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

Objective School anxiety is a prevalent mental health concern that drives school-related disability among youth with chronic pain. The only available measure of school anxiety—the School Anxiety Inventory, Short Version (SAI-SV)—lacks content specificity for measuring school anxiety in pediatric pain populations. We aimed to refine the SAI-SV by obtaining qualitative data about unique school situations that are anxiety-provoking for youth with pain and characterizing the nature of symptoms experienced in these situations. Methods Adolescents with chronic pain (n = 16) completed a semistructured interview focused on experiences with anxiety in school-related academic and social contexts. We employed thematic analysis to extend the empirical understanding of school anxiety from the perspective of patients suffering from pain and to generate new item content. The content was refined with iterative feedback from a separate group of adolescents with chronic pain (n = 5) and a team of expert pain psychologists (n = 3). Results We identified six themes within the data and generated new items designed to capture anxiety related to negative interactions with teachers and peers, falling behind with schoolwork, and struggles with concentration and fatigue. Participants and experts rated new item content as highly relevant for use among youth with pain. The updated item bank was named the School Anxiety Inventory for Chronic Pain. Conclusions Future research is needed to complete the psychometric evaluation of the item bank and finalize items to be included in a measure that can be used in research and clinical settings. Implications for treating school-related anxiety among youth with pain are also discussed.

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited disorders of connective tissue. EDS hypermobility type (EDS-HT), characterized by joint hypermobility, is most common and increasingly recognized in pediatrics. Treatment involves protecting joints, preventing injuries, and managing symptoms/comorbidities. Pediatric EDS-HT patients often see multiple medical providers; however, data on healthcare utilization (HCU) in this population are lacking. This retrospective, electronic chart review examines HCU data 1 year prior and subsequent to a new diagnosis of EDS-HT using Villefranche criteria. Demographics, diagnoses, and HCU (office visits, therapies, hospital encounters/procedures, and tests) were obtained for N = 102 youth attending a Connective Tissue Disorder Clinic over a 21-month timeframe. After EDS-HT diagnosis, HCU patterns shifted to reflect greater involvement of therapy (physical, psychological, and occupational) and symptom management. More genetics, rheumatology, and orthopedics visits occurred prediagnosis, and more physical therapy, pain management, cardiology, and neurology visits occurred postdiagnosis. Testing and hospital encounter/procedure frequencies did not change. Overall, the pattern of HCU changed from diagnostic to treatment, in accordance with evidence-based EDS-HT care. Understanding HCU patterns of pediatric patients with EDS-HT can elucidate patient interaction with the health care system, with the potential to inform and improve the standard of care.

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.

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 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.

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.