Initial Adjustment to the COVID-19 Pandemic and the Associated Shutdown in Children and Adolescents With Chronic Pain and Their Families.

Objectives: Youth with chronic pain often struggle to function in multiple domains due to pain and associated psychosocial distress. In 2020, schools and businesses shut down and people were encouraged to remain at home due to the COVID-19 pandemic, eliminating or reducing stress due to functional difficulties. This study assessed whether pain and associated psychosocial outcomes improved in youth with chronic pain during the shutdown, compared with before the pandemic. Methods: Patients who completed clinical outcome measures during a multidisciplinary evaluation before the pandemic were readministered the same measures (PROMIS Anxiety, Depression, Sleep Disturbance, PCS, PedsQL) during the shutdown. At follow-up, patients also completed measures of adjustment to COVID-19 and their parents completed a measure of pandemic effects. Results: Participants included 47 patients ages 8-18 and a parent/guardian. The pandemic impacted families in both positive (e.g., more quality time with family) and negative ways (e.g., social isolation, disruption in care). Pain intensity and pain catastrophizing significantly decreased during the shutdown (ps <0.01). Change in pain catastrophizing was correlated positively with change in psychological stress (p = 0.004) and anxiety (p = 0.005) and negatively with change in quality of life (p = 0.024). Discussion: Pain and pain catastrophizing decreased initially during the shutdown related to the COVID-19 pandemic. Change in catastrophizing was associated with change in stress and anxiety. It may be that the reduction in functional demands contributed to this change. Functional difficulties should be addressed in treatment, including pain coping and also environmental modification to support optimal functioning in youth with chronic pain.

Pediatric Headache and Sleep Disturbance: A Comparison of Diagnostic Groups.

OBJECTIVE: To examine whether sleep disturbance differs by headache diagnosis in a pediatric sample, and whether this effect remains when other factors affecting sleep are included. BACKGROUND: Primary headache disorders can be severe and disabling, impacting a child's functioning and quality of life. Many children and adolescents with chronic headaches also experience sleep difficulties, and there is likely a bidirectional relationship between headaches and sleep difficulties. Sleep problems may intensify functional and developmental difficulties in youth with chronic headaches. Despite this, research on sleep has largely been conducted only on those with migraines, with a dearth of studies including samples with tension-type headache (TTH) or new daily persistent-headache (NDPH). METHODS: This retrospective chart review included 527 patients, ages 7-17 years, with a primary headache diagnosis of migraine (n = 278), TTH (n = 157), and NDPH (n = 92). Patients completed measures of disability, anxiety, and depression and their parents completed measures of sleep disturbance. RESULTS: Sleep disturbance was greater in patients with TTH (10.34 ± 5.94, P = .002) and NDPH (11.52 ± 6.40, P < .001) than migraine (8.31 ± 5.89). Across patient groups, greater sleep disturbance was significantly associated with higher levels of functional disability (rs ≥ .16), anxiety (rs ≥ .30), and depression (rs ≥ .32). Additionally, higher pain levels were significantly associated with greater sleep disturbance among TTH patients (r = .23), with this association non-significant among the other headache groups. When simultaneously examining demographic, pain-related, and emotional distress factors, older age, higher levels of disability and depression, and NDPH diagnosis were all significant predictors of greater sleep disturbance (r2 = .25). CONCLUSIONS: Assessment and treatment of sleep problems in pediatric patients with chronic headache is important with several contextual and headache diagnostic factors influencing the severity of sleep disturbance.

The Sleep Hygiene Inventory for Pediatrics: Development and Validation of a New Measure of Sleep in a Sample of Children and Adolescents With Chronic Headache.

Sleep plays a pivotal role in children and adolescents with headache. Although several sleep measures exist, no developed measures target the sleep issues common in pediatric patients with headache. The Sleep Hygiene Inventory for Pediatrics (SHIP) was developed for clinical purposes to fulfill this need. The aim of this study was to validate the SHIP for potential research applications in a sample of 1078 children and adolescents (7-17 years) with a primary headache diagnosis. Measure validation included assessments of internal consistency, construct validity, and criterion validity. The SHIP demonstrated strong internal consistency (Cronbach α = 0.84). The SHIP differentiated well between participants for whom sleep was and was not a clinical concern ( P < .001; d =1.65), and was positively correlated with anxiety, depression, and disability. These analyses suggest that the SHIP is a psychometrically strong and valid assessment of sleep habits in pediatric patients with headache.

School functioning and chronic tension headaches in adolescents: improvement only after multidisciplinary evaluation.

Pediatric patients with chronic tension-type headaches often experience significant school impairment. Although some improve after treatment with a neurologist, many require more comprehensive treatment. The authors examined whether school functioning and attendance improved after a multidisciplinary evaluation focusing on a return to functioning despite headaches. They also examined whether patients' headaches improved. Participants were 47 adolescents ages 12-17, most of whom had not responded to past neurological treatment. Adolescents completed the PedsQL School Functioning Scale at evaluation, 2-3 months later, and again 6 months after evaluation. Information regarding headache frequency, severity and duration, and school attendance was obtained from medical records. Using repeated measures analyses of variance, the authors found that school functioning and attendance improved significantly from evaluation to follow-up, as did headache frequency and duration. An emphasis on returning to functioning can help patients with chronic, difficult-to-treat tension-type headaches improve in their school functioning and experience fewer, shorter headaches.

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.

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.

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.

Measuring parent beliefs about child acceptance of pain: a preliminary validation of the Chronic Pain Acceptance Questionnaire, parent report.

Parent perceptions of and responses to pain have been identified as important factors in understanding pain-related disability among children and adolescents with chronic pain. The ability to accept chronic pain rather than focus on ways to avoid or control it has been linked to positive outcomes in chronic pain research. To examine parent beliefs about child acceptance of pain, the Chronic Pain Acceptance Questionnaire, parent report (CPAQ-P), was developed and administered to 195 parents of children with persistent pain evaluated in a multidisciplinary pain clinic. Analyses support the internal consistency of the CPAQ-P (α=.89) and 1-month stability estimates were acceptable for the total scale score (α=.72), and results suggest some responsivity to change. Exploratory factor analysis identified a 2-factor model with 4 items removed from the original 20-item measure. Confirmatory factor analysis strongly supported the modified version. For construct validity, parent beliefs about child acceptance were negatively correlated with parent pain catastrophizing and parent fear of pain. Greater acceptance was also negatively associated with protective parent responses to pain. These results support the CPAQ-P as a promising measure for assessing parent beliefs about child acceptance of pain and reinforce the importance of the social context and parental influence on child functioning.

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.

Assessment of relationship-specific incentive and threat sensitivities: predicting satisfaction and affect in adult intimate relationships.

Self-report scales assessing relationship-specific incentive and threat sensitivity were created. Initial tests of factor structure and associations with relationship quality were conducted in a sample of persons in intimate relationships (Study 1). Associations with conceptually related measures were examined to determine convergent and discriminant validity in a sample of dating couples (Study 2). Cross-validation of the factor structure was established in engaged couples (Study 3) and in newlywed couples (Study 4). In Study 4, couples also engaged in a laboratory-based threat task (discussion about a significant marital problem) and incentive task (discussion about loving aspects of the partner/marriage). Relationship incentive sensitivity predicted higher positive affect after the incentive task for both husbands and wives. Relationship threat sensitivity predicted greater anxiety in response to the threat laboratory task for wives only. Implications of approach and avoidance motivations in close relationship processes and outcomes are discussed.

Factor structure of the Adult Responses to Children's Symptoms: validation in children and adolescents with diverse chronic pain conditions.

OBJECTIVE: To examine how the Adult Responses to Children's Symptoms (ARCS) does in a sample of children and adolescents with a variety of complex chronic pain conditions and to further validate the ARCS by examining associations among the subscale scores and patients' functional disability and depressive symptoms. METHODS: A retrospective chart review was conducted for patients from multidisciplinary pain clinics in 2 large urban children's hospitals. Patients completed self-report measures of their pain, functional disability, and symptoms of depression. Their parents completed a self-report measure assessing adult responses to children's pain complaints (ARCS). RESULTS: Confirmatory factor analysis was used to establish a model that included the original 3 factors (Protect, Minimize, and Encourage/Monitor) and provided good fit to the data, with minor modifications to the original measure. As expected, parental protective behavior was associated with increased child disability. Parental protective behaviors also were linked to higher levels of child depressive symptoms and longer pain duration. DISCUSSION: This study provides the first-known examination of the factor structure of the ARCS in a large sample of pediatric patients with diverse chronic pain conditions. Confirmatory factor analyses indicate that the ARCS is a valid measure for use with children and adolescents presenting to outpatient pain clinics with a variety of chronic pain complaints.

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.

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.

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.

Marital conflict, maternal and paternal parenting, and child adjustment: a test of mediation and moderation.

Parenting was examined as a mediator of associations between marital and child adjustment, and parent gender was examined as a moderator of associations among marital, parental, and child functioning in 226 families with a school-age child (146 boys). Parenting fully mediated associations between marital conflict and child internalizing and externalizing behaviors. Parent gender did not moderate associations when data from the full sample or families with girls only were evaluated. Parent gender did moderate associations when families with boys were evaluated, with the association between marital conflict and parenting stronger for fathers than mothers. A trend suggested fathers' parenting may be more strongly related to internalizing behavior and mothers' parenting may be more strongly related to externalizing behavior in boys.