Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of ...Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included were 273 adolescents (205 females and 68 males), aged 11 to 17 years with mixed chronic pain conditions and their parents, who were randomly assigned in a parallel-group design to Internet-delivered CBT (n = 138) or Internet-delivered Education (n = 135). Assessments were completed before treatment, immediately after treatment, and at 6-month follow-up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to 6-month follow-up for Internet CBT compared with Internet education (b = -1.13, P = 0.03). On secondary outcomes, significant beneficial effects of Internet CBT were found on sleep quality (b = 0.14, P = 0.04), on reducing parent miscarried helping (b = -2.66, P = 0.007) and protective behaviors (b = -0.19, P = 0.001), and on treatment satisfaction (P values < 0.05). On exploratory outcomes, benefits of Internet CBT were found for parent-perceived impact (ie, reductions in depression, anxiety, self-blame about their adolescent's pain, and improvement in parent behavioral responses to pain). In conclusion, our Internet-delivered CBT intervention produced a number of beneficial effects on adolescent and parent outcomes, and could ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families.
The primary aim of this systematic review was to examine the evidence for a pain-sleep relationship in children with persistent pain by reviewing studies using single and mixed pediatric persistent ...pain samples.
Electronic searches of Medline, PubMed, the Cochrane Database of Systematic Reviews, and PsycINFO were conducted to identify all relevant empirical studies. Studies were included in the review if the majority of participants were between 0 and 17 years and from one of the following pediatric pain populations: juvenile idiopathic arthritis, sickle cell disease, migraine/headache, functional abdominal pain, juvenile fibromyalgia syndrome, chronic musculoskeletal pain, or mixed populations including the aforementioned conditions.
Research from single and mixed sample studies support the hypothesis that children and adolescents with persistent pain suffer from sleep impairment. Literature addressing factors that may influence or mediate the pain-sleep relationship and the functional outcomes of the pain-sleep relationship was reviewed, and a model of the interrelationships with pain and sleep was developed.
Findings from this review highlight the need to assess and treat sleep problems in children presenting with persistent pain. Health care providers should consider conducting routine sleep screenings, including a comprehensive description of sleep patterns and behaviors obtained through clinical interview, sleep diaries, and/or the use of standardized measures of sleep. Future research focusing on investigating the mechanisms associating sleep and pediatric persistent pain and on functional outcomes of poor sleep in pediatric pain populations is needed.
Objective
To use electronic diaries (e‐diaries) to determine whether pain, stiffness, and fatigue continue to be common, disabling symptoms in children with juvenile idiopathic arthritis (JIA) ...despite the use of aggressive treatments in contemporary medical management.
Methods
Fifty‐nine children with JIA (ages 8–18 years) provided ratings of pain, stiffness, and fatigue intensity and functional limitations using a smartphone e‐diary 3 times each day for 1 month. Medication information was collected via parent report and checked for accuracy by chart review. Descriptive analyses were conducted to determine typical symptom intensity, frequency, and variability. Multilevel modeling was used to analyze associations between symptoms and functional outcomes and between medication use and symptom intensity.
Results
Children reported moments of pain in 66% of e‐diary entries. No children were entirely pain‐free across the reporting period. In 31% of all e‐diary entries the visual analog scale score for pain was >40 (high pain intensity), with 86% of children reporting a high level of pain at least once during the study period. The mean ratings of pain, stiffness, and fatigue intensity were in the mild‐to‐moderate range. Medication class was not a reliable predictor of differences in symptom intensity, even though 79% of children were prescribed a disease‐modifying antirheumatic drug and 47% were prescribed a biologic agent. Moments of higher pain intensity and higher stiffness intensity were each uniquely predictive of higher concurrent functional limitations.
Conclusion
Self‐reported pain, stiffness, and fatigue continue to be common in children with JIA, despite contemporary advances in treatment strategies, including use of biologic agents. These findings are surprisingly consistent with previous results from research using daily paper diaries in the pre‐biologics era. There remains a pressing and ongoing need to optimize pain and symptom management in JIA.
To assess whether adolescent-parent agreement on treatment goals as part of an Internet-delivered cognitive-behavioral pain intervention was associated with adolescent outcomes. 122 adolescent-parent ...dyads selected two treatment goals. Pain intensity and pain-related disability were assessed at pre-treatment, post-treatment, and 6- and 12-month follow-ups. We compared dyads who had goal agreement versus no agreement. 74 dyads (61%) agreed on one or more treatment goals, most commonly going to school, sports, and sleep. In dyads who chose the same goal, regardless of the content, adolescents had lower pain intensity post-treatment and at follow-up. When goals were categorized by domain, in dyads who agreed on physically active goals, adolescents were more likely to report lower pain intensity compared with other groups. Agreement of goals was not associated with changes in pain-related disability. Agreement on treatment goals may be an important treatment process to maximize outcomes in self-management therapies.
Abstract
Objective
Insomnia is a highly prevalent sleep disorder that is particularly common among adolescents with health conditions. We aimed to develop and validate a brief screening measure of ...insomnia in adolescents that can be used across clinical and community samples. We hypothesized that we would identify evidence supporting reliability, convergent/discriminant validity, and that we would determine preliminary clinical cutoff scores.
Methods
A team of experts in behavioral sleep medicine developed a 13-item brief screening measure of insomnia in adolescents (Adolescent Insomnia Questionnaire AIQ). We evaluated the psychometric properties of the AIQ in a sample of 315 youth (11–18 years old, Mean = 14.90, SD = 2.02; 64% female) who had chronic pain (n = 37), headache (n = 170), insomnia diagnosed by a sleep specialist (n = 22), or were otherwise healthy (n = 86).
Results
Using Exploratory and Confirmatory Factor Analysis, we identified three subscales consistent with major diagnostic criteria of insomnia. As expected, the measure showed strong reliability through high internal consistency (α =.91). We also found strong convergent validity through expected positive relationships between the AIQ and self-report measures of sleep disturbance, and divergent validity via weak relationships with parent-report of snoring. Results of receiver operating characteristic (ROC) identified a clinical cutoff score that may assist in clinical decision making.
Conclusions
We found that the AIQ has sound psychometric properties in a large heterogeneous sample of treatment-seeking youth and youth from the community. The AIQ can quickly screen adolescent insomnia and could address an important clinical need in identifying youth in need of insomnia treatment in pediatric practice settings.
Objective: Children with arthritis experience frequent pain, but the predictors of daily pain variations are largely unidentified. The goal of this study was to examine sleep quality as a predictor ...of pain in children with arthritis and to determine whether mood moderates this relationship. Method: In this prospective, longitudinal study children with polyarticular arthritis (n = 51, ages 8-16 years) tracked daily symptoms, including sleep quality over 2 months. Self-reported daily pain intensity, as indicated on a visual analog scale, was used as the primary outcome measure in multilevel models. Results: Poorer sleep quality was associated with higher next-day pain ratings (p < .01). Mood moderated this relationship such that as positive mood increased, the relationship between poor sleep quality and high pain weakened (p < .01). Daily pain did not predict nightly sleep quality (p > .05). Conclusions: Sleep quality is an important predictor of pain in children with arthritis. These findings add to the growing body of literature on the use of daily diaries for analyzing patterns of pain, sleep, and mood in children with chronic painful conditions.
This prospective longitudinal study examined the long-term physical and psychosocial outcomes of adolescents with juvenile-onset fibromyalgia (JFM), compared with healthy control subjects, into early ...adulthood.
Adolescent patients with JFM initially seen at a pediatric rheumatology clinic (n = 94) and age- and gender-matched healthy control subjects (n = 33) completed online measures of demographic characteristics, pain, physical functioning, mood symptoms, and health care utilization at ∼6 years' follow-up (mean age: 21 years). A standard in-person tender-point examination was conducted.
Patients with JFM had significantly higher pain (P < .001), poorer physical function (P < .001), greater anxiety (P < .001) and depressive symptoms (P < .001), and more medical visits (P < .001)than control subjects. The majority (>80%) of JFM patients continued to experience fibromyalgia symptoms into early adulthood, and 51.1% of the JFM sample met American College of Rheumatology criteria for adult fibromyalgia at follow-up. Patients with JFM were more likely than control subjects to be married and less likely to obtain a college education.
Adolescent patients with JFM have a high likelihood of continued fibromyalgia symptoms into young adulthood. Those who met criteria for fibromyalgia in adulthood exhibited the highest levels of physical and emotional impairment. Emerging differences in educational attainment and marital status were also found in the JFM group. JFM is likely to be a long-term condition for many patients, and this study for the first time describes the wide-ranging impact of JFM on a variety of physical and psychosocial outcomes that seem to diverge from their same-age peers.
This study examined outcomes and predictors of different types of responses to child pain used by caregivers of youth with chronic disease. Sixty-six children and adolescents (ages 7-18) with ...juvenile idiopathic arthritis answered questions about pain, pain interference in activities, and mood on a smartphone three times per day for one month, while a caregiver contemporaneously answered questions about their own mood and use of protecting, monitoring, minimizing, or distracting responses to their child's pain. Multilevel models were used to evaluate (a) how a child's pain and pain interference changes after a caregiver uses different types of pain responses; (b) the extent to which caregiver responses to pain vary across days; and (c) whether variability in caregiver responses to pain is predicted by changes in child pain characteristics, child mood, and/or caregiver mood. Results showed that children's pain intensity and pain interference increased following moments when caregivers used more protective responses, whereas children's pain interference decreased following times when caregivers responded with minimizing responses. Caregiver pain responses varied considerably across days, with caregivers responding with more protecting and monitoring responses and fewer minimizing responses at moments when their child reported high levels of pain unpleasantness and pain interference. Caregivers also were found to respond with fewer protective responses at moments when they themselves were in a more positive mood. Implications for clinical recommendations and future studies are discussed.
Aim
Adolescents with physical disabilities may have co‐occurring chronic pain, but the prevalence and specific associated factors are unknown. The aims of this study were to determine (1) the ...prevalence of chronic pain in adolescents with physical disabilities and (2) whether known correlates of chronic pain in the general population are also present in young people both with physical disability and with chronic pain relative to peers.
Method
We conducted a secondary analysis of cross‐sectional nationally representative data from the National Longitudinal Study of Adolescent to Adult Health. Multivariate linear regression analysis was used to identify demographic and psychosocial factors associated with chronic pain.
Results
A total of 989 (4.3%) adolescents reported physical disabilities. They had a significantly higher rate of pain (27.2%) compared with able‐bodied peers (15.6%, χ2=86.3550, p<0.001). There was no significant interaction between physical disability status and chronic pain in relation to depressive symptoms, anxiety, or insomnia.
Interpretation
Adolescents with physical disabilities experience chronic pain at a significantly higher rate than able‐bodied peers, but the comorbidity of physical disability and chronic pain is not related to depression, anxiety, or insomnia. Evaluation of chronic pain and tailored pain interventions need to be developed for this population.
What this paper adds
Chronic pain and its correlates are important problems for adolescents with physical disabilities.
These adolescents present with higher rates of chronic pain than other young people.
Chronic pain is associated with increased levels of depressive symptoms, anxiety, and insomnia regardless of disability status.
Resumen
Prevalencia del dolor crónico y factores asociados en adolescentes con y sin discapacidades físicas
Objetivo
Los adolescentes con discapacidades físicas pueden tener dolor crónico concurrente, pero la prevalencia y los factores asociados específicos son desconocidos. Los objetivos de este estudio fueron determinar (1) la prevalencia de dolor crónico en adolescentes con discapacidades físicas y (2) comprobar si los correlatos conocidos de dolor crónico en la población general también están presentes en los jóvenes con discapacidad física y con dolor crónico relativo a los pares.
Método
Llevamos a cabo un análisis secundario de datos transversales representativos a nivel nacional del Estudio Nacional Longitudinal de Salud de Adolescentes y Adultos. El análisis de regresión lineal multivariante se utilizó para identificar los factores demográficos y psicosociales asociados con el dolor crónico.
Resultados
Un total de 989 (4,3%) adolescentes reportaron discapacidades físicas. Tenían una tasa de dolor significativamente más alta (27,2%) en comparación con los compañeros sanos (15,6%, χ2 = 86,3550, p <0,001). No hubo una interacción significativa entre el estado de discapacidad física y el dolor crónico en relación con los síntomas depresivos, la ansiedad o el insomnio.
Interpretación
Los adolescentes con discapacidades físicas experimentan dolor crónico a una tasa significativamente más alta que los compañeros sin discapacidades físicas, pero la comorbilidad de la discapacidad física y el dolor crónico no está relacionada con la depresión, la ansiedad o el insomnio. La evaluación del dolor crónico y las intervenciones de dolor individualizadas deben desarrollarse para esta población.
Resumo
Prevalência de dor crônica e fatores associados em crianças e adolescentes com e sem deficiências físicas
Objetivo
Adolescentes com deficiência física podem ter co‐ocorrência de dor crônica, mas a prevalência e fatores associados específicos são desconhecidos. Os objetivos deste estudo foram determinar 1) a prevalência de dor crônica em adolescentes com deficiência física e 2) se correlatos conhecidos da dor crônica na população geral também estão presentes em jovens com deficiência física e com dor crônica em relação a seus pares.
Método
Realizamos uma análise secundária de dados transversais nacionalmente representativos do Estudo Longitudinal Nacional de Saúde do Adolescente ao Adulto. Análise de regressão linear multivariada foi usada para identificar fatores demográficos e psicossociais associados com dor crônica.
Resultados
Um total de 989 (4,3%) dos adolescentes relataram deficiência física. Eles tiveram uma taxa significantemente mais alta de dor (27,2%) comparados com seus pares sem deficiência (15,6%, χ2=86,3550, p<0,001). Não houve interação significativa entre deficiência física e dor crônica em relação a sintomas depressivos, ansiedade, ou insônia.
Interpretação
Adolescentes com deficiência física experienciam dor crônica em uma taxa significantemente mais alta do que seus pares sem deficiência, mas a comordidade da deficiência física e dor crônica não está relacionada a depressão, ansiedade ou insônia. A avaliação da dor crônica e intervenções direcionadas para a dor precisam ser desenvolvidas para esta população.
What this paper adds
Chronic pain and its correlates are important problems for adolescents with physical disabilities.
These adolescents present with higher rates of chronic pain than other young people.
Chronic pain is associated with increased levels of depressive symptoms, anxiety, and insomnia regardless of disability status.
This article is commented on by McGuire and Lydon on page 538 of this issue.
This article's has been translated into Spanish and Portuguese.
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OBJECTIVES:Suicidal ideation (SI) is common during adolescence and may have lethal outcomes. Despite evidence of the high prevalence and impact of suicidality in adults with chronic pain (CP), ...remarkably little is known about suicidality in adolescents with CP. This study aimed to examine the rates and characteristics of SI in a clinical sample of adolescents with CP compared with youth without CP. We also examined the relationship between pain-related and psychosocial factors and SI in youth.
MATERIALS AND METHODS:Adolescents with (n=95) and without CP (n=91) completed self-reports of pain, functional disability, loneliness, family functioning, self-worth, and depressive symptoms including SI.
RESULTS:Rates of SI were not different in youth with CP when compared with those without ((Equation is included in full-text article.), P>0.05). The content of suicidal thoughts also did not vary by group. Multivariate analysis showed an identical pattern of psychosocial correlates of SI in youth with and without CP; higher depressive symptoms and lower self-worth were associated with higher SI severity, controlling for demographics. Pain characteristics and functional disability were not significantly related to SI in youth with CP.
DISCUSSION:Contrary to hypotheses and past findings in adults with CP, adolescents with CP did not endorse SI more frequently than peers without CP. Several psychosocial correlates were significantly associated with SI severity in our sample. Findings from this study serve as a foundation for future research on SI and associated risk factors in this population.
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