WASHINGTON, DC—Data reported this week at the American Pain Society's 26th Annual Scientific Meeting show that treating adolescents who have chronic musculoskeletal pain may require helping parents to avoid reinforcing pain behaviors, as well as treating the patient's underlying physical problems and depression.¹ Lead author Jessica W. Guite, PhD, of the Pain Management Service at The Children's Hospital of Philadelphia, told CIAOMed that the findings are likely to have implications for clinicians treating adolescents with arthritis and other chronic, painful rheumatoid diseases.

"Clinicians should take time to assess depression in adolescents with chronic pain and also should consider how the parents are responding to the patient's pain complaints. If pain is chronic [and] continues for more than 3 months, the tactics for dealing with acute pain episodes are no longer helpful. We need to help parents encourage these young patients to be functional [and] cope with the pain, and maintain school activities, time with friends, and adequate sleep. Counseling may be useful in helping parents support more adaptive coping patterns. Consider not only the adolescent's level of depression, but [also] how the parents are responding to their child's ongoing pain," Dr. Guite said.

Catastrophizing predicts pain, disability

The focus of this study was "catastrophizing"—the tendency to respond to pain with an exaggerated negative "mental set" that is threatening to one's sense of well-being. Dr. Guite said that the tendency to catastrophize is an important predictor of pain intensity and functional disability in adults with chronic pain, but has not been well studied in adolescents. Her team set out to confirm earlier studies suggesting that catastrophizing also predicts pain intensity and functional disability for adolescents and to explore the contribution of adolescent psychological functioning and of parental pain-reinforcing behaviors to the patient's tendency to catastrophize. Parental pain- reinforcing behaviors include, for example, allowing the adolescent to sleep late or to skip school in response to pain.

The study evaluated 138 adolescents with chronic musculoskeletal pain, who had been referred to the tertiary care pain clinic at Children's Hospital. The large majority of these patients were female (84%), from 13-to-18 years old (mean age 15.6 years). In nearly all cases (92%) the parent reporter for the study was the patient's mother. Pain categories included complex regional pain syndrome (37 patients, 26.8%), localized amplified musculoskeletal pain (39 patients, 28.3%), diffuse amplified musculoskeletal pain (59 patients, 42.8%), and diffuse intermittent pain (3 patients, 2.2%).

The researchers assessed current pain intensity on a 100-mm visual analog scale (VAS). They also used the Brief Symptom Inventory (BSI) to assess psychological distress; the Functional Disability Inventory (FDI) to measure the impact of adolescent health on physical and psychosocial functioning; the Illness Behavior Encouragement Scale (IBES) to assess the frequency with which parents engage in pain- reinforcing behaviors in response to the  adolescent's pain; and the Pain Catastrophizing Scale (PCS), which assesses threatening thoughts about actual or anticipated painful experiences.

And parental behavior predicts catastrophizing

Dr. Guite et al report that the pain-catastrophizing score predicted pain intensity, but parental pain reinforcement and global psychological distress did not. Hierarchical regression analysis showed that, pain catastrophizing significantly predicted disability, beyond the effect found for the actual pain (P<.05). They also found that both the patient's depression level and the degree of parental pain-reinforcement behavior predicted whether the adolescent would engage in pain catastrophizing. Parental pain-reinforcing behavior worsened the degree of catastrophizing associated with depression.

"While the cross-sectional nature of this study precludes making causal inferences, clinical implications may include the importance of assessing and intervening [in cases of] maladaptive patterns of parental pain-reinforcing behaviors, in addition to [treating the] adolescent's depressive symptoms, in order to improve how adolescents think and cope with their pain and to ultimately help break the negative pain-disability cycle," Dr. Guite concluded.

Reference

1. Guite JW, Rose JB, McCue RL, et al. Adolescents with chronic musculoskeletal pain: the role of pain catastrophizing, psychological distress, and parental pain reinforcement. Paper presented at: American Pain Society 26th Annual Scientific Meeting; May 2–5, 2007; Philadelphia, PA. Abstract #7082.