Karen J. Kaczynski

The Fear Avoidance model of chronic pain: examination for pediatric application.

UNLABELLED The current study examined the Fear Avoidance (FA) model of chronic pain in pediatric chronic pain patients. Multiple structural equation models were tested in the current study with pairwise parameter comparisons made between younger children (8-12 years) and adolescents (13-17 years). Within a sample of 350 children and adolescents, we examined functional disability and depressive symptoms in separate models with the following predictor variables-pain, pain catastrophizing, fear of pain, and avoidance of activities-after controlling for duration of pain. For a subset of patients (n = 151), we also tested a brief prospective outcome model with baseline predictor variables and functional disability at 1-month follow-up. The FA models predicting functional disability concurrently and prospectively were an excellent fit to the data. The theorized FA model for depression was a poor fit. When the model was modified to include direct pathways from the cognitive processes of pain catastrophizing and fear of pain to depressive symptoms, the model fit was significantly improved. In the examination of developmental differences between younger children and adolescent patients, duration of pain contributed to the model for younger children, whereas pain-related fears were more influential for adolescent patients. PERSPECTIVE The FA model of chronic pain appears to be applicable for pediatric patients with some modification to account for developmental differences across childhood. We discuss the developmental, theoretical, and clinical implications of these results.

Risk for maternal depression and child aggression in Early Head Start families: A test of ecological models

Current literature indicates that risk for maternal depression is substantial in low-income families. A large body of research also indicates that when mothers are depressed, children are at risk for a number of developmental difficulties. While mutual influence between child and parental difficulties has been noted, few studies examine risk factors for both depression and child aggression within ecological models. The present cross-site study examined the unique and additive contributions of contextual factors, including SES and family functioning, on maternal depression and child aggression in Early Head Start families. A multiethnic sample of parents and their children, between the ages of 12 and 43 months, participated in this study. Families came from five Early Head Start programs across the United States, representing both urban and rural areas. Structural equation models (SEM) demonstrate mutual links between depression and aggression, mediated at least in part by ecological factors. SEM indicated that 36.4% of the variance in child aggression is accounted for in a model linking aggressive behavior to parent depression, stress, and couple-level functioning, as well as other family interaction variables. A second model focusing on maternal depression revealed that 44.5% of the variance in maternal depression was accounted for through family factors, including couple-related support and satisfaction and parenting stress. In this second model, child aggression was indirectly linked to maternal depression. These data have important implications for programs serving at-risk families.

Subjective Reactions of Children to Single-Pulse Transcranial Magnetic Stimulation

Single-pulse transcranial magnetic stimulation is a useful tool to investigate cortical function in childhood neuropsychiatric disorders. Magnetic stimulation is associated with a shock-like sensation that is considered painless in adults. Little is known about how children perceive the procedure. We used a self-report questionnaire to assess childrens subjective experience with transcranial magnetic stimulation. Normal children and children with attention-deficit hyperactivity disorder (ADHD) underwent transcranial magnetic stimulation in a study of cortical function in ADHD. Subjects were asked to rate transcranial magnetic stimulation on a 1 to 10 scale (most disagreeable = 1, most enjoyable = 10) and to rank it among common childhood events. Thirty-eight subjects completed transcranial magnetic stimulation; 34 said that they would repeat it. The overall rating for transcranial magnetic stimulation was 6.13, and transcranial magnetic stimulation was ranked fourth highest among the common childhood events. These results suggest that although a few children find transcranial magnetic stimulation uncomfortable, most consider transcranial magnetic stimulation painless. Further studies are necessary to confirm these findings. (J Child Neurol 2001;16:891-894).

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.

Couple power dynamics, systemic family functioning, and child adjustment: A test of a mediational model in a multiethnic sample

Power dynamics in the marital dyad and systemic elements of whole-family functioning (cohesion, subsystem boundary formations) were examined in relation to each other and also in relation to child adjustment in a multiethnic sample of families. Support was found for a mediational model, such that family functioning was found to mediate the relationship between marital power dynamics and childrens internalizing and externalizing behavior. Some support also was found for ethnicity as a moderator of the association between systemic family processes and childrens adjustment. Disturbances in family cohesion and subsystem boundaries were more strongly related to internalizing symptomatology for children in European American families compared to children in Hispanic American families.

Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response.

UNLABELLED Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment. PERSPECTIVE This paper presents results underscoring the importance of pain-related fear in relation to treatment response for children and adolescents with chronic pain. These findings support the need to develop and implement interventions that target reductions in pain-related fear.

Anxiety, Coping, and Disability: A Test of Mediation in a Pediatric Chronic Pain Sample

OBJECTIVE To evaluate pain coping as a mediator of associations between anxiety and functional disability and anxiety and somatic symptoms in adolescents with chronic pain. METHOD Participants (mean age = 14.76 years, range: 12-17 years) included 280 patients (212 girls) with chronic pain who underwent multidisciplinary evaluation at a tertiary pain clinic in a northeast pediatric hospital. Patients completed measures of current pain, anxiety, active, passive, and accommodative pain coping, functional disability, and somatic symptoms. RESULTS Structural equation modeling was employed. The association between anxiety and disability was fully mediated by passive coping. The association between anxiety and somatic symptoms was not mediated by coping. CONCLUSIONS Links between anxiety symptoms and pain-related outcomes in adolescents with chronic pain are complex. Assessing how an adolescent copes with his/her pain provides further understanding of this relationship.

Testing Gender as a Moderator of Associations Between Psychosocial Variables and Functional Disability in Children and Adolescents with Chronic Pain

OBJECTIVE To evaluate gender as a moderator of associations between psychosocial variables and functional disability in children and adolescents with chronic pain. METHOD Participants included 266 patients (177 girls; mean age = 13.3 years) with chronic or recurrent headache or abdominal pain who were evaluated at a pediatric chronic pain clinic. Patients completed measures of pain intensity, anxiety, depression, pain coping, and functional disability. Parents completed a measure of protective behavior. RESULTS Girls and boys reported similar levels of pain intensity. Girls were more likely to endorse depressive symptoms, and internalizing symptoms were associated with disability in girls, not in boys. No gender differences were found in links between coping and protective parenting and disability. CONCLUSIONS In general, psychosocial factors influenced functional disability similarly in girls and boys, although some gender differences were found. Findings highlight the importance of considering child gender when evaluating factors that contribute to functional disability.

Relations Between Pain Characteristics, Child and Parent Variables, and School Functioning in Adolescents With Chronic Headache: A Comparison of Tension-Type Headache and Migraine

OBJECTIVE To assess for differences in headache characteristics and psychosocial factors based on headache diagnosis, and to evaluate whether headache diagnosis moderates relations between psychosocial factors and school difficulties. METHODS Retrospective chart review was conducted with 262 adolescents with chronic tension-type headache (TTH; N = 153) and migraine evaluated at a pediatric headache clinic. Adolescents completed measures of anxiety, depression, and pain coping. Parents completed a measure of parental protective behavior and school functioning. RESULTS Adolescents with TTH reported greater depression symptoms, and their parents endorsed greater school difficulties, whereas parents of adolescents with migraine reported more protective parenting. Protective parenting was positively associated with school difficulties in both groups, but the relation was significantly stronger in adolescents with TTH. Headache duration and depression symptoms were significant predictors of school functioning in both groups. CONCLUSIONS Headache duration and depression may impact school functioning independent of headache diagnosis. Protective parenting, in particular, seems to be linked to school-related disability in adolescents with TTH, and this link may be important to consider in assessment and treatment.