Patricia A. McGrath

Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders.

While self-injurious behaviors (SIB) can cause significant morbidity for children with autism spectrum disorders (ASD), little is known about its associated risk factors. We assessed 7 factors that may influence self-injury in a large cohort of children with ASD: (a) atypical sensory processing; (b) impaired cognitive ability; (c) abnormal functional communication; (d) abnormal social functioning; (e) age; (f) the need for sameness; (g) rituals and compulsions. Half (52.3%, nxa0=xa0126) of the children (nxa0=xa0241, aged 2–19xa0years) demonstrated SIB. Abnormal sensory processing was the strongest single predictor of self-injury followed by sameness, impaired cognitive ability and social functioning. Since atypical sensory processing and sameness have a greater relative impact on SIB, treatment approaches that focus on these factors may be beneficial in reducing self-harm in children with ASD.

Pain Prevalence in Nine- to 13-Year-Old School Children

BACKGROUNDnDespite significant progress in the epidemiology of chronic pain in adults, major gaps remain in our understanding of the epidemiology of chronic pain in children. In particular, the incidence, prevalence and sensory characteristics of many types of pain in Canadian children are unknown.nnnOBJECTIVESnA study to obtain the lifetime and point prevalence of common acute pains, recurrent pain syndromes and chronic pains was conducted in a cohort of 495 school children, nine to 13 years of age, in eastern Ontario.nnnMETHODSnChildren reported their pain experiences and described the intensity, affect and duration of the pains experienced over the previous month by completing the Pain Experience Interview -- Short Form.nnnRESULTSnThe majority of children (96%) experienced some acute pain over the previous month, with headache (78%) being most frequently reported. Lifetime prevalence for certain acute pains differed significantly by sex (P<0.05). Fifty-seven per cent of children reported experiencing at least one recurrent pain, while 6% were identified as having had or currently having chronic pain.nnnDISCUSSIONnThe prevalence of acute pain in this Canadian cohort is consistent with international estimates of acute pain experiences (ie, headache) and recurrent pain problems (ie, recurring headache, abdominal pain and growing pains). However, 6% of children reported chronic pain. The self-completed Pain Experience Interview--Short Form provides a feasible administration technique for obtaining population estimates of childhood pain, and for conducting longitudinal studies to identify risk and prognostic factors for chronic pain.

The complex minds of teenagers: neuroanatomy of personality differs between sexes.

Extraversion and neuroticism influence behaviour and mood. Extreme expressions of these personality traits may predispose individuals to developing chronic functional pains and mood disorders that predominantly affect women. We acquired anatomical MRI scans and personality scores from healthy male and female adolescents and measured gray matter volume (GMV) and cortical thickness to test the hypothesis that neuroticism and extraversion contribute to sex differences in fronto-limbic cortical development during a crucial period of social and biological maturation. In females, extraversion correlated negatively with medial frontal gyrus GMV and neuroticism correlated positively with subgenual anterior cingulate cortex GMV and cortical thickness. Interestingly, correlations between GMV and personality in males showed an opposite effect. Given the association of these cortical areas with social cognition and emotional processing, we suggest that a neuro-maturational divergence during adolescence accounts for the higher prevalence of specific chronic pains and mood disorders in females.

Children with chronic pain: impact of sex and age on long-term outcomes.

Abstract The present study examined the long‐term pain and disability outcomes of a pediatric chronic pain clinic cohort and evaluated whether these outcomes differed by age and sex. Patients were interviewed a mean of 3 years after their last appointment at a pediatric pain clinic. The cohort comprised 95 females and 48 males, aged 5–23 years when interviewed. Of the cohort, 62.2% (67 females, 22 males) reported continuing pain. Females were significantly more likely than males to report continuing pain (OR = 2.9, 95% CI = 1.4–5.8, p = .005), use of health care (OR = 5.1, 95% CI = 1.4–18.5, p = .01), medication (OR = 4.7, 95% CI = 1.3–16.9, p = .02) and non‐drug methods of pain control (OR = 3.4, 95% CI = 1.3–9.2, p = .02). For patients whose pain had associated psychosocial factors, females (76.4%) were significantly more likely than males (21.4%) to report continuing pain (OR = 13.8, 95% CI = 3.3–58.4, p = .005). Finally, among patients still experiencing pain, the frequency of pain episodes increased significantly with age (OR = 1.3, 95% CI = 1.0–1.5, p = .02). Results indicate that chronic pain persists for many children despite treatment at specialized clinics. Females may be at higher risk for continuing pain and report greater use of health care, medication, and non‐drug methods of pain control.

Assessing pain intensity in children with chronic pain: Convergent and discriminant validity of the 0 to 10 numerical rating scale in clinical practice

BACKGROUNDnIn clinical practice, children are often asked to rate their pain intensity on a simple 0 to 10 numerical rating scale (NRS). Although the NRS is a well-established measure for adults, no study has yet evaluated its validity for children with chronic pain.nnnOBJECTIVESnTo examine the convergent and discriminant validity of the NRS as it is used within regular clinical practice to document pain intensity for children with chronic pain. Interchangeability between the NRS and an analogue pain measure was also assessed.nnnMETHODSnA cohort of 143 children (mean [± SD] age 14.1±2.4 years; 72% female) rated their pain intensity (current, usual, lowest and strongest levels) on a verbally administered 0 to 10 NRS during their first appointment at a specialized pain clinic. In a separate session that occurred either immediately before or after their appointment, children also rated their pain using the validated 0 to 10 coloured analogue scale (CAS).nnnRESULTSnNRS ratings met a priori criteria for convergent validity (r>0.3 to 0.5), correlating with CAS ratings at all four pain levels (r=0.58 to 0.68; all P<0.001). NRS for usual pain intensity differed significantly from an affective pain rating, as hypothesized (Z=2.84; P=0.005), demonstrating discriminant validity. The absolute differences between NRS and CAS pain scores were small (range 0.98±1.4 to 1.75±1.9); however, the two scales were not interchangeable.nnnCONCLUSIONSnThe present study provides preliminary evidence that the NRS is a valid measure for assessing pain intensity in children with chronic pain.

Decreased Sensitivity to Thermal Stimuli in Adolescents With Autism Spectrum Disorder: Relation to Symptomatology and Cognitive Ability

UNLABELLEDnSocial communication deficits and repetitive behaviors are established characteristics of autism spectrum disorder (ASD) and the focus of considerable study. Alterations in pain sensitivity have been widely noted clinically but remain understudied and poorly understood. The ASD population may be at greater risk for having their pain undermanaged, especially in children with impaired cognitive ability and limited language skills, which may affect their ability to express pain. Given that sensitivity to noxious stimuli in adolescents with ASD has not been systematically assessed, here we measured warm and cool detection thresholds and heat and cold pain thresholds in 20 high-functioning adolescents with ASD and 55 typically developing adolescents using a method-of-limits quantitative sensory testing protocol. Adolescents with ASD had a loss of sensory function for thermal detection (P < .001, both warm and cool detection thresholds) but not pain threshold (P > .05, both heat and cold pain thresholds) in comparison to controls, with no evidence for significant age or sex effects (P > .05). Intelligence quotients and symptomatology were significantly correlated with a loss of some types of thermal perception in the ASD population (ie, warm detection threshold, cool detection threshold, and heat pain threshold; P < .05). Decreased thermal sensitivity in adolescents with ASD may be associated with cognitive impairments relating to attentional deficits. Our findings are consistent with previous literature indicating an association between thermal perception and cortical thickness in brain regions involved in somatosensation, cognition, and salience detection. Further brain-imaging research is needed to determine the neural mechanisms underlying thermal perceptual deficits in adolescents with ASD.nnnPERSPECTIVEnWe report quantitative evidence for altered thermal thresholds in adolescents with ASD. Reduced sensitivity to warmth, coolness, and heat pain was related to impaired cognitive ability. Caregivers and clinicians should consider cognitive ability when assessing and managing pain in adolescents with ASD.

Clinical Impact and Evidence Base for Physiotherapy in Treating Childhood Chronic Pain

PURPOSEnAs part of the special series on pain, our objectives are to describe the key features of chronic pain in children, present the rationale for interdisciplinary treatment, report a case study based on our biopsychosocial approach, and highlight the integral role of physiotherapy in reducing childrens pain and improving function. We also evaluate the evidence base supporting physiotherapy for treating chronic neuropathic pain in children.nnnSUMMARY OF KEY POINTSnChronic pain affects many children and adolescents. Certain challenging pain conditions begin primarily during adolescence and disproportionately affect girls and women. Children with these conditions require an interdisciplinary treatment programme that includes physiotherapy as well as medication and/or psychological intervention. Converging lines of evidence from cohort follow-up studies, retrospective chart reviews, and one randomized controlled trial support the effectiveness of physiotherapy within an interdisciplinary programme for treating children with chronic pain.nnnCONCLUSIONSnEvidence-based practice dictates that health care providers adopt clear guidelines for determining when treatments are effective and for identifying children for whom such treatments are most effective. Thus, additional well-designed trials are required to better identify the specific physiotherapy modalities that are most important in improving childrens pain and function.

Psychological interventions with children and adolescents: evidence for their effectiveness in treating chronic pain

Abstract Psychological interventions are an integral component of treatment programs for chronic pain in children and adolescents. However, the evidence base supporting their efficacy varies widely. Although strong and consistent evidence supports the efficacy of cognitive-behavioral interventions for relieving children’s headache, the evidence base supporting the use of cognitive and behavioral interventions for relieving other types of chronic pain is weak, as assessed by the number of controlled trials that have been conducted in children and by the few types of chronic pain that have been formally studied. Empirical support for most psychological interventions targeting nonheadache chronic pain derives from anecdotal reports and case studies. In this study we review this evidence, identify specific gaps in our knowledge base, and recommend practical strategies to obtain critical information about which therapies are best for which children and for which types of chronic pain.

Caring for children with chronic pain: ethical considerations

Clinical decisions about whether children were experiencing pain and, if so, about the particular pain therapies required, were long based primarily on physicians personal beliefs rather than on scientific evidence. Regrettably, common misbeliefs – that children did not feel pain as intensely as adults and consequently did not require similar analgesics and pervasive fears – that children were at heightened risk for opioid addiction and should receive minimal analgesic doses, caused many children to suffer needlessly (1,2). Unprecedented scientific and clinical attention subsequently focused on the unique pain problems of infants, children and adolescents – revealing the adverse impact of untreated postoperative pain and inadequately treated procedural pain for children with cancer. The ensuing publicity as people learned that minimal anesthesia and analgesia represented the norm in pediatric postoperative management , rather than the exception, sparked a revolution (2). Clinical practice started to change so that children began to receive more appropriate analgesics at adequate doses and regular dosing intervals. Treatment emphasis also shifted gradually from an almost exclusive disease-centered focus – detecting and treating the putative source of tissue damage – to a more child-centered perspective – assessing the child to identify any environmental and psychological factors that contributed to pain, so as to target interventions accordingly. Today, increasing attention is focused on the rights of all children to receive adequate pain control (3–7). Yet, despite our continuing efforts to make children s pain control a higher priority throughout the world, serious challenges remain. In particular, the management of childhood chronic pain is a continuing problem in many centers, creating ethical dilemmas from patient-centered, health care and societal perspectives.