Amy S. Lewandowski

Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: An updated meta-analytic review

&NA; The purpose of this meta‐analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth. Specifically, in this review we updated previous systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes. Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE, PsycLIT, EMBASE, and the Social Sciences Citation Index were conducted from inception through August 2008. Methodological quality of the studies was assessed, and data extracted on the three primary outcomes of interest. Twenty‐five trials including 1247 young people met inclusion criteria and were included in the meta‐analysis. Meta‐analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post‐treatment and follow‐up in youth with headache, abdominal pain, and fibromyalgia. Small and non‐significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes available in the included studies. Omnibus cognitive–behavioral therapy, relaxation therapy, and biofeedback all produced significant and positive effects on pain reduction. Studies directly comparing the effects of self‐administered versus therapist‐administered interventions found similar effects on pain reduction. Psychological therapies result in improvement in pain relief across several different pain conditions in children. Future trials are needed that incorporate non‐pain outcome domains, that focus significant therapeutic content on reductions in disability, and that include extended follow‐up to better understand maintenance of treatment effects.

Randomized controlled trial of an Internet-delivered family cognitive-behavioral therapy intervention for children and adolescents with chronic pain.

ABSTRACT Cognitive–behavioral therapy (CBT) interventions show promise for decreasing chronic pain in youth. However, the availability of CBT is limited by many factors including distance to major treatment centers and expense. This study evaluates a more accessible treatment approach for chronic pediatric pain using an Internet‐delivered family CBT intervention. Participants included 48 children, aged 11–17 years, with chronic headache, abdominal, or musculoskeletal pain and associated functional disability, and their parents. Children were randomly assigned to a wait‐list control group or an Internet treatment group. Primary treatment outcomes were pain intensity ratings (0–10 NRS) and activity limitations on the Child Activity Limitations Interview, both completed via an online daily diary. In addition to their medical care, the Internet treatment group completed 8 weeks of online modules including relaxation training, cognitive strategies, parent operant techniques, communication strategies, and sleep and activity interventions. Youth randomized to the wait‐list control group continued with the current medical care only. Findings demonstrated significantly greater reduction in activity limitations and pain intensity at post‐treatment for the Internet treatment group and these effects were maintained at the three‐month follow‐up. Rate of clinically significant improvement in pain was also greater for the Internet treatment group than for the wait‐list control group. There were no significant group differences in parental protectiveness or child depressive symptoms post‐treatment. Internet treatment was rated as acceptable by all children and parents. Findings support the efficacy and acceptability of Internet delivery of family CBT for reducing pain and improving function among children and adolescents with chronic pain.

Systematic Review of Family Functioning in Families of Children and Adolescents With Chronic Pain

UNLABELLED Disturbances in family functioning have been identified in youth with chronic pain and are associated with worse child physical and psychological functioning. Assessment measures of family functioning used in research and clinical settings vary. This systematic review summarizes studies investigating relationships among family functioning, pain, and pain-related disability in youth with chronic pain. Sixteen articles were reviewed. All studies were cross-sectional; 7 utilized between-group comparisons (chronic pain versus healthy/control) and 12 examined within-group associations among family functioning, pain, and/or pain-related disability. Studies represented youth with various pain conditions (eg, headache, abdominal pain, fibromyalgia) ages 6 to 20 years. Findings revealed group differences in family functioning between children with chronic pain and healthy control subjects in 5 of 7 studies. Significant associations emerged among family variables and pain-related disability in 6 of 9 studies with worse family functioning associated with greater child disability; relationships between family functioning and childrens pain were less consistent. Different patterns of results emerged depending on family functioning measure used. Overall, findings showed that families of children with chronic pain generally have poorer family functioning than healthy populations and that pain-related disability is more consistently related to family functioning than pain intensity. PERSPECTIVE This review highlights the importance of family factors in pain-related disability in youth with chronic pain. Results suggest that family-level variables may be an important target for intervention. Family functioning measures showed significant variation, and researchers should take this into account when selecting instruments for use in research and clinical settings.

Temporal daily associations between pain and sleep in adolescents with chronic pain versus healthy adolescents

&NA; Adolescents with chronic pain frequently report sleep disturbances, particularly short sleep duration, night wakings, and poor sleep quality. Prior research has been limited by assessment of subjectively reported sleep only and lack of data on daily relationships between sleep and pain. The current study utilized multilevel modeling to compare daily associations between sleep and pain in adolescents with chronic pain and healthy adolescents. Ninety‐seven adolescents (n = 39 chronic pain; n = 58 healthy) aged 12–18, 70.1% female participated. Adolescents completed pain diary ratings (0–10 NRS) and actigraphic sleep monitoring for 10 days. Actigraphic sleep variables (duration, efficiency, WASO) and self‐reported sleep quality were tested as predictors of next‐day pain, and daytime pain was tested as a predictor of sleep that night. Effects of age, gender, study group, and depressive symptoms on daily associations between sleep and pain were also tested. Multivariate analyses revealed that nighttime sleep (p < .001) and minutes awake after sleep onset (WASO) (p < .05) predicted next‐day pain, with longer sleep duration and higher WASO associated with higher pain. Contrary to hypotheses, neither nighttime sleep quality nor sleep efficiency predicted pain the following day. The interaction between nighttime sleep efficiency and study group was significant, with adolescents with pain showing stronger associations between sleep efficiency and next‐day pain than healthy participants (p = .05). Contrary to hypotheses, daytime pain did not predict nighttime sleep. Daily associations between pain and sleep suggest that further work is needed to identify specific adolescent sleep behaviors (e.g., compensatory sleep behaviors) that may be targeted in interventions.

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

&NA; This study aimed to (1) identify differences in sleep behaviors, sleep quality, pre‐sleep arousal and prevalence of insomnia symptoms in adolescents with chronic pain compared to a healthy age and sex‐matched cohort and (2) examine pain intensity, pubertal development, depression, and pre‐sleep arousal as risk factors for insomnia symptoms. Participants included 115 adolescents, 12–18 years of age (73.0% female), 59 youth with chronic pain and 56 healthy youth. During a home‐based assessment, adolescents completed validated measures of pain, sleep quality, sleep hygiene, pre‐sleep arousal, depressive symptoms, and pubertal development. Findings revealed a significantly higher percentage of adolescents with chronic pain reporting symptoms of insomnia (54.2%) compared to healthy adolescents (19.6%), p < .001. Youth with chronic pain also reported higher cognitive and somatic arousal at bedtime, and lower sleep quality compared to the healthy cohort. In a logistic regression, two factors emerged as significant predictors of insomnia, having chronic pain (OR = 6.09) and higher levels of cognitive pre‐sleep arousal (OR = 1.24). Level of pain intensity did not predict insomnia. While sleep disruption may initially relate to pain, these symptoms may persist into a separate primary sleep disorder over time due to other behavioral and psychosocial factors. Assessment of insomnia may be important for identifying behavioral targets for the delivery of sleep‐specific interventions to youth with chronic pain.

Validation of a self-report questionnaire version of the Child Activity Limitations Interview (CALI): The CALI-21

Abstract The Child Activity Limitations Interview (CALI) is a measure designed to assess functional impairment due to chronic pain in school‐age children. In this study, we present a self‐report questionnaire version of the CALI (the CALI‐21) that extends the original interview measure. The purpose of this study was to provide internal consistency, cross‐informant reliability and construct validity of the CALI‐21 on a clinical sample of children and adolescents with chronic pain conditions. One hundred fifty‐five children and adolescents (65 males, 90 females; ages 8–18 years, M = 14.31, SD = 2.45) with chronic pain completed questionnaires as part of their clinic intake procedures at their consultation visit in a pediatric pain management clinic. An exploratory factor analysis was conducted to measure latent constructs within the broader domain of functional impairment. Results of the exploratory factor analysis yielded two factors representing limitation in Active and Routine activities on both parent and child reports. Parent and child total CALI scores correlated with measures of pain intensity, however, different patterns of correlations emerged between age, pain intensity, depressive symptoms, and the Active and Routine factors. The CALI‐21 showed good internal consistency, high cross‐informant reliability, and demonstrated construct validity. The CALI‐21 provides increased flexibility via the questionnaire format in the assessment of pain‐related activity limitations in children. Factor analysis extends information about specific types of activity limitations experienced by children.

Sleep problems in children and adolescents with common medical conditions.

Untreated sleep disturbances and sleep disorders pose significant adverse daytime consequences and place children at considerable risk for poor health outcomes. Sleep disturbances occur at a greater frequency in children with acute and chronic medical conditions compared with otherwise healthy peers. Sleep disturbances in medically ill children can be associated with sleep disorders, comorbid with acute and chronic conditions, or secondary to underlying disease-related mechanisms, treatment regimens, or hospitalization. Clinical management should include a multidisciplinary approach with particular emphasis on routine, regular sleep assessments and prevention of daytime consequences, and promotion of healthy sleep habits and health outcomes.

Patterns and predictors of health service utilization in adolescents with pain: comparison between a community and a clinical pain sample.

UNLABELLED There is limited research describing the patterns of healthcare utilization in adolescents with chronic pain. This study describes healthcare utilization in a clinical chronic pain sample, and compares the patterns of service use of this group to a community sample with intermittent pain complaints. We also investigated demographic and clinical factors that predicted healthcare visits and medication use in the clinical sample. Data on 117 adolescents (aged 12-18; n = 59 clinical pain sample, n = 58 community) were collected. Caregivers and adolescents reported on sociodemographics, medical visits, current medications, pain, activity limitations, and depression. As hypothesized, the clinical pain sample had higher rates of healthcare consultation on all types of medical visits (general, specialty care, complementary medicine, mental health, OT/PT), and higher medication use compared to the community sample. Regression analyses revealed that higher annual income, greater pain frequency, and higher levels of caregiver-reported activity limitations were associated with a greater number of healthcare visits for the total sample. Within the clinical pain sample, higher pain frequency and greater activity limitations (caregiver report) predicted more specialty care visits. Additionally, higher income and greater levels of depressive symptoms predicted a higher number of prescribed medications. PERSPECTIVE This study contributes to the limited available data on health service and medication use in a clinical chronic pain sample versus a community sample of adolescents. We also identify clinical factors (pain frequency, parent-reported activity limitations, depressive symptoms) and demographic factors (gender, income) associated with healthcare utilization.

Fear-avoidance beliefs and parental responses to pain in adolescents with chronic pain

BACKGROUND The fear-avoidance model of chronic pain posits that fear of pain is associated with fear and avoidance of activity, which can lead to deconditioning and persistence of pain and disability. Despite being well supported in adults, little is known about the role of fear-avoidance beliefs regarding physical activity in children. Research has shown that parental protectiveness contributes to activity limitations in children; however, no studies have examined relationships between protectiveness, and fear and avoidance. OBJECTIVES To conduct a cross-sectional study to provide additional information regarding the reliability and validity of the Fear-Avoidance Beliefs Questionnaire physical activity subscale among adolescents with chronic pain; examine fear-avoidance beliefs and depressive symptoms as concurrent predictors of physical activity limitations; and test competing models using fear-avoidance beliefs as mediators and moderators of the association between parental protectiveness and activity limitations. METHODS Adolescents (n=42) 11 to 17 years of age with chronic pain completed questionnaires assessing pain intensity, fear-avoidance beliefs, depressive symptoms and physical activity limitations. Their parents completed questionnaires regarding protectiveness and adolescent activity limitations. RESULTS The Fear-Avoidance Beliefs Questionnaire physical activity subscale was useful for assessing fear-avoidance beliefs in the present population. In support of hypotheses, greater fear-avoidance beliefs were associated with greater activity limitations, above pain intensity and depressive symptoms. Support was found for fear-avoidance beliefs as mediators of the association between parental protectiveness and activity limitations. Tests of moderation were not significant. CONCLUSIONS Fear-avoidance beliefs may be an important target for interventions focused on decreasing activity limitations in youth with chronic pain. Future research should investigate these associations longitudinally.

Age-Dependent Relationships Among Pain, Depressive Symptoms, and Functional Disability in Youth With Recurrent Headaches

Objective.—To assess age differences associated with depressive symptoms and functional disability in children and adolescents with recurrent headache.