Evidence-based assessment of health-related quality of life and functional impairment in pediatric psychology

Voice-related quality of life in the pediatric population: validation of the Brazilian version of the Pediatric Voice-Related Quality-of Life survey

Purpose: To measure the voice-related quality of life in children/adolescents with vocal complaints through the validation of the Brazilian Pediatric Voice-Related Quality-of-Life survey - VR-QOL-P (Qualidade de Vida em Voz Pediátrico - QVV-P), to verify whether the presence of vocal complaints interfere with the quality of life of children/adolescents, and to determine the relationship between the vocal assessment carried out by parents and the VR-QOL-P scores. Methods: The participants included 246 parents of children/adolescents of both sexes, aged between 2 years and 18 years (divided into preschoolers, schoolers and adolescents), with and without vocal complaints. All participants signed the informed consent form. Translation, linguistic and cultural adaptation, assessment of cultural equivalence, implementation of the protocol in its final version, voice assessment by parents, demographic and clinical descriptive statistical analysis of the population, individual analysis of the items, verification of psychometric measures of validation, reliability, reproducibility and responsiveness of the instrument to treatment, were carried out. Results: Low scores, especially in the physical domain, were found in subjects with vocal complaints. Among those, adolescents suffered the greatest impact. The social-emotional domain was not sensitive in preschoolers. There was a correlation among the overall, social-emotional and physical scores, and the vocal assessment performed by parents. The VR-QOL-P was reliable, reproducible and responsive to voice problems. Conclusion: Voice change interferes with the quality of life of children/adolescents, and there is a relationship between the assessment of voice quality and VR-QOL-P scores - the older the individual, the worse the quality of life in aspects related to voice, especially in the physical domain, and the better the vocal quality, as perceived by the parents.

The role of social support for promoting quality of life among persistently obese adolescents: importance of support in schools

BACKGROUND

Despite school-based and other interventions for pediatric obesity, many obese youth of the present generation will persist in their obesity into adolescence and adulthood. Thus, understanding not only how better to tailor weight interventions but how to promote overall adjustment for persistently obese youth is of utmost importance. This study examined the role of perceived social support in predicting later psychosocial status (ie, weight-related quality of life) for persistently obese adolescents.

METHODS

This study used a longitudinal design whereby persistently obese and nonoverweight comparison youth completed measures at 2 time points approximately 4 years apart.

RESULTS

Obese youth reported lower levels of social support than comparison youth. Among obese youth, classmate and teacher support predicted future weight-related quality of life.

CONCLUSIONS

Social support, particularly from classmates, is an important predictor for the longitudinal psychosocial functioning of persistently obese youth. High levels of perceived teacher support may signal the presence of other psychosocial difficulties. Implications for school-based interventions are discussed.

Measurement of mealtime behaviors in rural overweight children: an exploratory factor analysis of the Behavioral Pediatrics Feeding Assessment Scale

OBJECTIVE

The current study presents results of an exploratory factor analysis (EFA) of the Behavioral Pediatric Feeding Assessment Scale (BPFAS) in a sample of rural children with overweight and obesity. Relationships between mealtime behavior and health outcomes are also explored.

METHODS

EFA was used to assess the fit of the BPFAS in a group of 160 treatment-seeking children (Mage = 9.11, SD = 1.77) living in rural Midwest communities. Correlations were also computed between factor scores and select health variables (child body mass index z-score and diet variables).

RESULTS

The EFA identified a 5-factor solution as the best fitting model (Tucker-Lewis Index = .96, root mean square error of approximation = .05), although several items (i.e., 7 of 25) did not load on any factor. 2 factors were correlated with health variables of interest.

CONCLUSION

Study results suggest that certain items on the BPFAS may not be appropriate for use with rural children with pediatric overweight or obesity. Implications for future research and practice are discussed.

Validation and clinical application of a biopsychosocial model of pain intensity and functional disability in patients with a pediatric chronic pain condition referred to a subspecialty clinic

Background. Pediatric chronic pain is considered to be a multidimensional construct that includes biological, psychological, and social components. Methods. The 99 enrolled study patients (mean age 13.2 years, 71% female, 81% Caucasian) and an accompanying parent completed a series of health-related questionnaires at the time of their initial appointment in a pediatric chronic pain medicine clinic. Results. Significant correlations (r ≥ 0.30, P < 0.05) were observed between pediatric chronic pain intensity and patient anxiety, patient depression, patient pain coping, parent chronic pain intensity, and parent functional disability. Pediatric chronic pain intensity was significantly associated with patient anxiety (P = 0.002). Significant correlations (r ≥ 0.30, P < 0.05) were observed between pediatric functional disability and patient chronic pain intensity, patient anxiety, patient depression, patient pain coping, parent chronic pain intensity, parent functional disability, parent anxiety, parent depression, and parent stress. Pediatric functional disability was significantly associated with patient chronic pain intensity (P = 0.025), patient anxiety (P = 0.021), patient pain coping (P = 0.009), and parent functional disability (P = 0.027). Conclusions. These findings provide empirical support of a multidimensional Biobehavioral Model of Pediatric Pain. However, the practical clinical application of the present findings and much of the similar previously published data may be tenuous.

Patient versus parental perceptions about pain and disability in children and adolescents with a variety of chronic pain conditions

BACKGROUND

Cross-informant variance is often observed in patient self-reports versus parent proxy reports of pediatric chronic pain and disability.

OBJECTIVE

To assess the relationship and merit of the child versus parent perspective.

METHODS

A total of 99 patients (eight to 17 years of age [mean 13.2&nbsp;years]; 71% female, 81% Caucasian) and parents completed the Pediatric Pain Questionnaire and Functional Disability Inventory at their initial clinic visit. Patients' and parents' pain intensity and disability scores were analyzed using an intraclass correlation coefficient (ICC), Wilcoxon signed-rank test, Bland-Altman plot and Spearman's correlation coefficient. The association between clinical⁄demographic variables and differences in patient⁄parent pain intensity and disability scores was assessed using multivariable regression.

RESULTS

There was significant agreement between patients' self-reports and parents' proxy reports of their child's pain intensity (ICC=0.52; P<0.001) and disability (ICC=0.57; P=0.004) at the individual level. There were no significant group differences in patient versus parent-proxy pain intensity scores (P=0.40) and disability scores (P=0.54). The difference between patient and parent-proxy pain intensity was associated with patients' self-reported pain intensity (P<0.001). The difference between patient and parent-proxy disability was associated with patient's self-reported pain disability (P<0.001). Bland-Altman plots revealed major inter-rater variation in the Pediatric Pain Questionnaire and Functional Disability Inventory across their score ranges. A significant relationship (r=0.38; P<0.001) was observed between patients' self-reported pain intensity and disability.

CONCLUSIONS

While equal merit should ideally be given to pediatric chronic pain patients' self-reports and their parents' proxy reports of pain intensity and disability, it would appear that, as needed, pediatric patients or parents can offer a clinically valid, single clinical perspective.

Health-related quality of life and symptom reporting: similarities and differences between children and their parents

Health-related quality of life (HRQOL) is increasingly seen as important to reflect the impact of an illness and its treatment on a patient from the patient's perspective. However, there may be times when it is difficult to obtain this information directly from pediatric patients, and parents are therefore used as substitutes. Nevertheless, an informant discrepancy between children and their parents increase the need to identify variables which contribute to the observed differences between children's self-reports and parents' proxy-reports. Discrepancies between child and parent reports have often been regarded as "methodological error" and have led to misconceived arguments about who is "right." The aims of this review are to provide an overview and update to help understand the relation between children's self-report of their symptoms and HRQOL and parents' proxy-reports, the circumstances in which informant discrepancies might be expected, and potential reasons for these discrepancies. Discrepancies can be summarized in relation to characteristics of the child, the adult and the HRQOL domain being measured. We conclude that informant discrepancy is not simply an irritating measurement error, but also has its clinical implications. We argue that parents and children base their judgments of pediatric HRQOL on different information and as such, comprehensive evaluation needs to take account of both perspectives. This perspective has implications for the design of clinical trials and necessitates routine collection of data from both sources in clinical research and practice.

Health-related quality of life in children with abdominal pain due to functional or organic gastrointestinal disorders

OBJECTIVE

Comparing health-related quality of life (HRQOL) in children suffering from functional and organic gastrointestinal disorders and to identify predictors for HRQOL.

METHODS

Children with functional (n = 70) and organic (n = 100) gastrointestinal disorders, aged 8-18 years and referred to a pediatric gastroenterologist, completed questionnaires assessing pain severity, coping, and HRQOL.

RESULTS

The sample reported low HRQOL scores, even significantly lower compared with reference values of chronically ill children, derived from normative data of KINDL-R, a generic QOL questionnaire. HRQOL was not significantly associated with age, gender, duration of pain, and diagnosis (functional gastrointestinal disorder vs. organic gastrointestinal disorder). Pain severity and catastrophizing were significantly associated with HRQOL, with catastrophizing fully mediating the relationship between pain and HRQOL.

CONCLUSION

The emotional burden associated with chronic abdominal pain-regardless of its cause-is enormous. Interventions should target the children's coping strategies, as catastrophizing seems to be the causal link between pain and HRQOL.

Health-related quality of life and perceived need for mental health services in adolescent solid organ transplant recipients

The purpose of the current investigation was to assess interest in mental health services among parents of adolescent solid organ transplant recipients and the relationship between parent perceived need for mental health services and patient health-related quality of life (HRQOL). Sixty-three parents rated interest in receiving 10 mental health services, and patient HRQOL ratings were gathered from adolescent transplant recipients and their parents. Ninety-four percent of parents expressed some level of interest in at least one of the proposed services, with over 40 % indicating maximum interest. Parents' perceived need for mental health services was inversely related to adolescent and parent reports of HRQOL on the behavior, mental health, family cohesion, and parental impact-emotional domains. Results suggest that parents of adolescent solid organ transplant recipients are interested in receiving mental health services for their families. Assessment of need for mental health services and HRQOL may inform the medical team of families requiring intervention.

Utilization of patient-reported outcomes as a step towards collaborative medicine

Patient-reported outcomes (PROs) have been successfully developed for a variety of chronic respiratory diseases, such as asthma and cystic fibrosis (CF). They have recently been used to evaluate the efficacy of new medications and assess current patient functioning. Although regulatory bodies have favored PROs that measures symptoms, other domains of functioning, such as treatment burden, should be considered. This review examines current guidelines for the development and application of PROs in clinical trials, describes methods for selecting appropriate measures for paediatric populations, and presents a model incorporating PROs into clinical practice. Guidance on interpretation of these measures and graphic presentation of results are illustrated. PROs can serve as the link between the health care provider and patient to foster collaborative and personalized medicine. This model promotes greater patient responsibility, facilitates communication with providers, encourages shared decision-making, and enhances adherence.

Parental perception of functional status following tracheostomy in infancy: a single center study

OBJECTIVE

To examine the functional outcomes of children who underwent a tracheostomy in the initial hospitalization after birth and to determine their correlates.

STUDY DESIGN

We administered the validated 43-item Functional Status-II (FS-II) questionnaire by Stein and Jessop over the telephone to caregivers of surviving children. The FS-II items generated a total score, age-specific: (1) total; (2) general health (GH); and (3) responsiveness, activity, or interpersonal functioning (IPF) scores in specific age group categories.

RESULTS

FS-II was administered to 51/62 (82.2%) survivors at a median (range) age of 5 (1-10) years; 27% children were on the ventilator and 43% required devices. About 40% of children had a median of 1 (1-4) hospitalization in the previous 6 months. Scores were >2 SD below means in 55%, 24%, and 55% cases for age-specific T, GH, and R/A/IPF scores respectively. The T and R/A/IPF scales were significantly higher in those with private, rather than public, maternal insurance, as were T and R/A/IPF scores for children ≥ 4 years, compared with younger children. On regression analysis, FS-II T, GH, and R/A/IPF scores were independently associated with maternal private insurance (P = .02). R/A/IPF scores were also significantly associated with corrected age at FS-II administration.

CONCLUSIONS

One-third of surviving children who underwent tracheostomy during their initial hospitalization remained technology-dependent. The parental FS-II questionnaires revealed low R/A/IPF scores, especially at younger ages and in those with maternal public insurance. Further research on family-level interventions to improve functional outcomes in this population is warranted.

Health related quality of life of obese adolescents in Kuwait

Background

Obesity impairs health related quality of life (HRQL) in adolescents, but most evidence in this area has mostly come from western societies. We wanted to test the hypothesis that obesity impairs HRQL in Kuwaiti adolescents, and to test for differences in HRQL assessed by self-report and parent-proxy report.

Methods

In 500 Kuwaiti 10–14 year olds HRQL was assessed using the Peds QL^TM with both adolescent self-reports (n = 500) and parent-proxy reports (n = 374).

Results

Obesity was not significantly associated with HRQL in regression analysis. In a paired comparison of 98 pairs of obese adolescents vs. 98 healthy weight peers, impairment of HRQL reached significance only for physical score (95% CI = −1.5, -9.4), not for psychosocial score or total score. In a paired comparison of parent-proxy vs. self-reports for the obese adolescents, total score (95% CI = −4.9, -10.9), physical score (95% CI = −3.2, -11.0), and psychosocial score (95% CI = −4.2, -10.8) were all significantly lower in the parent reports.

Conclusions

Obesity is not associated with marked impairment of HRQL in adolescents in Kuwait, in contrast to studies in western societies. This may reflect cultural differences in attitudes towards obesity.

Parenting and restrictions in childhood epilepsy

PURPOSE

From the overprotection literature, the predictive and interactional (moderation) effects of controlling and indulgent parenting on restrictions in children with epilepsy were examined.

METHODS

Parents of 73 children with epilepsy completed questionnaires on parenting, restrictions, and functional status. Predictive and moderation effects were tested using multiple regression analysis. Moderation was tested with interactive computational methods.

RESULTS

Restrictions were significantly (R(2)=.38, FΔ=6.59***, p<.001) predicted from seizure frequency (β=.24*, p<.05), functional status (β=-.42***, p<.001), and interaction between controlling and indulgent parenting (β=.28**, p<.01). Moderation occurred predominantly for high values of control: controlling parents who were not indulgent imposed fewer restrictions. In contrast, controlling parents who were indulgent imposed more restrictions.

CONCLUSION

Parents who were controlling and more indulgent imposed more restrictions. Clinicians should ask parents about parenting and restrictions. Future research should examine whether the current study's findings can be replicated.

Agreement in quality of life assessment between adolescents with intellectual disability and their parents

Intellectual disability affects different aspects of functioning and quality of life, as well as the ability to independently assess the quality of life itself. The paper examines the agreement in the quality of life assessments made by adolescents with intellectual disability and their parents compared with assessments made by adolescents without intellectual disability and their parents. Participants included 67 adolescents with intellectual disability and the same number of their parents. Control group consisted of 122 typically developed adolescents and an equal number of their parents. In order to assess the quality of life we used The PedsQL 4.0 Generic Core Scale questionnaire, for adolescents aged between 13 and 18 and their parents. Agreement in assessing quality of life between adolescents and parents was analyzed using t-test, Kappa Statistics and Pearson correlation. The agreement between adolescents with intellectual disability and their parents was found to be acceptable (k=0.43), while the agreement between adolescent from control group and their parents was judged to be good (k=0.84). Correlations between adolescents with intellectual disability and their parents varied across subscales from weak (r=0.31) on the physical health subscale to moderate (r=0.56) on the social subscale. Adolescents with intellectual disability were less satisfied with their social functioning. The highest agreement, as well as the lowest means value was found on the social agreement scale. Assessment of the quality of life by both adolescents and their parents provides a comprehensive insight into functioning and different aspects of quality of life in these adolescents.

The effectiveness of self-care support interventions for children and young people with long-term conditions: a systematic review

Children's health policy has highlighted the need to develop self-care programmes. However, there is a lack of evidence on which to base the development of such programmes. This paper reviews the published research on the effectiveness of self-care support interventions for children and young people with asthma, cystic fibrosis and diabetes. A systematic search was conducted of a range of electronic databases, supplemented by searching the reference lists of retrieved papers and published reviews. Retrieved studies were assessed against quality and eligibility criteria by two independent reviewers. The results were narratively synthesized to examine the effectiveness of self-care support interventions on health status, psycho-social well-being, condition-related knowledge, health service use and participant satisfaction. The search strategy identified 4261 papers which were screened against the review inclusion criteria. A total of 194 papers were assessed as being potentially eligible for inclusion with 15 papers being judged as adequate to include in the review. There is strong evidence of the effectiveness of interventions that target children/young people; use e-health or group-based methods; that are delivered in community settings. There is no evidence that interventions that focus on parents alone or are delivered only in hospital settings are effective. While there is some evidence to inform the development of self-care support programmes, there is a need for well-designed trials of interventions that are feasible to transfer into real-life settings and which involve parents and children in their development.

Daily changes in pain, mood and physical function in children hospitalized for sickle cell disease pain

BACKGROUND

Youth with sickle cell disease (SCD) are commonly hospitalized for treatment of painful vaso-occlusive episodes (VOE). However, limited data are available concerning the course of hospitalization for these children and adolescents and, in particular, whether daily changes occur in pain, emotional status and physical function.

OBJECTIVES

To characterize changes in daily pain intensity, physical function and mood over the course of hospitalization, and to determine whether specific clinical characteristics were associated with these changes.

METHODS

Daily ratings of pain (0 to 10 numerical rating scale) and mood (Positive and Negative Affect Scale for Children) were completed by 25 youth (11 to 20 years of age) with SCD over a total of 152 days (mean [± SD] = 6.7±5.6 days) of hospitalization. Trained raters determined each youth's daily physical function.

RESULTS

Linear mixed modelling was used to examine changes in pain, mood and physical function during hospital stay. The rate of change over the course of hospitalization was significant for reductions in pain intensity (P<0.001) and improvements in physical (motor) function (P=0.001). Positive affect over time was significantly associated with subjects' physical function scores (B 0.24 [95% CI 0.12 to 0.35]) but not with their pain scores. In contrast, negative affect was positively associated with pain and inversely associated with physical function scores (B 1.58 [95% CI 0.23 to 2.93]).

CONCLUSIONS

The results of the present study demonstrated that children made daily improvements in physical function and pain over hospitalization for VOE. Mood was related to changes in pain and physical recovery. Assessment of physical function and mood during hospitalization may help guide strategies to better understand the pain experience in youth with SCD hospitalized with VOE.

Psychosocial issues in pediatric inflammatory bowel disease: report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Pediatric inflammatory bowel disease (IBD) can affect many areas of psychosocial functioning, and comprehensive medical care includes consideration of psychosocial issues as well as disease factors. The purpose of this clinical report is to review research on psychosocial functioning in pediatric IBD and to provide recommendations for care providers in the areas of psychopathology, health-related quality of life, and social, family, and school functioning. Youth with IBD are at increased risk for difficulty in all areas reviewed, and many psychosocial factors are associated with disease activity, which highlights the importance of monitoring psychosocial functioning as part of clinical care. Several interventions have empirical support or show promise for addressing psychosocial difficulty, and recommendations for monitoring and treating these issues are provided.

Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury

OBJECTIVE To examine reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury (TBI) over the first year postinjury as compared with children with orthopedic injuries. DESIGN Prospective, longitudinal cohort. SETTING Emergency departments at 2 children's hospitals. PARTICIPANTS Eight- to 15-year-old children with mild TBI (n = 186) or orthopedic injuries (n = 99). MAIN EXPOSURE Closed-head or orthopedic trauma. MAIN OUTCOME MEASURES Parents rated preinjury symptoms retrospectively shortly after injury and postconcussive symptoms at 2 weeks and 3 and 12 months postinjury. A regression-based approach was used to determine whether each child displayed reliable increases in postconcussive symptoms at each postinjury occasion. Health-related quality of life was assessed at 3 and 12 months postinjury. Information regarding children's educational programming was collected at the initial and 12-month assessments. RESULTS Children with mild TBI were significantly more likely than those with orthopedic injuries to show reliable increases in both cognitive and somatic symptoms. Group differences in the likelihood of reliable increases became less common with time for somatic symptoms but persisted to 12 months postinjury for cognitive symptoms. Among children with mild TBI, reliable increases in symptoms were more common among children with loss of consciousness or abnormalities on neuroimaging. Reliable increases in symptoms were associated with significant declines in health-related quality of life and an increased likelihood of educational intervention. CONCLUSION Many children with mild TBI show reliable increases in postconcussive symptoms that are associated with significant functional impairment in their daily lives.

Psychological therapies for the management of chronic and recurrent pain in children and adolescents

BACKGROUND

Chronic pain affects many children, who report severe pain, distressed mood, and disability. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update adds recently published randomised controlled trials (RCTs) to the review published in 2009.

OBJECTIVES

To assess the effectiveness of psychological therapies, principally cognitive behavioural therapy and behavioural therapy, for reducing pain, disability, and improving mood in children and adolescents with recurrent, episodic, or persistent pain. We also assessed the risk of bias and methodological quality of the included studies.

SEARCH METHODS

Searches were undertaken of MEDLINE, EMBASE, and PsycLIT. We searched for RCTs in references of all identified studies, meta-analyses and reviews. Date of most recent search: March 2012.

SELECTION CRITERIA

RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment were eligible for inclusion (waiting list or standard medical care) for children or adolescents with episodic, recurrent or persistent pain.

DATA COLLECTION AND ANALYSIS

All included studies were analysed and the quality of the studies recorded. All treatments were combined into one class: psychological treatments; headache and non-headache outcomes were separately analysed on three outcomes: pain, disability, and mood. Data were extracted at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (at least three months after the post-treatment assessment point, but not more than 12 months).

MAIN RESULTS

Eight studies were added in this update of the review, giving a total of 37 studies. The total number of participants completing treatments was 1938. Twenty-one studies addressed treatments for headache (including migraine); seven for abdominal pain; four included mixed pain conditions including headache pain, two for fibromyalgia, two for pain associated with sickle cell disease, and one for juvenile idiopathic arthritis. Analyses revealed five significant effects. Pain was found to improve for headache and non-headache groups at post-treatment, and for the headache group at follow-up. Mood significantly improved for the headache group at follow-up, although, this should be interpreted with caution as there were only two small studies entered into the analysis. Finally, disability significantly improved in the non-headache group at post-treatment. There were no other significant effects.

AUTHORS' CONCLUSIONS

Psychological treatments are effective in reducing pain intensity for children and adolescents (<18 years) with headache and benefits from therapy appear to be maintained. Psychological treatments also improve pain and disability for children with non-headache pain. There is limited evidence available to estimate the effects of psychological therapies on mood for children and adolescents with headache and non-headache pain. There is also limited evidence to estimate the effects on disability in children with headache. These conclusions replicate and add to those of the previous review which found psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up.

Multilevel socioeconomic effects on quality of life in adolescent and young adult survivors of leukemia and lymphoma

PURPOSE

Cancer registry survival analyses have shown that adolescent and young adult patients with low socioeconomic status (SES) have reduced survival compared to those with higher SES. The objective of this study was to determine whether neighborhood- (nSES) and/or individual-level SES (iSES) also predicted current quality of life in adolescent and young adult survivors.

METHODS

The Socioeconomics and Quality of Life study surveyed adolescent and young adult survivors of leukemia and lymphoma at least one year post-diagnosis using population-based ascertainment. Factor analysis was used to create a multidimensional age-relevant iSES score and compared with a preexisting census-block-group derived nSES score. Four quality of life domains were assessed: physical health, psychological and emotional well-being, social relationships, and life skills. Nested multivariable linear regression models were run to test the associations between both SES measures and quality of life and to compare the explanatory power of nSES and iSES.

RESULTS

Data from 110 individuals aged 16-40 were included in the final analysis. After adjustment for sociodemographic confounders, low nSES was associated only with poorer physical health, whereas low iSES was related to poorer quality of life in all four domains with iSES accounting for an additional 14, 12, 25, and 10 % of the variance, respectively.

CONCLUSIONS

Measures of SES at the individual as compared to the neighborhood level may be stronger indicators of outcomes in adolescents and young adults, which has important implications for SES measurement in the context of cancer surveillance.

An observational study of patient versus parental perceptions of health-related quality of life in children and adolescents with a chronic pain condition: who should the clinician believe?

Background

Previous pediatric studies have observed a cross-informant variance in patient self-reported health-related quality of life (HRQoL) versus parent proxy-reported HRQoL. This study assessed in older children and adolescents with a variety of chronic pain conditions: 1) the consistency and agreement between pediatric patients’ self-report and their parents’ proxy-report of their child’s HRQoL; 2) whether this patient-parent agreement is dependent on additional demographic and clinical factors; and 3) the relationship between pediatric patient HRQoL and parental reported HRQoL.

Methods

The 99 enrolled patients (mean age 13.2 years, 71% female, 81% Caucasian) and an accompanying parent completed the PedsQL^TM 4.0 and 36-Item Short-Form Health Survey Version 2 (SF-36v2) at the time of their initial appointment in a pediatric chronic pain medicine clinic. Patients’ and parents’ total, physical, and psychosocial HRQoL scores were analyzed via an intra-class correlation coefficient, Spearman’s correlation coefficient, Wilcoxon signed rank test, and Bland-Altman plot. A multivariable linear regression model was used to evaluate the association between clinical and demographic variables and the difference in patient and proxy scores for the Total Scale Score on the PedsQL™.

Results

With the exception of the psychosocial health domain, there were no statistically significant differences between pediatric patients’ self-report and their parents’ proxy-report of their child’s HRQoL. However, clinically significant patient-parent variation in pediatric HRQoL was observed. Differences in patient-parent proxy PedsQL™ Total Scale Score Scores were not significantly associated with patient age, gender, race, intensity and duration of patient’s pain, household income, parental marital status, and the parent’s own HRQoL on the SF-36v2. No significant relationship existed among patients’ self-reported HRQoL (PedsQL™), parental proxy-reports of the child’s HRQoL, and parents’ own self-reported HRQoL on the SF-36v2.

Conclusions

We observed clinically significant variation between pediatric chronic pain patients’ self-reports and their parents’ proxy-reports of their child’s HRQoL. While whenever possible the pediatric chronic pain patient’s own perspective should be directly solicited, equal attention and merit should be given to the parent’s proxy-report of HRQoL. To do otherwise will obviate the opportunity to use any discordance as the basis for a therapeutic discussion about the contributing dynamic with in parent-child dyad.

Challenges of disorders of sex development: diverse perceptions across stakeholders

BACKGROUND/AIMS

Disorders of sex development (DSD) are congenital conditions in which chromosomal, gonadal, or anatomic sex development is atypical. Optimal management is patient- and family-centered and delivered by interdisciplinary teams. The present pilot study elicits concerns held by important stakeholders on issues affecting young patients with DSD and their families.

METHODS

Content from focus groups with expert clinicians (pediatric urologists (n = 7), pediatric endocrinologists (n = 10), mental health professionals (n = 4), DSD patient advocates (n = 4), and interviews with parents of DSD-affected children (newborn to 6 years; n = 11) was coded and content-analyzed to identify health-related quality of life issues.

RESULTS

Key stressors varied across stakeholder groups. In general, family-centered issues were noted more than child-centered. In the child-centered domain, providers worried more about physical functioning; family and advocates emphasized gender concerns and body image. In the family-centered domain, parental concerns about medication management outweighed those of providers. Advocates reported more stressors regarding communication/information than other stakeholders.

CONCLUSION

Variability exists across stakeholder groups in the key concerns affecting young children/families with DSD. Interdisciplinary DSD healthcare team development should account for varying perspectives when counseling families and planning treatment.

Psychometric properties of sizing me up in a community sample of 4th and 5th grade students with overweight and obesity

OBJECTIVE

To extend the health-related quality of life assessment literature by examining the reliability and validity of Sizing Me Up in a community sample of nontreatment-seeking overweight and obese children.

METHODS

Participants included 302 students (M age = 10.34) recruited from 6 elementary schools, who completed self-report measures of health-related quality of life and weight-related health.

RESULTS

134 overweight and obese children were included in the analyses to establish validity for the measure. Confirmatory factor analyses supported a 5-factor first-order factor structure with 1 second-order factor representing a total score. Convergent and criterion-related validity was established among overweight and obese children. Estimates of internal consistency for the 5-factor Sizing Me Up factor structure indicated that the subscales are not acceptable outside of a structural equation modeling approach.

CONCLUSION

Outside of a structural equation modeling framework, only the total score appears to be appropriate in this population.

Evaluating the protective role of racial identity in children with sickle cell disease

OBJECTIVE

This study examined whether racial identity moderates the relation between pain and quality of life (QOL) in children with sickle cell disease (SCD).

METHODS

100 children 8-18 years of age with SCD participated during a regularly scheduled medical visit. Children completed questionnaires assessing pain, QOL, and regard racial identity, which evaluates racial judgments.

RESULTS

Analyses revealed that regard racial identity trended toward significance in moderating the pain and physical QOL relation, (β = -0.159, t(93) = -1.821, p = 0.07), where children with low pain and high regard reported greater physical QOL than children with low pain and low regard. Regard racial identity did not moderate the relation between pain and other QOL dimensions. Pain significantly predicted all dimensions of QOL and regard racial identity significantly predicted social QOL.

CONCLUSIONS

Racial identity may be important to consider in future research examining QOL in children with SCD.

Cognitive Behavioral Therapy for Pediatric Chronic Pain: The Problem, Research, and Practice

The purpose of this article is to outline the rationale and use of cognitive behavioral therapy (CBT) for the treatment of pediatric chronic pain. The article begins by demonstrating the scope and impact of the problem of pediatric chronic pain. It then provides an overview of the framework of CBT for pediatric chronic pain and standard treatment components are outlined. A summary of the current state of research and its efficacy is provided. The article concludes by presenting outcome data from a specific example of a CBT group for pediatric recurrent abdominal pain. Future directions for research in this area are discussed.

A biopsychosocial pilot study of overweight youth and care providers' perceptions of quality of life

This pilot study examined the relationship between youth and care provider self-reports of depressive symptoms assessed through the Patient Health Questionnaire and reports of youth physical and psychosocial functioning assessed by PedsQL4.0 in a rural outpatient overweight pediatric population (N = 66 child and care provider pairs). The relationship between youth body mass index (BMI), youth and care provider depression, youth quality of life (QOL), care provider perception of youth QOL, and youth and care provider congruence of QOL perceptions was examined. Paired t tests were completed to assess the differences between QOL scores for youth and care providers for subgroups based on age, age and gender, and age and race. The mean age of youth participants was 11.9 years; youth BMI ranged from 26.76 to 54.10 (M = 37.20). Our results showed that there are significant differences in youth and care providers' perceptions of QOL when specific demographic categories are assessed by age, gender, and race.

Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms

OBJECTIVES

Mild traumatic brain injury (TBI) and injury-related outcomes such as postconcussive symptoms (PCS) may influence health-related quality of life (HRQOL) in children.

METHODS

We evaluated HRQOL in 186 8- to 15-year-old children with mild TBI and 99 children with orthopedic injuries (OI). Parents rated the frequency and severity of PCS at an initial assessment within 2-weeks postinjury and rated HRQOL at 3- and 12-months postinjury.

RESULTS

The mild TBI and OI groups did not differ in psychosocial HRQOL, but the mild TBI group showed lower physical HRQOL at the 12-month follow-up. Somatic PCS were a significant predictor of physical HRQOL over time, and both cognitive and somatic PCS were significant predictors of psychosocial HRQOL over time. Children with higher PCS at the initial assessment had lower HRQOL scores at later time points.

CONCLUSIONS

Effective management of PCS may be associated with improvements in HRQOL following pediatric mild TBI.

Predictors of long-term health-related quality of life in adolescent solid organ transplant recipients

OBJECTIVES

This study aimed to identify prospective predictors of health-related quality of life (HRQOL) for adolescent solid organ (kidney, liver, heart, lung) transplant recipients.

METHODS

Data regarding demographics, individual/transplant characteristics, and environmental characteristics were gathered from 66 adolescent transplant recipients and their families at baseline and used to predict the physical functioning, mental health, and general health perceptions domains of HRQOL 18 months later.

RESULTS

Baseline levels of HRQOL explained the greatest amount of variance in levels of HRQOL at follow-up; however, specific demographic (i.e., income), individual/transplant (i.e., adherence, frequency of rescheduled clinic appointments, and presence of a rejection episode), and environmental factors (i.e., family conflict) contributed to the variance in HRQOL domains beyond baseline levels.

CONCLUSIONS

This study identified certain modifiable individual and environmental factors and non-modifiable risk factors associated with lower future HRQOL. Transplant centers should begin screening and addressing these factors to potentially improve HRQOL.

Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL

BACKGROUND

This study examined the relationship between emotional distress as measured by the Hospital Anxiety and Depression Scale (HADS) and the Fertility Quality of Life (FertiQoL) questionnaire.

METHODS

The FertiQoL and HADS were distributed to a random sample of 785 patients attending 29 Dutch clinics for medically assisted reproduction. FertiQoL was psychometrically tested for reliability. Pearson's correlations were calculated between subscales of FertiQoL and HADS. Using an independent t-test, differences between patient subgroups were computed for both instruments. The threshold for clinically meaningful depression/anxiety on the HADS subscales was used to ascertain the critical threshold for high distress on the FertiQoL scales.

RESULTS

FertiQoL and HADS were completed by 583 patients (response 74%). Reliability of FertiQoL scales was high (reliability coefficient between 0.72 and 0.91). Significant negative correlations were found between FertiQoL subscales and HADS scores for anxiety and depression, ranging from -0.29 to -0.71. Means on FertiQoL scales and HADS scales of couples undergoing an assisted reproductive technology (ART) treatment and a non-ART treatment did not differ significantly. Patients scoring above the HADS threshold for pathology on anxiety had an average FertiQoL score of 58.8, whereas patients exceeding the HADS depression threshold had a FertiQoL total score of 51.9 (range 0-100).

CONCLUSIONS

Our study confirms the expected negative relation between quality of life as measured by FertiQoL and anxiety and depression. The data support that FertiQoL reliably measures QoL in women facing infertility. FertiQoL enables clinicians to tailor care more specifically to the patient in a comprehensive way.

The PedsQL™ Infant Scales: feasibility, internal consistency reliability, and validity in healthy and ill infants

OBJECTIVE

The PedsQL™ (Pediatric Quality of Life Inventory™) is a modular instrument designed to measure health-related quality of life (HRQOL) and disease-specific symptoms in children and adolescents ages 2-18. The new PedsQL™ Infant Scales were designed as a generic HRQOL instrument specifically for healthy and ill infants ages 1-24 months. The objective of this study was to report on the initial feasibility, internal consistency reliability, and validity of the PedsQL™ Infant Scales in healthy, acutely ill, and chronically ill infants.

METHODS

The 36-item (ages 1-12 months) and 45-item (ages 13-24 months) PedsQL™ Infant Scales (Physical Functioning, Physical Symptoms, Emotional Functioning, Social Functioning, Cognitive Functioning) were completed by 683 parents of healthy, acutely ill, and chronically ill infants.

RESULTS

The PedsQL™ Infant Scales evidenced minimal missing responses, achieved excellent internal consistency reliability for the Total Scale Scores (α = 0.92), distinguished between healthy infants and acutely and chronically ill infants, and demonstrated a confirmatory factor structure largely consistent with the a priori conceptual model.

CONCLUSIONS

The results demonstrate the initial measurement properties of the PedsQL™ Infant Scales in healthy and ill infants. The findings suggest that the PedsQL™ Infant Scales may be utilized in the evaluation of generic HRQOL in infants ages 1-24 months.

Obesity in children and adolescents with chronic pain: associations with pain and activity limitations

OBJECTIVES

Obesity is associated with functional disability in adults with chronic pain, but less is known about obesity among youth with chronic pain. The purpose of this study was to (1) identify the prevalence of overweight and obesity in children and adolescents receiving treatment for chronic pain, and (2) examine associations between Body Mass Index (BMI), pain intensity, and activity limitations in this population.

METHODS

Data were obtained from records of 118 patients, ages 8 to 18, seen in a multidisciplinary pediatric pain clinic. Information about age, sex, pain problem, duration and severity, medical diagnoses, medications, height, and weight were collected from medical records and intake questionnaires. The CDC's pediatric BMI calculator was used to obtain percentile and category (underweight, healthy weight, overweight, obese). Children and parents completed the Child Activity Limitations Interview-21 (CALI-21), a self-report measure of activity limitations.

RESULTS

A significantly higher rate of overweight and obesity was observed among youth with chronic pain compared with a normative sample. BMI percentile was predictive of concurrent limitations in vigorous activities, according to parent report.

DISCUSSION

BMI percentile and weight status may contribute to activity limitations among children and adolescents with chronic pain. Weight status is an important factor to consider in the context of treatment of chronic pain and disability in children and adolescents.

The PedsQL™ Infant Scales: feasibility, internal consistency reliability, and validity in healthy and ill infants

OBJECTIVE

The PedsQL™ (Pediatric Quality of Life Inventory™) is a modular instrument designed to measure health-related quality of life (HRQOL) and disease-specific symptoms in children and adolescents ages 2-18. The new PedsQL™ Infant Scales were designed as a generic HRQOL instrument specifically for healthy and ill infants ages 1-24 months. The objective of this study was to report on the initial feasibility, internal consistency reliability, and validity of the PedsQL™ Infant Scales in healthy, acutely ill, and chronically ill infants.

METHODS

The 36-item (ages 1-12 months) and 45-item (ages 13-24 months) PedsQL™ Infant Scales (Physical Functioning, Physical Symptoms, Emotional Functioning, Social Functioning, Cognitive Functioning) were completed by 683 parents of healthy, acutely ill, and chronically ill infants.

RESULTS

The PedsQL™ Infant Scales evidenced minimal missing responses, achieved excellent internal consistency reliability for the Total Scale Scores (α = 0.92), distinguished between healthy infants and acutely and chronically ill infants, and demonstrated a confirmatory factor structure largely consistent with the a priori conceptual model.

CONCLUSIONS

The results demonstrate the initial measurement properties of the PedsQL™ Infant Scales in healthy and ill infants. The findings suggest that the PedsQL™ Infant Scales may be utilized in the evaluation of generic HRQOL in infants ages 1-24 months.

Pediatric health-related quality of life: Feasibility, reliability and validity of the PedsQL transplant module

The measurement properties of the newly developed Pediatric Quality of Life Inventory (PedsQL) 3.0 Transplant Module in pediatric solid organ transplant recipients were evaluated. Participants included pediatric recipients of liver, kidney, heart and small bowel transplantation who were cared for at seven medical centers across the United States and their parents. Three hundred and thirty-eight parents of children ages 2-18 and 274 children ages 5-18 completed both the PedsQL 4.0 Generic Core Scales and the Transplant Module. Findings suggest that child self-report and parent proxy-report scales on the Transplant Module demonstrated excellent reliability (total scale score for child self-report alpha= 0.93; total scale score for parent proxy-report alpha= 0.94). Transplant-specific symptoms or problems were significantly correlated with lower generic HRQOL, supporting construct validity. Children with solid organ transplants and their parents reported statistically significant lower generic HRQOL than healthy children. Parent and child reports showed moderate to good agreement across the scales. In conclusion, the PedsQL Transplant Module demonstrated excellent initial feasibility, reliability and construct validity in pediatric patients with solid organ transplants.

The PedsQL in pediatric patients with Duchenne muscular dystrophy: feasibility, reliability, and validity of the Pediatric Quality of Life Inventory Neuromuscular Module and Generic Core Scales

OBJECTIVE

To evaluate the reliability and validity of the PedsQL 3.0 Neuromuscular Module (NMM) in assessing health-related quality of life in the Duchenne muscular dystrophy (DMD) population for use as a secondary outcome measure in phase III clinical trials.

BACKGROUND

DMD is the most common genetic form of muscular dystrophy in childhood. Clinical trials are underway to evaluate modalities of treatment. The NMM was developed based on interviews of patients with DMD and spinal muscular atrophy. To determine the PedsQL reliability and validity, we administered the NMM to patients with DMD and their caregivers.

DESIGN/METHODS

Boys 8 to 18 years old with DMD were recruited from a neuromuscular disease clinic. At baseline, the child and caregiver completed the NMM and the PedsQL 4.0 Generic Core Scales (GC). The NMM was repeated 2 to 6 weeks later. Reliability was assessed using Cronbach's coefficient alpha (internal consistency) and intraclass correlation (ICC) (test-retest consistency). Construct validity was assessed by comparing baseline child and caregiver NMM total scores with the GC Total Score, forced vital capacity, cardiac ejection fraction, and ambulatory status.

RESULTS

Forty-four children and their caregivers completed the study. Internal consistency reliability of the total scale score of the NMM was demonstrated (Child alpha = 0.85; Caregiver alpha = 0.87). Test-retest reliability of the NMM was also demonstrated (Child ICC = 0.75, P = 0.001; Caregiver ICC = 0.85, P < 0.001). Validity of the total scale score of the NMM when compared with the GC Total Scale Score was supported (Child r (41) = 0.63, P < 0.001; Caregiver r (42) = 0.64, P < 0.001). Validity of the NMM compared with forced vital capacity was also supported (Child r (38) = 0.35, P = 0.032; Caregiver r (39) = 0.41, P = 0.01). The NMM parent-proxy-report and child self-report "About My Child's Neuromuscular Disease" scale was significantly related to wheelchair use (P < 0.008 and 0.016, respectively); the GC "Child Self-Report "Physical Health" scale was also significantly related to wheelchair use (P < 0.001). We were unable to conduct any analysis with ejection fraction because of the small number of children across all categories.

CONCLUSIONS

The PedsQL NMM is a reliable measure of disease-specific health-related quality of life in the DMD population and may be used as an outcome measure in clinical trials.

Health-related quality of life of youth with inflammatory bowel disease: a comparison with published data using the PedsQL 4.0 generic core scales

BACKGROUND

This study compared youth and parent-proxy reports of health-related quality of life (HRQoL) among youth with inflammatory bowel disease (IBD) to published comparison group data and examined concordance between youth and parent-proxy reports of HRQoL.

METHODS

One hundred thirty-six youth and parent-proxy reports on the PedsQL 4.0 Generic Core Scales were compared to published data from chronically ill, acutely ill, and healthy comparison groups using independent samples t-tests. Reporter agreement was examined using paired samples t-tests and intraclass correlations (ICCs).

RESULTS

Youth with IBD reported lower psychosocial functioning than the healthy comparison group, higher physical and social functioning than the chronically ill group, and lower school functioning than all published comparison groups. Parent-proxy reports of youth HRQoL were higher than the chronically ill group, but lower than the healthy group on all scales except psychosocial functioning. Youth with active IBD reported lower physical health domain scores than youth with inactive disease. Concordance between youth and parent-proxy reports was moderate, with the lowest agreement in school and social functioning.

CONCLUSIONS

Youth with IBD and their parents rate HRQoL as lower than healthy youth but do not perceive the impact of IBD to be as limiting as in other chronic conditions. Youth report suggests that IBD may be particularly detrimental to HRQoL in the school functioning domain. Moderate agreement between parent and youth reports substantiates continued use of multiple informants in studies of pediatric HRQoL.

Lung transplantation for cystic fibrosis

Lung transplantation is a complex, high-risk, potentially life-saving therapy for the end-stage lung disease of cystic fibrosis (CF). The decision to pursue transplantation involves comparing the likelihood of survival with and without transplantation as well as assessing the effect of wait-listing and transplantation on the patient's quality of life. Although recent population-based analyses of the US lung allocation system for the CF population have raised controversies about the survival benefits of transplantation, studies from the United Kingdom and Canada have suggested a definite survival advantage for those receiving transplants. In response to these and other controversies, leaders in transplantation and CF met together in Lansdowne, Virginia, to consider the state of the art in lung transplantation for CF in an international context, focusing on advances in surgical technique, measurement of outcomes, use of prognostic criteria, variations in local control over listing, and prioritization among the United States, Canada, the United Kingdom, and The Netherlands, patient adherence before and after transplantation and other issues in the broader context of lung transplantation. Finally, the conference members carefully considered how efforts to improve outcomes for lung transplantation for CF lung disease might best be studied. This Roundtable seeks to communicate the substance of our discussions.

Parenting an adolescent with chronic pain: an investigation of how a taxonomy of adolescent functioning relates to parent distress

OBJECTIVE

Cluster analyses allow health professionals to classify adolescents with chronic pain into subgroups, which might allow efficient tailoring of treatment. Given the nature of family relationships when a child has chronic pain, we aimed to evaluate whether an adolescent-disability-derived cluster formula would appropriately classify their parents via parenting stress, anxiety, and depression.

METHODS

A patient-report data-derived cluster formula sorted 204 parents of adolescents with chronic pain into 4 groups. Parents completed measures of distress, anxiety, and depression.

RESULTS

The 4-group solution generally sorted parents accurately, with parents of the least disabled adolescents functioning well and parents of the most disabled adolescents reporting clinically significant levels of stress, anxiety, and depression.

CONCLUSIONS

Findings suggest the patient-derived 4-group cluster solution might be an efficient method of distinguishing subgroups of parents with varying levels of stress, anxiety, and depression, which can be used to guide family-oriented treatment efforts.

Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review

The purpose of this meta-analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth. Specifically, in this review we updated previous systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes. Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE, PsycLIT, EMBASE, and the Social Sciences Citation Index were conducted from inception through August 2008. Methodological quality of the studies was assessed, and data extracted on the three primary outcomes of interest. Twenty-five trials including 1247 young people met inclusion criteria and were included in the meta-analysis. Meta-analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post-treatment and follow-up in youth with headache, abdominal pain, and fibromyalgia. Small and non-significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes available in the included studies. Omnibus cognitive-behavioral therapy, relaxation therapy, and biofeedback all produced significant and positive effects on pain reduction. Studies directly comparing the effects of self-administered versus therapist-administered interventions found similar effects on pain reduction. Psychological therapies result in improvement in pain relief across several different pain conditions in children. Future trials are needed that incorporate non-pain outcome domains, that focus significant therapeutic content on reductions in disability, and that include extended follow-up to better understand maintenance of treatment effects.

The PedsQL in pediatric patients with Spinal Muscular Atrophy: feasibility, reliability, and validity of the Pediatric Quality of Life Inventory Generic Core Scales and Neuromuscular Module

For Phase II and III clinical trials in children with Spinal Muscular Atrophy (SMA), reliable and valid outcome measures are necessary. Since 2000, the American Spinal Muscular Atrophy Randomized Trials (AmSMART) group has established reliability and validity for measures of strength, lung function, and motor function in the population from age 2 years to 18 years. The PedsQL (Pediatric Quality of Life Inventory) Measurement Model was designed to integrate the relative merits of generic and disease-specific approaches, with disease-specific modules. The PedsQL 3.0 Neuromuscular Module was designed to measure HRQOL dimensions specific to children ages 2-18 years with neuromuscular disorders, including SMA. One hundred seventy-six children with SMA and their parents completed the PedsQL 4.0 Generic Core Scales and PedsQL 3.0 Neuromuscular Module. The PedsQL demonstrated feasibility, reliability, and validity in the SMA population. Consistent with the conceptualization of disease-specific symptoms as causal indicators of generic HRQOL, the majority of intercorrelations among the Neuromuscular Module Scales and the Generic Core Scales were in the medium to large range, supporting construct validity. For the purposes of a clinical trial, the PedsQL Neuromuscular Module and Generic Core Scales provide an integrated measurement model with the advantages of both generic and condition-specific instruments.

Optimism and pessimism in children with cancer and healthy children: confirmatory factor analysis of the youth life orientation test and relations with health-related quality of life

OBJECTIVE

To test the measurement equivalence of the Youth Life Orientation Test (YLOT) in children with cancer (N = 199) and healthy controls (N = 108), and to examine optimism and pessimism as predictors of children's health-related quality of life (HRQL).

METHODS

Confirmatory factor analysis (CFA) was conducted to establish the two factor structure of the YLOT and to test for metric invariance.

RESULTS

A two-factor structure for the YLOT was confirmed and found to be stable across our study groups. There were no differences in mean levels of optimism and pessimism between cancer patients and controls after controlling for race/ethnicity. Higher optimism was associated with lower self-reports of pain and better emotional/behavioral functioning, whereas pessimism was related to poorer mental health and general behavior, and greater impact on the family.

CONCLUSIONS

Optimism and pessimism appear to be differentially related to certain aspects of children's HRQL, and should be investigated separately in relation to these outcomes.

Psychological therapies for the management of chronic and recurrent pain in children and adolescents

BACKGROUND

Headache, recurrent abdominal pain, and musculoskeletal pain affect many children, who report severe pain, distressed mood, and disability. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This is a substantially updated and expanded version of the Cochrane review published in 2003.

OBJECTIVES

To assess the effectiveness of psychological therapies for reducing pain, disability, and improving mood in children and adolescents with recurrent, episodic, or persistent pain.

SEARCH STRATEGY

Searches were undertaken of MEDLINE, PsycLIT, EMBASE and CONSORT. RCTs were sought in references of all identified studies, meta-analyses and reviews. Date of most recent search: August 2008.

SELECTION CRITERIA

Randomised Controlled Trials (RCTs) with at least ten participants in each arm post-treatment comparing psychological therapies with placebo, waiting list or standard medical care for children or adolescents with episodic, recurrent or persistent pain, were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

All included studies were analysed and the quality of the studies recorded. All treatments were combined into one class: psychological treatments; headache and non-headache outcomes were separately analysed on three outcomes: pain, disability, and mood.

MAIN RESULTS

Thirty-four RCT studies were recovered; 29 met the inclusion criteria. The total number of participants completing treatments was 1432. Twenty studies addressed treatments for headache (including migraine); six for abdominal pain; one for both headache and abdominal pain, one study was for fibromyalgia, and one was for pain associated with sickle cell disease. The analysis of headache treatment versus control differences immediately post-treatment for pain gave an odds ratio (OR) of 5.51 (95% CI 3.28 to 9.24; z = 6.46, P < 0.05); NNT = 2.57 (CI 2.2 to 3.13). At follow-up, the OR was 9.91 (95% CI 3.73 to 26.33); z = 9.91, P < 0.05); NNT = 1.99 (CI 1.63 to 2.72). Analysis of non-headache treatment versus control differences immediately post-treatment for pain found a large effect size of -0.94 (95% CI -1.43 to -0.44) Z = 3.71, P < 0.05. At follow-up, a large effect size was found of -1.08 (95%CI -1.84 to -0.33); Z = 2.82, P < 0.05). There were no other significant effects.

AUTHORS' CONCLUSIONS

Psychological treatments are effective in pain control for children with headache and benefits appear to be maintained. Psychological treatments may also improve pain control for children with musculoskeletal and recurrent abdominal pain. There is little evidence available to estimate effects on disability or mood.

Assessment of chronic pain in children: current status and emerging topics

The present paper reviews the current status of research on assessment of chronic pain in children and adolescents, primarily in the context of treatment outcome research. Two specific primary aims are addressed. First, the degree of attention devoted to several major domains of chronic pain assessment (pain, physical functioning, role functioning, sleep and emotional functioning) is summarized, highlighting areas where further instrument development and validation are needed. Second, sensitivity of instruments within these domains is presented using data from clinical trials of psychological therapies aimed at treatment of chronic pain in children and adolescents. Findings demonstrate that although there has been recent progress in developing and validating a range of measures of pain-related outcomes, as of yet, very few clinical trials have included any outcomes other than pain intensity. Moreover, in randomized controlled trials where physical, role or emotional functioning outcomes have been included, there have been limited positive findings. The present paper lists some challenges and future directions in assessment of physical and role functioning, including highlighting emerging methodologies for assessment of physical activity and function in children with chronic pain. Clinical implications of integrating assessment tools into clinical practice are discussed. In conclusion, progress in developing and validating specific tools to assess important outcome domains in chronic pain has been realized. Opportunities exist for further measurement validation in most domains, and further theory-driven treatment research to match goals of the treatment with specific interventions and outcomes.