Anna C. Wilson, PhD

Assistant Professor

Anesthesiology and Perioperative Medicine

Overview� Background and theory

� Chronic pain in adolescence� Fear-avoidance beliefs in adolescence � Parent factors in adolescent chronic pain

� Aims and methods of current study

� Results and conclusions� Future directions

Chronic and Recurrent Pain is a

Significant Pediatric Health Problem

� 20-40% of children and adolescents in community samples experience persistent pain (Perquin et al., 2000; Stanford et al., 2008)

� More severe persistent pain in 8%� Pain accompanied by moderate to severe disability in

5% (Huguet & Miro, 2008)

� Most common locations: head, abdomen, limbs

� Multiple pains are common

� More commonly reported in girls than boys� Peak incidence: ages 14-15 years (Stanford et al., 2008)

� Comorbid anxiety and depression common

Fear-avoidance beliefs

� Cognitions (thoughts and beliefs) about pain being linked to physical activity or movement

� “Physical activity makes my pain worse” or “I cannot do movements that make my pain worse”

� Fear-avoidance beliefs are related to higher levels of pain and disability: Well-supported in adults with chronic low back pain (e.g., Jensen et al., 2001; Poiraudeau et al., 2006)

� Few measures of fear-avoidance beliefs that have been used in children and adolescents

Vlaeyen & Linton, 2000

� Cognitions and avoidance behaviors develop within a family context

� Parental responses to child pain may influence cognitions about pain, including fear-avoidance

� Children and parents play a role in appraising or judging pain to be more or less threatening

Vlaeyen & Linton, 2000

Parent behaviors

� Specific parent responses to child pain behaviors may serve to inadvertently reinforce or encourage pain behaviors

� Protective or solicitous responses to child pain associated with higher pain intensity and disability (Claar et al., Pain, 2008; Chambers et al., J Ped Psych, 2002)

� Behaviors include: � Frequent attending to pain symptoms

� Allowing activity withdrawal from less preferred activities (e.g., chores, school attendance)

� Giving special privileges or rewards

� 1. Describe fear-avoidance beliefs and correlates in a sample of adolescents with chronic pain

� 2. Examine fear-avoidance beliefs and depressive symptoms as predictors of disability

� 3. Test fear-avoidance beliefs as a potential moderator and mediator of parental protectiveness

� n = 42 adolescents with chronic pain (pain 1x/wk or more, present for >3 months), recruited through outpatient pediatric specialty care clinics at a university children’s hospital (pain clinic, gastroenterology, neurology)� Abdominal pain (n = 23)

� Headache (n = 11)

� Musculoskeletal pain (n = 8)

� 11-17 years old, Mean age 14.90 (SD = 2.11)� 73.8% female

� 88.1% Caucasian; 7.1% Hispanic; <3% other ethnicity

� Mean annual family income $50-69K

� Pain characteristics

� Usual pain intensity, 0-10 NRS

� Pain frequency in last 3 months

� Fear and Avoidance Beliefs Questionnaire –Physical Activity 5-item subscale (FABQ-PA; Waddell et al., 1993)

� Depressive Symptoms: 10-item Major Depressive Disorder subscale of Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita et al., 2005)

� Parental Protectiveness: Adult Responses to Children’s Symptoms 15-item Protect subscale (Van Slyke & Walker, 2006)� Item examples: “When your child has aches and

pains, how often do you…pay more attention than usual to your child; give your child special privileges; bring your child special treats or little gifts”

� Physical Activity Limitations: Child Activity Limitations Interview (CALI; Palermo et al., 2004)� Assesses difficulty doing physical and routine

activities because of pain

Variable M (SD)

Pain Intensity (0-10) 6.57 (1.74)

Depressive Symptoms 55.98 (13.50)

Disability (CALI): Adolescent Report

19.86 (6.19)

Disability (CALI): Parent report

21.05 (6.09)

Parental Protectiveness 1.79 (.51)

� Adolescents reported moderate levels of fear-avoidance (FABQ-PA, M = 11.52)

� Slightly lower than samples of adults with chronic low back pain (FABQ-PA, M = 14.0-14.2)

� FABQ-PA had slightly low internal consistency: Chronbach’s alpha = .69

� As hypothesized, the FABQ-PA was significantly correlated with:

� Parent-report disability (r = .42, p < .01)� Child-report disability (r = .44, p < .01)

� Parental protectiveness (r = .47, p < .01)

� FABQ-PA was not related to:

� Depressive symptoms� Usual pain intensity

� Pain location

CALI: Child report CALI: Parent report

∆R2β at final

step ∆R2β at final

step

Step 1:

Household Income

Usual Pain Intensity

.38***

-.23

.47***

.08

.09

.23

Step 2:

Depressive Symptoms

.00

-.03

.02

.05

Step 3:

Fear-avoidance Beliefs

.16**

.42**

.17**

43**

Total R2: .54*** .27*

* p < .05, ** p < .01, *** p < .001

� Tested two models: fear-avoidance as a moderator and as a mediator

Parental

Protectiveness

Child Activity

Limitations

Fear-Avoidance

Beliefs

� Tested two models: fear-avoidance as a moderator and as a mediator

Parental

Protectiveness

Child Activity

Limitations

Fear-Avoidance

Beliefs

� Tested two models: fear-avoidance as a moderator and as a mediator

Parental

Protectiveness

Child Activity

Limitations

Fear-Avoidance

Beliefs

� Results: No support found for moderation model� The association between protectiveness and activity

limitations is not altered by child fear-avoidance

Parental

Protectiveness

Child Activity

Limitations

Fear-Avoidance

Beliefs

.29*

n.s.

� Support for mediation model (Sobel z = 1.97, p = .05)

� Fear-avoidance beliefs may serve as one pathway through which parental protectiveness influences activity limitations.

Parental

Protectiveness

Child Activity

Limitations:

Adol. report

Fear-Avoidance

Beliefs

.51** .42*/.40*

.29*/.05

� As in adult chronic pain populations, fear-avoidance beliefs play an important role in adolescent disability

� Fear-avoidance beliefs seem to be important for adolescents with a variety of pain problems

� Fear-avoidance beliefs may be less tied to depressive symptoms and pain intensity in adolescents than in adults

� Parental behaviors in response to adolescent pain may influence adolescent cognitions and fears which in turn increase activity limitations

� Strengths:� Associations demonstrated across reporters

(adolescent and parent)

� Fear-avoidance beliefs examined in a mixed pain problem sample (not only back or musculoskeletal pain)

� Limitations:

� Cross-sectional study limits our ability to draw conclusions about the direction of these effects

� Relatively small sample limited power to detect moderation

� Did not examine anxiety symptoms

� Examine role of parental behaviors and cognitions in shaping adolescent cognitions over time

� Examine additional parental behaviors and beliefs:

� Parent catastrophizing about their child’s pain� Parent modeling of pain behaviors

� Enhance understanding of how adolescent fear-avoidance beliefs relate to other pain-related cognitions such as catastrophizing

� Both parent behaviors and adolescent fear-avoidance cognitions may be potential intervention targets

� Pediatric Health Pilot Project (PI: Wilson): Oregon Clinical and Translational Research Institute (OCTRI), grant # UL1 RR024140 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research

� Colleagues and collaborators:

� Tonya Palermo, PhD

� Amy Lewandowski, PhD� Caitlin Murray, BA