Centering Patient and Clinician Voices in Developing Tools to Address Pain Related School Impairment: A Phase I Study of a Virtual Reality School Simulation for Children and Adolescents with Chronic Pain.

Building on growing evidence supporting virtual reality (VR) interventions for pain management, this study describes the process of developing vReal-School (vRS), a VR-based school simulation for children and adolescents with chronic pain and associated school impairment. Following guidelines for developing user-centered VR interventions, initial phases of intervention development focus on understanding and incorporating patient and clinician perspectives when designing this digital health tool. Phase I entailed focus groups with patients undergoing intensive interdisciplinary pain treatment (IIPT). A total of 19 participants across four focus groups shared their experiences related to dealing with pain at school and provided initial feedback on the concept of a VR-based school simulation. In phase II, we pilot-tested a vRS prototype and collected patient and clinician feedback via mixed method approaches. Phase I results highlight four themes related to pain in school, including physical/environmental challenges and solutions, academic challenges and solutions, peer interaction challenges and solutions, and teacher interaction challenges and solutions. These themes guided the development of our vRS prototype. Nine patients and eleven treating clinicians then engaged with the vRS prototype and provided feedback via semi-structured interviews and validated self-report measures. The results indicate high levels of patient engagement/immersion (mean total score of 17.0 on the Child Presence Measure). Qualitative feedback from both groups identified positive aspects of vRS, including finding the simulation realistic and easy to use and offering ways to address school functioning goals that are not otherwise feasible in the IIPT setting. Areas for improvement included integrating more physical movement as well as increasing the number of scenarios and the level of demands of the tasks available. Both patients and clinicians found vRS to be useful in the IIPT context and relevant to treatment goals. This user input will guide subsequent iterations of intervention development.

Clinical Characterization of Juvenile Fibromyalgia in a Multicenter Cohort of Adolescents Enrolled in a Randomized Clinical Trial.

OBJECTIVE: Juvenile fibromyalgia (JFM) is a complex chronic pain condition that remains poorly understood. The study aimed to expand the clinical characterization of JFM in a large representative sample of adolescents with JFM and identify psychological factors that predict pain interference. METHODS: Participants were 203 adolescents (ages 12-17 years) who completed baseline assessments for the multisite Fibromyalgia Integrative Training for Teens (FIT Teens) randomized control trial. Participants completed the Pain and Symptom Assessment Tool, which includes a Widespread Pain Index (WPI; 0-18 pain locations) and Symptom Severity checklist of associated somatic symptoms (SS; 0-12) based on the 2010 American College of Rheumatology criteria for fibromyalgia. Participants also completed self-report measures of pain intensity, functional impairment, and psychological functioning. RESULTS: Participants endorsed a median of 11 painful body sites (WPI score) and had a median SS score of 9. Fatigue and nonrestorative sleep were prominent features and rated as moderate to severe by 85% of participants. Additionally, neurologic, autonomic, gastroenterologic, and psychological symptoms were frequently endorsed. The WPI score was significantly correlated with pain intensity and catastrophizing, while SS scores were associated with pain intensity and all domains of physical and psychological functioning. Depressive symptoms, fatigue, and pain catastrophizing predicted severity of pain impairment. CONCLUSION: JFM is characterized by chronic widespread pain with fatigue, nonrestorative sleep, and other somatic symptoms. However, how diffusely pain is distributed appears less important to clinical outcomes and impairment than other somatic and psychological factors, highlighting the need for a broader approach to the assessment and treatment of JFM.

FIT Teens RCT for juvenile fibromyalgia: Protocol adaptations in response to the COVID 19 pandemic.

Objective: To describe protocol adaptations to the Fibromyalgia Integrative Training for Teens (FIT Teens) randomized controlled trial in response to the COVID-19 pandemic. The overarching aims of the FIT Teens multi-site 3-arm comparative effectiveness trial are to assess whether a specialized neuromuscular exercise training intervention combined with cognitive-behavioral therapy (CBT) is superior to CBT alone or graded aerobic exercise alone. Design/methods: The trial was originally designed as an in-person, group-based treatment with assessments at baseline, mid- and post-treatment, and four follow-up time points. The original study design and methodology was maintained with specific modifications to screening, consenting, assessments, and group-based treatments to be delivered in remote (telehealth) format in response to COVID-19 restrictions. Results: Study enrollment was paused in March 2020 for five months to revise operations manuals, pilot remote treatment sessions for accuracy and fidelity, complete programming of REDCap assent/consent and assessment materials, train study staff for new procedures and obtain regulatory approvals. The trial was relaunched and has been successfully implemented in remote format since July 2020. Trial metrics thus far demonstrate a consistent rate of enrollment, strong attendance at remote treatment sessions, high retention rates and high treatment fidelity after protocol adaptations were implemented. Conclusions: Preliminary findings indicate that FIT Teens protocol adaptations from in-person to remote are feasible and allowed for sustained enrollment, retention, and treatment fidelity comparable to the in-person format. Methodologic and statistical considerations resulting from the adaptations are discussed as well as implications for interpretation of results upon completion of the trial.

Promoting readiness and engagement in pain rehabilitation for youth and families: Developing a pediatric telehealth motivational interviewing protocol.

Objective: Intensive interdisciplinary pain treatment (IIPT) is a promising approach for youth with complex, disabling, refractory pain conditions. However, youth and families who initiate IIPT without sufficient acceptance of its focus on functional rehabilitation or readiness to adopt a self-management approach to their pain may face challenges in IIPT and/or experience suboptimal outcomes. Motivational interviewing (MI) techniques have been shown to enhance readiness to make a number of health behavior changes for adults and youth, but it has not been systematically examined in the context of pediatric IIPT. The authors developed an MI telehealth intervention protocol explicitly designed to prepare youth and families for admission to IIPT. Method: The protocol development process is detailed here, including influential models, expert consultation, and feedback from IIPT clinical experts. The intervention protocol was then piloted with a group of eligible families to elicit feedback and prompt further refining. Feasibility and acceptability were explored through measures of treatment engagement and satisfaction. Results: The Promoting Readiness and Engagement in Pain Rehabilitation (PREPaRe) intervention protocol contains four modules aimed to enhance youth and parent readiness to adopt a self-management approach to persistent pain, through a motivational interviewing approach. Initial responses from the test group suggested high levels of treatment engagement and treatment satisfaction with PREPaRe. Conclusions: PREPaRe appears feasible to administer and acceptable to families of youth with persistent pain seeking IIPT. Implications for implementation are discussed. Further study via randomized control trial is warranted. Trial registration: ClinicalTrials.gov identifier: NCT04093921.

From One Pain to Many: The Emergence of Overlapping Pains in Children and Adolescents.

OBJECTIVES: The objective of this study was to compare children and adolescents with overlapping chronic pains (OCP) to those with single chronic pains (SCP) among youth presenting in specialized clinical settings, in an effort to identify potential risk factors for developing overlapping pains. METHODS: A total of 1235 youth ages 8 to 18 seen in a tertiary care multidisciplinary pain clinic or a multidisciplinary headache clinic completed self-report measures of pain, disability, psychological functioning and clinical history and characteristics at the time of initial clinic visit. Information was captured in a chronic pain data repository and accessed for the current study. RESULTS: Subsequent pain symptoms developed on average 11.9 months (SD=24.5 mo) after onset of the first pain symptom. Compared with patients with SCP, patients with OCP report more medical comorbidity, more developmental issues, and poorer current sleep and school functioning. They also scored significantly higher than patients with SCP on self-reported functional disability, pain catastrophizing, fear of pain, depression, anxiety, and psychological stress and lower quality of life (all Ps<0.001). In multivariate analysis, variables most strongly associated with presenting with OCP were age (odds ratio [OR]: 1.1, P<0.001), having a clinically significant high functional disability (OR: 1.4, P=0.3), and low quality of life (OR: 2.5, P<0.001). DISCUSSION: Given their tendency toward more psychological and medical comorbidities, patients with OCP may require more intense and diverse treatment approaches. Some early life experiences may be a risk factor for development of OCP. Longitudinal studies are needed to fully evaluate the heightened risk for OCP associated with some of these factors.

Leveraging Virtual Reality and Augmented Reality to Combat Chronic Pain in Youth: Position Paper From the Interdisciplinary Network on Virtual and Augmented Technologies for Pain Management.

BACKGROUND: Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions. However, in this young field, there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions. OBJECTIVE: The INOVATE-Pain (Interdisciplinary Network on Virtual and Augmented Technologies for Pain management) consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population. METHODS: An interdisciplinary meeting of 16 academics, clinicians, industry partners, and philanthropy partners was held in January 2020. RESULTS: Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR and AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR and AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions. CONCLUSIONS: To realize the promise of this realm of innovation, key ingredients for success include productive partnerships among industry, academic, and clinical stakeholders; a uniform set of outcome domains and measures for standardized evaluation; and widespread access to the latest opportunities, tools, and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.

Randomized clinical trial of Fibromyalgia Integrative Training (FIT teens) for adolescents with juvenile fibromyalgia - Study design and protocol.

OBJECTIVE: Juvenile-onset fibromyalgia (JFM) is a chronic debilitating pain condition that negatively impacts physical, social and academic functioning. Cognitive-behavioral therapy (CBT) is beneficial in reducing functional disability among adolescents with JFM but has only a modest impact on pain reduction and does not improve physical exercise participation. This randomized controlled trial (RCT) aims to test whether a novel intervention that combines CBT with specialized neuromuscular exercise training (the Fibromyalgia Integrative Training program for Teens "FIT Teens") is superior to CBT alone or a graded aerobic exercise (GAE) program. DESIGN/METHODS: This 3-arm multi-site RCT will examine the efficacy of the FIT Teens intervention in reducing functional disability (primary outcome) and pain intensity (secondary outcome), relative to CBT or GAE. All interventions are 8-weeks (16 sessions) in duration and are delivered in small groups of 4-6 adolescents with JFM. A total of 420 participants are anticipated to be enrolled across seven sites with approximately equal allocation to each treatment arm. Functional disability and average pain intensity in the past week will be assessed at baseline, post-treatment and at 3-, 6-, 9- and 12-month follow-up. The 3-month follow-up is the primary endpoint to evaluate treatment efficacy; longitudinal assessments will determine maintenance of treatment gains. Changes in coping, fear of movement, biomechanical changes and physical fitness will also be evaluated. CONCLUSIONS: This multi-site RCT is designed to evaluate whether the combined FIT Teens intervention will have significantly greater effects on disability and pain reduction than CBT or GAE alone for youth with JFM. Clinical trials.gov registration: NCT03268421.

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.

The Impact of Sleep on Disability and School Functioning: Results From a Tertiary Pediatric Headache Center.

Pediatric headache patients often experience significant sleep disturbance, which may be a risk factor for poor physical, academic, and emotional functioning, including increased anxiety/fear. The current retrospective cohort study of a clinical sample of youth with persistent headache aimed to examine the impact of sleep on functional outcomes and to explore pain-related fear as a mediator of the association between sleep problems and functioning. A total of 109 youth (aged 7-17 years) with persistent headache presenting to a tertiary pediatric headache center (and their parents) completed measures of sleep problems, fear of pain, functional disability, and school functioning at the time of an initial evaluation and 6 months later. After controlling for age and headache frequency and severity, linear regression analyses indicated that increased sleep problems at baseline were associated with increased functional disability and poorer school functioning at baseline (ß = 0.28, P = .01; ß = -0.42, P < .001, respectively). Poor sleep at baseline was associated with poorer school functioning (but not functional disability) at follow-up (ß = -0.25, P = .02). Mediation models demonstrated an indirect mediating effect of pain-related fear on the association between baseline sleep problems and follow-up functional disability (ß = 0.06, 95% confidence interval 0.01, 0.15) and between baseline sleep problems and follow-up school functioning (ß = -0.06, 95% confidence interval -0.13, -0.004). Sleep disturbance in youth with headache may be a risk factor for poor functional outcomes, both concurrently and over time, and may be explained partially through pain-related fear. Given the frequency with which pediatric headache patients experience co-occurring sleep problems, sleep should be thoroughly assessed and considered as a potential early treatment target.

Under Pressure to Perform: Impact of Academic Goal Orientation, School Motivational Climate, and School Engagement on Pain and Somatic Symptoms in Adolescents.

OBJECTIVES: Various academic factors are known to influence pain and somatic symptoms in adolescents, but the roles of academic goal orientation, school motivational climate, and school engagement are unknown. This study examined how these understudied academic factors are associated with adolescent pain and somatic symptoms and whether sex moderates the relations. MATERIALS AND METHODS: High school students (n=90) from a high-achieving community completed questionnaires assessing academic variables, various pain characteristics, and somatic symptoms. RESULTS: The majority of adolescents (67%) experienced pain and somatic symptoms in the past month, with 56% reporting multisite pain and 58% reporting at least 1 severe somatic symptom. Headache and abdominal pain were the most frequently reported "most bothersome" pains, and pain was rated, on average, as moderately severe, typically occurring several times per month, and was primarily chronic in nature (duration, ≥3 mo). Higher levels of ego goal orientation and perceived performance motivational climate were associated with more somatic symptoms, and ego goal orientation was also associated with more intense and frequent pain. Alternatively, greater school engagement was associated with fewer somatic symptoms. Task goal orientation and mastery motivational climate were unassociated with all pain and somatic symptom outcomes. DISCUSSION: This study demonstrates that adolescents from a high-achieving community report more somatic symptoms and pain when they are less engaged in school and when their academic focus is on grades and outperforming peers. Results suggest that de-emphasizing competition and performance outcomes may support physical well-being in adolescents.

Social Robots for Hospitalized Children.

BACKGROUND AND OBJECTIVES: Social robots (SRs) are increasingly present in medical and educational contexts, but their use in inpatient pediatric settings has not been demonstrated in studies. In this study, we aimed to (1) describe the introduction of SR technology into the pediatric inpatient setting through an innovative partnership among a pediatric teaching hospital, robotics development, and computational behavioral science laboratories and (2) present feasibility and acceptability data. METHODS: Fifty-four children ages 3 to 10 years were randomly exposed to 1 of 3 interventions: (1) interactive SR teddy bear; (2) tablet-based avatar version of the bear; or (3) plush teddy bear with human presence. We monitored intervention enrollment and completion patterns, obtained qualitative feedback on acceptability of SR use from child life-specialist stakeholders, and assessed children's positive and negative affect, anxiety, and pain intensity pre- and postintervention. RESULTS: The intervention was well received and appeared feasible, with 93% of those enrolled completing the study (with 80% complete parent data). Children exposed to the SR reported more positive affect relative to those who received a plush animal. SR interactions were characterized by greater levels of joyfulness and agreeableness than comparison interventions. Child life specialist stakeholders reported numerous potential benefits of SR technology in the pediatric setting. CONCLUSIONS: The SR appears to be an engaging tool that may provide new ways to address the emotional needs of hospitalized children, potentially increasing access to emotionally targeted interventions. Rigorous development and validation of SR technology in pediatrics could ultimately lead to scalable and cost-effective tools to improve the patient care experience.

Back to Living: Long-term Functional Status of Pediatric Patients Who Completed Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: To provide a descriptive account of long-term functioning (≥5 y posttreatment) among youth who completed intensive interdisciplinary pain treatment (IIPT) for pediatric chronic pain conditions. MATERIALS AND METHODS: A total of 95 patients (mean age at follow-up=20.0 y) treated at least 5 years previously at a single IIPT program completed questionnaires assessing pain, functional disability, health care utilization, academic/career achievement, and quality of life. Data analyses focused on pain, functioning, and progress toward developmental goals at long-term follow-up. RESULTS: The majority of respondents report significant reduction in pain compared with preadmission (P<0.001). Five years posttreatment, average functional disability scores were in the minimal range, with statistically significant decrease in functional disability from time of admission (P<0.001). Nearly 80% of respondents characterized themselves as having no functional difficulties at follow-up. Clinically significant improvement was established for both pain and function. Respondents generally reported developmentally appropriate status, with 89% graduating high school on schedule. DISCUSSION: Results show long-term positive functioning among individuals who underwent intensive rehabilitation treatment for chronic pain as children or adolescents. Despite experiencing one or more pain flares at some point after treatment, most former IIPT patients report minimal to no ongoing functional disability, complete or partial resolution of pain symptoms, and developmentally appropriate progress toward goals (eg, school completion, independent living).

Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment.

Intensive pain rehabilitation programs for children with chronic pain are effective for many patients. However, characteristics associated with treatment response have not been well documented. In this article we report trajectories of pain and functional impairment in patients with chronic pain up to 1 year after intensive pain rehabilitation and examine baseline factors associated with treatment response. Patients (n = 253) with chronic pain and functional disability were assessed at 5 time points (admission, discharge, 1-month, 4-month, and 12-month follow-ups). Individual trajectories were empirically grouped using SAS PROC TRAJ. For functional disability, 2 groups emerged: treatment responders (88%) and nonresponders (12%). Using a binomial logistic regression model to predict disability trajectory group, no baseline variables were significant predictors for the disability trajectory group. For pain, 3 groups emerged: early treatment responders (35%), late treatment responders (38%), and nonresponders (27%). Using multinomial regression analyses to predict pain trajectory group, older age, higher pain scores, fewer social difficulties, higher anxiety levels, and lower readiness to change were characteristics that distinguished nonresponders from responders; no significant predictors distinguished the late responders from the early responders. These results provide key information on the baseline factors that influence intensive pain rehabilitation outcomes, including risk factors that predict treatment nonresponse. Our findings have implications for developing more targeted treatment interventions. PERSPECTIVE: Deriving groups of individuals with differing treatment response trajectories stimulates new thinking regarding potential mechanisms that may be driving these outcomes.

Development of the Parent Responses to School Functioning Questionnaire.

Parents play an important role in supporting school functioning in youth with chronic pain, but no validated tools exists to assess parental responses to child and adolescent pain behaviors in the school context. Such a tool would be useful in identifying targets of change to reduce pain-related school impairment. The goal of this study was to develop and preliminarily validate the Parent Responses to School Functioning Questionnaire (PRSF), a parent self-report measure of this construct. After initial expert review and pilot testing, the measure was administered to 418 parents of children (ages 6-17 years) seen for initial multidisciplinary chronic pain clinic evaluation. The final 16-item PRSF showed evidence of good internal consistency (α = .82) and 2-week test-retest reliability (intraclass correlation coefficient = .87). Criterion validity was demonstrated by significant correlations with school absence rates and overall school functioning, and construct validity was demonstrated by correlations with general parental responses to pain. Three subscales emerged capturing parents' personal distress, parents' level of distrust of the school, and parents' expectations and behaviors related to their child's management of challenging school situations. These results provide preliminary support for the PRSF as a psychometrically sound tool to assess parents' responses to child pain in the school setting. PERSPECTIVE: The 16-item PRSF measures parental responses to their child's chronic pain in the school context. The clinically useful measure can inform interventions aimed reducing functional disability in children with chronic pain by enhancing parents' ability to respond adaptively to child pain behaviors.

School Self-Concept in Adolescents With Chronic Pain.

Objective: This study investigated school self-efficacy and sense of school membership (collectively "school self-concept") as potential influences on impaired school function among adolescents with chronic pain, including comparison of adolescents with primary pain to those with disease-based pain and pain-free peers. Methods: In all, 264 adolescents (12-17 years old) with primary pain conditions, juvenile idiopathic arthritis, or no pain completed measures of functional disability, school functioning, pain characteristics, and school self-concept, the Self-Efficacy Questionnaire for School Situations (SEQ-SS), and Psychological Sense of School Membership (PSSM). Results: Both the SEQ-SS and PSSM demonstrated reliability and some validity, with the SEQ-SS more strongly supported. As a group, adolescents with primary pain conditions reported poorer school self-concept. School self-efficacy, but not school belongingness, predicted school functioning later in the school year. Conclusions: School self-concept, especially as assessed with the SEQ-SS, is relevant and important to assess when addressing school functioning in youth with chronic pain.

Changes in Maternal and Paternal Pain-Related Attitudes, Behaviors, and Perceptions across Pediatric Pain Rehabilitation Treatment: A Multilevel Modeling Approach.

Objectives: This prospective study compared paternal versus maternal factors and their impact on child outcomes in the context of an intensive pediatric pain rehabilitation program. Methods: One hundred four youth with treatment refractory chronic pain and their parents enrolled in an intensive pediatric pain rehabilitation program completed measures of pain, functional disability, and parent pain-related attitudes, perceptions, and behaviors at admission and discharge. Results: Linear mixed models were used. Controlling for significant demographic and clinical characteristics, mothers and fathers who were present for the program typically demonstrated significantly better improvement from admission to discharge compared with nonpresent fathers. Mothers made the most significant gains in protective parent responses. Children also had significant decreases in pain and improvements in functioning over time. Conclusions: Results indicate the efficacy of this treatment model for both children with chronic pain and their parents and highlights the importance of parental presence in treatment.

Racial Differences in Parental Responses to Children's Chronic Pain.

OBJECTIVE: Parental responses to children's pain are related to how youth cope with chronic pain. However, little research has explored cultural differences in the 4 major pain response categories (ie, protect, minimize, distract, and monitor). This study compared parental responses to children's pain between minority parents (ie, black, Hispanic, multiracial) and parents of white children. MATERIALS AND METHODS: Participants included 234 patients, ages 8 to 17, with chronic pain (73.5% female; age M [SD]=13.91 [2.38]; 50% white, 15.39% black, 20.90% Hispanic, 13.68% multiracial). Patients' parents completed the Adult Responses to Children's Symptoms. Parental responses included: protect, monitor, minimize, and distrct. For between-group comparisons, white participants (N=117) were matched on age and sex with black (N=36), Hispanic (N=49), and multiracial (N=32) participants. RESULTS: Paired-samples t tests revealed that protectiveness was higher for parents of black children (t48=-3.84, P<0.001, black M [SD]=1.93 [0.69], white M [SD]=0.94 [0.77], Cohen d=1.09) and parents of Hispanic children (t71=-7.10, P<0.001, Hispanic M [SD]=1.65 [0.76], white M [SD]=0.94 [0.77], Cohen d=1.52) compared with parents of white children. In addition, parents of black children (t40=-2.90, P=0.006, black M [SD]=3.55 [0.49], white M [SD]=2.89 [0.93], Cohen d=0.80) and parents of Hispanic children (t71=-3.62, P<0.001, Hispanic M [SD]=3.35 [0.69], white M [SD]=2.89 [0.93], Cohen d=0.81) were significantly more monitoring their children than were parents of white children. Parents of Hispanic children were also significantly more minimizing than parents of white children (t71=-3.68, P<0.001, Hispanic M [SD]=0.88 [0.75], white M [SD]=0.51 [0.58], Cohen d=0.80). No other significant differences were found. DISCUSSION: Results highlight the need to adapt pediatric chronic pain interventions to family culture and context. Further research is needed to understand pediatric chronic pain from a cross-cultural perspective.

Pain in School: Patterns of Pain-Related School Impairment among Adolescents with Primary Pain Conditions, Juvenile Idiopathic Arthritis Pain, and Pain-Free Peers.

Children with chronic pain frequently experience impairment in the school setting, but we do not yet understand how unique these struggles are to children with primary pain conditions compared to peers with disease-related pain or those without chronic pain symptoms. The objective of this study is to examine school functioning, defined as school attendance rates, overall quality of life in the school setting, and school nurse visits among adolescents with primary pain conditions, those with juvenile idiopathic arthritis (JIA)-related pain, and healthy peers. Two hundred and sixty adolescents participated in the study, including 129 with primary pain conditions, 61 with JIA, and 70 healthy comparison adolescents. They completed self- and parent-reported measures of school function. Findings show that as a group, youth with primary pain conditions reported more school absences, lower quality of life in the school setting, and more frequent school nurse visits compared to both adolescents with JIA-related pain and healthy peers. We conclude that compared to those who experience pain specific to a disease process, adolescents with primary pain conditions may face unique challenges in the school setting and may require more support to help them succeed in school in spite of pain.

Perspectives on the clinical significance of functional pain syndromes in children.

Functional pain syndromes (FPS) characterize a subset of individuals who experience pain and related symptoms and disability without clear structural or disease etiology. In the pediatric population, FPS hold high clinical importance due to significant prevalence rates and potential to persist into adulthood. Although extensive research has been executed to disambiguate FPS, the syndromes that fall within its spectrum remain conceptually complex and sometimes ill-defined. This paper provides an overview of available research on the classification and multifaceted etiology of FPS in youth and their effects on interpersonal, psychological, and familial function. Vital aspects of a successful multidisciplinary approach to treating this population are described; however, it is evident that future research requires more longitudinal studies.

Pediatric Pain Screening Tool: rapid identification of risk in youth with pain complaints.

Moderate to severe chronic pain is a problem for 1.7 million children, costing $19.5 billion dollars annually in the United States alone. Risk-stratified care is known to improve outcomes in adults with chronic pain. However, no tool exists to stratify youth who present with pain complaints to appropriate interventions. The Pediatric Pain Screening Tool (PPST) presented here assesses prognostic factors associated with adverse outcomes among youth and defines risk groups to inform efficient treatment decision making. Youth (n = 321, ages 8-18, 90.0% Caucasian, 74.8% female) presenting for multidisciplinary pain clinic evaluation at a tertiary care center participated. Of these, 195 (61.1%) participated at 4-month follow-up. Participants completed the 9-item PPST in addition to measures of functional disability, pain catastrophizing, fear of pain, anxiety, and depressive symptoms. Sensitivity and specificity for the PPST ranged from adequate to excellent, with regard to significant disability (78%, 68%) and high emotional distress (81%, 63%). Participants were classified into low- (11%), medium- (32%), and high- (57%) risk groups. Risk groups did not significantly differ by pain diagnosis, location, or duration. Only 2% to 7% of patients who met reference standard case status for disability and emotional distress at 4-month follow-up were classified as low risk at baseline, whereas 71% to 79% of patients who met reference standard case status at follow-up were classified as high risk at baseline. A 9-item screening tool identifying factors associated with adverse outcomes among youth who present with pain complaints seems valid and provides risk stratification that can potentially guide effective pain treatment recommendations in the clinic setting.