Adolescent social development and chronic pain

Exploring academic achievement and relevant risk factors among a community sample of adolescents with chronic pain compared to peers

OBJECTIVE

To compare adolescents in the United Kingdom with chronic pain with their peers in relation to psychological and behavioral outcomes (i.e., mental health, bullying, substance use) and academic achievement.

METHODS

Participants were adolescents with chronic pain (n = 856) and peers without chronic pain (n = 3,093) from the Avon Longitudinal Study of Parents and Children (ALSPAC) who attended a research clinic in the United Kingdom at 17 years and completed data collection at multiple timepoints. Chi-square and t-tests were used to explore group differences across psychological and behavioral measures. Regression and mediation analyses examined the relationship between chronic pain and academic achievement measures, including the derived variables of pathway to higher education and educational qualifications.

RESULTS

Adolescents with chronic pain were found to experience more difficulties with mental health, bullying, and substance use. Additionally, a relationship between chronic pain and reporting a pathway to higher education was found after key variables were accounted for, although group differences were not observed across other academic achievement measures. Further analyses identified a moderate indirect effect of chronic pain on reporting a pathway to higher education when mediated by sleep difficulties.

CONCLUSIONS

The limited predictive relationship between chronic pain and academic achievement potentially indicates that, despite struggling more with factors such as mental health, bullying, and substance use, adolescents with chronic pain may utilize enhanced skills in maintaining a developmental trajectory at school or external factors such as support from their caregivers or school. The complex interrelationship between sleep and chronic pain is also an important consideration for the ability to achieve academically.

A systematic review of social functioning and peer relationships in adolescents with chronic pain

OBJECTIVE

There is a need for a systematic review on social functioning and peer relationships among adolescents with chronic pain (ACP) given the high prevalence of chronic pain in adolescence and integral role of peer relationships in adolescent development. This review aims to examine the methods used to evaluate social functioning, the types and extent of peer relationship difficulties, and pain characteristics and sociodemographic factors related to social functioning in ACP.

METHODS

A systematic literature search of PubMed, PsycINFO, CINAHL, Web of Science, and Cochrane databases was performed. Included studies were written in English, presented original, quantitative, peer-reviewed research, had a primary focus on social functioning or peer relationships in ACP, and included study participants between the ages of 10 and 18 years. The review was registered in PROSPERO (No. CRD42022364870).

RESULTS

Twenty-eight articles were included in the review. All studies used self-, parent-, or peer-report questionnaires to evaluate social functioning. Most (89%) of the studies were cross-sectional. Findings suggest that ACP experience social difficulties frequently characterized by loneliness, social anxiety, withdrawal, and peer victimization. Studies examining the associations between social functioning and sociodemographic variables, pain location, and pain-related characteristics yielded mixed findings. Study quality was mixed, with 57.14% rated as "good."

CONCLUSIONS

Findings from this review emphasize the increased risk of reduced social connectedness and the complexity of underlying mechanisms associated with poorer social functioning among ACP. Additional research utilizing longitudinal methodologies is needed to understand potential moderators and directionality of associations between chronic pain and social functioning.

The multifaceted role of physiotherapy - a qualitative study exploring the experiences of physiotherapists working with adolescents with persistent pain

BACKGROUND

Persistent pain is increasingly recognized as a growing issue among adolescents worldwide, with an estimated prevalence of 10-30%. Physical therapy is a recommended treatment modality for managing this kind of pain. Yet, there is still limited knowledge regarding how physiotherapists experience, manage, and follow up this patient population.

PURPOSE

This qualitative study aimed to explore the experiences of physiotherapists in Norwegian primary healthcare working with adolescents experiencing persistent pain. The study examined the resources the therapists make use of, and the challenges they encounter.

METHOD

Four focus group interviews were conducted with a total of 13 Norwegian physiotherapists experienced in treating adolescents with persistent pain. The interviews explored the physiotherapists' experiences of working with adolescents with persistent pain. A reflexive thematic analysis was conducted to analyze the data.

RESULTS

Three main themes were identified from the data analysis: (1) Relationship building as the foundation of the intervention. (2) Accompanying the adolescents into their everyday life. (3) Challenging cases that are also rewarding to work with.

CONCLUSION

This study sheds light on the importance of sufficient and multifaceted clinical competence among physiotherapists to enable them to work effectively with adolescents experiencing persistent pain, and their families. The experiences of physiotherapists show the importance of a strong therapeutic alliance and individualized treatment approaches, based on shared decision-making and age-appropriate communication and interventions. The therapists in our study emphasized the need to integrate interventions into the adolescents' everyday lives, tailoring treatments to the unique life of each individual. Physiotherapists must navigate the complexities of meeting individual patient needs and adapting to challenges beyond traditional practice. To support this patient group effectively, ongoing professional development is recommended, either through continued education or colleague guidance from other experienced physiotherapists.

Eating concerns in youth with functional abdominal pain disorders

OBJECTIVES

Adolescents with functional abdominal pain (FAP) often experience pain and other gastrointestinal symptoms in the context of eating, which may place them at risk for eating disorders. This study compared disordered eating and its sequalae in adolescents with FAP to those with chronic headache.

METHODS

Participants in this retrospective chart review study were 270 adolescents and young adults (mean age 15.9; standard deviation [SD] = 1.63; 60% female) attending an intensive, interdisciplinary pain treatment program, including 135 youth with FAP and an age- and gender-matched control group with a primary pain diagnosis of chronic headache. Information was extracted related to eating- and weight-related symptoms.

RESULTS

Independent t-tests and χ2 analyses found that compared with adolescents with chronic headache, patients with FAP showed significantly more eating pathology as reflected by scores on the Eating Attitudes Test-26 (EAT-26) (p < 0.001), endorsement of pain-related restrictive eating (p < 0.01), eating disorder history (p < 0.001), and avoidant restrictive food intake disorder (ARFID) diagnoses (p < 0.001). Compared to those with chronic headache, significantly more patients with FAP had lost 10 pounds or more (p < 0.01) and a higher proportion were underweight (p < 0.001). Among all participants, a history of exclusion diets used to manage symptoms significantly increased the risk for ARFID (p < 0.001).

CONCLUSION

The results of this study highlight the increased risk of eating-related concerns among youth with FAP, as well as the judicious use of exclusion diets to manage symptoms in these patients.

The perception, understanding and experience of flourishing in young people living with chronic pain: A Q-methodology study

Much research has adopted a deficits-based approach to chronic pain, neglecting the study of flourishing. Using a Q-methodological framework, this study sought to explore how individuals experience, understand and perceive flourishing in the context of young people living with chronic pain. Fifty-four individuals completed a Q-sorting task, indicating their level of agreement and disagreement with 52 statements. Q-analysis generated three factors that represented clear viewpoints of participants: 'Pain is not a barrier to flourishing', 'Adapting to a new life' and 'Adopting a positive perspective'. Factors expressed the viewpoints that flexibility is key to enjoying life despite chronic pain, while resilience, management of stressors, acceptance and problem-solving may be required to flourish with chronic pain. Participants' understanding of flourishing also focused on the appreciation and enjoyment of life and achievements. This study provides a useful contribution towards furthering our understanding of flourishing in young people living with chronic pain.

Does diagnosis matter? Evaluating impact of pediatric chronic pain diagnosis on pain and function

PURPOSE

This study aimed to A) evaluate changes in pain and function following an outpatient interdisciplinary pain management program (IPMP) for children with different chronic pain conditions and B) explore differences in pain and function at baseline and discharge for different diagnoses.

METHODS

A retrospective chart review was performed for 488 children who participated in an outpatient IPMP. Children's pain and physical, social, and emotional functioning were assessed at initial evaluation, discharge, and one-to-two-month follow-up. Patients were stratified by diagnosis (complex regional pain syndrome [CRPS], headache, musculoskeletal pain, visceral pain, and widespread pain) to evaluate differences in pain and functioning at baseline and discharge.

RESULTS

Children's pain and function improved from initial evaluation to discharge. Those with headache and musculoskeletal pain exhibited better baseline physical and emotional functioning than other diagnostic groups (p = 0.03; p = 0.005; p = 0.002; p = 0.04). Children with CRPS displayed the worst baseline physical functioning (p = 0.003). Those with widespread pain exhibited the worst baseline emotional functioning at both initial evaluation and discharge (p = 0.009; p = 0.007).

CONCLUSION

Children with CRPS, visceral pain, and widespread pain undergoing treatment in an IPMP exhibited the most impaired baseline functioning, while those with musculoskeletal pain and headache were least impaired. All exhibited improvements in pain and function following the IPMP.

Looking on the bright side: The relationships between flourishing and pain-related outcomes among adolescents living with chronic pain

A deficits-based approach to adolescent chronic pain currently dominates the literature, to the exclusion of positive approaches, such as flourishing. Addressing this knowledge gap, this study examined the relationships between flourishing and pain-related outcomes in adolescent chronic pain. Seventy-nine adolescents aged 11-24 years were asked to complete self-report measures of three domains of flourishing and four pain-related outcomes. Correlation coefficients and four hierarchical linear regression analyses were conducted, controlling for age and gender. Flourishing mental health was associated with, and significantly contributed to explaining, anxiety and depressive symptoms, and social and family functioning impairment. Benefit finding and posttraumatic growth were each associated with social and family functioning impairment, while posttraumatic growth was also associated with anxiety and depressive symptoms. Additionally, benefit finding significantly contributed to explaining pain intensity. Study findings underscore the importance of assessing the relationships between flourishing and pain-related outcomes in adolescents with chronic pain.

Roadmap to the 'Chronic Pain GPS for Adolescents' Intervention: Content and Design Considerations for a Group Peer Support Intervention

OBJECTIVES

A biopsychosocial approach to understanding and treating pain is crucial; however, there are limited socially targeted interventions for adolescents with chronic pain (ACP). Peer support interventions implemented with other populations are associated with positive outcomes. ACPs perceive peer support to have high potential value. This study explored the preferences of ACP regarding the content and design of a group peer support intervention.

METHODS

Fourteen ACP (M age : 15.21 y; 9 females; 3 males, 1 nonbinary, and 1 gender questioning) completed a virtual interview and survey. Interviews were analyzed using inductive qualitative content analysis, and surveys were analyzed using descriptive statistics.

RESULTS

Adolescents described how they want to both talk and do activities together within a fun and casual environment with a facilitator present-ideally, someone with lived experience of chronic pain. Preferences were for a medium-sized group intervention that was in-person, at a consistent time on a weekday after school, and semi-structured. Barriers to attending and engaging in the potential group peer intervention were also discussed.

DISCUSSION

ACPs desire a facilitated socially focused intervention that provides them with the opportunity to spend time with other ACPs. A group peer support environment where ACPs can provide and receive peer support through sharing their experiences with others who understand them as well as engage in activities was described. The findings from this study provide insights for the development of a group peer support intervention.

An examination of questioning methods and the influence of child maltreatment on paediatric pain assessments: Perspectives of healthcare providers

AIMS AND OBJECTIVES

Children with a history of maltreatment have underestimated and undertreated pain; however, it is unknown if healthcare providers consider maltreatment when assessing children's pain. The current study aimed to address this issue by investigating healthcare providers' pain assessment practices, and specifically, their consideration of child maltreatment.

METHOD

Healthcare providers (N = 100) completed a survey, asking them to reflect upon their pediatric pain assessment practices (e.g., methods and questions used to assess pain) through self-report and case vignette questions.

RESULTS

Participants who received continuing education about child maltreatment were more likely to consider maltreatment in several areas of their pediatric pain assessment practice, whereas participants who received continuing education about pediatric pain, were not. Participants were also more likely to report that they would consider maltreatment in vignette responses than in questions regarding their daily practice.

CONCLUSION

Findings indicate healthcare providers use multidimensional methods when assessing children's pain, although it is unclear when or how they use open-ended vs. option posing questions. Healthcare providers also tended to consider the effects of child maltreatment on children's ability to communicate their pain more so when the history of maltreatment was known to them.

Social health in young women with chronic pain

Introduction

Chronic pain may negatively affect social functioning, but no study to date has examined the specific social impact of different chronic pain conditions in young women, and whether living with multiple chronic overlapping pain conditions (COPCs) differently influences social domains.

Objectives

This study aimed to assess social functioning (social isolation, hostility, informational support satisfaction, social roles, emotional support, friendships, and family relationships) among young women with chronic pain compared with pain-free controls and to test whether the number of COPCs influenced the extent of social burden.

Methods

Participants aged 18 to 30 years with a physician-confirmed diagnoses of migraine, fibromyalgia, or temporomandibular disorder (TMD) and pain-free controls were invited to participate from across the United States. After confirming eligibility, participants completed a 1-hour REDCap online questionnaire assessing social functioning.

Results

One hundred four participants (mean age 24.54 ± 3.35 years) were included (n = 26 with TMD, n = 25 with fibromyalgia, n = 25 with migraine, and n = 28 controls). All 3 chronic pain groups combined reported worse functioning than controls on friendship (P = 0.038), social isolation (P = 0.002), and social roles (P < 0.001). There were no differences on social variables between the 3 chronic pain groups (all P's > 0.05). Compared with those with 3 COPCs, participants with 1 condition reported better family relationships (P = 0.024).

Conclusions

Experience of chronic pain-regardless of the specific pain condition-may negatively affect some areas of social functioning in young women.

Don't judge a book by its cover: Exploring low self-reported distress and repressive coping in a pediatric chronic pain population

Repression has been linked to greater illness, somatic symptoms, and poorer physical health, both in adult and pediatric populations. The current study examined psychological and pain profiles of children with chronic pain who may under-report levels of psychological distress at a first interdisciplinary chronic pain assessment. Children and their caregiver completed measures of psychopathology and pain intensity, while clinicians rated their levels of disability. Based on self-report measures, children were classified as "repressors" (low anxiety/high social desirability) or as "true low anxious" (low anxiety/low social desirability). Groups were then compared on psychological and pain characteristics. Compared to children with true low anxiety, repressors reported lower levels of depressive and somatic symptoms but provided higher ratings on pain intensity, pain-unpleasantness, and self-oriented perfectionism. Caregivers of repressors rated their children as having higher levels of adaptability compared to caregivers of children in the true low anxious group. Groups did not differ on clinician-rated level of disability. Children classified as repressors exhibited different profiles than children classified as having true low anxiety on both psychological outcomes and pain characteristics. Repression may be an important factor to consider for those assessing and treating children with chronic pain.

A systematic review of the biopsychosocial dimensions affected by chronic pain in children and adolescents: identifying reliable and valid pediatric multidimensional chronic pain assessment tools

Pediatric chronic pain is a complex experience that is often challenging to describe and measure. Multidimensional tools that evaluate the biopsychosocial impact of chronic pain in pediatric patients can help clinicians to prioritize and tailor interdisciplinary pain care; yet, the psychometric value and clinical utility of such tools has not yet been systematically studied in the literature. The purpose of this review was to identify multidimensional biopsychosocial tools used in pediatric chronic pain, synthesize their reliability and validity evidence, and draw on this evidence to describe the relationships between chronic pain and biopsychosocial domains. The search involved 2 phases to (1) identify eligible tools and (2) conduct a measured forward citation search of tool development articles. Tool eligibility was guided by the Multidimensional Biobehavioral Model of Pediatric Pain and study eligibility was focused on primary chronic pain diagnoses unrelated to disease. Data extraction was focused on reliability and validity evidence of eligible tools, guided by the Standards for Educational and Psychological Testing. Results yielded 6 tools that included 64 eligible studies, highlighting 84 significant relationships between pain and functional interference across 11 biopsychosocial variables. All tools were shown to have good internal consistency and evidence of validity, primarily through relationships to other variables. Of the 6 tools, the most brief and easy to use were the most under studied. Further psychometric research is warranted for these tools to investigate their clinical utility and psychometric properties in guiding and prioritizing pain care for children and adolescents.

Beliefs About Pain in Pediatric Inflammatory and Noninflammatory Chronic Musculoskeletal Conditions: A Scoping Review

OBJECTIVE

The Common Sense Self-Regulatory Model posits that beliefs about pain influence coping behaviors and subsequent physical and mental health outcomes in children/young people with chronic musculoskeletal conditions. It was unclear how and what beliefs had been investigated in this population, and whether there were similarities and differences in beliefs held about pain by those experiencing inflammatory versus noninflammatory musculoskeletal conditions. This scoping review addressed this gap.

METHODS

A systematic search was conducted using four databases (MEDLINE, PsycINFO, Embase, and CINAHL) in November 2021. Primary studies exploring key stakeholders' (including children, parents, and/or healthcare professionals) beliefs about pain underlying pediatric chronic musculoskeletal conditions were synthesized.

RESULTS

Eighteen articles were identified. Cross-sectional designs were predominantly used to explore beliefs (n = 6). The majority used questionnaires to assess beliefs (n = 12). Beliefs common across musculoskeletal conditions were that children/young people felt their pain was not understood by others, and pain affected their physical functioning. Differences included children/young people and parents thinking they had some ability to control pain, and causal beliefs relating to underlying disease activity. These pain beliefs were more likely to be held in relation to inflammatory diagnoses. In contrast, children/young people and parents were more likely to view pain as uncontrollable, with more uncertainty regarding underlying causes, relating to noninflammatory diagnoses.

CONCLUSIONS

Methods used to explore pain beliefs were inconsistent. Studies identified similarities and differences which appear to be closely related to the underlying diagnosis. Findings justify further exploration to identify potentially modifiable targets to improve pain outcomes in this population.

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments

BACKGROUND

Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them.

OBJECTIVES

1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services?

SEARCH METHODS

Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022.

SELECTION CRITERIA

To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families.

DATA COLLECTION AND ANALYSIS

We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain.

MAIN RESULTS

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

Flourishing among Children and Adolescents with Chronic Pain and Emotional, Developmental, or Behavioral Comorbidities

Pediatric chronic pain is an important public health issue given its notable impact on numerous domains of living. Pediatric chronic pain is also often comorbid with emotional, developmental, or behavioral conditions, which can lead to more severe negative outcomes and an even greater reduction in positive outcomes compared to those without comorbidities. Flourishing is a positive outcome that chronic pain status has been shown to impact. Flourishing in children aged 6-17 years living with chronic pain, as well as those with chronic pain and comorbidities, was explored using data from the 2018/2019 National Survey of Child Health. Chronic pain occurred in 4.0% of our sample, and the prevalence of chronic pain plus comorbidities was 3.9%. There were significant associations between the chronic pain condition status and all demographic variables (sex, age, race/ethnicity, poverty level, parental education, and health insurance status). The results of the hierarchical logistic regression found that the chronic pain condition status significantly predicted flourishing. Children with chronic pain were 2.33 times less likely to flourish, and children with chronic pain plus an emotional, developmental, or behavioral comorbidity were 13 times less likely to flourish than their typical peers. Given their significantly lower likelihood of flourishing, there is an urgent need for interventions targeted at children experiencing chronic pain and mental health comorbidities.

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

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

Perceptions of Adolescents With Chronic Pain About Peer Support: Reflexive Thematic Analysis

OBJECTIVE

Social challenges are a common experience for adolescents with chronic pain. Group peer support for these adolescents could be a promising intervention; however, no studies have focused exclusively on the peer support needs of this population. The present study addressed this gap in the literature.

METHODS

Adolescents with chronic pain between 12 and 17 years of age completed a virtual interview and demographics questionnaire. Interviews were analyzed using inductive reflexive thematic analysis.

RESULTS

Fourteen adolescents (Mage: 15.21 years; 9 females; 3 males, 1 nonbinary, 1 gender questioning) with chronic pain participated. Three themes were generated: "Being Misunderstood," "They Would Understand Me," and "Moving Forward Together in Our Pain Journeys." Adolescents with chronic pain feel misunderstood and under supported by their peers without pain leading to feeling "othered" by having to explain their pain, yet not feeling free to talk about their pain with friends. Adolescents with chronic pain expressed that peer support would provide the forms of social support they are missing amongst their friends without pain as well as companionship and a sense of belonging due to shared knowledge and experiences.

CONCLUSIONS

Adolescents with chronic pain desire peer support from others like themselves, highlighting the challenges in their everyday friendships as the impetus for this support, as well as their anticipated short- and long-term benefits, including learning from their peers and developing new friendships. Findings indicate that adolescents with chronic pain may benefit from group peer support. Findings will inform the development of a peer support intervention for this population.

Glass half full: A diary and interview qualitative investigation of flourishing among adolescents living with chronic pain

BACKGROUND

Counter to paediatric pain literature that typically highlights the deleterious impacts associated with adolescent chronic pain, evidence suggests that some adolescents flourish in their experience of pain. This study sought to explore how adolescents experience, understand and perceive flourishing while living with chronic pain.

METHODS

Twenty-four adolescents aged 11-24 years were recruited via clinical and online settings. All adolescents were asked to complete daily diary entries, with a subset of 10 participants asked to complete follow-up interviews.

RESULTS

Inductive reflexive thematic analysis generated two themes: 'Appreciating the moment' and 'Becoming a better version of myself'. Themes addressed how self and other comparisons facilitated a renewed appreciation for achievements and pleasures in life due to living with chronic pain. Adolescents further demonstrated a perception of continued personal and social growth in their experience of chronic pain, including increased emotional maturity, resilience, positivity, kindness and improved communication skills.

CONCLUSIONS

We conclude that adolescents can experience positive changes in functioning and flourish in some domains of life despite, or resulting from, chronic pain. Further research with an exclusive focus on flourishing is needed to build on this work and address this important gap in knowledge.

SIGNIFICANCE

We present evidence that adolescents can flourish when living with chronic pain. Such knowledge may inform the development of positive psychological treatment strategies that are focused on reinforcing adolescents' existing strengths, to expand on current treatment options for adolescents living with chronic pain.

Exploring User Visions for Modeling mHealth Apps Toward Supporting Patient-Parent-Clinician Collaboration and Shared Decision-making When Treating Adolescent Knee Pain in General Practice: Workshop Study

BACKGROUND

Long-standing knee pain is one of the most common reasons for adolescents (aged 10-19 years) to consult general practice. Generally, 1 in 2 adolescents will continue to experience pain after 2 years, but exercises and self-management education can improve the prognosis. However, adherence to exercises and self-management education interventions remains poor. Mobile health (mHealth) apps have the potential for supporting adolescents' self-management, enhancing treatment adherence, and fostering patient-centered approaches. However, it remains unclear how mHealth apps should be designed to act as tools for supporting individual and collaborative management of adolescents' knee pain in a general practice setting.

OBJECTIVE

The aim of the study was to extract design principles for designing mHealth core features, which were both sufficiently robust to support adolescents' everyday management of their knee pain and sufficiently flexible to act as enablers for enhancing patient-parent collaboration and shared decision-making.

METHODS

Overall, 3 future workshops were conducted with young adults with chronic knee pain since adolescence, parents, and general practitioners (GPs). Each workshop followed similar procedures, using case vignettes and design cards to stimulate discussions, shared construction of knowledge and elicit visions for mHealth designs. Young adults and parents were recruited via social media posts targeting individuals in Northern Jutland. GPs were recruited via email and cold calling. Data were transcribed and analyzed thematically using NVivo (QSR International) coding software. Extracted themes were synthesized in a matrix to map tensions in the collaborative space and inform a conceptual model for designing mHealth core-features to support individual and collaborative management of knee pain.

RESULTS

Overall, 38% (9/24) young adults with chronic knee pain since adolescence, 25% (6/24) parents, and 38% (9/24) GPs participated in the workshops. Data analysis revealed how adolescents, parents, and clinicians took on different roles within the collaborative space, with different tasks, challenges, and information needs. In total, 5 themes were identified: adolescents as explorers of pain and social rules; parents as supporters, advocates and enforcers of boundaries; and GPs as guides, gatekeepers, and navigators or systemic constraints described participants' roles; collaborative barriers and tensions referred to the contextual elements; and visions for an mHealth app identified beneficial core features. The synthesis informed a conceptual model, outlining 3 principles for consolidating mHealth core features as enablers for supporting role negotiation, limiting collaborative tensions, and facilitating shared decision-making.

CONCLUSIONS

An mHealth app for treating adolescents with knee pain should be designed to accommodate multiple users, enable them to shift between individual management decision-making, take charge, and engage in role negotiation to inform shared decision-making. We identified 3 silver-bullet principles for consolidating mHealth core features as enablers for negotiation by supporting patient-GP collaboration, supporting transitions, and cultivating the parent-GP alliance.

Growing up with chronic pain: a systematic review of the evidence in transitional care for young people with chronic pain

Objective

Paediatric chronic pain presents a significant individual and societal burden, with an estimated prevalence of 11-38%. A large proportion of adolescents with chronic pain will have unresolved pain that continues into adulthood and thus requires transitional care. The aim of this review was to investigate the current evidence for the core components of effective transitional care interventions designed for young people with chronic pain.

Methods

Studies were identified by searching the Embase, MEDLINE, CINAHL and PsycINFO databases. A search strategy using terms such as 'Adolescent', 'Persistent long-term pain' and 'Transition' (or variations of such words) was implemented. Inclusion criteria were sample population age 10-24 years, a confirmed diagnosis of a condition characterized by chronic pain, any healthcare setting, any service provider, published peer reviewed and English language.

Results

Ninety-eight articles were identified by the search and 14 were selected after abstract screening. Two independent reviewers screened the articles, followed by a senior reviewer. Of the 14 articles, full-text review found that none of the articles looked specifically at evidence with respect to core components of effective transitional care designed for young people with chronic pain.

Conclusion

Chronic pain is a feature of many long-term health conditions. It remains unknown as to whether there are any pain-specific aspects of transitional care. How pain management is addressed in existing transitional care provision and the relationship of pain to outcomes needs further research. If effective interventions can be provided during these crucial years, the trajectory of these young people can potentially be improved into adulthood.

Prevalence and risk factors for pain-specific school absenteeism in adolescents with recurrent pain: A prospective population-based design

BACKGROUND

Adolescents with recurrent pain miss out from school more often than pain-free peers. Research has so far used cross-sectional designs, focusing on non-specific absenteeism in clinical samples. Hence, it is unknown whether estimates of absenteeism are specifically linked to the pain itself or reflects the characteristics of clinical samples.

OBJECTIVES

This study aimed to prospectively explore pain-related school absenteeism in a non-clinical sample, its variance and potential risk factors.

METHODS

This prospective study followed a cohort of 1300 Sweden-based adolescents (mean age = 16.9; 17.2% immigrants; 62.7% girls) with recurrent pain (headache, abdominal and/or musculoskeletal pain) through self-reports at two assessment points 12 months apart.

RESULTS

Overall, 64.2% reported any absenteeism at follow-up and about half of these (26.2%) reported frequent absenteeism. Adolescents who indicated missing school were more often girls, slightly older and had a higher overall pain burden and stressor levels. Yet, after adjusting for previous absenteeism, independent predictors were age, pain intensity, medication use and stress associated with school attendance. Further to this, immigrant status predicted frequent absenteeism.

CONCLUSIONS

Many adolescents with pain frequently miss out from school due to pain. Identified risk factors points at pain characteristics and coping, stressors associated with participation and advancing age. Taken together, the burden of pain and its correlates emerge earlier and escalate with increasing age hence, early interventions targeting broader domains are needed.

SIGNIFICANCE

This study adds substantially to the field by estimating the prevalence of pain-specific school absenteeism in a large sample of adolescents with recurrent pain in the general population using a prospective design. Furthermore, it identifies risk factors of pain-specific absenteeism from a broader context of the adolescent's life with independent predictors being the previous history of absenteeism, age, immigrant status, pain intensity, medication use and stress related to school attendance.

Self-evaluation and depression in adolescents with a chronic illness: A systematic review

OBJECTIVE

To conduct a systematic review to establish what is known about the relationship between depression and self-evaluation in adolescents with a chronic illness.

METHODS

A systematic search was conducted using MEDLINE, EMBASE, PsycINFO, Web of Science, The Cochrane Library, and hand-searching. We sought to identify primary research that examined both the cross-sectional and longitudinal associations between depression and self-evaluation in adolescents with chronic illness. The search resulted in 8941 retrieved articles that were screened against an inclusion criteria. A total of 4 papers were included in the review. The MMAT used to assess study methodological quality.

RESULTS

A narrative synthesis was conducted, and a summary figure was included. These 4 studies included 236 adolescents aged 9-18 years with depression and either Type 1 Diabetes (T1D), chronic pain, headaches, or Inflammatory Bowel Disease (IBD). The limited existing evidence indicated that that depression was associated with negative self-evaluation in adolescents in some but not all chronic illnesses investigated to date. We also found some evidence that psychological intervention can help to improve self-evaluation, specifically in adolescents with T1D.

CONCLUSIONS

More robust studies of the association between self-evaluation and depression in adolescents with a chronic illness is needed, with attention to the nuances of differences between chronic illnesses. The existing evidence indicates that there may be a stronger association in some chronic illnesses. Pilot data suggest that specific psychological therapies may improve self-evaluation, although much more extensive evaluation is needed.

Self-concept in Adolescents with Physical-Mental Comorbidity

Objective

Little is known about self-concept in adolescents with physical-mental comorbidity. This study investigated whether physical-mental comorbidity was associated with self-concept in adolescents and examined if adolescent age or sex moderated the association between physical-mental comorbidity and self-concept.

Methods

Study data were obtained from the Multimorbidity in Youth across the Life-course (MY LIFE), an ongoing Canadian study of adolescents with chronic physical illness who were recruited from outpatient clinics at a pediatric hospital. A total of 116 adolescents aged ≥ 10 years provided self-reports on key measures.

Results

Adolescents with comorbidity (n = 48) had lower self-concept scores on the Self-Determination Questionnaire (SDQ; d = 0.62) and Self-Perception Profile for Children (SPPC; d = 0.53) vs. adolescents without comorbidity (n = 68). An age × comorbidity status interaction was found and age-stratified models were computed to investigate this moderating effect of age. Amongst older adolescents, comorbidity was associated with lower SDQ (B = -2.55, p < .001), but this association was not found among younger adolescents (B = -0.29, p = .680). A similar effect was found for SPPC among older (B = -0.48, p = .001) and younger adolescents (B = 0.03, p = .842). Adolescent sex was not found to be a moderator.

Conclusions

Physical-mental comorbidity in adolescence was associated with lower self-concept and this association was moderated by age-differences between adolescents with vs. without comorbidity were greater for older adolescents and were clinically relevant. Opportunities to support positive self-perceptions for adolescents with comorbidity are warranted, especially when planning the transition from pediatric to adult health services.

Flourishing among adolescents living with chronic pain and their parents: A scoping review

Evidence exists regarding the impact of flourishing in individuals living with chronic pain, but there are currently no reviews which collate the literature on flourishing in adolescents living with chronic pain and their parents. Therefore, the aim of this scoping review was to map and review the current literature, to document how flourishing is defined and understood in the literature, and to identify gaps in the field. Six databases were searched (Web of Science, Medline, Embase, APA PsycNet and the Cochrane Central Register of Controlled Trials). In addition, a limited gray literature search was conducted. The resulting data were collated and reported in relation to the review questions, by examining the included papers to search for the presence of flourishing. Database searches resulted in 7326 papers after duplicate removal, with eight remaining papers being assessed for full-text eligibility. Following full-text screening, a final four papers were included in the review. Within the papers, flourishing was defined in relation to commonalities of benefit finding, enhanced maturity and growth, and social support. Gaps in the literature and directions for future research are considered. This review suggests that there is a dearth of knowledge and research regarding flourishing among adolescents living with chronic pain and their parents, despite aspects of flourishing identified in limited literature. This warrants further investigation.

The sands of time: Adolescents' temporal perceptions of peer relationships and autonomy in the context of living with chronic pain

The incidence of chronic and recurrent pain increases in adolescence. Prevalence of adolescent chronic pain is estimated to be 11%-44%, with approximately 5% adolescents experiencing moderate-to-severe chronic pain. Adolescents with chronic pain also report unwanted changes in emotional, social, and developmental functioning. Very little is known about how adolescents with chronic pain make sense of their development, the role of pain in that development, and how such developmental trajectories progress over time. A multi-methods qualitative study was designed to explore how adolescents make sense of their experience of chronic pain in the context of development. Nine adolescents (8 girls) aged 12-22 years old (Mean = 15.7, SD = 2.8) were recruited from a UK national pain service. Adolescents completed an interview on entering the service, and a follow-up interview 12 months later. They also completed monthly diaries in this 12-month period. Data comprised 18 interviews and 60 diary entries, which were analyzed using inductive reflexive thematic analysis. Analyses generated one overarching theme entitled "tug of war: push and pull," demonstrating developmental tension related to pain, and the cumulative impact these had over time. This overarching theme comprised two subthemes which capture these tensions across the developmental domains of peer relationships and autonomy. The first subtheme, "the shifting sands of peer relationships," explores the ever-changing closeness between self and peers. The second subtheme referred to "restricted choices" and how pain limited the participants' autonomy but that this, over time could push development forward. These results extend previous cross-sectional research on the developmental consequences of chronic pain, showing the dynamic fluctuations and alterations to developmental trajectories over time.

Cutting the cord? Parenting emerging adults with chronic pain

The role of parent factors, such as distress and protective behaviors, on pain and functional outcomes of emerging adults living with chronic pain has been largely unexplored. The effects of helicopter parenting and developmental changes occurring during this transition period between adolescence and adulthood (commonly defined as the ages between 18 and 30 years) may exacerbate the pain experience and have the potential to influence chronic pain management. Clinical practice, with an additional focus on supporting the parent(s), may aid in meeting the needs of this population. In this paper, we review the available literature on (a) the socio-cultural shift in parenting over the past decade with a focus on helicopter parenting; (b) the impact of this parenting style on the pain experience and outcomes of emerging adults living with chronic pain; (c) provide recommendations for chronic pain management with a focus on the parent-emerging adult dyad; and (d) conclude with future research recommendations. This narrative review is the first to consider the impacts and outcomes of helicopter parenting on emerging adults with chronic pain.

Transitional Pain Care in Quebec: Did We Forget Our Youths? A Brief Research Report

Adolescents and young adults (AYAs) represent a unique population with distinct psycho-social risks and care needs. About 10% of AYAs live with chronic pain (CP) and transition to adult pain care between 16 and 25 years of age. These transitions in care happen simultaneously with other bio-psycho-social changes and require flexible multi-disciplinary support models. As it stands, transitional pain care appears suboptimal, fragmented, and opportunistic in Quebec (Canada). The objective of this Brief Report is, therefore, to present our study findings and propose a multi-disciplinary transitional framework vision applicable to AYAs living with CP. Data were collected using a sequential-consensual qualitative design with a longitudinal participatory component. The consecutive stages of this work included an exploratory stage, semi-structured interviews with primary care providers, and inter-disciplinary deliberative stakeholder consultation groups. The deductive inductive thematic approach and the three-level Health Care Transition Research Consortium's theoretical framework were used to analyze the data. A representative group of stakeholders discussed findings from the first two steps, made fifteen actionable recommendations and formulated their vision of a transitional pain care model that can be further adapted in other settings. The study results present important insights into various psycho-social factors associated with transitional pain care for AYAs.

Pediatric Chronic Pain in the Midst of the COVID-19 Pandemic: Lived Experiences of Youth and Parents

During the coronavirus 2019 (COVID-19) pandemic youth with chronic pain have experienced additional barriers to accessing treatment and managing their pain. This study explored the experiences of youth with chronic pain and their parents during the COVID-19 pandemic. Individual semi-structured interviews were conducted with 20 youth with chronic pain (aged 13-20 years) and one of their parents, recruited from a tertiary level pediatric chronic pain program. Interviews occurred between the months of June to August 2020 and enabled participants to describe their experiences of the COVID-19 pandemic according to their own unique perspectives. Transcripts were analyzed using inductive reflexive thematic analysis. Four themes were generated and labelled: "temporality, mental health, and pain," "coping with pain during a global pandemic," "impact on care," and "re-appraisal in the context of development and pandemic life." Across these themes, youth and parents described their unique challenges of living with pain as they adapted to changing circumstances of the COVID-19 pandemic. Notably, youth experienced increased difficulties managing their mental health and pain, which were intricately connected and related to social isolation, temporality, and uncertainty exacerbated by the COVID-19 pandemic. Restrictions due to the COVID-19 pandemic impacted youth's access to care and their abilities to engage in coping strategies to manage their pain. The COVID-19 pandemic was also perceived to have interrupted youth's development and growing autonomy, prompting youth to re-appraise their current circumstances and imagined futures. PERSPECTIVE: This manuscript provides an in-depth understanding of the impact of the COVID-19 pandemic on youth with chronic pain and their parents. Youth and their parents perceived the COVID-19 pandemic to have impacted youth's mental health, pain, socio-emotional development, and access to care.

Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective

A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child's quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.

Exploring the intersection of adverse childhood experiences, pediatric chronic pain, and rheumatic disease

BACKGROUND

While the general relationship between ACEs and the development of chronic pain has become increasingly clear, how ACEs may shape a child's clinical presentation with regards to chronic pain has yet to be fully expounded. We aimed to determine the association between ACEs and clinical manifestations of pediatric chronic pain and explore the interaction of ACEs and pediatric rheumatic disease among youth with chronic pain on health-related outcomes.

METHODS

We conducted a cross-sectional cohort study of patients aged ≤18 years with chronic pain seen in a pediatric rheumatology amplified pain clinic between August 2018 and July 2020. We stratified subjects into three groups: no ACEs, one ACE, and ≥ 2 ACEs. We assessed clinical signs and symptoms associated with the presence of ACEs using Chi-square or Wilcoxon-rank test. The association between ACEs as well as other variables of interest with functional impairment was tested using simple and multivariable linear regression.

RESULTS

Of the 412 patients included, more than 75% of patients reported at least one ACE. Most frequent included history of mental illness in a first degree relative (56%) and parental divorce or separation (20%). Those with ≥2 ACEs had more somatic symptoms, worse functional disability, and a higher proportion of mental health conditions. There appeared to be a dose dependent interaction between ACEs and functional disability from co-morbid rheumatologic disease. In multivariable regression, higher verbal pain score, symptom severity score (SSS), and presence of autonomic changes were associated with estimated average increase in FDI score (β = 1.05, 1.95 and 4.76 respectively; all p < 0.01).

CONCLUSION

Children with chronic pain and/or rheumatologic diseases who are exposed to ACEs are at increased risk of greater symptomatology, functional disability, and somatization of symptoms. Our findings indicate an ongoing need for systemic evaluation of ACEs in children with chronic pain and/or rheumatic disease and incorporation of trauma-based care.

Are They Still Friends? Friendship Stability of Adolescents With Chronic Pain: 1-Year Follow-Up

Most adolescents identify their best friend as their main source of social support. Adolescents with chronic pain (ACP) report the loss of friendships due to pain. Friendships protect against loneliness and depression, yet adolescents with pain experience increased levels of loneliness and depression compared to peers. This longitudinal study examines the friendship stability of dyads that included an adolescent with chronic pain compared to non-pain friendship dyads as well as the factors contributing to a friendship breakup. Eighty-three participants from 61 same-sex friendship dyads across 3 sites participated in a 1-year follow-up survey designed to capture friendship features, indices of social-emotional well-being, pain characteristics, and friendship stability. Chi-square, repeated measures ANOVA, and logistic regression were used to analyze the data. Dyads that included an ACP experienced higher rates of friendship breakup. The shorter length of friendship and having chronic pain predicted a friendship breakup at time 2. ACP continues to experience worse scores on indices of social-emotional well-being that are not predicted with a friendship breakup. Understanding what contributes to positive long-term friendships for those with pain may inform strategies to maintain and improve friendships for those with pain and who experience social challenges.

Chronic Pain in Schoolchildren and its Association With Psychological Wellbeing Before and During the COVID-19 Pandemic

PURPOSE

The current longitudinal observational study aimed to explore how chronic pain among schoolchildren changed before and during the COVID-19 pandemic, and how changes in chronic pain were related to changes in psychological wellbeing and COVID-19-related experiences.

METHODS

Data were collected from N = 777 German schoolchildren (aged 9-17 years) at two assessments before and one assessment during the COVID-19 pandemic lockdown. Participants self-reported chronic pain experience, anxiety, depression, and quality of life across all assessments; and COVID-19-related experiences at the last assessment. Trajectories of anxiety, depression, and quality of life as well as COVID-19-related experiences were analyzed separately for groups of stable chronic pain trajectories compared to chronic pain trajectories that changed during the pandemic.

RESULTS

Chronic pain prevalence was lowest at the assessment during the COVID-19 pandemic (22.8% vs. 29.2% and 29.9% before the pandemic). However, 4.6% experienced new chronic pain onset during the COVID-19 pandemic. This was preceded by heightened depression and anxiety, as well as lowered quality of life scores. These students were also more likely to describe time with their family during the COVID-19 pandemic as tense compared to students who did not develop chronic pain. During the COVID-19 pandemic boys were more likely to recover from ongoing chronic pain than girls.

CONCLUSIONS

Overall, during the COVID-19 pandemic the prevalence of chronic pain decreased. However, stressful situations and pre-existing vulnerabilities in psychological wellbeing can facilitate the development of chronic pain during the pandemic.

PAINSTORIES - Exploring the Temporal Developments in the Challenges, Barriers, and Self-Management Needs of Adolescents with Longstanding Knee Pain: A Qualitative, Retrospective Interview Study with Young Adults Experiencing Knee Pain Since Adolescence

Patient education is essential to enable rehabilitation and self-management of longstanding knee pain in adolescents. Currently, a lack of insights into the socio-cognitive processes governing adolescents' self-management remains an obstacle for enhancing treatment efficacy. This study developed a conceptual model for integrating adolescents' challenges and barriers into future treatments. We conducted semi-structured retrospective interviews with 14 young adults (age 21-25 years) with knee pain since adolescence (9 years mean duration). Temporal developments in participants' knee pain were captured through a memorization exercise. Data was analyzed via the General Inductive Approach. Themes were organized into a matrix, extracting a conceptual model, which was tested with eight new participants. The analysis identified seven themes. Further interpretation, via the matrix, organized these within a four-stage trajectory of; gaining awareness, knowledgeability, contextual application and reconceptualization, each with different challenges and dilemmas, participants had to overcome to progress their self-management. Testing the conceptual model, confirmed stages and highlighted acceptance as key to overcoming barriers. The study described adolescents' integration of self-management as proximal and inquiry-based, with acceptance, driving increasingly complex management behaviors. We hypothesize future interventions may benefit from exploring supporting adolescents' inquiries into their knee pain at different stages of the trajectory. PERSPECTIVE: This study presents a conceptual model and vocabulary for optimizing patient education concepts, to target the challenges, barriers and needs of adolescents with knee pain at different stages of their mastery journey. We believe our findings may inform reflections among clinicians and researchers, and development of more effective education interventions.

Targeting Coping to Improve Surgical Outcomes in Pediatric Patients With Median Arcuate Ligament Syndrome: Feasibility Study

Background: Median arcuate ligament syndrome (MALS) is a vascular compression syndrome leading to postprandial epigastric pain, nausea, and weight loss; it can be treated surgically. While most patients report improved quality of life following surgical intervention, 30% continue to experience chronic abdominal pain. Pre-surgical diagnoses of depression and/or anxiety have been found to significantly predict post-surgical: quality of life, highest experience of pain, anxiety, and parent- and self-reported coping strategies. As such, increasing the coping strategies of pediatric patients with MALS may impact their post-surgical outcomes. The purpose of the current study was to: (1) implement a pre-operative cognitive behavioral therapy protocol with a focus on psychoeducation and coping strategies; and (2) determine feasibility of a pre-surgical intervention for this population. Method: Children (<18 years of age) with a diagnosis of MALS who were eligible for surgical intervention were invited to participate in a 7-week in-person or video-based pre-surgical cognitive behavioral therapy intervention. Psychiatric comorbidities were assessed at baseline and post-surgery; patient-reported distress, pain interference and intensity, health-related quality of life, and health status were assessed at four time points (baseline, week 4, week 7, and post-surgery). Descriptive analyses were used to characterize the sample, assess feasibility outcomes (i.e., attrition rates), and explore symptom-based outcomes across time. Results: Twelve pediatric patients (M age = 15.2 ± 1.7; 91.7% female) and their parents (91.7% mothers) participated. Feasibility metrics based on protocol completion were exceeded for engagement at the stages of consent (68.4% vs. goal of ≥50%), treatment initiation (92.3% vs. 85%), and treatment completion (84.6% vs. 75%). Out of the 12 participants, nine (75%) met criteria for at least one comorbid psychiatric diagnosis at baseline and nine (75%) elected to undergo MALS surgery after completing the intervention. Conclusion: The intervention implementation was feasible, despite chronic pain symptoms experienced by the sample, a high prevalence of psychiatric diagnoses, and an international pandemic, suggesting that it would be beneficial to further evaluate the efficacy of the intervention. Future research should include stakeholder input in the design, deployment, and evaluation of a pilot efficacy trial of pre-surgical cognitive behavioral therapy for pediatric patients with MALS.

A qualitative study of risk and resilience in young adult women with a history of juvenile-onset fibromyalgia

BACKGROUND

Juvenile-onset Fibromyalgia (JFM) is a chronic pain condition characterized by widespread musculoskeletal pain, fatigue, sleep difficulties, mood concerns, and other associated symptoms. Although diagnosed in childhood, JFM often persists into adulthood can result in continued physical, social, and psychological impairment. The purpose of this qualitative study was to identify themes of risk and resilience for long-term outcomes among young adults diagnosed with JFM in childhood.

METHODS

The sample included 13 young adults (ages 26-34) who had been diagnosed with JFM in adolescence. Focus groups were used to elicit qualitative information about living with JFM and perceived challenges and buffering factors impacting their adjustment.

RESULTS

The majority of participants (80%, N = 12) continued to meet criteria for fibromyalgia (FM). An iterative, thematic analysis revealed themes of resilience (e.g., greater acceptance, re-setting expectations, active coping, addressing mental health) and risk (e.g., lack of information, stigma, isolation, negative healthcare experiences).

CONCLUSION

Results suggest the need for longer follow-up of youth with JFM as they transition to adulthood with multidisciplinary care and more attention to education about JFM and associated symptoms such as fatigue, as well as ongoing support for coping and mental health needs. A holistic approach to care during the transition years could be beneficial to minimize impact of JFM on long-term functioning.

COVID-19 Pandemic Impact and Response in Canadian Pediatric Chronic Pain Care: A National Survey of Medical Directors and Pain Professionals

Background: The COVID-19 pandemic presents one of the greatest threats to pediatric pain care seen in generations. Due to public health restrictions, many pediatric pain clinics halted in-person appointments, delaying and disrupting access to care. There is no existing research on the impacts of COVID-19 on pediatric chronic pain care in Canada or the challenges experienced by health care professionals and pain clinics.

Aims: The aim of this study was to evaluate the impact of COVID-19 on Canadian pediatric chronic pain care by documenting how health care professionals provided care during the first six months of the pandemic.

Methods: Two Canadian online cross-sectional surveys were conducted: one among Canadian pediatric pain clinic directors (Study 1) and another among multidisciplinary pediatric pain health care professionals (Study 2).

Results: Responses from 13/13 Canadian pediatric pain clinics/rehabilitation programs indicated that all clinics provided virtual care during the pandemic. No significant changes were reported on the frequency of appointment requests. Most clinics reported no perceived change in patient pain levels (n = 9/13, 69%) or occurrence of pain flares (n = 10/13, 77%). Results from 151 individual health care professionals indicated that the majority (90%) of non–emergency department respondents were providing virtual care. The main challenges of virtual care included technological barriers, financial concerns, infrastructure and logistics, privacy, and clinical challenges.

Conclusions: This study documented the impact of the COVID-19 pandemic on pediatric chronic pain care in Canada and highlighted the rapid shift to using virtual solutions. Simultaneously, respondents outlined current challenges and potential solutions to consider in the development of virtual care guidelines and policy in Canada.

Sociodevelopmental Challenges Faced by Young People with Chronic Pain: A Scoping Review

OBJECTIVE

Map the current literature investigating autonomy development, identity development, and peer relationships in young people aged 10-24 years with chronic pain.

METHODS

A scoping review method was used to systematically search four databases (APA PsycNET, PubMed, Web of Science, and Cinahl) for peer-reviewed articles. Search results were screened against inclusion and exclusion criteria to ensure they met the objective. Eligible papers were assessed for quality, their data relating to the objective were extracted, and results are synthesized.

RESULTS

Searches returned 3,815 papers after the removal of duplicates, with 42 papers included in the full review. The majority of papers investigated peer relationships (86%). Fewer papers investigated autonomy (43%) and identity (21%) development. Included papers were mostly quantitative (64%), with fewer qualitative (34%) and mixed-methods papers (2%). Overall, we found bidirectional relationships between chronic pain in young people, their social development, and a range of functional outcomes. However, the mechanisms underlying these relationships remain relatively unexplored.

CONCLUSIONS

Review results are mapped onto the model proposed by Palermo et al. (2014). Guided by this model, clinical treatment for young people with chronic pain should consider social development. The model also sets out a future research agenda focused on exploring: (a) identity development, (b) the mechanisms underlying the relationships between social-developmental domains, pain, and outcomes, (c) a variety of participants and populations, and (d) a variety of methods, including longitudinal study designs.

Long-term impact of adolescent chronic pain on young adult educational, vocational, and social outcomes

Despite evidence of broad impact on daily functioning in adolescence, little is known regarding the life course effects of childhood chronic pain. This is the first nationally representative study to characterize the disruptive impact of chronic pain in adolescence on key educational, vocational, and social outcomes in young adulthood (12 years later). Data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) were used, including 3174 youth with chronic pain and 11,610 without chronic pain. Multivariate regression analyses controlling for sociodemographic factors and adolescent depression found that chronic pain in adolescence was associated with long-term risk of a constellation of impairments indicative of socioeconomic disparities. Specifically, adolescent chronic pain was subsequently associated with reduced educational attainment (eg, lower odds of attaining a high school diploma and bachelor's degree), poor vocational functioning (eg, lower odds of receiving employer-provided benefits and higher odds of receiving public aid), and social impairments (eg, early parenthood, lower self-reported romantic relationship quality) in young adulthood. These findings provide a window into the future of adolescents with chronic pain, contributing to the limited knowledge base of the scope of adverse long-term outcomes during the transition to adulthood. However, several questions remain. Increased research attention is needed to understand the life course impact of pediatric chronic pain, including early risk factors and underlying mechanisms that drive adverse outcomes as they unfold across the lifespan.

A linguistic analysis of future narratives in adolescents with Complex Regional Pain Syndrome and their pain-free peers

BACKGROUND

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that often develops after injury, with a typical onset in adolescence. The impact of chronic pain is far-reaching, with many adolescents reporting atypical developmental trajectories compared with peers. Social Comparison Theory offers a framework for understanding how such comparisons influence well-being, whereby a heightened sense of disparity places adolescents at risk of poor cognitive, affective and social outcomes. Using a novel linguistic analysis programme, this study aims to investigate cognitive, affective and social language used by adolescents with CRPS in comparison to their peers during a task reflecting on their futures.

METHODS

A story completion task was completed by adolescents with CPRS (n = 49) and adolescents without pain (n = 48). This task involved asking adolescents to describe their imagined future. Narratives were analysed using a novel linguistic analysis programme, focusing on the cognitive, affective and social dimensions.

RESULTS

Findings revealed significant group differences in how adolescents with CRPS described their imagined futures. Adolescents with CRPS used significantly fewer positive affect and more negative affect, anger and sadness words, and greater insight and discrepancy words. No significant groups differences were found for social words.

CONCLUSIONS

Substantial differences in cognitive and affective words were found between adolescents with and without CRPS. Findings provide novel insights into current understandings of cognitive, affective and social processes in adolescents living with chronic pain, particularly with regard to adolescent developmental trajectories, and may in turn highlight potential targets in psychosocial interventions for adolescents living with chronic pain.

SIGNIFICANCE

Social comparisons are commonly undertaken by adolescents with CRPS in relation to peers, increasing risk for poor cognitive, affective and social outcomes. Findings promote the potential importance of targeting psychosocial factors in treatments for paediatric chronic pain.

Family functioning in pediatric heart transplantation: Variables associated with poor outcomes

Family functioning is integral in a child's life and is linked to quality of life in health as well as disease. This has been scarcely studied in pediatric orthotopic heart transplantation (pOHT). In this study, we evaluate demographic and clinical factors associated with family functioning in this patient population. Pediatric post-transplant families were recruited in an outpatient setting (n = 71). The PedsQL Family Impact Module was administered, along with the Parent and Adolescent Medication Barriers Scales (PMBS; AMBS) and the McArthur socioeconomic scale. Associations between clinical and demographic variables and scaled scores were evaluated. In our sample, patients with congenital heart disease, developmental delay, and enteral feeding had lower total impact (P = .026; P = .011; P = .008) and parent self-reported HRQL scores (P = .018; P = .012; P = .005). Patients with developmental delay and enteral feeding also had lower family functioning summary scores (P = .025; P = .031). Higher parent educational status was associated with lower total impact scores (P = .043). Higher PMBS scores demonstrated negative correlation with total impact (P < .001), parent self-reported HRQL (P < .001), and family functioning summary scores (P = .003). Multiple linear regression analysis identified developmental delay, parental education, and PMBS as independent variables associated with family functioning. Our study highlights important factors impacting family functioning in pOHT. Developmental delay, higher parental education, and PMBS were associated with poorer family functioning. Our findings emphasize the need for a multi-disciplinary approach including serial psychological assessment and interventions in the management of pOHT patients in order to optimize family functioning.

Loss-adjusting: Young People's Constructions of a Future Living With Complex Regional Pain Syndrome

OBJECTIVES

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that can present specific difficulties when occurring in adolescence. There is limited work exploring future narratives of healthy adolescents, and how these may differ for those who have chronic health conditions, but there is no research on the future narratives of adolescents who have CRPS.

MATERIALS AND METHODS

In this study, 50 adolescents (44 females, 5 males, 1 preferred not to say) aged 14 to 25 years (mean=19.8, SD=3.68), completed an online story completion task, with a further sample of 10 completing a follow-up telephone interview.

RESULTS

Story completion data were initially analyzed deductively based on the work of Morley and colleagues using hoped-for and feared-for future codes, revealing higher instances of hope (291 over 48 stories) than fear (99 over 27 stories). These codes were subsequently analyzed alongside the in-depth interview data using inductive thematic analysis, generating 2 themes that represent distinct, yet related, approaches of how adolescents incorporate CRPS into their future narratives: (1) the centrality of loss theme identifies the ways some adolescents described how CRPS brings loss, with narratives focused on how these adolescents imagine such losses continuing into the future, and (2) the adjusting to loss theme illustrates the ways other adolescents were able to imagine a future in which they were able to adjust to the losses which CRPS may bring.

DISCUSSION

CRPS may damage the future plans of adolescents. However, being or learning how to be flexible about these goals, may help them to build more positive future narratives.

Peer Support in the Treatment of Chronic Pain in Adolescents: A Review of the Literature and Available Resources

Peer support has found applications beyond the mental health field and is useful for managing several chronic disorders and supporting healthy lifestyle choices. Communication through telephone and the Internet allows for greater access to those who cannot meet in person. Adolescent chronic pain would seem ideally suited to benefit from online peer support groups. Research is lacking, however, to characterize benefit in terms of pain and function, despite a clear desire among adolescents for access to such programs. More rapid development of online applications is needed for peer support, and research into the associated outcomes will be necessary to optimally design such programs.

Parent-Child Reminiscing about Past Pain as a Preparatory Technique in the Context of Children's Pain: A Narrative Review and Call for Future Research

Pain permeates childhood and remains inadequately and/or inconsistently managed. Existing research and clinical practice guidelines have largely focused on factors influencing the immediate experience of pain. The need for and benefits of preparing children for future pain (e.g., painful procedures) has been well established. Despite being a robust predictor of future pain and distress, memories of past painful experiences remain overlooked in pediatric pain management. Just as autobiographical memories prepare us for the future, children’s memories for past pain can be harnessed to prepare children for future painful experiences. Children’s pain memories are malleable and can be reframed to be less distressing, thus reducing anticipatory distress and promoting self-efficacy. Parents are powerful agents of change in the context of pediatric pain and valuable historians of children’s past painful experiences. They can alter children’s pain memories to be less distressing simply by talking, or reminiscing, about past pain. This narrative review summarizes existing research on parent–child reminiscing in the context of acute and chronic pediatric pain and argues for incorporation of parent–child reminiscing elements into preparatory interventions for painful procedures.

A Phenomenological Exploration of the Personal Implications of Female Adolescents Living With Chronic Pain

INTRODUCTION

Chronic pain (CP) negatively impacts everyday previously taken-for-granted activities resulting in considerable psychosocial stress for the individual. Qualitative research in pediatric CP is limited despite the considerable influence CP has on the process of establishing one's personal identity during these formative years and invites the opportunity to understand how CP affects these young individuals from their perspective. The objective of the study was to inquire into the experiences of female adolescents living with CP in order to enhance our understanding of how CP affects their personal lives.

METHOD

We used an interpretive phenomenological approach; two researchers interviewed eight female patients of the Montreal Children's Hospital Chronic Pain Management Clinic (aged 14-17 years) for one session each.

RESULTS

Self-reported factors that improved these female adolescents' personal life included having engaging hobbies, accepting the incurability of CP, and envisioning a fulfilling future.

DISCUSSION

The findings from this study suggest a need to orient CP-related services around goals and interests that female adolescents living with CP set for themselves in order to improve their perceived quality of life.

Online paediatric chronic pain management: assessing the needs of UK adolescents and parents, using a cross-sectional survey

Background:

Adolescent chronic pain is prevalent, and interdisciplinary treatment is recommended. Although it is well known that technology is a key part of adolescents’ daily lives, there have not been any online, interdisciplinary interventions developed for adolescents with chronic pain in a UK healthcare context. Little is known about how adolescents currently use online resources to manage chronic pain, or what guidance they seek.

Methods:

Ninety-five participants from the community answered this mixed-methods, online survey (adolescent n = 54, parent n = 41), which assessed the needs of UK-based adolescents for a new online chronic pain management resource.

Results:

Findings indicated that, at the time of the survey, adolescents frequently used social media platforms, such as Instagram, for chronic pain management. Desired techniques for a new interdisciplinary resource for adolescents included ‘advice on explaining chronic pain to others’ (86.7% of adolescents) and sleep hygiene (82.2% of adolescents), though access to a range of pain management techniques was desired. Qualitative results indicated endorsement of a new programme by adolescents and parents.

Conclusions:

Adolescents and parents had a positive outlook towards the development of a UK-specific online resource to help manage chronic pain. Such an intervention should aim to be made accessible via the National Health Service. Adolescent use of social media platforms to seek support for chronic pain requires further exploration in future research.

Routine use of the Bath Adolescent Pain Questionnaire in a paediatric pain clinic

Introduction

Assessment of outcomes from health interventions are of increasing importance, primarily to identify effective and safe treatment, but also to justify funding decisions. The Bath Adolescent Pain Questionnaire (BAPQ) is a self-report questionnaire, validated in 11-18 year olds, assessing the impact of pain in multiple domains of adolescent life. The similarly validated Bath Adolescent Pain Questionnaire for Parents (BAPQ-P) uses the same domains as the BAPQ, assessing the functioning and development of the adolescent from the parents' perspective.

Methods

We conducted a prospective study, planning to routinely collect BAPQ/BAPQ-P data at initial assessment and 6 months later. All patients aged between 5 and 19 attending our chronic pain clinic for the first time between December 2009 and December 2014 were mailed BAPQ and BAPQ-P questionnaires before the first appointment and 6 months after the first appointment.

Results

In total, 376 of 386 families returned questionnaires at time 0 and 96 after 6 months, 26% of those responded at time 0. We found statistically significant differences on patients' BAPQ questionnaires from 0 to 6 months showing improvement in all domains. A different result was found on parents' questionnaires where we only found a statistically significant difference on daily and emotional functioning. When comparing patient and parent questionnaires at 0 and 6 months, we found statistically significant differences between patients' and parents' questionnaires in the daily functioning and development domains.

Conclusion

We believe BAPQ and BAPQ-P measurement proved useful tools to assess response to pain management input in adolescents over a 6-month period. Our experience and results suggest that these tools can, with appropriate administrative support, be used in routine clinical practice to assess patient outcomes. We also believe that BAPQ and BAPQ-P measurements have a utility to audit pain clinic activity and potentially a use in demonstrating beneficial outcomes to commissioners.