Behavioral and psychosocial factors associated with insomnia in adolescents with chronic pain

Adolescent girls' musculoskeletal pain is more affected by insomnia than boys', and through different psychological pathways

Prior research has established that insomnia is predctive of pain in adolescents and that psychological mechanisms have a crucial role in this relationship. Adolescent girls report more insomnia and pain than boys, yet little is known of gender differences in how insomnia influences pain. This study assessed gender differences in levels and trajectories of insomnia and pain during adolescence, and whether rumination and negative mood mediated the effect of insomnia on pain. Longitudinal survey data measured on 5 annual occasions (Nbaseline = 2,767) were analyzed in a multigroup longitudinal serial mediation model. A final model was generated with insomnia as the predictor, rumination and depressed mood as mediators, pain as the outcome, and gender the grouping variable. The results showed that insomnia predicted pain in adolescents, with an effect 3.5 times larger in girls than boys. Depressed mood was the main mediator in boys. In girls, rumination was the only significant mediator. There were significant gender differences in the effects of insomnia on rumination and pain, and in the effects of rumination on depressed mood and pain, with stronger effects in girls. These results highlight that girls and boys should be considered separately when studying the relationship between insomnia and pain. PERSPECTIVE: Levels of insomnia and pain are progressively higher in adolescent girls than boys, across adolescence. The predictive strength of insomnia symptoms for future pain is 3.5 times greater in girls, with distinct gender-specific underlying pathways: rumination partially mediates this effect in girls, while depressed mood does so in boys.

Personalized Multimodal Lifestyle Intervention as the Best-Evidenced Treatment for Chronic Pain: State-of-the-Art Clinical Perspective

Chronic pain is the most prevalent disease worldwide, leading to substantial disability and socioeconomic burden. Therefore, it can be regarded as a public health disease and major challenge to scientists, clinicians and affected individuals. Behavioral lifestyle factors, such as, physical (in)activity, stress, poor sleep and an unhealthy diet are increasingly recognized as perpetuating factors for chronic pain. Yet, current management options for patients with chronic pain often do not address lifestyle factors in a personalized multimodal fashion. This state-of-the-art clinical perspective aims to address this gap by discussing how clinicians can simultaneously incorporate various lifestyle factors into a personalized multimodal lifestyle intervention for individuals with chronic pain. To do so the available evidence on (multimodal) lifestyle interventions targeting physical (in)activity, stress, sleep and nutritional factors, specifically, was reviewed and synthetized from a clinical point of view. First, advise is provided on how to design a personalized multimodal lifestyle approach for a specific patient. Subsequently, best-evidence recommendations on how to integrate physical (in)activity, stress, sleep and nutritional factors as treatment targets into a personalized multimodal lifestyle approach are outlined. Evidence supporting such a personalized multimodal lifestyle approach is growing, but further studies are needed.

Executive Functioning and Self-Management Processes Mediate the Relationship Between Insomnia and Pain-Related Disability

Insomnia has been identified as a predictor of reduced benefit from cognitive-behavioral treatment (CBT) for adolescent chronic pain; however, it is not well understood how insomnia leads to reduced treatment response. The purpose of this study was to evaluate executive function and self-management processes as 2 potential mediators of the relationship between insomnia symptoms and pain-related disability outcomes from internet-delivered CBT using a single-arm clinical trial design. Eighty-five adolescents with chronic pain (77% female, ages 12-17 years) and their caregiver received an 8-week internet-delivered CBT intervention. Youth completed validated measures of insomnia symptoms, executive function, self-management processes, and pain-related disability at baseline, mid-treatment, immediate post-treatment, and 3-month follow-up. Results from multilevel structural equation modeling indicated that more severe insomnia symptoms were associated with greater problems with executive function, which, in turn, led to lower engagement in self-management processes and less improvement in pain-related disability. These findings identify 2 mediators by which higher insomnia symptoms may lead to reduced benefit from CBT intervention for chronic pain. Research is needed to understand whether psychological treatments for chronic pain may be optimized by strategies targeting insomnia, executive function, and/or engagement in self-management. This trial was registered at clinicaltrials.gov (NCT04043962). PERSPECTIVE: Our study suggests that executive functioning and self-management processes mediate the relationship between insomnia and treatment outcomes for pediatric chronic pain, highlighting the impact of insomnia on youth learning and implementation of self-management strategies and the critical need for targeted sleep interventions in this population.

Sleep Disorders and Chronic Pain Syndromes in the Pediatric Population

Sleep problems are widespread in children and adolescents suffering from chronic pain disorders. Sleep loss intensifies the experience of pain and is detrimental to the budding self-efficacy of a young individual with limitless horizons. Addressing sleep disorders may prevent the chronification of pain and prevent adverse health outcomes, such as functional impairment, psychiatric comorbidities and overall poor quality of life. This review will explore the cyclical nature between sleep, pain and mood, as well as the functional impact of this relationship on children and adolescents. There will be a discussion about sleep assessment and diagnostic testing, followed by a description of sleep disturbances found in specific pain conditions, ranging from headache, musculoskeletal/abdominal pain, to rheumatologic disorders. Finally, there will be a brief review of pharmacologic and behavioral interventions designed to improve sleep quality, and when possible, to alleviate pain.

Focus Groups to Inform User-Centered Development of an eHealth Sleep Intervention for Adolescents: Perspectives of Youth with Insomnia Symptoms, with and without Pain

INTRODUCTION

Adolescence is a developmental stage that often coincides with increasing sleep problems. Focus groups were conducted to inform development of an adolescent eHealth sleep intervention by exploring opinions about (1) healthy sleep practices, and (2) using an eHealth intervention.

METHODS

Adolescents 14-18 years old experiencing symptoms of insomnia based on the Insomnia Sleep Index, with and without recurrent pain, and associated stakeholders (i.e., parents, school personnel, and health care providers) were recruited. Across six online focus groups, 24 adolescents with insomnia participated (14 pain-free, 10 with recurrent pain; 10 male, 14 female). Across seven online focus groups, 22 stakeholders participated, including 8 parents, 9 school professionals, and 5 health care providers (10 male, 8 female). Using a content analysis, subthemes were induced from transcripts.

RESULTS

Most healthy sleep practices were perceived as reasonable for adolescents to implement, except avoiding technology before bed and using bedrooms only for sleep. Three primary barriers to sleep practices were identified, including a variable schedule due to lifestyle factors, technology at night, and academics interfering with sleep, and only in the pain group, the barrier related to pain was identified. Content addressing adolescent-specific barriers was considered important to include in a sleep intervention. Desirable eHealth components included interactive features, videos, audio, and pictures to present information. A common barrier to using an eHealth sleep intervention was the program feeling too academic, with accessibility of the sleep information and strategies as a common facilitator.

CONCLUSIONS

This research represents the first step in a user-centered approach to developing an adolescent eHealth sleep intervention. These results provide insights from a range of perspectives on guiding adolescents to follow healthy sleep practices. Next, these findings will be integrated in the development of an eHealth intervention for adolescents with and without recurrent pain.

Investigating the shared genetic architecture and causal relationship between pain and neuropsychiatric disorders

Pain often occurs in parallel with neuropsychiatric disorders. However, the underlying mechanisms and potential causality have not been well studied. We collected the genome-wide association study (GWAS) summary statistics of 26 common pain and neuropsychiatric disorders with sample size ranging from 17,310 to 482,730 in European population. The genetic correlation between pair of pain and neuropsychiatric disorders, as well as the relevant cell types were investigated by linkage disequilibrium (LD) score regression analyses. Then, transcriptome-wide association study (TWAS) was applied to identify the potential shared genes by integrating the gene expression information and GWAS. In addition, Mendelian randomization (MR) analyses were conducted to infer the potential causality between pain and neuropsychiatric disorders. Among the 169 pairwise pain and neuropsychiatric disorders, 55 pairs showed positive correlations (median r_g = 0.43) and 9 pairs showed negative correlations (median r_g =  -0.31). Using MR analyses, 26 likely causal associations were identified, including that neuroticism and insomnia were risk factors for most of short-term pain, and multisite chronic pain was risk factor for neuroticism, insomnia, major depressive disorder and attention deficit/hyperactivity disorder, and vice versa. The signals of pain and neuropsychiatric disorders tended to be enriched in the functional regions of cell types from central nervous system (CNS). A total of 19 genes shared in at least one pain and neuropsychiatric disorder pair were identified by TWAS, including AMT, NCOA6, and UNC45A, which involved in glycine degradation, insulin secretion, and cell proliferation, respectively. Our findings provided the evidence of shared genetic structure, causality and potential shared pathogenic mechanisms between pain and neuropsychiatric disorders, and enhanced our understanding of the comorbidities of pain and neuropsychiatric disorders.

The complexities of the sleep-pain relationship in adolescents: A critical review

Chronic pain is a common and disabling condition in adolescents. Disturbed sleep is associated with many detrimental effects in adolescents with acute and chronic pain. While sleep and pain are known to share a reciprocal relationship, the sleep-pain relationship in adolescence warrants further contextualization within normally occurring maturation of several biopsychological processes. Since sleep and pain disorders begin to emerge in early adolescence and are often comorbid, there is a need for a comprehensive picture of their interrelation especially related to temporal relationships and mechanistic drivers. While existing reviews provide a solid foundation for the interaction between disturbed sleep and pain in youth, we will extend this review by highlighting current methodological challenges for both sleep and pain assessments, exploring the recent evidence for directionality in the sleep-pain relationship, reviewing potential mechanisms and factors underlying the relationship, and providing direction for future investigations. We will also highlight the potential role of digital technologies in advancing the understanding of the sleep and pain relationship. Ultimately, we anticipate this information will facilitate further research and inform the management of pain and poor sleep, which will ultimately improve the quality of life in adolescents and reduce the risk of pain persisting into adulthood.

Baseline Sleep Disturbances Modify Outcome Trajectories in Adolescents With Chronic Pain Receiving Internet-Delivered Psychological Treatment

Over 50% of adolescents with chronic pain report comorbid sleep disturbances (eg, difficulties with falling asleep), which is associated with increased pain-related disability and poorer quality of life. However, limited longitudinal data are available to understand how sleep disturbance may impact response to psychological treatment. Our primary hypothesis was that baseline sleep disturbances would significantly modify how adolescents responded to an internet-delivered psychological intervention for chronic pain in terms of outcome trajectories. The sample included 85 adolescents, 12 to 17 years, with chronic pain recruited from a multidisciplinary pain clinic and headache clinic who received access to an internet-delivered psychological intervention for chronic pain. Baseline sleep assessment included actigraphy monitoring for 7 days and survey measures. Outcomes were assessed at baseline, 8 weeks, and 3 months including core pain-related outcomes, executive functioning, fatigue, positive and negative affect. Results demonstrated that greater baseline insomnia and poorer sleep quality was associated with worse outcome trajectories for pain-related disability, depression, anxiety, fatigue, negative affect, and executive functioning. Findings extend the limited studies that examine how sleep disturbance may modify effectiveness of psychological treatments for adolescent chronic pain and emphasize the importance of treating comorbid sleep disturbance. This trial was registered at clinicaltrials.gov (NCT04043962). PERSPECTIVE: Our study suggests that sleep deficiency, in particular insomnia and poor sleep quality, may modify the effectiveness of psychological treatments for chronic pain, highlighting the urgent need to screen youth for sleep problems prior to initiating treatment, and to consider implementation of sleep-specific treatments such as cognitive-behavioral therapy for insomnia.

New insight into the neural mechanisms of migraine in adolescents: Relationships with sleep

OBJECTIVE

This case-control study examines if measures of subjective and objective (actigraphic) sleep difficulties mediate alterations in amygdalar connectivity in adolescents with migraine compared to healthy adolescents.

BACKGROUND

Adolescents with migraine have different functional connectivity of the amygdala compared to individuals without migraine. Sleep is often disturbed in adolescents with migraine, and could contribute to the alterations in functional connectivity.

METHODS

Twenty adolescents with migraine and 20 healthy controls were recruited from Cincinnati Children's Hospital. Participants completed surveys about their headaches and overall sleep quality, sleep hygiene, and perceived sleep difficulties (Insomnia Severity Scale [ISI]); completed wrist-worn actigraphy; and underwent a magnetic resonance imaging scan.

RESULTS

Adolescents with migraine differed from healthy controls only in perceived difficulty in sleep initiation and maintenance (ISI: 8.5 ± 4.7 and 4.5 ± 3.7 [mean ± standard deviation], -4.00 [95% confidence: -6.7 to -1.3], p = 0.005) and had greater functional connectivity between the amygdala and the posterior cingulate cortex, precuneus, dorsolateral prefrontal, sensorimotor, and the occipital cortexes. The differences in functional connectivity of the amygdala were not mediated by the subjective/objective sleep measures (ISI/wake minutes after sleep onset).

CONCLUSIONS

Adolescents with migraine have greater connectivity between the amygdala and areas involved in sensory, affective, and cognitive aspects of pain. These alterations may not be due to higher levels of sleep difficulties in adolescents with migraine, suggesting that both amygdala and sleep alterations may play an independent role in migraine pathophysiology. This advances the understanding of the mechanisms underlying pediatric migraine and can potentially advance migraine management.

Sleep phase and pre-sleep arousal predicted co-developmental trajectories of pain and insomnia within adolescence

The onset of both chronic pain and insomnia is high during adolescence. Although a bidirectional relationship between pain and insomnia has support, how pain and sleep co-develop throughout adolescence remains unknown. Sleep–wake patterns, pre-sleep behavior and pre-sleep arousal may influence the co-development of pain and insomnia. Four waves of longitudinal self-report data were used (N^baseline = 2767, Age^baseline M = 13.65 years, SD = 0.65). Multidimensional growth mixture modeling was used to identify four subgroups of adolescents with different concurrent trajectories of pain and insomnia. The trajectories followed each other across time in all classes: one class of consistently low pain and insomnia (68.7%), one class with persistent high symptoms (4.9%), as well as one class of increasing (13.9%), and one of decreasing (12.5%), trajectories. Later sleep–wake patterns and more pre-sleep cognitive-emotional arousal predicted both increasing and decreasing trajectories of concurrent pain and insomnia. The current study showed that developmental trajectories of pain and insomnia follow each other within adolescents and across adolescence. Both sleep-phase focused interventions as well as psychological interventions that focus on pre-sleep cognitive-emotional arousal may prove beneficial for adolescents with comorbid pain and insomnia.

Sleep Health Assessment and Treatment in Children and Adolescents with Chronic Pain: State of the Art and Future Directions

Sleep is interrelated with the experience of chronic pain and represents a modifiable lifestyle factor that may play an important role in the treatment of children and adolescents with chronic pain. This is a topical review of assessment and treatment approaches to promote sleep health in children and adolescents with chronic pain, which summarizes: relevant and recent systematic reviews, meta-analyses, and methodologically sound prospective studies and clinical trials. Recommendations are provided for best practices in the clinical assessment and treatment of sleep health in youth with chronic pain. This overview can also provide researchers with foundational knowledge to build upon the best evidence for future prospective studies, assessment and intervention development, and novel clinical trials.

Prevalence of somatic and pain complaints and associations with sleep disturbance in adolescents with insomnia presenting to a behavioral sleep medicine clinic

STUDY OBJECTIVES

Sleep problems are highly comorbid with pediatric pain, yet there is a dearth of research on how pain and somatic complaints impact adolescent insomnia presentation and response to cognitive-behavioral therapy for insomnia (CBT-I). This study aims to (1) determine the prevalence of parent-reported somatic/pain complaints in adolescents with insomnia presenting to a behavioral sleep clinic, (2) assess the impact of somatic/pain complaints on initial sleep presentation, and (3) assess the impact of baseline somatic/pain complaints on response to CBT-I.

METHODS

Participants included adolescents (n = 375) presenting to a behavioral sleep medicine center with a primary diagnosis of insomnia. As a part of clinical care, pre-evaluation measures were completed including the Pediatric Insomnia Severity Index, Adolescent Sleep Hygiene Scale, Adolescent Sleep Wake Scale, and Child Behavior Checklist. The Somatic Syndrome Scale of the Child Behavior Checklist measured somatic complaints and teens were categorized as endorsing pain if reported to experience aches/pains, headaches, or stomachaches. Adolescents completed the Pediatric Insomnia Severity Index at end of treatment.

RESULTS

Most adolescents had parent-reported somatic (61.1%) and/or pain complaints: headaches (66.6%), stomachaches (48.5%), and aches/pains (45.1%). Greater somatic and pain complaints predicted a worse sleep presentation at intake (all P < .05). After controlling for insomnia severity at intake, neither end-of-treatment insomnia severity nor treatment status were predicted by somatic and pain complaints at intake.

CONCLUSIONS

Results suggest that parent-reported somatic/pain complaints are prevalent in > 50% of adolescents seeking behavioral insomnia treatment. Although complaints are associated with more severe insomnia at intake, they do not appear to interfere with treatment response.

CITATION

Van Dyk TR, Krietsch KN, King CD, Byars KC. Prevalence of somatic and pain complaints and associations with sleep disturbance in adolescents with insomnia presenting to a behavioral sleep medicine clinic. J Clin Sleep Med. 2022;18(1):151-160.

The associations between sleep disturbance, psychological dysfunction, pain intensity, and pain interference in children with chronic pain

OBJECTIVES

This study aimed to better understand the associations between both sleep disturbance and psychological dysfunction (i.e., anxiety and depressive symptoms, and anger), and pain intensity and pain interference, in a sample of children with chronic pain.

DESIGN

Cross-sectional design.

METHODS

Three hundred and forty-two children with chronic pain (8-18 years) completed measures assessing pain intensity, pain interference, sleep disturbance, anxiety, depressive symptoms, and anger. Regression analyses examined the direct, interaction (with sex), and mediation effects of sleep quality and psychological dysfunction on pain intensity and interference.

RESULTS

Sleep disturbance was significantly associated with both pain intensity and pain interference. However, measures of psychological dysfunction were associated significantly only with pain interference. Sex did not moderate these associations. The measures of psychological dysfunction mediated the associations between sleep disturbance and pain interference, but not those between sleep disturbance and pain intensity.

CONCLUSIONS

The results confirmed significant cross-sectional associations between both sleep disturbance and psychological dysfunction and pain outcomes in children with chronic pain. Future research to test for causal associations is warranted.

Ergonomic Consideration in Pillow Height Determinants and Evaluation

(1) Background: Sleep problems have become one of the current serious public health issues. Pillow height affects the alignment of the cervical spine and is closely related to the mechanical environment of the cervical spine. An appropriate pillow height can provide adequate support for the head and neck to reduce the stress in the cervical spine and relax the muscles of the neck and shoulder, thereby relieving pain and improving sleep quality. (2) Methods: We reviewed the current trends, research methodologies, and determinants of pillow height evaluation, summarizing the evidences published since 1997. In particular, we scrutinized articles dealing with the physiological and mechanical characteristics of the head-neck-shoulder complex. (3) Results: Through the investigation and analysis of these articles, we presented several quantitative and objective determinants for pillow height evaluation, including cervical spine alignment, body dimension, contact pressure, and muscle activity. The measurement methods and selection criteria for these parameters are described in detail. However, the suggested range for achieving optimal cervical spine alignment, appropriate pressure distribution, and minimal muscle activity during sleep cannot yet be identified considering the lack of sufficient evidence. Moreover, there remain no firm conclusions about the optimal pillow height for the supine and lateral positions. (4) Conclusions: A comprehensive evaluation combining the above determinants provides a unique solution for ergonomic pillow design and proper pillow height selection, which can effectively promote the public sleep health. Therefore, it is necessary to develop a reasonable algorithm to weigh multiple determinants.

Improvements in Sleep Correlate With Improvements in Clinical Outcomes Among Adolescents Undergoing Intensive Interdisciplinary Pain Treatment

OBJECTIVES

Intensive interdisciplinary pain treatment (IIPT) programs have been shown to restore function, improve coping, and reduce pain in adolescents with chronic pain. Yet, little is known about patients' sleep during IIPT and whether or not improvements in pain treatment outcomes are associated with changes in sleep pre-to-post IIPT treatment. The objectives of the current study were to describe sleep among adolescents entering IIPT and examine associations between sleep parameters and IIPT treatment effects.

MATERIALS AND METHODS

Self-reported sleep measures and clinical outcomes (eg, functional disability, coping, average pain), were collected from 44 adolescents (mean age=14.57, 68.2% female) at admission and discharge from an inpatient IIPT program. Wrist-worn actigraphy data and sleep diaries from participants' first week and last week in the program were analyzed to characterize sleep parameters.

RESULTS

Participants self-reported poor sleep/wake patterns, high levels of insomnia symptoms, and subclinical problems with daytime sleepiness upon admission into IIPT, although actigraphic indices of sleep from the first week of IIPT admission were only just under clinical guidelines for healthy adolescent sleep. Better self-reported sleep quality assessed via aggregated sleep diaries from the first week was associated with improvement in average pain and disability over the course of the program. Furthermore, improvements in insomnia symptoms and daytime sleepiness throughout the program were positively correlated with concurrent improvements in functional disability and coping.

DISCUSSION

Taken together, results suggest that sleep may be associated with IIPT treatment effects and pave the way for future research to continue examining these relationships.

Sleep Deficiency and Pediatric Chronic Pain

Sleep deficiency in children is a public health concern, and it is highly comorbid in pediatric chronic pain conditions. Children may be particularly vulnerable to the deleterious effects of sleep deficiency, because comorbid sleep deficiency in chronic pain may further exacerbate already existent symptoms of pain, anxiety, depressions, daytime function, and increase health care use. Sleep deficiency is modifiable and integrating human-centered approaches into the development of sleep interventions is a pragmatic approach to partner with parents and children to provide them with the knowledge, motivation, and skills for setting and achieving goals, adapting to setbacks, and problem solving.

The German version of the revised Adolescent Sleep-Wake Scale (rASWS) - A validation study in pediatric pain patients and school children

OBJECTIVE

Sleep problems are common in children and adolescents with chronic pain. The revised Adolescent Sleep-Wake Scale (rASWS) is an internationally well-established instrument to assess sleep quality in adolescents. So far, no German version is available. The study aimed to provide a validated German version of the rASWS, specifically for use in children and adolescents with chronic pain.

METHODS

The translated questionnaire was validated in a sample of N = 159 pediatric outpatients with chronic pain (8-17 years; 65.4% female), who presented to a specialized pediatric pain center. For cross-validation a community sample of N = 1348 school children was analyzed.

RESULTS

Confirmatory factor analysis was conducted to examine the factor structure of the original 10-item 3-factor model in the sample of children and adolescents with chronic pain, which showed poor model fit. Model modifications were carried out by deleting 3 items with low factor loadings stepwise. The overall model fit of the final 3-factor model containing 7 items was excellent. Cronbach's α of the derived scales ranged from 0.74 to 0.86. Cross-validation in a community sample of school children confirmed the superiority of the 7-item model. The convergent validity of the measure was proved by moderate correlations between the rASWS and self-reported sleep problems. Associations with chronic pain characteristics were evident for pain-related disability.

CONCLUSIONS

The use of the 7-item version of the rASWS for German-speaking children and adolescents with and without chronic pain is recommended as a self-report measure of sleep quality.

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.

Development and Validation of the Adolescent Insomnia Questionnaire

OBJECTIVE

Insomnia is a highly prevalent sleep disorder that is particularly common among adolescents with health conditions. We aimed to develop and validate a brief screening measure of insomnia in adolescents that can be used across clinical and community samples. We hypothesized that we would identify evidence supporting reliability, convergent/discriminant validity, and that we would determine preliminary clinical cutoff scores.

METHODS

A team of experts in behavioral sleep medicine developed a 13-item brief screening measure of insomnia in adolescents (Adolescent Insomnia Questionnaire [AIQ]). We evaluated the psychometric properties of the AIQ in a sample of 315 youth (11-18 years old, Mean = 14.90, SD = 2.02; 64% female) who had chronic pain (n = 37), headache (n = 170), insomnia diagnosed by a sleep specialist (n = 22), or were otherwise healthy (n = 86).

RESULTS

Using Exploratory and Confirmatory Factor Analysis, we identified three subscales consistent with major diagnostic criteria of insomnia. As expected, the measure showed strong reliability through high internal consistency (α =.91). We also found strong convergent validity through expected positive relationships between the AIQ and self-report measures of sleep disturbance, and divergent validity via weak relationships with parent-report of snoring. Results of receiver operating characteristic (ROC) identified a clinical cutoff score that may assist in clinical decision making.

CONCLUSIONS

We found that the AIQ has sound psychometric properties in a large heterogeneous sample of treatment-seeking youth and youth from the community. The AIQ can quickly screen adolescent insomnia and could address an important clinical need in identifying youth in need of insomnia treatment in pediatric practice settings.

Manifestation and parental assessment of children's cancer pain at home: An exploratory mixed-methods study

AIMS AND OBJECTIVES

To describe pain manifestation in children with cancer at home and understand how parents assess this pain.

BACKGROUND

Pain is experienced by children with cancer throughout their cancer journey. Short-term, and into survivorship, pain has negative physical and psychological consequences. Changes in treatment location mean children with cancer spend more time at home. Little is known about pain experienced by children at home or how parents assess this pain.

DESIGN

A mixed-methods convergent parallel study was reported using STROBE.

METHOD

Parents of children with cancer on active treatment were recruited from one tertiary cancer centre. Parental attitudes towards pain expression were assessed using surveys. Parents recorded their child's pain manifestation in pain diaries kept for one month. Interviews captured a deeper understanding of pain manifestation and how parents assess this pain at home. Integration occurred after each data collection method was analysed separately.

RESULTS

Predominantly children were not in pain at home. However, most children experienced at least one episode of problematic pain over the pain diary period. Surveys showed parents held misconceptions regarding children's pain expression. Interviews diverge from surveys and suggest parents used a range of information sources to assess pain.

CONCLUSION

Children with cancer may differ from one another in the manifestation of pain at home resulting in multiple pain trajectories. Parents of children with cancer are able to adequately assess their child's pain using information from multiple sources.

RELEVANCE TO CLINICAL PRACTICE

It is not currently possible to predict which children will experience problematic pain at home, so all parents require pain management education prior to discharge. Teaching parents to use bundled approaches to pain assessment may accelerate their learning. Healthcare professionals may benefit from using multiple information sources to assess pain.

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.

A Multimethod, Case-Controlled Study of Sleep-Wake Disturbances in Adolescents With Spina Bifida

Objective

This study aimed to compare sleep-wake disturbances in adolescents with spina bifida (SB) to typically developing (TD) peers. Exploratory analyses examined sex as moderator of disrupted sleep.

Methods

Adolescents with SB (ages 12-18 years; N = 37) and a demographically matched sample of TD adolescents (N = 37) completed validated sleep questionnaires and underwent 10 days of actigraphy monitoring.

Results

Adolescents with SB evidenced worse sleep quality, shorter sleep duration, greater sleep maintenance difficulties, and higher levels of fatigue compared with their TD peers. Exploratory analyses revealed females with SB were particularly vulnerable to developing sleep disturbances.

Conclusions

Adolescents with SB are at risk for nighttime sleep disturbances and daytime fatigue. Additional research will need to identify mechanisms and adverse consequences of poor sleep to develop interventions addressing sleep deficiency. Sex-specific disparities in sleep patterns in pediatric SB is a novel finding that requires assessment of etiological underpinnings to clarify clinical implications.

Sleep and stress in adolescents: the roles of pre-sleep arousal and coping during school and vacation

STUDY OBJECTIVES

This study explored the relationship between stress and actigraphy-measured and self-reported sleep in adolescents during periods of restricted (school) and unrestricted (vacation) sleep opportunities. We further examined whether (1) cognitive pre-sleep arousal (PSA) mediated the relationship between stress and sleep onset latency (SOL), and (2) coping moderated the effect of stress on PSA.

METHODS

Participants were 146 (77 females) adolescents (M = 16.2, SD = 1.0) recruited from the community. Actigraphy assessed daily sleep over the last week of a school-term and the following two-week vacation. The following self-report measures were administered during both school and vacation: the Pittsburgh Sleep Quality Index, Inventory of High-School Students Recent Life Experiences (stress), Pre-Sleep Arousal Scale, and the Brief COPE (coping).

RESULTS

Path analyses showed that during both school and vacation, higher cognitive PSA mediated the relationship between higher stress and longer self-report SOL (p < 0.01). During vacation, higher PSA also mediated the relationship between higher stress and longer actigraphy SOL (p < 0.05). During vacation (but not school), problem-focused coping moderated the mediating effects of PSA (p < 0.05), such that more frequent use of coping was associated with weaker association between stress and cognitive PSA, and shorter actigraphy and self-report SOL.

CONCLUSIONS

Cognitive PSA and coping may be two modifiable factors influencing how stress affects adolescents' sleep onset. Interventions that reduce cognitive arousal at bedtime may therefore shorten adolescents' sleep onset during both school and vacation. Further, the use of problem-focused coping strategies might be protective against the effects of stress on sleep onset, especially during vacation periods.

STATEMENT OF SIGNIFICANCE

This paper expands the understanding of the stress-sleep association in adolescents by examining the mediating role of cognitive pre-sleep arousal and the moderating effects of coping. By examining these associations during both school and vacation periods, findings are likely to be applicable to both restricted and relatively unconstrained sleep conditions. Practically, our findings suggest that interventions directed towards the reduction of cognitive pre-sleep arousal may improve adolescents' sleep onset latency. Additionally, fostering healthy coping, especially problem-focused coping strategies such as problem solving, may mitigate the effects of stress on adolescents' sleep.

Lifestyle and Chronic Pain across the Lifespan: An Inconvenient Truth?

Chronic pain has a tremendous personal and socioeconomic impact and remains difficult to treat. Therefore, it is important to provide an update on the current understanding regarding lifestyle factors in people with chronic pain across the lifespan. Lifestyle factors such as physical (in)activity, sedentary behavior, stress, poor sleep, unhealthy diet, and smoking are associated with chronic pain severity and sustainment. This applies to all age categories, that is, chronic pain across the lifespan. Yet current treatment options often do not or only partly address the many lifestyle factors associated with chronic pain or attempt to address them in a standard format rather than providing an individually tailored multimodal lifestyle intervention. The evidence regarding lifestyle factors is available in adults, but limited in children and older adults having chronic pain, providing important avenues for future research. In conclusion, it is proposed that treatment approaches for people with chronic pain should address all relevant lifestyle factors concomitantly in an individually-tailored multimodal intervention. Ultimately, this should lead to improved outcomes and decrease the psychological and socioeconomic burden of chronic pain. Level of Evidence: IV.

Acute and Chronic Pain in Children and Adolescents With Cerebral Palsy: Prevalence, Interference, and Management

OBJECTIVE

To determine the prevalence, interference, and management of acute and chronic pain among youth with cerebral palsy (CP) aged 5-18 years attending outpatient rehabilitation services.

DESIGN

A cross-sectional study using the Faces Pain Scale-Revised, Patient Reporting Outcomes Measurement Information System Pediatric Pain Interference Scale, and the Cerebral Palsy Quality of Life questionnaire. Where children were unable to self-report, parent or caregiver proxy was obtained.

SETTING

Outpatient rehabilitation.

PARTICIPANTS

Participants (N=280) with CP aged 5-18 years and their parent or caregiver. Self-report was obtained by 45.7% (n=128) and proxy-report was obtained by 54.3% (n=152) of the cohort.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Presence or absence of acute pain and chronic pain. Secondary measures were pain intensity, pain interference, pain management, and quality of life.

RESULTS

Acute pain and chronic pain were reported by 67.1% and 31.4% of participants, respectively. Of those reporting acute pain, 42% also experienced chronic pain. Factors that increased the odds of chronic pain were: predominately dyskinesia (odds ratio [OR]=3.52; 95% confidence interval [CI], 1.64-7.55); mixed spasticity-dyskinesia (OR=1.93; 95% CI, 1.07-3.47); bilateral involvement (OR=3.22; 95% CI, 1.844-5.61) and Gross Motor Function Classification System level IV (OR=2.32; 95% CI, 1.02-5.25), and V (OR=3.73; 95% CI, 1.70-8.20). Pain frequently interferes with sleep, attention, ability to have fun, and quality of life. Short-acting pharmacologic analgesics, thermotherapy, hydrotherapy, and massage were commonly used for pain management.

CONCLUSIONS

Routine screening for pain is critical for early identification and intervention. Multimodal interventions are needed to address the biopsychosocial model of pain, and should be tailored for all abilities across the CP spectrum.

The Interrelationship between Sleep and Chronic Pain in Adolescents

Over half of youth with chronic pain report sleep deficiency including difficulties falling asleep, maintaining sleep, feeling unrested, and experiencing short sleep duration. Sleep deficiency has been shown to play a causal role in the development or worsening of chronic pain, and is associated with a variety of negative consequences for youth with chronic pain. The purpose of this review is to provide a summary of the literature on the interrelationship of sleep and chronic pain in adolescents. We review the impact and prevalence of sleep disturbances, conceptual models of the interrelationship of sleep and pain, biobehavioral mechanisms and risk factors, sleep assessment, and treatment of sleep deficiency and chronic pain in adolescents. Our recommendations for future research include understanding biobehavioral mechanisms that underlie the link between chronic pain and sleep deficiency to help guide development and testing of treatments for co-occurring pain and sleep disturbance in adolescents.

Neurobiological mechanisms underlying the sleep-pain relationship in adolescence: A review

Adolescence characterizes a period of significant change in brain structure and function, causing the neural circuitry to be particularly susceptible to the environment and various other experiences. Chronic pain and sleep deprivation represent major health issues that plague adolescence. A bidirectional relationship exists between sleep and pain; however, emerging evidence suggests that sleep disturbances have a stronger influence on subsequent pain than vice versa. The neurobiological underpinnings of this relationship, particularly during adolescence, are poorly understood. This review examines the current literature regarding sleep and pain in adolescence, with a particular focus on the neurobiological mechanisms underlying pain, sleep problems, and the neural circuitry that potentially links the two. Finally, a research agenda is outlined to stimulate future research on this topic. Given the high prevalence of these health issues during adolescence and the debilitating effects they inflict on nearly every domain of development, it is crucial that we determine the neurobiological mechanisms fundamental to this relationship and identify potential therapeutic strategies.

Social Media Content About Children's Pain and Sleep: Content and Network Analysis

BACKGROUND

Social media is often used for health communication and can facilitate fast information exchange. Despite its increasing use, little is known about child health information sharing and engagement over social media.

OBJECTIVE

The primary objectives of this study are to systematically describe the content of social media posts about child pain and sleep and identify the level of research evidence in these posts. The secondary objective is to examine user engagement with information shared over social media.

METHODS

Twitter, Instagram, and Facebook were searched by members of the research team over a 2-week period using a comprehensive search strategy. Codes were used to categorize the content of posts to identify the frequency of content categories shared over social media platforms. Posts were evaluated by content experts to determine the frequency of posts consistent with existing research evidence. User engagement was analyzed using Netlytic, a social network analysis program, to examine visual networks illustrating the level of user engagement.

RESULTS

From the 2-week period, nearly 1500 pain-related and 3800 sleep-related posts were identified and analyzed. Twitter was used most often to share knowledge about child pain (639/1133, 56.40% of posts), and personal experiences for child sleep (2255/3008, 75.00% of posts). For both topics, Instagram posts shared personal experiences (53/68, 78% pain; 413/478, 86.4% sleep), Facebook group posts shared personal experiences (30/49, 61% pain; 230/345, 66.7% sleep) and Facebook pages shared knowledge (68/198, 34.3% pain; 452/1026, 44.05% sleep). Across platforms, research evidence was shared in 21.96% (318/1448) of pain- and 9.16% (445/4857) of sleep-related posts; 5.38% (61/1133) of all pain posts and 2.82% (85/3008) of all sleep posts shared information inconsistent with the evidence, while the rest were absent of evidence. User interactions were indirect, with mostly one-way, rather than reciprocal conversations.

CONCLUSIONS

Social media is commonly used to discuss child health, yet the majority of posts do not contain research evidence, and user engagement is primarily one-way. These findings represent an opportunity to expand engagement through open conversations with credible sources. Research and health care communities can benefit from incorporating specific information about evidence within social media posts to improve communication with the public and empower users to distinguish evidence-based content better. Together, these findings have identified potential gaps in social media communication that may be informative targets to guide future strategies for improving the translation of child health evidence over social media.

Chronic non-cancer pain in children: we have a problem, but also solutions

Chronic non-cancer pain in children and adolescents has been described as "a modern public health disaster" that has generated significant medical and economic burdens within society. Seen as a disease in its own right, chronic pain has short and long-term consequences that impact not only the patient's health but also that of friends and families, due to significant parenting stress and disruptions in family life and structure. The evidence supporting pharmacological treatments and interventional procedures is limited, and no single strategy has been shown to be completely effective in children with chronic non-cancer pain. Therefore, considering the multifactorial nature of chronic pain, these patients should be treated with a multidisciplinary, balanced approach that seeks a primary outcome of improved functioning rather than of pain reduction. Using a bio-psycho-social approach, a multidisciplinary team, including a physiotherapist, nurse, social worker, psychologist, and physician, has been effective in achieving this outcome of improved functioning in children and adolescents with chronic pain. In this review, we discuss the impact, associated conditions, and evolution of chronic pain, along with the crucial role of every member of a multidisciplinary chronic pain clinic involved in the care of the children and adolescents with chronic non-cancer pain.

Methadone as the Initial Long-Acting Opioid in Children with Advanced Cancer

BACKGROUND

Methadone is an attractive medication for treating children with advanced cancer with pain as it is the only long-acting opioid available as a liquid. However, it is not frequently used due to concerns about potential toxicities and side effects.

OBJECTIVE

Evaluate the efficacy and safety of methadone as the first long-acting opioid in children with advanced cancer.

DESIGN

Retrospective chart review of 52 consecutive patients referred to Pediatric Supportive Care for pain management started on methadone as their first long-acting opioid. Data collected at baseline, follow-up visits #1 (F1) and #2 (F2) included child and parent-reported outcomes for various physical and psychological symptoms, opioid side effects and other clinical data. Symptoms were rated on a 0 (not at all) to 4 (a lot) scale.

RESULTS

Pain (mean ± standard deviation [SD]) scored by the child was 3.6 (±0.6)/4 at baseline and 1.8 (±1.1)/4 at F1 (p < 0.0001). Compared to baseline, pain scored by the child at F2 was 1.2 (±1.3)/4 (p < 0.0001). Pain scored by the parent was 3.5 (±0.7)/4 at baseline and 1.4 (±1.3)/4 at F1 (p < 0.0001). Compared to baseline, pain scored by the parent at F2 was 1.0 (±1.2)/4 (p < 0.0001). Thirty-three (70%) patients at F1 and 23 (79%) patients at F2 did not need a change in dose of methadone. No cardiac arrhythmias or opioid neurotoxicity was observed.

CONCLUSIONS

Initiation of methadone was effective and safe as the first long-acting opioid in children with pain.

Sleep in adolescents and young adults

Sleep has an important role in maintaining health and wellbeing; this relationship is becoming increasingly recognised for adolescents and young adults. Many physicians will encounter young people who present with complaints or conditions that have some relation to poor sleep. This review article looks at why sleep matters within this population group, how it can impact on longer term health consequences and discusses some tools to help enable the clinician to evaluate and address sleep within clinical practice.

Mechanisms of chronic pain - key considerations for appropriate physical therapy management

In last decades, knowledge of nociceptive pain mechanisms has expanded rapidly. The use of quantitative sensory testing has provided evidence that peripheral and central sensitization mechanisms play a relevant role in localized and widespread chronic pain syndromes. In fact, almost any patient suffering with a chronic pain condition will demonstrate impairments in the central nervous system. In addition, it is accepted that pain is associated with different types of trigger factors including social, physiological, and psychological. This rational has provoked a change in the understanding of potential mechanisms of manual therapies, changing from a biomechanical/medical viewpoint, to a neurophysiological/nociceptive viewpoint. Therefore, interventions for patients with chronic pain should be applied based on current knowledge of nociceptive mechanisms since determining potential drivers of the sensitization process is critical for effective management. The current paper reviews mechanisms of chronic pain from a clinical and neurophysiological point of view and summarizes key messages for clinicians for proper management of individuals with chronic pain.

Longitudinal and Temporal Associations Between Daily Pain and Sleep Patterns After Major Pediatric Surgery

Approximately 20% of children develop persistent pain after major surgery. Sleep disruption has been implicated as a predictor of children's acute postsurgical pain. However, perioperative sleep patterns have not been longitudinally assessed, and the role of sleep in persistence of postsurgical pain has not been explored. We aimed to examine sleep patterns over 4 months in children having major surgery, and temporal relationships between daily sleep and pain. Sixty children age 10 to 18 (mean = 14.7) years having major surgery completed 7 days of actigraphy sleep monitoring (sleep duration, efficiency), twice daily electronic diaries (sleep quality, pain intensity, medication use), and validated questionnaires at presurgery, 2 weeks, and 4 months postsurgery. Generalized linear models, controlling for age, sex, naps, and medication, showed sleep quality (β [B] = -.88, P < .001) and efficiency (B = -1.50, P = .036) were significantly reduced at 2 weeks compared with presurgery, and returned to baseline by 4 months. Poorer night-time sleep quality was significantly associated with greater next day pain intensity (B = -.15, P = .005). Sleep duration and efficiency were not associated with subsequent pain; daytime pain was not associated with subsequent sleep. Findings suggest sleep quality may be an important target for intervention after surgery in children; research is needed to understand how other sleep parameters may relate to recovery.

PERSPECTIVE

This study assessed longitudinal sleep patterns over 4 months after major pediatric surgery using actigraphy, diaries, and validated measures. Sleep quality and efficiency were significantly reduced at 2 weeks. Poorer sleep quality was associated with greater next day pain intensity suggesting that sleep quality may be an important target for intervention.

Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints

Primary pain disorders (formerly “functional pain syndromes”) are common, under-diagnosed and under-treated in children and teenagers. This manuscript reviews key aspects which support understanding the development of pediatric chronic pain, points to the current pediatric chronic pain terminology, addresses effective treatment strategies, and discusses the evidence-based use of pharmacology. Common symptoms of an underlying pain vulnerability present in the three most common chronic pain disorders in pediatrics: primary headaches, centrally mediated abdominal pain syndromes, and/or chronic/recurrent musculoskeletal and joint pain. A significant number of children with repeated acute nociceptive pain episodes develop chronic pain in addition to or as a result of their underlying medical condition “chronic-on-acute pain.” We provide description of the structure and process of our interdisciplinary, rehabilitative pain clinic in Minneapolis, Minnesota, USA with accompanying data in the treatment of chronic pain symptoms that persist beyond the expected time of healing. An interdisciplinary approach combining (1) rehabilitation; (2) integrative medicine/active mind-body techniques; (3) psychology; and (4) normalizing daily school attendance, sports, social life and sleep will be presented. As a result of restored function, pain improves and commonly resolves. Opioids are not indicated for primary pain disorders, and other medications, with few exceptions, are usually not first-line therapy.

Internet-delivered cognitive-behavioral treatment for adolescents with chronic pain and their parents: a randomized controlled multicenter trial

Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included were 273 adolescents (205 females and 68 males), aged 11 to 17 years with mixed chronic pain conditions and their parents, who were randomly assigned in a parallel-group design to Internet-delivered CBT (n = 138) or Internet-delivered Education (n = 135). Assessments were completed before treatment, immediately after treatment, and at 6-month follow-up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to 6-month follow-up for Internet CBT compared with Internet education (b = -1.13, P = 0.03). On secondary outcomes, significant beneficial effects of Internet CBT were found on sleep quality (b = 0.14, P = 0.04), on reducing parent miscarried helping (b = -2.66, P = 0.007) and protective behaviors (b = -0.19, P = 0.001), and on treatment satisfaction (P values < 0.05). On exploratory outcomes, benefits of Internet CBT were found for parent-perceived impact (ie, reductions in depression, anxiety, self-blame about their adolescent's pain, and improvement in parent behavioral responses to pain). In conclusion, our Internet-delivered CBT intervention produced a number of beneficial effects on adolescent and parent outcomes, and could ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families.

Factors Associated with Higher Reported Pain Levels in Patients with Chronic Musculoskeletal Pain: A Cross-Sectional, Correlational Analysis

BACKGROUND

Chronic musculoskeletal pain is highly prevalent, disabling, and costly, and has many negative effects on quality of life. The aim of this study was to investigate factors associated with higher reported pain levels in patients with chronic musculoskeletal pain among demographic, clinical, and psychological factors, and to evaluate whether insomnia is independently associated with pain intensity in this population.

METHODS

A total of 357 patients with chronic musculoskeletal pain (pain duration ≥ six months) satisfied the study inclusion criteria and were included in the analyses. Patient demographics, clinical, and psychological factors were evaluated with hierarchical multivariate logistic analysis to identify factors associated with severe pain (NRS [numeric rating scale] ≥ 7). Hierarchical linear regression analysis also performed to identify factors associated with pain intensity (0 to 10 NRS).

RESULTS

Multivariate logistic analyses revealed older age (OR [odds ratio] = 1.017, 95% CI [confidence interval] 1.001-1.032, P = 0.034), high anxiety level (OR = 1.162, 95% CI 1.020-1.324, P = 0.024), high pain catastrophizing (OR = 1.043, 95% CI 1.007-1.081, P = 0.018), and severe insomnia (OR = 1.112, 95% CI 1.057-1.170, P<0.001) were significantly associated with severe pain. Hierarchical linear regression analysis showed age (β = 0.106, P = 0.041), pain catastrophizing (β = 0.249, P<0.001), and insomnia (β = 0.286, P<0.001) were significantly associated with pain intensity. The variance in pain intensity explained by the final model was 32.2%.

CONCLUSIONS

Older age, severe insomnia, and high pain catastrophizing were significantly associated with higher reported pain levels. Insomnia was independently associated with pain intensity, even after controlling for various demographic and clinical factors. These factors should be considered when devising pain management strategies for this population.

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.

Sleep and Pain in Pediatric Illness: A Conceptual Review

BACKGROUND

Sleep disruption is a common comorbidity of pediatric pain. Consequences of pain and disrupted sleep, evidence for the pain-sleep relation, and how aspects of illness, treatment, and pharmacological pain management may contribute to or exacerbate these issues are presented.

AIMS

This conceptual review explored the relation between pain and sleep in children diagnosed with chronic medical or developmental conditions. The goal of this review is to expand upon the literature by examining common themes in sleep disturbances associated with painful conditions across multiple pediatric illnesses. Populations reviewed include youth with intellectual and developmental disabilities (IDD), migraines, cystic fibrosis (CF), sickle cell disease (SCD), cancer, juvenile idiopathic arthritis (JIA), juvenile fibromyalgia (JFM), and functional gastrointestinal disorders (FGIDs).

RESULTS

Consistent evidence demonstrates that children with medical or developmental conditions are more vulnerable to experiencing pain and subjective sleep complaints than healthy peers. Objective sleep concerns are common but often under-studied. Evidence of the pain-sleep relationship exists, particularly in pediatric SCD, IDD, and JIA, with a dearth of studies directly examining this relation in pediatric cancer, JFM, CF, and FGIDs. Findings suggest that assessing and treating pain and sleep disruption is important when optimizing functional outcomes.

CONCLUSION

It is essential that research further examine objective sleep, elucidate the pain-sleep relationship, consider physiological and psychosocial mechanisms of this relationship, and investigate nonpharmacological interventions aimed at improving pain and sleep in vulnerable pediatric populations.

Pediatric Chronic Abdominal Pain and Median Arcuate Ligament Syndrome: A Review and Psychosocial Comparison

Chronic abdominal pain (CAP) occurs in children and adolescents with a reported prevalence of 4% to 41% with significant direct and indirect costs to the child, family, and society. Median arcuate ligament syndrome (MALS) is a vascular compression syndrome of the celiac artery that may cause symptoms of epigastric pain and weight loss and is a frequently overlooked cause of CAP in the pediatric population. We have observed that the psychosocial presentation of patients with MALS is notable for various psychiatric comorbidities. In this article, we review MALS as well as our study results of the psychosocial profile of 30 MALS patients. Our data suggest that children and adolescents with MALS have similar psychosocial profiles to children with other gastrointestinal disorders resulting in CAP. The overlap of physical and psychosocial symptoms of patients who have MALS with other CAP disorders leads us to recommend that patients with CAP should be evaluated for MALS. [Pediatr Ann. 2016;45(7):e257-e264.].

Post-traumatic stress symptoms in children and adolescents with chronic pain: A topical review of the literature and a proposed framework for future research

BACKGROUND AND OBJECTIVE

The co-occurrence of chronic pain and post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) has gained increasing research attention. Studies on associations among pain and PTSS or PTSD in youth have largely been conducted in the context of acute injury or trauma. Less is known about the risk for co-occurrence with paediatric chronic pain. In this review, we (1) propose a conceptual framework to outline factors salient during childhood that may be associated with symptom severity, co-occurrence and mutual maintenance, (2) present relevant literature on PTSS in youth with acute and chronic pain and identify research gaps and (3) provide recommendations to guide paediatric research examining shared symptomatology.

DATABASES AND DATA TREATMENT

Electronic databases (PubMed and Google Scholar) were used to identify relevant articles using the search terms 'child, adolescent, paediatric, chronic pain, acute pain, post-traumatic stress symptoms and post-traumatic stress disorder'. Studies were retrieved and reviewed based on relevance to the topic.

RESULTS

Our findings revealed that existing biobehavioural and ecological models of paediatric chronic pain lack attention to traumatic events or the potential development of PTSS. Paediatric studies are also limited by lack of a conceptual framework for understanding the prevalence, risk and trajectories of PTSS in youth with chronic pain.

CONCLUSIONS

Our new developmentally informed framework highlights individual symptoms and shared contextual factors that are important when examining potential associations among paediatric chronic pain and PTSS. Future studies should consider bidirectional and mutually maintaining associations, which will be aided by prospective, longitudinal designs. WHAT DOES THIS REVIEW ADD?: This review presents relevant literature on pain and PTSS in youth and proposes a conceptual framework to examine factors salient during childhood that may be associated with symptom severity, comorbidity and mutual maintenance of chronic pain and PTSS in paediatric populations. We highlight dynamic factors that may change across children's development and provide recommendations to guide paediatric research examining potential associations among PTSS and chronic pain.

The effects of cognitive-behavioral therapy for youth anxiety on sleep problems

The present study examined (a) whether sleep related problems (SRPs) improved following cognitive-behavioral therapy (CBT) for youth with anxiety disorders, (b) whether variables that may link anxiety and SRPs (e.g., pre-sleep arousal, family accommodation, sleep hygiene) changed during treatment, and (c) whether such changes predicted SRPs at posttreatment. Youth were diagnosed with anxiety at pretreatment and received weekly CBT that targeted their principal anxiety diagnosis at one of two specialty clinics (N=69 completers, Mage=10.86). Results indicated that parent-reported SRPs improved from pre- to post-treatment and that treatment responders with regard to anxiety yielded greater SRP improvements than nonresponders. Parent report of bedtime resistance and sleep anxiety showed significant improvements. Youth reported lower rates of SRPs compared to their parents and did not demonstrate pre- to post-treatment changes in SRPs. Pre-sleep arousal and family accommodation decreased over treatment but did not predict lower SRPs at posttreatment. Higher accommodation was correlated with greater SRPs. Sleep hygiene evidenced no change and did not mediate links between accommodation and posttreatment SRPs.

Cognitive processes in comorbid poor sleep and chronic pain

We examined the unique and shared contributions of pain catastrophizing, cognitive pre-sleep arousal, and somatic pre-sleep arousal, to the prediction of insomnia severity in chronic pain. Forty-eight adults with chronic pain completed self-report measures of these study variables, health, and mood. Hierarchical regression showed that pain catastrophizing accounted for unique variance in insomnia severity, independent of pain intensity, depression, restless legs symptoms, and demographics. However, when cognitive and somatic pre-sleep arousal were also taken into account, the significance of cognitive pre-sleep arousal rendered pain catastrophizing non-significant. We identify research and clinical implications of this study.

Pilot Randomized Controlled Trial of Internet-Delivered Cognitive-Behavioral Treatment for Pediatric Headache

OBJECTIVE

To evaluate the feasibility and preliminary effectiveness of an Internet-delivered cognitive-behavioral therapy (CBT) intervention for adolescents with chronic headache.

BACKGROUND

Headache is among the most common pain complaints of childhood. Cognitive-behavioral interventions are efficacious for improving pain among youth with headache. However, many youth do not receive psychological treatment for headache due to poor access, which has led to consideration of alternative delivery modalities such as the Internet.

METHODS

We used a parallel arm randomized controlled trial design to evaluate the feasibility and preliminary effectiveness of an Internet-delivered family-based CBT intervention, Web-based management of adolescent pain. Adolescents were eligible for the trial if they were a new patient being evaluated in a specialized headache clinic, between 11 and 17 years of age, and had recurrent headache for 3 months or more as diagnosed by a pediatric neurologist. Eighty-three youths were enrolled in the trial. An online random number generator was used to randomly assign participants to receive Internet CBT adjunctive to specialized headache treatment (n = 44) or specialized headache treatment alone (n = 39). The primary treatment outcome was headache days.

RESULTS

Youth and parents in the Internet CBT group demonstrated high levels of engagement with the web program and reported satisfaction with the intervention. Multilevel modelling (MLM) was used to conduct hypothesis testing for continuous outcomes. For our primary treatment outcome of headache days, adolescents reported a statistically significant reduction in headache days from baseline to post-treatment and baseline to 3-month follow-up in both treatment conditions (main effect for time F(2, 136) = 19.70, P < .001). However, there was no statistically significant difference between the Internet CBT group and the specialized headache treatment group at post-treatment or follow-up (group × time interaction F(2, 134) = 0.94, P = .395). For our secondary treatment outcomes, findings from MLM showed that adolescents in both groups demonstrated statistically significant improvement headache pain intensity, activity limitations, depressive symptoms, and parent protective behaviors from baseline to post-treatment and these gains were maintained at 3-month follow-up. Adolescent anxiety symptoms and sleep did not change during the study period for either group. There were no statistically significant group differences on any secondary outcomes at post-treatment or follow-up (P > .05 for all outcomes). No adverse events were reported.

CONCLUSION

Although adjunctive Internet CBT did not lead to additional benefit in this population, future research should evaluate whether it is an effective intervention for adolescents with headache who are unable to access specialized headache treatment.

Examination of the Factor Structure of the Adolescent Sleep-Wake Scale (ASWS)

This study examined the factor structure of the Adolescent Sleep-Wake Scale (ASWS) among 491 adolescents (12-18 years) with and without pediatric health conditions. Exploratory factor analyses were conducted using iterated principal axis factoring with varimax rotation. Highly cross-loading items were systematically removed and analyses were rerun until a clean solution was attained. The final solution explained 57.1% of the total model variance, including 10 items and three factors: Falling Asleep and Reinitiating Sleep-Revised, returning to Wakefulness-Revised, and Going to Bed-Revised. Internal consistency reliability scores were acceptable to good, with the exception of the Going to Bed-Revised subscale for the healthy sample. Adolescents with chronic pain reported significantly poorer overall sleep quality and more problems in falling asleep, reinitiating sleep, and returning to wakefulness as compared to healthy adolescents, providing preliminary evidence for construct validity of the new factors. The resulting ASWS version is a concise assessment tool with empirically derived, distinct behavioral sleep dimensions that can be used for clinical and research purposes.

Subjective and objective assessment of sleep in adolescents with mild traumatic brain injury

There is increased recognition that sleep problems may develop in children and adolescents after mild traumatic brain injury (mTBI). However, few studies have utilized both subjective and objective measures to comprehensively assess sleep problems in the pediatric population following the acute post-TBI period. The aims of this study were to compare sleep in adolescents with mTBI to healthy adolescents using subjective and objective measures, and to identify the clinical correlates associated with sleep problems. One hundred adolescents (50 adolescents with mTBI recruited from three to twelve months post-injury and 50 healthy adolescents) completed questionnaires assessing sleep quality, depression, and pain symptoms, and underwent 10 day actigraphic assessment of sleep patterns. Adolescents with mTBI reported poorer sleep quality and demonstrated significantly shorter actigraphic-measured sleep duration, poorer sleep efficiency, and more wake time after onset of sleep, compared with healthy adolescents (all, p<0.05). For both groups of adolescents, poorer self-reported sleep quality was predicted by greater depressive symptoms. Poorer actigraphic sleep efficiency was predicted by membership in the mTBI group after controlling for age, sex, depressive symptoms, and presence of pain. Our findings suggest that adolescents may experience subjective and objective sleep disturbances up to one year following mTBI. These findings require further replication in larger samples. Additionally, research is needed to identify possible mechanisms for poor sleep in youth with mTBI.