Hannah Connell

Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents

&NA; Adolescents with chronic pain also report severe disability and emotional distress. A clinical sample of 80 adolescents and accompanying parents were investigated to first measure the extent of distress, and second to investigate the relationships between adolescent distress, parental distress and adolescent coping. Measures of pain intensity, anxiety, depression, disability and coping were obtained from adolescents. Parents completed measures including their own anxiety, depression and parenting stress. Overall, adolescents reported high levels of disability, depression and anxiety, and parents reported high levels of depression, anxiety and parenting stress. Multiple regression analyses revealed that the best predictors of adolescent emotional distress were the extent to which the adolescents catastrophize and seek social support to cope with the pain. There were no clear predictors of parental anxiety or depression but the specific pattern of parenting stress was best predicted by the younger age of the adolescent, the greater the chronicity of the problem, and the greater the extent of adolescent depression. These findings suggest that emotional coping is a critical variable in the distress associated with adolescent chronic pain. It is argued that adolescent emotional coping may best be understood within a relational context of seeking emotional support.

Chronic pain in adolescents: evaluation of a programme of interdisciplinary cognitive behaviour therapy.

Aim: To determine the effectiveness of an interdisciplinary cognitive behavioural treatment for adolescents with chronic pain. Methods: Fifty seven adolescents (mean age 14.28 years) with chronic pain and 57 accompanying adults underwent an interdisciplinary three week residential programme of group cognitive behavioural therapy. Mean chronicity of pain was 4.02 years; 75% were absent from full time education (mean absence 17 months). Results: Post-treatment adolescents reported significant improvements for self report of disability (mean difference 3.37 (95% CI 0.65 to 6.09)), physical function (mean difference timed walk of 2.61seconds (1.02 to 4.2) and sit to stand of 3.22 per minute (0.79 to 5.65)). At three months post-treatment adolescents maintained physical improvements and reduced anxiety (mean difference 1.7 (0.72 to 2.67)), disability (mean difference 4.3 (1.44 to 7.17)), and somatic awareness (mean difference 4.43 (1.53 to 7.33)). Following treatment adults reported significant improvement in their report of adolescent disability (mean difference 4.43 (2.17 to 6.7)), adult anxiety (mean difference 1.73 (0.54 to 2.92)), depression (mean difference 1.16 (0.34 to 1.98)), and parental stress (mean difference 10.81 (2.91 to 18.78)). At three months significant improvements were maintained. At three months 64% improved school attendance; 40% had returned to full time education. Conclusions: Interdisciplinary cognitive behavioural pain management (with family involvement) is a promising approach to the management of pain, pain related distress, and disability.

The Bath Adolescent Pain Questionnaire (BAPQ): development and preliminary psychometric evaluation of an instrument to assess the impact of chronic pain on adolescents

&NA; Chronic pain causes significant problems in the lives of many adolescents, considerably affecting their physical, psychological and social functioning. The assessment of the multidimensional impact of chronic pain is an essential clinical task. This study reports on the development and psychometric evaluation of the Bath Adolescent Pain Questionnaire (BAPQ); an assessment tool designed specifically for use with adolescents who experience chronic pain. A sample of 222 adolescents (11–18 years) experiencing chronic pain completed the 109‐item draft inventory. Participants were recruited from two different UK clinics. All participants responded to items using a 5‐point frequency scale. Psychometric evaluation of the data resulted in a reduced inventory length of 61 items. Internal consistency of all seven questionnaire subscales was established using Cronbachs alpha. Comparative validity was undertaken by comparison of all individual subscales with existing validated measures (SCAS, CDI‐S, FDI, Brief FAM. PCS and CASAFS). The temporal reliability of each inventory subscale was established using a sub‐sample of 30 adolescent participants over a 17‐day period. Psychometric evaluation of the data suggests the inventory yields both a reliable and valid assessment of the impact of chronic pain on the lives of adolescents. The BAPQ may offer a comprehensive way to assess the widespread deleterious impact of adolescent chronic pain in both a research and clinical setting. Further investigation is needed on the predictive validity of the subscales. Additional data from samples of patients with diagnoses that are not musculoskeletal in origin would be of great assistance.

Chronic musculoskeletal and other idiopathic pain syndromes

Chronic or recurrent pain in children and adolescents, for which no specific cause can be found, is very common with a point prevalence of at least 15%.1 Such idiopathic pain conditions are usually “benign” in the sense that they are relatively easy to diagnose with a minimum of investigations, and are treated effectively with reassurance and use of simple measures including appropriate use of analgesics. A number of children develop a chronic pain syndrome and become quite disabled. How frequently this “malignant” outcome occurs, and how many children with chronic pain become adults with chronic pain is uncertain, but is probably not rare.2 3 Several studies show that idiopathic musculoskeletal pain persists in both the short and medium term in a significant minority of children, but there are no long term data available.4-6 Adolescents with chronic pain are often fatigued and adolescents diagnosed with chronic fatigue syndrome frequently have musculoskeletal pain. It has been suggested that chronic fatigue syndrome in adolescents and juvenile fibromyalgia syndrome (one form of chronic pain syndrome) may be overlapping clinical entities, that may be indistinguishable by current diagnostic criteria.7 Many individuals with either a chronic pain syndrome or with chronic fatigue syndrome could be considered as having a somatoform disorder according to the DSM IV criteria. Somatisation refers to individuals who report symptoms that have no organic cause, or who report symptoms that greatly exceed those expected by the physical condition. Psychosomatic refers to symptoms that may be exaggerated by psychosocial factors. These terms suggest a dualistic (mind/body) model to approaching symptoms of uncertain cause. Increasingly the term biopsychosocial is being used to describe a model that more fully encompasses the biological, psychological, and social factors that may be important in the manifestations of chronic symptom complexes such as chronic pain …

Acceptance and Values-Based Treatment of Adolescents With Chronic Pain: Outcomes and Their Relationship to Acceptance

OBJECTIVE Psychological treatments for pediatric chronic pain are moderately effective. However, there have been few studies of the psychological processes associated with treatment response. This study examines the effects of Acceptance and Commitment Therapy (ACT) treatment on a severely disabled group of adolescents with chronic pain, examining relationships between outcome and acceptance. METHODS 98 adolescents with pain, mean age 15.6 years, underwent an uncontrolled trial of 3-week residential ACT treatment. RESULTS Adolescents improved in self-reported functioning and objective physical performance at 3-month follow-up. They were less anxious and catastrophic, attended school more regularly, and used health care facilities less often. Most positive treatment outcomes were associated with improvements in acceptance. CONCLUSIONS An intensive ACT-based pain rehabilitation course was an effective treatment for disabled adolescents with chronic pain. Its results were theoretically consistent--improvements were associated with changes in acceptance and were achieved without pain control or cognitive restructuring techniques.

The Bath Adolescent Pain – Parental Impact Questionnaire (BAP-PIQ): development and preliminary psychometric evaluation of an instrument to assess the impact of parenting an adolescent with chronic pain

&NA; When an adolescent has chronic pain many aspects of a parent’s life can be affected, including their emotional and social functioning. The assessment of this multidimensional parental impact is an essential, yet often neglected, clinical task. This study reports on the development and psychometric evaluation of the Bath Adolescent Pain – Parental Impact Questionnaire (BAP‐PIQ), an assessment tool comprising multiple scales thought to be relevant for better understanding changes in functioning and behavior associated with parenting an adolescent with chronic pain. A sample of 194 parents of adolescents with chronic pain, recruited from three UK clinics, completed the 94 item draft inventory. Frequency and item correlation analyses resulted in a final inventory of 62 items. Internal consistency of all eight scales was established based on Cronbach’s alpha. Convergent validity was undertaken by comparison of individual scales with existing validated measures of parental stress, mood, parenting behavior, marital adjustment, and general functioning. The temporal reliability of each scale was established using a sub‐sample of 46 participants over a 14‐day period. Psychometric evaluation suggests that the inventory yields a reliable and valid assessment of the multiple impacts of parenting an adolescent with chronic pain. The BAP‐PIQ may offer a comprehensive assessment of these impacts in both a research and a clinical setting. Further study of the validity of BAP‐PIQ scales and their ability to detect clinically meaningful change would be of use. Additional data from samples comprising fathers of adolescents with chronic pain and parents of adolescents with non‐musculoskeletal pain would be of benefit.

Residential Treatment Settings for Adolescent Chronic Pain Management

We argue that an option for a residential treatment setting is sensible in developed health care economies. First, an analysis of the public health study of chronic pain finds that there is no good public health evidence base for any adolescent chronic pain intervention. Second, a conceptual analysis is undertaken for why removal of adolescents from their normal environments may offer a useful therapeutic option. Third, examples of current residential models, including summer camps and residential treatments, are given, and a more in-depth description is given of the Bath Pain Management Unit in the United Kingdom. Fourth, further discussion is provided on the barriers that often arise when stakeholders in children’s pain services attempt to persuade each other of the importance or otherwise of intensive treatments. Finally, advice is given regarding how to develop and sustain an evidence-supported chronic pain management service for adolescents in chronic pain.

When painkillers don’t kill pain

A 13-year-old boy named Nick presents to the Accident and Emergency Department of his local hospital with severe pain in his left leg. He gives a history of having injured it five months previously during a rugby match, describing it as getting a “dead” leg that eventually got better. He subsequently injured the same leg during rugby again—this time, his knee. At the time the injury appeared trivial and he finished the rugby game. Over the following five days the pain worsens and he attends hospital. The senior house officer in A&E feels that the history does not suggest significant injury as Nick has been walking around on the leg for several days. On examination she notes that his knee ligaments are stable but that his joints are generally quite hypermobile. She reassures Nick and his parents that there is no serious injury, his leg pain should improve with time, and that he does not need any further investigations or treatment. The doctor suggests some mild analgesics such as paracetamol and ibuprofen and Nick is discharged. A small but significant proportion of the population has some hypermobile joints. Paediatric prevalence varies from study to study from about 5% to 30%. There appears to be a racial variation, with Caucasian children least affected.1 Benign hypermobility syndrome (BHS) is the term used when a person has pain associated with hypermobility which scores at least 4 out of a possible 9 on the Beighton hypermobility score, which looks for hypermobility in nine parts of the body. The diagnosis can be made using the Brighton criteria2 which use a combination of major and minor criteria (table 1). The patient may have arthralgia, which is either diffuse or quite localised, or just complain of generalised aches and pains which seem a bit non-descript. …

G289 Increasing parent resilience in chronic paediatric conditions: the case of chronic pain

Aims Parenting a child with a chronic health condition can be difficult. Parent wellbeing is important in its own right, and also for the sake of the child. Parents who become, albeit understandably, anxious, over-protective or detached from their ill children may not provide them with ideal support. Where a child’s illness improves, parental stress is likely to decrease. However, there are a range of conditions where a child’s underlying health remains problematic. We aimed to establish whether parent resilience could be improved in the face of ongoing symptoms, in this case, in a population of adolescents undergoing treatment for chronic pain. Methods 92 parents accompanied their child (adolescent, ages 11–18) for a course of residential treatment for non-malignant chronic pain. The adolescents had disabling idiopathic pain requiring treatment at a tertiary national specialist service. Parents accompanied their children through most of the three week programme, participating in exercise and psychology sessions, as well as having three hours of dedicated parent intervention. We examined (1) parental catastrophising about pain, (2) parenting behaviour and (3) parent stress up to a three month follow up. Results Adolescents going through the programme showed no change in their underlying pain intensity, which remained high (7.7/10). They did make functional improvements. Despite ongoing adolescent pain, parents at the three month follow up period (n – 72, 76% data completion) showed significantly decreased catastrophizing about their child’s pain, less protective parenting behaviour, and reduced parenting stress. Parents showed a decrease in defensive responding around their child, and did not show any increase in their tendency to ‘minimise’ their child’s ongoing pain. Conclusions Parents can increase their resilience and show increasingly adaptive parenting, even in cases where their child’s underlying condition does not improve. Here, parents were exposed to a programme of intensive psychological and physical rehabilitation with some dedicated sessions targeted at parent resilience. Their children’s pain did not change, but their approach to it did. However, the intervention studied was targeted both at child and parent; research is needed to establish whether parent-only interventions can improve resilience.

Book Review: Promoting Adherence to Medical Treatment in Chronic Childhood Illness: Concepts, Methods and Interventions

the health professions think are less likely to benefit from a transplantation. Such procedures are used by over 95 percent of transplant programmes in the USA. Switzer, Dew and Twillman’s chapter on psychosocial issues in organ donation is also interesting and opens with a quotation from Marcel Mauss’s The Gift: ‘the theme of the gift, of freedom and obligation in the gift, of generosity and self interest . . .’. Indeed volunteer donors may undergo discomfort, inconvenience and physical risk to be the bearer of such ‘gifts’. What motivates live organ donations to unknown people and what are the psychological sequelae of such acts? This chapter concludes that while many experience considerable ‘psychic gains’ from helping others, some may feel that their own physical health has been damaged in the process or that their ‘altruistic sacrifice has not been adequately appreciated’. In the case of unsuccessful transplants the donor may feel in some way responsible for the death of the recipient. The authors also conclude that less positive donation outcomes are best predicted by pre-donation ambivalence or uncertainty about donation, and this has obvious implications for donor selection. Gillett’s chapter on ethics is a very useful inclusion in the book and allows for something of a reflective perspective. He suggests that a ‘lingering mysticism’ about the dead and, in some, an often latent belief that people should not have ‘spare parts’, contributes to an unease about organ transplantation. When is it OK to take someone’s organs? When they are dead? When they are brain dead? When they are in a persistent vegetative state (PVS)? Or, should healthy, but impoverished, people be able to harvest their bodily resources by selling a kidney, and use the proceeds to improve their own, or loved ones’, quality of life? Is this exploitation, and if so, who is exploiting whom? ‘The idea of having a part of someone living inside another person seems to import into the debate images of identity and the persisting life of the dead person’, states Gillett. He draws our attention also to xenotransplantation (e.g. the transplant of a pig’s kidney into a human). To be sure, we are more than the sum of our parts, especially when some of our parts, are not ‘us’ at all! The value of this book is not only in its scholarly and practical contribution to understanding the transplant patient but also because it offers a window into a new world—not of its making. This is the world of body part production-to-demand, from stem cells, of possibly exchanging organs with other humans, or animals, because theirs is better/bigger/longer lasting than our own. Body sculpturing, whether in the form of cosmetic plastic surgery or xenotransplanation, challenges us to answer questions that once seemed to be fanciful philosophical indulgence: ‘What is a person?’ ‘How are people embodied?’ ‘When I die is there some part of me that goes on?’ ‘Where do I stop, and you begin?’ While this volume does not address such questions directly, the material covered in some of its chapters can surely contribute to some of the answers.