Emma Fisher

Systematic Review and Meta-Analysis of Psychological Therapies for Children With Chronic Pain

OBJECTIVES This systematic review and meta-analysis examined the effects of psychological therapies for management of chronic pain in children.  METHODS Randomized controlled trials of psychological interventions treating children (<18 years) with chronic pain conditions including headache, abdominal, musculoskeletal, or neuropathic pain were searched for. Pain symptoms, disability, depression, anxiety, and sleep outcomes were extracted. Risk of bias was assessed and quality of the evidence was rated using GRADE.  RESULTS 35 included studies revealed that across all chronic pain conditions, psychological interventions reduced pain symptoms and disability posttreatment. Individual pain conditions were analyzed separately. Sleep outcomes were not reported in any trials. Optimal dose of treatment was explored. For headache pain, higher treatment dose led to greater reductions in pain. No effect of dosage was found for other chronic pain conditions.  CONCLUSIONS Evidence for psychological therapies treating chronic pain is promising. Recommendations for clinical practice and research are presented.

Systematic Review and Meta-Analysis of Parent and Family-Based Interventions for Children and Adolescents With Chronic Medical Conditions

OBJECTIVE To quantify the effects of parent- and family-based psychological therapies for youth with common chronic medical conditions on parent and family outcomes (primary aim) and child outcomes (secondary aim). METHODS MEDLINE, EMBASE, and PsycINFO were searched from inception to April 2013. 37 randomized controlled trials were included. Quality of the evidence was evaluated using GRADE criteria. Data were extracted on parent, family, and child outcomes. RESULTS Pooled psychological therapies had a positive effect on parent behavior at posttreatment and follow-up; no significant improvement was observed for other outcome domains. Problem-solving therapy (PST) improved parent mental health and parent behavior at posttreatment and follow-up. There was insufficient evidence to evaluate cognitive-behavioral and systems therapies for many outcome domains. CONCLUSIONS Parent- and family-based psychological therapies can improve parent outcomes, with PST emerging as particularly promising. Future research should incorporate consensus statements for outcomes assessment, multisite recruitment, and active comparator conditions.

Worry and catastrophizing about pain in youth: a reappraisal.

Catastrophizing about pain is defined as “an exaggerated negative ‘mental set’ brought to bear during actual or anticipated pain experience” [25]. It is a salient form of worry, and one that has proven useful in explaining pain severity, disability, and adaptation to treatment in a range of different conditions and settings [7] and [12]. Catastrophizing involves repeated thought about threat as uncontrollable and likely to have awful consequences. These aspects have been captured neatly by Sullivan and colleagues with the labels of “rumination,” “helplessness,” and “magnification” [24]. Catastrophizing was identified as important for children’s adaptation to pain and included in early measurement tools focused on coping [20]. However, interest has been fuelled by the development of the child version of the adult Pain Catastrophizing Scale, the PCS-C [3], [27] and [29]. We suggest that a reappraisal of catastrophic thinking about pain in young people is needed before research blooms. In what follows, we focus on a developmental view of emotional coping, we look again at how catastrophizing about pain has been researched with children, and we suggest an alternative view. Finally, we introduce the research and clinical implications of this reappraisal.

Anxiety at 13 and its effect on pain, pain-related anxiety, and pain-related disability at 17: An ALSPAC cohort longitudinal analysis.

The aim of the present study was to investigate the influence of anxiety at 13 years of age on the presence of chronic pain, pain-related anxiety, and pain-related disability at 17 years of age in a large longitudinal cohort. We hypothesized that mother-reported anxiety at 13 would be associated with the presence of chronic pain at 17 and an increase in pain-related anxiety using all available data from the longitudinal cohort. Further, we hypothesized that anxiety at 13 would predict pain-related disability in adolescents who reported chronic pain at 17 years of age. Participants were recruited from the Avon Longitudinal Study of Parents and Children based in the UK who attended a university research clinic at 17. Child anxiety (reported by the mother) was extracted at child age 13, and self-report of the presence of chronic pain, pain-related anxiety, and pain-related disability at 17. Analyses revealed that child anxiety at 13 was not significantly associated with the presence of chronic pain at 17 (n = 842). However, anxiety at 13 was significantly associated with pain-related anxiety at 17 (n = 1831). For the subsample of adolescents who reported chronic pain, anxiety at 13 was associated with pain-related disability at 17 (n = 393). Further analyses revealed that pain-related anxiety at 17 mediated the association between anxiety at 13 and pain-related disability at 17, suggesting that pain-related anxiety should be a target for treatment in adolescents with chronic pain, to reduce the impact of pain in later adolescence. General anxiety at 13 was unrelated to the presence of chronic pain at 17, but should be considered a risk factor for later pain-related anxiety and disability in a subset of adolescents who develop chronic pain.

Longitudinal change in parent and child functioning after internet-delivered cognitive-behavioral therapy for chronic pain

Abstract Theoretical models of pediatric chronic pain propose longitudinal associations between childrens pain experiences and parent and family factors. A large body of cross-sectional research supports these models, demonstrating that greater parent distress and maladaptive parenting behaviors are associated with greater child disability. Family-based cognitive-behavioral therapy interventions have been developed for youth with chronic pain which aim to improve child disability and reduce maladaptive parenting behaviors. However, little is known about temporal, longitudinal associations between parent and child functioning in this population. In the present study, we conducted a secondary analysis of data from 138 families of youth with chronic pain aged 11 to 17 years old who received family-based cognitive-behavioral therapy delivered through the Internet as part of a randomized controlled trial. Measures of child disability, parent protective behavior, and parent distress were obtained at pretreatment, immediate posttreatment, 6-month follow-up, and 12-month follow-up. Latent growth modeling indicated that child disability, parent protective behavior, and parent distress improved with treatment over the 12-month study period. Latent growth modeling for parallel processes indicated that higher parent distress at pretreatment predicted less improvement in child disability over 12 months. No other predictive paths between parent and child functioning were significant. These findings indicate that parent distress may increase the risk of poor response to psychological pain treatment among youth with chronic pain. At present, parent distress is not routinely targeted in psychological interventions for pediatric chronic pain. Research is needed to determine optimal strategies for targeting parent and family factors in the treatment of pediatric chronic pain.

Attention bias modification training for adolescents with chronic pain: A randomized placebo-controlled trial

Abstract Attention bias for pain-related information is theorised to maintain chronic pain, indicating that changing this bias could improve pain-related outcomes. Modifying attention biases in adolescents, when chronic pain often first emerges, may be particularly beneficial. We report here a randomized, placebo-controlled, parallel-group trial of attention bias modification (ABM) training in adolescents with chronic noncancer pain. Adolescent patients (N = 66) were randomly assigned to complete multiple sessions of dot-probe ABM training (N = 23), placebo training (N = 22), or no training (waitlist; N = 21) across a period of 4 weeks. Patients completed all assessments at a hospital-based pediatric pain clinic and completed all training at home. We examined the relative effects of ABM on attention bias and attention control, as well as pain symptomatology (primary outcome), pain catastrophizing, anxiety and depression symptoms, and functional disability (secondary outcomes) immediately after training and 3 months later. We found no evidence that ABM changed attention bias or attention control in comparison with placebo training or no training. We also found that pain and pain-related outcomes were no different for those undergoing ABM compared with placebo training or no training when tested immediately after training or 3 months later. Overall, we found no evidence to support the efficacy of dot-probe ABM for improving pain-related outcomes in adolescents with chronic pain. This study was registered on the NIHR Clinical Research Network Portfolio in August 2014 (UK Clinical Trials Gateway: CPMS 17251) and funded by a Research Training Fellowship awarded to Lauren Heathcote by Action Medical Research for Children.

Adolescent and Parent Treatment Goals in an Internet-Delivered Chronic Pain Self-Management Program: Does Agreement of Treatment Goals Matter?

Objective To assess whether adolescent-parent agreement on treatment goals as part of an Internet-delivered cognitive-behavioral pain intervention was associated with adolescent outcomes. 122 adolescent-parent dyads selected two treatment goals. Pain intensity and pain-related disability were assessed at pre-treatment, post-treatment, and 6- and 12-month follow-ups. We compared dyads who had goal agreement versus no agreement. 74 dyads (61%) agreed on one or more treatment goals, most commonly going to school, sports, and sleep. In dyads who chose the same goal, regardless of the content, adolescents had lower pain intensity post-treatment and at follow-up. When goals were categorized by domain, in dyads who agreed on physically active goals, adolescents were more likely to report lower pain intensity compared with other groups. Agreement of goals was not associated with changes in pain-related disability. Agreement on treatment goals may be an important treatment process to maximize outcomes in self-management therapies.

Postsurgical pain in children: unraveling the interplay between child and parent psychosocial factors

Spinal fusion surgery is performed on approximately 10,000 children annually in the United States. A recent systematic review identified the prevalence of chronic postsurgical pain (CPSP) ranging from 11% to 54% after pediatric spinal fusion. Chronic postsurgical pain is associated with significant functional disability and impaired health-related quality of life in youth. Thus, research that can lead to identifying youth at risk for the transition from acute postsurgical pain to CPSP is a critical research question in this field. Currently, there are few highquality research studies investigating this topic, but findings suggest that parent and child psychosocial factors place children at risk of CPSP. In recognition of the importance of family and parent factors in understanding and treating pediatric pain, we suggest here that in the context of surgery, it is also critical to understand how child and parent factors interact to maintain pain over time. In this issue of PAIN, Birnie et al. take an important step in investigating the cross-sectional and longitudinal relationship among child and parent reports of pain catastrophizing and pain intensity related to spinal fusion. The actor–partner interdependence model was used to measure bidirectional effects in the child–parent dyads. The primary results reported by Birnie et al. are (1) significant cross-sectional relationships at baseline and follow-up between child, but not parent, pain catastrophizing and children’s pain intensity, (2) a lack of longitudinal relationships between baseline child and parent pain catastrophizing and children’s postoperative pain intensity, and (3) only moderate stability in child and parent pain catastrophizing from baseline to follow-up, with significantly lower stability of this construct in children than parents. Although other studies have not used the actor–partner interdependence model to analyze data, they have examined parent–child relationships finding significant cross-sectional associations between child and parent pain catastrophizing, and significant longitudinal relationships between baseline child and parent pain catastrophizing and postoperative pain intensity. There are several possible reasons for these contrasting results, including differences in study design and perioperative care models within which studies were conducted. As discussed by Birnie et al., questions have specifically been raised regarding timing of pain catastrophizing assessment in the perioperative setting (ie, presurgery vs postsurgery), when pain catastrophizing might be evolving in response to the experience of intense pain. However, we posit that the inconsistency of findings between studies may rather indicate that psychosocial constructs beyond pain catastrophizing are important and have been overlooked. For example, research in children with chronic pain has found that higher parent protectiveness, distress, and fear of pain are associated with higher child pain-related disability. The relationship of a broader range of parent emotions, behaviors, and cognitions with children’s postoperative pain should be explored. Related, there has been limited application of theory to guide research on child psychosocial factors in the perioperative setting, and an overreliance on constructs deemed relevant for adults. There has been a large focus on pain catastrophizing in the perioperative setting, despite several notable limitations. First, the Pain Catastrophizing Scale, originally developed in adults with chronic pain and then later adapted for children with chronic pain and their parents, has not been validated in the perioperative setting with children or parents and may not be relevant to children during the preoperative or acute postoperative periods. Indeed, Birnie et al. found a lack of stability in pain catastrophizing over time, particularly in children. Second, as Eccleston et al. have argued, pain catastrophizing may not be a developmentally appropriate construct to assess in youth with pain because of the different ways that children think about pain compared with adults which may require other measures of emotional coping. Third, the primary focus on pain catastrophizing may divert us away from other important child cognitive, emotional, and behavioral factors, which may be linked to persistence of pain and disability. Unfortunately, this has likely hindered our progress in addressing this major health issue for children. Although dyadic interactions between parent and child are considered key in the maintenance of pain, very limited methodologies for understanding these interactions have been used in the perioperative setting thus far. Observational methodology may be needed to capture the richness of dyadic interactions, rather than relying on self-report questionnaires. For example, Caes et al. coded parent-child interactions before and after minor procedures in children undergoing cancer treatment to explore parental responses to child procedural pain and their impact on child experiences. They found significant interactions between parent distress and behavioral responses, and children’s distress and pain behaviors. Similar approaches Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. a Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA, b Center for Clinical and Translational Research, Seattle Children’s Hospital, Seattle, WA c Center for Child Health, Behavior, and Development, Seattle Children’s Hospital, Seattle, WA, USA

Adolescents' approach-avoidance behaviour in the context of pain

Abstract Adolescents who experience pain often face competing goals and have to choose whether to approach (confront) or avoid pain. This study investigates the decisions adolescents make when their pain conflicts with a valued goal. Adolescents between the ages of 15 and 18 years (N = 170) completed questionnaires on general and pain-specific anxiety, courage, and dispositional avoidance. Adolescents were presented with 16 vignettes (8 high pain intensity, 8 low pain intensity), which described pain conflicting with a goal (eg, doing well at school, seeing friends). Adolescents rated goals for importance and reported how likely they would be to approach or avoid each pain. Adolescents were more likely to avoid and were more fearful of high pain intensity than low pain intensity vignettes. Pain anxiety predicted higher levels of avoidance for both pain intensities. General anxiety was not a significant predictor of avoidance for either pain intensity. Goal importance promoted approach of goals, but only when pain was described as intense. However, pain anxiety predicted avoidance beyond the importance of goals for high pain intensity vignettes. In addition, we compared approach-avoidance of adolescents with and without chronic pain; analyses revealed no differences in approach-avoidance behaviour. We also found that behavioural endurance was predictive of approach and dispositional avoidance predicted higher avoidance, but courage was not predictive of behaviour in this task. We adopt a motivational perspective when interpreting the findings and consider whether the fear-avoidance model should be extended to include the function of avoidance or approach in the pursuit of a desired goal.

Associations Between Adolescent Chronic Pain and Prescription Opioid Misuse in Adulthood

Prescription opioid misuse is a serious public health concern, yet antecedent factors are poorly described. Using data from the National Longitudinal Study of Adolescent to Adult Health (N = 14,784), we examined the longitudinal relationship between a history of adolescent chronic pain and the odds of misusing prescription opioids in adulthood. The primary predictor variable was chronic pain status during adolescence. The primary outcome variables were prescription opioid misuse during early adulthood and adulthood. Multivariate models controlled for known risk factors of opioid misuse, including sociodemographics (sex, race, and ethnicity), adolescent mental health symptoms (anxiety, depression), adolescent self-reported physical health status, adolescent substance use/abuse, childhood trauma, and adult legitimate opioid use. We found that adults with a history of adolescent chronic pain were more likely to misuse opioids than those without history of chronic pain, even after controlling for other known risk factors. Further, we found that among individuals with history of adolescent chronic pain that race (white), other substance use, and exposure to trauma were risk factors for later opioid misuse. Longitudinal associations between adolescent chronic pain and subsequent adult prescription opioid misuse highlight the need for early targeted screening and prevention efforts that may reduce later opioid misuse. Perspective: Using a large, nationally representative sample, we found that chronic pain during adolescence was an independent risk factor for opioid misuse in adulthood, over and above other known risk factors. Furthermore, among those individuals with adolescent chronic pain, substance use, exposure to trauma, and race were associated with opioid misuse.