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Objective Anxiety is common in pediatric chronic pain and is related to a higher risk for poor outcomes; thus, there is a need for effective clinical screening methods to identify youth with chronic pain and co-occurring anxiety. The Screen for Child Anxiety-related Disorders (SCARED) is a validated measure that defines clinically significant anxiety using the traditional clinical cut-off, but in pain populations, may fail to screen in youth with subclinical anxiety that may also be at increased risk. Two studies aimed to devise a clinically meaningful approach to capture anxiety severity in pediatric chronic pain. Materials and methods Study 1 (n=959) and Study 2 (n=207) were completed at 2 separate pediatric pain clinics, where the SCARED was administered along with measures of disability, activity limitations, pain intensity, quality of life, and pain catastrophizing. Groups with different levels of anxiety were compared on clinical outcomes via multivariate analyses of variance or independent samples t tests. Results A tertile solution suggested the following anxiety groupings based on the SCARED: minimal (0 to 12), subclinical (13 to 24), and clinical (≥25). Across both studies, the tertile solution was generally superior in classifying different levels of pain-related outcomes. Discussion Future directions include testing the utility of this anxiety classification system to identify youth with subclinical levels of anxiety for early intervention focused on both pain and anxiety management.

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: NCT 03268421.

Children with acute recurrent and chronic pancreatitis experience severe abdominal pain that may be intermittent or chronic. Pain is often debilitating, causing interference with academic, social, family, and extracurricular activities that are important to youth. Disruption of these routines and the unpredictability of pain flares place children with pancreatitis at increased risk for development of anxious or depressive symptoms. Pediatric psychologists trained in cognitive-behavioral treatment are well-suited to intervene on functional disability and mood disturbance, as well as teach coping skills. In an era where there is movement away from opioids, non-pharmacological strategies have an important place for pain management. In fact, positive outcomes following for children with other recurrent abdominal pain syndromes have been reported for this evidence-based intervention. In addition to pain management, pediatric psychologists can address other co-occurring behavioral and emotional problems in children with pancreatitis, such as needle phobia and poor adherence to the prescribed medical regimen.

INTRODUCTION A variety of factors influence parent responses to pain behaviors they observe in their adolescents with chronic pain. Certain parental responses to pain, such as attention or overprotection, can adversely impact adolescent adaptive functioning and correspond to poor clinical outcomes. OBJECTIVES It was hypothesized that the relationship between adolescent pain behaviors and functional disability was mediated by maladaptive parenting (protective, monitoring, solicitousness) responses. MATERIALS AND METHODS Participants were 303 adolescents and their mothers presenting to a pain clinic. Adolescents completed measures of functional disability and pain intensity; mothers completed measures assessing adolescent pain behaviors, their own catastrophizing about their adolescent's pain, and responses to pain. A path model tested the direct and indirect associations between pain behaviors and disability via 3 parenting responses, controlling for average pain intensity and parent pain catastrophizing. RESULTS Greater pain behavior was associated with increased protective responses (α path, P

Objective Despite the availability of measures for assessing physical, psychological, and health impact in children with chronic pain, there are not established guidelines for interpretation of children’s pain outcomes following psychological treatment. The purpose of this topical review is to discuss clinical significance as a neglected area of consideration in pediatric chronic pain assessment and to make recommendations on how the field can move toward benchmarking on core outcome domains. Method We review definitions of clinical significance and examples of several methodologies that have been used in other populations or are emerging in pediatric chronic pain including anchor-based methods, distribution-based methods, or multimethod approaches. Results Few measures across pediatric chronic pain outcome domains have established clinical significance of scores to interpret meaningful change following treatment limiting the interpretability of findings from clinical trials. In the context of clinical practice, several efforts to examine clinical significance to improve the translation of evidence-based measurement into standard clinical decision-making exist. Conclusions Recommendations are provided to encourage additional validation efforts of outcome measures in pediatric chronic pain and to encourage authors to report clinical significance in clinical trials of psychological interventions for pediatric chronic pain.

Objective School anxiety is a prevalent and debilitating mental health problem among youth with chronic pain. Despite evidence that anxiety in the context of school is associated with significant school-related disability, no studies have examined specific aspects of school anxiety in a pediatric chronic pain population. Materials and methods Adolescents with chronic pain (n=30) and age-matched and sex-matched controls (n=30) and their parents completed questionnaires assessing school anxiety and functioning. Results Adolescents with chronic pain reported significantly more cognitive, behavioral, and psychophysiological symptoms of school anxiety relative to healthy controls. Youth with pain also endorsed significantly greater school anxiety in situations involving negative social evaluation and peer aggression. Exploratory analyses indicated that adolescents with chronic pain reporting school refusal behaviors more strongly endorsed behavioral and psychophysiological school anxiety symptoms, and more symptoms in social-evaluative situations. Youth with pain reporting lower school functioning endorsed more cognitive school anxiety symptoms and anxiety in situations involving academic failure relative to those reporting higher functioning. Discussion Present results offer a nuanced perspective into the underlying sources of school anxiety among adolescents with chronic pain. Our findings may inform future research efforts and targeted school functioning interventions. In particular, findings suggest that an individualized approach to the assessment of school anxiety which considers the unique sources of anxiety (eg, social vs. academic) may lay the groundwork for the refinement of school functioning interventions in pediatric chronic pain.

To evaluate whether clinical anxiety in children presenting to a pediatric pain management center is associated with a poorer treatment response for those who completed pain-focused cognitive behavioral therapy (CBT).The total sample consisted of 175 children, 40 of whom completed CBT for chronic pain. The Screen for Child Anxiety Related Emotional Disorders was completed at initial evaluation and outcome measures (average pain intensity and the Functional Disability Inventory) were collected during the initial evaluation and at the end of CBT. Group differences in outcomes were examined following CBT. The role of anxiety in CBT initiation and completion was also explored.Presence of clinical anxiety was associated with greater initiation and/or completion of pain-focused CBT but also a poorer treatment response. Specifically, the group with subclinical anxiety exhibited a substantial reduction in pain intensity, and the group with clinical anxiety exhibited a more limited response to treatment (F [1, 36] = 13.68 P.01). A similar effect was observed for Functional Disability Inventory, such that the group with clinical anxiety had a significantly smaller response to treatment (F [1, 38] = 4.33 P.05). The difference in pain and disability between groups following CBT suggest moderate effects (Cohen d = 0.77 and 0.78, respectively).Although youths with clinical anxiety are more likely to start and/or complete pain-focused CBT, anxiety has an adverse impact on CBT treatment response in children with chronic pain. Identification of patients with anxiety and use of tailored behavioral interventions may improve clinical outcomes.

Widespread musculoskeletal pain is a chronic and debilitating pain condition associated with impairment in multiple domains of functioning, with notable declines in physical functioning and difficulty tolerating basic activities such as attending school, spending time with friends, and helping with chores. Activity limitations and physical deconditioning may present challenges for mental health clinicians seeking to provide intervention. Cognitive behavioral therapy (CBT) is an evidence-based, effective treatment modality to reduce functional disability and improve pain-specific cognitions (e.g., fear of movement, pain catastrophizing) in youth with widespread musculoskeletal pain. In addition to psychoeducation and relaxation training, CBT for chronic widespread musculoskeletal pain has a strong emphasis on resuming normal physical functioning using behavioral activation, activity pacing with scheduled breaks, and cognitive restructuring for maladaptive pain-specific beliefs. Additionally, there is evidence that incorporating graded exercise training within treatment can be particularly useful to build endurance and address physical deconditioning.

Juvenile-onset fibromyalgia (JFM) is typically diagnosed in adolescence and characterized by widespread pain and marked functional impairment. The long-term impact of JFM into adulthood is poorly understood. The objectives of this study were to describe physical and psychosocial outcomes of youth diagnosed with JFM in early adulthood (~ 8-year follow-up), examine longitudinal trajectories of pain and depressive symptoms from adolescence to young adulthood, and examine the impact of pain and depressive symptoms on physical functioning over time. Participants were 97 youth with JFM enrolled in a prospective longitudinal study in which pain symptoms, physical and psychosocial functioning were assessed at four time points over approximately eight years. At the Time 4 follow-up (M(age) = 24.2 years), the majority continued to suffer from pain and impairment in physical, social, and psychological domains. However, trajectories of pain and emotional symptoms showed varying patterns. Longitudinal analysis using growth mixture modeling revealed two pain trajectories (Steady Improvement and Rapid Rebounding Improvement); whereas depressive symptoms followed three distinct trajectories (Low-Stable, Improving, and Worsening). Membership in the Worsening Depressive symptoms group was associated with poorer physical functioning over time (p < .001) compared to the Low-Stable and Improving groups. This study offers evidence that while JFM symptoms persist for most individuals, pain severity tends to decrease over time. However, depressive symptoms follow distinct trajectories that indicate subgroups of JFM. In particular, JFM patients with worsening depressive symptoms showed decreasing physical functioning and may require more intensive and consistent intervention to prevent long-term disability.

OBJECTIVE: The current study tested the utility of the PROMIS Pediatric Pain Interference (PPI) in relation to the widely-used Functional Disability Inventory (FDI) in a small-scale clinical trial. METHODS: Forty youth with juvenile fibromyalgia (JFM) were randomized to either CBT only or a combined CBT and neuromuscular exercise group (i.e., FIT Teens). Participants completed the PPI and FDI at baseline, post-treatment, and three-month follow-up. RESULTS: The PPI and FDI were significantly correlated at baseline (r = .51) and post treatment (r = .53), and demonstrated similar improvements (d PPI = .87, d FDI = 1.22, p

Juvenile-onset fibromyalgia (JFM) is a chronic pain condition typically diagnosed in adolescence and characterized by widespread pain and marked functional impairment, including mood difficulties. However, the long-term impact of JFM during the period when adolescents transition into young adulthood is poorly understood. The objectives of this study were to describe physical and psychosocial outcomes of youth diagnosed with JFM in early adulthood (∼ 8-years after initial assessment), examine longitudinal trajectories of pain and depressive symptoms from adolescence to young adulthood, and examine the impact of pain and depressive symptoms on physical functioning over time. Participants were 97 youth with JFM enrolled in a prospective longitudinal study, in which pain symptoms, physical and psychosocial functioning were assessed at four time points over approximately eight years. The 8-year follow-up data were evaluated descriptively, and trajectories were identified using growth mixture modeling analyses in MPlus. At the final assessment (T4) (Mage = 24.2 years), a majority of young adults continued to suffer from pain and impairment in physical, social, and psychological domains, with 58% meeting ACR 2010 criteria for adult fibromyalgia (FM). However, trajectories of pain and emotional symptoms showed varying patterns. Longitudinal analyses revealed two pain trajectories (Steady Improvement and Rapid Rebounding Improvement). Depressive symptoms followed three distinct trajectories (Low-Stable, Improving, and Worsening). The group with worsening depressive symptoms was associated with poorer physical functioning over time (p

Purpose Juvenile-onset fibromyalgia (JFM) affects physical, social, and emotional functioning. Little is known about how social support and social interactions are impacted in the transition to young adulthood for patients diagnosed with JFM. Methods Young adults (M age = 21.6) diagnosed with JFM during adolescence (N = 94) and matched healthy controls (N = 33) completed measures of social network size and diversity, perceived social support, physical functioning, and depressive symptoms as part of a cross-sectional survey study. Results No difference in social network diversity was found, although JFM patients reported fewer total people within their social networks. JFM patients reported poorer emotional and tangible support and fewer positive social interactions than healthy controls. After controlling for condition and pain intensity, the level of perceived social support was a significant predictor of physical functioning and depressive symptoms, whereas social network size also contributed uniquely to physical functioning. Conclusions Given the developmental importance of social support in adolescence and young adulthood, interventions should include methods of improving social support into fibromyalgia management.

INTRODUCTION For a large portion of youth, pain-associated functional gastrointestinal disorders (FGIDs) are associated with significant impairment over time. Clinically feasible methods to categorize youth with FGIDs at greatest risk for persistent pain-related impairment have not yet been identified. METHODS Measures of functional disability, pain intensity, and anxiety were collected on 99 patients with FGIDs (ages 8-18) during a visit to a pediatric gastroenterology office to assess for the presence of risk. Follow-up data were obtained on a subset of this sample (n = 64) after 6 months, either in person or via mail. The present study examined whether a greater number of risk factors at baseline predicted greater pain-related disability at follow-up. RESULTS Patients were divided into 4 groups based on number of risk factors present at the initial assessment: 0 (18.2%), 1 (24.2%), 2 (26.3%), and 3 (31.3%). The presence of 2 or 3 risk factors significantly predicted greater disability at follow-up compared to those with 0 risk factors (R = 0.311) and those with just 1 risk factor (Cohen's d values of -1.07 and -1.44, respectively). DISCUSSION A simple approach to risk categorization can identify youth with FGIDs who are most likely to report increased levels of pain-related impairment over time. These findings have important clinical implications that support the utility of a brief screening process during medical care to inform referral for targeted treatment approaches to FGIDs.

Functional abdominal pain (FAP) in children, is a set of recurrent pain conditions without an organic cause (1), is highly prevalent and can lead to substantial impairment including decreased involvement in social, academic, and other daily activities (2–4). Based on Rome-III criteria, subtypes of FAP include functional dyspepsia, irritable bowel syndrome, and abdominal migraine (1). Youth with FAP who have the greatest level of impairment may be characterized by anxiety, expressed as maladaptive thinking about pain, or other family risk factors (i.e., overprotective parenting) that are potentially modifiable with behavioral intervention (5). Greater impairment has been associated with the child’s use of poor psychological coping strategies such as catastrophic thinking about pain [e.g., belief that pain will not resolve or get worse, (6)] as well as parental responses to pain, such as overprotection (i.e., checking in repeatedly about pain symptoms) or minimizing/criticism (7). Understanding how children develop maladaptive coping strategies in response to FAP involves recognition of the caregiving environment in which these coping behaviors develop (8). A recent community-based study found that the impact of child catastrophizing on disability was less pronounced in the context of high levels of adaptive parenting behaviors (e.g., promotion of children’s well behaviors) in generally healthy schoolchildren dealing with occasional pain (9). There is emerging evidence that the joint impact of parenting factors and child pain catastrophizing is relevant for understanding impairment in samples of youth with mixed chronic pain conditions (10, 11) and in youth with organic causes of abdominal pain, such as Inflammatory Bowel Disease (12) Multiple studies in pediatric chronic pain have documented the impact of parenting factors in children’s adjustment to pain. For example, parent protection and criticism have been implicated in predicting disability in youth with an array of chronic pain conditions (13–15) and more specifically in children with FAP (16–20). Some research suggests that parental overprotectiveness (i.e., limiting the child’s normal activities and/or giving the child special attention secondary to pain) and/or minimizing (i.e., criticism) uniquely influence FAP-related disability (16, 18) whereas other research did not find evidence of such relationships (20). Given the tendency for pain conditions to occur in families, it is conceivable that parents’ catastrophizing may be related to the expression of disability in youth with FAP, though this research has generally focused on the role of parent catastrophizing about their own pain versus their child’s pain (17), though there are several recent exceptions (12, 21). In youth with Inflammatory Bowel Disease, parent catastrophizing about their child pain partially explained the relationship between child pain behavior and parental protective responses; however, the relationship between these factors and child impairment was not examined (12). Yet another recent investigation has found support for the role of child pain catastrophizing underlying the association between parent catastrophizing about their child’s pain and pain related disability in a school-based sample of adolescents (21). However, it is unclear if child pain catastrophizing is related to disability in the presence of other parental responses to child pain (i.e., overprotection, criticism, or symptom monitoring) in youth with FAP. Thus, investigating multiple parenting behaviors can be beneficial to fully capture the range of responses that children with FAP may receive from their caregivers. In general, models examining the simultaneous influence of child and parenting factors in predicting impairment in youth with chronic pain have focused on mixed pediatric pain samples, youth with IBD, or healthy controls and have shown mixed results (10, 13, 15, 22, 23), with some support that catastrophizing may mediate the relationship between parenting factors and disability, particularly in youth with chronic musculoskeletal pain (10, 15). Guite and colleagues also found that child pain catastrophizing may account for the relationship between pain intensity and disability (10); thus, it may be valuable to examine if these variables operate similarly in youth with FAP. Thus, the purpose of this study is to examine how pain catastrophizing in children and parental responses to their child’s pain interact to affect disability in a clinical sample of youth with FAP. We predict that child pain catastrophizing will mediate the relationship between parental responses to pain (i.e., protectiveness, encouragement/symptom monitoring, and minimization) and disability, consistent with prior literature. We also investigated the role of child pain catastrophizing in mediating the relationship between pain intensity and disability to assess whether these factors operate similarly in predicting disability in our sample as compared to prior research in youth with musculoskeletal pain (10). We undertook exploratory analysis examining the role of parent pain catastrophizing about the child’s pain in relation to parent responses to pain and disability. This project is the first part of an ongoing research program in developing tailored interventions for youth with FAP and their caregivers.

Patients presenting for treatment of chronic pain often believe that pain reduction must be achieved before returning to normal functioning. However, treatment programs for chronic pain typically take a rehabilitative approach, emphasizing decreasing pain-related disability first with the expectation that pain reduction will follow. This information is routinely provided to patients, yet no studies have systematically examined the actual trajectories of pain and disability in a clinical care setting. In this study of youth with chronic pain (N = 94, 8 to 18 years), it was hypothesized that 1) functional disability and pain would decrease over the course of psychological treatment for chronic pain and 2) functional disability would decrease more quickly than pain intensity. Participants received cognitive behavioral therapy (CBT) for pain management (M = 5.6 sessions) plus standard medical care. The Functional Disability Inventory and a Numeric Rating Scale of average pain intensity were completed by the child at every CBT session. Hierarchical linear modeling was conducted to examine the longitudinal trajectories of disability and pain. Standardized estimates of the slopes of change were obtained to test differences in rates of change between pain and disability. Results showed an overall significant decline in functional disability over time. Although pain scores reduced slightly from pretreatment to posttreatment, the longitudinal decline over treatment was not statistically significant. As expected, the rate of change of disability was significantly more rapid than pain. Evidence for variability in treatment response was noted, suggesting the need for additional research into individual trajectories of change in pediatric pain treatment.

The primary objective of this study was to estimate a clinically significant and quantifiable change in functional disability to identify treatment responders in a clinical trial of cognitive-behavioral therapy (CBT) for youth with juvenile fibromyalgia (JFM). The second objective was to examine whether baseline functional disability (Functional Disability Inventory), pain intensity, depressive symptoms (Children's Depression Inventory), coping self-efficacy (Pain Coping Questionnaire), and parental pain history predicted treatment response in disability at 6-month follow-up. Participants were 100 adolescents (11-18 years of age) with JFM enrolled in a recently published clinical trial comparing CBT to a fibromyalgia education (FE) intervention. Patients were identified as achieving a clinically significant change in disability (i.e., were considered treatment responders) if they achieved both a reliable magnitude of change (estimated as a > or = 7.8-point reduction on the FDI) using the Reliable Change Index, and a reduction in FDI disability grade based on established clinical reference points. Using this rigorous standard, 40% of patients who received CBT (20 of 50) were identified as treatment responders, compared to 28% who received FE (14 of 50). For CBT, patients with greater initial disability and higher coping efficacy were significantly more likely to achieve a clinically significant improvement in functioning. Pain intensity, depressive symptoms, and parent pain history did not significantly predict treatment response. Estimating clinically significant change for outcome measures in behavioral trials sets a high bar but is a potentially valuable approach to improve the quality of clinical trials, to enhance interpretability of treatment effects, and to challenge researchers to develop more potent and tailored interventions.

Patient-Reported Outcomes Measurement Information System (PROMIS) measures are reliable, brief instruments to measure patient health. The PROMIS pediatric anxiety short form assesses anxiety symptoms; however, its ability to capture a clinically meaningful understanding of anxiety is unknown. Within pediatric chronic pain, anxiety is generally assessed by legacy measures examining anxiety symptoms specific to pain [e.g., Pain Catastrophizing Scale for Children, (PCS-C)] or broadly [The Screen for Child Related Anxiety Disorders, (SCARED)], which have been shown to predict pain-related outcomes. The aim of this study was to describe the relationship between the three measures and assess how PROMIS anxiety relates to clinically-validated measures commonly used to understand anxiety in pediatric chronic pain. Participants were 65 youth presenting to a multidisciplinary pediatric pain clinic. Self-report anxiety measures (PROMIS, PCS-C, and SCARED) were collected as part of standard clinical outcomes. Participants were primarily adolescent females (53, 81.5%, Mage =15.0, SD = 1.8). Pain-specific anxiety was moderate (MPCS-C = 19.7, SD = 11.9), while broader anxiety approached clinical cut-offs (MSCARED = 24.6, SD = 19.8, clinical cut-off ≥ 25). PROMIS anxiety was average (total score = 10, SD = 8.4; T-score = 53.8). Correlations between PROMIS and the legacy measures were moderate to high (rSCARED = .81, rPCS-C = .73, p's

Little is known regarding treatment choices of youth diagnosed with juvenile-onset fibromyalgia (JFM) as they move into young adulthood. Additionally, there is little empirical evidence to guide youth with FM into appropriate treatment options, leading to a variety of therapies used to manage FM symptoms. The purpose of this descriptive study was to examine all therapies used by individuals with JFM as they entered young adulthood and the perceived effectiveness of these treatments. As part of a larger follow-up study, participants completed a web-based survey of all current and past treatments received for FM symptoms 2 years after their initial presentation and diagnosis at a pediatric rheumatology clinic. One hundred ten out of 118 eligible patients participated in the follow-up assessment as young adults (mean age 18.97 years; 93.6% female). A majority of participants reported use of conventional medications (e.g., antidepressants, anti-convulsants) and nondrug therapies (e.g., psychotherapy). Currently and within the past 2 years, antidepressant medications were the most commonly used to manage FM. Complementary treatments were used less often, with massage being the most popular choice. Although currently used treatments were reported as being effective, past treatments, especially medications, were viewed as being more variably effective. This is a potential reason why young adults with JFM might try more complementary and alternative approaches to managing their symptoms. More controlled studies are needed to investigate the effectiveness of these complementary methods to assist treatment providers in giving evidence-based treatment recommendations.

Objective The PedsQL rheumatology module is currently the only available measure of disease-specific quality of life for children and adolescents with juvenile fibromyalgia (FM), but limited information has been published about the psychometric properties of the instrument, specifically in juvenile FM. The objective of this study was to assess the reliability, validity, and sensitivity to change of the 5 scales (pain and hurt, daily activities, treatment, worry, and communication) of the patient and parent proxy versions of the PedsQL rheumatology module in the context of a randomized controlled trial in juvenile FM. Methods The entire PedsQL rheumatology module was administered as a supplementary outcome measure at baseline, posttreatment, and 6-month followup assessments of 114 children and adolescents with juvenile FM enrolled in a trial testing the efficacy of cognitive–behavioral therapy. Results Internal consistency reliabilities for the scales were adequate to strong (Cronbach's α = 0.68–0.86). Parent proxy and child reports on most scales (except for daily activities and communication) showed moderate correlations (Spearman's r = 0.33–0.45). Support for construct validity was found by comparing child and parent reports with other related measures of pain and functioning (visual analog scale pain ratings and the Functional Disability Inventory). Finally, sensitivity to change was demonstrated by significant changes in 4 of the 5 scales (excluding the daily activities scale) after treatment. Conclusion The PedsQL rheumatology module generally appears to have good utility for use in juvenile FM patients, but there are some caveats to the interpretation of specific scales in this population.

Catastrophizing is a coping style linked to poorer patient outcomes. Little attention has focused on the parent-adolescent dyad and catastrophizing as a shared coping style. The purpose of this study was to: (1) examine the effects of adolescent and parent pain catastrophizing on adolescent functioning and (2) explore concordance in catastrophizing in parent-adolescent dyads, with equal interest in outcomes of dyads with discordant coping styles.Pain intensity, catastrophizing, depressive symptoms, quality of life, and pain behaviors were assessed in adolescents (ages 11 to 17) presenting to a pediatric chronic pain clinic (N=240).Significant correlations between (1) parent and adolescent catastrophizing; (2) catastrophizing and pain behaviors; and (3) catastrophizing and adolescent outcomes were found. Parents and adolescents were classified into concordant or discordant dyads based on catastrophizing with a majority of dyads (70%) showing concordant coping styles. Among discordant dyads, functional disability and depressive symptoms were significantly higher in a dyad with a high catastrophizing adolescent and low catastrophizing parent.Results provide further support for catastrophizing being a maladaptive coping strategy for adolescents with pain and their parents. Greater adolescent catastrophizing was related to increased pain behaviors and poorer adolescent functioning. Parent catastrophizing also seems related to poorer adolescent outcomes, and most parent-adolescent dyads showed concordance in use of catastrophizing, which may suggest a shared tendency for adaptive or maladaptive styles of coping with pain. Future research should investigate pain coping at a dyadic or family level to explore how family coping styles magnify distress and disability or buffer adolescents from such problems.

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.

Objective Little is known about the impact of family environment on the long-term adjustment of patients with juvenile-onset fibromyalgia (JFM). Our objective was to evaluate whether family environment in early adolescence predicted later physical functioning and depressive symptoms of adolescents with JFM as they transitioned to early adulthood in the context of a controlled long-term followup study. Methods Participants consisted of 39 youth (mean age 18.7 years) with JFM and 38 healthy matched controls who completed web-based surveys about their health status (Short Form 36 health survey) and depressive symptoms (Beck Depression Inventory II) ∼4 years after a home-based, in-person assessment of child and family functioning. During the initial assessment, parents of the participants (94% mothers) completed the Family Environment Scale and adolescents (mean age 14.8 years) completed self-report questionnaires about pain (visual analog scale) and depressive symptoms (Children's Depression Inventory). Results The results indicated that family environment during early adolescence significantly predicted greater depressive symptoms in early adulthood for both the JFM group and the healthy controls. In particular, a controlling family environment (use of rules to control the family and allowing little independence) during early adolescence was the driving factor in predicting poorer long-term emotional functioning for patients with JFM. Family environment did not significantly predict longer-term physical impairment for either group. Conclusion Adolescents with JFM from controlling family environments are at an increased risk for poorer emotional functioning in early adulthood. Behavioral and family interventions should foster independent coping among adolescents with JFM and greater parenting flexibility to enhance successful long-term coping.

A recent randomized multisite clinical trial found that cognitive-behavioral therapy (CBT) was significantly more effective than fibromyalgia education (FE) in reducing functional disability in adolescents with juvenile fibromyalgia (JFM). The primary objective of this study was to examine the psychological processes of CBT effectiveness by evaluating changes in pain coping, catastrophizing, and coping efficacy and to test these changes as mediators of continued improvements in functional disability and depressive symptoms at 6-month follow-up. One hundred adolescents (11–18 years old) with JFM completed the clinical trial. Coping, catastrophizing, and coping efficacy (Pain Coping Questionnaire) and the outcomes of functional disability (Functional Disability Inventory) and depressive symptoms (Children's Depression Inventory) were measured at baseline, posttreatment, and 6-month follow-up. Participants in both conditions showed significant improvement in coping, catastrophizing, and efficacy by the end of the study, but significantly greater improvements were found immediately following treatment for those who received CBT. Treatment gains were maintained at follow-up. Baseline to posttreatment changes in coping, catastrophizing, and efficacy were not found to mediate improvements in functional disability or depressive symptoms from posttreatment to follow-up. Future directions for understanding mechanisms of CBT effectiveness in adolescents with chronic pain are discussed. Perspective CBT led to significant improvements in pain coping, catastrophizing, and efficacy that were sustained over time in adolescents with juvenile fibromyalgia. Clinicians treating adolescents with JFM should focus on teaching a variety of adaptive coping strategies to help patients simultaneously regain functioning and improve mood.

Objective To examine the differential presentation(s) of psychological and health-related outcomes in young adults with juvenile-onset fibromyalgia (FM) with and without a history of trauma, compared to healthy controls. Methods In total, 110 participants (86 with juvenile-onset FM and 24 healthy controls, with a mean age of 23.4 years) completed a structured clinical interview to assess for trauma and psychological comorbidities, as well as self-report questionnaires on pain, physical functioning, and health care utilization. Results Of the juvenile-onset FM participants, 37% (n = 32) reported a history of trauma. Three group comparisons (i.e., juvenile-onset FM with trauma versus juvenile-onset FM with no trauma versus healthy controls) revealed that juvenile-onset FM participants significantly differed from healthy controls on all psychological and health-related outcomes. Further, although juvenile-onset FM participants with and without a history of trauma did not significantly differ on pain and physical functioning, juvenile-onset FM participants with a history of trauma were significantly more likely to have psychological comorbidities. Conclusion This is the first controlled study to examine the differential outcomes between juvenile-onset FM participants with and without a history of trauma. Group comparisons between juvenile-onset FM participants and healthy controls were consistent with previous research. Further, our findings indicate that juvenile-onset FM participants with a history of trauma experience greater psychological, but not physical, impairment than juvenile-onset FM participants without a history of trauma.

Juvenile fibromyalgia syndrome (FMS) is a chronic pain condition that is estimated to affect 2–7% of school-age children (1–3), primarily adolescent girls. As in adult fibromyalgia (FM), juvenile FMS is characterized by persistent and widespread musculoskeletal pain, sleep difficulty, fatigue, and mood disturbances (3). Patients with juvenile FMS experience substantial impairment in physical, school, social, and emotional functioning (4–6), and the majority of them continue to have ongoing symptoms and functional disability into late adolescence and early adulthood (7). Although progress has been made in the understanding and treatment of adult FM (8), there are few studies of juvenile FMS. Two recent meta-analytic reviews of cognitive–behavioral therapy (CBT) clinical trials for FM arrived at slightly different conclusions, with one supporting the effectiveness of CBT (9) and the other reporting no significant effect on pain and function (10). However, both reviews indicated significant improvement in coping and emphasized the need for higher quality trials of CBT. It is unclear whether findings from the 2 meta-analytic reviews, based mainly on adult FM patients, are applicable to pediatric patients. In a recent meta-analysis of psychological therapies for pediatric chronic pain (mostly headache and abdominal pain), Palermo et al (11) reported a large positive effect for pain reduction. It is possible that behavioral interventions found to be promising for adults with FM can be even more effective in juvenile FMS because they are implemented at an early age when pain coping and lifestyle factors are more malleable. There are no rigorously controlled studies of CBT for juvenile FMS at present. Early evidence for possible efficacy of CBT for improving function and decreasing pain and symptoms of depression in children and adolescents with juvenile FMS was shown in 2 small-scale studies (12,13). Unfortunately, neither study controlled for the nonspecific therapeutic effects of attention and support from health professionals, which by themselves could have resulted in improved outcomes. Therefore, the specific effects of CBT that go beyond providing emotional support and include intensive training in behavioral pain coping skills targeted at improving functioning by increasing patients' psychological coping and confidence in pain self-management skills have not yet been tested in a controlled study. We performed a multisite, randomized controlled trial in a sample of children and adolescents with juvenile FMS to rigorously assess the safety and efficacy of an 8-session, individually delivered CBT intervention compared to an 8-session supportive FM education program in reducing functional disability, pain severity, and depressive symptoms. The CBT treatment protocol was developmentally tailored for older school-age children and adolescents and included parental instruction to ensure family support for the behavioral interventions. We hypothesized that 1) CBT would be significantly more effective than FM education in reducing functional disability (primary outcome) in youth with juvenile FMS and 2) CBT would be significantly more effective than FM education in reducing pain severity and symptoms of depression (secondary outcomes). Unlike a “no-treatment” placebo control, the FM education condition was designed to be an “attention control” condition in which the nonspecific psychological benefits of the therapeutic relationship and educational information provided were expected to lead to some improvement in the short term (posttreatment assessment). However, we hypothesized that CBT would lead to sustained benefit and be demonstrably superior to FM education in reducing disability, pain, and symptoms of depression 6 months after the end of active treatment (end-of-study assessment). Selection of the outcome domains of function, pain severity, and symptoms of depression was consistent with the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) guidelines for measurement of outcomes in clinical trials of pediatric chronic pain (14). Functional disability was selected as the primary outcome because the goal of CBT is to reduce pain-related disability by teaching patients both coping and self-management behaviors (and providing parental guidance in behavior management) to improve function, while secondarily reducing pain severity and symptoms of depression. Other outcomes of interest such as tender point sensitivity, health-related quality of life (HRQOL), sleep quality, and physician's global assessment were also measured at each assessment.

Pain behaviors provide meaningful information about adolescents in chronic pain, enhancing their verbal report of pain intensity with information about the global pain experience. Caregivers likely consider these expressions when making judgments about their adolescents’ medical or emotional needs. Current validated measures of pain behavior target acute or procedural pain and young or non-verbal children, while observation systems may be too cumbersome for clinical practice. The objective of this research was to design and evaluate the Adolescent Pain Behavior Questionnaire (APBQ), a parent-report measure of adolescent (11–19 years) pain expressions. This paper provides preliminary results on reliability and validity of the APBQ. Parent-adolescent dyads ( N = 138) seen in a multidisciplinary pain management clinic completed the APBQ and questionnaires assessing pain characteristics, quality of life, functional disability, depressive symptoms, and pain catastrophizing. Principal components analysis of the APBQ supported a single component structure. The final APBQ scale contained 23 items with high internal consistency ( α = 0.93). No relationship was found between parent-reported pain behaviors and adolescent-reported pain intensity. However, significant correlations were found between parent-reported pain behaviors and parent- and adolescent-reported functional disability, pain catastrophizing, depressive symptoms, and poorer quality of life. The assessment of pain behaviors provides qualitatively different information than solely recording pain intensity and disability. It has clinical utility for use in behavioral treatments seeking to reduce disability, poor coping, and distress.

Juvenile primary fibromyalgia syndrome (JPFS) is a chronic pain condition associated with significant impairment in physical functioning, but no studies have used newer technologies such as actigraphy to document objective physical activity levels in JPFS. This is the first study to objectively describe physical activity in JPFS patients and examine the relationship of pain, perceived functional impairment, and depressive symptoms on physical activity. One hundred four clinically referred adolescents with JPFS (ages 11 to 18 years) wore a hip-mounted actigraph for 1 week. Data on pain intensity, functional disability, depressive symptoms, and psychiatric diagnoses were obtained using self- and parent-report measures and a standardized psychiatric interview. Results showed that younger patients were more active. Pain intensity was not significantly associated with physical activity levels overall, but the most highly active group of adolescents reported lower levels of pain and disability than the least active. Parent report of adolescents' physical functioning and depressive symptoms were significantly correlated with adolescents' physical activity levels. Actigraphy provides a unique source of information about physical functioning which is distinct from adolescents' self-report of physical functioning in JPFS. Preliminary findings suggest that further study of factors that predict perceived and actual physical functioning in JPFS is warranted. Perspective This study presents the results of physical activity monitoring in adolescents with JPFS using actigraphy. Results indicate that actigraphy provides a unique source of objective information that can advance our understanding of physical disability in JPFS and the factors associated with physical impairment.

Objective.Adolescents with juvenile-onset fibromyalgia (JFM) have increased rates of psychiatric disorders, but to our knowledge no studies have examined psychiatric disorders in adolescents with JFM when they enter young adulthood. This study examined the prevalence of psychiatric disorders in young adults diagnosed with JFM during adolescence and the relationship between mental health diagnoses and physical functioning.Methods.Ninety-one young adults (mean age 21.60, SD 1.96) with a history of JFM being followed as part of a prospective longitudinal study and 30 matched healthy controls (mean age 21.57, SD 1.55) completed a structured interview of psychiatric diagnoses and a self-report measure of physical impairment.Results.Young adults with a history of JFM were more likely to have current and lifetime histories of anxiety disorders (70.3% and 76.9%, respectively) compared with controls (33.3% for both, both p < 0.001). Individuals with JFM were also more likely to have current and lifetime histories of major mood disorders (29.7% and 76.9%, respectively) compared with controls (10% and 40%, p < 0.05). The presence of a current major mood disorder was significantly related to impairment in physical functioning [F (1, 89) = 8.30, p < 0.01] and role limitations attributable to a physical condition [F (1, 89) = 7.09, p < 0.01].Conclusion.Psychiatric disorders are prevalent in young adulthood for individuals with a history of JFM, and a current major mood disorder is associated with greater physical impairment. Greater attention to early identification and treatment of mood disorders in patients with JFM is warranted.

Functional abdominal pain (FAP) is associated with significant anxiety and impairment. Prior investigations of child anxiety in youth with FAP are generally limited by small sample sizes, based on child report, and use lengthy diagnostic tools. It is unknown whether a brief anxiety-screening tool is feasible, whether parent and child reports of anxiety are congruent, and whether parent and child agreement of child anxiety corresponds to increased impairment. The purpose of this investigation was to examine anxiety characteristics in youth with FAP using parent and child reports. Parent-child agreement of child anxiety symptoms was examined in relation to pain and disability.One hundred patients with FAP (8-18 years of age) recruited from pediatric gastroenterology clinics completed measures of pain intensity (Numeric Rating Scale) and disability (Functional Disability Inventory). Patients and caregivers both completed a measure of child anxiety characteristics (Screen for Child Anxiety and Related Disorders).Clinically significant anxiety symptoms were more commonly reported by youth (54%) than their parents (30%). Panic/somatic symptoms, generalized anxiety, and separation anxiety were most commonly endorsed by patients, whereas generalized anxiety, separation anxiety, and school avoidance were most commonly reported by parents. The majority (65%) of parents and children agreed on the presence (26%) or absence (39%) of clinically significant anxiety. Parent-child agreement of clinically significant anxiety was related to increased impairment.A brief screening instrument of parent and child reports of anxiety can provide clinically relevant information for comprehensive treatment planning in children with FAP.

OBJECTIVE: This prospective longitudinal study examined the long-term physical and psychosocial outcomes of adolescents with juvenile-onset fibromyalgia (JFM), compared with healthy control subjects, into early adulthood. METHODS: Adolescent patients with JFM initially seen at a pediatric rheumatology clinic (n = 94) and age- and gender-matched healthy control subjects (n = 33) completed online measures of demographic characteristics, pain, physical functioning, mood symptoms, and health care utilization at ∼6 years’ follow-up (mean age: 21 years). A standard in-person tender-point examination was conducted. RESULTS: Patients with JFM had significantly higher pain (P < .001), poorer physical function (P < .001), greater anxiety (P < .001) and depressive symptoms (P < .001), and more medical visits (P < .001)than control subjects. The majority (>80%) of JFM patients continued to experience fibromyalgia symptoms into early adulthood, and 51.1% of the JFM sample met American College of Rheumatology criteria for adult fibromyalgia at follow-up. Patients with JFM were more likely than control subjects to be married and less likely to obtain a college education. CONCLUSIONS: Adolescent patients with JFM have a high likelihood of continued fibromyalgia symptoms into young adulthood. Those who met criteria for fibromyalgia in adulthood exhibited the highest levels of physical and emotional impairment. Emerging differences in educational attainment and marital status were also found in the JFM group. JFM is likely to be a long-term condition for many patients, and this study for the first time describes the wide-ranging impact of JFM on a variety of physical and psychosocial outcomes that seem to diverge from their same-age peers.

Functional abdominal pain (FAP) is a common pediatric disorder associated with impairment in functioning that may persist for the long term. Anxiety is common in youth with FAP, and may be an important factor in predicting youth who are at greatest risk for increased impairment because of pain symptoms. In this article, we examine the relation between anxiety and impairment in youth with FAP. Furthermore, we explore various biopsychosocial factors (eg, neurobiological substrates, coping strategies, social factors) that may be implicated in the relation among FAP, anxiety, and increased impairment. Finally, we propose physician guidelines for screening and treatment of youth with FAP and co-occurring anxiety. Youth with FAP and co-occurring anxiety may benefit from cognitive-behavioral therapy in the context of multidisciplinary care.

Chronic pain is a prevalent problem in adolescents, resulting in considerable disability across multiple domains. Several pain conditions—back, abdominal, and musculoskeletal pain—are seen frequently in clinical settings and are reviewed in detail in this chapter. The biopsychosocial model is widely used to conceptualize the pain experience and explains the genetic, biological, emotional, and environmental contributions to chronic pain. Emerging biological research provides insight into the heritability of pain conditions and the influence of stress on pain perception. Adolescent coping style and mood problems are one of many psychological factors that can impact adolescents with chronic pain. The social environment provides a context for better understanding pain-related impairment, with attention to the parental factors affecting adolescent adaptive or maladaptive adjustment to pain. A rehabilitative approach to pain management is recommended, and multidisciplinary treatment typically includes medication management, physical therapy, and cognitive behavioral therapy.

The Functional Disability Inventory (FDI) is a well-established and commonly used measure of physical functioning and disability in youth with chronic pain. Further validation of the measure has been called for, in particular, examination of the clinical utility and factor structure of the measure. To address this need, we utilized a large multicenter dataset of pediatric patients with chronic pain who had completed the FDI and other measures assessing pain and emotional functioning. Clinical reference points to allow for interpretation of raw scores were developed to enhance clinical utility of the measure and exploratory factor analysis was performed to examine its factor structure. Participants included 1300 youth ages 8 to 18 years (M=14.2 years; 76% female) with chronic pain. Examination of the distribution of FDI scores and validation with measures of depressive symptoms and pain intensity yielded three distinct categories of disability: No/Minimal Disability, Moderate Disability and Severe Disability. Factor analysis of FDI scores revealed a two-factor solution representing vigorous Physical Activities and non-physically strenuous Daily Activities. The three-level classification system and factor structure were further explored via comparison across the four most commonly encountered pain conditions in clinical settings (head, back, abdominal and widespread pain). Our findings provide important new information regarding the clinical utility and validity of the FDI. This will greatly enhance the interpretability of scores for research and clinical use in a wide range of pediatric pain conditions. In particular these findings will facilitate use of the FDI as an outcome measure in future clinical trials.

Objectives. Currently, there are no prospective studies exploring the prognosis of patients with juvenile primary FM syndrome (JPFS) or their physical, emotional and social outcomes as they enter the early adult years. The primary objective of this study was to assess long-term outcomes of a paediatric sample of clinically referred JPFS patients and their matched healthy controls. Methods. Participants were 48 youths (current mean age = 19 years) diagnosed with JPFS in childhood or adolescence and 43 healthy controls matched in age, gender and race. The average length of follow-up was 3.67 years (range 2–6 years). Participants completed online (web-based) self-report questionnaires about current pain and physical symptoms, health status, anxiety, depressive symptoms and current and past treatments. Results. Results showed that 62.5% of participants in the JPFS group continued to experience widespread pain and 60.4% reported having all the cardinal features of FM syndrome (including widespread pain, poor sleep and fatigue) at follow-up. The JPFS group reported significantly lower scores on all measures of health status and physical functioning compared with healthy controls and significantly greater symptoms of anxiety and depression. Conclusion. The results of this controlled follow-up study demonstrate that symptoms of FM appear to be chronic in a majority of clinically referred JPFS patients and the associated physical and emotional impairment can also be persistent. Implications for treatment and the need for further prospective longitudinal studies are discussed.

Objective To describe school absences in adolescents with Juvenile Primary Fibromyalgia Syndrome (JPFS) and examine the relationship between school absenteeism, pain, psychiatric symptoms, and maternal pain history. Methods Adolescents with JPFS (N ¼ 102; mean age 14.96 years) completed measures of pain and depressive symptoms, and completed a psychiatric interview. Parents provided information about the adolescents’ school absences, type of schooling, and parental pain history. School attendance reports were obtained directly from schools. Results Over 12% of adolescents with JPFS were homeschooled. Those enrolled in regular school missed 2.9 days per month on average, with one-third of participants missing more than 3 days per month. Pain and maternal pain history were not related to school absenteeism. However, depressive symptoms were significantly associated with school absences. Conclusion Many adolescents with JPFS experience difficulties with regular school attendance. Long-term risks associated with school absenteeism and the importance of addressing psychological factors are discussed.

Objective This article describes the application of quality improvement methodology to implement a measurement tool for the assessment of functional status in pediatric patients with chronic pain referred for behavioral intervention. Methods The Functional Disability Inventory (FDI), a validated instrument for assessment of pain-related disability, was chosen as the primary clinical outcome measure. Using improvement science methodology, PDSA (Plan-Do-Study-Act) cycles were run to evaluate: (a) regular FDI administration, (b) two administration methods, (c) regular patient feedback, and (d) documentation methods. Results Within 1 month, psychologists were administering the FDI at least 80% of the time to patients. A high level of reliability using two administration methods (92.8%) was demonstrated. The FDI was feasible to integrate into clinical practice. Modifications to electronic records further enhanced clinician reliability of documentation. Conclusions Quality improvement methods are an innovative way to make process changes in pediatric psychology settings to dependably gather and document evidence-based patient outcomes.

Objectives To evaluate the utility of the 2010 American College of Rheumatology (ACR) adult fibromyalgia criteria for use in adolescents with juvenile fibromyalgia (JFM). Study design Participants included 47 adolescent girls diagnosed with JFM (mean age = 15.3 years) and 48 age- and sex-matched adolescents (mean age = 15.0 years) with localized chronic pain (eg, headaches or abdominal pain). A trained examiner administered the Widespread Pain Index and Symptom Severity measures and also completed a manual tender point exam. Clinicians completed a form indicating the presence of active JFM per Yunus and Masi (1985) criteria, the only available and most commonly used measure for JFM. Criterion validity analysis was performed as well as t tests comparing symptoms between JFM and controls. Results With the Yunus and Masi criteria used as the gold standard, the 2010 ACR fibromyalgia criteria showed a sensitivity of 89.4% and specificity of 87.5%. Conclusion The 2010 ACR measure appears to be a valuable tool for the identification of JFM. However, a slight modification to the 2010 ACR measure and inclusion of a clinical exam is recommended.