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The current study used a dyadic analytic approach (actor-partner interdependence models) to assess the stability and interrelationships of intolerance of uncertainty (IU) among a cohort of youth with chronic pain and their parents (n = 156 dyads). Relationships between parent and youth IU, parent and youth pain interference, and parent and youth internalizing mental health symptoms were examined. At baseline and follow-up, youth and parents completed psychometrically-sound questionnaires to assess their respective IU, pain characteristics, and clinical outcomes (pain interference, anxiety, depressive, and posttraumatic stress symptoms). Our findings support the construct stability of IU over time, as well as intrapersonal (ie, actor) effects of IU on follow-up youth pain interference and mental health symptoms and parents' mental health symptoms (but not parent pain interference). There were no interpersonal (ie, partner) effects over time between youth and parent IU or between youth and parent IU and pain interference or mental health symptoms. These findings align with previous research evidencing IU as a transdiagnostic risk factor for a range of mental health concerns and extend previous findings by showing the stability of parent and youth IU over time and its potential predictive relevance to outcomes in a clinical sample of youth with chronic pain. PERSPECTIVE: This article presents dyadic analyses assessing intrapersonal and interpersonal associations between intolerance of uncertainty (IU) and pain and mental health symptoms in youth with chronic pain and their parents. Analyses evidenced short-term construct stability of IU and intrapersonal (but not interpersonal) effects of IU on pain and mental health symptoms.

The present study examined the role of attention control in understanding the development of negatively-biased pain memories as well as its moderating role in the relationship between pain catastrophizing and negatively-biased pain memories. Youth with chronic pain (N = 105) performed a cold pressor task (CPT) and completed self-report measures of state/trait pain catastrophizing and attention control, with the latter comprising both attention focusing and attention shifting. Two weeks after the CPT, youth's pain-related memories were elicited via telephone allowing to compute pain and anxiety memory bias indices (ie, recalling pain intensity or pain-related anxiety, respectively, as higher than initially reported). Results indicated no main effects of attention control and pain catastrophizing on pain memories. However, both components of attention control (ie, attention focusing and attention shifting) moderated the impact of pain catastrophizing on youth's memory bias, with opposite interaction effects. Specifically, whereas high levels of attention shifting buffered the influence of high pain catastrophizing on the development of pain memory bias, high levels of attention focusing strengthened the influence of high pain catastrophizing on the development of anxiety memory bias. Interaction effects were confined to trait catastrophizing (ie, not state catastrophizing). Theoretical and clinical implications are discussed. Perspective This article investigates the role of attention control in the development of negatively-biased pain memories in children with chronic pain. Findings underscore the importance of targeting differential components of attention control and can inform intervention efforts to minimize the development of negatively biased pain memories in youth with chronic pain.

During the coronavirus 2019 (COVID-19) pandemic youth with chronic pain have experienced additional barriers to accessing treatment and managing their pain. This study explored the experiences of youth with chronic pain and their parents during the COVID-19 pandemic. Individual semi-structured interviews were conducted with 20 youth with chronic pain (aged 13–20 years) and one of their parents, recruited from a tertiary level pediatric chronic pain program. Interviews occurred between the months of June to August 2020 and enabled participants to describe their experiences of the COVID-19 pandemic according to their own unique perspectives. Transcripts were analyzed using inductive reflexive thematic analysis. Four themes were generated and labelled: “temporality, mental health, and pain,” “coping with pain during a global pandemic,” “impact on care,” and “re-appraisal in the context of development and pandemic life.” Across these themes, youth and parents described their unique challenges of living with pain as they adapted to changing circumstances of the COVID-19 pandemic. Notably, youth experienced increased difficulties managing their mental health and pain, which were intricately connected and related to social isolation, temporality, and uncertainty exacerbated by the COVID-19 pandemic. Restrictions due to the COVID-19 pandemic impacted youth's access to care and their abilities to engage in coping strategies to manage their pain. The COVID-19 pandemic was also perceived to have interrupted youth's development and growing autonomy, prompting youth to re-appraise their current circumstances and imagined futures. Perspective: This manuscript provides an in-depth understanding of the impact of the COVID-19 pandemic on youth with chronic pain and their parents. Youth and their parents perceived the COVID-19 pandemic to have impacted youth's mental health, pain, socio-emotional development, and access to care.

Attentional biases are posited to play a key role in the development and maintenance of chronic pain in adults and youth. However, research to date has yielded mixed findings, and few studies have examined attentional biases in pediatric samples. This study used eye-gaze tracking to examine attentional biases to pain-related stimuli in a clinical sample of youth with chronic pain and pain-free controls. The moderating role of attentional control was also examined. Youth with chronic pain (n = 102) and pain-free controls (n = 53) viewed images of children depicting varying levels of pain expressiveness paired with neutral faces while their eye gaze was recorded. Attentional control was assessed using both a questionnaire and a behavioural task. Both groups were more likely to first fixate on high pain faces but showed no such orienting bias for moderate or low pain faces. Youth with chronic pain fixated longer on all pain faces than neutral faces, whereas youth in the control group exhibited a total fixation bias only for high and moderate pain faces. Attentional control did not moderate attentional biases between or within groups. The results lend support to theoretical models positing the presence of attentional biases in youth with chronic pain. Further research is required to clarify the nature of attentional biases and their relationship to clinical outcomes.

Youth with chronic pain and their parents face uncertainty regarding their diagnosis, treatment, and prognosis. Given the uncertain nature of chronic pain and high comorbidity of anxiety among youth, intolerance of uncertainty (IU) may be critical to the experience of pediatric chronic pain. This study longitudinally examined major tenets of the Interpersonal Fear Avoidance Model of Pain and included parent and youth IU as key factors in the model. Participants included 152 youth with chronic pain (Mage = 14.23 years; 72% female) and their parents (93% female). At baseline, parents and youth reported on their IU and catastrophic thinking about youth pain; youth reported on their fear of pain, pain intensity, and pain interference; and parents reported on their protective responses to child pain. Youth reported on their pain interference 3 months later. Cross-lagged panel models, controlling for baseline pain interference, showed that greater parent IU predicted greater parent pain catastrophizing, which, in turn, predicted greater parent protectiveness, greater youth fear of pain, and subsequently greater youth 3-month pain interference. Youth IU had a significant indirect effect on 3-month pain interference through youth pain catastrophizing and fear of pain. The results suggest that parent and youth IU contribute to increases in youth pain interference over time through increased pain catastrophizing, parent protectiveness, and youth fear of pain. Thus, parent and youth IU play important roles as risk factors in the maintenance of pediatric chronic pain over time and may be important targets for intervention.

Attentional biases have been posited as one of the key mechanisms underlying the development and maintenance of chronic pain and co-occurring internalizing mental health symptoms. Despite this theoretical prominence, a comprehensive understanding of the nature of biased attentional processing in chronic pain and its relationship to theorized antecedents and clinical outcomes is lacking, particularly in youth. This study used eye-tracking to assess attentional bias for painful facial expressions and its relationship to theorized antecedents of chronic pain and clinical outcomes. Youth with chronic pain (n = 125) and without chronic pain (n = 52) viewed face images of varying levels of pain expressiveness while their eye gaze was tracked and recorded. At baseline, youth completed questionnaires to assess pain characteristics, theorized antecedents (pain catastrophizing, fear of pain, and anxiety sensitivity), and clinical outcomes (pain intensity, interference, anxiety, depression, and posttraumatic stress). For youth with chronic pain, clinical outcomes were reassessed at 3 months to assess for relationships with attentional bias while controlling for baseline symptoms. In both groups, youth exhibited an attentional bias for painful facial expressions. For youth with chronic pain, attentional bias was not significantly associated with theorized antecedents or clinical outcomes at baseline or 3-month follow-up. These findings call into question the posited relationships between attentional bias and clinical outcomes. Additional studies using more comprehensive and contextual paradigms for the assessment of attentional bias are required to clarify the ways in which such biases may manifest and relate to clinical outcomes.

Objectives Internalizing mental health issues co-occur with pediatric chronic pain at high rates and are linked to worse pain and functioning. Although the field has prioritized anxiety and posttraumatic stress disorder, little is known about co-occurring depression and chronic pain in youth, despite its high prevalence. The purpose of this narrative review was to examine the existing literature on the co-occurrence of pediatric chronic pain and depressive disorders and symptoms and propose a conceptual model of mutual maintenance to guide future research. Methods The literature from both fields of pediatric pain and developmental psychology were searched to review the evidence for the co-occurrence of pediatric chronic pain and depression. Conceptual models of co-occurring mental health issues and chronic pain, as well as child depression, were reviewed. From both literatures, we provide evidence for a number of proposed child, parent, and neurobiological factors that may serve to mutually maintain both conditions over time. On the basis of this evidence, we propose a conceptual model of mutual maintenance and highlight several areas for future research in this area. Results Evidence was found for the prevalence of depression in pediatric chronic pain as well as the co-occurrence of both conditions. The key mutually maintaining factors identified and proposed included neurobiological, intrapersonal (eg, cognitive biases, sleep disturbances, emotion regulation, and behavioral inactivation), and interpersonal (eg, parent mental health and pain, genes, and parenting) factors. Discussion Given the dearth of research on mutual maintenance in this area, this review and conceptual model could drive future research in this area. We argue for the development of tailored treatments for this unique population of youth to improve outcomes.

Background Chronic pain is a pervasive condition in adolescence and is associated with significant psychological distress, functional disability, social isolation, and decreased quality of life for a subset of affected youth. There is a paucity of research examining potential resilience factors and adaptive processes in pediatric chronic pain. Benefit finding refers to the process of perceiving positive consequences in the face of adversity. Previous research on benefit finding in pediatric samples (e.g., oncology; acute injury) has yielded inconsistent results. This is the first study to examine this construct in youth with chronic pain. Objective The objective of the current investigation was to extend previous research on benefit finding to adolescents with chronic pain and to assess relationships between benefit finding, internalizing mental health symptoms (i.e., anxiety, depression, and posttraumatic stress disorder [PTSD]), pain outcomes (pain intensity and interference), and quality of life. Methods Psychometrically sound self-report measures of benefit finding, anxiety, depressive, and PTSD symptoms, pain intensity, pain interference, and quality of life were completed by 145 youth (67.4% female, Mage = 13.3 years, SD = 2.6), referred to a tertiary-level chronic pain program. Results Benefit finding was significantly correlated with internalizing mental health symptoms, pain outcomes, and quality of life. Further, benefit finding significantly predicted children's self-reported pain intensity, pain interference, and quality of life when controlling for age and sex. Conclusions Findings suggest that benefit finding is associated with internalizing mental health symptoms, pain outcomes, and quality of life in youth with chronic pain. Future research examining this construct is warranted.

Clinically elevated rates of post-traumatic stress disorder (PTSD) symptoms are found among many youth with chronic pain and their parents and are linked to worse child pain outcomes. Conceptual models of mutual maintenance in pediatric PTSD and chronic pain posit that child and parent pain catastrophizing are key mechanisms underlying this co-occurrence. To our knowledge, the current study is the first to examine child and parent pain catastrophizing as potential mediators in the child PTSD-child pain and parent PTSD-child pain relationships among a cohort of youth with chronic pain. One hundred two children (72.5% female, mean age=13.5 years), recruited from a tertiary level chronic pain program, and 1 of their parents participated. At intake, parents completed psychometrically sound self-report measures of PTSD symptoms and catastrophizing about child pain. Children completed self-report measures of PTSD symptoms, pain catastrophizing, pain interference, and pain intensity. Findings revealed that relationships between child PTSD and child pain as well as parent PTSD and child pain were mediated by child (but not parent) pain catastrophizing. This suggests that children's catastrophic thinking about pain may explain how child and parent PTSD symptoms influence children's experience of chronic pain and is a potential target in family-based interventions to improve pain and mental health outcomes. Perspective Consistent with conceptual models of co-occurring PTSD and chronic pain, children's catastrophic thinking about child pain mediated relationships between parent and child PTSD symptoms and child chronic pain outcomes. Child pain catastrophizing may be a fruitful target in interventions to improve children's chronic pain and mental health outcomes.