factors investigated as potentially associated with the presence of a persistent neuropathic pain were: age, weight, the presence of continuous preoperative pain over the 3 months before surgery, surgical characteristics, pain scores during the first five postoperative days, and DN4 at day 3. Statistical analysis employed univariate analysis and a multivariate logistic regression model.

Results

Thirty six patients were included in the study. Nineteen (52.8%) had pain at one year after surgery. Among them 17 (48.2%) had neuropathic pain. Logistic regression found continuous pain over the 3 months preceding surgery and day 1 morphine consumption ≥0.5 mg kg-1 as independent predictors of persistent chronic pain with a neuropathic component. The overall model accuracy was 80.6 and the area under the curve of the model was 0.89 (95% confidence interval 0.78–0.99).

Conclusions

The present study found a high proportion of paediatric patients developing chronic persistent pain after surgical correction of scoliosis diformity. It allows identifying two factors associated with the occurrence of persistent chronic pain with a neuropathic component: the presence of persistent preoperative pain during the 3 months preceeding surgery and postoperative opioid consumption at day 1 –;0.5 mg kg-1

Implication

Patients scheduled for spine surgery and presenting with preoperative pain should be considered at risk of chronic pain after surgery and managed accordingly by the chronic and/or acute pain team. Postoperative opioid consumption should be lowered as possible by using multimodal analgesia and regional analgesia such as postoperative epidural analgesia.

The Parent Psychological Flexibility Questionnaire (PPFQ): Item Reduction and Validation in a Clinical Sample of Swedish Parents of Children with Chronic Pain

In pediatric chronic pain, research indicates a positive relation between parental psychological flexibility (i.e., the parent’s willingness to experience distress related to the child’s pain in the service of valued behavior) and level of functioning in the child. This points to the utility of targeting parental psychological flexibility in pediatric chronic pain. The Parent Psychological Flexibility Questionnaire (PPFQ) is currently the only instrument developed for this purpose, and two previous studies have indicated its reliability and validity. The current study sought to validate the Swedish version of the 17-item PPFQ (PPFQ-17) in a sample of parents (n = 263) of children with chronic pain. Factor structure and internal reliability were evaluated by means of principal component analysis (PCA) and Cronbach’s alpha. Concurrent criterion validity was examined by hierarchical multiple regression analyses with parental anxiety and depression as outcomes. The PCA supported a three-factor solution with 10 items explaining 69.5% of the total variance. Cronbach’s alpha (0.86) indicated good internal consistency. The 10-item PPFQ (PPFQ-10) further explained a significant amount of variance in anxiety (29%), and depression (35.6%), confirming concurrent validity. In conclusion, results support the reliability and validity of the PPFQ-10, and suggest its usefulness in assessing psychological flexibility in parents of children with chronic pain.