Development and Validation of the Adolescent Insomnia Questionnaire.

OBJECTIVE: Insomnia is a highly prevalent sleep disorder that is particularly common among adolescents with health conditions. We aimed to develop and validate a brief screening measure of insomnia in adolescents that can be used across clinical and community samples. We hypothesized that we would identify evidence supporting reliability, convergent/discriminant validity, and that we would determine preliminary clinical cutoff scores. METHODS: A team of experts in behavioral sleep medicine developed a 13-item brief screening measure of insomnia in adolescents (Adolescent Insomnia Questionnaire [AIQ]). We evaluated the psychometric properties of the AIQ in a sample of 315 youth (11-18 years old, Mean = 14.90, SD = 2.02; 64% female) who had chronic pain (n = 37), headache (n = 170), insomnia diagnosed by a sleep specialist (n = 22), or were otherwise healthy (n = 86). RESULTS: Using Exploratory and Confirmatory Factor Analysis, we identified three subscales consistent with major diagnostic criteria of insomnia. As expected, the measure showed strong reliability through high internal consistency (α =.91). We also found strong convergent validity through expected positive relationships between the AIQ and self-report measures of sleep disturbance, and divergent validity via weak relationships with parent-report of snoring. Results of receiver operating characteristic (ROC) identified a clinical cutoff score that may assist in clinical decision making. CONCLUSIONS: We found that the AIQ has sound psychometric properties in a large heterogeneous sample of treatment-seeking youth and youth from the community. The AIQ can quickly screen adolescent insomnia and could address an important clinical need in identifying youth in need of insomnia treatment in pediatric practice settings.

Chronic pain prevalence and associated factors in adolescents with and without physical disabilities.

AIM: Adolescents with physical disabilities may have co-occurring chronic pain, but the prevalence and specific associated factors are unknown. The aims of this study were to determine (1) the prevalence of chronic pain in adolescents with physical disabilities and (2) whether known correlates of chronic pain in the general population are also present in young people both with physical disability and with chronic pain relative to peers. METHOD: We conducted a secondary analysis of cross-sectional nationally representative data from the National Longitudinal Study of Adolescent to Adult Health. Multivariate linear regression analysis was used to identify demographic and psychosocial factors associated with chronic pain. RESULTS: A total of 989 (4.3%) adolescents reported physical disabilities. They had a significantly higher rate of pain (27.2%) compared with able-bodied peers (15.6%, χ2 =86.3550, p<0.001). There was no significant interaction between physical disability status and chronic pain in relation to depressive symptoms, anxiety, or insomnia. INTERPRETATION: Adolescents with physical disabilities experience chronic pain at a significantly higher rate than able-bodied peers, but the comorbidity of physical disability and chronic pain is not related to depression, anxiety, or insomnia. Evaluation of chronic pain and tailored pain interventions need to be developed for this population. WHAT THIS PAPER ADDS: Chronic pain and its correlates are important problems for adolescents with physical disabilities. These adolescents present with higher rates of chronic pain than other young people. Chronic pain is associated with increased levels of depressive symptoms, anxiety, and insomnia regardless of disability status.

Parent and Child Report of Pain and Fatigue in JIA: Does Disagreement between Parent and Child Predict Functional Outcomes?

While previous research in juvenile idiopathic arthritis (JIA) has identified discrepancy between parent and child perception of disease-related symptoms such as pain, the significance and impact of this disagreement has not been characterized. We examined the extent to which parent-child discordance in JIA symptom ratings are associated with child functional outcomes. Linear regression and mixed effects models were used to test the effects of discrepancy in pain and fatigue ratings on functional outcomes in 65 dyads, consisting of youth with JIA and one parent. Results suggested that children reported increased activity limitations and negative mood when parent and child pain ratings were discrepant, with parent rated child pain much lower. Greater discrepancy in fatigue ratings was also associated with more negative mood, whereas children whose parent rated child fatigue as moderately lower than the child experienced decreased activity limitations relative to dyads who agreed closely on fatigue level. Implications of these results for the quality of life and treatment of children with JIA are discussed.

Suicidal Ideation in Adolescents With and Without Chronic Pain.

OBJECTIVES: Suicidal ideation (SI) is common during adolescence and may have lethal outcomes. Despite evidence of the high prevalence and impact of suicidality in adults with chronic pain (CP), remarkably little is known about suicidality in adolescents with CP. This study aimed to examine the rates and characteristics of SI in a clinical sample of adolescents with CP compared with youth without CP. We also examined the relationship between pain-related and psychosocial factors and SI in youth. MATERIALS AND METHODS: Adolescents with (n=95) and without CP (n=91) completed self-reports of pain, functional disability, loneliness, family functioning, self-worth, and depressive symptoms including SI. RESULTS: Rates of SI were not different in youth with CP when compared with those without ((Equation is included in full-text article.), P>0.05). The content of suicidal thoughts also did not vary by group. Multivariate analysis showed an identical pattern of psychosocial correlates of SI in youth with and without CP; higher depressive symptoms and lower self-worth were associated with higher SI severity, controlling for demographics. Pain characteristics and functional disability were not significantly related to SI in youth with CP. DISCUSSION: Contrary to hypotheses and past findings in adults with CP, adolescents with CP did not endorse SI more frequently than peers without CP. Several psychosocial correlates were significantly associated with SI severity in our sample. Findings from this study serve as a foundation for future research on SI and associated risk factors in this population.

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.

Use of Smartphones to Prospectively Evaluate Predictors and Outcomes of Caregiver Responses to Pain in Youth with Chronic Disease.

This study examined outcomes and predictors of different types of responses to child pain used by caregivers of youth with chronic disease. Sixty-six children and adolescents (ages 7-18) with juvenile idiopathic arthritis answered questions about pain, pain interference in activities, and mood on a smartphone three times per day for one month, while a caregiver contemporaneously answered questions about their own mood and use of protecting, monitoring, minimizing, or distracting responses to their child's pain. Multilevel models were used to evaluate (a) how a child's pain and pain interference changes after a caregiver uses different types of pain responses; (b) the extent to which caregiver responses to pain vary across days; and (c) whether variability in caregiver responses to pain is predicted by changes in child pain characteristics, child mood, and/or caregiver mood. Results showed that children's pain intensity and pain interference increased following moments when caregivers used more protective responses, whereas children's pain interference decreased following times when caregivers responded with minimizing responses. Caregiver pain responses varied considerably across days, with caregivers responding with more protecting and monitoring responses and fewer minimizing responses at moments when their child reported high levels of pain unpleasantness and pain interference. Caregivers also were found to respond with fewer protective responses at moments when they themselves were in a more positive mood. Implications for clinical recommendations and future studies are discussed.

Daily Pain, Physical Activity, and Home Fluid Intake in Pediatric Sickle Cell Disease.

Objectives: This study examined the temporal relationship between physical activity, fluid intake, and daily pain in children with sickle cell disease (SCD) with frequent pain. Methods: A total of 30 African American children ( M age = 13.9; 53% female; 76.3% type SS) who reported pain more than or equal to once every 2 weeks and their parents completed measures of pain and anxiety/depressive symptoms. Children then completed a daily pain diary and wore a physical activity Actiwatch for 14 days at home. Results: Contrary to physiological theory-based hypotheses, lower physical activity was associated with greater pain during the same day and the next day. Less pain was associated with greater physical activity the next day. There was no relationship between self-reported home fluid intake and daily pain ( p 's < .05). Conclusions: Results lend support for a complex bidirectional relationship between physical activity and daily pain in pediatric SCD, and identify physical activity as a target for future research.

Prospective Mediation Models of Sleep, Pain, and Daily Function in Children With Arthritis Using Ecological Momentary Assessment.

OBJECTIVES: Sleep is an emerging area of concern in children with juvenile idiopathic arthritis (JIA). Research shows the presence of poor sleep quality and related adverse outcomes in pediatric pain populations, including JIA, but few studies have examined the prospective patterns of association between sleep and associated outcomes. This prospective study evaluated the direction and magnitude of associations between subjective sleep characteristics (sleep quality, difficulty initiating sleep, and sleep duration), pain intensity, and functional limitations in children with JIA. We hypothesized that pain intensity would partially mediate the relationship between sleep and functional limitations. METHODS: Children and adolescents with JIA (n=59; age range, 8 to 18 y) recruited during clinic visits, completed smartphone-based diaries for 1 month. Subjective sleep characteristics were reported each morning; pain and functioning were assessed 3 times daily. RESULTS: As hypothesized, the associations between sleep quality and functional limitations and between difficulty initiating sleep and functional limitations were partially mediated by pain intensity, at any given moment (z=-3.27, P=0.001, z=2.70, P<0.05). Mediation was not detected in a model testing the association between sleep duration, pain intensity, and functional limitations (z=-0.58, P=0.56). DISCUSSION: Results suggest that sleep is integral to understanding the momentary association between pain intensity and functioning in children with JIA.

Internet-delivered cognitive-behavioral treatment for adolescents with chronic pain and their parents: a randomized controlled multicenter trial.

Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included were 273 adolescents (205 females and 68 males), aged 11 to 17 years with mixed chronic pain conditions and their parents, who were randomly assigned in a parallel-group design to Internet-delivered CBT (n = 138) or Internet-delivered Education (n = 135). Assessments were completed before treatment, immediately after treatment, and at 6-month follow-up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to 6-month follow-up for Internet CBT compared with Internet education (b = -1.13, P = 0.03). On secondary outcomes, significant beneficial effects of Internet CBT were found on sleep quality (b = 0.14, P = 0.04), on reducing parent miscarried helping (b = -2.66, P = 0.007) and protective behaviors (b = -0.19, P = 0.001), and on treatment satisfaction (P values < 0.05). On exploratory outcomes, benefits of Internet CBT were found for parent-perceived impact (ie, reductions in depression, anxiety, self-blame about their adolescent's pain, and improvement in parent behavioral responses to pain). In conclusion, our Internet-delivered CBT intervention produced a number of beneficial effects on adolescent and parent outcomes, and could ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families.

A Qualitative Examination of a New Combined Cognitive-Behavioral and Neuromuscular Training Intervention for Juvenile Fibromyalgia.

OBJECTIVES: Adolescents with juvenile fibromyalgia (JFM) are typically sedentary despite recommendations for physical exercise, a key component of pain management. Interventions such as cognitive-behavior therapy (CBT) are beneficial but do not improve exercise participation. The objective of this study was to obtain preliminary information about the feasibility, safety, and acceptability of a new intervention--Fibromyalgia Integrative Training for Teens (FIT Teens), which combines CBT with specialized neuromuscular exercise training modified from evidence-based injury prevention protocols. MATERIALS AND METHODS: Participants were 17 adolescent females (aged 12 to 18 y) with JFM. Of these, 11 completed the 8-week (16 sessions) FIT Teens program in a small-group format with 3 to 4 patients per group. Patients provided detailed qualitative feedback via individual semistructured interviews after treatment. Interview content was coded using thematic analysis. Interventionist feedback about treatment implementation was also obtained. RESULTS: The intervention was found to be feasible, well tolerated, and safe for JFM patients. Barriers to enrollment (50% of those approached) included difficulties with transportation or time conflicts. Treatment completers enjoyed the group format and reported increased self-efficacy, strength, and motivation to exercise. Participants also reported decreased pain and increased energy levels. Feedback from participants and interventionists was incorporated into a final treatment manual to be used in a future trial. DISCUSSION: Results of this study provided initial support for the new FIT Teens program. An integrative strategy of combining pain coping skills via CBT enhanced with tailored exercise specifically designed to improve confidence in movement and improving activity participation holds promise in the management of JFM.

Alcohol and tobacco use in youth with and without chronic pain.

OBJECTIVE: To compare rates of alcohol and tobacco use in youth with and without chronic pain and to identify risk factors for use. METHODS: Participants included 186 youth (95 mixed chronic pain; 91 without chronic pain; 12-18 years old) who reported current alcohol and tobacco use, pain intensity, activity limitations, loneliness, and depressive symptoms. RESULTS: Adolescents with chronic pain were less likely to use alcohol compared with adolescents without chronic pain (7.4% vs. 22%), and as likely to use tobacco (9% vs. 8%). Across groups, youth with higher depressive symptoms, less loneliness, and fewer activity limitations were more likely to endorse alcohol and tobacco use. Exploratory analyses revealed that risk factors for substance use differed among youth with and without chronic pain. CONCLUSIONS: Chronic pain may not increase risk for tobacco and alcohol use in adolescents. Research is needed to understand use of other substances in this medically vulnerable population.

Persistent pain in chronically ill children without detectable disease activity.

Children with organic diseases may experience persistent pain in the presence of controlled disease, as evidenced by little or no measurable disease activity or inflammation. Historically, dualistic definitions of pain have informed standard diagnostic approaches to persistent pain; aggressive investigation and treatment targeting underlying disease, even in the absence of evidence indicating disease escalation. Evidence across disease populations, in children with inflammatory bowel disease, sickle cell disease, and juvenile idiopathic arthritis indicates that persistent pain in these conditions may be better conceptualized as functional in nature, potentially resulting from disordered somatosensory processing including central sensitization. Applying a biopsychosocial understanding of persistent pain and multidisciplinary functional pain management strategies may lead to improved health outcomes.

Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood.

OBJECTIVE: This prospective longitudinal study examined the long-term physical and psychosocial outcomes of adolescents with juvenile-onset fibromyalgia (JFM), compared with healthy control subjects, into early adulthood. METHODS: Adolescent patients with JFM initially seen at a pediatric rheumatology clinic (n = 94) and age- and gender-matched healthy control subjects (n = 33) completed online measures of demographic characteristics, pain, physical functioning, mood symptoms, and health care utilization at ∼6 years' follow-up (mean age: 21 years). A standard in-person tender-point examination was conducted. RESULTS: Patients with JFM had significantly higher pain (P < .001), poorer physical function (P < .001), greater anxiety (P < .001) and depressive symptoms (P < .001), and more medical visits (P < .001)than control subjects. The majority (>80%) of JFM patients continued to experience fibromyalgia symptoms into early adulthood, and 51.1% of the JFM sample met American College of Rheumatology criteria for adult fibromyalgia at follow-up. Patients with JFM were more likely than control subjects to be married and less likely to obtain a college education. CONCLUSIONS: Adolescent patients with JFM have a high likelihood of continued fibromyalgia symptoms into young adulthood. Those who met criteria for fibromyalgia in adulthood exhibited the highest levels of physical and emotional impairment. Emerging differences in educational attainment and marital status were also found in the JFM group. JFM is likely to be a long-term condition for many patients, and this study for the first time describes the wide-ranging impact of JFM on a variety of physical and psychosocial outcomes that seem to diverge from their same-age peers.

Self-reported pain and disease symptoms persist in juvenile idiopathic arthritis despite treatment advances: an electronic diary study.

OBJECTIVE: To use electronic diaries (e-diaries) to determine whether pain, stiffness, and fatigue continue to be common, disabling symptoms in children with juvenile idiopathic arthritis (JIA) despite the use of aggressive treatments in contemporary medical management. METHODS: Fifty-nine children with JIA (ages 8-18 years) provided ratings of pain, stiffness, and fatigue intensity and functional limitations using a smartphone e-diary 3 times each day for 1 month. Medication information was collected via parent report and checked for accuracy by chart review. Descriptive analyses were conducted to determine typical symptom intensity, frequency, and variability. Multilevel modeling was used to analyze associations between symptoms and functional outcomes and between medication use and symptom intensity. RESULTS: Children reported moments of pain in 66% of e-diary entries. No children were entirely pain-free across the reporting period. In 31% of all e-diary entries the visual analog scale score for pain was >40 (high pain intensity), with 86% of children reporting a high level of pain at least once during the study period. The mean ratings of pain, stiffness, and fatigue intensity were in the mild-to-moderate range. Medication class was not a reliable predictor of differences in symptom intensity, even though 79% of children were prescribed a disease-modifying antirheumatic drug and 47% were prescribed a biologic agent. Moments of higher pain intensity and higher stiffness intensity were each uniquely predictive of higher concurrent functional limitations. CONCLUSION: Self-reported pain, stiffness, and fatigue continue to be common in children with JIA, despite contemporary advances in treatment strategies, including use of biologic agents. These findings are surprisingly consistent with previous results from research using daily paper diaries in the pre-biologics era. There remains a pressing and ongoing need to optimize pain and symptom management in JIA.

A systematic review of sleep in pediatric pain populations.

OBJECTIVE: The primary aim of this systematic review was to examine the evidence for a pain-sleep relationship in children with persistent pain by reviewing studies using single and mixed pediatric persistent pain samples. METHODS: Electronic searches of Medline, PubMed, the Cochrane Database of Systematic Reviews, and PsycINFO were conducted to identify all relevant empirical studies. Studies were included in the review if the majority of participants were between 0 and 17 years and from one of the following pediatric pain populations: juvenile idiopathic arthritis, sickle cell disease, migraine/headache, functional abdominal pain, juvenile fibromyalgia syndrome, chronic musculoskeletal pain, or mixed populations including the aforementioned conditions. RESULTS: Research from single and mixed sample studies support the hypothesis that children and adolescents with persistent pain suffer from sleep impairment. Literature addressing factors that may influence or mediate the pain-sleep relationship and the functional outcomes of the pain-sleep relationship was reviewed, and a model of the interrelationships with pain and sleep was developed. CONCLUSION: Findings from this review highlight the need to assess and treat sleep problems in children presenting with persistent pain. Health care providers should consider conducting routine sleep screenings, including a comprehensive description of sleep patterns and behaviors obtained through clinical interview, sleep diaries, and/or the use of standardized measures of sleep. Future research focusing on investigating the mechanisms associating sleep and pediatric persistent pain and on functional outcomes of poor sleep in pediatric pain populations is needed.

Daily sleep quality and mood as predictors of pain in children with juvenile polyarticular arthritis.

OBJECTIVE: Children with arthritis experience frequent pain, but the predictors of daily pain variations are largely unidentified. The goal of this study was to examine sleep quality as a predictor of pain in children with arthritis and to determine whether mood moderates this relationship. METHOD: In this prospective, longitudinal study children with polyarticular arthritis (n = 51, ages 8-16 years) tracked daily symptoms, including sleep quality over 2 months. Self-reported daily pain intensity, as indicated on a visual analog scale, was used as the primary outcome measure in multilevel models. RESULTS: Poorer sleep quality was associated with higher next-day pain ratings (p < .01). Mood moderated this relationship such that as positive mood increased, the relationship between poor sleep quality and high pain weakened (p < .01). Daily pain did not predict nightly sleep quality (p > .05). CONCLUSIONS: Sleep quality is an important predictor of pain in children with arthritis. These findings add to the growing body of literature on the use of daily diaries for analyzing patterns of pain, sleep, and mood in children with chronic painful conditions.

Emotion regulation predicts pain and functioning in children with juvenile idiopathic arthritis: an electronic diary study.

OBJECTIVES: This study utilized e-diaries to evaluate whether components of emotion regulation predict daily pain and function in children with juvenile idiopathic arthritis (JIA). METHODS: 43 children ages 8-17 years and their caregivers provided baseline reports of child emotion regulation. Children then completed thrice daily e-diary assessments of emotion, pain, and activity involvement for 28 days. E-diary ratings of negative and positive emotions were used to calculate emotion variability and to infer adaptive emotion modulation following periods of high or low emotion intensity. Hierarchical linear models were used to evaluate how emotion regulation related to pain and function. RESULTS: The attenuation of negative emotion following a period of high negative emotion predicted reduced pain; greater variability of negative emotion predicted higher pain and increased activity limitation. Indices of positive emotion regulation also significantly predicted pain. CONCLUSIONS: Components of emotion regulation as captured by e-diaries predict important health outcomes in children with JIA.

Parent pain responses as predictors of daily activities and mood in children with juvenile idiopathic arthritis: the utility of electronic diaries.

The present study used electronic diaries to examine how parent responses to their child's pain predict daily adjustment of children with juvenile idiopathic arthritis (JIA). Nine school-aged children with JIA along with one of their parents completed thrice-daily assessments of pain-related variables, activity participation, and mood using handheld computers (Palm pilots) for 14 days, yielding a potential of 42 child and parent assessments for each dyad. Children provided information on current pain level, mood, and participation in social, physical, and school activities. Parents independently rated their own mood as well as their behavioral responses to their child's pain at the same time points using a separate handheld computer. Results of multilevel modeling analyses demonstrated that use of "protective" pain responses by parents significantly predicted decreases in child activity and positive mood, with an even stronger inverse relationship between protective pain response and positive mood observed in children with higher than average disease severity. Protective pain responses were not found to be significantly predictive of daily negative mood in children. The use of "distracting" responses by parents significantly predicted less child activity restrictions but only in children having higher disease severity. There also was an unexpected trend in which parent use of more distracting pain responses tended to be associated with lower child positive mood. These preliminary findings suggest the importance of the parent in influencing adjustment in children with JIA and lend support to the incorporation of parents into comprehensive pain management approaches. The potential benefits of using electronic daily diaries as a strategy to examine pain and adjustment in children with JIA pain are discussed.