Development and preliminary psychometric evaluation of the parent report version of the Bath Adolescent Pain Questionnaire (BAPQ-P): A multidimensional parent report instrument to assess the impact of chronic pain on adolescents

Assessing the experience and impact of pain in adolescents with chronic pain is necessary to guide both individual treatment and to inform treatment development. Ideally, to obtain a comprehensive understanding of the impact of pain, assessment should be multidimensional, should be sensitive to contextual variables, and should allow for multiple informants (in particular, parents). The purpose of this study was to develop a standardized parent-report measure of chronic pain in adolescents, the Bath Adolescent Pain Questionnaire - Parent report (BAPQ-P). Participants included 222 adolescents with chronic pain and their parents recruited from two specialty clinics in the UK. The adolescents completed a battery of self-report inventories related to their pain and daily functioning whilst parents completed the BAPQ-P and additional measures of adolescent functioning. Scales of the BAPQ-P emerged to be internally consistent and temporally stable over a 17-day period. Validity was examined in relation to existing validated child report measures of anxiety, depression, catastrophizing, disability, family, and social functioning and parent report measures of disability and family functioning. Psychometric evaluation suggests that the BAPQ-P is a reliable and valid parental report tool for assessing the multidimensional impact of adolescent chronic pain. It can be used in conjunction with the previously established adolescent self-report measure, the BAPQ, alone where adolescent self report is not possible, in studies where parent report is the focus, or in studies where concordance between parent and adolescent reports is of interest.     

Spinal cord injury‐related pain in rehabilitation: A cross‐sectional study of relationships with cognitions,mood and physical function

Although psychological aspects of SCI‐related pain have been investigated in those with chronic pain, little data is available regarding these factors in those early in the course of the injury. Using a sample admitted for SCI rehabilitation, this paper describes the relationships between usual pain intensity, mood, disability and both pain and SCI‐related psychological factors. The sample were largely similar to other samples of individuals with SCI‐related chronic pain in terms of mood, but were noted to be less catastrophic in their thinking about pain than a comparative pain clinic sample. They also reported SCI self‐efficacy and acceptance scores consistent with other SCI samples. Compared with other SCI populations there were mixed findings in relation to physical disability. Consistent with previous findings in chronic pain SCI samples, usual pain intensity was found to have a strong relationship with symptoms of anxiety and depression, and pain‐related life interference. SCI acceptance was significantly negatively associated with depression scores, pain catastrophizing was significantly positively associated with both anxiety and depression scores, and SCI self‐efficacy was significantly negatively associated with both anxiety and depression scores. SCI self‐efficacy was also significantly positively associated with physical function scores. These findings suggest that pain‐related psychological factors may have importance even early in the clinical course following SCI, but that it is important, however, to consider more general SCI‐related psychological factors alongside them. In addition, these findings suggest the possibility that early interventions based upon the cognitive behavioural treatment of pain may be integrated into SCI rehabilitation programmes.     

Self‐discrepancies in work‐related upper extremity pain: Relation to emotions and flexible‐goal adjustment

Recurrent pain not only has an impact on disability, but on the long term it may become a threat to one's sense of self. This paper presents a cross‐sectional study of patients with work‐related upper extremity pain and focuses on: (1) the role of self‐discrepancies in this group, (2) the associations between self‐discrepancies, pain, emotions and (3) the interaction between self‐discrepancies and flexible‐goal adjustment. Eighty‐nine participants completed standardized self‐report measures of pain intensity, pain duration, anxiety, depression and flexible‐goal adjustment. A Selves Questionnaire was used to generate self‐discrepancies. A series of hierarchical regression analyses showed relationships between actual–ought other, actual–ought self, actual–feared self‐discrepancies and depression as well as a significant association between actual–ought other self‐discrepancy and anxiety. Furthermore, significant interactions were found between actual–ought other self‐discrepancies and flexibility, indicating that less flexible participants with large self‐discrepancies score higher on depression. This study showed that self‐discrepancies are related to negative emotions and that flexible‐goal adjustment served as a moderator in this relationship. The view of self in pain and flexible‐goal adjustment should be considered as important variables in the process of chronic pain.     

Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents

Adolescents with chronic pain also report severe disability and emotional distress. A clinical sample of 80 adolescents and accompanying parents were investigated to first measure the extent of distress, and second to investigate the relationships between adolescent distress, parental distress and adolescent coping. Measures of pain intensity, anxiety, depression, disability and coping were obtained from adolescents. Parents completed measures including their own anxiety, depression and parenting stress. Overall, adolescents reported high levels of disability, depression and anxiety, and parents reported high levels of depression, anxiety and parenting stress. Multiple regression analyses revealed that the best predictors of adolescent emotional distress were the extent to which the adolescents catastrophize and seek social support to cope with the pain. There were no clear predictors of parental anxiety or depression but the specific pattern of parenting stress was best predicted by the younger age of the adolescent, the greater the chronicity of the problem, and the greater the extent of adolescent depression. These findings suggest that emotional coping is a critical variable in the distress associated with adolescent chronic pain. It is argued that adolescent emotional coping may best be understood within a relational context of seeking emotional support.     

The Impact of Adolescent Chronic Pain on Functioning: Disentangling the Complex Role of Anxiety

A number of adolescents with chronic pain have clinically significant disability across physical, social, and academic activities, and pain severity only explains a portion of the variance in functioning. Thus, it is important to identify therapeutic options to improve adolescents' functioning. In contrast to studies with adults with chronic pain, research in pediatric pain has not consistently found anxiety to be a good predictor of pain-related disability. The present study evaluated pain, anxiety, and functioning in 222 adolescents with chronic pain. Results indicated that pain was consistently and linearly related to disability across measures of physical and social functioning, school attendance, and physician visits. The relation between anxiety and functioning was complex; increased anxiety was related to poorer physical and social functioning and was related to fewer physician visits, although it was not associated with school attendance. Additional analyses revealed that anxiety serves to moderate the relation between pain and functioning. Specifically, at high anxiety, pain was not related to functioning, but at low anxiety, pain consistently predicted disability. In other words, highly anxious adolescents were functioning poorly regardless of the level of pain. The moderating role of anxiety highlights a number of research and clinical possibilities to explore with adolescents with chronic pain-related disability.     

A comparison of family functioning when mothers have chronic pain

Multiple aspects of family functioning were assessed when mothers experienced either chronic pain, a chronic illness (diabetes), or no illness. Mothers' and fathers' self-report measures of depression, anxiety, and family environment were collected. Children's self-report measures of depression and anxiety, as well as information about their overall adjustment, were collected. Family communication patterns were also assessed. Families with a mother who had chronic pain had poorer perceived family environments and higher levels of depression and anxiety compared to the other two groups of families. Children from chronic pain families also appeared to be adversely affected. The data suggest that level of disability appeared more salient than the type of chronic illness. Implications of the findings are discussed in light of the fact that mothers with chronic pain in the present sample reported relatively mild disability and were not actively seeking treatment for their condition.     

Marital functioning, chronic pain, and psychological distress

This study examined whether marital functioning variables related uniquely to psychological distress and diagnoses of depressive disorder independent of pain severity and physical disability. Participants were 110 chronic musculoskeletal pain patients. Hierarchical regression results showed that marital variables (i.e. marital satisfaction, negative spouse responses to pain) contributed significantly to depressive and anxiety symptoms over and above the effects of pain severity and physical disability. In contrast, marital variables were not significantly related to diagnoses of depressive disorder (i.e. major depression, dysthymia, or both) after controlling for pain variables. In multivariate analyses, physical disability and marital satisfaction were uniquely related to depressive symptoms whereas physical disability, pain severity, and negative spouse responses to pain were uniquely related to anxiety symptoms. Only physical disability was uniquely related to major depression. The results suggest that models of psychological distress in chronic pain patients might be enhanced by attributing greater importance to interpersonal functioning and increasing attention to anxiety.     

The relationship between maternal and child mental health in Mexican immigrant families

Depression is a leading cause of disability in the United States, with Mexican immigrant women reporting depression rates higher than the national average. The purposes of this study were to describe mental health symptoms in a sample (n = 182) of Mexican immigrant mothers and their relationships to child mental health, family functioning, and acculturation. Over one third of the mothers reported depression and anxiety symptoms above standardized cutoffs while 31% of the children scored in the depressed range. Of those children with high depression scores, 51% also had a mother with high depression and anxiety scores. Boys' depression scores were related to maternal reports of family functioning and stress, while girls' depression scores were related to maternal reports of depression, anxiety, and stress. Maternal mental health symptoms were associated with family functioning but not with acculturation. These data indicate that poorer maternal mental health and family functioning is associated with greater stress in Mexican immigrant children.     

Illness‐specific anxiety: Implications for functioning and utilization of medical services in adolescents with inflammatory bowel disease

Purpose. Adolescents with inflammatory bowel disease (IBD) may be at heightened risk for developing anxiety and depression. This cross‐sectional pilot study examined the relationship between anxiety and depression and health‐related behaviors. Methods. Thirty‐six adolescents with diagnosed IBD, ages 12–17, and their parents were recruited from two pediatric gastroenterology medical centers. Results. Clinical levels of anxiety (22%) and depressive symptoms (30%) were reported by patients. Regression analyses revealed that IBD‐specific anxiety was significantly associated with greater utilization of medical services and worsened psychosocial functioning. Practice Implications. Results provide preliminary support that IBD‐specific anxiety may play an important role in disease management, yet concerns are rarely systematically assessed by health professionals.     

Young people making sense of pain: Cognitive appraisal,function, and pain in 8–16 year old children

Recurrent pain is a common childhood problem which for some becomes chronic and is associated with severely impaired functioning. Relationships of psychological variables with impaired functioning have rarely been investigated in samples of children reporting pain in non‐clinical settings. The aim of this study was to examine the role of cognitive appraisal in the relationship between chronic pain and level of functioning in a normal school‐attending population of children who report pain as a common experience. Five hundred and sixty one schoolchildren aged between 8 and 16 years and their parents participated in a cross‐sectional interview and questionnaire study. Child functioning was measured in two ways: self‐reported quality of life, and self‐reported functional disability associated with pain. Results showed a consistent pattern across both specific measures of functioning used. Catastrophic appraisals of pain can explain partially the functional impairment found in a sample of normal schoolchildren with chronic pain. Positive expectations about ability, the responsibility to exert control over the pain, and the belief that medication and doctors will help to control the pain, were found to be protective of normal functioning in chronic pain. Cognitive factors were found to mediate but not moderate the relationship between pain and disability, and quality of life.     

Schmerzbezogene Beeinträchtigung bei Jugendlichen mit chronischen Schmerzen

Background

Pain-related disability affects many children and adolescents suffering from chronic pain and may exert an impact on all areas of their lives. Reduction of pain-related disability is, therefore, a fundamental aim of treatment; however, no validated means exist to assess pain-related disability in children and adolescents. The aim of this study was to translate the Pediatric Pain Disability Index (P-PDI) of Varni into German and to investigate its psychometric qualities.

Methods

Principal component and item analyses were conducted on outpatient (n=163) and inpatient samples (n=167) of adolescents suffering from chronic pain. Changes in pain-related disability 3 months after starting treatment were analysed in an outpatient sample of 110 adolescents. Correlations between pain-related disability, emotional variables and school absence as well as concordance with parents’ ratings were investigated.

Results

The P-PDI is a one-dimensional assessment tool with sufficient reliability. There were significant correlations between pain-related disability and pain intensity and school absence but not with pain duration, fear and depression. Parents and adolescents ratings correlated significantly, but 57% of parents underestimated the pain-related disability of their children.

Conclusion

There is now a validated German version of the P-PDI to measure pain-related disability in adolescents suffering from chronic pain, which can be used in studies investigating treatment effectiveness.     

Chronic Pain and Mental Health Co-Morbidity in Adolescents: An Urgent Call for Assessment and Evidence-Based Intervention

BackgroundNearly 30% of children are affected by chronic pain which puts a significant burden on the child's family and society with estimated cost of over $19.5 billion each year. Children and adolescent's quality of life is often impacted leading to physical disability, low self-esteem, depression, anxiety, school stress or decreased performance, insomnia, and fatigue. The purposes of this paper are to: 1) provide an overview of chronic pain in children and adolescents; 2) describe findings from a quality improvement project that assessed the prevalence of negative mood, quality of life, functional disability, and coping with pain in teens with chronic pain, and 3) discuss screening, assessment and evidence-based management of co-morbid chronic pain and mental health problems in children and teens.FindingsFindings for a quality improvement project indicated that 16.8% of the adolescents scored high risk for depression, which was higher than the national average. Approximately 57% of adolescents were screened as high risk on the Pediatric Quality of Life inventory (PedsQL™). One in four adolescents showed poor functioning on the Functional Disability Inventory and nearly one-third of the adolescents reported poor coping with pain on the Pain Coping Questionnaire. This project indicates that adolescents with chronic pain are at high risk for mental health problems. The outcomes suggest the mental health needs of adolescents with chronic pain need to be identified and addressed to help improve outcomes.DiscussionChildren and youth with chronic pain need to be routinely screened and assessed for mental health problems, especially anxiety and depression. The use of Cognitive Behavioral Therapy (CBT) or CBT-skills building for children and youth with anxiety and depressive disorders has been widely studied and are helpful for children with chronic pain include psychoeducation, which helps the child to learn age and developmental specific information on chronic pain. Evidence-based manualized and internet-based CBT programs should be scaled rapidly to decrease depression and anxiety in children and youth with chronic pain.     

Adverse Childhood Experiences in Mothers With Chronic Pain and Intergenerational Impact on Children

Adverse childhood experiences (ACEs; eg, parental divorce, physical or sexual abuse) are more prevalent in individuals with chronic pain compared with the general population. Both increased maternal ACEs and chronic pain have been associated with poor physical and emotional functioning in offspring. However, the mechanisms driving these associations are poorly understood. Thus, this cross-sectional study evaluated the relation between maternal ACEs, mothers’ current functioning, and children's physical and emotional functioning in a sample of mothers with chronic pain and their 8- to 12-year-old children. Results indicated a higher prevalence of ≥1 ACE in this sample of mothers with chronic pain (84%) compared with normative data from a community sample of women. Higher maternal ACE scores corresponded with lower physical and social functioning, greater anxiety and depressive symptoms, greater fatigue and sleep disturbances, and greater pain intensity and pain interference in mothers. Higher maternal ACE scores significantly correlated with higher child self-reported depressive symptoms, but not somatic symptoms or functional impairment. A path model indicated that maternal depressive symptoms accounted for the relation between higher maternal ACE scores and children's depressive symptoms. Intervening on maternal depression among mothers with chronic pain may reduce the impact of intergenerational ACE transmission.Perspective: This article presents evidence regarding the intergenerational impact of ACEs in a large sample of mothers with chronic pain and their school-aged children. Maternal depressive symptoms accounted for the relation between maternal ACEs and children's depressive symptoms providing evidence regarding targets for preventive interventions.     

Domains of Chronic Low Back Pain and Assessing Treatment Effectiveness: A Clinical Perspective

Nonspecific chronic low back pain (CLBP) is a common clinical condition that has impacts at both the individual and societal level. Pain intensity is a primary outcome used in clinical practice to quantify the severity of CLBP and the efficacy of its treatment; however, pain is a subjective experience that is impacted by a multitude of factors. Moreover, differences in effect sizes for pain intensity are not observed between common conservative treatments, such as spinal manipulative therapy, cognitive behavioral therapy, acupuncture, and exercise training. As pain science evolves, the biopsychosocial model is gaining interest in its application for CLBP management. The aim of this article is to discuss our current scientific understanding of pain and present why additional factors should be considered in conservative CLBP management. In addition to pain intensity, we recommend that clinicians should consider assessing the multidimensional nature of CLBP by including physical (disability, muscular strength and endurance, performance in activities of daily living, and body composition), psychological (kinesiophobia, fear‐avoidance, pain catastrophizing, pain self‐efficacy, depression, anxiety, and sleep quality), social (social functioning and work absenteeism), and health‐related quality‐of‐life measures, depending on what is deemed relevant for each individual. This review also provides practical recommendations to clinicians for the assessment of outcomes beyond pain intensity, including information on how large a change must be for it to be considered “real” in an individual patient. This information can guide treatment selection when working with an individual with CLBP.     

A content analysis of ideal,ought, and feared selves in patients with chronic low back pain

Patients with chronic pain are not only faced with disabilities but are also challenged to maintain a valued sense of self. This sense of self is in part determined by the extent to which patients can accomplish their identity‐related goals. The present study explores the content of three domains of the self, namely the ideal, ought and feared self and examines how the content relates to disability and depression. The ideal, ought and feared attributes of 80 chronic low back pain patients were analyzed and categorized in eight general goal‐domains: interpersonal attributes, personal abilities, physical, emotional and psychological well‐being, close interpersonal relationships, self‐expression abilities, achievement‐related attributes, physical appearance, and religion. Results showed that most of the attributes that patients generated involved interpersonal attributes. Comparisons between the self‐guides revealed that ideal attributes were more intrapersonally focused while ought and feared attributes were interpersonally focused. The content appeared to be related to disability but not to depression. More specifically, the more disabled patients were, the more they listed well‐being related attributes as part of their ought self. None of the other goal‐domains was related to disability or depression. The present study provides additional insight into the goals of patients with chronic pain at the level of identity and has shown that these are, at least in part, related to the level of functional disability. These results might be useful for future studies incorporating the role of identity in chronic pain, such as psychological interventions.     

Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash

Cognitive behavior therapy (CBT) has made important contributions to chronic pain management, but the process by which it is effective is not clear. Recently, strong arguments have been raised concerning the need for theory driven research to e.g. identify mechanisms of change in CBT and enhance the effectiveness of this type of treatment. However, the number of studies addressing these issues is still relatively scarce. Furthermore, the arrival of varieties of CBT with seemingly different process targets increases the need for such information. The present study explored the processes of change in a previously reported successful randomized controlled trial evaluating the effectiveness of an exposure‐based form of behavioral and cognitive therapy, Acceptance and Commitment Therapy (ACT), on improvement in pain‐related disability and life satisfaction for patients suffering from whiplash‐associated disorder (WAD). Several process variables relevant to theories underlying traditional CBT were included: pain, distress, kinesiophobia, self‐efficacy, and the process primarily targeted by ACT: psychological inflexibility. Mediation analyses were performed using a non‐parametric cross‐product of the coefficients approach. Results illustrated that pain intensity, anxiety, depression, kinesiophobia, and self‐efficacy did not have significant mediating effects on the dependent variables. In contrast, significant indirect effects were seen for psychological inflexibility on pain‐related disability (pre‐ to post‐change scores) and life satisfaction (pre‐ to post; pre‐ to 4‐month follow‐up change scores). Although tentative, these results support the mediating role of psychological inflexibility in ACT‐oriented interventions aimed at improving functioning and life satisfaction in people with chronic pain.     

Neuropsychological Functioning and Treatment Outcomes in Acceptance and Commitment Therapy for Chronic Pain

Neuropsychological (NP) performance has been associated with psychosocial treatment outcomes in nonpain conditions, but has never been investigated in chronic pain. We performed a secondary analysis on the association of baseline NP performance with treatment outcomes among veterans with chronic pain (N?=?117) undergoing an 8-week acceptance and commitment therapy (ACT) intervention. Participants completed measures of pain interference, pain severity, quality of life, activity levels, depression, and pain-related anxiety at baseline, midtreatment, and post-treatment. Executive functioning, working memory, processing speed, learning, and verbal memory were assessed at baseline. All study measures significantly improved from baseline to post-treatment. NP performance was related to changes in depression and pain-related anxiety during treatment. Specifically, relatively lower executive functioning and processing speed was associated with greater decreases in depressive symptoms, and relatively lower processing speed was associated with greater decreases in pain-related anxiety. Consistent with research in nonpain conditions, those with relatively lower NP functioning received greater benefit from psychosocial treatment, although most study outcomes did not differ as a function of NP performance. Our results suggest relatively lower NP functioning is not contraindicated for participation in psychosocial interventions like ACT but instead may be associated with greater relief.

Subjective sleep disturbances in adolescents with chronic pain: relationship to daily functioning and quality of life.

The purpose of this study was to examine the relationship between pain symptoms, daily functioning, health-related quality of life (HRQOL), and subjectively reported sleep disturbances in adolescents with chronic pain. Depressive symptoms were tested as a general risk factor for increased sleep problems. During routine subspecialty clinic visits, 86 adolescents (mean age, 14.75 years; 67% female) diagnosed with chronic headaches, juvenile idiopathic arthritis, or sickle cell disease completed measures to assess pain, sleep disturbances, functional disability, depression, and HRQOL. Across pain diagnoses, adolescents experienced similar sleep patterns and sleep behaviors with the exception of daytime sleepiness, which was higher in adolescents with headache compared to adolescents with sickle cell disease. Bivariate correlations showed low relationships between pain and sleep and moderate to high relationships between depressive symptoms, daily functioning, HRQOL, and sleep. In multivariate analyses, as hypothesized, depressive symptoms were predictive of the severity of sleep disturbances after controlling for the effect of all other demographic, pain, and functional impact variables. Results suggest that a relationship between the experience of recurrent and chronic pain and sleep disturbances exists for adolescents, and these sleep disturbances are linked to mood disturbances and reductions in daily functioning and quality of life. Sleep disturbances have been described in adult patients with chronic pain, but little is known about sleep in adolescents with chronic pain. This study examined the complex interrelationship between sleep, pain, mood, functioning, and HRQOL. Findings suggest that mood is strongly related to sleep and might share common pathophysiologic or behavioral origins in adolescents with chronic pain.     

Gender moderates the association between depression and disability in chronic pain patients.

Pain-related anxiety and depression are important correlates of disability amongst chronic pain patients. Furthermore, women may differ in their experience of pain, anxiety and depression when compared to men. The aim of the current study was to determine the relative contribution of anxiety and depression on disability in male and female chronic pain patients. The sample consisted of 260 patients (101 males, 159 females) referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases in Bath, UK. As part of an initial assessment, all patients completed measures of depression, pain-related anxiety and disability. As predicted, both anxiety and depression were found to be significant positive predictors of pain, number of medications used and disability. Although gender did not significantly predict disability, it did moderate the relationship between depression and disability, in that when depression was high, women report greater disability than men. Gender was also found to moderate the relationship between depression and number of medications used, in that a positive association was found for men, but not women. However, gender did not significantly moderate the relationship between anxiety and disability. Together these results not only suggest that gender is an important moderator of the relationship between emotional responses and disability, but that such associations may be related more to depression than anxiety.     

Prevalence,severity, and chronicity of pain and general health‐related quality of life in patients with localized prostate cancer

Aims: To analyze the prevalence and the severity spectrum of pain and its relationships to health‐related quality of life and the bio‐psycho‐social consequences of pain among patients scheduled for radical prostatectomy. Methods: Urological inpatients completed an epidemiological pain questionnaire extensively exploring pre‐operative acute and chronic pains in 21 body regions. The severity of pain was determined using von Korff's Pain Grading (CPGQ). Pain chronicity was estimated employing the Mainz Pain Staging System (MPSS). Anxiety and depressive symptoms were identified with the HADS and the Habitual Well‐Being Questionnaire (FW‐7). Health‐related quality of life was measured using the SF‐12. Comorbidities and comorbidity‐related interferences with daily activities were ascertained with the Weighted Illness Checklist (WICL). Results: Eighty of 115 patients (69.6%) reported about pain during the last 3 months pre‐operatively. 28.7% of the pain patients had pain related to urological disease. Severe dysfunctional pain was identified by pain Grades 3 and 4 of the CPGQ in 20% and 13.8%, respectively. Advanced pain chronicity characterized by pain Stages II and III of the MPSS was present in 38.8% and 11.3%. Patients with localized prostate cancer without pain complaints had significantly better health‐related quality of life and habitual well‐being and lower anxiety and depression scores and fewer comorbidities. Patients with cancer‐related and non‐cancer pain did not differ in pain chronicity, pain severity, pain intensities, anxiety, comorbidities and physical health (SF12‐PCS). Conclusions: The high prevalence of severe and chronic pain in cancer patients before scheduled radical prostatectomy – combined with considerable disability effects and markedly reduced quality of life necessitate a short routine screening‐analysis of the severity spectrum of pain and psychopathology. Patient self‐rated pain chronicity staging and psychological distress analysis will allow a disorder severity‐guided treatment and the prevention of suffering and additional new chronic post‐surgical pain.