Parental Catastrophizing Partially Mediates the Association between Parent-Reported Child Pain Behavior and Parental Protective Responses

Parental responses and catastrophizing in online cognitive behavioral therapy for pediatric functional abdominal pain: A mediation analysis of a randomized controlled trial

Objective

To test if decreased parental protective behaviors, monitoring behaviors, and parental catastrophizing mediate relief of gastrointestinal symptoms in children 8-12 years with functional abdominal pain disorders (FAPDs). The study uses secondary data analyses of a randomized controlled trial in which exposure-based online cognitive behavioral therapy (ICBT) was found superior to treatment as usual in decreasing gastrointestinal symptoms.

Methods

The ICBT included 10 weekly modules for children and 10 weekly modules for parents. Treatment as usual consisted of any medication, dietary adjustments, and healthcare visits that the participants engaged in during 10 weeks. All measures were self-assessed online by parents. Biweekly assessments of the Adult Responses to Children's Symptoms (ARCS), Protect and Monitor subscales, and the Pain Catastrophizing Scale, parental version (PCS-P) were included in univariate and multivariate growth models to test their mediating effect on the child's gastrointestinal symptoms assessed with the Pediatric Quality of Life Gastrointestinal Symptoms Scale (PedsQL).

Results

A total of 90 dyads of children with FAPDs and their parents were included in the study, of which 46 were randomized to ICBT and 44 to treatment as usual. The PCS-P was found to mediate change in the PedsQL ab = 0.639 (95% CI 0.020-2.331), while the ARCS Monitor ab = 0.472 (95% CI -1.002 to 2.547), and Protect ab = -0.151 (95% CI -1.455 to 0.674) were not mediators of change.

Conclusions

To target parental catastrophizing in ICBT for pediatric FAPDs is potentially important to reduce abdominal symptoms in children.

Exploring Parental Responses to Pre-schoolers' "Everyday" Pain Experiences Through Electronic Diary and Ecological Momentary Assessment Methodologies

Objective: Parental influence during children's "everyday" pain events is under-explored, compared to clinical or experimental pains. We trialed two digital reporting methods for parents to record the real-world context surrounding their child's everyday pain events within the family home. Methods: Parents (N = 21) completed a structured e-diary for 14 days, reporting on one pain event experienced by their child (aged 2.5-6 years) each day, and describing child pain responses, parental supervision, parental estimates of pain severity and intensity, and parental catastrophizing, distress, and behavioral responses. During the same 2-week period, a subsample of parent-child pairs (N = 9) completed digital ecological momentary assessments (EMA), immediately after any chosen pain event. Children reported their current pain while parents estimated the child's pain and indicated their own distress. Results: "Everyday" pain events frequently featured minor injuries to the child's head, hands or knees, and child responses included crying and non-verbal comments (e.g., "Ouch!"). Pain events occurred less frequently when parents had been supervising their child, and supervising parents reported lower levels of worry and anxiety than non-supervising parents. Child sex was significantly associated with parental estimates of pain intensity, with parents of girls giving higher estimates than parents of boys. Child age was significantly associated with both the number of pain events and with parental estimates of pain intensity and child distress: the youngest children (2-3 years) experienced the fewest pain events but received higher pain and distress estimates from parents than older children. Hierarchal Linear Modeling revealed that parental estimates of pain severity were significant positive predictors of parental distress and catastrophizing in response to a specific pain event. Furthermore, higher levels of parental catastrophic thinking in response to a specific pain event resulted in increased distress, solicitousness, and coping-promoting behaviors in parents. The EMA data revealed that children reported significantly higher pain intensity than their parents. Conclusion: The electronic pain diary provided a key insight into the nature of "everyday" pain experiences around the family home. Digital daily reporting of how the family copes with "everyday" events represents a viable means to explore a child's everyday pains without disrupting their home environment.

Perceived Injustice Is Associated With Pain-related Function and Mood in Youth With Acute Musculoskeletal Pain

OBJECTIVES

Perceived injustice (PI), which is one's appraisal of justice or fairness regarding the pain experience, is an emerging area of interest in pediatric pain research. No previous studies have investigated PI in youth with acute pain. To fill this gap, this study examined (1) associations among PI, pain-related function, and psychological function in treatment-seeking youth with acute musculoskeletal (MSK) pain, and (2) the impact of parent-child PI discordance on children's pain and psychosocial function.

MATERIALS AND METHODS

Participants were youth (aged 11 to 17, 55% male) with acute pain (onset <1 mo) recruited from emergency departments or outpatient clinics and participating parents (102 parent-child dyads). Dyads completed study questionnaires within 1 month of the child's pain onset.

RESULTS

Youth-reported PI was significantly correlated with poorer physical and psychosocial quality of life, higher pain catastrophizing, higher fear of pain, increased pain-related disability, and greater depression and anxiety. Furthermore, PI was significantly associated with the physical quality of life, psychosocial quality of life, and pain-related disability. Moreover, discordance in youth and parent ratings of PI was associated with children's psychological and pain-related function. Specifically, compared with Concordant dyads, youth in the Discordant dyads (youth high PI/parent low PI) reported significantly poorer physical quality of life, psychosocial quality of life, higher pain-related disability, depression, anxiety, and pain catastrophizing.

DISCUSSION

These findings reveal that PI in youth with acute MSK pain is associated with quality of life and pain-related disability. Furthermore, results highlight the importance of discordance between youth and parent reports of PI on pain-related functioning.

Passive Coping Associations With Self-Esteem and Health-Related Quality of Life in Youth With Inflammatory Bowel Disease

Pediatric patients with inflammatory bowel disease (IBD) may experience chronic stress related to disease symptoms and treatment, with negative consequences to their health-related quality of life (HRQOL). Lower HRQOL among pediatric patients with IBD has been associated with worse disease-related symptoms and psychological functioning, while higher HRQOL has been associated with more adaptive coping with disease symptoms and treatment. In addition, patients’ self-esteem may impact the selection and use of coping strategies through global cognitions about their abilities and perceived competence. The current study seeks to extend existing research on HRQOL in youth with IBD by examining cross-sectional associations among self-esteem and passive coping strategies. Youth ages 9–18 with IBD (n = 147) rated their HRQOL using a disease-specific measure, typical strategies used to cope with pain or GI symptoms, and their general self-esteem. Mediation analyses were performed using regression-based techniques and bootstrapping. Results indicated that greater self-esteem was positively associated with HRQOL but negatively associated with passive coping. Controlling for disease activity, age, and gender, significant indirect effects were found in the relation between self-esteem and HRQOL through passive coping. Multiple mediation analyses using the three passive coping subscales found that self-esteem was indirectly associated with HRQOL through its effects specifically on catastrophizing as a passive coping strategy. Results suggest that pediatric patients’ general self-esteem can impact their HRQOL through passive coping and specifically, maladaptive cognitions (e.g., catastrophizing). Interventions aimed at addressing both self-esteem and catastrophizing as a passive coping strategy may offer promise for improving HRQOL in youth with IBD.

Parent and Family Functioning in Pediatric Inflammatory Bowel Disease

Although the impact of pediatric inflammatory bowel disease (IBD) extends beyond the patient to their parents and families, the focus of previous literature has largely been on investigating the patient’s medical and psychosocial functioning, with less consideration of the family system. Having a comprehensive understanding of parent and family functioning within the context of pediatric IBD is important given the role parents and family members have in the successful management of the disease and caring of the child. The current review paper aggregates the empirical research regarding parent and family functioning, including comparisons to normative samples, other illness groups, and how functioning relates to child psychosocial and health outcomes. Extant literature on parents and families in pediatric IBD has largely focused on the variables of parenting stress, parent psychosocial functioning, parent quality of life, and family functioning. Summary findings elucidate the complex relationships between parents, families, and children affected by IBD and highlight the importance of assessing parent and family functioning within pediatric IBD. The current review also offers implications for clinical practice, notes the limitations of the present literature, and provides recommendations for future research.

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.

Biopsychosocial Correlates of Presence and Intensity of Pain in Adolescents With Inflammatory Bowel Disease

Background: There is growing consensus that pain in pediatric inflammatory bowel disease (IBD) is not fully explained by disease-related processes. However, previous studies have largely measured individual biological, psychological, or social risk factors for pain in isolation. Further, not all youth with IBD presenting to clinic will report presence of pain, and those who do vary in their reports of pain intensity. This study therefore extends prior research by determining biopsychosocial correlates of both presence and intensity of pain in adolescents with IBD, in order to inform targeted pain management intervention approaches. Methods: Adolescents with IBD followed at SickKids, Toronto, and their parents were consecutively enrolled from outpatient clinic. IBD characteristics (diagnosis, time since diagnosis, patient-reported disease activity) were collected. Adolescents reported on current pain (NRS-10), internalizing symptoms (Strengths and Difficulties Questionnaire), and pain catastrophizing (Pain Catastrophizing Scale-Child). Parents reported on protective responses to child pain (Adult Responses to Child Pain) and pain catastrophizing (Pain Catastrophizing Scale-Child). Hurdle models were conducted to examine predictors of presence and intensity of pain in the same model. Biological (patient-reported disease activity, IBD diagnosis subtype, illness duration), psychological (internalizing symptoms, pain catastrophizing), and social (parent pain catastrophizing, parent protective responses) factors were entered as predictors, adjusting for age and sex. Results: Participants included 100 adolescents (12-18; Mean = 15 years) with IBD (60% Crohn's Disease, 40% Ulcerative Colitis or IBD-unclassified) and 76 parents. The majority of the sample was in clinical remission or reported minimal symptoms. Half of participants reported no current pain; for those reporting pain, intensity ranged 1-7 (M = 3.43, SD = 1.98). Disease activity (OR = 53.91, p < 0.001) and adolescent internalizing symptoms (OR = 7.62, p = 0.03) were significant predictors of presence of pain. Disease activity (RR = 1.37, p = 0.03) and parent protective responses (RR = 1.45, p = 0.02) were significant predictors of intensity of pain. Conclusions: Results suggest that the experience of pain in pediatric IBD is biopsychosocially determined. Patient-reported disease activity and internalizing symptoms predicted presence of pain, while disease activity and parent protective responses predicted intensity of pain. While medical intervention in pediatric IBD is focused on disease management, results suggest that depression/anxiety symptoms as well as parent protective responses may be important targets of pain management interventions in pediatric IBD.

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.

TRANSLATION, CROSS-CULTURAL ADAPTATION AND PRELIMINARY EVALUATION OF THE BRAZILIAN VERSIONOF THE PAIN CATASTROPHIZING SCALE-PARENTS

OBJECTIVE

In Brazil, there is no scale to assess parental catastrophizing about their child's pain. This study aimed to translate and cross-culturally adapt the Pain Catastrophizing Scale-Parents to the Brazilian Portuguese language, as well as to preliminarily evaluate its psychometric properties among parents/guardians of children with and without a toothache.

METHODS

A cross-sectional study was conducted with 237 parents/other relatives of 237 children. Across-cultural adaptation of the scale into Brazilian Portuguese was carried out according to the universalistic approach. To assess the reliability and validity of the scale, parents/other relatives reported on the child's toothache and filled out the Brazilian versions of the Pain Catastrophizing Scale-Parents and the Dental Discomfort Questionnaire.

RESULTS

There was semantic equivalence with the original version after minor modifications. TheCronbach's alpha for the 13 items of the scale was 0.83, and the respective test-retest intraclass correlation coefficients ranged from 0.63 to 0.97. The scores obtained from the Pain Catastrophizing Scale-Parents and the Dental Discomfort Questionnaire had a low correlation (rho=0.25; p<0.001). Thetotal score of the Pain Catastrophizing Scale-Parents differed significantly (p<0.001) in children with a toothache at night (median: 3.0, 25-75 percentile: 25.0-35.5) compared to those who did not have a toothache at night (25.5; 20.0-31.0).

CONCLUSIONS

The Brazilian version of the Pain Catastrophizing Scale-Parents was acceptable in this preliminary evaluation and can be used in Brazilian clinical and research practice.

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.

Maladaptive Coping and Depressive Symptoms Partially Explain the Association Between Family Stress and Pain-Related Distress in Youth With IBD

Objective

To extend existing research on the pain burden experienced by youth with inflammatory bowel disease (IBD) by examining the complexity of psychosocial factors involved in pain-related distress.

Methods

Parents completed measures of family stress and their child's pain-related expressions of distress and coping. Youth with IBD rated their depressive symptoms (n = 183 dyads). Mediation analyses were performed using regression-based techniques and bootstrapping.

Results

Greater family stress was positively related to children's pain-related expressions of distress and passive coping. Significant indirect effects were found in the relationship between family stress and expressed pain-related distress through parent-reported passive coping, depressive symptoms, and both passive coping and depressive symptoms sequentially.

Conclusions

Results suggest that family stress can place children at risk for greater expressed pain-related distress through effects on coping and depressive symptoms. Addressing psychosocial difficulties is important for closing the gap between disability and health in youth with IBD.

Psychological Factors May Play an Important Role in Pediatric Crohn's Disease Symptoms and Disability

OBJECTIVE

To examine the relative contributions of disease activity and psychological factors to self-reported symptoms and disability in children with Crohn's disease.

STUDY DESIGN

Participants (n = 127 children age 8-18 years) completed questionnaires on symptom severity and disability, as well as psychological measures assessing anxiety, depression, pain beliefs and coping. Disease activity was measured by the Pediatric Crohn's Disease Activity Index. Structural equation modeling was used to test the effects of disease activity and psychological factors on symptoms and disability.

RESULTS

In the hypothesized model predicting symptoms, psychological factors (β = 0.58; P < .001) were significantly associated with disease symptoms but disease activity was not. The model for disability yielded significant associations for both psychological factors (β = 0.75; P < .001) and disease activity (β = 0.61, P < .05).

CONCLUSION

Crohn's disease symptoms in children and adolescents are not only driven by disease activity. Coping, anxiety, depression, and cognition of illness are important in the patient-reporting of symptom severity and disability. Physicians need to be aware that symptom self-reporting can be driven by psychological factors and may not always be simply an indicator of disease activity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00679003.

Maternal Anxiety and Children's Laboratory Pain: The Mediating Role of Solicitousness

There has been limited empirical examination of how parent variables such as anxiety and solicitousness collectively impact child pain response. We sought to examine the relationships among maternal anxiety, solicitous parenting, and children’s laboratory anxiety and pain intensity in children with chronic pain. Participants included 80 children and adolescents (ages 8–18) with chronic pain and their mothers. Children completed questionnaires and lab pain tasks measuring their parents’ solicitous parenting, pressure, cold and heat pain anticipatory anxiety and pain intensity. Using bootstrapping analysis, maternal anxiety predicted child anticipatory anxiety and pain intensity in girls with chronic pain, which was mediated by the child’s report of parental solicitousness. For boys with chronic pain, maternal anxiety predicted boys’ anticipatory anxiety and pain intensity, with no support for mediation. This study adds to the growing literature demonstrating the impact of maternal anxiety on children’s pain. The study highlights the importance of considering parents in treatment designed to reduce children’s pain.

The Sensitivity to Change and Responsiveness of the Adult Responses to Children's Symptoms in Children and Adolescents With Chronic Pain

OBJECTIVE

To examine the sensitivity to change and responsiveness of the Adult Responses to Children's Symptoms (ARCS) among parents of youth with chronic pain. 

METHODS

Participants included 330 youth (89 children aged 7-11 years, 241 children aged 12-17 years) and their parents who participated in randomized controlled trials of family-based cognitive-behavioral therapy for chronic pain. Child pain and disability, parental emotional functioning, and parental responses to child pain were assessed at baseline and posttreatment. 

RESULTS

The Protect and Monitor scales of the ARCS were sensitive to change following intervention for both developmental groups, with clinically meaningful reductions in these behaviors, thereby demonstrating responsiveness. Among the adolescent sample, greater change on some ARCS scales was associated with better parental emotional functioning and lower child pain at posttreatment. 

CONCLUSIONS

Findings support the sensitivity to change and responsiveness of the Protect and Monitor scales among parents of youth with chronic pain.

Role of Coping With Symptoms in Depression and Disability: Comparison Between Inflammatory Bowel Disease and Abdominal Pain

BACKGROUND

Inflammatory bowel disease (IBD) and abdominal pain of functional origin (AP) are common gastrointestinal disorders in children, which are associated with increased risk for depression and disability. Both symptom severity and coping with symptoms may contribute to these outcomes. We hypothesized that children with AP use different coping strategies compared with those with IBD for a number of reasons, including the fact that fewer treatment options are available to them. We also examined whether coping was related to depression and functional disability beyond the contributions of symptom severity.

METHODS

The study method included secondary data analysis of 2 existing data sets including 200 children with AP (73% girls, mean age 11.2 years) and 189 children with IBD (49% girls, mean age 13.8 years).

RESULTS

Compared with patients with IBD, patients with AP reported more use of coping strategies of self-isolation, behavioral disengagement, and catastrophizing, as well as problem solving and seeking social support. Multivariate analyses revealed that, in both samples, ≥1 coping strategies were associated with depression and functional disability, independent of symptom severity, and controlling for age and sex. In IBD, symptoms were not a significant predictor of depression but coping was. Catastrophizing predicted depression and disability in both samples.

CONCLUSIONS

Patients with AP report more frequent use of several of the coping strategies we measured compared with patients with IBD. Certain types of coping, particularly catastrophizing, were associated with greater depression and functional disability in both groups. Clinicians should be aware of maladaptive coping, which may be a risk factor for poor psychosocial and functional outcomes in both patient groups.

A developmental analysis of the factorial validity of the parent-report version of the Adult Responses to Children's Symptoms in children versus adolescents with chronic pain or pain-related chronic illness

The widely used Adult Responses to Children's Symptoms measures parental responses to child symptom complaints among youth aged 7 to 18 years with recurrent/chronic pain. Given developmental differences between children and adolescents and the impact of developmental stage on parenting, the factorial validity of the parent-report version of the Adult Responses to Children's Symptoms with a pain-specific stem was examined separately in 743 parents of 281 children (7-11 years) and 462 adolescents (12-18 years) with chronic pain or pain-related chronic illness. Factor structures of the Adult Responses to Children's Symptoms beyond the original 3-factor model were also examined. Exploratory factor analysis with oblique rotation was conducted on a randomly chosen half of the sample of children and adolescents as well as the 2 groups combined to assess underlying factor structure. Confirmatory factor analysis was conducted on the other randomly chosen half of the sample to cross-validate factor structure revealed by exploratory factor analyses and compare it to other model variants. Poor loading and high cross-loading items were removed. A 4-factor model (Protect, Minimize, Monitor, and Distract) for children and the combined (child and adolescent) sample and a 5-factor model (Protect, Minimize, Monitor, Distract, and Solicitousness) for adolescents was superior to the 3-factor model proposed in previous literature. Future research should examine the validity of derived subscales and developmental differences in their relationships with parent and child functioning.

PERSPECTIVE

This article examined developmental differences in the structure of a widely used measure of caregiver responses to chronic pain or pain-related chronic illness in youth. Results suggest that revised structures that differ across developmental groups can be used with youth with a range of clinical pain-related conditions.

Child pain catastrophizing mediates the relation between parent responses to pain and disability in youth with functional abdominal pain

OBJECTIVES

Functional abdominal pain (FAP) in youth is associated with substantial impairment in functioning, and prior research has shown that overprotective parent responses can heighten impairment. Little is known about how a range of parental behaviors (overprotection, minimizing, and/or encouragement) in response to their child's pain interact with child coping characteristics (eg, catastrophizing) to influence functioning in youth with FAP. In this study, it was hypothesized that the relation between parenting factors and child disability would be mediated by children's levels of maladaptive coping (ie, pain catastrophizing).

METHODS

Seventy-five patients with FAP presenting to a pediatric pain clinic and their caregivers participated in the study. Youth completed measures of pain intensity (Numeric Rating Scale), pain catastrophizing (Pain Catastrophizing Scale), and disability (Functional Disability Inventory). Caregivers completed measures of parent pain catastrophizing (Pain Catastrophizing Scale), and parent responses to child pain behaviors (Adult Responses to Child Symptoms: Protection, Minimizing, and Encouragement/Monitoring subscales).

RESULTS

Increased functional disability was significantly related to higher child pain intensity, increased child and parent pain catastrophizing, and higher levels of encouragement/monitoring and protection. Parent minimization was not related to disability. Child pain catastrophizing fully mediated the relation between parent encouragement/monitoring and disability and partially mediated the relation between parent protectiveness and disability.

CONCLUSIONS

The impact of parenting behaviors in response to FAP on child disability is determined, in part, by the child's coping style. Findings highlight a more nuanced understanding of the parent-child interaction in determining pain-related disability levels, which should be taken into consideration in assessing and treating youth with FAP.