Emotional/behavioural, social correlates and one-year predictors of frequent pains among early adolescents: Influences of pain characteristics

Immigration background as a risk factor of chronic pain and high-impact chronic pain in children and adolescents living in Spain: differences as a function of age

ABSTRACT

The number of people immigrating from one country to another is increasing worldwide. Research has shown that immigration background is associated with chronic pain (CP) and pain disability in adults. However, research in this issue in children and adolescents has yielded inconsistent results. The aims of this study were to examine (1) the association between immigration background, CP, high-impact chronic pain (HICP) in a community sample of children and adolescents; and (2) the extent these associations differed as a function of sex and age. Participants of this cross-sectional study were 1115 school children and adolescents (mean age = 11.67; 56% girls). Participants were asked to provide sociodemographic information and respond to a survey including measures of pain (location, extension, frequency, intensity, and interference). Results showed that having an immigration background was associated with a greater prevalence of CP (OR = 1.91, p <.001) and HICP (OR = 2.55, p <. 01). Furthermore, the association between immigration background and CP was higher in children (OR = 6.92, p <.001) and younger adolescents (OR = 1.66, p <.05) than in older adolescents. Children and adolescents with an immigration background are at higher risk for having CP -especially younger children- and HICP. More resources should be allocated in the prevention of CP and HICP in children and adolescents with an immigration background.

Predictors and concomitants of the remission of frequent headache in pediatrics: A longitudinal community study

OBJECTIVE

We aimed to examine factors associated with frequent headache remission in schoolchildren aged 10-18 years.

BACKGROUND

Frequent headache is a common health problem in adolescence, and some individuals in this population experience remission. Factors preceding headache remission as opposed to ongoing headache, and their development over time, have not been examined extensively.

METHODS

Data were derived from a large school sample (N = 2280). Over the course of 1 year, n = 156 adolescents experienced remission from frequent headaches, while n = 125 adolescents continued to have frequent headaches throughout the year. In this longitudinal case-control study, we predicted headache remission using demographic, pain, psychosocial, sleep, and physiological characteristics. Additionally, we sought to explore the development of psychosocial, sleep, and physiological characteristics in relation to remitted versus ongoing headache over the 1-year period.

RESULTS

A model containing the variables sex (odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.248-0.76, p = 0.003), headache intensity (OR = 0.85, 95% CI = 0.73-0.99, p = 0.035), anxiety score (OR = 0.92, 95% CI = 0.85-1.01, p = 0.071), and depression score (OR = 0.94, 95% CI = 0.89-1.00, p = 0.041) predicted the outcome variable (remitted vs. non-remitted headache), explaining 17% of the variance in group membership. Schoolchildren reporting remitted headache at the end of the year exhibited lower depression (F[1, 557.01] = 45.77, p < 0.001) and anxiety scores (F[1, 557.01] = 21.72, p < 0.001), higher school satisfaction (F[1, 209.46] = 7.15, p = 0.008), and fewer difficulties falling asleep (F[1, 856.52] = 41.21, p < 0.001) or sleeping through the night (F[1, 731.12] = 26.42, p < 0.001) throughout the year compared to those with non-remitted headache. Depression scores declined significantly over the year in the group with remitted headache, whereas these scores remained constant in the group with non-remitted headache.

CONCLUSION

Our results suggest a correlation between headache remission and male sex, improved mental health, and reduced pain-related burden. Moreover, there was an observed decline in symptoms of depression during headache remission. Psychotherapy may be a promising treatment strategy for addressing frequent headaches reported by children and adolescents.

Family structure and multisite musculoskeletal pain in adolescence: a Northern Finland Birth Cohort 1986 study

BACKGROUND

Family structure is suggested to be associated with adolescent pain, but evidence on its association with multisite MS pain is sparse. The purpose of this cross-sectional study was to investigate the potential associations between family structure ('single-parent family', 'reconstructed family', and 'two-parent family') and multisite musculoskeletal (MS) pain in adolescence.

METHODS

The dataset was based on the 16-year-old Northern Finland Birth Cohort 1986 adolescents with available data on family structure, multisite MS pain, and a potential confounder (n = 5,878). The associations between family structure and multisite MS pain were analyzed with binomial logistic regression and modelled as unadjusted, as the evaluated potential confounder, mother's educational level, did not meet the criteria for a confounder.

RESULTS

Overall, 13% of the adolescents had a 'single-parent family' and 8% a 'reconstructed family'. Adolescents living in a single-parent family had 36% higher odds of multisite MS pain compared to adolescents from two-parent families (the reference) (Odds Ratio [OR]: 1.36, 95% Confidence Interval [CI]: 1.17 to 1.59). Belonging to a 'reconstructed family' was associated with 39% higher odds of multisite MS pain (OR 1.39, 1.14 to 1.69).

CONCLUSION

Family structure may have a role in adolescent multisite MS pain. Future research is needed on causality between family structure and multisite MS pain, to establish if there is a need for targeted support.

An Exploration of the Influence of Non-Biomechanical Factors on Lifting-Related LBP

Objective: The primary objective was to compare non-biomechanical factors between manual workers with and without a history of LBP related to lifting. A secondary objective was to investigate associations between the change in pain intensity during repeated lifting (termed pain ramp) and non-biomechanical factors tested in the LBP group. Methods: Manual workers currently in lifting occupations with and without a history of lifting-related LBP were recruited (21 LBP and 20 noLBP) and took part in a repeated (100) lift task. A series of non-biomechanical factors, including psychological, work-related, lifestyle, whole health and psychophysical factors, were collected. Psychophysical factors (pressure pain thresholds (PPTs) and fatigue) were also measured at different time points. Associations between pain ramp during lifting and non-biomechanical factors were investigated with linear regression. Results: The LBP group reported worse perceived sleep quality, more musculoskeletal pain sites other than LBP and greater symptoms related to gastrointestinal complaints and pseudo-neurology compared to the group with no history of LBP. The group with LBP were also slightly more worried about the lifting task and felt more fatigued at the end of the lifting task. The feeling of fatigue during lifting was positively associated with pain ramp in the LBP group. Anxiety and gastrointestinal complaints were weakly negatively associated with pain ramp during lifting. Conclusions: The group differences of poorer perceived sleep, greater non-specific health complaints, slightly more worry about the lifting task and more perceived fatigue in the LBP group highlight the complex and multi-factorial nature of LBP related to lifting. The feeling of fatigue was positively associated with pain ramp in the LBP group, suggesting a close relationship with pain and fatigue during lifting that requires further exploration.

Refining the prediction of multisite pain in 13-year-old boys and girls by using parent-reported pain experiences in the first decade of life

Background

We evaluated different pain profiles as prospective predictors of multisite pain in 13‐year‐old adolescents (1300 girls and 1457 boys) enrolled in Generation XXI, a birth cohort study in Portugal.

Methods

Pain history was queried using the Luebeck Pain Questionnaire through parent proxy‐ (ages 7 and 10) and adolescent (age 13) self‐reports. We estimated the risk of multisite pain (2 or more pain sites) at age 13, according to previous pain experiences, including accumulation and timing. We defined five profiles that combined adverse features at ages 7 and 10 (recurrence, multisite, frequency, duration, intensity, triggers, activity restrictions, passive coping, and family history) and estimated their relative risks (RR) and likelihood ratios (LR) for adolescent multisite pain.

Results

At age 13, 39.2% of girls and 27.2% of boys reported multisite pain in the previous three months. The risk was higher among girls with multisite and recurrent pain at ages 7 and 10 than in girls without those adverse features, especially if psychosocial triggers were also present (RR 1.87; 95% confidence interval 1.36, 2.36 and LR 3.49; 1.53, 7.96). Boys with recurrent pain of higher frequency and causing activity restrictions at ages 7 and 10 had a higher risk of multisite pain at 13 (RR 2.05; 1.03, 3.05 and LR 3.06; 1.12, 8.39). Earlier adverse experiences were more predictive of future pain in girls than in boys.

Conclusions

Different profiles were useful to rule in future multisite pain in boys and girls. This provides clues for early stratification of chronic pain risk.

Significance

We identified sex‐specific pain features that can be collected by practitioners in the first decade of life to improve the stratification of children in terms of their future risk of a maladaptive pain experience in adolescence. Using a prospective population‐based cohort design, we show that early multisite pain and psychosocial triggers are relevant predictors of future multisite pain in girls, whereas repeated reports of high‐frequency pain leading to activity restrictions are predictive of adolescent multisite pain in boys.

Painful and non-painful comorbidities associated with short- and long-term painful temporomandibular disorders: A cross-sectional study among adolescents from Brazil, Canada, and France

BACKGROUND

Temporomandibular disorder (TMD) pain is common among adolescents. The association between painful TMD and other comorbidities has been demonstrated. However, the difference between short-term (<6 months) and long-term (≥ 6 months) painful TMD is not yet clear.

OBJECTIVE

The aim of this study was to assess the association between comorbidities and short- and long-term painful TMD among adolescents.

METHODS

In this cross-sectional study, adolescents were recruited from Montreal (Canada), Nice (France), and Arceburgo (Brazil). Self-reported painful TMD, comorbidities, school absence, and analgesic intake were assessed using reliable instruments. Multivariable logistic regression analyses were conducted to assess the study aims.

RESULTS

The prevalence of short- and long-term painful TMD was estimated at 22.29% and 9.93%, respectively. The number of comorbidities was associated with short- (OR = 1.71, 95%CI = 1.53-1.90) and long-term painful TMD (OR = 1.79, 95%CI = 1.55-2.08) compared to controls. Frequent headaches (OR_short-term = 4.39, 95%CI = 3.23-5.98, OR_long-term = 3.69, 95%CI = 2.45-5.57) and back pain (OR_short-term = 1.46, 95%CI=1.06-2.03, OR_long-term  = 1.69, 95%CI = 1.11-2.59) were associated with both painful TMD groups. Frequent neck pain (OR = 2.23, 95%CI = 1.53-3.26) and allergies were only associated with short-term painful TMD (OR = 1.54, 95%CI = 1.13-2.10). Frequent stomach pain was related to long-term (OR = 2.01, 95%CI = 1.35-3.26), and it was the only comorbidity significantly more frequent among the long than short-term TMD (OR = 1.82, 95%CI: 1.14-2.90). These analyses were adjusted by sex, age, and city.

CONCLUSION

In this multi-center study, both short- and long-term painful TMD are associated with frequent headaches and back pain, whereas frequent neck pain and allergies are related to only short-term, and frequent stomach pain with long-term painful TMD.

From One Pain to Many: The Emergence of Overlapping Pains in Children and Adolescents

OBJECTIVES

The objective of this study was to compare children and adolescents with overlapping chronic pains (OCP) to those with single chronic pains (SCP) among youth presenting in specialized clinical settings, in an effort to identify potential risk factors for developing overlapping pains.

METHODS

A total of 1235 youth ages 8 to 18 seen in a tertiary care multidisciplinary pain clinic or a multidisciplinary headache clinic completed self-report measures of pain, disability, psychological functioning and clinical history and characteristics at the time of initial clinic visit. Information was captured in a chronic pain data repository and accessed for the current study.

RESULTS

Subsequent pain symptoms developed on average 11.9 months (SD=24.5 mo) after onset of the first pain symptom. Compared with patients with SCP, patients with OCP report more medical comorbidity, more developmental issues, and poorer current sleep and school functioning. They also scored significantly higher than patients with SCP on self-reported functional disability, pain catastrophizing, fear of pain, depression, anxiety, and psychological stress and lower quality of life (all Ps<0.001). In multivariate analysis, variables most strongly associated with presenting with OCP were age (odds ratio [OR]: 1.1, P<0.001), having a clinically significant high functional disability (OR: 1.4, P=0.3), and low quality of life (OR: 2.5, P<0.001).

DISCUSSION

Given their tendency toward more psychological and medical comorbidities, patients with OCP may require more intense and diverse treatment approaches. Some early life experiences may be a risk factor for development of OCP. Longitudinal studies are needed to fully evaluate the heightened risk for OCP associated with some of these factors.

Pain Management in Children During the COVID-19 Pandemic

PURPOSE OF REVIEW

For many children, the SARS-CoV-2 pandemic has impacted the experience and treatment of their pain. This narrative review draws from the pain literature and emerging findings from COVID-19 research to highlight potentially meaningful directions for clinical consideration and empirical inquiry in the months and years to come.

RECENT FINDINGS

COVID-19 has been linked to diffuse acute pains as well as chronic pain sequelae. Contextual factors known to increase vulnerability for pain and associated functional disability have been exacerbated during the pandemic. Beyond these salient concerns has been the remarkable resilience demonstrated by patients and providers as healthcare systems have sought to harness creativity and innovative digital solutions to support optimal child wellbeing throughout this crisis.

SUMMARY

Ongoing research is needed to elucidate the short- and long-term effects of the pandemic on children's pain and to consider how the delivery of treatment via digital technology has impacted existing paradigms of pain management.

Cohort profile: The Youth and Mental Health Study (YAMHS) - a longitudinal study of the period from adolescence to adulthood

The aim of this article is to provide a detailed description of the Youth and Mental Health Study (YAMHS),a population-based, representative (cluster sampling), prospective cohort study that was conducted to investigate risk and resilience factors for mental health conditions, specifically depressive symptoms and disorders, from adolescence to adulthood. The baseline data were collected in 1998 (T1) in two counties in central Norway from 2464 adolescents (response rate 88.3%, mean age 13.7 years). The first follow-up was conducted in 1999 (T2) (n = 2432, response rate of 87.1%, mean age 14.9 years). A subgroup of individuals was assessed at T2 (n = 345) with clinical interviews, and this subgroup was reassessed in 2005 (T3) (n = 265, 70.1%, 20 years). The last follow-up (of participants assessed at T1 and T2) was conducted in 2012 (T4) (n = 1266, 51.9%, 27.2 years). Demographics, depressive symptoms, general psychopathology, suicidal ideation and attempts and psychological and somatic factors were recorded. Among adolescents of both sexes, psychosocial variables were correlated with and predicted depressive symptom severity. The strongest predictors were sex (female), the levels of depressive symptoms the preceding year, and the total number of stressful events. The association between stressful life events and depressive symptoms was moderated by physical activity, while the relationship between stressful events and coping style was mediated by depressive symptoms. The rate of use of specialised mental health services among the depressed was low. The lifetime prevalence of depressive disorders was 23% at 15 years, and the most common disorder was minor depression. Adolescents who attempted suicide were more often victims of violence and less resilient than were non-suicide attempters. The existing longitudinal data from the cohort will be further analysed. Follow-up data will be obtained from existing national registries by links created with individual identification numbers.

Sleep among Youth with Severely Disabling Chronic Pain: Before, during, and after Inpatient Intensive Interdisciplinary Pain Treatment

Poor sleep is commonly reported in pediatric chronic pain. There are signals that intensive interdisciplinary pain treatments (IIPT) may inadvertently improve objective sleep, but this claim cannot be substantiated without baseline sleep data prior to IIPT. This study followed the objective sleep/wake patterns (e.g., duration, quality, timing, consistency) of pediatric patients with severely functionally disabling chronic pain before, during, and after inpatient IIPT (the Functional Independence Restoration Program-"FIRST Program"), alongside a similarly-disabled chronic pain Comparison Group. The final sample included N = 10 FIRST Patients and N = 9 Comparison Group patients. At baseline, the whole sample showed healthy sleep duration (~9 h), average sleep efficiency <90%, late sleep onset and offset (mean = 11:56 p.m.-8:50 a.m.), and highly inconsistent sleep schedules night to night. During IIPT, FIRST Patients maintained healthy sleep durations, moved sleep schedules 2 h earlier, and decreased timing and duration variability by >60 min while the Comparison Group maintained similar sleep to baseline. At follow up (1-2 months later), FIRST Patients' sleep schedules shifted later but were still less variable than at baseline. Results point to the malleability of sleep/wake patterns within treatment contexts with strict environmental control but suggest that these gains may be difficult for youth with chronic pain to maintain in the home environment.

Are psychological symptoms a risk factor for musculoskeletal pain in adolescents?

Adolescent musculoskeletal pain is common and is associated with musculoskeletal pain in adulthood. Psychological symptoms, also common in adolescence, have been shown to be associated with musculoskeletal pain, but the current evidence is mixed and may be dependent on effect modifiers. This study investigated whether adolescents with psychological symptoms (internalizing and externalizing constructs) at age 13 years were at higher odds for musculoskeletal pain at age 17 years and whether the associations were modified by pubertal status and sex. A prospective cohort design examined data on 3865 adolescents from the Avon Longitudinal Study of Parents and Children (ALSPAC). Associations between baseline (aged 13 years) internalizing and externalizing symptoms and musculoskeletal pain at follow-up (aged 17 years) were investigated using logistic regression producing odds ratios (OR) and 95% confidence intervals (95% CI). In total 43.1% of adolescents reported musculoskeletal pain at follow-up. Externalizing symptoms at baseline increased the odds of musculoskeletal pain (OR 1.68, 95% CI 1.28, 2.20), and internalizing symptoms demonstrated a non-significant increase (OR 1.26, 95% CI 0.98, 1.62). Effect modification analysis showed an increased effect dependent on pubertal status.Conclusion: Adolescents with externalizing symptoms, and to some extent internalizing symptoms, are at increased odds of later musculoskeletal pain. Future research is now required to understand the reasons for these associations. What is Known: • Current evidence regarding the association between internalizing symptoms and externalizing symptoms and future musculoskeletal pain in adolescents is mixed. What is New: • This study found that adolescents with externalizing symptoms, and to some extent internalizing symptoms, are at increased odds for musculoskeletal pain, with an increased influence dependent on pubertal status. • These results are of interest for the development of timely preventative interventions designed to reduce the risk of musculoskeletal pain.

Talking to Children and Families about Chronic Pain: The Importance of Pain Education-An Introduction for Pediatricians and Other Health Care Providers

Chronic pain in children and adolescents is a common and debilitating health problem. This narrative review will give a brief overview on what pediatric chronic pain is and what treatment options there are for children and adolescents. The specific emphasis will be on pediatric chronic pain education and communication: this narrative review aims to show how important a good patient-health care provider relationship is-it builds the foundation for successful communication-and how this relationship can be established. In addition, we will present five steps that health care providers can perform to explain pediatric chronic pain to patients and their parents and what to keep in mind in their clinical routine. Our review is intended for pediatricians and other health care providers who treat pediatric patients with chronic pain but might feel uncertain on how to best communicate with them.

Self-reported recurrent pain and medicine use among 15-year-olds: results from the HBSC Italian study

Background

The prevalence of adolescent pain varies considerably across epidemiological studies, and little information is available on pain-related behaviours among adolescents, including medicine use. The aims of this study were: [1] to examine the prevalence of recurrent pain among 15-year-old adolescents in Italy; [2] to investigate the association between recurrent pain and medicine use among boys and girls; and [3] to evaluate the consistency of these associations across Regions.

Methods

The World Health Organization (WHO) collaborative International Health Behaviour in School-aged Children 2013/2014 study collected self-reported data on pain and medicine use from 13611 15-year-old adolescents in 21 Italian Regions. We used multi-level multivariate logistic regression, stratified by gender, to analyse the association between recurrent pain and medicine use for headache, stomachache, nervousness and difficulties in getting to sleep.

Results

On average, across all Regions, almost 45% of adolescents reported recurrent headache, more than 30% reported recurrent backache and approximately 30% reported recurrent stomachache. Although the prevalence of both pain and medicine use was much higher among girls, the association between pain and medicine use was similarly strong in adolescents of both genders. Adolescents with recurrent pain proved more likely to use medicines also for non-corresponding pain, nervousness and difficulties in getting to sleep. The association between recurrent pain and medicine use was consistent across Regions despite large inter-regional differences in the prevalence of both phenomena.

Conclusions

Recurrent pain in adolescence is common nationwide. Adolescents with recurrent pain are more likely to use medicines in general. Recurrent pain and medicine use should be addressed by adolescent health policies.

The Role of School-Related Well-Being for Adolescent Subjective Health Complaints

BACKGROUND

This study aimed to explore the prevalence of chronic specific-site and multisite pain in adolescents and to investigate how it can possibly be determined by school-related factors.

METHODS

A population-based cross-sectional study was conducted in 2014 in Lithuania as a Health Behavior in School-Aged Children (HBSC) survey. The sample consisted of 5730 school children, aged 11, 13, and 15 years. The analyzed data focused on the school-related context (relations with family, peers, and teachers; school demand, satisfaction, and bullying) of adolescents and subjective health complaints. The relationships between social support and health complaint variables were estimated using multivariate analyses.

RESULTS

The most common subjective health complaint among respondents was a headache. Backache, headache, and stomachache were more common among girls than boys. All somatic complaints were expressed more in younger ages. Multisite complaints were more common among girls and were associated with age-older ones reported more complaints. School-related bullying, school demand, satisfaction, and social support were the most relevant and independent factors for multisite somatic complaints among adolescents.

Prevalence and Association of Pain Experiences, Medication Literacy, and Use of Medication among Children and Adolescents in Taiwan

OBJECTIVE

This study assessed the prevalence of children's and adolescents' pain experiences and use of medicine and examined the relationships between pain experiences, medication knowledge, literacy, and use of medicine.

METHOD

A probability-proportionate-to-size sampling method was used to systematically draw a random sample of schools. In 2014, a national representative sample of 2309 students from 35 primary schools (5th-6th grade), 2700 students from 30 middle schools, and 2013 students from 20 high schools completed the online survey.

RESULTS

Overall, 85.6% of children and adolescents reported experiencing pain during the past year that included headache (63.0%), throat ache (59.3%), muscle ache (58.3%), stomach pain (42.9%), menstrual pain (girls: 42.1%), and dental pain (38.5%). Children and adolescents had taken cold/cough medicine (48.1%), acetaminophen (15.0%), antacids (14.8%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (10.5%) in the past year. Multivariate analysis results indicated that after controlling for pain experiences children and adolescents who had lower levels of medication knowledge and literacy were more likely to use pain medication and antacids more frequently. In addition, children and adolescents who had lower medication knowledge, lower literacy, asked doctors to prescribe antacids, and co-administered with antacids were more likely to report long-term use of antacids.

CONCLUSIONS

Lower levels of medication knowledge and literacy among children and adolescents were associated with more frequent use of pain medication and antacids.

Adverse Childhood Experiences in Mothers With Chronic Pain and Intergenerational Impact on Children

Adverse childhood experiences (ACEs; eg, parental divorce, physical or sexual abuse) are more prevalent in individuals with chronic pain compared with the general population. Both increased maternal ACEs and chronic pain have been associated with poor physical and emotional functioning in offspring. However, the mechanisms driving these associations are poorly understood. Thus, this cross-sectional study evaluated the relation between maternal ACEs, mothers' current functioning, and children's physical and emotional functioning in a sample of mothers with chronic pain and their 8- to 12-year-old children. Results indicated a higher prevalence of ≥1 ACE in this sample of mothers with chronic pain (84%) compared with normative data from a community sample of women. Higher maternal ACE scores corresponded with lower physical and social functioning, greater anxiety and depressive symptoms, greater fatigue and sleep disturbances, and greater pain intensity and pain interference in mothers. Higher maternal ACE scores significantly correlated with higher child self-reported depressive symptoms, but not somatic symptoms or functional impairment. A path model indicated that maternal depressive symptoms accounted for the relation between higher maternal ACE scores and children's depressive symptoms. Intervening on maternal depression among mothers with chronic pain may reduce the impact of intergenerational ACE transmission. Perspective: This article presents evidence regarding the intergenerational impact of ACEs in a large sample of mothers with chronic pain and their school-aged children. Maternal depressive symptoms accounted for the relation between maternal ACEs and children's depressive symptoms providing evidence regarding targets for preventive interventions.

Giving less importance to pain and focusing on achieving objectives

Giving less importance to pain and focusing on achieving objectives in accordance with values can help people to live their lives in spite of the pain. We present a rationale for this orientation and several techniques that can help people achieve this. Specifically, we present the importance of starting the intervention by educating people about pain and setting objectives in line with each person's personal values. After that, we present some techniques that can help people deal with triggers and barriers that can make it difficult to stay on track when it comes to giving less importance to pain and more to achieving objectives.

Somatic symptoms in adolescence as a predictor of severe mental illness in adulthood: a long-term community-based follow-up study

BACKGROUND

Somatic symptoms are common and costly for society and correlate with suffering and low functioning. Nevertheless, little is known about the long-term implications of somatic symptoms. The objective of this study was to assess if somatic symptoms in adolescents with depression and in their matched controls predict severe mental illness in adulthood by investigating the use of hospital-based care consequent to different mental disorders.

METHODS

The entire school population of 16-17-year-olds in the city of Uppsala, Sweden, was screened for depression in 1991-1993 (n = 2300). Adolescents with positive screenings (n = 307) and matched non-depressed controls (n = 302) participated in a semi-structured diagnostic interview for mental disorders. In addition, 21 different self-rated somatic symptoms were assessed. The adolescents with depression and the matched non-depressed controls were engaged in follow-up through the National Patient Register 17-19 years after the baseline study (n = 375). The outcome measures covered hospital-based mental health care for different mental disorders according to ICD-10 criteria between the participants' ages of 18 and 35 years.

RESULTS

Somatic symptoms were associated with an increased risk of later hospital-based mental health care in general in a dose-response relationship when adjusting for sex, adolescent depression, and adolescent anxiety (1 symptom: OR = 1.63, CI 0.55-4.85; 2-4 symptoms: OR = 2.77, 95% CI 1.04-7.39; ≥ 5 symptoms: OR = 5.75, 95% CI 1.98-16.72). With regards to specific diagnoses, somatic symptoms predicted hospital-based care for mood disorders when adjusting for sex, adolescent depression, and adolescent anxiety (p < 0.05). In adolescents with depression, somatic symptoms predicted later hospital-based mental health care in a dose-response relationship (p < 0.01). In adolescents without depression, reporting at least one somatic symptom predicted later hospital-based mental health care (p < 0.05).

CONCLUSIONS

Somatic symptoms in adolescence predicted severe adult mental illness as measured by hospital-based care also when controlled for important confounders. The results suggest that adolescents with somatic symptoms need early treatment and extended follow-up to treat these specific symptoms, regardless of co-occurring depression and anxiety.

Cumulative effects of multiple pain sites in youth with chronic pain

BACKGROUND

The experience of persistent pain in multiple locations is common in youth. Based on current literature, youth with multiple pain sites (MPS) are at risk of experiencing poorer emotional outcomes and a spread of symptoms into late adolescence and adulthood. Little is known regarding the association between MPS with physical and school functioning domains, particularly after initiation of multidisciplinary pain treatment. Therefore, the objective of this study was to examine the association of MPS with disability and school functioning among youth with chronic pain.

METHODS

A total of 195 patients with chronic pain, aged 8-17, and their parents completed measures assessing patient distress and functioning at a multidisciplinary pain clinic evaluation and at 4-month follow-up.

RESULTS

At evaluation, 63% of patients presented with MPS; 25% reporting MPS endorsed pain in five or more locations. When controlling for relevant demographic and emotional distress factors, MPS were associated with lower school functioning at evaluation with a persistent trend at follow-up. Although MPS were not a significant predictor of pain-related disability at evaluation, it emerged as significant at follow-up.

CONCLUSIONS

Potentially due to the MPS load and the inverse effects that such a pain state has on function, such patients may be at risk for poorer health and school-related outcomes. The mechanisms influencing these relationships appear to extend beyond psychological/emotional factors and warrant further investigation in order to aid in our understanding of youth with MPS.

SIGNIFICANCE

Youth with MPS may be at risk for experiencing poorer physical and school functioning in comparison with single-site peers, despite treatment initiation. Further research is warranted to inform assessment and treatment approaches for this subgroup of patients.

A Conceptual Framework for Understanding the Role of Adverse Childhood Experiences in Pediatric Chronic Pain

OBJECTIVES

This review outlines a conceptual framework adapted from the biopsychosocial model of pain to examine the relationship between adverse childhood experiences (ACEs) and chronic pain in youth to highlight the state of current research and guide future efforts.

METHODS

A review of the literature was performed in the areas of ACEs and health outcomes with general adult and pediatric populations in addition to studies within the pain literature. Potential relationships between ACEs, chronic pain, and its impact in youth are outlined and discussed.

RESULTS

The literature suggests an association between adverse outcomes of ACEs and chronic pain in children and adolescents although causal links have not been confirmed. However, ACEs are associated with multiple risk factors identified in the biopsychosocial model of pain, and may serve to exacerbate or confer heightened risk for pain and poor outcomes.

DISCUSSION

Adverse experiences in childhood may be associated with greater risk for the development/maintenance of chronic pain in youth. More research is needed on ACEs and how they uniquely affect the biopsychosocial mechanisms underlying chronic pain in children throughout the lifespan.

Predicting the occurrence of headache and back pain in young adults by biopsychological characteristics assessed at childhood or adolescence

The aim of the current study was to identify predictors of recurrent headache and back pain in young adults (aged 18–27 years) from data assessed in childhood or adolescence, i.e., 9 years before the final survey. Our interest was whether psychological characteristics contribute to the risk of pain prevalence in adult age when controlling for already empirically supported risk factors such as parental pain, pediatric pain and sex. The study was part of a five-wave epidemiological investigation of >5000 families with children aged between 7 and 14 years when addressed first. In a multiple hierarchical regression analysis, the abovementioned three variables (Block-I variables) were entered first followed by five psychological trait variables (Block-II variables: internalizing, anxiety sensitivity, somatosensory amplification, catastrophizing and dysfunctional stress coping) to find out the extent of model improvement. The multivariable hierarchical regression analysis confirmed the hypothesis that the Block-I variables significantly enhance the risk of future pain at young adult age. None of the psychological variables did so. Thus, the hypothesis of a significant surplus predictive effect was not confirmed. The amount of total explained variance differed strongly between headache and back pain. In particular, a valid prediction of back pain was not possible. When analyzed separately in simple regression analysis, psychological variables turned out to be significant predictors, however, of very low effect size. The inclusion of Block-I variables in the model clearly reduced the impact of the psychological variables. This risk profile is discussed in the context of the different trajectories of headache and back pain from childhood to adult age, which were proposed by various studies. We propose that a biopsychological characteristic denoted as emotional negativity, especially regarding self-reference, might be a common factor behind all selected variables. Risk research in recurrent pain is a field where much more multidisciplinary research is needed before progress can be expected.

Long-term adolescent multi-site musculoskeletal pain is associated with psychological distress and anxiety

OBJECTIVE

Although several studies have shown that adolescent musculoskeletal pain is associated with psychological problems in a cross-sectional setting, the associations of long-term musculoskeletal pain with psychological distress and anxiety are not known.

METHODS

The study included 1773 adolescents belonging to the Northern Finland Birth Cohort 1986. They received a postal questionnaire at the age of 16years and a follow-up questionnaire two years later. The first inquiry contained questions about the sites of musculoskeletal pain; the second had the same pain questions, along with measures of distress and anxiety. Risk ratios (RR) were assessed by log-linear regression analysis.

RESULTS

Multi-site musculoskeletal pain (in ≥2 body locations) at both 16 and 18years was common, reported by 53% of girls and 30% of boys. Multi-site pain at both ages, compared to those with multi-site pain neither at 16 nor 18years, was associated with psychological distress at the age of 18 among both girls (RR 1.8 95% CI 1.2-2.7) and boys (RR 3.5 95% CI 2.1-5.9). For anxiety, the corresponding relative risks were 1.5 (95% CI 1.0-2.2) and 1.8 (95% CI 1.4-2.3), respectively. For short-term multi-site pain (prevalent only at the age of 16 or 18), these relative risks were between 0.8 and 2.3.

CONCLUSIONS

Adolescents with long-term multi-site pain have higher levels of distress and anxiety than those without or with only short-term multi-site pain. Associations were found in both genders, but the relationship between pain and distress was more pronounced among boys. The associations had modest effect strength.

Pain extent and function in youth with physical disabilities

Background

The aim of this study was to increase our understanding of the role that spatial qualities of pain (location and extent) play in functioning, among youths with disabilities and chronic pain.

Methods

One-hundred and fifteen youths (mean age 14.4 years; SD ±3.3 years) with physical disabilities and chronic pain were interviewed and were asked to provide information about pain locations and their average pain intensity in the past week, and to complete measures of pain interference, psychological function and disability. Most of the participants in this sample were males (56%), Caucasian (68%), and had a cerebral palsy (34%) or muscular dystrophy (25%) problem. Most participants did not report high levels of disability ( X¯=12.7, SD ±9.5, range 0–60) or global pain intensity ( X¯=3.2, SD ±2.4, range 0–10).

Results

Pain at more than one body site was experienced by 91% of participants. There were positive associations between pain extent with pain interference (r = 0.30) and disability (r = 0.30), and a negative association with psychological function (r = –0.38), over and above average pain intensity. Additionally, pain intensity in the back (as opposed to other locations) was associated with more pain interference (r = 0.29), whereas pain intensity in the shoulders was associated with less psychological function (r = –0.18), and pain intensity in the bottom or hips was associated with more disability (r = 0.29).

Conclusion

The findings support the need to take into account pain extent in the assessment and treatment of youths with physical disabilities and chronic pain, call our attention about the need to identify potential risk factors of pain extent, and develop and evaluate the benefits of treatments that could reduce pain extent and target pain at specific sites.

Child and Family Antecedents of Pain During the Transition to Adolescence: A Longitudinal Population-Based Study

Pediatric persistent pain is associated with poorer physical and psychosocial functioning in children, as well as immediate and long-term societal costs. Onset typically occurs in early adolescence, suggesting that late childhood is a key window for identifying potential intervention targets before pain symptoms become entrenched. This study used population-based data from the Longitudinal Study of Australian Children (n = 3,812) and adopted a biopsychosocial and ecological systems approach to investigate child, family, and sociodemographic factors associated with pain problems in children transitioning to adolescence. The prevalence of at least weekly parent-reported pain in the study sample was approximately 5% at 10 to 11 years of age, and pain continued at 12 to 13 years of age for 40% of these children. Key factors at 10 to 11 years that uniquely predicted parent-reported pain problems at 12 to 13 years were frequency of previous pain (1-3 times weekly: odds ratio [OR] = 7.49; 95% confidence interval [CI], 4.3-13.0; 4-7 times weekly: OR = 17.8; 95% CI, 8.7-36.5) and sleep difficulties (OR = 1.86; 95% CI, 1.16-2.97). This study highlights the importance of early intervention for persistent pain in childhood, because pain complaints in late childhood tend to persist into early adolescence.

PERSPECTIVE

This article used a biopsychosocial and ecological systems approach to understanding predictors of pain problems during the transition to adolescence within a nationally representative community-based cohort. Sleep difficulties at 10 to 11 years uniquely predicted pain at ages 12 to 13 years, suggesting that early intervention using sleep interventions may be a promising direction for future research.

Pain is prevalent among adolescents and equally related to stress across genders

Background

Young people seem increasingly disabled due to pain and stress. Pain and stress are health risks with adverse long-term health effects. Traditionally, these health risks have been most prevalent and strongest associated in females, also regarding children and adolescents. Main objectives in this study were to investigate current gender differences in musculoskeletal pain and perceived stress in adolescents aged 15 and 16 years with respect to prevalence and group differences for various aspects of stress and pain, and to explore the relationship between stress and pain, specified for gender.

Methods

A cross-sectional study was conducted with 17 participating public schools. The survey was administrated by the schools in accordance with given procedures, emphasizing the volunteer and anonymous participation of the pupils. Primary study measurements were pain and stress. The pain measurements addressed different aspects of musculoskeletal pain including pain sites, pain duration and pain intensity (measured by a Visual analogue scale; VAS). The stress instrument used was the Perceived stress questionnaire (PSQ) comprising different factors of stress, i.e. worries, tension, joy and demands. The secondary study measurement was body mass index (BMI).

Results

The study sample comprised 422 adolescents aged 15 and 16 years; 218 females and 204 males. The pain reporting was high in both genders, 57.3 per cent of the females and 44.6 per cent of the males. In general, the female adolescents reported more pain and stress, although several pain measures corresponded between genders. The pain prevalence was similar across genders with respect to lower extremity pain, back pain and arm pain. Lower extremity pain was the most frequent reported pain in both genders. More females reported head pain (Pearson Chi-Square 7.11, p = .008), severe pain (VAS ≥ 7, Pearson Chi-Square 13.12, p = .004) and moderate to severe stress (PSQ ≥ 0.45, Pearson Chi-Square 29.11, p < .001). Comparison analyses of the continuous pain and stress variables revealed significant mean (95% confidence interval [CI]) differences between genders for all stress variables with the highest mean scores in females. In both genders there were significant (p < .01) correlations between all the continuous pain and stress variables. In 9 out of 15 correlations, the stress-pain associations were strongest in males (Pearson product-moment correlation (r) between 0.34 and 0.38). Only in females, the body mass index (BMI) appeared associated (weakly) to pain and stress, in terms of pain intensity (VAS, r = 0.19) and lack of joy (as a factor of stress, r = 0.16).

Conclusion

Pain and stress were prevalent in the adolescent sample, with generally higher reporting among females. Several pain measures corresponded between genders, but stress differed significantly between genders for all variables. Scrutinizing the relationship between pain and stress revealed significant stress-pain associations regarding all variables across genders, i.e. the pain complaints among the adolescents seemed equally related to stress in males and females in the sample.

The relationship between back pain and schoolbag use: a cross-sectional study of 5,318 Italian students

BACKGROUND CONTEXT

Back pain at a young age is considered to be predictive of chronicity. Several studies have investigated the relationship between the use of a schoolbag and back pain, although some aspects are still unclear.

PURPOSE

The aim of this study was to evaluate back pain due to schoolbag use in terms of (1) prevalence and intensity, (2) differences between male and female pupils, and (3) predisposing factors.

STUDY DESIGN

This is a cross-sectional study.

PATIENT SAMPLE

The sample was composed of 5,318 healthy pupils aged 6 to 19 years (classified according to three age groups: children, younger adolescents, and older adolescents).

OUTCOME MEASURES

Schoolbag-related pain was assessed by means of an ad hoc questionnaire. The intensity of pain was assessed using the Wong scale.

METHODS

Subjects underwent a face-to-face interview using an ad hoc questionnaire. The intensity of pain was assessed using the Wong scale. On the basis of the prevalence and intensity of back pain, we divided our population into two groups: (1) no or mild pain group and (2) moderate or severe pain group. The "schoolbag load" (ratio between schoolbag and pupil weight multiplied by 100) was calculated for each subject.

RESULTS

More than 60% of the subjects reported pain. Although the schoolbag load decreased from children to young and older adolescents, schoolbag-related pain significantly increased (p<.001). Girls reported significantly more frequent and more severe pain than boys. The logistic model confirmed that adolescent girls are the group at greatest risk of suffering from intense pain. The schoolbag load had a weak impact on back pain, whereas the schoolbag carrying time was a strong predictor.

CONCLUSIONS

Adolescent girls have the highest risk of experiencing severe back pain, regardless of schoolbag load. This suggests that other factors (anatomical, physiological, or environmental) might play an important role in pain perception. These aspects should be investigated to plan appropriate preventive and rehabilitative strategies.

Customized CBT via internet for adolescents with pain and emotional distress: A pilot study

The aim of this pilot study was to explore the effects of an early and customized CBT intervention, mainly delivered via internet, for adolescents with coexisting recurrent pain and emotional distress (low mood, worry, and/or distress). The intervention was based on a transdiagnostic approach, to concurrently target pain and emotional distress. A single case experimental design (SCED) was employed with six participants, 17-21 years old, who were recruited via school health care professionals at the student health care team at an upper secondary school in a small town in Sweden. The intervention consisted of 5-9 modules of CBT, delivered via internet in combination with personal contacts and face to face sessions. The content and length of the program was customized depending on needs. The effects of the program were evaluated based on self-report inventories, which the participants filled out before and after the intervention and at a six month follow-up. They did also fill out a diary where they rated symptoms on a daily basis. The results were promising, at least when considering changes during the intervention as well as pre- and posttest ratings. However, the results were more modest when calculating the reliable change index (RCI), and most of the treatment effects were not sustained at the follow-up assessment, which raises questions about the durability of the effects. Taken together, this study indicates that this type of program is promising as an early intervention for adolescents with pain and concurrent emotional distress, although the outcomes need to be explored further, especially in terms of long-term effects.

Pain and Moderate to Vigorous Physical Activity in Adolescence: An International Population-Based Survey

OBJECTIVE

To evaluate whether individual types of pain (headache, stomach-ache, and backache) or multiple pains affect the odds of young people achieving the recommended 60 minutes of moderate to vigorous physical activity (MVPA) per day in a large representative sample.

DESIGN

Multicenter cross-sectional survey.

SETTING

Twenty-eight countries across Europe and North America.

SUBJECTS

Adolescents (N = 242,103).

METHODS

An analysis of data collected in two waves (2001/02 and 2005/06) of the health behavior in school-aged children (HBSC) study was performed. Survey questions included the HBSC symptoms checklist and the amount of regular physical activity. Multilevel logistic regression was used to account for clustering effect of MVPA within countries. Models investigated the relationship between pain and physical activity, adjusted for the HBSC study year. Six models were conducted separately for gender and age-group (11, 13, and 15 years) strata.

RESULTS

In general, the presence of pain was associated with reduced physical activity. Headache alone was associated with reduced physical activity in all six strata (odd ratios 0.77-0.84), stomach-ache alone in five strata (0.77-0.92), and backache alone in four strata (0.86-0.96). In 11- and 13-year-old girls, headache, stomach-ache, and backache, individually and in combination, were associated with decreased odds of being physically active (odds ratios ranging from 0.73 to 0.91). Within the other four age and gender strata, the relationship was less consistent.

CONCLUSION

Pain is associated with reduced physical activity in adolescents but this association varies according to gender, age, and the type of pain experienced.

Chronic multisite pain in adolescent girls and boys with emotional and behavioral problems: the Young-HUNT study

The aim of this study was to assess the prevalence of chronic multisite pain with high disability in relation to emotional or behavioral problems and resilience factors in adolescence. A second aim was to investigate if resilience factors could attenuate the associations between psychiatric symptoms and chronic multisite pain. The study was based on a large cross-sectional study carried out in Norway between 2006 and 2008 and included 7,070 adolescents aged 13-19 years. Chronic multisite pain was defined as pain at least once a week during the last 3 months, scoring high on a disability index, and occurring in three or more locations. Chronic multisite pain was prevalent among adolescents with high scores (>85%) for anxiety/depression, social anxiety, conduct or attention problems (22.8-31.0 for girls, 8.8-19.0% for boys). Several coexistent psychiatric symptoms increased the prevalence of chronic multisite pain for both girls and boys. Resilience factors, including high self-esteem, seldom feeling lonely, and high scores for family cohesion or social competence, were associated with a lower prevalence and markedly attenuated the association between psychiatric symptoms and chronic multisite pain. Psychiatrists should be careful to assess and treat comorbid chronic pain in adolescents with emotional or behavioral problems.

Is involvement in school bullying associated with general health and psychosocial adjustment outcomes in adulthood?

The aim was to examine prospectively associations between bullying involvement at 14-15 years of age and self-reported general health and psychosocial adjustment in young adulthood, at 26-27 years of age. A large representative sample (N=2,464) was recruited and assessed in two counties in Mid-Norway in 1998 (T1) and 1999/2000 (T2) when the respondents had a mean age of 13.7 and 14.9, respectively, leading to classification as being bullied, bully-victim, being aggressive toward others or non-involved. Information about general health and psychosocial adjustment was gathered at a follow-up in 2012 (T4) (N=1,266) with a respondent mean age of 27.2. Logistic regression and ANOVA analyses showed that groups involved in bullying of any type in adolescence had increased risk for lower education as young adults compared to those non-involved. The group aggressive toward others also had a higher risk of being unemployed and receiving any kind of social help. Compared with the non-involved, those being bullied and bully-victims had increased risk of poor general health and high levels of pain. Bully-victims and those aggressive toward others during adolescence subsequently had increased risk of tobacco use and lower job functioning than non-involved. Further, those being bullied and aggressive toward others had increased risk of illegal drug use. Relations to live-in spouse/partner were poorer among those being bullied. Involvement in bullying, either as victim or perpetrator, has significant social costs even 12 years after the bullying experience. Accordingly, it will be important to provide early intervention for those involved in bullying in adolescence.

The influence of condition parameters and internalizing symptoms on social outcomes in youth with spina bifida

OBJECTIVE

To test a model of social competence in youth with spina bifida (SB). Involvement in social activities was expected to mediate associations between SB-related condition parameters (pain, body mass index, and motor function) and social competence. Internalizing symptoms were predicted to amplify the negative impact of condition parameters on social activity involvement.

METHODS

108 youth with SB, their caregivers, peers, and teachers participated in a multimethod study that included cognitive testing, questionnaires, and observational interaction tasks.

RESULTS

Social activity involvement partially mediated the relation between pain and lower social competence. Internalizing symptoms had a significant indirect effect on social competence via decreased involvement in social activities.

CONCLUSIONS

Pain and internalizing symptoms interfere with social activity involvement, which is, in turn, important for social competence development in youth with SB. Assessing and treating these condition parameters and activity factors may be important areas of focus in clinical practice and research with these youth.

Self-reported recurrent pain and medicine use behaviours among 15-year olds: results from the international study

BACKGROUND

There is considerable variation in adolescent pain prevalence across epidemiological studies, with limited information on pain-related behaviours among adolescents, including medicine use. The aims of this study were (1) to examine the prevalence of recurrent pain among 15-year-old adolescents internationally; (2) to investigate the association between recurrent pain and medicine use behaviours among boys and girls; and (3) to evaluate the consistency of these associations across countries.

METHODS

The World Health Organization (WHO) collaborative international Health Behaviour in School-aged Children 2009/2010 study collects data about self-reported aches and medicine use from 36,762 15-year-old adolescents from 22 countries/regions in Europe and the United States. Multi-level multivariate logistic regression, stratified by gender, was used to analyse the association between recurrent pain and medicine use for headache, stomachache, nervousness and difficulties in getting to sleep.

RESULTS

More than 30% of adolescents reported recurrent headache, almost 30% recurrent backache and approximately 20% recurrent stomachache. Although pain prevalence and medicine use for aches were much higher for girls, the association between pain and medicine use was similarly strong for both genders. Adolescents with recurrent pain are more likely to use medicines also for non-corresponding pain, nervousness and difficulties in getting to sleep. The association between recurrent pain and medicine use was consistent across countries despite large-country differences in the prevalence of recurrent pain and medicine use.

CONCLUSIONS

Recurrent pain in adolescence is common cross-nationally. Adolescents with recurrent pain are more likely to use medicine in general. Recurrent pain and medicine use should be addressed in adolescent health policies.

In search of risk factors for chronic pain in adolescents: a case-control study of childhood and parental associations

Objectives

This study was designed to investigate whether an individual and parental history of functional pain syndromes (FPS) is found more often in adolescents suffering from chronic pain than in their pain-free peers.

Methods

Our case–control study involved 101 adolescents aged 10–18 years. Cases were 45 patients of the Chronic Pain Clinic at Sydney Children’s Hospital with diverse chronic pain disorders. Controls consisted of 56 adolescent volunteers who did not have chronic pain. Adolescents and their parents filled out questionnaires assessing demographic data as well as known and potential risk factors for chronic pain. A history of FPS was assessed by questionnaire, including restless legs syndrome (RLS). Chi-squared tests and t-tests were used to investigate univariate associations between chronic pain in adolescents and lifetime prevalence of FPS. Logistic regression was used to test multivariate associations, while controlling for possible confounders.

Results

Migraine, non-migraine headaches, recurrent abdominal pain (RAP), and RLS were reported significantly more frequently in cases than controls (P-values of 0.01, <0.001, 0.01, and 0.03, respectively). Parental migraine, RAP, and RLS were also significantly associated with adolescent chronic pain in the multivariate analyses. Individual history of migraine, non-migraine headaches, and RAP, along with parental history of RAP and depression significantly accounted for 36%–49% of variance in chronic pain. Other associations with chronic pain were generally in accordance with previous reports.

Discussion

It may be helpful when assessing a child who has chronic pain or is at risk of chronic pain, to enquire about these associations. Based on the current findings, an individual history of migraine, non-migraine headaches, and RAP, as well as parental migraine, RAP, and RLS are symptoms that are of particular relevance to assess.

Adolescents' multiple, recurrent subjective health complaints: investigating associations with emotional/behavioural difficulties in a cross-sectional, school-based study

BACKGROUND

Adolescence has been documented as the peak age of onset for mental health perturbations, clinical disorders and unsubstantiated health complaints. The present study attempted to investigate associations between multiple, recurrent subjective health complaints (SHC) with emotional/behavioural difficulties, as measured by the Strengths and Difficulties Questionnaire scale (SDQ), among Greek adolescents.

METHODS

Questionnaires were administered in a large, nation-wide, random, school-based sample of Greek adolescents, aged 12-18 years. Data from 1170 participants were analyzed. Adolescents with multiple, recurrent SHC were compared in terms of their emotional/behavioural difficulties to their peers with lower levels of health complaints. SDQ scales were separately investigated for their associations with multiple, recurrent SHC, after adjustment for gender, age and socioeconomic status (ses). Further analysis included multiple logistic regression models with multiple, recurrent SHC as the dependent variable and gender, age, ses and SDQ Total difficulties score as independent factors. Potential gender and age interactions were also explored.

RESULTS

Almost half of the study participants reported multiple, recurrent SHC. Adolescents with multiple, recurrent SHC had higher scores on all SDQ scales, except from the Prosocial behavior scale, compared to their peers with lower levels of health complaints. Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention and Peer Problems were associated with greater likelihood of having multiple, recurrent SHC, after adjustment for gender, age and ses. The multiple logistic regression models revealed that older adolescents and girls, as well as those with increased Total difficulties score had an increased risk for multiple, recurrent SHC reporting. No significant interaction between SDQ scales and gender or age was found.

CONCLUSIONS

Our study highlights the magnitude of psychological burden among adolescents experiencing multiple, recurrent SHC. Professionals in school and clinical settings should be cautious for impaired emotional/behavioural functioning when assessing adolescents with multiple, recurrent SHC, so as early identification of at-risk individuals and timely, appropriate referrals are facilitated.

Parent pain and catastrophizing are associated with pain, somatic symptoms, and pain-related disability among early adolescents

OBJECTIVE

To examine associations between parental history of pain and catastrophizing and their adolescent's pain, somatic symptoms, catastrophizing, and disability.

METHODS

Participants included 178 youths aged 11-14 years recruited through public schools. Adolescents completed measures assessing pain characteristics, somatic symptoms, and pain catastrophizing. Parents reported on their own pain, and catastrophizing about their adolescent's pain.

RESULTS

About one quarter of the adolescents and two thirds of parents reported having pain. Parent pain was associated with adolescent pain, somatic symptoms, and pain catastrophizing. Parent catastrophizing was a significant predictor of adolescent somatic symptoms and pain-related disability, beyond the contribution of parent pain. Adolescent catastrophizing mediated the association between parent catastrophizing and adolescent pain-related disability.

CONCLUSIONS

Parent history of pain and pain-related cognitions may contribute to adolescent risk for chronic pain.

The German Pain Catastrophizing Scale for Children (PCS-C) - psychometric analysis and evaluation of the construct

Objective: The Pain Catastrophizing Scale, adapted for children (PCS-C) by Crombez et al. (2003), was translated into German (SKS-D) and evaluated regarding its factorial structure, its reliability and validity. The association of catastrophizing with various pain characteristics and disability measures was examined as well as its association to neighboring constructs.

Method: The paper-and-pencil version of the SKS-D was used in two different samples of children and adolescents. Analyses were conducted on a subgroup of participants from an epidemiological sample [n=898; age: M=12.9 (SD=1.4)] who had experienced monthly headaches in the 6-months period before and a clinical sample [n=60; age: M=12.6 (SD=0.8)] seeking treatment for recurrent headaches.

Results: Exploratory factor analysis (PCA) suggested a one-factor model in contrast to the 3-factor model suggested by Crombez et al. (2003). The unidimensional scale showed distinct homogeneity and satisfying reliability. The clinical sample showed significantly higher scores than the epidemiological group. Also girls scored higher than boys. The catastrophizing explained a considerable amount of variance in pain and disability parameters in both samples thus underlining its validity.

The psychological variables internalising, anxiety sensitivity and somatosensory amplification showed significant small to moderate associations with pain catastrophizing and also with pain and disability. After controlling for the above mentioned psychological variables, catastrophizing still yielded an independent contribution to the explanation of variance in pain and disability parameters.

Conclusions: The PCS-C in its German form is a valid and reliable instrument for assessing catastrophizing in children with recurrent pain, in particular headache, in the age of 10–16 years. Pain catastrophizing is suggested to be assessed especially in pediatric pain patients as it is a significant moderator of pain and disability. In children with a distinct tendency to catastrophize cognitive restructuring should become a target of pediatric pain therapy, as a reduction of catastrophizing cognitions may indirectly help to ameliorate pain and disability.

Psychosocial and lifestyle correlates of musculoskeletal pain patterns in adolescence: a 2-year follow-up study

BACKGROUND

The prevalence of musculoskeletal (MS) pain has been increasing among adolescents in the last decades. This may be related to either adverse changes in lifestyle and/or the psychosocial environment. Our study analysed the psychosocial and lifestyle correlates of musculoskeletal pain progression in adolescence.

METHODS

The study was based on the 1986 Northern Finland Birth Cohort and included 1773 adolescents at the ages of 16 to 18. Latent class analysis was applied to find the homogeneous profiles of MS pains in four body areas (neck, shoulder, low back and limb). We analysed the associations between time spent in sedentary activities and sleeping, physical activity level, body mass index, alcohol consumption, smoking, and emotional and behavioural factors at 16 years, and belonging to pain clusters at 16 and 18 years.

RESULTS

We found an association between a higher probability of MS pains between 16 and 18 years and increasing emotional and behavioural problems in both genders. Among boys, a high likelihood of MS pains during follow-up was also associated with a long time spent sitting and insufficient sleeping time. Among girls, alcohol consumption associated with high pain probability. MS pains already co-occur to a large extent in their early course.

CONCLUSIONS

The strong overlap of emotional and behavioural problems and MS pains in adolescence requires awareness in both research and clinical work.

A greater number of somatic pain sites is associated with poor mental health in adolescents: a cross-sectional study

BACKGROUND

Identifying indicators of poor mental health during adolescence is a significant public health issue. Previous studies which suggested an association between the number of somatic pains and depression have mainly focused on adults or have employed samples with a narrow age range. To date, results from previous studies have been inconsistent regarding the association between somatic pain and academic impairment. Therefore, the main aims of the present study were to 1) investigate the association between the number of somatic pain sites and poor mental health using a community sample of adolescents aged 12 to 18 years and employing a simple method of assessment, and 2) examine the association between the number of somatic pain sites and perceived academic impairment.

METHODS

Data analysis was conducted using a large cross-sectional survey of adolescents in grades 7 to 12. The one-month prevalence rates for three sites of somatic pain including head, neck and shoulders, and abdomen were examined. Poor mental health was evaluated using the General Health Questionnaire, and perceived academic impairment was measured using a self-report questionnaire.

RESULTS

A total of 18,104 adolescents participated in the survey. A greater number of pain sites was associated with poor mental health, and this association was consistent across age and gender. There was no difference in effect on mental health between any of the pain sites. Although there was an association between the number of somatic pain sites and perceived academic impairment, the results suggested that the association was mediated by poor mental health.

CONCLUSIONS

Simple reporting methods for assessing the number of pain sites may be a feasible indicator of poor mental health in adolescents. Professionals working with adolescents should consider the possibility of poor mental health, especially when students report multiple somatic pains.

Reciprocal longitudinal associations between pain and depressive symptoms in adolescents

BACKGROUND

Elevated depressive symptoms are common in youth with chronic pain, and pain symptoms are frequent in adolescents with depressive disorders. While studies have identified concurrent associations between pain and depression over time in youth, it is unclear how change in one symptom impacts change in the other symptom.

METHODS

This three-time point 12-month longitudinal study examined reciprocal associations among pain and depression in a clinical sample of adolescents (12-18) diagnosed with chronic pain (n = 55) or a depressive disorder (n = 40). Mixed-effects multivariate models were used to test if changes over a preceding time interval predicted symptom severity at subsequent time points. Study group, age, sex, race, baseline pain intensity and baseline depressive symptoms were included as covariates.

RESULTS

Generalized estimating equations revealed that pain and depressive symptoms were significantly associated over time (β = 1.54; p < 0.001). As hypothesized, changes in pain were associated with subsequent depressive symptoms (β = 1.16; p < 0.001). Conversely, changes in depressive symptoms predicted subsequent pain (β = 0.026; p < 0.05), but with a weaker association. In the model predicting pain, an interaction between depressive symptoms and study group emerged (β = -0.02; p < 0.05), with change in depressive symptoms having the greatest impact on pain in the depressed sample.

CONCLUSIONS

Findings extend previous adult research to an adolescent sample showing changes in pain intensity are predictive of subsequent depressive symptoms. In comparison to adult data, changes in depressive symptoms had less impact on subsequent pain in youth. Future research can examine how targeting persistent pain may also aid the treatment of depressive symptoms in adolescents.

Phenomena associated with sick leave among primary care patients with Medically Unexplained Physical Symptoms: a systematic review

OBJECTIVE

To explore and synthesize the literature on phenomena associated with sick leave among patients with Medically Unexplained Physical Symptoms (MUPS).

DESIGN

A systematic review of the literature was undertaken in three phases: (1) a search of the following databases: Medline, Embase, Psych Info, Cochrane Collaboration Library, Digital Dissertations, DiVA, SweMed +, NORART, and ISI Web of Science, (2) selection of studies based on pre-specified inclusion criteria was undertaken, extracting study design and results, (3) quality assessment was undertaken independently by two reviewers. Due to heterogeneity in study designs, populations, interventions, and outcome measures, a mixed research synthesis approach was used. Results were assessed in a pragmatic and descriptive way; textual and numerical data were extracted from the included studies, and classified into patient- and doctor-related factors.

RESULTS

Sixteen studies were included. With regard to patients, an association was found between sick leave and psychiatric comorbidity as well as total symptom burden. With regard to doctors, knowledge of the patient, sympathy, and trust appeared to increase the probability of the patient being sick-listed. None of the interventions in the educational programmes aiming to improve doctors' management of MUPS patients succeeded in lowering sick leave.

IMPLICATIONS

Despite MUPS being a leading cause of sickness absence, the review identified only a small number of studies concerning phenomena associated with sick leave. The authors did not identify any studies regarding the impact of the working conditions on sick leave among MUPS patients. This is an important area for further studies.

Headache disorders in children and adolescents: their association with psychological, behavioral, and socio-environmental factors

OBJECTIVE

This cross-sectional study on a randomly drawn population sample of children and adolescents (n = 3399; aged 9 to 15) aimed at the assessment of patterns of associations between psychosocial variables and primary headache disorders like migraine (MIG) or tension-type headache. A headache-free group served as a control.

METHODS

Data on headache and psychological trait variables (eg, internalizing symptoms), behavioral factors (eg, physical activities), and socio-environmental factors (eg, life events) were gathered by questionnaire. Logistic regression analyses were conducted with headache types (MIG, tension-type, and non-classifiable headache) as dependent variables.

RESULTS

The pattern of correlations was largely congruent between the headache disorders. Associations were closest regarding maladaptive psychological traits (in particular internalizing symptoms with an odds ratio > 4 regarding MIG) compared with socio-environmental factors and particularly the behavioral factors. Unfavorable psychological traits and socio-environmental strains demonstrated distinctly stronger associations with MIG than tension-type headache and explained more variance in the occurrence of pediatric headache disorders than parental headache. Sex-specific analyses showed similarities as well as differences regarding the correlations, and in general, the associations were stronger in girls than boys.

CONCLUSIONS

A common path model as posited by several researchers in the field may explain the parallelism in biopsychosocial vulnerability regarding the different headache disorders.

Early signaling, referral, and treatment of adolescent chronic pain: a study protocol

Background

Chronic pain is prevalent among young people and negatively influences their quality of life. Furthermore, chronic pain in adolescence may persist into adulthood. Therefore, it is important early on to promote the self-management skills of adolescents with chronic pain by improving signaling, referral, and treatment of these youngsters. In this study protocol we describe the designs of two complementary studies: a signaling study and an intervention study.

Methods and design

The signaling study evaluates the Pain Barometer, a self-assessed signaling instrument for chronic pain in adolescents. To evaluate the feasibility of the Pain Barometer, the experiences of youth-health care nurses will be evaluated in semi-structured interviews. Also, we will explore the frequencies of referral per health-care provider. The intervention study evaluates Move It Now, a guided self-help intervention via the Internet for teenagers with chronic pain. This intervention uses cognitive behavioural techniques, including relaxation exercises and positive thinking. The objective of the intervention is to improve the ability of adolescents to cope with pain. The efficacy of Move It Now will be examined in a randomized controlled trial, in which 60 adolescents will be randomly assigned to an experimental condition or a waiting list control condition.

Discussion

If the Pain Barometer is proven to be feasible and Move It Now appears to be efficacious, a health care pathway can be created to provide the best tailored treatment promptly to adolescents with chronic pain. Move It Now can be easily implemented throughout the Netherlands, as the intervention is Internet based.

Trial registration

Dutch Trial Register NTR1926

Psychosocial determinants of headache, abdominal pain, and sleep problems in a community sample of Finnish adolescents

The aims of this study were to examine the prevalence, co-occurrence, and psychosocial determinants of self-perceived headache, abdominal pain, and sleep problems among adolescents. The adolescents from two cities in Finland (n = 2,215, 90.9% of the target population) attending 7th and 9th grade (age range 13-18 years) participated in the cross-sectional survey inquiring about frequency of headache, abdominal pain, sleep problems, and psychosocial difficulties. The 6-month prevalence of weekly headache was 13%, abdominal pain 6%, and sleep problems 27%. All three symptoms were strongly associated with each other. Of the adolescents suffering from one symptom, 32% reported one co-occurring symptom and 17% two co-occurring symptoms. In the multivariate analysis, female gender, experience of psychological difficulties, emotional symptoms, smoking, victimization, and feeling not cared about by teachers were independently associated with all the individual symptoms, as well as an increasing number of symptoms. Sleep problems were associated with older age and peer and alcohol problems. Abdominal pain was associated with conduct problems, and both headache and abdominal pain were linked with immigration background. An increasing number of symptoms was associated with older age, having a chronic illness, and conduct and alcohol problems. Adolescents' headache, abdominal pain and sleep problems were common and often co-occurred. An increasing frequency of each symptom and number of symptoms were associated with psychosocial factors in a similar way. Screening for psychiatric symptoms, substance use, victimization and difficulties with teachers should be included in the assessment of adolescents who suffer from recurrent headache, abdominal pain or sleep problems.