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Mechanisms explaining the relationship between pain-related injustice appraisals and functional outcomes in youth with chronic pain have yet to be examined. In studies of adults, greater pain-related injustice is associated with worse depressive symptoms and greater pain through greater anger. No study to date has examined anger expression as a mediator in the relationships between pain-related injustice appraisals and physical and psychosocial functioning in youth with chronic pain. The current sample consisted of 385 youth with varied pain conditions (75% female, 88% White, Mage=14.4 years) presenting to a university-affiliated pain clinic. Patients completed self-report measures assessing anger expression (anger-out and anger-in), pain-related injustice, pain intensity, functional disability, and emotional, social, and school functioning. Bootstrapped mediation analyses indicated that only anger-out (indirect effect= -.12, 95% CI: -.21, -.05) mediated the relationship between pain-related injustice and emotional functioning, whereas both anger-out (indirect effect= -.17, 95% CI: -.27, -.09) and anger-in (indirect effect= -.13, 95% CI: -.09, -.001) mediated the relationship between pain-related injustice and social functioning. Neither mode of anger expression mediated the relationship between pain-related injustice and pain intensity, functional disability, or school functioning. Collectively, these findings implicate anger as one mechanism by which pain-related injustice impacts psychosocial outcomes for youth with chronic pain. Perspective: Anger expression plays a mediating role in the relationship between pain-related injustice appraisals and psychosocial outcomes for youth with chronic pain. Anger represents one target for clinical care to decrease the deleterious impact of pain-related injustice on emotional and social functioning.

Multi-region pain during adolescence is associated with a higher symptom burden and lower quality of life. The purpose of this study was to describe and compare the biopsychosocial attributes of single-region and multi-region pain among healthy young adolescents.We analyzed data from 10,320 children aged 10.6 to 14 years who self-reported pain in the Adolescent Brain and Cognitive Development Study. Pain was coded as single-region or multi-region based on body map data.One in 5 young adolescents indicated recent multi-region pain. Sequential regression supported improved model fit when psychological and sociocultural factors were added to a biological model of pain; however, these models improved the classification of multi-region but not single-region pain. A significant interaction effect of sex and puberty remained constant across models with increased odds of pain at each advancing pubertal stage for both sexes compared with prepuberty, but no difference between girls and boys at late puberty (adjusted odds ratio [OR]=2.45 [1.72, 3.49] and adjusted OR=1.63 [1.20, 2.23], respectively). Psychological factors improved the classification of multi-region pain with significant effects of anxiety, somatic symptoms, and somnolence. Finally, compared with White and non-Hispanic children, Black and Hispanic children were less likely to report pain (adjusted OR=0.70 [0.61, 0.80]; adjusted OR=0.88 [0.78, 0.99], respectively) but had significantly higher pain interference when pain was present (adjusted OR=1.49 [1.29, 1.73] and adjusted OR=1.20 [1.06, 1.35], respectively).Pain is a biopsychosocial phenomenon, but psychological and sociocultural features may be more relevant for multi-region compared with single-region pain during early adolescence.

ImportanceCo-occurring physical and psychological symptoms during childhood and early adolescence may increase risk of symptom persistence into adulthood.ObjectiveTo describe co-occurring pain, psychological, and sleep disturbance symptom (pain-PSS) trajectories in a diverse cohort of children and the association of symptom trajectory with health care utilization.Design, Setting, and ParticipantsThis cohort study was a secondary analysis of longitudinal data from the Adolescent Brain Cognitive Development (ABCD) Study, collected between 2016 and 2022 at 21 research sites across the US. Participants included children with 2 to 4 complete annual symptom assessments. Data were analyzed from November 2022 to March 2023.Main Outcomes and MeasuresFour-year symptom trajectories were derived from multivariate latent growth curve analyses. Pain-PSS scores, including depression and anxiety, were measured using subscales from the Child Behavior Checklist and the Sleep Disturbance Scale of Childhood. Nonroutine medical care and mental health care utilization were measured using medical history and Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) items.ResultsA total of 11 473 children (6018 [52.5%] male; mean [SD] age at baseline, 9.91 [0.63] years) were included in analyses. Four no pain-PSS and 5 pain-PSS trajectories were supported with good or excellent model fit (predicted probabilities, 0.87-0.96). Most children (9327 [81.3%]) had asymptomatic or low, intermittent, or single symptom trajectories. Approximately 1 in 5 children (2146 [18.7%]) had moderate to high co-occurring symptom trajectories that persisted or worsened. Compared with White children, there was a lower relative risk of having moderate to high co-occurring symptom trajectories among Black children (adjusted relative risk ratio [aRRR] range, 0.15-0.38), Hispanic children (aRRR range, 0.58-0.67), and children who identified as another race (including American Indian, Asian, Native Hawaiian, and other Pacific Islader; aRRR range, 0.43-0.59). Less than half of children with moderate to high co-occurring symptom trajectories used nonroutine health care, despite higher utilization compared with asymptomatic children (nonroutine medical care: adjusted odds ratio [aOR], 2.43 [95% CI, 1.97-2.99]; mental health services: aOR, 26.84 [95% CI, 17.89-40.29]). Black children were less likely to report nonroutine medical care (aOR, 0.61 [95% CI, 0.52-0.71]) or mental health care (aOR, 0.68 [95% CI, 0.54-0.87]) than White children, while Hispanic children were less likely to have used mental health care (aOR, 0.59 [95% CI, 0.47-0.73]) than non-Hispanic children. Lower household income was associated with lower odds of nonroutine medical care (aOR, 0.87 [95% CI, 0.77-0.99]) but not mental health care.Conclusions and RelevanceThese findings suggest there is a need for innovative and equitable intervention approaches to decrease the potential for symptom persistence during adolescence.

OBJECTIVES Pediatric patients with chronic musculoskeletal conditions such as idiopathic scoliosis awaiting surgical correction can experience pain that interferes with their daily functioning. Reports of this interference are commonly gathered from patients through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Scale and through parent-proxy scores. However, the child and parent/caregiver reports vary. To provide appropriate treatment for young patients with pain, the nature of the discrepancies and under which circumstances the reports differ needs to be understood. This report offers new information on the level of concordance among parent and child report of pain interference within this patient population, and which parent and child characteristics may influence concordance rates. METHODS Youth (age=10 to 17 y) with a history of musculoskeletal disorders, including idiopathic scoliosis, under consideration for surgical correction of that scoliosis and parent/caregiver dyads (n=103) completed the PROMIS Pain Interference Scale during an orthopedic presurgical visit. The current data was taken from a larger study examining postsurgical pain among patients undergoing orthopedic surgical procedures to correct scoliosis. The purpose of the current study was to measure the degree of agreement between parent and child reports of pain interference and discovery of relationships among predictors of pain interference score correspondence among dyads. RESULTS Correspondence between parent/caregiver and child reports of pain interference was modest (intraclass correlation coefficient=0.530). In total, 46% of dyads had similar pain interference scores, whereas 24% of parents reported higher pain interference in comparison to their child, the remaining 30% reported lower pain interference in relation to their child's report. Among children where discrepancies appeared, using logistic regression models, only child catastrophizing scores were associated with differences in parent and child estimation of child's pain interference scores. No parental characteristics predicted discrepancies between dyad pain interference reports. DISCUSSION Parent-proxy and child reports generally correspond, but when discrepant, 24% of parents reported higher pain interference in relationship to the child report of pain interference and 31% noted less intense pain interference than their child's pain interference. Given these results, care should be taken when interpreting parent reports of child pain interference, especially when a child reports higher degrees of pain interference.

Objective Pain-related appraisals, including pain-related injustice, impact the development and maintenance of chronic pain. This cross-sectional study aimed to examine the relationship between the cognitive-emotional components of pain-related injustice—blame/unfairness and severity/irreparability of loss—and functioning in a mixed sample of adolescents with chronic pain. Methods Pediatric patients age 11–18 years (N = 408) completed forms assessing pain-related injustice, pain intensity, and physical and psychosocial functioning as part of their routine assessment in a pediatric chronic pain clinic between January 2014 and January 2019. A series of hierarchical regressions were used to evaluate the relationships among the separate components of pain-related injustice appraisals and functioning. Results Pain intensity and blame/unfairness appraisals were significantly associated with emotional functioning with blame/unfairness being the stronger association (β = −.27). Blame/unfairness appraisals, severity/irreparability appraisals, and pain intensity were significantly associated with physical functioning with pain intensity being the strongest association (β = .36). Pain intensity, blame/unfairness appraisals, and severity/irreparability appraisals were significantly associated with social functioning with blame/unfairness being the strongest association (β = −.34). Pain intensity and severity/irreparability appraisals were significantly associated with school functioning with severity/irreparability being the stronger association (β = −.19). Conclusions These results lend further support to incorporating pain-related injustice appraisals in standard clinical pain assessments. Treatment practices should target the specific injustice appraisals and domains of functioning impacted for each pediatric patient with chronic pain.

Pain appraisals are closely tied to pain and functional outcomes. Pain-related injustice and pain catastrophizing appraisals have both been identified as important cognitive-emotional factors in the pain experience of youth. Although pain-related injustice and catastrophizing have been linked to worse pain outcomes – as primary predictors and intermediary variables – little is known about whether they operate as independent or parallel mediators of the relationship between pain and functioning in youth. We tested pain-related injustice and catastrophizing appraisals as candidate mediators of the relationship between baseline pain intensity and 3-month functional outcomes in adolescents. Youth with chronic pain (N = 89, 76% female, 89% White, average age = 15 years) completed measures assessing pain intensity, pain-related injustice, and catastrophizing at baseline, as well as measures assessing functional disability and overall quality of life 3 months later. Multiple mediation analyses indicated that injustice mediated the relationship between pain intensity and 3 month quality of life. Exploratory analyses of specific quality of life domains indicated that injustice mediated the relationship between pain intensity and 3 month emotional functioning, whereas catastrophizing mediated the relationship between pain intensity and 3 month social functioning. The findings suggest these pain-related appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes. Perspective Pain-related injustice and catastrophizing appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes in youth with chronic pain. Treatments targeting pain-related injustice appraisals in pediatric populations are needed to complement existing treatments for catastrophizing.

OBJECTIVES Persistent or recurrent pain is common among adolescents and is associated with poor functioning. The purpose of this study was to determine whether preteens who present with pain, and higher, co-occurring psychological and somatic symptoms (PSS) are at higher risk for persistent pain than other children. MATERIALS AND METHODS We conducted a secondary analysis of the longitudinal Adolescent Brain and Cognitive Development database (version 2.0.1) that includes 11,863 children aged 9 to 12 years. We differentiated children into baseline Pain/PSS profiles using the Child Behavior Checklist assessments of pain, cognitive-fogginess, somatic symptoms, depression, and anxiety and the Sleep Disorder Survey-Children somnolence subscale. We examined whether Pain/PSS profile predicted 1-year new/persistent pain when controlled for child characteristics and intergenerational mental health factors. RESULTS Four profiles were differentiated: No Pain/Low PSS, No Pain/High PSS, Pain/Low PSS, Pain/High PSS. Trauma exposure and family symptoms were associated with increased odds of being in the higher PSS groups. Baseline symptom profile predicted 14% of the variance in new/persistent pain at 1-year. Compared with the No Pain/Low PSS group, an increased odds of 1-year new or persistent pain was found in children with No Pain/High PSS (adjusted odds ratio [OR]: 1.44; [95% confidence interval: 1.14, 1.82]), Pain/Low PSS (adjusted OR: 4.69 [4.01, 5.48]) and Pain/High PSS (adjusted OR: 5.48 [4.35, 6.91]). DISCUSSION Preteen children with higher comorbid Pain/PSS symptomology were at higher risk for new or persistent pain at 1 year when controlled for important child and family characteristics. Findings support the importance of considering co-occurring symptoms when evaluating children with pain.

Background Pain location and widespread pain are important but underexamined dimensions of paediatric pain. Body map tools to assess pain location in youth have been used for several decades, but few studies have established reliability and validity of these measures. The purpose of this study was to explore the reliability and validity of a pain body map among youth with orthopaedic conditions before surgery. Method Youth ages 10-17 years completed the body map and other self-reported outcomes at their preoperative clinic visit and at their day of surgery. Results Most (91.7%) youth had small discrepancy between body map scores at preoperative clinic visit (baseline) and day of surgery (second assessment), and site-to-site agreement ranged from 78% to 98%. Those with back and lower extremity diagnoses had high correspondence between body map sites and diagnostic sites. Body map scores and widespread pain were associated with other dimensions of pain, as well as other patient-reported outcomes. Higher pain intensity and widespread pain predicted greater discrepancy between body map scores. Conclusions These results support the use of body map tools in further research examining widespread pain among youth by demonstrating adequate reliability, descriptive validity and associative validity. Significance These results contribute to the limited information regarding psychometric properties of paediatric pain body maps, provide novel information about widespread pain among youth undergoing orthopaedic surgeries, and pave the way for improved assessment and treatment of paediatric pain.

Background Symptom severity is negatively associated with physical activity in multiple sclerosis (MS). However, it is unclear how physical activity and symptoms correlate on a day-to-day basis in persons with MS. Purpose To determine the temporal within-person associations of pain, fatigue, depressed mood, and perceived cognitive function with physical activity in MS. Methods Ambulatory adults with MS (N = 107) completed 7 days of home monitoring. Continuous physical activity data (assessed via wrist-worn accelerometer) and concurrent ecological momentary assessment (5X/day) of pain, fatigue, depressed mood, and perceived cognitive function were collected. Data were analyzed using multilevel mixed modeling. Results Fatigue and depressed mood demonstrated bidirectional associations with physical activity, whereas pain and cognitive function did not. Higher than usual fatigue (B = -5.83, p = .001) and depressed mood (B = -4.12, p = .03) were followed by decreased physical activity. In contrast, higher than usual physical activity was associated with subsequent decline in fatigue (B = -0.001, p = .02) and depressed mood (B = -0.0007, p = .02); however, the association between physical activity and fatigue varied across the day. Conclusions Physical activity is dynamically related to fatigue and mood on a moment-to-moment basis in MS. Efforts to increase physical activity in MS must incorporate a focus on how symptoms affect and are affected by activity.

Adolescents with chronic illness, particularly when accompanied by debilitating, painful, and/or fatiguing symptoms, face challenges that are disruptive to their normal physical, psychological, and social development. The Children’s Health and Illness Recovery Program (CHIRP) is an evidence-based program specifically designed to address the skills needed by adolescents with chronic illnesses to become more confident and independent in coping and managing their illness and lifestyle. The flexible 12-session format of CHIRP can be administered with individual teens and their families or conducted in teen groups with a parallel parent group component. CHIRP integrates and adapts effective treatment components from behavioral family systems therapy, cognitive behavioral therapy, coping strategies intervention, interpersonal psychotherapy, assertiveness training, among others, into therapeutic activities in the companion CHIRP Teen and Family Workbook. This CHIRP Clinician Guide provides detailed instructions for implementing the manualized treatment protocol in the workbook. CHIRP was developed from both a careful review of the evidence-based literature on treatments for adolescents with chronic physical illness and the authors’ more than six decades of combined experience in helping children and families improve their quality of life and independence while coping with a chronic illness. Clinical outcome data on teens who have completed CHIRP demonstrate significant improvement in independent functioning and reduction in symptoms of fatigue and chronic pain; longitudinal data suggest these improvements not only persist but that teens continue to make gains on these factors beyond the completion of treatment, allowing them to pursue meaningful life goals as they transition to young adulthood.

For teens with a chronic illness, setting reasonable and reachable personal expectations while titrating their activities in response to their disease/symptoms is often a major stressor. In Session 5 the teen is taught specific strategies to distinguish between desired (want to) and required (have to) activities and to create (and revise) personal schedules that address problems they may have with over- and/or underscheduling physical and social activities in their daily life. These issues are particularly important in working with teens who are on home-hospital/home-bound schooling or who are home-schooled and thus more likely to have less structure and peer social contact.

During the remaining Sessions 10–12 of the Children’s Health and Illness Recovery Program (CHIRP) no new skills or strategies are introduced. Rather, these sessions focus on continuing to practice the skills introduced in Sessions 1–9 so that they become positive habits and routines in the your and your family’s coping with their chronic illness while becoming more confident and competent in their movement toward more independence.

In Session 7 you are introduced to the concept of avoidant coping. We all use avoidance at times in dealing with stressful, unpleasant and uncomfortable situations. However, if we use avoidance as the major way to cope with these challenges, it will have a negative impact on our ability to function physically, emotionally, and in school and social situations. In order to make sure we don’t fall into the trap of over-using avoidance in dealing with the challenges of a chronic medical problem, CHIRP uses activities that teach you strategies that can disrupt this cycle by improving your skills and confidence in dealing with stressful situations you may encounter socially and in your daily life. Key skills you will learn include improving interpersonal communication and assertive behaviors. Increasing your skills and comfort in communicating and asserting your wants and needs with others is a primary goal of this session.

During the remaining Sessions 10–12 of the Children’s Health and Illness Recovery Program (CHIRP) no new skills or strategies are introduced. Rather these sessions focus on continuing to practice and consolidate the skills introduced in Sessions 1–9 and problem solve those areas where the teen and parent(s) continue to struggle.

Session 2 of the Children’s Health and Illness Recovery Program (CHIRP) builds on the topic of stress and stress management by introducing the concept of reducing the impact of stressors via developing more effective coping strategies. In CHIRP, two specific forms of coping are emphasized: “Solving the Problem” coping and “Managing the Impact” coping. This session focuses on teaching the teen about these two forms of coping and learning the when and how of applying each, with the main emphasis being on developing active problem-solving skills in order to reduce stress by addressing and altering the situation.

In Session 7 the teen is introduced to the concept of avoidant coping and the pernicious impact this has on creating increased functional disability in multiple areas of one’s life physically, academically, and socially. Behavioral strategies to disrupt this cycle inevitably involve improving engagement behaviors such as increasing social contacts and improving school attendance, all of which call for improved interpersonal communication skills and assertive behaviors; that is, the behavioral antithesis of avoidance. The clinician will employ several worksheets in the Workbook in the process of increasing teen skills and comfort at communicating and asserting their wants and needs with others.

In Session 5 you will learn specific strategies for determining what is a desired (want to) versus a required (have to) activity and how to create a more reasonable personal schedule. When dealing with a chronic illness, learning to conserve energy and make good decisions about daily activities is important. Also, being on home-bound/home-hospital or home-schooled academic schedules can result in a less structured daily schedule and decreased peer social contact. Over- and/or underscheduling physical and social activities can become a major problem and source of stress. Setting reasonable and reachable goals and expectations is very important and requires that you learn how to prioritize and adjust your schedule of activities in response to your symptoms and illness.

This session introduces important information on understanding just what stress is and how it can affect our bodies. Learning to identify situations that can be stressful is the first step, followed by understanding how different stressors call for different stress management strategies. One particularly important issue in managing the stress that comes from having a chronic illness is sleep. The Children’s Health and Illness Recovery Program (CHIRP) introduces the importance of improving sleep by learning healthy sleep hygiene practices and monitoring this with the help of the Sleep Log. Improvement in sleep hygiene and physical activity are emphasized as important building blocks of CHIRP.

Chapter 11 provides supplemental material for teens whose chronic illness challenges involve major problems with chronic pain. While pain is a necessary protective mechanism of the body, chronic pain involves complex interactions between the nervous system, the brain, our emotions, and various situational factors that can actually make our experience of pain worse. The activities in this session are intended to help teens better understand these interactions and apply pain management strategies. Many of the coping strategies in the Children’s Health and Illness Recovery Program (CHIRP) have been shown to be effective in helping teens manage chronic pain more effectively so that they are able to more actively participate in the multiple areas so important to development.

Session 6 is intended to be a family-focused session, with the teen and parent(s) seen conjointly for all or at least a major portion of the session. This format allows the clinician to observe the ways in which the teen and parent(s) approach such issues as problem solving and decision making and to coach and provide feedback and guidance in developing family dynamics that increase teen confidence and skills in becoming more confident and independent. The mechanism for stimulating these discussions is generated from the Workbook exercises and Worksheets addressing the activity schedule of a healthy teen versus the teen with a chronic illness and together generating strategies for increasing teen independence that they will approach between sessions.

When, for various reasons, the teen cannot alter the stressfulness of a challenging situation via active problem solving (“Solving the Problem”), such circumstances call for employing strategies to “Manage the Impact” of the stressor on their physical and emotional functioning. In Session 3 of the Children’s Health and Illness Recovery Program (CHIRP), the clinician instructs the teen in effective relaxation skills including diaphragmatic breathing and progressive muscle relaxation. These are introduced and practiced in the session, with homework practice assigned for skill development. Cognitive behavioral therapy skills are introduced to help the teen understand the bidirectional relationships between thoughts, emotional responses, and behavioral responses. Finally, thought-changing skills and activities are introduced from the CHIRP Workbook with the assignment of recoding stressful situations and their associated thoughts and feelings on a Thought Record sheet.

Employing information from their Thought Record homework, in Session 4 the teen is instructed in applying cognitive behavioral therapy (CBT) thought-challenging skills employing the “Challenging Your Thoughts” worksheet in the Children’s Health and Illness Recovery Program (CHIRP) Workbook. Common cognitive errors (e.g., hopelessness, catastrophizing, mind reading) are introduced and applied to the teen’s own identified automatic thoughts. For youth with chronic illness, the impact of their symptoms on their functioning can adversely impact on their expectations and willingness to set challenging yet appropriate goals for themselves. CBT skills in challenging and changing unsubstantiated and disabling beliefs and schema are crucial to overcoming these barriers.

Session 9 involves a review with you and your parent(s) of the individual skills you have acquired in Children’s Health and Illness Recovery Program (CHIRP) and providing guidance aimed at avoiding a relapse in your improvement. Key components of CHIRP are emphasized as they apply to your “Working Toward a Normal Daily Schedule.” The benefits of improved sleep and activity level, increased social contacts with peers, and increased comfort in assertively communicating with others are reinforced as critical for continued progress. Your parents are encouraged to support and trust your efforts in becoming more independent in managing various aspects of your medical condition, as well as in your decision making in setting a personal schedule and making lifestyle choices. Family members are strongly encouraged to continue to follow family rules for communicating about symptoms and resolving conflicts as discussed in the CHIRP sessions.

Session 1 of the Children’s Health and Illness Recovery Program (CHIRP) addresses the impact of illness- and non–illness-related stressors on teens with chronic illness and coping strategies needed to reduce stress. This chapter provides the clinician with techniques for guiding the teen in developing methods for identifying stressors and assessing the impact they may have on their symptoms and functioning. The importance of sleep and developing healthy sleep hygiene practices are introduced, along with instructions for the teen in completing a Sleep Log to assess their own sleep patterns and practices. Graduated physical activity is also assessed and encouraged. These data will be collected over the course of several sessions in order to facilitate more effective coping, stress management, and sleep hygiene practices.

This chapter provides an explanation as to how having a chronic illness can start a cascading effect that results in the teen becoming more inactive and less involved in important life events experienced by healthy teens, and how this can actually worsen some of their symptoms and lead to more disability. The CHIRP interventions are introduced as a program specifically designed to provide teens, and their parents, with skills that can disrupt this process and allow the teen to more actively participate in life. A “Weekly Activity and Exercise Action Plan” Worksheet is provided to begin the process of gradually becoming more active at a level that is sensitive to the teen’s medical and health issues.

This chapter provides the clinician with an overview of the clinical issues prevalent in working with teens with chronic illnesses and their families and the rationale and evidence supporting the Children’s Health and Illness Recovery Program (CHIRP) as an effective intervention designed to maximize teen functioning and independence. While many adolescents with chronic health problems are able to have normal developmental and social experiences, a number of factors related to having a chronic illness serve to adversely impact the teen’s ability to participate in crucial developmental experiences essential in preparing for the transition to young adulthood. The clinician is provided detailed background on the CHIRP model and strategies for conducting effective sessions with teens and parents to impart skills that can alter individual and family dynamics while supporting increased teen independence and self-confidence.

Session 8 focuses on improving family communication, so important to improving your confidence in becoming more independent in managing both the challenges of your medical condition as well as you lifestyle as a teen. You and your family will be engaged in a discussion of parent and teen roles in the family and how the your illness has impacted and changed these roles. To expand on improving family communication skills, “misguided support” and “strong beliefs” are introduced and explored to better understand how these may unintentionally serve to make it harder to increase your feelings of confidence and skills in moving toward the greater independence needed for transitioning to young adulthood.

Session 6 is a family-focused session. In these family sessions you and your parent(s) will be seen together for all, or at least a major part, of the session. When a teen has a chronic medical problem it affects everyone in the family. The activities for these sessions are designed to begin the process of helping you and your family better understand the importance of helping put medical challenges in perspective while balancing these needs with the important experiences for teens to have to remain confident and competent in their lives. Workbook exercises and worksheets are used to identify how your lifestyle and activity schedule have been affected by your medical condition. This information is then used to help you and your parent(s) generate ways for increasing your activities and independence so important to this stage of your life.

Being a teenager with a chronic illness can be challenging. The symptoms of an illness, particularly pain and fatigue, can interfere with just being a normal teen. The Children’s Health and Illness Recovery Program, or CHIRP, was developed to teach teens and their family strategies to help them live as normal a life as possible while coping with the effects of their chronic illness. The skills acquired in the CHIRP intervention are life skills almost every teen can use, and these skills can be especially valuable for those working to overcome the negative effects of chronic illness. The CHIRP Teen and Family Workbook provides evidence-based activities shown to improve coping skills, stress management, communication skills, and functioning in teens with chronic medical conditions. In addition, family-based activities included in CHIRP assist teens and parents in developing more effective ways to communicate about their illness and increase teen confidence and independence in both managing their illness and their lifestyle. These skills are important building blocks to help teens move toward recovery and improve functioning and quality of life as they approach young adulthood. The skills acquired in the program also serve as a guide and motivation for continuing the gains that teens and their families make in CHIRP.

Sometimes even problem-solving skills can’t reduce the stressfulness of a situation. In these circumstances, “Managing the Impact” coping skills are needed to reduce the effects of a stressor on physical and emotional functioning. In Session 3 of the Children’s Health and Illness Recovery Program (CHIRP), the use of diaphragmatic breathing and progressive muscle relaxation skills are introduced as proven methods for increasing relaxation, creating a sense of well-being, and decreasing the impact of stress on chronic illness symptoms. Cognitive behavioral therapy (CBT) skills, what CHIRP refers to as “Thought Challenging and Thought Changing Skills,” are then introduced to help you understand the relationship between thoughts, emotions/feelings, and actions that we take in responding to these.

Session 8 is again focused primarily on family communication and dynamics for the purposes of identifying and addressing parenting behaviors and parent–teen dynamics that may unwittingly undermining teen confidence in becoming more independent in managing their illness and lifestyle. The clinician engages the family in a discussion of parental and teen roles within the family system and an examination of the impact of the teen’s illness on family members’ roles. Behavioral family systems concepts of “misguided support” and “strong beliefs” that family members hold, but that inadvertently may be serving to maintain a dependent or even overprotective/enmeshed family dynamic, are introduced and applied to the family situation, along with strategies for moving these dynamics in a more independence-engendering direction.

Youth chronic pain management presents unique challenges to the pediatric psychologist in both inpatient and outpatient settings. This chapter includes specific and practical guidance for working with youth and their families/caregivers presenting to an inpatient setting for treatment of chronic pain. Conceptualization of pediatric chronic pain from a biopsychosocial framework informs the chapter which includes guidance in specific domains to consider within an initial assessment. Practical advice is provided regarding communicating with families about taking a rehabilitative treatment approach in such a way as to increase readiness for treatment of their child’s chronic pain upon discharge from the hospital. The chapter gives clinical pearls for psychologists to make valuable contributions to multidisciplinary treatment teams which seek to incorporate psychological information relevant to the child’s treatment within the hospital setting. Finally, information is offered for referring and coordinating care for patients upon discharge when they have ongoing pain needs including school reentry, effective non-pharmacologic treatment, and prioritizing mental health needs that co-occur with patient’s pain symptoms.

Like nearly all professional fields, pediatric psychology is being increasingly molded and shaped by the rapid advances in technology. Clinicians have access to a variety of technologically innovative methods to collect and evaluate psychological data about patient’s mental, physical, and emotional states while also providing engaging and novel ways to disseminate psychological interventions. This chapter highlights the current use of technology for psychological consultation-liaison services as well as outpatient psychological treatment for the medically ill child. Current technology-based interventions are reviewed as methods to enhance self-assessment and self-monitoring, psychoeducation, goal setting, skill building, and feedback. Technology-based applications reviewed include online information and videos, smartphone applications, wearable physiological monitoring, and biofeedback devices that may enhance existing evidence-based models of care. Findings from existing studies and reviews are summarized and descriptions are provided that demonstrate practical ways to apply technology in inpatient medical units and outpatient treatment programs. Recommendations are provided for developing evidence-based practice using technology devices, acknowledging the barriers to address when building this field of practice and research, and reviewing initial resources. The chapter concludes with a case example of optimizing patient care utilizing technological innovations.

A central concern raised by many patients attending a pediatric chronic pain interdisciplinary clinic is physical functioning decline, fatigue, and diminished endurance. However, most studies examining treatment effects of pain programs on physical outcomes have relied on self- and/or parent-reported measures without confirming the results using objective indices, and predictors of objective indices of physical function in this population have rarely been examined. The purpose of the present study was to evaluate changes in objective physical functioning and to investigate psychosocial predictors of physical functioning over time in a sample of pediatric patients who completed an intensive outpatient pain program (IOP). Participants (N=55; Mage=14.92 years; 12.7% male, 87.3% female; 83.6% White, 5.6% African-American/Black; 9.1% Latinx) completed baseline measures assessing pain levels (Brief Pain Inventory), anxiety/depressive symptoms (Hospital Anxiety and Depression Scale), pain catastrophizing (Coping Strategies Questionnaire), and kinesiophobia (Tampa Scale for Kinesiophobia). Participants completed the FitKids Treadmill Test ("FitKids") assessing physical endurance and the high-level mobility assessment tool (HiMAT) assessing physical ability pre- and post-IOP completion. Paired samples t-tests indicated significant improvement in Total Time to Exhaustion (TTE) on FitKids (p .138). Participation in an IOP led to significant improvement in physical endurance and ability. Depressive symptoms were negatively associated with endurance at baseline but not after program completion. Depressive symptoms may influence pre-treatment objective physical endurance and should be assessed in pediatric chronic pain patients beginning rehabilitation.

There is growing evidence that opioid prescribing in the United States follows a pattern in which patients who are at the highest risk of adverse outcomes from opioids are more likely to receive long-term opioid therapy. These patients include, in particular, those with substance use disorders (SUDs) and other psychiatric conditions. This study examined health insurance claims among 10,311,961 patients who filled prescriptions for opioids. Specifically, we evaluated how opioid receipt differed among patients with and without a wide range of preexisting psychiatric and behavioral conditions (ie, opioid and nonopioid SUDs, suicide attempts or other self-injury, motor vehicle crashes, and depressive, anxiety, and sleep disorders) and psychoactive medications (ie, antidepressants, benzodiazepines, hypnotics, mood stabilizers, antipsychotics, and medications used for SUD, tobacco cessation, and attention-deficit/hyperactivity disorder). Relative to those without, patients with all assessed psychiatric conditions and medications had modestly greater odds of subsequently filling prescriptions for opioids and, in particular, substantially greater risk of long-term opioid receipt. Increases in risk for long-term opioid receipt in adjusted Cox regressions ranged from approximately 1.5-fold for prior attention-deficit/hyperactivity disorder medication prescriptions (hazard ratio [HR] = 1.53; 95% confidence interval [CI], 1.48-1.58) to approximately 3-fold for prior nonopioid SUD diagnoses (HR = 3.15; 95% CI, 3.06-3.24) and nearly 9-fold for prior opioid use disorder diagnoses (HR = 8.70; 95% CI, 8.20-9.24). In sum, we found evidence of greater opioid receipt among commercially insured patients with a breadth of psychiatric conditions. Future studies assessing behavioral outcomes associated with opioid prescribing should consider preexisting psychiatric conditions.

Chronic pain is prevalent in children/adolescents and contributes to high rates of healthcare utilization. Research suggests injustice perceptions about pain are important in adult patients and a possible treatment focus. We conducted a preliminary evaluation of the psychometric properties of the Injustice Experiences Questionnaire (IEQ) and the relationship between injustice perceptions, pain, and functioning in chronic pain patients (N = 139, mean age = 15 years, 72% female) presenting to a pediatric pain clinic. Patients completed measures assessing pain intensity, injustice perceptions about pain, catastrophizing, overall functional disability, emotional functioning, social functioning, and school functioning. The IEQ showed good reliability and validity. Higher levels of perceived injustice were associated with higher levels of pain intensity, catastrophizing, and functional disability, and with poorer emotional, social, and school functioning. Additionally, perceived injustice remained significantly associated with pain intensity, functional disability, emotional functioning, social functioning, and school functioning after accounting for relevant demographic and clinical factors. This is the first study to suggest that injustice perceptions are important in the experience of pediatric chronic pain patients. Future studies should more thoroughly examine the psychometric properties of the IEQ in children/adolescents and elucidate the causal nature of these relationships, which will inform treatment efforts to improve pediatric pain care. Perspective This initial investigation suggests that injustice perceptions about pain can be reliably and validly measured and are tied to important clinical outcomes in children/adolescents. Future studies that replicate and extend these preliminary results are necessary to determine the extent to which injustice perceptions are an important target for intervention.

Objective To examine mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care, including antibiotic prophylaxis, hydroxyurea therapy, and transcranial Doppler screenings, among children with sickle cell anemia (SCA). Study design Children aged 1-17 years with SCA from 6 states having 3 or more Medicaid claims with a SCA diagnosis within a year (2005-2012) were included. Children with mental health diagnoses were identified with 1 or more mental health encounters. Poisson and logistic regression models with general estimating equations assessed the relationship between mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care. Results In total, 7963 children with SCA were identified (22 424 person-years); 1593 person-years (7.1%) included 1 or more mental health diagnoses. Children with a mental health diagnosis were more likely to have inpatient admissions (incidence rate ratio [IRR] 1.46, 95% CI 1.36-1.56) and outpatient (IRR 1.27, 95% CI 1.21-1.34), emergency department (IRR 1.39, 95% CI 1.30-1.48), and well-child visits (IRR 1.19, 95% CI 1.11-1.29). Those with a mental health diagnosis were more likely to receive hydroxyurea therapy (odds ration [OR] 1.17, 95% CI 1.03-1.33) and less likely to receive transcranial Doppler screenings (OR 0.79, 95% CI 0.68-0.93). Conclusions Children with SCA do not receive adequate age-appropriate preventive care. Further research is necessary to identify key points of coordination between mental health and SCA services throughout the life course. This approach may help to increase receipt of age-appropriate preventive care and decrease reliance on acute care.

Although social abnormalities in young children raised in abnormal environments have been described for many years, it was not until the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) that reactive attachment disorder (RAD) appeared in psychiatric nosologies. The disorder described aberrant social behaviors in young children that were believed to derive from being reared in caregiving environments lacking in species-typical nurturance and stimulation, such as in instances of maltreatment or institutional rearing. Subsequent to the original description of the disorder, criteria in the fifth edition of the DSM have been revised, bifurcating RAD into separate diagnoses. This chapter describes features, characteristics, and treatment considerations for RAD and disinhibited social engagement disorder.

Background The past several decades have seen dramatic growth in empirically supported treatments for adolescent substance use disorders (SUDs), yet even the most well-established approaches struggle to produce large or long-lasting improvements. These difficulties may stem, in part, from the high rates of comorbidity between SUDs and other psychiatric disorders. Method We critically reviewed the treatment outcome literature for adolescents with co-occurring SUDs and internalizing disorders. Results Our review identified components of existing treatments that might be included in an integrated, evidence-based approach to the treatment of SUDs and internalizing disorders. An effective program may involve careful assessment, inclusion of parents or guardians, and tailoring of interventions via a modular strategy. Conclusions The existing literature guides the development of a conceptual evidence-based, modular treatment model targeting adolescents with co-occurring internalizing and SUDs. With empirical study, such a model may better address treatment outcomes for both disorder types in adolescents.

Pain is experienced within and influenced by social environments. For children with chronic pain, the child-parent relationship and parental beliefs about pain are particularly important and may influence pain outcomes. Pain-related injustice perceptions have recently been identified as an important cognitive-emotional factor for children with pain. The current study aimed to better understand the pain-related injustice perceptions of children with chronic pain and their parents. The sample consisted of 253 pediatric chronic pain patients (mean age = 14.1 years, 74% female) presenting to a tertiary pain clinic. Patients completed measures of pain intensity, pain-related injustice perceptions, stress, functional disability, and quality of life. Parents completed a measure of pain-related injustice perceptions about their child's pain. Child-parent dyads were categorized into 1 of 4 categories based on the degree of concordance or discordance between their scores on the injustice measures. One-way analysis of variances examined differences in pain intensity, stress, functional disability, and quality of life across the 4 dyad categories. Our findings indicated that both the degree (concordant vs discordant) and direction (discordant low child-high parent vs discordant high child-low parent) of similarity between child and parent injustice perceptions were associated with child-reported pain intensity, stress, functional disability, and quality of life. The poorest outcomes were reported when children considered their pain as highly unjust, but their parents did not. These findings highlight the important role of parents in the context of pain-related injustice perceptions in pediatric chronic pain.

Objective To examine the relative association between daily change in pain, fatigue, depressed mood, and cognitive function and 4 outcomes—positive affect and well-being, ability to participate in social roles and activities, upper extremity (UE) functioning, and lower extremity (LE) functioning. Design Data analysis, multilevel mixed modeling. Setting General community. Participants Ambulatory adults (N=102) with multiple sclerosis. Interventions Not applicable. Main Outcome Measures Customized short-forms of the Quality of Life in Neurological Disorders positive affect and well-being, UE functioning, and LE functioning item banks and the Patient-Reported Outcomes Measurement Information System ability to participate in social roles and activities item bank adapted for daily use and administered as end-of-day diaries. Results Above and beyond the effects of demographic and clinical covariates, daily pain was associated with 3 of the 4 outcomes; days of higher than usual pain were related to lower same-day social participation (unstandardized β, B=−1.00; P =.002), UE functioning (B=−1.04; P =.01), and LE functioning (B=−.71; P =.04). Daily fatigue and depressed mood were independently related to daily positive affect and well-being; days of worse fatigue (B=−.54; P =.006) and depressed mood (B=−1.17; P Conclusions The results indicate the role of fluctuations in symptoms in daily functioning and quality of life of individuals with multiple sclerosis. Daily increases in pain intensity are related to social and physical functioning, whereas increases in fatigue and depressed mood are related to lower daily well-being. Findings implicate a person-centered approach to monitoring and treating symptoms.

Pediatric surgeries and postoperative pain interventions with opioids pose risks for functional recovery and analgesic dependence. Prehabilitation, optimizing of physical functioning prior to surgery, is a possibly efficacious intervention with minimal adverse effects not yet assessed among children. Little is known about typical physical activity patterns of children undergoing orthopedic surgeries, or whether measurement with commercial accelerometry is feasible. This pilot study aimed to determine the feasibility of actigraphy assessment in children undergoing posterior spinal fusion (PSF) and assess the variability of their pre-operative activity. Children and adolescents undergoing PSF (n=15) wore a Fitbit Flex for approximately two weeks between their preoperative clinic appointment and surgery date, with no instructed change to activity level. Daily step counts were obtained from the Fitbit account for each participant. Of 15 participants, two dropped out (surgery or postoperative visit canceled). Overall, 73% of data was obtained from the pre-surgical period. The median number of data points per day was 11 [IQR:4-13]. The median average steps per day was 5,423 [IQR:4222-8060], the median maximum was 11,513 [IQR:6862-16142] and the median difference between highest and lowest step counts was 10,680 [IQR:4,886-15,662]. Four participants had consistently lower counts, defined as ≥50% of the recorded day total th percentile of the population average (4,222 steps). No participants had consistently higher counts preoperatively, defined as ≥50% of the recorded day total >75 th percentile of the population average (8,060 steps). Results demonstrate that assessing children's physical activity preoperatively is feasible and provides a description of the typical patterns of physical activity among children undergoing posterior spinal fusion. These findings support the possibility for implementation of prehabilitation in children. Prehabilitation can help prevent poor post-surgical outcomes among adults undergoing orthopedic surgeries and holds promise for possible preventative intervention for children to reduce risks associated with surgeries and opioid use.

Building Our Solutions and Connections (BOSC) focused on enhancing problem-solving skills (PSS) of primary caregivers of children with mental health problems. Aims were determining feasibility, acceptability, and effect size ( ES ) estimates for depression, burden, personal control, and PSS. Methods: Caregivers were randomized to BOSC ( n = 30) or wait-list control (WLC) groups ( n = 31). Data were collected at baseline, post-intervention, and 3 and 6 months post-intervention. Results: Three-months post-intervention, ES for burden and personal control were .07 and .08, respectively. ES for depressed caregivers for burden and personal control were 0.14 and 0.19, respectively. Conclusions: Evidence indicates that the intervention had desired effects.

PURPOSE The aim of this study was to describe strategies for recruiting participants into an intervention study that focused on improving problem-solving skills in caregivers of children with mental health problems. BACKGROUND Caregivers of children with mental health problems report feeling physically and psychologically overwhelmed and have high rates of depression because of the demands of caregiving. Research on the needs of these caregivers and interventions to ameliorate their stress is needed. However, recruiting this population can be particularly difficult because of the stigma of mental illness. Available literature on recruitment of caregivers of persons with physical illness cannot be transferred to caregivers of children with mental health problems because of the different caregiving situations. There is a need to identify effective recruitment strategies to reduce cost and answer research questions. Clinical nurse specialists have the skills to facilitate the recruitment of research participants. We revised and expanded health system referrals, community outreach, and recruiting advertisement (ads). When these strategies did not increase recruitment, radio ads were used. The Andersen's Behavioral Model of Health Services Utilization was selected as a guiding framework. OUTCOME Radio ads were the most effective strategy for recruiting caregivers of children with mental health problems for this study. CONCLUSION Recruitment was ultimately successful because we were flexible and made decisions consistent with the Andersen's Behavioral Model of Health Services Utilization. IMPLICATIONS Clinical nurse specialists who study this population of caregivers should really consider the use of radio ads and systematically track which recruitment strategies lead to the greatest number of participants screened, eligible, and enrolled into studies.