Which passengers are on your bus? A taxonomy of the barriers adolescents with chronic pain face in achieving functional recovery.

BACKGROUND: Despite evidence that intensive interdisciplinary pain treatment (IIPT) is effective in facilitating functional recovery in adolescents with chronic pain, engagement with IIPT is suboptimal among adolescents. A key aspect of IIPT is to support functional recovery via (re)engagement with age-appropriate daily activities. The aim of this study was to gain a comprehensive insight into adolescents' perceptions of the barriers they need to overcome to engage with age-appropriate activities in order to achieve functional recovery. METHODS: Forty-one adolescents who were starting an IIPT programme completed the 'passenger-on-the-bus metaphor', an exercise in which they identify and describe their perceived barriers (i.e. 'passengers' on their bus) that prevent them from engaging with age-appropriate activities. The responses were analysed using inductive thematic analyses to generate a taxonomy of perceived barriers to functional recovery. RESULTS: We generated a taxonomy of seven different barriers that participants described facing on their road to functional recovery: physical constraints, being 'fed up', low self-confidence and self-esteem, perfectionism, avoidance of engagement with pain, feelings (such as sadness, anger, guilt, anxiety) and social barriers (received from a range of sources such as parents, friends, school and wider society). CONCLUSION: The findings reveal a variety of barriers that were perceived to hinder functional recovery through reduced engagement with age-appropriate activities and thereby hamper progress within IIPT. The Passenger on the bus metaphor can be used to identify similar barriers faced by adolescents in an individualized treatment approach, thereby making it possible for clinicians to target their IIPT more precisely.

Dispositional Mindfulness and Its Relationship With Distress and Functioning in Adolescents With Chronic Pain and Low-Level Pain.

Objective: Dispositional mindfulness is the general tendency to pay attention to present-moment awareness without judgment. The main aim of this cross-sectional study was to determine (a) whether dispositional mindfulness is associated with psychological distress in adolescents with chronic pain and low-level pain, and (b) whether it accounts for unique variance in distress after controlling for key variables from the pain literature. A secondary aim was to explore the relationship between dispositional mindfulness and functioning. Method: 54 adolescents seeking help for chronic pain and 94 "healthy" adolescents with recent low-level pain from the general population completed the same battery of measures, including the Child and Adolescent Mindfulness Measure of dispositional mindfulness. Results: As predicted, dispositional mindfulness was associated with mood and anxiety in both groups and also accounted for unique variance in mood and anxiety in standard regression models after controlling for group, age, pain-intensity, pain-catastrophizing, and pain-acceptance. Dispositional mindfulness did not differ significantly across the two groups and did not predict physical functioning. However, it did account for unique variance in social functioning. Conclusions: Dispositional mindfulness may be an important construct to consider in the context of adolescents experiencing mood and anxiety problems in both low-level and chronic pain samples. Further research should aim to replicate these findings in larger clinical samples and explore the predictive power of dispositional mindfulness using longitudinal designs.

Cognitive Biases in Children and Adolescents With Chronic Pain: A Review of Findings and a Call for Developmental Research.

Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain by facilitating fear and avoidance. Whereas extensive research has established attention, interpretation, and memory biases in adults with chronic pain, far less is known about these same biases in children and adolescents with pain. Studying cognitive biases in attention, interpretation, and memory in relation to pain occurring in youth is important because youth is a time when pain can first become chronic, and when relationships between cognitive biases and pain outcomes emerge and stabilize. Thus, youth potentially offers a time window for the prevention of chronic pain problems. In this article, we summarize the growing corpus of data that have measured cognitive biases in relation to pediatric pain. We conclude that although biases in attention, interpretation, and memory characterize children and adolescents with varying pain experiences, questions regarding the direction, magnitude, nature, and role of these biases remain. We call for independent extension of cognitive bias research in children and adolescents, using well powered longitudinal studies with wide age ranges and psychometrically sound experimental measures to clarify these findings and any developmental trends in the links between cognitive biases and pain outcomes. PERSPECTIVE: This article provides a rationale for the theoretical and practical importance of studying the role of cognitive biases in children and adolescents with chronic pain, which has to date, been relatively understudied. Existing findings are reviewed critically, and recommendations for future research are offered.

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

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.

Negative Interpretation Bias and the Experience of Pain in Adolescents.

UNLABELLED: Negative interpretation bias, the tendency to appraise ambiguous situations in a negative or threatening way, has been suggested to be important for the development of adult chronic pain. To our knowledge, this is the first study to examine the role of a negative interpretation bias in adolescent pain. We first developed and piloted a novel task that measures the tendency for adolescents to interpret ambiguous situations as indicative of pain and bodily threat. Using this task in a separate community sample of adolescents (N = 115), we then found that adolescents who catastrophize about pain, as well as those who reported more pain issues in the preceding 3 months, were more likely to endorse negative interpretations, and less likely to endorse benign interpretations, of ambiguous situations. This interpretation pattern was not, however, specific for situations regarding pain and bodily threat, but generalized across social situations as well. We also found that a negative interpretation bias, specifically in ambiguous situations that could indicate pain and bodily threat, mediated the association between pain catastrophizing and recent pain experiences. Findings may support one potential cognitive mechanism explaining why adolescents who catastrophize about pain often report more pain. PERSPECTIVE: This article presents a new adolescent measure of interpretation bias. We found that the tendency to interpret ambiguous situations as indicative of pain and bodily threat may be one potential cognitive mechanism explaining why adolescents who catastrophize about pain report more pain, thus indicating a potential novel intervention target.

The relationship between adolescents' pain catastrophizing and attention bias to pain faces is moderated by attention control.

This study considered the attentional functioning of adolescents with varying levels of pain catastrophizing. Specifically, we investigated the relationship between pain catastrophizing and attention bias to pain facial expressions. Furthermore, drawing on dual process models in the context of pain, we investigated the moderating role of attention control on this relationship. Adolescents (N = 73; age, 16-18 years) performed a dot-probe task in which facial expressions of pain and neutral expressions were presented for 100 milliseconds and 1250 milliseconds. Participants also completed self-report pain catastrophizing and attention control measures. We found that although there was no main effect of pain catastrophizing on attention bias towards pain faces, attention control did significantly moderate this relationship. Further analysis revealed that lower levels of attention control were significantly associated with increasing attentional vigilance towards pain faces only within high catastrophizing adolescents. In addition, we found that poorer attention control was related to increased attention bias for pain faces (regardless of pain catastrophizing level) when these faces were presented for relatively longer durations (ie, 1250 milliseconds) but not for short durations (ie, 100 milliseconds). This study supports a dual process model of attentional processes in pain, thus replicating previous findings within the psychopathology literature but extending them to the study of pain. Theoretical and clinical implications of our findings are discussed.