A “dyadic dance”: pain catastrophizing moderates the daily relationships between parent mood and protective responses and child chronic pain

Exposure to perinatal trauma modifies nociception and gene expression in the prefrontal cortex and hypothalamus of adolescent rats

The perinatal period encompasses a critical window for neurodevelopment that renders the brain highly responsive to experience. Trauma, such as intimate partner violence (IPV) and early life stress/neglect, during this period negatively affects physical and mental health outcomes, including increasing ones risk for chronic pain. Although epigenetic programming likely contributes, the mechanisms that drive the relationship between perinatal trauma and adverse health outcomes, are not fully understood. Therefore, we explored the relationship between perinatal trauma (in utero exposure to IPV and/or early life neglect) and socio-emotional functioning, nociceptive sensitivity, and transcriptomic changes within the prefrontal cortex (PFC) and hypothalamus in dams and their adolescent offspring. Rat dams were randomly assigned to an IPV (i.e., combined mild traumatic brain injury and strangulation) or sham procedure during pregnancy. Following birth, offspring were subsequently assigned the early life neglect or control paradigm. In adolescence, offspring received a plantar incision or sham injury. Perinatal trauma altered nociception and emotional functioning in a sex-dependent manner when combined with the surgical procedure. We identified transcriptomic changes related to DNA transcription and expression within the PFC and hypothalamus of the dams. Examination of the offspring transcriptome highlighted impairment in immune regulation, dysfunction in stress-reactivity, as well as microglia activation. We also identified altered expression of genes associated with chronic pain. This demonstrates that perinatal trauma modifies offspring behaviour, including nociceptive sensitivity. We provide insight into the mechanisms that contribute to the chronification of pain, thereby informing future research targeted at the generation of prevention and therapeutic strategies. PERSPECTIVE: Perinatal trauma impaired cognitive, socio-emotional, and pain processing in offspring, while also inducing changes in gene expression, in both mothers and offspring. The findings highlight possible mechanisms responsible for intergenerational transmission of risk for chronic pain and provide targets for therapeutics which could potentially reverse perinatal-trauma induced epigenetic change.

Interpersonal dyadic influences on transitions between pain states: a narrative review and synthesis

ABSTRACT

Pain is not experienced in isolation; it is affected by and affects other people. Interactions between parents and partners and people living with pain affect beliefs, emotions and behaviours, and pain progress and change. We searched systematically for longitudinal studies of associations between specific familial, dyadic, interpersonal factors and quantitative pain transitions. We coded studies for risk of bias. For the narrative synthesis, we grouped findings by dyads-parents and children, and people with pain and their partners (usually spouses), and then by the psychosocial mechanism/s. We described certainty of evidence for each pain transition and each mechanism. Patient and public contributors were involved throughout. Of 52 studies, 38 were of parents and children (27,814 dyads) and 14 of partners (4904 dyads). Three groups of predictive factors were identified for parent and child studies: parent mental health, parent cognitions, and parent behaviours. Parental anxiety (but not depression) predicted children's onset of pain and worsening; the evidence was of moderate certainty and almost exclusively involved mothers. Evidence that some parental behaviours, such as protective behaviours, were associated with worse child pain was of very low certainty. The evidence for partners was of poor quality, precluding synthesis. The review highlights that most interpersonal pain research fails to capture the complex dynamics of longstanding relationships and highlights the difficulty of doing so using simple models.

Experimental Pain Sensitivity and Parental Pain Catastrophizing

BACKGROUND/OBJECTIVES

Variability in biopsychosocial factors can explain the interindividual variability in pain. One factor that can impact pain is the pain catastrophizing level. Interestingly, parental pain catastrophizing is related to the severity of the clinical pain of their children. This study explored whether parental pain catastrophizing is also associated with their children's experimental pain sensitivity.

METHODS

Forty-five healthy girls (mean age 12.07 ± 1.47 years) and one of their parents participated in this study. Parents completed the Pain Catastrophizing Scale (PCS) about their child's pain (PCS-Parentchild) as well as their pain (PCS-Parent). Children completed the PCS about their pain (PCS-Child) and the Pubertal Developmental Scale (PDS). Children underwent psychophysical tests, including paradigms of temporal summation, heat- and pressure-conditioned pain modulation, offset analgesia, and cold pain tolerance. Correlations and regression models were conducted to assess the relationships between parental pain catastrophizing scales (separately for PCS-Parentchild and PCS-Parent) and experimental pain sensitivity with and without controlling for PCS-Child and PDS. T-tests were used to compare pain sensitivity between participants with vs. without a family history of psychiatric disorder.

RESULTS

No significant relationships were found between the experimental pain sensitivity measures and either PCS-Parentchild or PCS-Parent with and without controlling for PCS-Child and PDS. No differences were found in experimental pain sensitivity between participants with and without a family history of psychiatric disorder.

CONCLUSIONS

Parental pain catastrophizing may contribute minimally to the individual variability in experimental pain sensitivity of healthy adolescent girls.

Parental narrative style moderates the relation between pain-related attention and memory biases in youth with chronic pain

ABSTRACT

Negatively biased pain memories robustly predict maladaptive pain outcomes in children. Both attention bias to pain and parental narrative style have been linked with the development of these negative biases, with previous studies indicating that how parents talk to their child about the pain might buffer the influence of children's attention bias to pain on the development of such negatively biased pain memories. This study investigated the moderating role of parental narrative style in the relation between pain-related attention and memory biases in a pediatric chronic pain sample who underwent a cold pressor task. Participants were 85 youth-parent dyads who reminisced about youth's painful event. Eye-tracking technology was used to assess youth's attention bias to pain information, whereas youth's pain-related memories were elicited 1 month later through telephone interview. Results indicated that a parental narrative style using less repetitive yes-no questions, more emotion words, and less fear words buffered the influence of high levels of youth's attention bias to pain in the development of negatively biased pain memories. Opposite effects were observed for youth with low levels of attention bias to pain. Current findings corroborate earlier results on parental reminiscing in the context of pain (memories) but stress the importance of matching narrative style with child characteristics, such as child attention bias to pain, in the development of negatively biased pain memories. Future avenues for parent-child reminiscing and clinical implications for pediatric chronic pain are discussed.

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.

Adverse Childhood Experiences Moderate the Relationship Between Pain and Later Suicidality Severity Among Youth: A Longitudinal High-Risk Cohort Study

Pain in adolescence can lead to the development of serious mental health issues, including suicidality. This risk may be strengthened among youth exposed to more adverse childhood experiences (ACEs; abuse, neglect, household challenges). This longitudinal study examined the role of ACEs in the relationship between pain and later suicidality onset and severity among a cohort of adolescents at risk for developing mental health problems. Participants were 139 healthy youth (Mage = 13.74 years, standard deviation = 1.56, 64% female) between the ages of 11 to 17 years, recruited based on parental history of depression or anxiety. Youth completed validated measures of internalizing symptoms, ACEs, and pain characteristics at baseline and follow-up diagnostic interviews 9 and/or 18 months later to assess for onset and severity of suicidality. After controlling for demographics, baseline internalizing symptoms, and ACEs, worse pain interference and increased ACEs at baseline predicted increased suicidality severity at follow-up. Moderation analyses revealed that there was a significant interaction between ACEs and pain interference and pain intensity. Increased pain interference (b = 7.65, P < .0001) or intensity (b = 6.96, P = .0003) was only associated with increased suicidality severity at follow-up in youth with high levels of ACEs. This study demonstrates that ACEs strengthen the relationship between pain and later suicidality severity among youth at risk of developing mental health problems. Findings underscore the critical need to adopt a trauma-informed lens to pediatric pain prevention and treatment (eg, screening for ACEs) and for the pain to be on the child's mental health agenda. PERSPECTIVE: This article provides evidence that, while pain is a risk factor for future increased suicidality severity, it is a particularly strong risk factor in youth who experienced increased childhood adversity. These results may help identify youth at greatest risk for suicidality.

Parent Anxiety, Depression, Protective Responses, and Parenting Stress in the Context of Parent and Child Chronic Pain: A Daily Diary Study of Parent Variability

Parents with (vs without) chronic pain report poorer psychosocial functioning (eg, worse mental health, parenting difficulties), which has been linked to poorer child outcomes (eg, child pain). However, emerging research suggests that individuals vary in their functioning from day-to-day, particularly those with chronic pain. This study used daily diaries to compare parents with (versus without) chronic pain on variability in their anxiety, mood, protective responses, and parenting stress. We also examined parent chronic pain status as a moderator of the associations between parent variability and youth daily pain and interference. Participants were 76 youth with chronic pain (Mage = 14.26; 71.1% female) and one of their parents (89.5% mothers; n = 38 or 50.0% endorsing chronic pain). Parents and youth completed self-report questionnaires and 7 days of diaries. Parent variability was calculated to reflect the frequency and size of day-to-day changes. Multilevel models revealed that parents with (vs without) chronic pain were significantly more variable in their parenting stress, but not in their anxiety, mood, or protective responses. Contrary to hypotheses, parent variability was not significantly related to youth daily pain intensity or interference and parent chronic pain did not moderate any associations. Instead, mean levels of parent anxiety, protective responses, and parenting stress across the week significantly predicted youth daily pain interference. Findings suggest that while variability was observed among parents (with and without chronic pain) of youth with chronic pain, it did not significantly predict youth's daily pain-related functioning. Further research is needed to confirm these initial findings. PERSPECTIVE: Parents with chronic pain have expressed concerns that the variable nature of their pain negatively impacts their children. Our results found that parents (with and without chronic pain) were variable in their anxiety, mood, protective responses, and parenting stress, but this variability did not significantly predict youth's chronic pain-related functioning.

Transcultural adaptation and validation of IMPACT-III and IMPACT-III-P in Spanish families: a multicenter study from SEGHNP

IMPACT-III and IMPACT-III-P are health-related quality of life (HRQoL) questionnaires for patients with pediatric inflammatory bowel disease (p-IBD) and their parents/caregivers. We aimed to perform a transcultural adaptation and validation for the Spanish context. Translation, back-translation, and evaluation of the questionnaires were performed by an expert committee and 12 p-IBD families. We recruited p-IBD patients aged 10-17 and their parents/caregivers. Utility, content, and face validity were considered. Validation was performed with Cronbach's alpha coefficient and varimax rotation. We confirmed the adequacy of the factor analysis using Kaiser-Meyer-Olkin (KMO) and Bartlett's sphericity tests. A confirmatory factor analysis was performed using the following goodness indexes: chi-square, Normed Fit Index (NFI), Root Mean Square Error of Approximation index (RMSEA), Standardized Root Mean Square Residual (SRMR), and Comparative Fit Index (CFI). The correlation coefficient between IMPACT-III and IMPACT-III-P was analyzed. We included 370 patients and 356 parents/caregivers (37 hospitals). Both questionnaires had good content and face validity and were considered user-friendly. The KMO measure (0.8998 and 0.9228, respectively) and Bartlett's sphericity test (p-value < 0.001 for both) confirmed the adequacy of the factor analysis. The 4-factor model, complying with Kaiser's criterion, explained 89.19% and 88.87% of the variance. Cronbach's alpha (0.9123 and 0.9383) indicated excellent internal consistency. The CFA showed an adequate fit (NFI 0.941 and 0.918, RMSEA 0.048 and 0.053, SRMR 0.037 and 0.044, and CFI 0.879 and 0.913). The correlation coefficient was excellent (0.92).

CONCLUSION

The SEGHNP versions of IMPACT-III and IMPACT-III-P are valid and reliable instruments for Spanish p-IBD families.

WHAT IS KNOWN

• IMPACT-III and parent-proxy IMPACT-III (IMPACT-III-P) are useful questionnaires for assessing health-related quality of life (HRQoL) in pediatric inflammatory bowel disease (p-IBD) patients and their parents/caregivers and have been translated and validated in several countries. • To date, no transcultural adaptation and validation of these questionnaires have been published for Spanish patients with p-IBD and their families.

WHAT IS NEW

• This is the first transcultural adaptation and validation of IMPACT-III and IMPACT-III-P for Spanish p-IBD families. • These are valid and reliable instruments for assessing HRQoL in Spanish families of patients with p-IBD.

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.

The Relationship Between Chronic Pain, Depression, Psychosocial Factors, and Suicidality in Adolescents

BACKGROUND

Chronic pain in youth is often associated with social conflict, depression, and suicidality. The interpersonal theory of suicide posits that there are psychosocial factors, such as peer victimization and lack of fear of pain, that may also influence suicidality.

OBJECTIVES

The objective of this study was to determine whether depressive symptoms, peer victimization, and lack of fear of pain predict suicidality in adolescents with chronic pain. It was hypothesized that higher levels of depressive symptoms and peer victimization, and lower levels of fear of pain, would predict a higher lifetime prevalence of suicidality.

METHODS

Participants consisted of 184 youth with primary chronic pain conditions (10 to 18 y, M = 14.27 y). Measures included diagnostic clinical interviews assessing suicidality and self-report questionnaires assessing depressive symptoms, peer victimization, and fear of pain.

RESULTS

Forty-two (22.8%) participants reported suicidality. Regression analyses demonstrated that the occurrence of suicidality was associated with higher rates of depressive symptoms (β = 1.03, P = 0.020, 95% CI: 1.01, 1.06) and peer victimization (β = 2.23, P < 0.05, 95% CI: 1.07, 4.63), though there was no association between lower fear of pain and suicidality.

DISCUSSION

These results suggest that depressive symptoms and peer victimization are significant predictors of suicidality in adolescents with chronic pain; however, lower fear of pain was not shown to be a significant predictor. Given these findings, depression and peer victimization should be further explored and considered in the design and implementation of prevention and early intervention strategies that target chronic pain and suicidality in youth.

Pain and insomnia as risk factors for first lifetime onsets of anxiety, depression, and suicidality in adolescence

ABSTRACT

Chronic pain and mental health problems have both been identified as public health emergencies and co-occur at high rates. This prospective, longitudinal investigation examined whether chronic pain status, pain-related symptoms (intensity, interference), pain catastrophizing, and insomnia severity predicted first lifetime onset of depressive and/or anxiety disorders as well as suicidality in a cohort of youth with a parental history of mood and/or anxiety disorders. Participants included 145 youth (Mage = 13.74 years; 64% female) who completed structured diagnostic interviews at baseline and at 9- and 18-month follow-up to assess depressive and anxiety disorders as well as suicidality. Participants completed baseline questionnaires assessing depressive and anxiety symptoms, pain symptoms and characteristics, pain interference, pain catastrophizing, and insomnia severity. Approximately 25% of youth reported having chronic pain at baseline. Nearly half (47.3%) developed a depressive disorder (21.3%), anxiety disorder (15.7%), or both (10.3%), and 34% endorsed experiencing suicidality at follow-up. Increased pain interference, intensity, catastrophizing, and insomnia severity predicted increased likelihood of first lifetime onset of a depressive disorder at follow-up, over and above sex and baseline symptoms. Chronic pain at baseline was associated with the increased likelihood of onset of suicidality at follow-up. Increased pain intensity and interference at baseline predicted increased severity of suicidality at follow-up. Insomnia severity predicted increased likelihood of anxiety disorder onset. The presence of chronic pain and elevated pain-related symptoms and insomnia are premorbid risk factors for the development of significant mental health disorders and issues in youth.

The association of spouse interactions and emotional learning in interference related to chronic back pain

Social interactions affect individual behaviours, preferences, and attitudes. This is also critical in the context of experiencing pain and expressing pain behaviours, and may relate to learned emotional responses. In this respect, individual variability in the medial prefrontal cortex (mPFC), which is involved in adjusting an organism's behaviour to its environment by evaluating and interpreting information within the context of past experiences, is important. It is critical for selecting suitable behavioural responses within a social environment and may reinforce maladaptation in chronic pain. In our study, we used brain imaging during appetitive and aversive pavlovian conditioning in persons with chronic back pain (CBP), subacute back pain (SABP), and healthy controls (HC), together with information on spouse responses to pain behaviours. We also examined the relationship of these responses with pain-related interference in the patients. Our findings yielded a significant negative association between mPFC responses to appetitive and aversive learning in CBP. We also observed a significant negative association for mPFC responses during aversive learning and distracting spouse responses, and a significant positive association between mPFC responses during appetitive learning and solicitous spouse responses in CBP. Both significantly predicted pain-related interference in the CBP group (explained variance up to 53%). Significant associations were not found for SABP or HC. Our findings support an association between appetitive and aversive pavlovian learning, related brain circuits and spouse responses to pain in CBP, where appetitive and aversive learning processes seem to be differentially involved. This can inform prevention and early intervention in a mechanistic approach.

Chronic Pain and Its Impact on Child Mental Health: Management Challenges and Clinical Guidance for Child and Adolescent Psychiatrists

Chronic pain refers to recurrent or persistent pain that extends beyond the expected time of healing. In addition to the negative impact of chronic pain on a child's overall well-being and functioning in social and academic settings, chronic pain negatively impacts family functioning, caregiver well-being, and a family's financial resources.¹ Furthermore, youth with chronic pain frequently meet criteria for psychiatric disorders, such as mood and anxiety disorders, posttraumatic stress disorder, and disruptive disorders, and chronic pain increases the risk for suicidal behaviors and substance use on a long-term basis.^1,2 Comorbid psychiatric symptoms and behaviors among youth with chronic pain often add additional discomfort, dramatically reduce quality of life, exacerbate pain symptoms, and delay or prevent recovery.¹ Many youth do not receive ideal, multidisciplinary care.

Appraisals of Pain in Pediatric Inflammatory Bowel Disease: A Qualitative Study With Youth, Parents, and Providers

Background

Pain is a predominant symptom of inflammatory bowel disease (IBD), and is influenced by cognitive, emotional, and behavioral factors. The cognitive-affective model of symptom appraisal (CAMSA) has been used to understand how youth view symptoms in chronic conditions. We sought to (1) determine how youth with IBD and their parents appraise pain, and how their perspectives fit within CAMSA, and (2) explore health care providers' understanding and communication about pain.

Methods

Participants included 19 youth ages 10-17 years with chronic IBD pain and their parents, and 5 IBD providers from a gastroenterology clinic. Separate semi-structured qualitative interviews with youth, parents, and providers were conducted. Interview prompts were adapted from CAMSA, previous studies of pediatric pain and symptom monitoring, and a qualitative study in adults with IBD pain. Interviews were analyzed according to principles of reflexive thematic analysis.

Results

Three key components of CAMSA (IBD Threat, Fear/Worry, and Biased Attending) were identified in youth and parent dyads. Some youth showed Biased Attending, including difficulty disengaging, while other youth simply monitored pain. The overarching theme for provider interviews was Gastroenterologists view pain as a secondary (rather than primary) treatment issue.

Conclusions

CAMSA is potentially applicable to pain appraisal in youth with IBD and their parents. When health care providers communicate about pain, they should consider how symptom uncertainty may be influenced by threat, fear/worry, and biased attending. Further studies are needed to develop and test psychosocial interventions to reduce fear and threat of pain in youth with IBD in partnership with families and providers.

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.

The Impact of the COVID-19 Pandemic on Youth with Chronic Pain and Their Parents: A Longitudinal Examination of Who Are Most at Risk

Objectives: Chronic pain and mental illness in youth and parents are poised to reach new heights amidst the societal and healthcare impacts of the COVID-19 pandemic. Evidence from natural disasters (i.e., hurricanes) suggests that a degree of personal impact and individual personality may moderate the effects of high stress events, such as the COVID-19 pandemic, on mental health. Methods: In a pre-existing cohort of 84 youth with chronic pain (M_age = 14.39; 12–18 years; 67.8% female) and 90 parents (86.7% female), we examined changes in youth pain interference and youth and parent mental health (depression, anxiety) from before to during the first wave of the COVID-19 pandemic, and the influence of personal impact of the pandemic (i.e., financial, familial, health, social, occupational, and educational domains) and individual personality (neuroticism, conscientiousness, extroversion). Results: Overall, youth reported significantly lower pain interference and anxiety as compared to pre-pandemic; however, those more personally impacted by the pandemic reported worsening pain interference and anxiety symptoms. Overall, parents reported greater depressive symptoms as compared to pre-pandemic; however, those more personally impacted by the pandemic reported increased anxiety symptoms. Personality traits (high neuroticism, and low conscientiousness and extroversion) predicted worsened pain and mental health, and exacerbated effects of COVID-19-related personal impact on youth and parent anxiety symptoms. Discussion: Identifying risk and resilience profiles in youth and parents at high risk for worsening pain and mental health may better inform matching interventions to individual need.

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

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

Sensitivity to Pain Traumatization and Its Relationship to the Anxiety-Pain Connection in Youth with Chronic Pain: Implications for Treatment

The bidirectional relationship between anxiety and chronic pain in youth is well-known, but how anxiety contributes to the maintenance of pediatric chronic pain needs to be elucidated. Sensitivity to pain traumatization (SPT), an individual's propensity to develop responses to pain that resemble a traumatic stress response, may contribute to the mutual maintenance of anxiety and pediatric chronic pain. A clinical sample of youth (aged 10-18 years) with chronic pain completed a measure of SPT at baseline and rated their anxiety and pain characteristics for seven consecutive days at baseline and at three-month follow-up. Multiple linear regression analyses were conducted to model whether SPT moderated the relationship between baseline anxiety and pain intensity, unpleasantness, and interference three months later. SPT significantly moderated the relationship between anxiety and pain intensity. High anxiety youth with high SPT reported increased pain intensity three months later, while high anxiety youth with low SPT did not. High anxiety youth who experience pain as potentially traumatizing are more likely to report higher pain intensity three months later than high-anxiety youth who do not. Future research should examine whether children's propensity to become traumatized by their pain predicts the development of chronic pain and response to intervention.

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.

Mediation of outcomes for cognitive behavioral therapy targeted to parents of children with Functional Abdominal Pain Disorders

OBJECTIVE

There is a large body of evidence for the efficacy of Cognitive Behavioral Therapy (CBT) in treating Functional Abdominal Pain Disorders (FAPD) in children. In most CBT interventions for FAPD, parents participate together with their children. However, only one study to date has examined targeting parents alone for treatment. The aim of the current study was to examine mediators of a parent-only CBT treatment incorporating social learning (SLCBT) for FAPD in children.

METHODS

We examined mediators of child outcomes in an existing randomized controlled trial (n = 316) of parent-only social learning CBT compared to an education condition. Hypothesized mediators (parental protectiveness, perceived threat of pain, catastrophizing) were assessed at 3 months post-treatment, and outcomes (parent ratings of disability, quality of life, school absences, and health care visits) were assessed at 6 months post-treatment. Mediation analyses were performed using Hayes' PROCESS macro.

RESULTS

Pain catastrophizing significantly mediated treatment effects for all outcomes (B ranged from -1.65 to 2.22). Reduction in pain threat was a significant mediator for all outcomes (B ranged from -1.84 to 3.13) except school absences and health care visits. Decrease in parental protectiveness mediated effects on disability and missed school (B ranged from -1.47 to 1.34). Mediation effects did not differ by in-person or remote delivery of SLCBT.

CONCLUSION

Changes in maladaptive parental thoughts and behaviors following parent-only SLCBT intervention appeared to mediate the effects of the intervention. Parental catastrophizing appears to be a particularly important target given that decreases in that variable mediated all outcomes.

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.

The Moderating Role of Attention Control in the Relationship Between Pain Catastrophizing and Negatively-Biased Pain Memories in Youth With Chronic Pain

The present study examined the role of attention control in understanding the development of negatively-biased pain memories as well as its moderating role in the relationship between pain catastrophizing and negatively-biased pain memories. Youth with chronic pain (N = 105) performed a cold pressor task (CPT) and completed self-report measures of state/trait pain catastrophizing and attention control, with the latter comprising both attention focusing and attention shifting. Two weeks after the CPT, youth's pain-related memories were elicited via telephone allowing to compute pain and anxiety memory bias indices (ie, recalling pain intensity or pain-related anxiety, respectively, as higher than initially reported). Results indicated no main effects of attention control and pain catastrophizing on pain memories. However, both components of attention control (ie, attention focusing and attention shifting) moderated the impact of pain catastrophizing on youth's memory bias, with opposite interaction effects. Specifically, whereas high levels of attention shifting buffered the influence of high pain catastrophizing on the development of pain memory bias, high levels of attention focusing strengthened the influence of high pain catastrophizing on the development of anxiety memory bias. Interaction effects were confined to trait catastrophizing (ie, not state catastrophizing). Theoretical and clinical implications are discussed. PERSPECTIVE: This article investigates the role of attention control in the development of negatively-biased pain memories in children with chronic pain. Findings underscore the importance of targeting differential components of attention control and can inform intervention efforts to minimize the development of negatively biased pain memories in youth with chronic pain.

Parent-Child Dyadic Coping and Quality of Life in Chronically Diseased Children

Different forms of dyadic coping are associated with positive outcomes in partner relationships, yet little is known about dyadic coping in parent-child relationships. The current research explored the association between parent-child dyadic coping and children’s quality of life in 12–18-year old children with a chronic disease (i.e., cystic fibrosis, autoimmune diseases, and children post-cancer treatment). In a sample of 105 parent-child dyads, self-reported forms of dyadic coping (i.e., stress communication, problem-oriented, emotion-oriented, and negative dyadic coping) and children’s quality of life were assessed. Children reported more stress communication and negative dyadic coping than their parents, while parents reported more problem-oriented dyadic coping and emotion-oriented dyadic coping than their children. More stress communication of the child was associated with more emotion-oriented dyadic coping and less negative dyadic coping of the parent. More negative dyadic coping of the child was associated with less stress communication, problem-oriented dyadic coping and emotion-oriented dyadic coping of the parent. Additionally, both children’s and parents’ negative dyadic coping were associated with lower self-reported pediatric quality of life and parents’ emotion-oriented dyadic coping was associated with higher pediatric quality of life. These findings emphasize that children and their parents mutually influence each other and that dyadic coping is associated with children’s quality of life. Theoretical and practical implications are discussed.

Parental Catastrophizing and Goal Pursuit in the Context of Child Chronic Pain: A Daily Diary Study

Background: Despite daily variability in children's chronic pain experiences, little is known about how parents' emotions and goals toward their child's pain are influenced by these daily changes. This diary study examined how daily child pain intensity (as perceived by parents) moderates the associations between parental catastrophic thoughts about child pain on the one hand, and daily parental distress and parents' goals with regard to their child's pain (pain control vs. activity engagement) on the other hand.

Method: Participants were 25 parents of 20 different children (N = 18; 90% girls). Children, aged 8–14 years (M = 9.5, SD = 2.09), experienced either chronic headache or functional abdominal pain with an average pain duration of 22.5 months (SD = 24.5 months). Daily parental responses (i.e., perceived child pain intensity, distress and goal endorsement) were collected through a 3-week daily diary (resulting in 413 valid diary reports). Parents completed the Pain Catastrophizing Scale for Parents prior to starting the diary (PCS-P general) and a daily measure (PCS-P daily) included in the diary. To account for the interdependence of the data, the data were analyzed using multilevel modeling.

Results: Perceived daily child pain intensity moderated the impact of parental general and daily catastrophic thoughts on parents' daily distress. Only for parents experiencing low general catastrophic thoughts an increase in distress was observed on days when they perceived their child's pain intensity as high. For all parents, high levels of perceived child pain intensity were related to more distress on days where parents reported high levels of catastrophic thinking (i.e., PCS-P daily). Perceived daily child pain intensity also moderated the impact of parental general catastrophic thinking on parents' daily endorsement of goals. Parents with high levels of general catastrophic thinking reported a lower focus on child pain control on days when child pain intensity was perceived to be low. Parents with low general catastrophic thinking reported lower endorsement of the activity engagement goal on days where the child's pain intensity was perceived to be low.

Conclusion: These findings highlight the complexity of daily fluctuations in parental distress and goals regarding their child's pain. Clinical implications and future directions are critically assessed.

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.

Book Review: My Bodyguard Brain - How Your Brain Uses Pain to Protect You

Review of a practical resource providing children with ongoing pain (and their parents) information of the neurobiology of pain. The book 'My Bodyguard Brain - How your brain uses pain to protect you' explains why we feel pain. The brain makes pain when it notices any sort of danger. Pain is associated with acute injury but it can also be evoked by social interaction and unpleasant emotion that children don't know how to deal with. The text and drawings explain in a child-friendly way how your 'Bodyguard' brain wants to look after you, and how it sometimes gets a bit 'too good' at that job. It is a book I would recommend for teachers and clinicians dealing with children experiencing chronic pain. Ongoing pain in children is a huge problem in society. Paediatric pain should matter to everyone. It affects approximately one quarter to one third of all children and adolescents. Children with chronic pain have often cut back all their normal activities like school, sports, social life and sleep. Almost 60% of these children become adults experiencing pain and 50% of the children with pain has a parent suffering from chronic pain. Understanding what you feel will turn the oversensitive alarm down and is the first step to improve the lives of children and adolescents with pain.

Do Parental Pain Knowledge, Catastrophizing, and Hypervigilance Improve Following Pain Neuroscience Education in Healthy Children?

Pediatric chronic pain is a challenging problem for children and their families, although it is still under-recognized and under-treated. The aim of this study was to investigate whether a pain neuroscience education program for children (PNE4Kids) delivered to healthy children aged 8 to 12 years old and attended by their parents would result in improved parental knowledge about pain neurophysiology, decreased parental pain catastrophizing about their own pain and their children's, decreased parental pain vigilance and awareness, and decreased fear of pain in children. Twenty-seven healthy child-parent dyads received a 45 min PNE4Kids session. Demographic data were collected, and the Neurophysiology of Pain Questionnaire (NPQ), Fear of Pain Questionnaire-Parent Proxy Report (FOPQ-P), Pain Catastrophizing Scale (PCS), Pain Catastrophizing Scale for Parents (PCS-P), and the Pain Vigilance and Awareness Questionnaire (PVAQ) were completed by the parents before and after the PNE4Kids session. Twenty-six dyads completed study participation. In response to the PNE4Kids session, significant short-term (1 week) improvements were shown in the NPQ (p < 0.001) and the FOPQ-P (p = 0.002). Parents' level of pain knowledge and children's fear of pain, reported by their parents, improved after a 45 min PNE4Kids session. Thus, PNE4Kids should likewise be further investigated in healthy child-parent dyads as it might be useful to target parental and children's pain cognitions at a young age.

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.

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.

Diagnostic uncertainty in pediatric chronic pain: nature, prevalence, and consequences

Introduction

Diagnostic uncertainty (DU), which is the perception that a label or explanation for a patient's health problem is missing or inaccurate, has been linked to distress, anxiety, and difficulty coping among adults with pain. This study examined the prevalence of DU among youth with chronic pain and their parents and the relation of parent and youth DU with youth pain, pain-related constructs, and health-related quality of life (HRQoL).

Methods

Participants included 174 youth with chronic pain (M _age = 14.28 years; 73% female) and one of their parents (91% mothers) recruited from a tertiary-level pediatric chronic pain program in Canada. Youth and parent DU was assessed using a brief measure of 3 empirically derived yes/no questions regarding whether the youth and parent had received a clear diagnosis/explanation for their/their child's pain and whether they believed there was something else happening with their/their child's pain that doctors had not yet found. Youth reported on their pain intensity, pain interference, pain catastrophizing, fear of pain, and HRQoL.

Results

Thirty-one percent of youth and 28% of parents experienced DU. Seventy percent of parents and youth were in agreement regarding their experience of DU. Youth DU was linked to higher youth catastrophic thinking about their pain. Parent DU was linked to greater youth pain interference and intensity and lower youth HRQoL.

Conclusion

Diagnostic uncertainty is experienced by nearly a third of youth with chronic pain and their parents and is linked to worse youth pain, pain catastrophizing, and HRQoL.

Adverse childhood experiences in parents of youth with chronic pain: prevalence and comparison with a community-based sample

Supplemental Digital Content is Available in the Text.

Parents of youth with chronic pain reported high rates of adverse childhood experiences, including significantly higher rates of physical neglect than a community-based sample.

Introduction:

Adverse childhood experiences (ACEs) are common occurrences that are related to poor health outcomes, including chronic pain, in youth and adults. Research suggests that children of parents exposed to ACEs are also at risk of poor outcomes. However, little is known about the risk that ACEs confer for chronic pain across generations. Parent ACEs may play an important role in pediatric chronic pain, given their association with key parent factors (eg, mental and physical health).

Objectives:

This study evaluated the prevalence of ACEs in parents of youth with chronic pain and compared these rates to a community-based sample.

Methods:

One hundred seventy parents of youth (aged 10–18 years) with chronic pain, recruited from a tertiary-level chronic pain program at a pediatric hospital in Canada, completed a self-report measure of ACEs. A comparison sample (n = 3914) was drawn from a local, community-based study that examined ACEs among adults in primary care.

Results:

Among parents of youth with chronic pain, 67.6% reported ≥1 ACE and 23.5% reported ≥4 ACEs. Controlling for sociodemographic factors, ACEs were similar across samples, except parents of youth with chronic pain reported significantly higher rates of physical neglect (odds ratio = 2.14; 95% confidence interval = 1.35–3.40) than the community-based sample.

Conclusion:

Adverse childhood experiences are prevalent among parents of youth with chronic pain, with physical neglect reported more frequently than the community-based sample. Further research that examines the association between parent ACEs and child chronic pain, as well as neurobiological and psychosocial factors that may mediate this potential relation, is needed.

Guidance on authorship with and acknowledgement of patient partners in patient-oriented research

The Strategy for Patient-Oriented Research Chronic Pain Network was founded in 2016 and is a patient-oriented research network funded by the Canadian Institutes of Health Research. The Network incorporates patient partners throughout its governance and operations meaning that patient partners may contribute to research projects in ways that warrant scientific authorship as defined by the International Committee of Medical Journal Editors. The Network did a brief informal review of guidance on patient authorship in 2019, but could not find any practical documentation to guide its members on this topic. Note the term patient partner here refers to a patient (or caregiver or other person with lived experience) who is a partner or collaborator on a research team. This guidance does not address patients as participants in a research study. This guidance has been co-written by a group of researchers and patient partners of the Chronic Pain Network in an effort to address this gap. It is intended for both researchers and patient partner audiences. This guidance is meant to facilitate conversations between researchers and patient partners about authorship and/or acknowledgement regarding research projects on which they collaborate. While the overall principles of academic authorship and acknowledgement remain unchanged, nuances for interpreting these principles through the lens of patient engagement or patient-oriented research is provided. Teams that carry out patient-oriented research projects will require different preparation to empower all team members (researchers and patient partners) to discuss authorship and acknowledgement. To facilitate these conversations, we have included an overview of the scientific publishing process, explanation of some common terms, and sets of considerations are provided for both patient partners and researchers in determining the range of team member contribution from acknowledgement to authorship. Conversations about authorship can be difficult, even for established research teams. This guidance, and the resources discussed within it, are provided with the intention of making these conversations easier and more thoughtful.

Clinical relevance of attentional biases in pediatric chronic pain: an eye-tracking study

ABSTRACT

Attentional biases have been posited as one of the key mechanisms underlying the development and maintenance of chronic pain and co-occurring internalizing mental health symptoms. Despite this theoretical prominence, a comprehensive understanding of the nature of biased attentional processing in chronic pain and its relationship to theorized antecedents and clinical outcomes is lacking, particularly in youth. This study used eye-tracking to assess attentional bias for painful facial expressions and its relationship to theorized antecedents of chronic pain and clinical outcomes. Youth with chronic pain (n = 125) and without chronic pain (n = 52) viewed face images of varying levels of pain expressiveness while their eye gaze was tracked and recorded. At baseline, youth completed questionnaires to assess pain characteristics, theorized antecedents (pain catastrophizing, fear of pain, and anxiety sensitivity), and clinical outcomes (pain intensity, interference, anxiety, depression, and posttraumatic stress). For youth with chronic pain, clinical outcomes were reassessed at 3 months to assess for relationships with attentional bias while controlling for baseline symptoms. In both groups, youth exhibited an attentional bias for painful facial expressions. For youth with chronic pain, attentional bias was not significantly associated with theorized antecedents or clinical outcomes at baseline or 3-month follow-up. These findings call into question the posited relationships between attentional bias and clinical outcomes. Additional studies using more comprehensive and contextual paradigms for the assessment of attentional bias are required to clarify the ways in which such biases may manifest and relate to clinical outcomes.