Deirdre E. Logan

Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain.

&NA; The Functional Disability Inventory (FDI) is a well‐established and commonly used measure of physical functioning and disability in youth with chronic pain. Further validation of the measure has been called for, in particular, examination of the clinical utility and factor structure of the measure. To address this need, we utilized a large multicenter dataset of pediatric patients with chronic pain who had completed the FDI and other measures assessing pain and emotional functioning. Clinical reference points to allow for interpretation of raw scores were developed to enhance clinical utility of the measure, and exploratory factor analysis was performed to examine its factor structure. Participants included 1300 youth ages 8 to 18 years (mean = 14.2 years; 76% female) with chronic pain. Examination of the distribution of FDI scores and validation with measures of depressive symptoms and pain intensity yielded 3 distinct categories of disability: No/Minimal Disability, Moderate Disability, and Severe Disability. Factor analysis of FDI scores revealed a 2‐factor solution representing vigorous Physical Activities and non‐physically strenuous Daily Activities. The 3‐level classification system and factor structure were further explored via comparison across the 4 most commonly encountered pain conditions in clinical settings (head, back, abdominal, and widespread pain). Our findings provide important new information regarding the clinical utility and validity of the FDI. This will greatly enhance the interpretability of scores for research and clinical use in a wide range of pediatric pain conditions. In particular, these findings will facilitate use of the FDI as an outcome measure in future clinical trials. Clinical reference points and a preliminary factor structure for the Functional Disability Inventory (FDI) increase the clinical and research utility of the measure.

Parental response to children's pain: The moderating impact of children's emotional distress on symptoms and disability

&NA; Parental responses play a central role in the development and maintenance of children’s pain behavior. Previous studies examining the impact of parental responses on children’s pain have focused mainly on protective or solicitous responses. This study examined the impact of parental responses, including protectiveness, minimization of pain, and encouraging and monitoring responses, on children’s functional disability and somatic symptoms. Participants included 327 patients with chronic pain, ages 8–17, who completed measures of pain, disability, somatic symptoms, depression, and anxiety. Patients’ parents completed a measure assessing parental responses to their children’s pain. Results show that for children with higher levels of emotional distress, maladaptive parental responses to pain (e.g., criticism, discounting of pain, increased attention to pain, and granting of special privileges) were associated with increased disability and somatic symptoms. Results of this study demonstrate the important ways in which parents can influence how their children cope with and manage chronic pain. Children whose parents are overly protective or critical of their pain may experience more impairment or somatic symptoms, particularly those children who are already at risk for difficulties due to higher levels of emotional distress.

Social desirability response bias and self-report of psychological distress in pediatric chronic pain patients.

&NA; The objective of this study was to investigate associations between social desirability response bias and self‐report of pain, disability, and psychological distress (depression, anxiety, and somatic symptoms) in a sample of children presenting to a multidisciplinary pediatric chronic pain clinic. A retrospective review was conducted on 414 consecutive clinic patients, ages 12–17 years, with chronic pain complaints of at least 3 months’ duration. As part of a clinical battery, children completed self‐report psychological questionnaires including the Children’s Depression Inventory, Children’s Somatization Inventory, and Revised Children’s Manifest Anxiety Scale including the Lie Scale, an indicator of social desirability influence. Children also provided self report of pain intensity, pain duration and functional disability. Clinician ratings of anxiety and depressive symptoms also were collected. Results show that children scoring high on the measure of social desirability reported fewer symptoms of depression and anxiety compared to children scoring low on the social desirability index. No differences arose between these groups on reports of somatic symptoms, pain duration, or pain‐related disability. These findings suggest that social desirability response bias may have implications for the self‐report of psychological distress among pediatric chronic pain patients. The limits of self‐report of symptoms should be considered in the clinical and research contexts.

A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes.

Objectives:To examine clinical outcomes of an interdisciplinary day-hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS). Methods:The study is a longitudinal case series of consecutive patients treated in a day-hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents with ages 8 to 18 years (median=14 y) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy, and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at posttreatment follow-up at a median of 10 months after discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or analysis of variance as appropriate, with corrections for multiple comparisons. Results:Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (P<0.001), functional disability (P<0.001), subjective report of limb function (P<0.001), timed running (P<0.001), occupational performance (P<0.001), medication use (P<0.01), use of assistive devices (P<0.001), and emotional functioning (anxiety, P<0.001; depression, P<0.01). Functional gains were maintained or further improved at follow-up. Discussion:A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.

Too sick for school? Parent influences on school functioning among children with chronic pain

Summary Parental protective responses to pain mediated the association between parent pain catastrophizing and child school functioning as assessed by school attendance and subjective report. Promoting adaptive parental responses to pain may enhance success at school. Abstract Parental responses to children with chronic pain have been shown to influence the extent of the child’s functional disability, but these associations have not been well studied in relation to children’s pain‐related school functioning. The current study tests the hypothesis that parental pain catastrophizing and parental protective responses to child pain influence the extent of school impairment in children with chronic pain. A mediational model was tested to determine whether parental protective behaviors serve a mediating role between parental pain catastrophizing and child school impairment. Study participants were a clinical sample of 350 children ages 8–17 years with chronic pain and their parents. Measures of pain characteristics, demographic characteristics, child depressive symptoms, school attendance rates, overall school functioning, parental pain catastrophizing, and parental protective responses to pain were collected. Results show that, controlling for the known influences of pain intensity and child depressive symptoms, parental pain catastrophizing and parental protective responses to child pain each independently predict child school attendance rates and reports of overall school impairment. Parental protectiveness was found to mediate the association between parental cognitions (i.e., parent pain catastrophizing) and child school functioning outcomes. These findings underscore the importance of intervening with parents to foster parental responses to child pain that help children engage and succeed in the school environment despite pain.

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.

Engagement in multidisciplinary interventions for pediatric chronic pain: parental expectations, barriers, and child outcomes.

ObjectivesTo examine the adherence to the recommendations of pain treatment among children and adolescents evaluated for a variety of chronic and recurrent pain conditions. MethodsSeveral measures during initial evaluation and after 3 months were collected to assess satisfaction with initial evaluation, adherence to multidisciplinary recommendations, pain ratings, somatic symptoms, functional limitations, and school attendance. ResultsOf the 120 patients who initially enrolled in the study, 70 parents and 57 children participated in 3-month follow-up interviews and reported significantly fewer doctor visits, decreased somatic symptoms, fewer functional limitations, and decreased pain compared with their initial evaluation. Adherence to multidisciplinary recommendations ranged from 46.7% to 100% with the highest level of overall adherence to physical therapy. Factors associated with adherence varied across type of recommendation. For medical recommendations, higher parent-reported patient satisfaction and expectations that medical tests would be beneficial were associated with engagement in medical treatment, whereas parent reports of negative attitude-type barriers and experience with surgery were associated with less frequent engagement in recommended treatment. With regard to physical therapy recommendations, only earlier experience with exercise was associated with better adherence. For psychologic recommendations, familiarity with hypnosis and biofeedback in addition to positive expectations regarding psychologic treatment and biofeedback were all associated with subsequent engagement in psychologic treatment. Lastly, we identified modest associations between functional improvements and adherence to specific recommendations. DiscussionResults of this study support the importance of examining adherence to multidisciplinary interventions among children and adolescents with chronic pain.

Pain coping profiles in adolescents with chronic pain

Abstract This study sought to evaluate the extent to which the pain coping profiles observed by Walker and colleagues [28] in a sample of patients with chronic abdominal pain also were evident in a sample of adolescent patients who presented to a tertiary care clinic for evaluation of a variety of diverse pain conditions. In addition, we aimed to evaluate the relation of these pain coping profiles to patients’ emotional and physical functioning. Participants (n = 254) were adolescent patients aged 12–17 years. Patients completed the Pain Response Inventory (PRI) as well as measures of pain, somatic symptoms, anxiety and depressive symptoms, and functional disability. Using the PRI classification algorithm developed by Walker and colleagues [28], we successfully classified all the patients in our sample. We also found that the pain coping profiles successfully differentiated among patients with different levels of symptoms, disability, and emotional distress, further demonstrating the external validity of these profiles. Results have implications for tailoring pain treatment interventions to patients’ particular coping profiles.

School Functioning in Adolescents With Chronic Pain: The Role of Depressive Symptoms in School Impairment

OBJECTIVE To explore associations between depressive symptoms and school functioning, including school attendance, academic performance, self-perceived academic competence, and teacher-rated school adjustment among predominantly Caucasian and female adolescent chronic pain patients. METHODS A total of 217 clinically referred adolescents (aged 12-17 years) and their parents completed measures of pain characteristics, depression, and school functioning. Additional data were collected from school records and teacher reports. RESULTS Depressive symptoms strongly correlated with school functioning indicators. In linear regression analyses, higher levels of depressive symptoms predicted more school impairment. A model testing whether depressive symptoms mediated the association between current pain intensity and parent perceptions of the interference of pain on school functioning was supported by the data. CONCLUSIONS Depressive symptoms play a key role in influencing the extent of school impairment in adolescents with chronic pain. Interventions to alleviate depressive symptoms may enhance treatments designed to improve school functioning in this population.

Pain catastrophizing in children with chronic pain and their parents: proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure.

&NA; There is no strong evidence for the 3‐dimensional structure of the PCS‐C or PCS‐P. Proposed child clinical reference points may aid in assessment and treatment. &NA; The current study aimed to validate the child and parent pain catastrophizing scale in a large chronic pain sample and to identify child pain catastrophizing clinical reference points. Patients and parents (n = 697) evaluated at a pediatric pain program completed the Pain Catastrophizing Scale, child (PCS‐C) and parent (PCS‐P) reports, along with additional measures of psychological functioning. The measure’s psychometric properties were examined, as were relations across demographic, pain, and psychological characteristics and pain catastrophizing. Clinical reference points were identified for the PCS‐C from differences in pain catastrophizing across levels of disability, depressive symptoms, and anxiety. Overall, we did not find support for the hypothesized 3‐dimension structure, and we recommend potentially removing items 7 and 8 for both the PCS‐P and PCS‐C as a result of floor/ceiling effects. The 11‐item PCS‐C is most parsimonious as a unitary construct, while the 11‐item PCS‐P comprises 2 factors. Although parent catastrophizing was significantly associated with child outcomes after controlling for pain level, it was no longer significant when accounting for child catastrophizing. When comparing PCS‐C scores based on child outcomes, significant differences emerged for low, moderate, and high catastrophizing levels. It appears that the influence of parent catastrophizing on outcomes can be explained through its impact on child catastrophizing levels. PCS‐C reference points derived from this large sample can aid clinicians in assessment and treatment planning, in turn increasing the utility of the PCS‐C for both clinical and research purposes.