Establishing Clinical Cut-points on the Pediatric PROMIS-Pain Interference Scale in Youth With Abdominal Pain

Depression in children with abdominal pain in the emergency department

OBJECTIVE

This cross-sectional study examined depression and associated impairment in youth presenting to a pediatric emergency department (PED) with abdominal pain.

METHODS

Participants were 11-17 years old, presenting to a PED with idiopathic abdominal pain. Participants completed demographics, pain, pain-related impairment, and depression surveys. Depression was assessed using the Patient Health Questionnaire (PHQ-9A). Scores ≥10 met depression threshold and ≥1 on item 9 indicated self-harm ideation. Mean difference and logistic regression analyses were conducted.

RESULTS

Among 169 participants, 29.6% reported depression and 9.4% endorsed self-harm ideation. Depression was associated with Latinx ethnicity (X2 = 4.02, p = 0.045), higher pain intensity (Z = -3.09, p = 0.002), and higher pain-related impairment (Z = -4.86, p < 0.001). In regression analyses, pain-related impairment and Latinx ethnicity were independently associated with depression (OR = 3.89 [95%CI, 1.22-12.40]; OR = 1.13 [95%CI, 1.06-1.21]). Self-harm ideation was not associated with study variables.

CONCLUSIONS

Results highlight the need for enhanced mental health screening for youth presenting with idiopathic abdominal pain in the ED, particularly for Latinx youth. Early identification of depression and high pain-related impairment may inform interventions and improve outcomes.

IMPACT

Nearly 30% of youth, 11-17 years old, presenting to the ED with idiopathic abdominal pain screened positive for depression and 9.4% reported self-harm ideation. The higher likelihood of depression among Latinx youth experiencing pain emphasizes the importance of including diverse samples in future ED research to explore mechanisms contributing to poorer mental health in minoritized populations. Results highlight the need for enhanced mental health screening in youth presenting to the emergency department with idiopathic abdominal pain.

Psychosocial dimensions of pain disparities in youth diagnosed with unspecified abdominal pain in an emergency department

Diagnosis ambiguity, paired with pain care inequities experienced by marginalized groups may increase risk for ongoing pain and impairment in children diagnosed with unspecified abdominal pain in the pediatric emergency department (PED). This cross-sectional study examined psychological, caregiver, cultural, and socio-ecological factors associated with pain-related impairment in an ethnically and socioeconomically diverse population diagnosed with unspecified abdominal pain in a PED. The sample included 111 children 8-17 years old (59.8 % female, 72.7 % Latinx) and their caregivers. Exclusion criteria included an Emergency Severity Index < 2, psychiatric complaint, or not fluent in English or Spanish. Children completed the PROMIS Pain Interference Scale and reported pain intensity, pain duration, and pain catastrophizing. Caregivers reported language preference, pain catastrophizing, trait anxiety, and child internalizing symptoms. Area Deprivation Index quantified socio-ecological deprivation according to 9-digit zip code. Multivariable logistic regression analyses identified independent associations with likelihood of reporting severe levels of pain-related impairment. Approximately 35.3 % of children reported severe levels of pain-related impairment. In logistic regression analysis, an increased likelihood of endorsing severe pain-related impairment was associated with pain for > 1 month (OR=9.19, p = .044), higher child pain catastrophizing (OR=1.23, p < .001), caregiver Spanish language (OR=11.11, p = .044), and clinically significant caregiver trait anxiety (OR=58.16, p = .004). Results highlight the incidence of severe pain-related impairment in children diagnosed with unspecified abdominal pain in a PED. Moreover, findings underscore the importance of screening pain-related impairment and caregiver anxiety, and addressing language barriers in this PED population. PERSPECTIVE: This paper highlights the incidence of severe pain-related impairment among pediatric patients diagnosed with unspecified abdominal pain in a pediatric emergency department (PED). Results could inform early assessment and targeted interventions in the PED to prevent outcome disparities.

Recommendations for Patient-Reported Outcomes Measurement Information System pediatric measures in youth with chronic pain: a COnsensus-based Standards for the selection of health Measurement INstruments systematic review of measurement properties

ABSTRACT

The Patient-Reported Outcome Measurement Information System (PROMIS) pediatric measures assess physical, emotional, and social health among children and adolescents. However, their measurement properties have not been systematically examined in youth with chronic pain. A systematic review applying the COnsensus based Standards for the selection of health Measurement INstruments (COSMIN) methodology was conducted to evaluate self-reported PROMIS pediatric measures in youth with chronic pain, assessing 8 measurement properties across all versions (item bank, short form, and computer adaptive testing) from 63 studies covering 25 measures. Moderate or high-quality evidence was most available for content validity, structural validity, internal consistency (measurement precision), and construct validity. Four short-form PROMIS pediatric measures-mobility, anxiety, depressive symptoms, and physical stress experiences-achieved recommendation for the use in chronic pain clinical trials; 7 approached recommendation and 14, including the commonly used PROMIS Pediatric Pain Interference Scale, would be recommended with further evidence. Recommendations were also provided for the use of each measure in observational studies. Overall, based on the existing evidence, a total of 11 self-reported PROMIS pediatric short-form measures, including pain intensity, pain behavior, mobility, sleep disturbance, sleep-related impairment, anxiety, depressive symptoms, psychological stress experiences, physical stress experiences, family relationships, and positive effect, are recommended or approaching recommendation for use in youth ages 8 to 19 years with chronic pain. Research is needed to further establish test-retest reliability, measurement errors, cross-cultural validity, and responsiveness. Future work should expand the evaluation of PROMIS pediatric measures in subpopulations of youth with chronic pain, particularly young children and those with neurodevelopmental disabilities.

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.

A multi-site pilot randomized clinical trial of the Treatment and Education Approach for Childhood-onset Lupus (TEACH) program: study design and COVID-19 adaptations

BACKGROUND

Childhood-onset Systemic Lupus Erythematosus (cSLE) is an autoimmune disease associated with fatigue, mood symptoms, and pain. Fortunately, these symptoms are potentially modifiable with psychological intervention such as cognitive-behavioral therapy (CBT). The Treatment and Education Approach for Childhood-onset Lupus (TEACH) program is a CBT intervention developed to target these symptoms for adolescents and young adults with cSLE. This pilot randomized controlled trial (RCT) aims to determine the feasibility and effect of TEACH for youth with cSLE. Adjustments to the study protocol following the COVID-19 pandemic are also described.

METHODS

This two-arm multisite RCT will explore the feasibility (primary outcome) and effect (secondary outcome) of a remotely delivered TEACH protocol. Participants will be randomized to a six-week remotely delivered TEACH program plus medical treatment as usual (TAU) or TAU alone. We will include patients ages 12-22 years presenting to rheumatology clinics from six sites. Validated measures of fatigue, depressive symptoms, and pain will be obtained at baseline and approximately eight and 20 weeks later. Protocol adjustments were also made due to the COVID-19 pandemic, in collaboration with the investigative team, which included patients and caregivers.

CONCLUSIONS

Findings from this multi-site RCT aim to document the feasibility of TEACH and provide an estimate of effect of a remotely delivered TEACH protocol on fatigue, depression, and pain symptoms in youth with cSLE as compared to standard medical treatment alone. This findings may positively impact clinical care for patients with cSLE.

CLINICAL TRIALS

gov registration: NCT04335643.