Investigating key predictors of persistent low back pain: A focus on psychological stress.

AIM: To investigate the degree to which psychological stress, self-reported pain scores, and pain sensitivity during an acute state of low back pain (LBP) predict the development of persistent LBP trajectories. BACKGROUND: Identifying which factors influence LBP trajectories is critical to understand why some individuals experience persistent LBP and to illuminate areas for nursing intervention. METHODS: A secondary data analysis of a prospective study examining trajectories of LBP was conducted. The sample was comprised of 217 adults with acute-onset LBP recruited from the community and followed over 24 weeks. Variables of interest included demographic data, perceived stress scores, self-reported pain scores, and somatosensory characteristics collected within the first 4 weeks of LBP onset. The data were analyzed using non-parametric bivariate comparisons and a semi-parametric Cox proportional hazards model with interval-censoring. RESULTS: Individuals with higher psychological stress scores were less likely to experience pain resolution (Hazard ratio [HR] = 0.555, 95% confidence interval [CI] = 0.36-0.85, p = 0.02). After adjustment for covariates in the final model, the analysis revealed household income (HR = 2.79, 95% CI [1.63-4.67], p < 0.001) to be the dominant predictor of LBP persistence in this sample. CONCLUSION: Heightened psychological stress and pain severity as well as decreased pressure pain thresholds were indicated as influential factors of LBP trajectories. Household income was identified as the dominant predictor, demonstrating that individuals with a higher household income were more likely to resolve their pain. Strategies which integrate assessment of stress, self-reported pain scores, pain sensitivity, and social determinants for patients experiencing pain are needed to advance nursing care.

Deconstructing Pain Disability through Concept Analysis.

OBJECTIVE: Pain disability is a complex and challenging problem that impacts the daily lives of individuals living with persistent pain. Although this concept is measured throughout pain populations, conceptual clarity is needed to identify the defining characteristics and further understand what comprises this experience for clinical translation. DESIGN: We completed a concept analysis to identify major attributes and provide a broad framework of pain disability for improved recognition throughout the discipline of nursing. DATA SOURCES: Literature searches in PubMed, CINAHL, PsychINFO, and Scopus identified 39 relevant cross-disciplinary articles published between January 1990 and November 2017. REVIEW/ANALYSIS METHODS: We implemented Avant and Walker's method of concept analysis to establish the attributes, antecedents, and consequences of pain disability. RESULTS: Two major attributes of pain disability are discussed, including (1) physical and/or psychological responses leading to a functional loss; and (2) the degree of ability to fulfill role expectations. The antecedent to the development of pain disability is a painful trigger. Three leading consequences are identified as suffering, pain reactivity, and secondary loss. CONCLUSIONS: Pain disability is a fluid concept that is characterized by the subjective experiences of the individual. A new conceptualization of pain disability is offered as the inability to maintain role expectations due to the result of a painful trigger and subsequent physical and/or psychosocial dysfunction.

Adolescent pain catastrophizing mediates the relationship between protective parental responses to pain and disability over time.

OBJECTIVE: Examine whether the relation between protective parenting responses to pain and functional disability is mediated by pain catastrophizing in adolescents with chronic musculoskeletal pain and their parents over time. METHODS: Adolescents aged 11-18 years and their parents reported on parental protective responses to pain (PPRP), pain catastrophizing scale (PCS), and Functional Disability Inventory (FDI) before Time 1 (T1) and 2 months after Time 2 (T2) an initial interdisciplinary pain clinic evaluation. RESULTS: PCS was a significant mediator of the PPRP-FDI relationship at T1 and T2 for the adolescents and T2 for their parents. A decrease in PPRP over time was associated with T2 PCS, which in turn was associated with T2 FDI for adolescents and their parents. CONCLUSION: Parental protectiveness is associated with disability indirectly through pain catastrophizing at the initial visit and follow-up. Decreases in parent protectiveness, potentially initiated through the initial evaluation, were related to lower levels of disability at follow-up through pain catastrophizing.

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.

Digital Solutions to Alleviate the Burden on Health Systems During a Public Health Care Crisis: COVID-19 as an Opportunity.

The COVID-19 pandemic has generated unprecedented and sustained health management challenges worldwide. Health care systems continue to struggle to support the needs of the majority of infected individuals that are either asymptomatic or have mild symptoms. In addition, long-term effects in the form of long-lasting COVID-19 symptoms or widespread mental health issues aggravated by the pandemic pose a burden on health care systems worldwide. This viewpoint article considers aspects of digital health care solutions and how they can play an ongoing role in safely addressing gaps in the health care support available from initially and repeatedly overwhelmed providers and systems. Digital solutions can be readily designed to address this need and can be flexible enough to adapt to the evolving management requirements of various stakeholders to reduce COVID-19 infection rates, acute hospitalizations, and mortality. Multiplatform solutions provide a hybrid model of care, which can include mobile and online platforms accompanied by direct clinician input and feedback. Desirable components to be included are discussed, including symptom tracking, patient education, well-being support, and bidirectional communication between patients and clinicians. Customizable and scalable digital health platforms not only can be readily adapted to further meet the needs of employers and public health stakeholders during the ongoing pandemic, but also hold relevance for flexibly meeting broader care management needs into the future.

A Systematic Review of Biological Mechanisms and Chronic Pain Outcomes During Stress Reduction Interventions.

BACKGROUND: Nonpharmacologic stress reduction interventions provide an opportunity to modify chronic pain trajectories; however, the biological mechanisms underlying these interventions are poorly understood. OBJECTIVES: To examine clinical literature published in 2012-2018 with the goals of (1) identifying which biological mechanisms or biomarkers are currently being measured in nonpharmacologic stress reduction intervention studies for individuals with chronic pain and (2) evaluating the evidence to determine whether these stress reduction interventions lead to changes in (a) pain outcomes and/or (b) measured biomarkers. DATA SOURCES: Scientific articles in the electronic databases PubMed/Medline, Cumulative Index of Nursing and Allied Health Literature, PsychINFO, and SCOPUS following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. STUDY SELECTION: Randomized controlled trials and quasi-experimental studies that recruited subjects with a chronic pain condition, examined a relationship between a nonpharmacologic stress reduction intervention and pain-related outcome(s), and included measurement of a biomarker. RESULTS: The 13 articles that met inclusion criteria spanned four nonpharmacologic stress reduction categories: mindfulness-based stress reduction, physical exercise, manual therapies, and biofeedback. Methods for studying biomarkers included measuring biological samples, neurological function, and autonomic control. Although all studies investigated both biological measures and pain outcomes, only three demonstrated an association between the biomarker(s) and pain-related outcomes. CONCLUSIONS: The results of this review highlight the complex nature of stress-pain relationships and the lack of rigorous clinical research identifying specific stress-related biological factors that modulate pain outcomes. Stress reduction interventions remain a favorable method for symptom management in patients living with chronic pain, but consistency in study measures and design is needed for robust evaluation.

Forced Enlightenment: A Metasynthesis of Experiences During Childhood Cancer Survivorship.

BACKGROUND: Childhood cancer survivorship can be described as a lifelong experience that requires vigilant follow-up care and continual support. Although there is growing qualitative and quantitative literature on this experience, articles focusing on qualitative synthesis are lacking. Qualitative metasynthesis can further facilitate the knowledge of survivorship experiences to inform care. OBJECTIVE: The aim of this qualitative metasynthesis was to investigate the experiences of childhood cancer survivors and develop an integrated understanding of the survivorship experience. METHODS: The method of qualitative meta-ethnography guided this research. Data extracted from the studies were directly compared through reciprocal translation. RESULTS: A total of 18 qualitative articles met the inclusion criteria. The authors identified 4 key metaphors, including Transcendence, Lingering Shadows, Fortifying Bonds, and Ongoing Acclimation. The metaphors are brought together by 3 essential concepts that drive the survivorship experience: (1) recognition of wisdom gained, (2) acknowledgment of vulnerabilities, and (3) actions taken to manage present and future. Together, these metaphors and essential concepts make up the global theme "Forced Enlightenment." CONCLUSION: This metasynthesis illuminates the complex nature of the childhood cancer survivorship experience, in which survivors work to grow beyond their treatment experience while inevitably being tied to it. Next steps should include further exploration of individual metaphors and validation of forced enlightenment as an experience. IMPLICATIONS FOR PRACTICE: Each of the metaphors may be used to guide the development of nursing interventions. Translation to clinical practice should focus on prioritizing coping and adaptation skills during cancer treatment, which can be carried through survivorship.

Complementary Parent Components for Pediatric Pain Families: Innovations in Treatment.

For families with a child with chronic pain, the home environment is the context in which adaptive or maladaptive illness behaviors are developed. Supporting families to effectively cope with their child's chronic pain is a critical need. This work analyzes intervention approaches from emerging treatment programs to support families coping with pediatric pain that diverge from traditional treatment models by specifically targeting parents. Two novel parent intervention programs are presented that consider caregiver needs in both outpatient and inpatient pain treatment settings: Parents as Coping Coaches and Putting Parents FIRST. These programs are evaluated through comparing parental training components across different stages of treatment. Additionally, the efficacy of Putting Parents FIRST in promoting maintenance of children's functional gains achieved in intensive interdisciplinary pain treatment is presented, and compared to previous results of the efficacy of Putting Parents FIRST. Specifically, outcomes of 36 children whose parents received the intervention in Putting Parents FIRST were compared to a matched control sample of children whose parents did not receive the parent intervention. Similar to the findings from Parents as Coping Coaches, results indicated that patients whose parents received the intervention maintained/improved program gains in disability, coping, and pain significantly more than patients whose parents did not receive the intervention. Implications for parent-focused intervention development efforts targeting parent and youth functioning in the context of pediatric chronic pain are considered.

Parenting in the Context of Children's Chronic Pain: Balancing Care and Burden.

Parents of youth with chronic health conditions encounter numerous challenges in supporting their children across pediatric treatment contexts. Structural barriers to care, such as access issues and coordinating care across school, health, and family settings, can exacerbate challenges to daily functioning. Parents are often concomitantly managing their child's chronic condition, their own health care needs, work and family demands. For these parents, accomplishing a manageable "work-life balance" feels elusive, if not impossible, when a chronic health condition is part of family life. Based on a recent symposium presentation, combined perspectives from the disciplines of pediatric psychology, parenting, and human development and family studies consider key challenges and opportunities to assist parent coping with stress associated with caregiving amidst pervasive changes in healthcare service delivery. Two innovative interventions to support parents in both an outpatient ("Parents as Coping Coaches") and an inpatient ("Putting Parents FIRST") context are described, with commonalities and unique aspects highlighted for each. These programs are considered in reference to a rapidly changing healthcare landscape, growing focus on the family as a core context for care, and importance of parent/caregiver self-care and crucial role in supporting children's long-term health and resiliency.

Adolescent self-perception: associations with chronic musculoskeletal pain and functional disability.

UNLABELLED: Associations among pain, functional disability, and self-perceived competence were examined in a retrospective record review of the initial clinical evaluations of 115 adolescents (ages 13 to 18 years) with chronic musculoskeletal pain not associated with a specific organic cause. Adolescents self-reported on pain intensity, functional disability, and 9 developmentally relevant domains of self-perceived competence, using the Self-Perception Profile for Adolescents (Harter, 1988). Results confirmed a relation between usual pain intensity and functional disability (r = 0.47, P < .001). A series of multiple regression analyses revealed that adolescents' perceptions of global self-worth significantly moderated the relation between pain and disability. These findings extend our understanding of the relations among self-perception, chronic pain, and disability to include adolescents with chronic musculoskeletal pain syndromes and have future research and therapeutic implications. PERSPECTIVE: Adolescents with chronic pain syndromes can face significant challenges in accomplishing developmental goals with respect to the pain and disability they experience. Perceptions of self-worth appear to play an important role in understanding the relation between pain and functional disability among adolescents with chronic pain.

Pain, disability, and symptoms among siblings of children with functional abdominal pain.

OBJECTIVE: To examine reports of pain, disability, and somatic and psychological symptoms among siblings of children with functional abdominal pain (FAP) and siblings of "healthy" comparison children. METHODS: This survey study explored two groups of participants (FAP and healthy) consisting of (1) children with FAP and their siblings and parents and (2) healthy comparison children and their siblings, and parents. Participants included 13 FAP families and 10 healthy comparison families. Siblings and children were between 8 and 14 years of age. Measures included the Behavioral Assessment System for Children, Abdominal Pain Index, Children's Somatization Inventory, Functional Disability Inventory, and Family Inventory of Life Events. Cross-sectional data were analyzed using correlations and analysis of variance techniques. RESULTS: Siblings of children with FAP reported significantly greater mean levels of emotional/ behavioral symptoms than siblings of healthy comparison children. No significant between-group differences were identified in FAP and healthy comparison parents' reports of siblings' pain or emotional/behavioral symptoms. There were significantly more persons with pain problems living in the homes of FAP families. Among FAP families, a greater number of parent-reported family stressful life events was significantly associated with sibling functional disability and somatic symptoms. CONCLUSION: This investigation suggests that siblings of children with FAP experience more emotional/behavioral symptoms than peers and that their symptoms are not readily identified by parents. These findings highlight the importance of considering the psychological functioning of "unaffected" siblings and family stressors when children present with recurrent pain complaints.

Chronic Pain and Obesity Within a Pediatric Interdisciplinary Pain Clinic Setting: A Preliminary Examination of Current Relationships and Future Directions.

OBJECTIVES: Pediatric obesity and chronic pain are 2 of the most significant public health crises affecting youth today. Despite the high number of youth experiencing both chronic pain and obesity, little research has been done examining their relationship. This study aims to both replicate and extend this research base. METHODS: A retrospective chart review of 99 patients presenting for evaluation in a pediatric pain clinic was conducted. Demographic information, including patient weight status, and self-report measures completed by both patients and their parents, including the Pain Frequency-Severity-Duration scale, the Functional Disability Inventory, and the Pain Catastrophizing Scale were examined. RESULTS: Abdominal pain was the most frequently reported primary pain diagnosis category, with headache, diffuse musculoskeletal, localized musculoskeletal, and back pain categories reported from greatest to least frequency. Results show that 29% of our sample was obese. Age was related to weight status such that older children were more likely to have a higher body mass index. Among school-aged children, a higher body mass index percentile was associated with greater parent-reported pain catastrophizing. Obese youth had higher parent-reported Functional Disability Inventory scores than those in the normal weight group. Post hoc comparisons identified that this finding was only significant for girls. Further, obese youth were more likely to have a longer pain duration than those classified as normal weight. DISCUSSION: The results of this study add to the growing literature regarding the importance of taking weight status into account when intervening with youth with chronic pain.

Preliminary Outcomes of a Cross-Site Cognitive-Behavioral and Neuromuscular Integrative Training Intervention for Juvenile Fibromyalgia.

OBJECTIVE: Cognitive-behavioral therapy (CBT) is effective in reducing disability among youth with juvenile fibromyalgia (FM); however, engagement in moderate to vigorous physical activity remains poor, even after CBT. The purpose of this study was to evaluate the feasibility and preliminary outcomes of an innovative program combining CBT with specialized neuromuscular exercise: the Fibromyalgia Integrative Training for Teens (FIT Teens) program. METHODS: Adolescents with juvenile FM (n = 22, all female, ages 12-18 years) from 2 urban children's hospitals participated in the 8-week FIT Teens intervention. Participants completed measures of pain intensity, functional disability, depressive symptoms, pain catastrophizing, fear of movement, and readiness to change at baseline and after the intervention. RESULTS: The feasibility of the intervention across 2 sites was documented, including high retention rates (80%). Participants showed significant decreases in functional disability (P < 0.05), depression (P < 0.001), fear of movement (P < 0.01), and pain catastrophizing (P < 0.001) from pre- to postintervention. Results of the readiness to change measure indicated a significant decrease in precontemplation (P < 0.01) and increase in action/maintenance scores (P < 0.001). All results demonstrated medium to large effect sizes. CONCLUSION: Adolescents with juvenile FM reported significant improvements in physical function and reduced fear of movement following the intervention. Improvement in physical function was achieved in a shorter time frame than in a prior trial of CBT without an exercise component. Further work is needed to compare the FIT Teens program with existing approaches and determine whether objective changes in exercise participation are achieved.

Adolescent-parent relationships in the context of adolescent chronic pain conditions.

OBJECTIVE: This study explored adolescent-parent relationships in families of adolescents with chronic pain. METHODS: A retrospective review was conducted on 112 adolescents with chronic pain who presented for clinical evaluation at an outpatient pediatric multidisciplinary pain management clinic. Adolescents reported on pain severity and duration, functional disability, and psychological distress. Parents responded to a measure of adolescent-parent relationship distress. RESULTS: The findings show that as a group, parents of adolescents with chronic pain syndromes reported less adolescent-parent relationship distress compared to normative data. Adolescent-parent relationship distress was inversely correlated with pain severity. A multiple regression model containing indicators of global psychological distress, pain severity, and adolescent-parent relationship distress predicted levels of adolescents' functional disability. Pain severity and functional disability were more closely linked at the low end of Adolescent-Parent Relationship Domain scores. DISCUSSION: The findings suggest important directions for future research to advance our understanding of the role of adolescent-parent relationships in the pain-disability cycle.

What postoperative outcomes matter to pediatric patients?

Children are often excluded from making decisions related to their medical treatment, and parents' proxy reports are often used. This approach fails to consider that parents and children may differ in their perception of the child's health. In this study, we assessed children's decision-making processes related to postoperative pain management. Forty-five children who underwent an anterior cruciate ligament repair or Nuss procedure for pectus excavatum repair were studied. A standard gamble technique was used to assess children's perceptions of the utility of a hypothetical treatment that would provide them with perfect pain control, with respect to different rates of risk for vomiting during the postoperative period. The maximum risk of vomiting that the overall study population was willing to accept to decrease the pain level to zero was 32% +/- 24%. Girls were willing to take a significantly higher risk (41% +/- 24%) compared to boys (25% +/- 22%) (P = 0.02). Children who actually experienced vomiting before they were questioned were willing to take a higher risk (46% +/- 26%) compared to those who did not (23% +/- 17%) (P = 0.035). Children can express opinions about preferred postoperative outcomes and provide useful input about their care. Girls, more than boys, seem to perceive vomiting as less important than improved pain control in the postoperative period.

Managing Chronic Pain in Special Populations with Emphasis on Pediatric, Geriatric, and Drug Abuser Populations.

In the adult population chronic pain can lead to loss of productivity and earning potential, and decreased quality of life. There are distinct groups with increased vulnerability for the emergence of chronic pain. These groups may be defined by developmental status and/or life circumstances. Within the pediatric, geriatric, and drug abuser populations, chronic pain represents a significant health issue. This article focuses on known anatomic, physiologic, and genetic mechanisms underlying chronic pain in these populations, and highlights the need for a multimodal approach from multiple health care professionals for management of chronic pain in those with the most risk.

Psychometric Properties of the Pain Stages of Change Questionnaire: New Insights on the Measurement of Readiness to Change in Adolescents, Mothers, and Fathers.

UNLABELLED: There is increasing interest in the measurement of "readiness to change," or willingness to engage in a self-management approach to pain coping, as a predictor of treatment response in pediatric pain populations. The primary aim of the present study was to provide cross-validation of the Pain Stages of Change Questionnaire-Adolescent and -Parent versions in a new, independent pediatric chronic pain sample by examining aspects of reliability, validity, and generalizability of the factor structures identified in the initial validation study. Secondary aims were to 1) expand upon previously identified differences between the Pain Stages of Change Questionnaire-Adolescent and -Parent versions and 2) examine previously unreported aspects of father data. Although slight differences emerged, the factor structures identified in the initial validation were largely replicated, suggesting that the psychometric properties of the measure are robust across pediatric outpatient chronic pain samples. Variability between parent and adolescent reports suggests that there may be meaningful differences in the interpretation of each measure and that factors other than readiness to change may influence response patterns. Findings highlight the need for more fine-tuned analyses of the way the construct operates in youth with pediatric pain and their parents. PERSPECTIVE: Findings provide further validation of the Pain Stages of Change Questionnaire-Adolescent and -Parent versions measures in a new outpatient pediatric chronic pain sample. Previously uninvestigated father data showed good reliability and patterns of findings similar to validated mother reports. Moreover, the study suggests that the adolescent and parent versions may function in meaningfully different ways.

Treatment expectations among adolescents with chronic musculoskeletal pain and their parents before an initial pain clinic evaluation.

OBJECTIVES: To understand expectations regarding treatment recommendations among treatment-seeking adolescents with chronic musculoskeletal pain and their parents. METHODS: A total of 102 adolescent-parent dyads were recruited at the time of initial contact with a multidisciplinary pain management clinic. Each participant completed reports of adolescent pain intensity and disability, biopsychosocial perspective of pain, and treatment expectations related to recommendations and feedback for a vignette description of an adolescent presenting at an initial multidisciplinary pain clinic evaluation. RESULTS: Descriptive findings for individual treatment expectations and adolescent-parent dyad agreement statistics were examined. Slight to fair levels of agreement occurred for 50% of the expectations assessed. The strongest shared expectations were for recommendations to return to school, pursue psychological counseling, and pursue PT/OT treatment. Stronger agreement occurred for items reflecting alternative, emotional, behavioral, and activity recommendations with weaker agreement for medical interventions (eg, medication and surgery). Correlations emerged between individual expectations and adolescent pain intensity, disability, with the greatest number of significant relationships found for adolescent and parent expectations and biopsychosocial perspectives of pain. DISCUSSION: Our results document that adolescents and parents show modest levels of agreement on expectations for treatment at the time of an initial pain clinic evaluation. This may relate to expectations being internal perspectives not clearly expressed within families; thus, the initial treatment consultation may provide an important opportunity to create and align appropriate expectations. Implications of our findings are considered with respect to education, treatment, and future research to understand factors that contribute to treatment adherence and outcomes.

Pain beliefs and readiness to change among adolescents with chronic musculoskeletal pain and their parents before an initial pain clinic evaluation.

OBJECTIVES: To understand relationships between pain-related beliefs and readiness to change among treatment-seeking adolescents with chronic musculoskeletal pain and their parents. METHODS: A total of 102 adolescent-parent dyads were recruited at the time of initial evaluation at a multidisciplinary pain management clinic. Dyads completed self-report measures to assess pain, catastrophizing, endorsement of a biopsychosocial perspective of pain, and readiness to change/motivation to adopt a self-management approach to pain coping. RESULTS: Agreement between adolescent-parent dyad reports of pain catastrophizing and readiness to change was found; however, adolescents were less likely to view pain as "affected by feelings and emotions" than parents. The hypothesis that greater pain catastrophizing would be correlated with less readiness to change was partially supported. Adolescent and parents who reported lower levels of endorsement of a biopsychosocial perspective were less willing to adopt a self-management approach to pain coping. Endorsement of a biopsychosocial perspective of pain aligned with readiness to change stages more consistently for parents. DISCUSSION: This study documents initial relationships among pain catastrophizing, biopsychosocial perspectives of pain, and readiness to engage in a self-management approach to pain coping for adolescents with chronic pain and their parents. Although agreement exists between dyads regarding catastrophizing and readiness to change, differences were noted in biopsychosocial perspective and dominant readiness to change stage before an initial pain clinic encounter. Findings are considered in terms of future research to advance knowledge regarding the role these factors may play in treatment adherence and outcomes.

Factor structure of the children's depression inventory in a multisite sample of children and adolescents with chronic pain.

UNLABELLED: This study examined the factor structure of the Children's Depression Inventory (CDI) among children and adolescents with chronic pain using exploratory and confirmatory factor analysis in a large, multisite sample of treatment-seeking youth. Participants included 1,043 children and adolescents (ages 8-18) with a range of chronic pain complaints who presented for initial evaluation at 1 of 3 tertiary care pediatric chronic pain clinics across the United States. They completed the CDI and reported on pain intensity and functional disability. Factor analysis was conducted using a 2-step (exploratory and confirmatory) approach. Results supported a 5-factor model for the CDI with good fit to the data. The distribution and item-total correlations of the somatic items (eg, pain complaints, fatigue) were explored in this sample. Results indicate that the CDI is a useful tool for assessing depressive symptoms in youth with chronic pain, but some caution is warranted in interpreting the clinical significance of scores in light of the overlap of specific symptoms common to both pain and depression. PERSPECTIVE: The CDI can be considered a valid tool for assessing mood symptoms in children with chronic pain. Caution is encouraged when interpreting the clinical significance of scores due to symptom overlap between chronic pain and depression.