Coping strategy use: does it predict adjustment to chronic back pain after controlling for catastrophic thinking and self-efficacy for pain control?

OBJECTIVE: To explore whether coping strategy use predicted levels of adjustment in chronic low back pain after controlling for the influence of catastrophic thinking and self-efficacy for pain control. METHODS: Eighty-four patients with chronic low back pain completed the Coping Strategies Questionnaire, a pain VAS and the Roland Disability Questionnaire. To derive composite measures of coping, the Coping Strategies Questionnaire subscales, excluding the Catastrophizing subscale and 2 single-item scales, were entered into a principal components analysis. The extent to which scores on the coping measures predicted levels of adjustment after controlling for catastrophic thinking (Catastrophizing subscale) and self-efficacy for pain control (2 single-item scales) was explored using sequential multiple regression analysis. RESULTS: Two coping dimensions emerged from the principal components analysis, which were labelled Distraction and Praying or Hoping, and Denial of Pain and Persistence. Scores obtained on these coping measures explained an additional 5% and 13% of the variance in pain intensity and disability, respectively. Interestingly, however, the scores on the coping measures did not predict pain intensity or disability after controlling for the influence of catastrophic thinking and self-efficacy for pain control. CONCLUSION: Coping strategy use might only be related to levels of adjustment via the effect it has on catastrophic thinking and self-efficacy for pain control.     

Finding a solution to the problem of pain: conceptual formulation and the development of the Pain Solutions Questionnaire (PaSol)

We report the development of the Pain Solutions Questionnaire (PaSol), an instrument designed to measure assimilative (efforts at changing or solving pain) and accommodative (accepting that pain cannot be solved, and changing life goals) responses to the problems associated with pain. Data were collected from 476 adults suffering from chronic pain. Exploratory and confirmatory factor analyses resulted in a 14-item instrument with an adequate oblique 4-factor structure: (1) Solving Pain scale (4 items), (2) Meaningfulness of Life Despite Pain scale (5 items), (3) Acceptance of the Insolubility of Pain scale (3 items), and (4) Belief in a Solution scale (2 items). The validity of the PaSol was further tested by its value in explaining disability and affective distress after controlling for the effects of the demographic characteristics and pain severity. The Meaningfulness of Life Despite Pain scale was important in explaining disability and affective distress. The Solving Pain scale had a unique and independent contribution in explaining affective distress. Results are discussed in terms of how a persistence in assimilative coping, even though the pain problem is insoluble, may increase hypervigilance, catastrophizing, distress and disability.     

Educational achievement and chronic pain disability: mediating role of pain-related cognitions

OBJECTIVE: This study examined the relation between level of educational achievement (LOE) and the clinical morbidity associated with chronic pain. SETTING: a multidisciplinary pain rehabilitation program located within a university hospital. PATIENTS: Two hundred ninety-nine consecutive patients with chronic spinal pain, average age 39.6 years (SD = 10.7) and with an average duration of pain of 41.9 months (SD = 51.6). OUTCOME MEASURES: Age, duration of pain, sex, and compensation and litigation status were controlled for in the statistical analysis because each was found to be significantly associated with LOE. Pain intensity was assessed by the McGill Pain Questionnaire. Affective distress was assessed by the Global Severity Index from the Brief Symptom Inventory. Severity of depressive symptoms was derived from scores from the Center for Epidemiological Studies-Depression Scale. Pain beliefs and pain coping strategies were assessed by the Survey of Pain Attitudes and the Coping Strategies Questionnaire, respectively. Finally, self-report of pain-related disability was assessed by the Pain Disability Index. RESULTS AND CONCLUSIONS: After controlling for relevant covariates, LOE was unrelated to pain intensity, severity of depressive symptoms, or affective distress, but was inversely related to self-reported disability. Persons with lower LOEs possessed a greater belief that pain is a "signal of harm," unrelated to emotional experience, disabling and uncontrollable. They also endorsed more passive and maladaptive coping strategies, including a tendency to catastrophize about their pain. Path analysis indicated that, after controlling for the influence of both the belief that pain is a "signal of harm" and catastrophizing on the association between LOE and disability, this relation loses statistical significance. These results suggest that pain-related cognitions mediate the relation between LOE and pain disability and that persons with lower LOEs are more likely to develop maladaptive pain beliefs and coping strategies.     

Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain

OBJECTIVE: To investigate the mediating role of pain intensity, catastrophic thinking about pain, and negative affectivity in explaining enhanced attention for pain in patients with fibromyalgia. METHODS: Sixty-four patients with fibromyalgia and 46 patients with chronic low back pain completed self-report instruments of vigilance to pain, negative affectivity, and catastrophic thinking about pain. These measures, along with diagnostic group and pain intensity, were entered into a partial correlational analysis to investigate which variables mediate the relationship between diagnostic group (fibromyalgia vs. chronic low back pain) and vigilance to pain. RESULTS: Fibromyalgia patients reported significantly greater vigilance to pain than patients with chronic low back pain. They also reported higher pain intensity, more negative affectivity, and more catastrophic thinking about pain than patients with chronic low back pain. Vigilance to pain was correlated significantly with pain intensity, negative affectivity, and catastrophic thinking about pain. Further analyses revealed that pain intensity and catastrophic thinking about pain, but not negative affectivity, mediated the relationship between diagnostic group and vigilance to pain. CONCLUSION: Fibromyalgia patients report a heightened vigilance to pain. This vigilance is not a unique characteristic of fibromyalgia but is related to the intensity of pain and catastrophic thinking about pain.     

Psychosocial risks for disability in children with chronic back pain.

Psychosocial factors related to disability in adults with chronic back pain have been well studied, but little is known about factors associated with functional impairment in pediatric patients with chronic back pain. The purpose of this study was to examine whether 2 potential risk factors-use of catastrophizing as a coping technique and presence of a familial pain history-were associated with disability in pediatric back pain patients. Participants were 65 patients (ages 8-18) with chronic back pain seen at a multidisciplinary pain clinic. Patients completed measures of pain (visual analog scales), disability (Functional Disability Inventory), and catastrophizing (Internalizing/Catastrophizing subscale of the Pain Coping Questionnaire). Parents provided demographic information and familial pain history. Patients reported that chronic back pain caused disruptions in their daily functioning and they missed, on average, 2.5 days of school every month. Catastrophizing and familial chronic pain history both were significantly associated with greater disability, with use of catastrophizing being the stronger predictor of disability. This study presents important findings on potential psychosocial risk factors of functional disability in children and adolescents with chronic back pain. Future research might clarify mechanisms by which such coping styles are developed and explore how familial communication about pain might influence a child's coping ability. PERSPECTIVE: Pediatric patients seeking treatment for chronic back pain often present with substantial functional impairment that is not well explained by disease variables or pain intensity. Two important psychosocial variables (catastrophizing and familial pain history) may provide a context for a better understanding of pain-related disability in children.     

Brain Activation of Unpleasant Emotions Increases Catastrophizing in Patients with Chronic Pain

BackgroundCatastrophic thinking among patients with chronic pain impairs their quality of life and increases anxiety levels. Further, severe pain causes high emotional brain sensitivity and unpleasant feelings. However, the effects of emotional changes on catastrophic thinking in patients with chronic pain remain unclear.AimsWe hypothesised that emotional brain activity during mild pain stimuli would affect catastrophic thinking in these patients. We aimed to examine the relationship between unpleasant emotional brain activation and catastrophic thinking due to pain stimuli in patients with chronic pain.DesignThis was a prospective observational study.ParticipantsWe included patients with chronic pain and healthy individuals.MethodsThe impact of emotional brain activity on catastrophic thinking was evaluated, specifically, the skin conductance response and oxygenated haemoglobin levels using near-infrared spectroscopy. After receiving three different pain stimuli, the participants were evaluated using the Numeric Rating Scale, Pain Catastrophising Scale, and McGill Pain Questionnaire.ResultsThere were 28 patients in the chronic pain group and 33 patients in the healthy group. There was no between-group difference in oxygenated haemoglobin levels during pain stimulation. The chronic pain group showed a higher Pain Catastrophising Scale score and skin conductance response than the healthy group (p < .05). In the chronic pain group, oxygenated haemoglobin levels after pain stimuli were significantly associated with the Pain Catastrophising Scale score and skin conductance response (p < .05).ConclusionsBrain activity of unpleasant emotions may influence catastrophic thinking in patients with chronic pain.     

Parents who catastrophize about their child's pain prioritize attempts to control pain

How parents respond to their child in pain is critically important to how both parent and child attempt to cope with pain. We examined the influence of parental catastrophic thinking about child pain on their prioritization for pain control. Using a vignette methodology, parents reported, in response to different pain scenarios, on their imagined motivation for 2 competing goals: to control their child's pain (ie, pain control) or to encourage their child's participation in daily activities (ie, activity engagement). The effects of parent gender, pain intensity, and duration on parental goal priority were also explored. Findings indicated that higher levels of parental catastrophic thoughts were associated with the parents prioritizing child pain control over activity engagement. This effect was significantly moderated by pain duration. Specifically, pain control was more of a priority for those high in catastrophic thinking when the pain was more acute. In contrast, parental catastrophic thoughts had no effect on the pain control strategy favored by parents in situations with longer-lasting pain. Furthermore, independently of parental catastrophic thoughts, heightened priority for pain control was observed in highly intense and chronic pain situations. Moreover, in highly intense pain, priority for pain control was stronger for mothers compared with fathers. Theoretical and clinical implications and directions for future research are discussed.     

Sexual dysfunction and chronic pain: the role of psychological variables and impact on quality of life

We report two studies examining the prevalence of sexual dysfunction, and the role of psychological variables, including quality of life, on sexual activity in patients at the commencement of an outpatient cognitive-behavioural pain management programme. In Study 1, 151 patients with non-cancer pain, predominantly of musculoskeletal origin, completed a range of standardised measures, including the Pain Disability Index, Beck Depression Inventory and Coping Strategies Questionnaire. Sexual dysfunction was common, and using stepwise multiple regression analysis was found to be more frequently reported by those with greater disability and depression, shorter pain duration, and infrequent use of coping self-statements. Study 2 was a pilot investigation of the impact of sexual dysfunction on quality of life (as measured by the WHOQOL-100) in a similar sample (n=41). Although sexual dysfunction was again commonly reported, subjects perceived it had less importance in quality of life than did other factors. The combined results support the previously proposed notion of adaptation to the impact of chronic illness on sexual function. In conclusion, sexual dysfunction is common in this population and is predicted by psychological factors and pain duration. However, other issues impact more significantly on quality of life. Therapeutic approaches to sexual dysfunction in these patients might best be focused on improving psychological factors, particularly depression and coping skills.     

Acute low back pain: pain-related fear and pain catastrophizing influence physical performance and perceived disability

Pain-related fear and pain catastrophizing are associated with disability and actual performance in chronic pain patients. In acute low back pain (LBP), little is known about the prediction of actual performance or perceived disability by pain-related fear and pain catastrophizing. This experimental, cross-sectional study aimed at examining whether pain-related fear and pain catastrophizing were associated with actual performance and perceived disability. Ninety six individuals with an episode of acute LBP performed a dynamic lifting task to measure actual performance. Total lifting time was used as outcome measure. The results show that pain-related fear, as measured with the Tampa Scale for Kinesiophobia, was the strongest predictor of this physical task. Using the Roland Disability Questionnaire as a measure of perceived disability, both pain-related fear and pain catastrophizing, as measured with the Pain Catastrophizing Scale, were significantly predictive of perceived disability and more strongly than pain intensity was. The results of the current study suggest that pain-related fear is an important factor influencing daily activities in individuals suffering an episode of acute LBP. The study results have important clinical implications, especially in the development of preventive strategies for chronic LBP.     

The role of neuroticism, pain catastrophizing and pain-related fear in vigilance to pain: a structural equations approach

The present study aimed at clarifying the precise role of pain catastrophizing, pain-related fear and personality dimensions in vigilance to pain and pain severity by means of structural equation modelling. A questionnaire survey was conducted in 122 patients with chronic or recurrent low back pain. Results revealed that pain catastrophizing and pain-related fear mediated the relationship between neuroticism and vigilance to pain. Furthermore, vigilance to pain was found to be associated with heightened pain severity. Finally, we found that neuroticism moderated the relationship between pain severity and catastrophic thinking about pain. The results strongly support the idea that vigilance to pain is dependent upon catastrophic thinking and pain-related fear. Neuroticism is best conceived of as a vulnerability factor; it lowers the threshold at which pain is perceived as threatening, and at which catastrophic thoughts about pain emerge.     

Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain

Computerized diary measurement of pain, disability and psychological adaptation was performed four times a day for 4 weeks in 80 patients with various duration of unexplained pain. Reported are (1) the temporal characteristics and stability of pain report during the 4-week measurement period, (2) the association between pain duration and pain report, disability and general psychopathology, and (3) the accordance between diary assessment versus questionnaire assessment of pain, disability and psychological adaptation. No evidence of instrument reactivity was found: pain report was stable across the 4-week period. However, pain report appeared to be highly variable both between and within days. About half the patients showed a clear increasing trend in pain during the day. Several differences were found between subgroups of patients varying in pain duration. Patients with less than 6 months of pain reported significantly less pain intensity, disability and fatigue than patients whose pain persisted for more than 6 months. Pain coping and responses to pain behaviors by the spouse also differed for the subgroups: longer pain duration was associated with increased catastrophizing and solicitous responses from the spouse. Comparison of scores obtained with diary versus questionnaire assessment indicated moderate correlations for most variables. Retrospective (questionnaire) assessment of pain intensity yielded significantly higher pain scores than diary assessment.     

A typology of pain coping strategies in pediatric patients with chronic abdominal pain

This study aimed to identify clinically meaningful profiles of pain coping strategies used by youth with chronic abdominal pain (CAP). Participants (n=699) were pediatric patients (ages 8-18 years) and their parents. Patients completed the Pain Response Inventory (PRI) and measures of somatic and depressive symptoms, disability, pain severity and pain efficacy, and perceived competence. Parents rated their children's pain severity and coping efficacy. Hierarchical cluster analysis based on the 13 PRI subscales identified pain coping profiles in Sample 1 (n=311) that replicated in Sample 2 (n=388). Evidence was found of external validity and distinctiveness of the profiles. The findings support a typology of pain coping that reflects the quality of patients' pain mastery efforts and interpersonal relationships associated with pain coping. Results are discussed in relation to developmental processes, attachment styles, and treatment implications.     

Endogenous opioids and chronic pain intensity: interactions with level of disability

OBJECTIVE: To test whether endogenous opioid antinociceptive system dysfunction evidenced in response to acute pain stimuli is associated with increased clinical pain intensity in chronic pain sufferers, and to determine whether this association is moderated by disability level. DESIGN: A double-blind, placebo-controlled, randomized crossover design. Subjects underwent laboratory acute finger pressure pain stimulation and ischemic pain stimulation under placebo and under opioid blockade with naloxone. The primary independent measures, reflecting degree of endogenous opioid antinociception, were opioid Blockade Effects derived to reflect the change elicited by naloxone in pain intensity ratings for the acute pain tasks. High and Low Disability groups were derived based on Pain Disability Index scores to allow examination of the influence of disability level on the relationship between Blockade Effects and chronic pain intensity. SUBJECTS: Twenty-eight chronic low back pain sufferers. OUTCOME MEASURE: Seven-day diary ratings of overall chronic pain intensity based on McGill Pain Questionnaire-Short Form total scores. RESULTS: Greater daily chronic pain intensity was associated with greater placebo acute pain sensitivity in the laboratory (P < 0.05). Positive Blockade Effects (ie, presence of opioid analgesia) were associated as expected with lower placebo-condition acute pain sensitivity in the laboratory (P < 0.05). In main effects analyses, Blockade Effects were not associated significantly with daily chronic pain intensity. This absence of overall main effects was accounted for by significant opposing interactions between disability level and Blockade Effects (P < 0.05). Negative Blockade Effects (ie, absence of endogenous opioid analgesia to acute pain) in the High Disability group were associated with greater daily chronic pain intensity, consistent with the hypothesized effects of chronic pain-related opioid dysfunction. In contrast, Positive Blockade Effects (ie, effective opioid analgesia to acute pain) were associated with higher daily chronic pain intensity in the Low Disability group. CONCLUSIONS: These results suggest that endogenous opioid antinociceptive system dysfunction may contribute to elevated acute and chronic pain sensitivity among more disabled chronic pain patients. Among less disabled patients, chronic pain may serve as a primer producing up-regulated opioid antinociceptive responses to acute pain     

Pain coping profiles in adolescents with chronic pain

This study sought to evaluate the extent to which the pain coping profiles observed by Walker and colleagues in a sample of patients with chronic abdominal pain also were evident in a sample of adolescent patients who presented to a tertiary care clinic for evaluation of a variety of diverse pain conditions. In addition, we aimed to evaluate the relation of these pain coping profiles to patients' emotional and physical functioning. Participants (n=254) were adolescent patients aged 12-17 years. Patients completed the Pain Response Inventory (PRI) as well as measures of pain, somatic symptoms, anxiety and depressive symptoms, and functional disability. Using the PRI classification algorithm developed by Walker and colleagues, we successfully classified all the patients in our sample. We also found that the pain coping profiles successfully differentiated among patients with different levels of symptoms, disability, and emotional distress, further demonstrating the external validity of these profiles. Results have implications for tailoring pain treatment interventions to patients' particular coping profiles.     

Pain beliefs and perceived physical disability of patients with chronic low back pain

Cognitive-behavioural therapy and maintenance of exercise have emerged as major tools in the treatment of patients with chronic low back pain. Patients' beliefs about their problem may influence their uptake of and responses to particular treatment modalities. In particular, we hypothesised that patients' beliefs about the cause and treatment of pain may mediate changes in physical disability following participation in a multidisciplinary pain management programme. A cohort of 84 patients was invited to respond to booklets of self-report questionnaires prior to, immediately after and 3 months following participation in multidisciplinary pain management programmes. Questionnaires addressed subjects' beliefs about the nature and treatment of pain (Pain Beliefs Questionnaire), and their disability (Likert-modified Roland and Morris Disability Questionnaire, Physical Functioning scale of the Short Form-36 Health Survey, and Oswestry Low Back Pain Disability Questionnaire). Patients with chronic low back pain who more strongly endorsed 'organic' concepts about the nature and treatment of pain reported higher levels of physical disability at baseline, and displayed greater reductions in disability following participation in the pain management programmes. Reductions in reported 'organic' pain beliefs were associated with improvements in reported disability. Endorsement of 'psychological' concepts about the nature and treatment of pain was not associated with disability. These findings support a view that patients' beliefs about the nature and treatment of their pain can change during participation in a multidisciplinary pain management programme based on cognitive-behavioural intervention. Modification of these beliefs may be associated with improvements in patients' perceptions of the level of their disability.     

Dimensions of catastrophic thinking associated with pain experience and disability in patients with neuropathic pain conditions

The objective of the present study was to examine the relative contributions of different dimensions of catastrophic thinking (i.e. rumination, magnification, helplessness) to the pain experience and disability associated with neuropathic pain. Eighty patients with diabetic neuropathy, post-herpetic neuralgia, post-surgical or post-traumatic neuropathic pain who had volunteered for participation in a clinical trial formed the basis of the present analyses. Spontaneous pain was assessed with the sensory and affective subscales of the McGill Pain Questionnaire. Pinprick hyperalgesia and dynamic tactile allodynia were used as measures of evoked pain. Consistent with previous research, individuals who scored higher on a measure of catastrophic thinking (Pain Catastrophizing Scale; PCS) also rated their pain as more intense, and rated themselves to be more disabled due to their pain. Follow up analyses revealed that the PCS was significantly correlated with the affective subscale of the MPQ but not with the sensory subscale. The helplessness subscale of the PCS was the only dimension of catastrophizing to contribute significant unique variance to the prediction of pain. The PCS was not significantly correlated with measures of evoked pain. Catastrophizing predicted pain-related disability over and above the variance accounted for by pain severity. The findings are discussed in terms of mechanisms linking catastrophic thinking to pain experience. Treatment implications are addressed.     

Worrying about chronic pain. An examination of worry and problem solving in adults who identify as chronic pain sufferers

Worry is a common feature of chronic pain. The purpose of this study was to examine the extent of worry experienced by adults with chronic pain, and to explore features of problem solving associated with worry and chronic pain. A further purpose was to investigate whether there were differences in worry and problem solving for those presenting at a pain clinic for treatment, compared to those who identified as chronic pain sufferers but who were not presenting for treatment. A final purpose was to examine whether the extent of worry and problem solving attitudes helped to predict the primary clinical features of chronic pain such as intensity, disability and depressive mood. One hundred and eighty five adults with chronic pain provided completed questionnaires assessing worrying, problem solving, pain severity, disability, catastrophic thinking and depressive mood. Analyses showed that worry and problem solving approaches sampled in this study were not abnormal. Furthermore, no differences were found between the clinical and non-clinical sample for worrying and problem solving. In relation to the predictive value of worrying and problem solving, analyses revealed that only worrying had a unique contribution in explaining depressive mood. The results are discussed within a context of a model of worry and chronic pain, in which worry about chronic pain may be functioning to promote awareness of an insoluble problem.     

Perceived social support and coping responses are independent variables explaining pain adjustment among chronic pain patients.

The purpose of the present study was to test a hypothetical model of the relationships between perceived social support, coping responses to pain, pain intensity, depressed mood, and functional disability (functional status and functional impairment) in a population of patients with chronic pain in a Spanish Clinical Pain Unit. It was postulated that social support and pain coping responses both independently influence reported pain intensity, depressed mood, and functional disability. Analyses were performed by Structural Equation Modelling. The results indicated that satisfaction with social support is significantly associated with a depressed mood and pain intensity, but not with functional disability. Although this effect is independent of the use of active coping responses by patients, there is a modest but significant relationship between social support and passive coping strategies, indicating that higher levels of perceived social support are related to less passive pain coping strategies. The findings underscore the potential importance of psychosocial factors in adjustment to chronic pain and provide support for a biopsychosocial model of pain. PERSPECTIVE: This article tested a hypothetical model of the relationships between social support, pain coping, and chronic pain adjustment by using Structural Equation Modelling. The results indicate that perceived social support and pain coping are independent predictors of chronic pain adjustment, providing support for a biopsychosocial model of pain.     

Depression and functional disability in chronic pediatric pain.

OBJECTIVES: The primary aim of this study was to describe pain characteristics, coping strategies, depression, and functional disability in children and adolescents with chronic pain and to examine potential factors that are associated with functional disability in a pediatric pain population. The secondary aim of this study was to compare functional disability in two chronic pain conditions: localized musculoskeletal pain and chronic daily headaches. SUBJECTS: The participants in this study were 73 pediatric pain patients with a variety of chronic pain conditions. Subjects in the second part of the study were a subset of patients (N = 44) from the pain clinic sample with chronic localized musculoskeletal pain and a subset of patients (N = 38) from the headache center of the same hospital who had chronic daily headaches. DESIGN: Patients completed self-report measures of pain intensity, depression, coping strategies, coping efficacy, and functional disability. RESULTS: Results indicated that chronic pain had a substantial impact on the children's lives and that depression was strongly associated with functional disability. Maladaptive coping was correlated with depression and disability; however, maladaptive coping was not independently associated with functional disability. A comparison between the two groups found significant differences in pain intensity and functional disability. The localized musculoskeletal pain group reported higher levels of disability and more difficulty coping than the chronic daily headache group. CONCLUSIONS: The implications for treatment of chronic pain in children are discussed with an emphasis on greater attention to developmental issues and their relation to coping, emotional functioning, and disability in pediatric pain. Further research examining differences in coping and disability between different pediatric pain groups is also warranted.     

Parent perceptions of adolescent pain expression: the adolescent pain behavior questionnaire

Pain behaviors provide meaningful information about adolescents in chronic pain, enhancing their verbal report of pain intensity with information about the global pain experience. Caregivers likely consider these expressions when making judgments about their adolescents’ medical or emotional needs. Current validated measures of pain behavior target acute or procedural pain and young or non-verbal children, while observation systems may be too cumbersome for clinical practice. The objective of this research was to design and evaluate the Adolescent Pain Behavior Questionnaire (APBQ), a parent-report measure of adolescent (11-19 years) pain expressions. This paper provides preliminary results on reliability and validity of the APBQ. Parent-adolescent dyads (N = 138) seen in a multidisciplinary pain management clinic completed the APBQ and questionnaires assessing pain characteristics, quality of life, functional disability, depressive symptoms, and pain catastrophizing. Principal components analysis of the APBQ supported a single component structure. The final APBQ scale contained 23 items with high internal consistency (α = 0.93). No relationship was found between parent-reported pain behaviors and adolescent-reported pain intensity. However, significant correlations were found between parent-reported pain behaviors and parent- and adolescent-reported functional disability, pain catastrophizing, depressive symptoms, and poorer quality of life. The assessment of pain behaviors provides qualitatively different information than solely recording pain intensity and disability. It has clinical utility for use in behavioral treatments seeking to reduce disability, poor coping, and distress.