Phenotyping Pain in Patients With Fibrous Dysplasia/McCune-Albright Syndrome.

CONTEXT: Pain is a poorly managed aspect in fibrous dysplasia/McCune-Albright syndrome (FD/MAS) because of uncertainties regarding the clinical, behavioral, and neurobiological underpinnings that contribute to pain in these patients. OBJECTIVE: Identify neuropsychological and neurobiological factors associated with pain severity in FD/MAS. DESIGN: Prospective, single-site study. PATIENTS: Twenty patients with FD/MAS and 16 age-sex matched healthy controls. INTERVENTION: Assessments of pain severity, neuropathic pain, pain catastrophizing (pain rumination, magnification, and helplessness), emotional health, and pain sensitivity with thermal quantitative sensory testing. Central nervous system (CNS) properties were measured with diffusion tensor imaging, structural magnetic resonance imaging, and functional magnetic resonance imaging. MAIN OUTCOME MEASURES: Questionnaire responses, detection thresholds and tolerances to thermal stimuli, and structural and functional CNS properties. RESULTS: Pain severity in patients with FD/MAS was associated with more neuropathic pain quality, higher levels of pain catastrophizing, and depression. Quantitative sensory testing revealed normal detection of nonnoxious stimuli in patients. Individuals with FD/MAS had higher pain tolerances relative to healthy controls. From neuroimaging studies, greater pain severity, neuropathic pain quality, and psychological status of the patient were associated with reduced structural integrity of white matter pathways (superior thalamic radiation and uncinate fasciculus), reduced gray matter thickness (pre-/paracentral gyri), and heightened responses to pain (precentral, temporal, and frontal gyri). Thus, properties of CNS circuits involved in processing sensorimotor and emotional aspects of pain were altered in FD/MAS. CONCLUSION: These results offer insights into pain mechanisms in FD/MAS, while providing a basis for implementation of comprehensive pain management treatment approaches that addresses neuropsychological aspects of pain.

The Telehealth Tradeoff: A Multimethod Study of the Benefits and Challenges Associated With Maintaining Treatment Outcomes Using a Hybrid Model of Pediatric Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: The COVID-19 pandemic required intensive interdisciplinary pain treatment (IIPT) programs to shift to virtual models of care. This study used a multimethod approach to examine outcomes of a pediatric hybrid IIPT program (50% in-person treatment and 50% synchronous video-based telehealth) and assessed staff experiences while treating within this model. MATERIALS AND METHODS: Patients (M=14.73, SD=2.04; 79% female) reported pain intensity, functional disability, and psychological factors (anxiety, depressive symptoms, fear of pain, pain catastrophizing, social functioning) at admission, discharge, and short-term follow-up. Differences in treatment outcomes at discharge and short-term follow-up between patients who participated in the hybrid IIPT model (n=42) during the pandemic and those who participated in the traditional in-person model before the pandemic (n=42) were examined. Quantitative assessments of staff burnout and perceived effort and qualitative assessments exploring staff perspectives about the challenges and advantages of the hybrid IIPT model were gathered. RESULTS: Youth in both groups made significant improvements across the majority of treatment outcomes; however, the hybrid group reported higher levels of pain at discharge and anxiety at follow-up. The majority of IIPT staff reported moderate to high levels of overall burnout, and almost half reported high levels of emotional exhaustion. Staff highlighted various challenges and benefits associated with treating within the hybrid model. DISCUSSION: When considering telehealth as a treatment tool for youth with complex chronic pain, it is crucial to leverage its benefits while addressing its challenges for patients and providers.

Development and Validation of the Scale for Pain Self-Efficacy (SPaSE) in German and English Languages for Children and Adolescents.

No validated measure for pain self-efficacy in children and adolescents is currently available in the German language, and existing English versions have limitations. This study used a thorough development process to create the Scale for Pain Self-Efficacy (SPaSE) in both German and English languages. Scale development was based on self-efficacy theory, adapting items from existing self-efficacy measures, and review of patients' perspectives. The final version of the 11-item SPaSE was created with expert discussions and testing of content validity, comprehensibility, and construct validity. The validation process consisted of exploratory factor analysis, testing of item characteristics, internal consistency, and sensitivity to change in 2 German samples of children and adolescents with chronic pain (study 1: outpatient sample N = 150, inpatient sample N = 31). Cross-validation in a U.S. sample (study 2: N = 98) confirmed the 1-factor structure, the sound psychometric properties and reliability of the SPaSE. Sum scores of the SPaSE were negatively correlated with pain-related disability, pain intensity, passive pain coping strategies, and emotional distress, in line with previous research. The valid and reliable SPaSE can be used in clinical practice to monitor pain treatment progress, advances the field of pain self-efficacy research in Germany, and opens the door to comparative research in German and English samples. PERSPECTIVE: This article presents psychometric properties of a newly developed measure of pain self-efficacy in children and adolescents that is available in both German and English language. This measure could be used in both research and clinical practice to measure treatment progress and outcome.

Perfectly Tired: Perfectionism and Sleep in Adolescents With Chronic Pain.

OBJECTIVE: Conceptual links between perfectionism and chronic pain have been proposed yet minimal empirical data exists. Poor sleep is associated with high levels of perfectionism and is common among youth with chronic pain. This study explores associations between perfectionism and sleep quality in adolescents with chronic pain while considering levels of functional disability. METHODS: Adolescents (ages 12-18) with chronic pain (N = 423) completed baseline measures of self-oriented perfectionism (SOP), socially prescribed perfectionism (SPP), sleep quality, and functional disability as part of routine clinical care at an outpatient chronic pain clinic and a pain rehabilitation day treatment program. Multivariate multiple regression assessed associations between perfectionism (SOP and SPP) and sleep (falling asleep/reinitiating sleep, returning to wakefulness, and going to bed). Two moderation models explored how relations between perfectionism (SOP and SPP) and sleep quality (total score) varied depending on level of functional disability. All analyses controlled for clinic setting. RESULTS: Results indicated SPP was associated with more difficulties across all sleep subdomains in adolescents with chronic pain, while SOP was unrelated to sleep quality. Associations between perfectionism and sleep quality were dependent on functional disability; perfectionism was most strongly associated with worse sleep quality for adolescents with less functional disability. CONCLUSIONS: This study highlights the relationship between perfectionism and sleep quality in adolescents with chronic pain and suggests that perfectionistic youth with less disability are at the greatest risk for sleep problems. Longitudinal research is needed to understand how perfectionism, sleep, and disability interact over time in youth with chronic pain.

Understanding How Perfectionism Impacts Intensive Interdisciplinary Pain Treatment Outcomes: A Nonrandomized Trial.

OBJECTIVE: Several factors are known to impact response to the intensive interdisciplinary pain treatment (IIPT) program described in this study, yet no research has explored the role of perfectionism. This secondary data analysis explored direct and indirect relations between perfectionism and functional disability (primary outcome) and pain severity (secondary outcome) after IIPT, with pain catastrophizing and fear of pain as mediators. METHODS: Youth (N = 253) aged 8-21 with chronic pain and associated disability completed pre- and post-IIPT measures of self-oriented perfectionism (SOP), socially prescribed perfectionism (SPP), pain catastrophizing, fear of pain, functional disability, and pain characteristics for routine clinical care and this nonrandomized trial. Eight mediated models were run for the two predictors, two mediators, and two outcomes. RESULTS: Pretreatment perfectionism (SOP and SPP) led to greater reductions in pain catastrophizing over the course of IIPT, which resulted in lower pain severity (ß = -.02 [CI = -0.07, -0.01] for SOP and ß = -.02 [CI = -0.06, -0.003] for SPP) and less functional disability (ß = -.06 [CI = -0.13, -0.01] for SOP and ß = -.06 [CI = -0.14, -0.01] for SPP). Independent of pain catastrophizing, pretreatment SPP was directly associated with more posttreatment functional disability (ß = .16 [CI = 0.05, 0.27]). Fear of pain was not a mediator. CONCLUSIONS: Findings suggest perfectionism has the potential to negatively impact IIPT outcomes. However, when perfectionistic youth with chronic pain learn to manage pain-related distress, they benefit. Results highlight the importance of assessing for and treating perfectionism and pain-related distress in youth with chronic pain.

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.

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).

Topical Review: Perfectionism and Pediatric Chronic Pain: Theoretical Underpinnings, Assessment, and Treatment.

Objective: To use the biopsychosocial model and current literature to clarify conceptual underpinnings between chronic pain and perfectionism in youth, provide recommendations for assessment and treatment of co-existing perfectionism and chronic pain conditions, and suggest a research agenda. Methods: Current literature is used to identify biopsychosocial factors common between pediatric chronic pain and perfectionism, preliminary research findings are presented, and suggestions are made for research that will help inform inclusion and adaptations of assessment tools and interventions to address perfectionism. Results: Biopsychosocial factors that may contribute to the observed relationship between chronic pain and perfectionism seen in many youth are identified. For example, cognitive factors known to be associated with perfectionism (e.g., rumination) may also contribute to pain-related catastrophizing and disability. Biopsychosocial factors may serve as mediating variables between perfectionism and pain-related outcomes among youth with chronic pain and their parents. Conclusions: Research assuming a biopsychosocial perspective is needed to clarify observed links between chronic pain and perfectionism in youth. Findings related to the characterization of perfectionism in pediatric chronic pain will inform how assessment and treatment tools can better identify and address perfectionism.

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.

Feeling the Pressure to Be Perfect: Effect on Pain-Related Distress and Dysfunction in Youth With Chronic Pain.

Despite clinical observation of perfectionistic tendencies among youth with chronic pain and their parents as well as established relationships between perfectionism and functional somatic symptoms in adults and youth, no research in the pediatric pain literature has examined perfectionism. This study explored the role of various types of youth and parent perfectionism on youth and parent pain-related distress and behavior and youth pain-related dysfunction. At admission, 239 parent-child pairs from outpatient and day-treatment rehabilitation settings completed several questionnaires assessing perfectionism, pain-related distress, and pain-related dysfunction. Bivariate correlations indicated that socially prescribed perfectionism in youth and parents was linked to youth pain duration, parent and youth pain-related distress and behavior, and youth somatization. Indirect relations showed that youth socially prescribed perfectionism was the only form of perfectionism directly associated with youth somatization whereas all forms of youth perfectionism were indirectly associated with somatization and functional disability through increases in youth pain-related fear and catastrophizing. Additionally, socially prescribed perfectionism was the only type of parent perfectionism linked to youth pain-related dysfunction (somatization, functional disability) through its association with youth pain-related fear. Findings support clinical observations that parent and youth perfectionism is a psychosocial factor that should be targeted in pediatric chronic pain treatment. PERSPECTIVE: Perfectionism in youth with chronic pain and their parents was indirectly linked to youth pain-related dysfunction through its effect on youth pain-related catastrophizing and fear. Findings support clinical observations that parent and youth perfectionism is a psychosocial factor that should be targeted in pediatric chronic pain treatment.

Understanding affluent adolescent adjustment: The interplay of parental perfectionism, perceived parental pressure, and organized activity involvement.

This cross-sectional study examined relations between affluent adolescent adjustment and culturally salient factors within parent-child relationship and extracurricular domain. Bootstrapping techniques evaluated mediated effects among parental perfectionism, perceived parental pressure, intensity of organized activity (OA) involvement, and adolescent adjustment (i.e., depressive and anxiety symptoms, life satisfaction) within a sample of 10th graders and their parents (n = 88 parent-child pairs) from four high schools in affluent communities. Findings indicated that adolescents with more perfectionistic parents perceived more parental pressure and experienced poorer adjustment. Results also demonstrated that affluent adolescents who perceived more parental pressure were more intensely involved in OAs, but that higher OA intensity was linked to better adjustment. Findings highlight the importance of considering parental perfectionism when understanding adolescent behaviors and psychological outcomes, confirm the negative direct effects of parental pressure on adjustment, and corroborate prior research dispelling that highly intense OA involvement is linked to adolescent maladjustment.

The cost of perfection with apparent ease: Theoretical foundations and development of the Effortless Perfectionism Scale.

Effortless perfection is a term used to describe an intense pressure to be perfect without visible effort (Yee, 2003), and is thought to be linked to several indicators of maladjustment among college-age youth (Ruane, 2012; Yee, 2003). Although effortless perfectionism (EP) is a phenomenon referenced in popular culture, empirical support for this construct is needed. In addition to conceptualizing and discussing the theoretical underpinnings of EP, this paper describes the development of an instrument to assess EP: the 10-item Effortless Perfectionism scale (EPS). The responses of a large sample of students from a Midwestern university (N = 1,270) were used to develop a 1-factor measurement model for the EPS. The EPS showed good internal consistency and test-retest reliability, and demonstrated convergent, discriminant, and incremental validity in relation to other perfectionism scales, as a predictor of psychosocial adjustment, and as a mediator of the effects of gender on adjustment. The present study supports the reliability and construct validity of the EPS as a self-report measure of EP, a distinct type of perfectionism that warrants future investigation.

Brief report: adolescent adjustment in affluent communities: the role of motivational climate and goal orientation.

Researchers now recognize that affluent youth experience tremendous achievement pressures, yet contributing factors or outcomes are rarely explored. Using a sample of affluent adolescents, the present study investigates the mediating role of goal orientation (GO) on relations between school motivational climate (MC) and adolescent adjustment. Adolescents from four high schools completed measures of MC (i.e., Performance and Mastery), GO (i.e., Ego and Task), and adjustment (i.e., depressive symptoms, anxiety, and life satisfaction). Performance climates were associated with more adjustment problems while Mastery climates were associated with fewer adjustment problems. Adolescents with higher Ego orientation reported more depressive and anxiety symptoms, while adolescents with higher Task orientation indicated fewer depressive symptoms and greater life satisfaction. Adolescent Task orientation mediated the relations between Mastery climate and two adjustment outcomes (i.e., depressive symptoms and life satisfaction). Results suggest the importance of non-competitive achievement-oriented values and collaborative school contexts in adolescent adjustment.

Understanding threshold effects of organized activity involvement in adolescents: sex and family income as moderators.

The current study examined the curvilinear links between involvement in organized activities (OA) and sport activities specifically and various indicators of psychological and social development. Participants included 150 9th and 10th graders (57% females) from an urban, selective-enrollment high school. Eligibility for admission is based on city residence, high GPA, and high scores on standardized tests and an admission exam. Findings indicated that benefits of OA involvement leveled off at approximately 5-7 h/week, with diminishing returns for adolescents participating in more than 10 h/week. Results also suggest that OA involvement uniquely impacts male and lower-income participants. Males reported threshold effects in terms of perceived friendship competence and depressive symptoms. Male sport participants and lower-income adolescents reported a similar pattern for loneliness. Findings suggest that among a high achieving sample of urban adolescents, social and psychological benefits are linked to moderate but not intense involvement in OAs and sports.

The development and evaluation of a portion plate for youth: a pilot study.

OBJECTIVE: To develop and evaluate a portion plate for adolescents (Nutri-plate). METHODS: Sixteen African American adolescents (mean age = 12.94 years; 66% male) were randomized to participate in either plate design or nutrition education sessions. Adolescents' input was used to create the Nutri-plate, and participants' food selection and intake was evaluated. RESULTS: Adolescents indicated the plate should include simple yet colorful visual and textual information about healthful eating. Participants left less food on their plate when dining with the Nutri-plate as compared with a plain plate (P < .01). Examination of effect sizes suggested that when using the Nutri-plate, participants selected less food overall (d = 0.73), more fruit (d = -0.64), more broccoli au gratin (d = -0.85), and less steamed broccoli (d = 0.87). Participants with higher body mass index selected a greater amount of healthful food when using the Nutri-plate (P < .05). CONCLUSIONS AND IMPLICATIONS: Further evaluation is needed to determine the influence of a portion plate on adolescents' nutritional behaviors.

Organized activity involvement, depressive symptoms, and social adjustment in adolescents: ethnicity and socioeconomic status as moderators.

The current cross-sectional study investigated the links between various dimensions of organized activity involvement and depressive symptoms, loneliness, and peer victimization in an ethnically and economically diverse sample of adolescents (N = 152; 58% female). Results indicate that adolescents who were involved in organized activities for more years also reported lower levels of loneliness. There was evidence of diminishing returns when adolescents were very highly involved in organized activities; those who were either under- or over-involved reported the highest levels of depressive symptoms. Conversely, findings indicate that adolescents who participated in a narrow or wide range of activity contexts reported the lowest levels of depressive symptoms. In addition, results suggested that the relation between organized activity involvement and adjustment differs among adolescents from diverse ethnic and socioeconomic backgrounds. Findings from the current study also underscore the importance of considering multiple indices of activity involvement when assessing its association with adjustment.

Association between attention-deficit/hyperactivity disorder and bulimia nervosa: analysis of 4 case-control studies.

BACKGROUND: Impulsivity is a common feature of attention-deficit/hyperactivity disorder (ADHD), and evidence suggests that impulsivity traits may be an indicator of poor prognosis for individuals with bulimia nervosa. To identify whether there is an association between ADHD and bulimia nervosa, the authors systematically examined data from children and adults with and without ADHD. METHOD: We systematically identified rates of bulimia nervosa in individuals with and without ADHD (DSM-III-R criteria) in our 2 large pediatric and 2 large adult samples (N = 522 children, 742 adults). Subjects were assessed from the late 1980s to February 1999. RESULTS: In the 2 samples of adults with and without ADHD, significantly greater rates of bulimia nervosa were identified in women with versus without ADHD (12% vs. 3%, p < .05 for 1 sample and 11% vs. 1%, p < .05 for the other sample). No significant differences in rates of bulimia nervosa were identified in men or children with ADHD when compared to sex-matched control subjects. CONCLUSION: Although preliminary and requiring further confirmation, these findings suggest that ADHD may be associated with bulimia nervosa in some women. If confirmed, this association between bulimia nervosa and ADHD could have important clinical and therapeutic implications.