Posttraumatic stress disorder symptoms in youth with vs without chronic pain

Non-Cognitive Behavioral Therapy Psychological Interventions May Not Make the Difference in Children and Adolescents With Chronic Pain

Background and Aim

Chronic pain in pediatric populations presents a multifaceted challenge with biopsychosocial impact, requiring a multidisciplinary approach including psychological treatment. At our interdisciplinary pain center, the SARS-CoV-2 pandemic-related disruptions led to the cessation of cognitive-behavioral therapy (CBT) and other psychological interventions during the pandemic. The aim of this retrospective cohort study with secondary retrospective matched case-control analysis was to evaluate the impact of interruption of non-CBT psychological interventions, namely psychoanalysis and psychodynamic psychotherapy, on children and adolescents with chronic pain conditions during the SARS-CoV-2 pandemic.

Materials and Methods

We included pediatric patients with primary and secondary chronic pain conditions evaluated by our team during the SARS-CoV-2 pandemic. We excluded patients who did not receive psychological intervention when available, those with incomplete data on initial evaluation or follow-up, and those who received outside psychiatric care or individual or group CBT. The primary outcome was a Patients' Global Impression of Change (PGIC) score of 6-7. Secondary outcome measures were pain intensity, use of pain medication, sleep, physical function, school attendance, the incidence of suicidality, and the reason for end of treatment.

Results

The study included 146 patients, 77 who received non-CBT psychological interventions and 69 who did not receive any psychological interventions. We found no meaningful difference between the use of non-CBT psychological intervention and no treatment in the incidence of PGIC 6-7 points, pain intensity, school attendance, physical function, suicidality, and cause of end of treatment. Patients not receiving any psychological interventions were more likely to have normalized sleep at the end of treatment.

Conclusion

Non-CBT psychological interventions, namely psychoanalysis and psychodynamic psychotherapy, were not associated with meaningful benefits for children and adolescents with chronic pain during the COVID-19 pandemic. Patients who did not receive psychological interventions reported normalization of their sleep at the end of treatment compared to those who participated in non-CBT interventions.

Bidirectional Mendelian randomization study reveals interplay between multisite chronic pain and Post-traumatic stress disorder

To determine the causal relationship between multisite chronic pain (MCP) and post-traumatic stress disorder (PTSD) using Mendelian Randomization (MR) analysis. Genome-wide summary statistics for MCP and PTSD were obtained. Linkage disequilibrium score regression (LDSC) analysis was used to assess genetic correlation. Independent SNPs associated with MCP and PTSD were used as instrumental variables for forward and reverse MR analyses. The inverse variance weighted (IVW) method was the primary analysis, with additional sensitivity tests to ensure robustness. LDSC identified a significant genetic correlation between MCP and PTSD (rg = 0.635, P = 1.40E-110). The forward MR analysis indicated a positive causal association between the number of MCP sites and the PTSD risk (Odds Ratio [OR] = 1.103, 95% CI: 1.026-1.186, P = 7.89E-03). Conversely, the reverse MR analysis showed that PTSD significantly increased the number of MCP sites (β = 0.244, 95% CI: 0.143-0.345, P = 2.08E-06). Sensitivity tests suggested the robustness of the MR estimation, indicating no significant heterogeneity or horizontal pleiotropy. A bidirectional positive causal relationship between MCP and PTSD was identified, highlighting the need for integrated treatment and preventive strategies that address both conditions simultaneously to improve health outcomes.

Evolution and factors associated with pediatric post-traumatic stress disorder 1 year after mild traumatic brain injury: a prospective, longitudinal study

Mild traumatic brain injury (mTBI) can lead to lasting adverse outcomes, including post-traumatic stress disorder (PTSD) or post-traumatic stress symptoms (PTSS). This study examined whether PTSD and PTSS can occur even after mTBI and tracked the evolution of PTSD in the long term. A total of 85 youth post-mTBI (median age: 10.00, 25-75th percentile: 8.50-2.62; 24% girls) and their mothers participated in this study. Assessments included PTSS/PTSD, postconcussion symptoms, loss of consciousness status, child's anxiety, and maternal mental health, both shortly after mTBI (T1) and 1 year later (T2). Changes in PTSS scores from T1 to T2 were evaluated using the Wilcoxon test. T2 PTSS evolution was evaluated using correlations and partial correlations. To evaluate PTSD recovery trajectories, the percentage of youth in four recovery trajectories (chronic, delayed, recovery, and resilience) was calculated. Results showed a significant decrease in PTSS and PTSD rates from T1 (34%) to T2 (21%). PTSS at T2 was associated with PTSS and postconcussion symptoms at T1. After accounting for the child's sociodemographic and clinical characteristics, the child's self-reported PTSS at T1, along with self-reported postconcussion symptoms and symptom intensity, showed significant correlations with PTSS at T2 ( r  = 0.60, 0.32, and 0.37, respectively; P  < 0.05). Most youth fell into the 'resilient' (40%) or 'recovery' (35%) groups, with only 6% showing 'delayed' recovery. One year after mTBI, 20% of the youth still experienced PTSD. In conclusion, this study highlights the need for long-term monitoring of youth after mTBI, as a notable proportion continue to experience enduring PTSD or PTSS.

"He was not interested in pain": The experience of pain in child sexual abuse as conveyed by adult survivors

Although extensive efforts have been dedicated to uncovering the close link between trauma and chronic pain, very few research efforts have investigated the lived experience of pain during and following trauma. This study delves into the complex and multifaceted experiences of physical pain among adults who experienced child sexual abuse (CSA), examining 29 detailed testimonies provided to the Israeli Independent Public Inquiry into CSA. Using qualitative thematic analysis, the research identifies and elaborates on three pivotal themes: pain as a distress signal, the internalization of pain, and the intermingling of physical and mental pain. Thus, the study findings capture the immediate physical pain experienced during abusive incidents, which serves as an involuntary alert to the self and, at times, to the broader environment about the trauma being experienced. The findings also explore how this acute response transforms into a chronic state, becoming an embedded part of survivors' daily lives, influencing personal and relational dynamics, often without visible scars but with profound internal implications. Lastly, the findings reveal the blurred lines between the participant's physical and psychological pain, illustrating how they express psychological distress through physical pain symptoms and how this affects their coping mechanisms. The study underscores the necessity of recognizing pain as a complex, enduring component of the CSA survivor's experience, highlighting the need for integrated therapeutic approaches that address the intertwined nature of posttraumatic mental symptoms and physical pain. This study advocates for a more nuanced understanding and acknowledgment of pain in CSA survivors, urging further research and adapted clinical practices to better support their recovery and well-being.

Adverse childhood experiences, brain efficiency, and the development of pain symptoms in youth

BACKGROUND

Adverse childhood experiences (ACEs) are often reported by youths with chronic pain, and both ACEs and chronic pain disrupt how information is processed. However, it is unknown whether changes to shared neural networks underlie the relationship between ACEs and the development of pain symptoms. This study explored the relationships between ACEs, brain efficiency, and pain symptomology in youth.

METHODS

A community sample of youths aged 14-18 years underwent MRIs, answered trauma and pain questionnaires, and underwent pain sensory testing, twice, 3 months apart (Nbaseline = 44; Nfollow-up = 42). Sensory testing determined thresholds for mechanical and thermal stimuli. Global and local network efficiencies were evaluated using graph theory. Generalized estimating equations were applied to examine whether brain efficiency moderated the relationships between ACEs, pain intensity, and pain sensitivity (i.e., mechanical detection, heat pain, and temperature change thresholds).

RESULTS

There was a significant interaction between ACEs and global brain efficiency in association with pain intensity (β = -0.31, p = 0.02) and heat pain (β = -0.29, p = 0.004). Lower global brain efficiency exacerbated the relationship between ACEs and pain intensity (θX → Y|W = -1.16 = 0.37, p = 0.05), and heat pain sensitivity (θX → Y|W = -1.30 = 0.44, p = 0.05). Higher global brain efficiency ameliorated the relationship between ACEs and pain intensity (θX → Y|W = 1.75 = -0.53, p = 0.05).

CONCLUSIONS

The relationship between ACEs and pain symptomology was comparable to chronic pain phenotypes (i.e., higher pain intensity and pain thresholds) and may vary as a function of brain efficiency in youth. This stresses the importance of assessing for pain symptoms in trauma-exposed youth, as earlier identification and intervention are critical in preventing the chronification of pain.

SIGNIFICANCE

This article explores the relationship between ACEs, pain symptomology, and brain efficiency in youth. ACEs may affect how the brain processes information, including pain. Youths with lower brain efficiencies that were exposed to more ACEs have pain symptomology comparable to youths with chronic pain. Understanding this relationship is important for the earlier identification of pain symptoms, particularly in vulnerable populations such as youths exposed to trauma, and is critical for preventing the chronification of pain.

Hair cortisol sampling as a measure of physiological stress in youth with acute musculoskeletal pain

Stress physiology contributes to health outcomes. Hair cortisol concentration (HCC) is an objective measure of cumulative cortisol secretion associated with health, including pain. The aim of the current study was to describe associations between pre-injury stress physiology (as measured by HCC), acute pain characteristics and relevant demographic factors (i.e., BMI, age, sex, days since injury) in youth with an acute musculoskeletal (MSK) injury. Participants were 58 youth aged 11 to 17 with acute MSK pain. Participants completed self-report measures assessing pain intensity, pain catastrophizing, and pain interference. Hair was collected within 1 month after injury using hair cortisol collection procedures adapted from published research protocols. Correlations examining associations among HCC values and clinical/demographic factors revealed that higher HCC was associated with lower body mass index (BMI) and male sex. HCC was not associated with pain variables or age. Additional research is needed to clarify the relation between HCC and psychosocial variables to aid researchers in studying the role of pre-injury stress in acute MSK injury and pain recovery in youth.

Profiles of Trauma Exposure Type and Its Associations With Pain-Related Outcomes Among Adults With Chronic Pain: A 2-Year Longitudinal Study

Individuals with chronic pain report disproportionally higher rates of trauma, yet it is unclear whether different types of trauma (eg, sexual, accidental trauma) are associated with worse pain outcomes. The present study sought to 1) identify subgroups of people with chronic pain based on trauma type, and 2) determine whether subgroups differ in terms of pain characteristics over a 2-year period. Individuals with chronic pain (N = 1,451) participated in an online study and completed self-report questionnaires at baseline, 3-, 12-, and 24-month follow-up. Trauma was assessed via the Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Pain intensity and interference were measured via the Brief Pain Inventory, and pain distribution was evaluated using the Widespread Pain Index. Latent class analyses produced a 3-class solution consisting of individuals with high and diverse trauma (16.3%), high sexual trauma (18.4%), and low/accidental trauma (57.1%) with the rest of the sample endorsing no trauma history (8.2%). After controlling for key demographic variables and baseline outcome levels, individuals in the high- and diverse trauma group endorsed higher levels of pain severity and interference at the 3- and 12-month follow-ups compared with the group with no trauma (P < .01). Additionally, relative to the no trauma group, individuals in the high sexual trauma group reported higher levels of pain interference and more widespread pain at the 3-month follow-up (P < .05). The findings underscore the importance of screening for trauma and suggest that the type and variety of trauma experienced may be relevant to pain-related outcomes. PERSPECTIVE: This article highlights how an individual's unique trauma history may be related to their current pain experience. Knowledge of the type and frequency of past trauma may have relevant clinical implications for the treatment of chronic pain.

The relationship between traumatic exposure and pain perception in children: the moderating role of posttraumatic symptoms

ABSTRACT

Adverse childhood experiences (ACEs) affect approximately half of all children worldwide. These experiences have been linked to increased pain sensitivity in adulthood and a higher likelihood of developing severe chronic pain. However, most studies have assessed the effects of ACEs retrospectively, long after they occurred, leaving room for other factors to influence the observed outcomes. We investigated, for the first time, the association between ACEs and concurrent pain perception among young children who live in a conflict zone and are consistently exposed to potentially traumatic experiences. Participants were 60 elementary school children (ages 8-11 years) living in conflict regions (n = 39) or nonconflict regions (n = 21). Posttraumatic stress symptom (PTSS) severity, traumatic exposure, pressure pain threshold (PPT), and mechanical detection threshold (MDT) were measured. Trauma-exposed children had significantly lower PPT than did controls, but MDT was similar across groups. Pressure pain threshold correlated positively with proximity to the conflict zone and inversely with traumatic exposure magnitude and PTSS severity. In addition, PTSSs moderated the relationship between repeated traumatic exposure and PPT. Children with higher PTSS severity displayed pain hypersensitivity regardless of their traumatic exposure level, whereas in children with lower PTSS severity, greater traumatic exposure correlated with pain hypersensitivity. The results suggest that ACEs among children lead to concurrent pain hypersensitivity and distress and may put them at elevated risk of chronic pain early in life. In addition, our findings emphasize the need for identifying children with various PTSS levels to provide tailored interventions and mitigate the long-term negative effects of ACEs.

Narrative Accounts of Youth and Their Mothers With Chronic Headache: Application of a Socio-narratology Framework to Pain Narratives

OBJECTIVES

This study was the first to apply a socio-narratology framework to the narratives about child pain as told by youth with chronic pain and their parents, all of whom experience chronic headaches.

BACKGROUND

Storytelling is a powerful social transaction that occurs within systems (eg, families, clinical encounters) and is both shaped by, and can shape, the pain experience. Narrative can be harnessed as a clinical tool to aid in the ability to listen, understand, and improve clinical encounters.

METHODS

Twenty-six youth (aged 11 to 18 y) and their mothers, both with chronic headaches, recruited from a tertiary level pediatric pain clinic separately completed in-depth interviews about children's pain journey narratives. Data were analyzed using narrative analysis, which incorporated elements of socio-narratology to compare similarities and differences between and within dyads' narratives.

RESULTS

Five narrative types were generated: (1) The trauma origin story-parents, but not youth, positing traumatic events as the causal link to children's pain; (2) mistreated by the medical system-neglect, harm, and broken promises resulting in learned hopelessness or relying on the family system; (3) the invalidated-invalidation of pain permeated youth's lives, with mothers as empathic buffers; (4) washed away by the pain-challenges perceived as insurmountable and letting the pain take over; and (5) taking power back from pain-youth's ability to live life and accomplish goals despite the pain.

CONCLUSION

Findings support the clinical utility of narrative in pediatric pain, including both parents' and youths' narrative accounts to improve clinical encounters and cocreate more youth-centred, empowering narratives.

Nationwide Assessment of Chronic Pain among Hospitalized Individuals with Co-occurring Post Traumatic Stress Disorder and Substance Use Disorder in the United States

Objective: Chronic pain (CP) is independently associated with substance use disorders (SUD) and posttraumatic stress disorder (PTSD). However, little is known about factors associated with CP among patients with co-occurring PTSD and SUD. Patterns of hospital resource usage should also be explored further. Methods: Using the 2019 National Inpatient Sample (NIS), we identified 216,125 hospital discharges with co-occurring diagnoses of PTSD and SUD in 2019 and examined their association with CP. Multivariable logistic regression models were used to identify factors associated with an increased likelihood of CP in this cohort. Results: Among those with co-occurring PTSD and SUD (N = 216,125), 35,450 had associated CP, a prevalence of 164.02 cases per 1,000 discharges (95% CI [160.54, 167.52]). Individuals aged 55-64 with co-occurring PTSD and SUD were approximately 7.2 times more likely to experience CP, compared to those aged 16-24 (OR = 7.2; 95% CI [6.09, 8.60]). Being in the CP group was associated with 50% increased odds of insomnia and obesity (OR = 1.5; 95% CI [1.12, 2.03] and OR = 1.5; 95% CI [1.38, 1.55], respectively), 30% increased odds of anxiety (OR = 1.3; 95% CI [1.24, 1.38]), 20% increased odds of attention deficit disorder (ADD;OR = 1.2; 95% CI [1.12, 1.38]) and 10% increased odds of depression (OR = 1.1; 95% CI [1.01, 1.14]). Compared with females, being male was associated with slightly decreased odds of CP (OR = 0.9; 95% CI [0.84, 0.94]). Conclusions: Among hospitalized Americans with co-occurring PTSD and SUD, advanced age, being female, and the presence other mental health disorders were associated with an increased risk of CP. Providers treating co-occurring PTSD/SUD should evaluate for and consider evidence-based management of CP if present.

Peer Victimization, Posttraumatic Stress Symptoms, and Chronic Pain: A Longitudinal Examination

Chronic pain and posttraumatic stress disorder symptoms (PTSS) co-occur at high rates in youth and are linked to worse pain outcomes and quality of life. While peer victimization has been posited as a mechanism underlying the PTSS-pain relationship in youth, empirical evidence suggests that it may exacerbate both PTSS and pain. The present study aimed to longitudinally examine PTSS as a mediator in the relationship between peer victimization at baseline and pain-related outcomes at 3 months in youth with chronic pain. Participants included 182 youth aged 10 to 18 years recruited from a tertiary-level children's hospital in Western Canada. At baseline, participants completed measures to assess pain (intensity and interference), peer victimization (relational and overt), and PTSS. The pain was reassessed at a 3-month follow-up. Primary hypotheses were tested utilizing a series of mediation analyses with PTSS as a proposed mediator in the associations between peer victimization and pain outcomes. Youth PTSS mediated the relationship between higher baseline relational victimization and higher 3-month pain interference while controlling for baseline pain interference. Three-month pain intensity was not correlated with peer victimization; thus, pain intensity was not included in the analyses. These findings reveal that PTSS may be an underlying factor in the co-occurrence of peer victimization and chronic pain in youth. Further research is needed to better understand the role of peer victimization in the maintenance of chronic pain to ensure appropriate, effective, and timely interventions that address the social and mental health issues impacting the lives of these youth as well as their pain. PERSPECTIVE: PTSS may be an underlying factor in the co-occurrence between peer victimization and chronic pain in youth, highlighting the need to assess for both peer relationship problems and PTSS in youth with chronic pain.

Early childhood risk factors for later onset of pediatric chronic pain: a multi-method longitudinal study

BACKGROUND

Pediatric chronic pain (i.e., pain lasting ≥ 3 months) is prevalent, disabling, and costly. It spikes in adolescence, interrupts psychosocial development and functioning, and often co-occurs with mental health problems. Chronic pain often begins spontaneously without prior injuries and/or other disorders. Prospective longitudinal cohort studies following children from early childhood, prior to chronic pain onset, are needed to examine contributing factors, such as early pain experiences and mental health. Using data from a longitudinal community pregnancy cohort (All Our Families; AOF), the present study examined the associations between early developmental risk factors, including early childhood pain experiences and mental health symptoms, and the onset of pediatric chronic pain at ages 8 and 11 years.

METHODS

Available longitudinal AOF data from child age 4 months, as well as 1, 2, 3, 5, 8, and 11 years, were used. Mothers reported their child's pain experiences (e.g., hospitalizations, vaccinations, gut problems) at each timepoint from 4 months to 8 years, child chronic pain at age 8, and child mental health symptoms at ages 5 and 8 years. Children reported their chronic pain frequency and interference at age 11. Adaptive least absolute shrinkage and selection operator (LASSO) regressions were used to select predictor variables. Complete case analyses were complemented by multiple imputation using chained equation (MICE) models.

RESULTS

Gut problems, emergency room visits, frequent pain complaints, and headaches at age 5 or earlier, as well as female sex, were associated with increased risk of maternal reported child chronic pain at age 8. Maternal reported chronic pain at age 8 was associated with higher levels of child-reported pain frequency and pain interferences at age 11. Boys self-reported lower levels of pain interference at age 11.

CONCLUSIONS

Some, but not all, painful experiences (e.g., gut problems, ER visits, pain complaints) in early life contribute to pediatric chronic pain onset and should be considered for screening and early intervention.

Pain and Post-traumatic Stress Disorder Symptoms: Dyadic Relationships Between Canadian Armed Forces Members/Veterans With Chronic Pain and Their Offspring

Chronic pain and mental health issues occur at higher rates in Veterans than the general population. One widely recognized mental health issue faced by Veterans is post-traumatic stress disorder (PTSD). Trauma symptoms and pain frequently co-occur and are mutually maintained due to shared mechanisms. Many Veterans are also parents. Parental physical and mental health issues significantly predict children's chronic pain and related functioning, which can continue into adulthood. Only 1 U.S.-based study has examined pain in the offspring of Veterans, suggesting a heightened risk for pain. Research to date has not examined the associations between trauma and pain and the dyadic influences of these symptoms, among Veterans, and their children. The current study aimed to describe pain characteristics in Canadian Armed Forces Members/Veterans with chronic pain and their offspring (youth and adult children aged 9-38). Cross-lagged panel models were conducted to examine dyadic relationships between pain interference and trauma symptoms of Canadian Armed Forces Members/Veterans and their offspring. Over half of adult offspring and over one-quarter of youth offspring reported chronic pain. Results revealed effects between one's own symptoms of PTSD and pain interference. No significant effects of parents on offspring or offspring on parents were found. The findings highlight the interconnection between pain and PTSD consistent with mutual maintenance models and a lack of significant interpersonal findings suggestive of resiliency in this unique population. PERSPECTIVE: We characterized chronic pain in the offspring of Canadian Armed Forces Members/Veterans with chronic pain and examined dyadic relationships between PTSD symptoms and chronic pain interference. Findings revealed that PTSD symptoms and pain interference were related within Veterans and offspring, but no dyadic relationships were found, which could reflect resiliency.

Associations between adverse childhood experiences and pain in middle-aged and older adults: findings from the China Health and Retirement Longitudinal Study

OBJECTIVE

Adverse childhood experiences (ACEs) have been associated with a range of adverse health outcomes, with pain being potentially one of them. This population-based cross-sectional study aimed to investigate the associations between Adverse Childhood Experiences (ACEs) and pain in Chinese adults and evaluate whether physical activity and demographic and socioeconomic characteristics modify this associations.

METHODS

Cross-sectional data from the China Health and Retirement Longitudinal Study (CHARLS), were utilized in this study. A total of 9923 respondents with information on 12 ACE indicators and 15 self-reported body pains were included. Logistic regression models were used to assess associations of the ACEs and pain. Modification of the associations by physical activity, demographic and socioeconomic characteristics was assessed by stratified analyses and tests for interaction.

RESULTS

Among the 9923 individuals included in the primary analyses, 5098 (51.4%) males and the mean (SD) age was 61.18 (10·.44) years. Compared with individuals with 0 ACEs, those who with ≥ 5 ACEs had increased risk of single pains and multiple pain. A dose-response association was found between the number of ACEs and the risk of pain (e.g. neck pain for ≥ 5 ACEs vs. none: OR, 1.107; 95% CI, 0.903-1.356; p < 0.001 for trend). In the associations of each body pain with each ACE indicator, most ACE indicators were associated with an increased risk of pain. In addition, physical activity, sociodemographic and socioeconomic characteristics, such as age, sex, educational level, area of residence, childhood economic hardship, did not demonstrate a significant modify on the associations between ACEs and pain.

CONCLUSIONS

These findings indicate that cumulative ACE exposure is associated with increased odds of self-reported pain in Chinese adults, regardless of adult physical activity, sociodemographic and socioeconomic characteristics.

Neuropathic pain, mood, and stress-related disorders: A literature review of comorbidity and co-pathogenesis

Neuropathic pain can be caused by multiple factors, and its prevalence can reach 10% of the global population. It is becoming increasingly evident that limited or short-lasting response to treatments for neuropathic pain is associated with psychological factors, which include psychiatric comorbidities known to affect quality of life. It is estimated that 60% of patients with neuropathic pain also experience depression, anxiety, and stress symptoms. Altered mood, including stress, can be a consequence of several painful conditions but can also favor pain chronicization when preexisting. Despite the apparent tight connection between clinical pain and mood/stress disorders, the exact physiological mechanisms remain unclear. This review aims to provide an overview of state-of-the-art research on the mechanisms of pain related to the pathophysiology of depression, anxiety, and stress disorders.

The Sensitivity to Pain Traumatization Scale-Child Version (SPTS-C): Development and preliminary validation

Background

Sensitivity to pain traumatization is defined as the propensity to develop cognitive, affective, and behavioral responses to pain that resemble a traumatic stress reaction. To date, sensitivity to pain traumatization has been assessed in adults (Sensitivity to Pain Traumatization Scale [SPTS-12]) and parents of youth with chronic pain (Sensitivity to Pain Traumatization Scale-Parent version [SPTS-P]). SPT may be relevant in the context of pediatric chronic pain given the substantial comorbidity between posttraumatic stress symptoms and pain.

Aims

This prospective study aimed to adapt the SPTS-12 for use in youth and to evaluate the psychometric properties of the new scale.

Methods

Participants included 175 youth with chronic pain (Mage = 14.31 years, 73% girls) referred to outpatient chronic pain programs. At baseline, youth self-reported the levels of their sensitivity to pain traumatization (Sensitivity to Pain Traumatization Scale-Child version [SPTS-C]), as well as their pain symptoms, pain-related anxiety, posttraumatic stress symptoms, and attentional control. Three months later, youth self-reported their pain symptoms and completed the SPTS-C.

Results

The SPTS-C had a one-factor structure that explained 48% of variance and demonstrated good reliability and construct validity. SPTS-C baseline scores predicted follow-up levels of pain interference but not pain intensity or pain unpleasantness.

Conclusions

The results provide preliminary evidence for the psychometric properties of the SPTS-C and the potential role of SPT in pediatric chronic pain outcomes.

Pain, mental health and healthcare utilization: Impact of the COVID-19 pandemic on youth with chronic pain, parents and siblings

BACKGROUND

Paediatric chronic pain was a public health emergency before the novel coronavirus (COVID-19) pandemic, and this problem is predicted to escalate. Pain tends to occur intergenerationally in families, and youth with chronic pain and their parents have high rates of mental health issues, which can further exacerbate pain. Siblings of youth with chronic pain have been largely overlooked in research, as well as the impact of the pandemic on posttraumatic stress disorder (PTSD) symptoms and healthcare utilization.

METHODS

This cross-sectional study examined pain, mental health and healthcare utilization in three groups: youth with chronic pain (n = 357), parents of youth with chronic pain (n = 233) and siblings of youth with chronic pain (n = 156) during the COVID-19 pandemic in Canada.

RESULTS

More so than with pain symptoms, the results revealed high levels of mental health symptoms (i.e. anxiety, depressive, and PTSD), particularly in individuals more personally impacted by the pandemic. The largest effect was seen on PTSD symptoms for all groups. For parents with chronic pain, greater personal COVID-19 impact was related to worse pain interference. Reported rates of healthcare utilization were strikingly high, with youth with chronic pain, parents (reporting on behalf of their children with chronic pain), and siblings of youth with chronic pain reporting that most consultations were due to pain.

CONCLUSIONS

Longitudinal research assessing these outcomes across continued waves of the pandemic is needed to ensure timely, tailored and equitable access to pain and mental health assessment and treatment.

SIGNIFICANCE

This study examined pain, mental health, substance use and healthcare utilization in youth with chronic pain, siblings and parents during the COVID-19 pandemic. Greater personal impact of the pandemic was not largely associated with poorer pain outcomes; however, it was associated with mental health, with the largest effect on PTSD symptoms. The high rates and significant association of COVID-19 impact with PTSD symptoms underscore the importance of including PTSD assessment as part of routine screening practices in pain clinics.

Caregiver Psychological Burden in Pediatric Chronic Pain: A Systematic Review and Meta-Analysis of Associations with Caregiver Sociodemographic and Biopsychosocial Variables

OBJECTIVE

To investigate, via systematic review and meta-analysis, caregiver sociodemographic and biopsychosocial factors associated with anxiety, depression, posttraumatic stress symptoms, and stress of caregivers in the pediatric chronic pain context.

METHODS

EMBASE, Medline, and PsycINFO databases were searched from their inception to the search date (April 4, 2022). Studies were included if they examined caregivers of youth with chronic pain, were published in a peer-reviewed journal and assessed at least one quantitative association between relevant variables. Qualitative and intervention studies were excluded. A total of 3,052 articles were screened. Risk of bias was assessed using the JBI Checklist for analytical cross-sectional studies. Meta-analyses were conducted using robust variance estimation for associations reported in at least three studies, as well as a narrative synthesis of the evidence.

RESULTS

Fourteen studies assessing 1,908 caregivers were included in this review. Meta-analytic results showed a positive pooled correlation coefficient between caregiver catastrophizing about their child's pain and caregiver anxiety (r = 0.51; 95% CI: 0.35-0.65; p<.01) and depression (r = 0.45; 95% CI: 0.29-0.58; p < .01). Self-blame and helplessness were related to increased caregiver anxiety (r = 0.55; 95% CI: 0.40-0.67; p<.01), but not depression. No significant relationship was found for pain-promoting behavior and anxiety or depression. The qualitative synthesis of all other eligible studies showed associations between relevant psychological burden variables and various caregiver factors, which were mainly psychosocial.

CONCLUSION

Results should be interpreted with caution due to the small number of studies. Further research is needed to get a better understanding of these relationships and to examine the causal direction of effects.

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.

Participant-Generated Timelines: A Participatory Tool to Explore Young People With Chronic Pain and Parents' Narratives of Their Healthcare Experiences

Visual methods are becoming more evident in health research. Timeline drawings have been used as a participatory tool alongside interviews in life course research. In this article, we describe how a method involving timeline generation can explore patient experiences along a treatment continuum. Grounded in previously published evidence and using specific examples from two studies exploring the experiences of young people treated for chronic pain, we outline the key components of this method. Moreover, we highlight the flexibility of its application and the importance of using a person-centered approach in tailoring the application pragmatically to study population-specific needs and characteristics, while answering the research question. We also reflect on how the dynamic visual display of the timeline and participants' explanations add perspective and understanding to complex and multidimensional human experiences associated with healthcare treatment. Furthermore, we outline how this method can help capture changes in the meaning and sense-making of these experiences over time, all the while fostering empowerment in study participants. Finally, the key considerations of using the method are outlined. It is our aim that this article provides the details required to inspire others to consider this novel method as a means of capturing the healthcare experiences of young people with other chronic conditions, an important first step in fostering the changes required to improve the quality of healthcare services and research.

Gene expression changes in the cerebellum are associated with persistent post-injury pain in adolescent rats exposed to early life stress

Chronic pain develops following injury in approximately 20% of adolescents, at twice the rate in females than males. Adverse childhood experiences also increase the risk for poor health outcomes, such as chronic pain. Emerging literature suggests the cerebellum to be involved in pain processing, however detailed explorations into how the cerebellum contributes to pain are lacking. Therefore, this study aimed to characterise chronic pain outcomes and cerebellar gene expression changes following early life stress and injury in both sexes. The adverse childhood experience of neglect was modelled using a maternal separation (MS) paradigm, which was combined with a subsequent injury (mild traumatic brain injury (mTBI) or plantar incision surgery) in adolescent male and female Sprague-Dawley rats. We measured behavioural nociceptive sensitivity, systemic modulators of pain such as calcitonin gene-related protein (CGRP) and Substance P, as well as gene expression of IL1β, GFAP, GR, MR, GABRA1, CNR1, MAOA, and DAT1 in the cerebellum to examine associations between pain and neuroinflammation, the stress response, inhibitory neurotransmission, and monoaminergic function. We found increases in mechanical nociceptive sensitivity following plantar incision surgery. Sex differences were observed in anxiety-like behaviour and neuroinflammation, whereas systemic pain modulators showed cumulative effects with the addition of stressors. Most interestingly however, the increases in nociceptive sensitivity were associated with the suppressed expression of cerebellar genes that regulate stress, inhibition, cannabinoid function, and dopaminergic function, alongside sex-dependent distinctions for genes involved in inflammation and injury. This study highlights a novel link between nociception and molecular function in the cerebellum. Further investigation into how the cerebellum contributes to pain in males and females will facilitate novel therapeutic insights and opportunities.

The Impact of Comorbid Chronic Pain on Pharmacotherapy for Veterans with Post-Traumatic Stress Disorder

OBJECTIVE

Chronic pain can worsen PTSD symptomatology and may increase the risk of the prescription of multiple central nervous system (CNS)-active medications. The objective is to determine the impact of chronic pain on the number of CNS medications, including psychiatric medications, as well as the amount of medication changes.

METHODS

Veterans Affairs (VA) administrative data were used to identify VA-served Veterans with PTSD (N = 637,428) who had chronic pain (50.3%) and did not have chronic pain (49.7%) in 2020. The outcomes included the number of changes in psychiatric medications and the number of currently prescribed CNS-active mediations during a one-year observation period.

RESULTS

The number of changes in psychiatric medications was significantly higher for those with chronic pain (mean (M) = 1.8) versus those without chronic pain (M = 1.6) (Z = 38.4, p < 0.001). The mean number of concurrent CNS-active medications were significantly higher for those with chronic pain (M = 2.7) versus those without chronic pain (M = 2.0) (Z = 179.7, p < 0.001). These differences persisted after adjustment for confounding factors using negative binomial regression.

CONCLUSIONS

Veterans with comorbid chronic pain and PTSD are at increased risk for a higher number of medication changes and for receiving CNS-active polytherapy.

Neural correlates linking trauma and physical symptoms

Trauma and chronic pain frequently co-occur, but the underlying neurological mechanisms are poorly understood. The current study investigated the neural correlates of stress and physical symptoms in trauma patients using functional magnetic resonance imaging (fMRI) and follow-up smartphone surveys. Participants were 10 patients diagnosed with Trauma- and Stressor-Related Disorders and 18 demographically-matched healthy controls who completed a fMRI stress provocation task in which they viewed stressful and neutral-relaxing images. Subsequently, participants completed daily smartphone surveys which prospectively monitored their stress and physical symptoms for 30 days. The trauma group experienced a significantly higher frequency of physical symptoms than controls during the follow-up period. During stress, trauma patients exhibited increased activity in the hippocampus, insula, and sensorimotor areas, but decreased activity in the ventromedial prefrontal cortex (vmPFC), lateral prefrontal cortex (LPFC), and dorsal striatum relative to controls. In all participants, higher physical symptom frequency was significantly associated with a hyperactive left hippocampal response to stress. The current study reports that trauma is characterized by greater physical symptoms and decreased prefrontal but increased limbic responses to stress. Our findings suggest that trauma may increase physical health symptoms by compromising hippocampal function, which could also increase vulnerability to stress- and pain-related disorders.

Anxiety and Depressive Symptoms and Disorders in Children and Adolescents With Migraine: A Systematic Review and Meta-analysis

IMPORTANCE

Though it is presumed that children and adolescents with migraine are at risk of internalizing symptoms and disorders, high-level summative evidence to support this clinical belief is lacking.

OBJECTIVE

To determine if there is an association between internalizing symptoms and disorders and migraine in children and adolescents.

DATA SOURCES

A librarian-led, peer-reviewed search was performed using MEDLINE, Embase, PsycINFO, and CINAHL databases (inception to March 28, 2022).

STUDY SELECTION

Case-control, cohort, and cross-sectional studies on the association between internalizing symptoms and disorders and migraine in children and adolescents 18 years or younger were eligible.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently completed abstract and full-text screening, data extraction, and quality appraisal using the Newcastle-Ottawa scales. Studies were pooled with random-effects meta-analyses using standardized mean differences (SMD) or odds ratios (OR) with 95% CIs. Where sufficient data for pooling were unavailable, studies were described qualitatively.

MAIN OUTCOMES AND MEASURES

The primary outcome was migraine diagnosis; additional outcomes included migraine outcomes and incidence. Associations between these outcomes and internalizing symptoms and disorders were evaluated.

RESULTS

The study team screened 4946 studies and included 80 studies in the systematic review. Seventy-four studies reported on the association between internalizing symptoms and disorders and migraine, and 51 studies were amenable to pooling. Meta-analyses comparing children and adolescents with migraine with healthy controls showed: (1) an association between migraine and anxiety symptoms (SMD, 1.13; 95% CI, 0.64-1.63); (2) an association between migraine and depressive symptoms (SMD, 0.67; 95% CI, 0.46-0.87); and (3) significantly higher odds of anxiety disorders (OR, 1.93, 95% CI, 1.49-2.50) and depressive disorders (OR, 2.01, 95% CI, 1.46-2.78) in those with, vs without, migraine. Stratification of results did not reveal differences between clinical vs community/population-based samples and there was no evidence of publication bias. Twenty studies assessing the association between internalizing symptoms or disorders and migraine outcomes (n = 18) or incident migraine (n = 2) were summarized descriptively given significant heterogeneity, with minimal conclusions drawn.

CONCLUSIONS AND RELEVANCE

In this study, children and adolescents with migraine were at higher risk of anxiety and depression symptoms and disorders compared with healthy controls. It may be beneficial to routinely screen children and adolescents with migraine for anxiety and depression in clinical practice. It is unclear whether having anxiety and depressive symptoms or disorders has an affect on migraine outcomes or incidence.

Impacts of paediatric chronic pain on parents: A qualitative study

BACKGROUND

Paediatric chronic pain adversely impacts the child's functioning, health-related quality of life and development. However, there is a need for a holistic assessment of parental impacts of caring for a child with chronic pain. This qualitative study aimed to investigate the possible psychosocial, functional and work impacts of caring for a child with chronic pain on parents, including any positive effects of the experience.

METHODS

Ten parents (eight mothers and two fathers), whose child attended the Sydney Children's Hospital Interdisciplinary Chronic and Complex Pain Clinic, participated in semi-structured interviews exploring the impact of caring for a child with chronic pain. Interviews were audio-recorded, transcribed, coded (with good inter-coder agreement) and analysed using thematic analysis.

RESULTS

The parental experience of caring for a child with chronic pain was encapsulated by four overarching themes: (1) 'the constant and all-consuming nature of pain' - parents described the unpredictable, yet constant nature of chronic pain, contributing to wide-reaching impacts in various areas of their life; (2) 'dealing with uncertainty' - their experience was commonly characterized by a sense of uncertainty, stress, hopelessness and fear; (3) 'importance of support and self-care' - strong support networks and prioritizing self-care were crucial in alleviating the negative effects of paediatric chronic pain; and (4) 'a revitalized and optimistic view on life and relationships' - some parents identified unique and positive effects, such as stronger relationships, personal growth and a reformed view on life.

CONCLUSIONS

This study provided rich data on the various impacts of caring for a child with chronic pain, highlighting the need for the development of holistic, family-centred interventions addressing both child and parental functioning.

Intolerance of Uncertainty in Pediatric Chronic Pain: Dyadic Relationships Between Youth and Parents

The current study used a dyadic analytic approach (actor-partner interdependence models) to assess the stability and interrelationships of intolerance of uncertainty (IU) among a cohort of youth with chronic pain and their parents (n = 156 dyads). Relationships between parent and youth IU, parent and youth pain interference, and parent and youth internalizing mental health symptoms were examined. At baseline and follow-up, youth and parents completed psychometrically-sound questionnaires to assess their respective IU, pain characteristics, and clinical outcomes (pain interference, anxiety, depressive, and posttraumatic stress symptoms). Our findings support the construct stability of IU over time, as well as intrapersonal (ie, actor) effects of IU on follow-up youth pain interference and mental health symptoms and parents' mental health symptoms (but not parent pain interference). There were no interpersonal (ie, partner) effects over time between youth and parent IU or between youth and parent IU and pain interference or mental health symptoms. These findings align with previous research evidencing IU as a transdiagnostic risk factor for a range of mental health concerns and extend previous findings by showing the stability of parent and youth IU over time and its potential predictive relevance to outcomes in a clinical sample of youth with chronic pain. PERSPECTIVE: This article presents dyadic analyses assessing intrapersonal and interpersonal associations between intolerance of uncertainty (IU) and pain and mental health symptoms in youth with chronic pain and their parents. Analyses evidenced short-term construct stability of IU and intrapersonal (but not interpersonal) effects of IU on pain and mental health symptoms.

A Scoping Review and Proposed Framework for Coping in Youth With a History of Psychological Trauma and Chronic Pain

OBJECTIVE

Psychological trauma (e.g., abuse, neglect) and posttraumatic stress symptoms (PTSS) commonly occur in pediatric pain populations and may be related to various maladaptive coping strategies, which may in turn affect short- and long-term pain-related outcomes in youth. Accordingly, the current scoping review and conceptual framework seeks to identify important gaps in the field's current understanding of how coping impacts outcomes in youth who have experienced trauma/PTSS and pediatric chronic pain and explores avenues for future investigation.

METHODS

A scoping review of the literature was performed in Medline, Embase, Cochrane Library, PsycInfo, and Sociological Abstracts. Eligibility criteria included pediatric populations experiencing chronic pain, trauma, adverse childhood events, and/or PTSS and associated coping mechanisms. Nine research papers were selected and used to support the conceptual framework. The framework builds upon the work of Compas et al.'s' model of control-based coping (Compas et al., 2006; Compas & Harding Thomsen, 1999) and outlines the potential effects of trauma and/or PTSS and pain on coping and pain-related outcomes (e.g., pain chronicity, functional outcomes) in pediatric chronic pain populations.

RESULTS

A history of chronic pain and psychological trauma and/or PTSS in youth may contribute to increased risk for maladaptive coping and in turn, poorer pain-related and psychosocial outcomes long-term.

CONCLUSIONS

Findings from the current scoping review and proposed conceptual framework will guide future research and treatment efforts for youths experiencing pain and trauma and/or PTSS and thereby enhance long-term outcomes.

Influence of Cerebral Glucose Metabolism by Chronic Pain-Mediated Cognitive Impairment in Adolescent Rats

Chronic pain during adolescence can lead to mental health disorders in adulthood, but the underlying mechanism is still unclear. Furthermore, the homeostasis of cerebral glucose metabolism and neurotransmitter metabolic kinetics are closely associated with cognitive development and pain progression. The present study investigated changes in cognitive function and glucose metabolism in adult rats, which had experienced chronic pain during their adolescence. Here, spared nerve injury (SNI) surgery was conducted in 4-week-old male rats. Mechanical nociceptive reflex thresholds were analyzed, and SNI chronic pain (SNI-CP) animals were screened. Based on animal behavioral tests (open field, three-chambered social, novel object recognition and the Y maze), the SNI-CP animals showed learning and memory impairment and anxiety-like behaviors, compared to SNI no chronic pain (SNI-NCP) animals. The cerebral glucose metabolism in the prefrontal cortex and hippocampus of adult SNI-CP animals was decreased with positron emission tomography/computed tomography. GABA₂ and Glu₄ levels in the metabolic kinetics study were significantly decreased in the hippocampus, frontal cortex, and temporal cortex, and the expression of GLUT3 and GLUT4 was also significantly downregulated in the prefrontal cortex and hippocampus of adult rats in the SNI-CP group. These findings suggest that the rats which suffered chronic pain during adolescence have lower cerebral glucose metabolism in the cortex and hippocampus, which could be related to cognitive function during the development of the central nervous system.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

Trauma and pain sensitization in youth with chronic pain

Greater posttraumatic stress symptoms were associated with higher experimental pain tolerance. Pain may trigger dissociation in youth with chronic pain and higher posttraumatic stress symptoms.

Introduction:

Chronic pain (pain lasting ≥3 months) co-occurs with internalizing mental health issues, such as posttraumatic stress symptoms (PTSS), at high rates in youth. The mechanisms underlying these relationships remain unclear. Posttraumatic stress symptoms, including re-experiencing (eg, intrusive memories), alterations in cognition and mood, hyperarousal, and avoidance could lead to altered neuronal processing, pain sensitization, and greater reports of pain. However, the relationships between PTSS and pain sensitization in youth with chronic pain are not known.

Methods:

Youth (n = 165) aged 10 to 18 years were recruited from outpatient multidisciplinary chronic pain programs. Symptoms of PTSS were assessed using psychometrically sound questionnaires. Youth also underwent a cold-pressor task, the most commonly used experimental pain induction technique. During this task, they reported on their expected pain, actual pain intensity, and pre- and post-state pain catastrophizing. Their pain threshold was recorded. A multivariate general linear model was used to examine the relationships between PTSS, ratings of pain intensity, state pain catastrophizing, and pain threshold, controlling for age, gender, ethnicity, anxiety, and depressive symptoms.

Results:

Higher PTSS were associated with greater pain thresholds (P = 0.03) and higher pre- and post-state pain catastrophizing (P ≤ 0.05).

Conclusions:

Individuals with higher PTSS may avoid or dissociate from pain-inducing stimuli, thus leading to higher pain thresholds. However, individuals with higher PTSS also tend to catastrophize prior to and following exposure to pain. Avoidant and pain catastrophizing behaviors may serve to perpetuate chronic pain conditions. Future research is needed to determine how PTSS are related to pain sensitization prior to the development of chronic pain in at-risk youth.

Examining Parent Adverse Childhood Experiences as a Distal Risk Factor in Pediatric Chronic Pain

OBJECTIVES

Adverse childhood experiences (ACEs; ie, exposure to abuse, neglect, household dysfunction in childhood) are associated with poor mental and physical health outcomes across the lifespan. Emerging research suggests parent ACEs also confer risk for poor child outcomes. The relation between parent ACEs and child pain in youth with chronic pain has not yet been examined. The aim of the current longitudinal study was to examine the associations among parent ACEs, parent health, and child pain, in a clinical sample of youth with chronic pain.

METHODS

In total, 192 youth (75.5% female, 10 to 18 y old) and one of their parents (92.2% female) were recruited from tertiary pediatric chronic pain clinics in Canada. At baseline, parents completed self-report measures of ACEs, chronic pain status, anxiety and depressive symptoms, and posttraumatic stress disorder symptoms. At a 3-month follow-up, youth completed self-report measures of pain intensity and pain interference.

RESULTS

Regression and mediation analyses revealed that parent ACEs significantly predicted parent chronic pain status and depressive symptoms, but not parent anxiety or posttraumatic stress disorder symptoms. Moreover, parent ACEs were not significantly related to youth pain, either directly or indirectly through parent health variables.

DISCUSSION

Findings suggest that an intergenerational cascade from parent ACEs to parent health to child pain was not present in the current sample. Further research that examines the role of parent ACEs in the development of child chronic pain, as well as other risk and resiliency factors that may mediate or moderate the association between parent ACEs and child chronic pain, is needed.

Rapid Evidence and Gap Map of virtual care solutions across a stepped care continuum for youth with chronic pain and their families in response to the COVID-19 pandemic

ABSTRACT

Poor access to pediatric chronic pain care is a longstanding concern. The COVID-19 pandemic has necessitated virtual care delivery at an unprecedented pace and scale. We conducted a scoping review to create an interactive Evidence and Gap Map of virtual care solutions across a stepped care continuum (ie, from self-directed to specialist care) for youth with chronic pain and their families. Review methodology was codesigned with 8 youth with chronic pain and 7 parents/caregivers. Data sources included peer-reviewed scientific literature, gray literature (app stores and web sites), and a call for innovations. Records were independently coded and assessed for quality. Overall, 185 records were included (105 scientific records, 56 apps, 16 web sites, and 8 innovations). Most virtual care solutions were applicable across pediatric chronic pain diagnoses, with the greatest proportion at lower levels of stepped care (ie, >100 self-guided apps and web sites). Virtual delivery of psychological strategies was common. Evidence gaps were noted at higher levels of stepped care (ie, requiring more resource and health professional involvement), integration with health records, communication with health professionals, web accessibility, and content addressing social/family support, medications, school, substance use, sleep, diet, and acute pain flares or crises. Evidence and Gap Maps are a novel visual knowledge synthesis tool, which enable rapid evidence-informed decision-making by patients and families, health professionals, and policymakers. This evidence and gap map identified high-quality virtual care solutions for immediate scale and spread and areas with no evidence in need of prioritization. Virtual care should address priorities identified by youth with chronic pain and their families.

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.

Adverse Childhood Experiences (ACEs) and Internalizing Mental Health, Pain, and Quality of Life in Youth With Chronic Pain: A Longitudinal Examination

The aims of this longitudinal study were to 1) identify categories of adverse childhood experiences (ACEs) (ie, neglect, abuse, household dysfunction in childhood) that increase risk for internalizing mental health problems, pain-related impairment, and poorer quality of life and 2) examine the moderating role of posttraumatic stress symptoms (PTSS) in these associations, in a clinical sample of youth with chronic pain. At 2 timepoints, youth (N = 155; aged 10-18 years) completed measures of exposure to ACEs, PTSS, depressive and anxiety symptoms, pain intensity, pain interference, and quality of life. Multivariate analyses of variance, linear mixed modeling, and moderation analyses were conducted. Results from cross-sectional and longitudinal analyses were similar; youth with a history of 3+ ACEs reported significantly higher PTSS, depressive and anxiety symptoms, and poorer quality of life than youth with no ACE history. Results also revealed differences in functioning between youth exposed to different types of ACEs (ie, maltreatment only, household dysfunction only, both, none). Finally, PTSS was found to moderate the association between ACEs and anxiety and depressive symptoms. Findings underscore the influence that ACEs can have on the long-term functioning of youth with chronic pain as well as the important role of current PTSS in this association. PERSPECTIVE: This study found that the risk of poorer outcomes imposed by ACEs at baseline remains longitudinally and that posttraumatic stress symptoms (PTSS) moderate the relationship between ACEs and anxiety and depressive symptoms in youth with chronic pain. These results underscore the importance of assessing for ACEs and PTSS alongside chronic pain in youth.

Nonpharmacologic Management of Procedural Pain in Pediatric Burn Patients: A Systematic Review of Randomized Controlled Trials

Pain following burn injury is associated with long-term health consequences in the pediatric population. Literature suggests nonpharmacologic treatment may provide improved pain control as an effective adjunct for these patients. This study aims to summarize randomized controlled trials on nonpharmacologic procedural pain management in pediatric burn patients. A systematic review was conducted on nonpharmacologic procedural pain management techniques used in the pediatric burn population. Fifteen studies were included and involved virtual reality, distraction devices, child life therapy, directed play, digital tablet games, cartoons, hypnosis, and music therapy. Treatment was effective in 8 out of 15 studies. Compared to controls, nonpharmacologic treatments reduced mid procedure pain by 19.7% and post procedure pain by 20.1%. This study demonstrates nonpharmacologic therapy can be an effective adjunct in pediatric procedural burn pain management, however further studies are needed to develop standardized algorithms to integrate nonpharmacologic treatments with pharmacologic therapies.

A Systematic Review of the Prospective Relationship between Child Maltreatment and Chronic Pain

Objective: The present systematic review aimed to evaluate the association between childhood maltreatment and chronic pain, with specific attention to the temporal nature of the relationship and putative moderators, including, the nature (type), timing of occurrence, and magnitude of maltreatment; whether physical harm or injury occurred; and whether post-traumatic stress disorder (PTSD) subsequently developed. Method: We included studies that measured the prospective relationship between child maltreatment and pain. Medline, EMBASE, PsycINFO, and CINAHL were searched electronically up to 28 July 2019. We used accepted methodological procedures common to prognosis studies and preregistered our review (PROSPERO record ID 142169) as per Cochrane review recommendations. Results: Nine studies (17,340 participants) were included in the present review. Baseline participant age ranged from 2 years to more than 65 years. Follow-up intervals ranged from one year to 16 years. Of the nine studies included, three were deemed to have a high risk of bias. With the exception of one meta-analysis of three studies, results were combined using narrative synthesis. Results showed low to very low quality and conflicting evidence across the various types of maltreatment, with the higher quality studies pointing to the absence of direct (non-moderated and non-mediated) associations between maltreatment and pain. PTSD was revealed to be a potential mediator and/or moderator. Evidence was not found for other proposed moderators. Conclusions: Overall, there is an absence of evidence from high quality studies of an association between maltreatment and pain. Our results are limited by the small number of studies reporting the relationship between child maltreatment and pain using a prospective design. High quality studies, including prospective cohort studies and those that assess and report on the moderators described above, are needed to advance the literature.

Targeting the stress response in pediatric pain: current evidence for psychosocial intervention and avenues for future investigation

Nonpharmacological treatments for chronic pain in youth have been identified as first-line treatments over and above medication. Therapies such as cognitive-behavioral therapy and mindfulness-based stress reduction have shown good efficacy in reducing the psychological correlates (eg, anxiety, depression, and stress) and social or behavioral sequelae (eg, limited physical activity and lack of school engagement) associated with pediatric chronic pain. However, minimal research has examined the physiological mechanism(s) of action for these interventions. A recent review (Cunningham, et al., 2019) emphasized the need for objective (ie, physiological) assessment of treatment response in pediatric pain populations. The current review adds to this literature by identifying the physiological stress response as a particular target of interest in interventions for pediatric pain. Research indicates that youth with chronic pain report high rates of psychological stress, posttraumatic stress symptoms, and exposure to adverse childhood experiences (abuse/neglect, etc). In addition, a host of research has shown strong parallels between the neurobiology of pain processing and the neurobiology of stress exposure in both youth and adults. Interventions such as narrative or exposure therapy (eg, trauma-focused cognitive-behavioral therapy) and mindfulness-based or meditation-based therapies have shown particular promise in alleviating the neurobiological impact that stress and pain can have on the body, including reduction in allostatic load and altered connectivity in multiple brain regions. However, no study to date has specifically looked at these factors in the context of pediatric pain treatment. Future research should further explore these constructs to optimize prevention in and treatment of these vulnerable populations.

Relationship between anxiety, post-traumatic stress, insomnia and fibromyalgia among female refugees in jordan: A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Fibromyalgia (FM) is a syndrome of chronic widespread pain, typically associated with fatigue, sleep, cognitive dysfunction and disordered mood. FM may limit an individual's ability to participate in everyday work and social activities, thereby making it difficult to maintain normal relationships with other individuals. While it has been studied in different populations and settings, the impact of FM and associated psychological factors has not been previously studied among female war refugees. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The study showed the high impact of FM on female refugees in Jordan; approximately three quarters of the participants had a moderate to severe FM impact. Refugees settled in Irbid city, Iraq, showed increased age, anxiety and post-traumatic stress disorder correlated with a higher FM impact. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The study recommends evaluation of the impact of FM among all female refugees living in Jordan, along with its neighbouring countries hosting refugees. Healthcare providers, including mental health nurses, should be aware of the role of PTSD and anxiety on the impact of FM. Accordingly, healthcare workers should design appropriate mental health treatment plans to help to decrease the impact of FM. Mental health nurses should evaluate FM impact among all refugees worldwide. Nurses in Jordan are recommended to share their experience with nurses outside of Jordan as this may help with funds being obtained and the implementation of advanced psychological interventions.

ABSTRACT

INTRODUCTION: Fibromyalgia (FM) is a syndrome of chronic widespread pain. While it has been studied in different populations and settings, the impact of FM and its associated psychological factors has not been previously studied among female war refugees.

AIM

To assess the impact of FM and its associated factors in female refugees.

METHODS

A cross-sectional study was conducted. The impact of FM, anxiety, post-traumatic stress (PTSD) and insomnia was investigated.

RESULTS

288 refugees previously diagnosed with FM were recruited. The results showed that 73.62% of the participants had a moderate to severe FM impact. Refugees settled in Irbid city were six times more likely to have a higher FM impact than refugees settled in Zarqa, and Iraqi refugees were more likely to have a higher impact than Syrian. Increased age, anxiety and PTSD were correlated with a greater impact.

CONCLUSION

Mental health nursing services should be directed towards female refugees, particularly those with increased age, anxiety and PTSD.

IMPLICATIONS FOR PRACTICE

Mental health nurses should evaluate the FM impact among all refugees worldwide. Furthermore, nurses in Jordan are recommended to share their experiences with nurses outside of Jordan, as this may help to raise funds and implement advanced psychological interventions.

Characterizing pain in long-term survivors of childhood cancer

Many long-term survivors of childhood cancer (LTSCC), individuals at least 5 years post-diagnosis or 2 years post-treatment, experience late- and long-term effects from their treatments, including pain. Yet, pain is poorly understood among LTSCC. The current study aimed to (1a) describe rates and multiple dimensions of pain; (1b) identify patterns of chronic pain; and (2) test correlates of chronic pain in LTSCC. Survivors (n = 140; 48.6% male, M_age = 17.3 years (range = 8-25)) were recruited from across Canada. Between 2017 and 2019, participants completed the Pain Questionnaire, Pain Catastrophizing Scale, Pediatric Quality of Life Inventory, Patient-Reported Outcome Measurement Information System (PROMIS)-Pain Interference, Anxiety, and Depression scales, Child Posttraumatic Stress Scale, the Posttraumatic Stress Disorder Checklist for the DSM-V, and the Cancer Worry Scale. RESULTS: Twenty-six percent of LTSCC reported experiencing chronic pain. Exploratory cluster analysis showed 20% of survivors had moderate to severe chronic pain based on measures of pain intensity and interference. The combination of higher posttraumatic stress symptoms, older current age, more pain catastrophizing, and sex (being female) significantly predicted the presence of chronic pain in logistic regression, χ² (4, N = 107) = 28.10, p < .001. Higher pain catastrophizing (OR = 1.09; 95% CI = 1.02-1.16), older current age (OR = 1.20; 95% CI = 1.07-1.34), and higher posttraumatic stress (OR = 1.92; 95% CI = 1.01-3.63) were significant predictors of chronic pain. LTSCC should be screened for the presence and magnitude of chronic pain during long-term follow-up visits so appropriate interventions can be offered and implemented. Future research should investigate pain interventions tailored for this population. RELEVANCE: Findings support regular screening for the presence and magnitude of chronic pain in survivors of childhood cancer in long-term follow-up care.

The Parent Version of the Sensitivity to Pain Traumatization Scale (SPTS-P): A Preliminary Validation

Sensitivity to pain traumatization (SPT) is defined as the propensity to develop responses to pain that resemble a traumatic stress reaction. To date, SPT has been assessed in adults with a self-report measure (Sensitivity to Pain Traumatization Scale (SPTS-12)). SPT may also be relevant in the context of parenting a child with chronic pain, as many of these parents report clinically elevated posttraumatic stress symptoms (PTSS). This study aimed to develop and validate a measure of parent SPT by adapting the SPTS-12 and evaluating its psychometric properties in a sample of parents whose children have chronic pain. In total, 170 parents (90.6% female) and children (aged 10–18 years, 71.2% female) were recruited from a tertiary chronic pain program. Parents completed the parent version of the SPTS-12 (SPTS-P) and measures of PTSS, depression, anxiety and anxiety-related constructs, and parenting behaviors. Youth completed measures of pain. Consistent with the SPTS-12, the SPTS-P demonstrated a one-factor structure that accounted for 45% of the variance, adequate to good reliability and moderate construct validity. Parent SPT was positively related to their protective and monitoring behaviors but was unrelated to youth pain intensity, unpleasantness, and interference. These results provide preliminary evidence for the psychometric properties of the SPTS-P and highlight the interaction between parent distress about child pain and parent responses to child pain.

A Systematic Review of the Prospective Relationship Between Bullying Victimization and Pain

Objective

This systematic review synthesized evidence about the relationship between childhood bullying victimization and chronic pain, with a focus on the temporal nature of the relationship and moderating factors, such as the type and intensity of victimization.

Method

We included prospective cohort studies that examined the relationship between childhood bullying victimization and pain measured at least three months later. We conducted electronic searches of Medline, EMBASE, PsycINFO, and CINAHL up to June 30, 2019. Standard methodological procedures consistent with Cochrane reviews of prognosis studies were used (PROSPERO record ID 133146).

Results

We included four longitudinal studies (6275 participants) in this review. The mean age of participants at baseline ranged from 10 to 14 years and the follow-up periods ranged from 6 months to 12 years. Two of the four studies were judged as having high risk of bias. Meta-analysis of results from four studies revealed increased risk of pain among victimized compared to non-victimized youth (adjusted OR [95% CI] = 1.45 [1.06-1.97], but the effect size was small and not clinically important. Only one study examined the inverse association (ie, from pain to victimization), and there was not enough evidence to conduct a meaningful analysis of the proposed moderators.

Conclusions

Study findings were limited by few prospective studies. Meta-analytic findings suggested that victimization may incur some risk for later pain, although the evidence was judged to be very low quality. High-quality studies that measure and report the nuances of bullying victimization are needed to test the proposed moderator models.

A longitudinal examination of the interpersonal fear avoidance model of pain: the role of intolerance of uncertainty

Youth with chronic pain and their parents face uncertainty regarding their diagnosis, treatment, and prognosis. Given the uncertain nature of chronic pain and high comorbidity of anxiety among youth, intolerance of uncertainty (IU) may be critical to the experience of pediatric chronic pain. This study longitudinally examined major tenets of the Interpersonal Fear Avoidance Model of Pain and included parent and youth IU as key factors in the model. Participants included 152 youth with chronic pain (Mage = 14.23 years; 72% female) and their parents (93% female). At baseline, parents and youth reported on their IU and catastrophic thinking about youth pain; youth reported on their fear of pain, pain intensity, and pain interference; and parents reported on their protective responses to child pain. Youth reported on their pain interference 3 months later. Cross-lagged panel models, controlling for baseline pain interference, showed that greater parent IU predicted greater parent pain catastrophizing, which, in turn, predicted greater parent protectiveness, greater youth fear of pain, and subsequently greater youth 3-month pain interference. Youth IU had a significant indirect effect on 3-month pain interference through youth pain catastrophizing and fear of pain. The results suggest that parent and youth IU contribute to increases in youth pain interference over time through increased pain catastrophizing, parent protectiveness, and youth fear of pain. Thus, parent and youth IU play important roles as risk factors in the maintenance of pediatric chronic pain over time and may be important targets for intervention.

The Clinical Utility of a Brief Psychological Stress Measure (Patient-Reported Outcomes Measurement Information System) in Youth with Chronic Pain

OBJECTIVE

To preliminarily examine the psychometric properties (i.e., internal consistency reliability, construct validity) and clinical utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) psychological stress experiences scale in a sample of youth with chronic pain.

METHODS

Participant data were gathered from an institutional review board (IRB) approved clinical data registry. One hundred sixty-eight children and adolescents (age: mean = 14.97, SD = 2.78) with chronic pain presenting to a tertiary pain treatment clinic were included in the data set. Internal consistency estimates (i.e., Cronbach's alpha), bivariate correlations, and confirmatory factor analyses were performed to preliminarily examine reliability and validity. Multivariate regression analyses were performed to examine the associations between PROMIS psychological stress and pain-related and psychosocial outcomes.

RESULTS

Confirmatory factor analysis and correlational results indicated that the PROMIS psychological stress experiences scale shows promising reliability and validity in the current sample of youth with chronic pain. Additionally, the results indicated that almost 50% of youth with chronic pain report "high" or "very high" stress (T ≥ 60) and significantly higher rates of stress when compared with national validation samples (P < 0.001). The results also indicated that the PROMIS psychological stress experiences scale was significantly associated with both pain-related and psychosocial outcomes (all P <0.01).

CONCLUSIONS

The PROMIS psychological stress experiences scale shows promising psychometric properties in youth with pediatric pain and may be useful in assessing for psychological impairment. Future research should further examine the use of this brief measure to assess psychological stress in medical clinics as a way to enhance intervention and prevention efforts in these youth.

Prenatal Exposure And Child brain and mental Health (PEACH) study: protocol for a cohort study of children and youth with prenatal alcohol exposure

INTRODUCTION

Fetal alcohol spectrum disorder (FASD), which is caused by prenatal alcohol exposure (PAE), affects an estimated 4% of North Americans, and is the most common preventable cause of intellectual disability. Mental health problems, including anxiety and depression, are experienced by nearly all individuals with FASD. However, there is very limited knowledge about effective mental health treatments for individuals with FASD; effective treatments are hindered in part due to a lack of understanding of the basic neurobiology underlying internalising disorders in youth with FASD.

METHODS AND ANALYSIS

The Prenatal Exposure And Child brain and mental Health (PEACH) study includes children aged 7-18 years. We will use longitudinal neuroimaging (anatomical T1-weighted, diffusion and passive viewing function MRI) and mental health assessments (Behaviour Assessment Scale for Children, Multi-dimensional Anxiety Scale for Children, Children's Depression Inventory (CDI-2), Kiddie Scale of Affective Disorders) to: (1) characterise brain development trajectories in youth with FASD, (2) determine whether brain alterations mediate increased anxiety and depression in youth with FASD and (3) identify baseline brain features that predict changes of anxiety and depression symptoms over the next 2 years. All of this will be done while considering sex and adverse postnatal experiences, which can significantly impact mental health and brain outcomes. This project will forge new understanding of FASD and mental health from a neurobiological perspective, highlighting key time periods (ie, sensitive windows) and brain regions (ie, that may be susceptible to neurostimulation), while identifying factors that predict individual trajectories of anxiety and depression symptoms.

ETHICS AND DISSEMINATION

This study was approved by the University of Calgary Conjoint Health Research Ethics Board and the University of Alberta Health Research Ethics Board. Study results will be disseminated in peer-reviewed journals, at relevant conferences and in conjunction with our knowledge mobilisation partners.

A Pilot Study Investigating the Role of Gender in the Intergenerational Relationships between Gene Expression, Chronic Pain, and Adverse Childhood Experiences in a Clinical Sample of Youth with Chronic Pain

Chronic pain is a highly prevalent and costly issue that often emerges during childhood or adolescence and persists into adulthood. Adverse childhood experiences (ACEs) increase risk for several adverse health conditions, including chronic pain. Recent evidence suggests that parental trauma (ACEs, post-traumatic stress disorder (PTSD) symptoms) confers risk of poor health outcomes in their children. Intergenerational relationships between parental trauma and child chronic pain may be mediated by epigenetic mechanisms. A clinical sample of youth with chronic pain and their parents completed psychometrically sound questionnaires assessing ACEs, PTSD symptoms, and chronic pain, and provided a saliva sample. These were used to investigate the intergenerational relationships between four epigenetic biomarkers (COMT, DRD2, GR, and SERT), trauma, and chronic pain. The results indicated that the significant biomarkers were dependent upon the gender of the child, wherein parental ACEs significantly correlated with changes in DRD2 expression in female children and altered COMT expression in the parents of male children. Additionally, the nature of the ACE (maltreatment vs. household dysfunction) was associated with the specific epigenetic changes. There may be different pathways through which parental ACEs confer risk for poor outcomes for males and females, highlighting the importance of child gender in future investigations.

Subclinical post-traumatic stress symptomology and brain structure in youth with chronic headaches

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ACEs and PTSS did not significantly differ between patients and healthy controls.

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Patients demonstrated greater corticolimbic connectivity compared to controls.

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Greater PTSS and less corticolimbic connectivity increased headache frequency.

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Less corticolimbic connectivity may indicate greater disease progression.

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Patients may be more vulnerable to the effects of PTSS compared to controls.

Background/aims

Post-traumatic stress symptoms (PTSS) and chronic pain often co-occur at high rates in youth. PTSS may alter brain structure thereby contributing to headache chronicity. This study examined whether PTSS and altered limbic circuitry were associated with headache frequency in youth.

Methods

Thirty youth aged 10–18 years with chronic headaches and 30 age- and sex-matched controls underwent a 3T MRI scan. Volumes of the hippocampus and amygdala were obtained from T1-weighted images. Mean fractional anisotropy (FA, an index of white matter structure) axial and radial diffusivity values of the cingulum and uncinate fasciculus were extracted from diffusion-weighted images. Youth reported on their headaches daily, for one-month, and self-reported pubertal status, emotion regulation, adverse childhood experiences (ACEs) and PTSS using validated measures. Volumes of the hippocampus and amygdala and diffusivity values of the cingulum and uncinate were compared between patients and controls. Hierarchical linear regressions were used to examine the association between PTSS, subcortical volumes and/or diffusivity values and headache frequency.

Results

Mean FA values of the cingulum were higher in patients compared to controls (P = 0.02, Cohen’s d = 0.69). Greater PTSS (P = 0.04), smaller amygdala volumes (P = 0.01) and lower FA of the cingulum (P = 0.04) were associated with greater headache frequency, after accounting for age, puberty, pain duration, emotion regulation, and ACEs (Adjusted R² ≥ 0.15). Headache frequency was associated with increases in radial diffusivity (P = 0.002, Adjusted R² = 0.59), as opposed to axial diffusivity (n.s.).

Conclusions

PTSS, smaller amygdalar volume, and poorer cingulum structural connectivity were associated with headache frequency in youth, and may underlie headache chronicity.

Epidemiology of chronic pain in children and adolescents: a protocol for a systematic review update

INTRODUCTION

Chronic pain, defined as persistent or recurring pain or pain lasting longer than 3 months, is a common childhood problem and can profoundly impact children's physical, psychological and social functioning. The last comprehensive systematic review estimating the prevalence of chronic pain in children and adolescents was published in 2011. Since then, the literature on paediatric chronic pain has grown substantially. This manuscript outlines a protocol for an updated systematic review to provide updated estimates of the prevalence of various forms of chronic pain in children and adolescence. The review will also examine the relationship between sociodemographic and psychosocial factors related to chronic pain prevalence.

METHODS AND ANALYSIS

This review will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will search EMBASE, PubMed, CINAHL and PsycINFO for observational studies published in English between 2009 and 2020 reporting population-based estimates of chronic non-disease-related pain prevalence in children or adolescents (age ≤19 years). Two independent reviewers will screen the titles and abstracts retrieved from the search based on predefined eligibility criteria. The full texts of relevant studies will then be assessed by two reviewers. Studies meeting inclusion criteria will be categorised according to the type of pain investigated: headache only, abdominal pain only, back pain only, musculoskeletal pain, combined pain, general pain and other pain. Data will be extracted using customised forms and studies will be assessed for risk of bias using a 10-item tool developed by Hoy et al (2012). A narrative synthesis will summarise the prevalence estimates of paediatric chronic pain and associated sociodemographic and psychosocial correlates. Meta-analyses and meta-regressions will be performed if the data permit.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be disseminated through publication in an academic journal, presentations at conferences and in various media.

PROSPERO REGISTRATION NUMBER

CRD42020198690.

Executive Functioning in Youth With and Without Chronic Pain: A Comparative Analysis

OBJECTIVES

Preliminary research in youth with chronic pain suggests differences in attention and working memory, which has been similarly demonstrated in adults with chronic pain. There has been little research on other aspects of executive functioning (EF) in this population despite its critical role in problem solving, school functioning, and coping. This study aimed to examine differences in several aspects of EF between youth with chronic pain and a nonchronic pain comparison group using performance-based neuropsychological tests and a behavior rating scale.

MATERIALS AND METHODS

Participants completed ratings of pain; physical, emotional, social, and school functioning; sleep quality; medication; and a general intelligence screener. Standardized neuropsychological tests were used to examine EF with a focus on working memory, divided and alternating attention, inhibition, flexibility, incidental memory, and planning. A parent-report and self-report behavior rating of EF was also administered.

RESULTS

Recruitment from 2 tertiary-care pain clinics resulted in a sample of 26 youth with chronic pain (80.8% girls) and their parents. A comparison group of 30 youth without chronic pain and their parents were recruited from the community. Participants with chronic pain had significantly lower scores on several performance-based tests of working memory/divided attention, inhibition, and flexibility/alternating attention than the comparison group. Statistically significant group differences were also found on behavior ratings of emotion control, shifting, task initiation and completion, working memory, planning and organization, overall emotion and cognitive regulation as well as global EF. Covariate analysis was conducted in all analyses where there were significant group differences and several observed group differences remained.

DISCUSSION

This study is one of few multidimensional examinations of EF in youth with chronic pain, using a comprehensive neuropsychological test battery combined with behavior ratings. Our findings suggest EF differences in youth with chronic pain, across a variety of domains and may suggest risk for specific cognitive processing weaknesses in this population. Medical and educational teams should work toward identification, treatment, and compensatory support for EF within individualized pain management for youth.

The Relationship between Stressors and Pain-Related Clinical Outcomes in Pediatric Chronic Pain Patients

Youth with chronic pain and youth who have experienced stressors are at risk for poor outcomes; however, little is known about the intersection of pain and stressors. This study aims to understand the prevalence of stressors among youth with chronic pain and the relationship between stressors and pain-related outcomes. Seven hundred and seventy youth with chronic pain aged 8–18 (M_age = 14.15 years, 70% female) reported pain characteristics, stressors, anxiety, disability, and quality of life. Most participants (82%) endorsed at least one stressor. A greater number of stressors was significantly related to greater anxiety and disability, and lower levels of quality of life. School stressors were significantly associated with functional disability; family, school, and peer stressors were significantly associated with anxiety and quality of life. Stressors are common in youth with chronic pain, and the presence of stressors is related to greater functional impairment. The results of this preliminary study using semi-structured clinical interviews suggest the importance of developing a validated measure that encompasses a wide variety of stressors for youth with pain. Future research on patient-reported stressors, relative intensity, and impact are needed.