Christine B. Sieberg

The Fear of Pain Questionnaire (FOPQ): Assessment of Pain-Related Fear Among Children and Adolescents With Chronic Pain

UNLABELLED An important construct in understanding pain-related disability is pain-related fear. Heightened pain-related fear may result in behavioral avoidance leading to disuse, disability, and depression; whereas confrontation of avoided activities may result in a reduction of fear over time and reengagement with activities of daily living. Although there are several measures to assess pain-related fear among adults with chronic pain, none exist for children and adolescents. The aim of the current study was to develop a new tool to assess avoidance and fear of pain with pediatric chronic pain patients: the Fear of Pain Questionnaire, child report (FOPQ-C), and Fear of Pain Questionnaire, parent proxy report (FOPQ-P). After initial pilot testing, the FOPQ-C and FOPQ-P were administered to 299 youth with chronic pain and their parents at an initial multidisciplinary pain treatment evaluation. The FOPQ demonstrated very strong internal consistency of .92 for the child and parent versions. One-month stability estimates were acceptable and suggested responsivity to change. For construct validity, the FOPQ correlated with generalized anxiety, pain catastrophizing, and somatization. Evidence of criterion-related validity was found with significant associations for the FOPQ with pain, healthcare utilization, and functional disability. These results support the FOPQ as a psychometrically sound measure. PERSPECTIVE Pain-related fear plays an important role in relation to emotional distress and pain-related disability among children and adolescents with chronic pain. Identification of patients with high levels of fear avoidance of pain with the FOPQ will inform how to proceed with psychological and physical therapy interventions for chronic pain.

Do Parent Protective Responses Mediate the Relation Between Parent Distress and Child Functional Disability Among Children With Chronic Pain

OBJECTIVES To examine whether protective parent responses mediate the relation between parent distress and child functioning. METHODS At a pain clinic evaluation, 157 families participated. Parents completed measures of global distress (BSI-18), distress in the context of their childs pain (BAP-PIQ), and protective responses to their childs pain. Children completed measures of functional disability and pain. RESULTS BAP-PIQ subscales were significantly associated with child functional disability, whereas BSI subscales were unrelated. Protective parent responses partially mediated the relation between parent distress and child functional disability for depression, anxiety, and catastrophizing. However, parent protective behavior fully mediated the relationship between parent helplessness and child functional disability, indicating that feelings of parent helplessness did not uniquely contribute to child functional disability. Discussion Results suggest that when treating youth with chronic pain, parental distress in the context of childrens pain needs to be addressed.

Pain Prevalence and Trajectories Following Pediatric Spinal Fusion Surgery

UNLABELLED Factors contributing to pain following surgery are poorly understood, with previous research largely focused on adults. With approximately 6 million children undergoing surgery each year, there is a need to study pediatric persistent postsurgical pain. The present study includes patients with adolescent idiopathic scoliosis undergoing spinal fusion surgery enrolled in a prospective, multicentered registry examining postsurgical outcomes. The Scoliosis Research Society Questionnaire-Version 30, which includes pain, activity, mental health, and self-image subscales, was administered to 190 patients prior to surgery and at 1 and 2 years postsurgery. A subset (n = 77) completed 5-year postsurgery data. Pain prevalence at each time point and longitudinal trajectories of pain outcomes derived from SAS PROC TRAJ were examined using analyses of variance and post hoc pairwise analyses across groups. Thirty-five percent of patients reported pain in the moderate to severe range presurgery. One year postoperation, 11% reported pain in this range, whereas 15% reported pain at 2 years postsurgery. At 5 years postsurgery, 15% of patients reported pain in the moderate to severe range. Among the 5 empirically derived pain trajectories, there were significant differences on self-image, mental health, and age. Identifying predictors of poor long-term outcomes in children with postsurgical pain may prevent the development of chronic pain into adulthood. PERSPECTIVE This investigation explores the prevalence of pediatric pain following surgery, up to 5 years after spinal fusion surgery. Five pain trajectories were identified and were distinguishable on presurgical characteristics of age, mental health, and self-image. This is the largest study to examine longitudinal pediatric pain trajectories after surgery.

Anxiety and Functional Disability in a Large Sample of Children and Adolescents with Chronic Pain

BACKGROUND: Anxiety is the most common psychiatric condition in children and adolescents, and is linked to significant disruptions across domains of function. Due to the avoidant nature of anxiety and pain-related disability, studying anxiety symptoms in children with chronic and recurrent pain conditions is important.

What Does It Take? Comparing Intensive Rehabilitation to Outpatient Treatment for Children With Significant Pain-Related Disability

OBJECTIVES This study compared outcomes between day hospital pain rehabilitation patients and patients engaged in outpatient multidisciplinary pain treatment. METHODS This study included 100 children who presented for an initial tertiary care pain clinic evaluation. 50 patients enrolled in intensive day hospital pain rehabilitation and 50 patients pursued outpatient multidisciplinary treatment. Across 2 time points, children completed measures of functional disability, pain-related fear, and readiness to change and parents completed measures of pain-related fear and readiness to change. RESULTS Across both treatment modalities, patients and parents reported improvements. Patients enrolled in intensive pain rehabilitation had significantly larger improvements in functional disability, pain-related fear, and readiness to change. Parents of day hospital patients reported larger declines in child pain-related fear and increased readiness to change compared with their outpatient counterparts. Discussion For patients with high levels of pain-related disability and distress, intensive pain rehabilitation provides rapid, dramatic improvements in functioning.

Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program.

TOC summary In an intensive pediatric pain rehabilitation program, increases in children’s readiness to self‐manage pain from pretreatment to posttreatment were associated with improved functioning and decreased emotional distress. Abstract The importance of willingness to adopt a self‐management approach to chronic pain has been demonstrated in the context of cognitive‐behaviorally oriented interdisciplinary pain treatment programs for adults, both as a treatment outcome and as a process that facilitates functional improvements. Willingness to self‐manage pain has not been studied in pediatric interdisciplinary pain treatment settings. Study aims were (1) to investigate willingness to self‐manage pain among children and parents undergoing intensive interdisciplinary pain treatment and (2) to determine whether increased willingness to self‐manage pain influenced functional treatment outcomes. A total of 157 children ages 10 to 18 and their parents enrolled in a pediatric pain rehabilitation program completed the Pain Stages of Change Questionnaire (PSOCQ youth and parent versions) at pretreatment, posttreatment, and short‐term follow‐up. They also reported on pain, functional disability, depressive symptoms, fear of pain, and use of passive and accommodative coping strategies. Results show that willingness to self‐manage pain increased during treatment among both children and parents, with gains maintained at follow‐up. Increases in children’s readiness to self‐manage pain from pretreatment to posttreatment were associated with decreases in functional disability, depressive symptoms, fear of pain, and use of adaptive coping strategies. Increases in parents’ readiness to adopt a pain self‐management approach were associated with changes in parent‐reported fear of pain but not with other child outcomes. Few associations emerged between pretreatment willingness to self‐manage pain and posttreatment outcomes. Findings suggest that interdisciplinary pediatric pain rehabilitation may facilitate increased willingness to self‐manage pain, which is associated with improvements in function and psychological well‐being.

Measuring parent beliefs about child acceptance of pain: A preliminary validation of the Chronic Pain Acceptance Questionnaire, parent report

Summary This study validates the Chronic Pain Acceptance Questionnaire, parent report, which assesses parent acceptance of child pain and emphasizes the importance of the social context of pain. Abstract Parent perceptions of and responses to pain have been identified as important factors in understanding pain‐related disability among children and adolescents with chronic pain. The ability to accept chronic pain rather than focus on ways to avoid or control it has been linked to positive outcomes in chronic pain research. To examine parent beliefs about child acceptance of pain, the Chronic Pain Acceptance Questionnaire, parent report (CPAQ‐P), was developed and administered to 195 parents of children with persistent pain evaluated in a multidisciplinary pain clinic. Analyses support the internal consistency of the CPAQ‐P (&agr; = .89) and 1‐month stability estimates were acceptable for the total scale score (&agr; = .72), and results suggest some responsivity to change. Exploratory factor analysis identified a 2‐factor model with 4 items removed from the original 20‐item measure. Confirmatory factor analysis strongly supported the modified version. For construct validity, parent beliefs about child acceptance were negatively correlated with parent pain catastrophizing and parent fear of pain. Greater acceptance was also negatively associated with protective parent responses to pain. These results support the CPAQ‐P as a promising measure for assessing parent beliefs about child acceptance of pain and reinforce the importance of the social context and parental influence on child functioning.

Ecological system influences in the treatment of pediatric chronic pain.

Family, school and the peer network each shape the chronic pain experience of the individual child, and each of these contexts also represents a domain of functioning often impaired by chronic pain. The goal of the present article is to summarize what is known about these bidirectional influences between children with pain and the social systems that surround them. Case reports that illustrate these complex, transactional forces and their ultimate impact on the childs pain-related functioning are included. A case involving siblings participating in an intensive interdisciplinary program for functional restoration and pain rehabilitation highlights how parents change through this treatment approach and how this change is vital to the childs outcomes. Another case involving a child undergoing intensive interdisciplinary treatment illustrates how school avoidance can be treated in the context of pain rehabilitation, resulting in successful return to the regular school environment. Finally, an acceptance and commitment therapy-focused group intervention for children with sickle cell disease and their parents demonstrates the benefits of peer contact as an element of the therapeutic intervention.

Children with co-morbid recurrent abdominal pain and anxiety disorders: results from a multiple-baseline intervention study.

Recurrent Abdominal Pain (RAP), one of the most common complaints of childhood, is associated with many adverse outcomes. However, few treatment studies have been conducted, especially for children with co-morbid RAP and anxiety disorders. The primary aim of the present study was to explore the utility of a cognitive-behavioral treatment (CBT) and a treatment that combined both CBT and family-based approaches in a community sample of children with co-morbid anxiety and RAP. A multiple-baseline across participants design utilizing repeated measures of anxiety and pain was implemented (n = 8 families). An examination of the clinical significance of both treatment approaches is suggestive of their utility in the treatment of anxiety and pain symptoms in children with RAP. More research is warranted in RAP treatment outcome research, particularly with family-based approaches to treatment.

Living life with my child’s pain: The Parent Pain Acceptance Questionnaire (PPAQ)

Objective:Parents’ emotional, cognitive, and behavioral responses are highly influential on children’s pain and functional outcomes. One important response to pediatric pain is acceptance: the degree to which an individual participates in routine daily activities in the presence of pain and is willing to let pain be a part of their life without efforts to control or avoid it. However, no tool currently exists to assess parents’ own acceptance of their child’s pain. The aim of this study was to validate the Parent Pain Acceptance Questionnaire (PPAQ). Materials and Methods:The PPAQ was administered to 310 parents of youth with chronic pain in an outpatient pediatric headache program and a day hospital pain rehabilitation program. An exploratory factor analysis revealed 2 factors for the PPAQ: an 11-item Activity Engagement scale and a 4-item Acceptance of Pain-related Thoughts and Feelings scale. Results:The PPAQ total score and subscales demonstrated strong internal consistency. Greater parent pain acceptance was positively associated with child pain acceptance, and was negatively correlated with parent protective behaviors, parent minimizing behaviors, parent and child pain catastrophizing, and child fear of pain. Parent protective behaviors and child pain acceptance both served as mediators of the relationship between parent pain acceptance and child functional disability. Conclusions:The PPAQ is a valid measure of parent pain acceptance and may provide valuable insights into parent responses to child pain and the ways in which parent acceptance influences child outcomes. Clinical implications and suggestions for future research are discussed.