PEDIATRIC PAIN SIG NEWSLETTER
Fall 2018
In this issue...
Letter from the SIG Co-Chairs - by Sara Williams, PhD & Dustin Wallace, PhD
Webinar Series Updates- Upcoming webinars & how to access previous webinars!
Research Spotlights: "Predicting Suicidal Ideation in Adolescents With Chronic Amplified Pain: The Roles of Depression and Pain Duration" by Bernadette Lewcun, MA and Traci M. Kennedy, PhD & "Prevalence of self‐reported chronic pain among adolescents: evidence from 42 countries and regions" by Inese Gobina, PhD & Alina Cosma
Clinical Spotlight - "Bringing the Comfort Ability Pain Management Program to Lurie Children’s Hospital" by Bonnie Essner, PhD
Collaboration Corner- Opportunities for faculty and trainees in the Pain In Child Health (PICH) Training Consortium
Hello from the Pediatric Pain SIG Co-Chairs!
We are pleased to share with you the Fall 2018 edition of Division 54’s Pain SIG Newsletter! In our biannual letter, we aim to highlight important topics in pediatric pain, including research, clinical, and training activities, as well as update readers on what we’ve been up to in the Pain SIG.
As you are getting caught up with all of the goings-on, keep in mind that it’s never too early to start thinking about getting more involved in the Pain SIG—there will be a number of positions up for reelection in the spring, including:
- SIG co-Chair
- Research Committee Chair
- Clinical Committee Chair
- Education Committee Chair
- Student co-Chair (works closely with education committee and coordinates newsletter)
Each of these is a 2-year position, except the student co-Chair position which is a 1-year commitment. We hope that many of you will consider lending your time and talents to take on a leadership role in the Pain SIG! Stay tuned for opportunities to run for those positions in early 2019. Finally, if you have an article you would like to contribute to a future edition, please contact our Student Representative Melissa Pielech (Mpielech@unm.edu), newsletter organizer extraordinaire.
A special thanks to those who contributed to the current newsletter! Please enjoy the read!
Your 2018-2019 SIG co-chairs,
Dustin Wallace, Ph.D., and Sara Williams, Ph.D.
Pain SIG Webinar Updates
Last year, Pain SIG leadership decided to use some of our available resources to host a brief series of three webinars in 2018. We are thrilled to have hosted two successful and informative webinars so far, and have a third scheduled in January 2019. The goal of these is to provide education to our psychologist and trainee members across a broad variety of issues relevant to young people with chronic pain and their families. We have had good attendance and satisfaction ratings have been strong, so we may continue these if we are able. In the meantime, please check out the two previous webinars on the education tab of our SIG website: https://ppainsig.weebly.com/education.html And, look for an email to register for the January webinar through our SIG listserv or the SPP listserv.
Upcoming:
- February 1, 2019 (1pm Eastern): “Clinical Applications of Mindfulness in Pediatric Pain” by Lynn C. Waelde, PhD, Professor, Pacific Graduate School of Psychology, Palo Alto University.
Past webinars available for viewing: https://ppainsig.weebly.com/education.html
- June 2018: "Sleep-Pain Relations in Pediatric Populations" by Cecelia Valrie, PhD, Virginia Commonwealth University
- February 2018: "Psychophysiological markers of Pain in Children and Adolescents" by Taryn Allen, PhD, the Frederick National Laboratory for Cancer Research
RESEARCH SPOTLIGHTS
Predicting Suicidal Ideation in Adolescents With Chronic Amplified Pain: The Roles of Depression and Pain Duration
Bernadette Lewcun, M.A. and Traci M. Kennedy, Ph.D.
Student Author Spotlight: Bernadette Lewcun is a third year doctoral student in La Salle University’s Clinical Psychology Program, who is involved in conducting research at The Children’s Hospital of Philadelphia Center for Amplified Musculoskeletal Pain Syndromes. She is particularly interested in the complex associations between pain and comorbid mood disorders in children, as well as examining individual, social, and environmental factors that may impact treatment for pediatric patients with chronic pain.
Suicide is growing public health crisis among adolescents in the United States (Kann et al., 2014, 2016; Sullivan, Annest, Simon, Luo, & Dahlberg, 2015), indicating a vital need to expand our understanding of factors that may lead to or exacerbate suicidal ideation (SI) in youth. Pediatric chronic pain is one such factor that may put children at greater risk for the emergence or escalation of suicidal thoughts, as chronic pain in youth has been linked to a myriad of psychosocial concerns (Forgerone et al., 2010; Kasikar-Zuck et al., 2008; Kasikar-Zuck et al., 2002). In addition, research examining the associations between pain and suicidality in adults have found chronic pain symptoms to be significant independent predictors of suicidal ideation (Cheatle, 2014; Fishbain, Lewis, & Gao, 2014; Smith, Edwards, Robinson, & Dworkin, 2004) and suicide attempts (Fishbain et al., 2014). Though studies in this area among children and adolescents are sparse, their results indicate that depressive symptoms may account for the relation between chronic pain symptoms (i.e. severity, duration, and functional limitations) and suicidality (Bromberg et al., 2017; van Tilburg, Spence, Whitehead, Bangdiwala, & Goldston, 2011). As such, along with our co-authors, we recently reported the results of a study that sought to investigate the specific mechanisms through which chronic pain symptoms relate to suicidality, with particular attention to the relations among pain symptoms, depressive symptoms, and suicidal ideation (SI) in adolescents with amplified musculoskeletal pain syndrome (AMPS; Lewcun, Kennedy, Tress, Miller, Sherker, & Sherry, 2018). Since previous research has documented that 90% of first suicide attempts occurred within one year of developing SI (Kessler, Borges, & Walters, 1999), we focused on predicting SI as a key risk factor for preventable suicide, and we hypothesized that depressive symptoms would mediate the connections between pain symptoms and SI.
Hierarchical ordinal logistic regression analyses were conducted to predict three levels of SI (none, passive, active) from relevant demographics (sex, age, race), pain-related factors (family history of pain disorder, severity, duration, functional disability), and depressive symptoms. Mediation was tested through bias-corrected bootstrapping using the PROCESS macro for SPSS, following the steps outlined by Hayes (2013). Our results indicated that of all demographic and pain-related factors, pain duration was the only significant independent predictor of SI, indicating that longer pain duration corresponds with increased odds of SI severity (i.e., increase from no SI to passive SI or from passive SI to active SI). Further, as anticipated, depressive symptoms was indeed a significant independent predictor of SI, which fully mediated the associations between pain duration and SI.
In applying these findings to clinical care, although adolescents with chronic pain are at risk for SI when pain is especially persistent, this link appears to operate through depressive symptoms. Thus, SI may not solely be a direct result of physical pain, but rather the depressive symptoms that may develop over time as adolescents struggle to find a diagnosis, seek effective treatment, and live with debilitating pain. Depression is therefore an important proximal signal for SI risk among adolescents with chronic pain, suggesting that targeted treatment for depression may be warranted among youth experiencing chronic amplified pain to prevent the development of depression and, in turn, SI. This finding further highlights the importance of collaborative care among mental health and medical professionals to successfully address the complex interconnection among psychological and physical health. Specific recommendations for providers might include referral of all patients treated by a pain specialist for psychological services, regardless of their pain symptoms severity. Given the empirical support for psychotherapy interventions significantly reducing pain severity, functional disability, and depressive symptoms among pediatric patients with AMPS (Fisher et al., 2014; Palermo, 2012), psychological services should play a prominent role in chronic pain treatment.
In addition, the implementation of screening measures by mental health providers may identify adolescents with pain who may be at heightened risk for developing SI. This screening can be conducted as part of routine clinical care, with the regular use of measures such as symptom checklists or health-related quality of life measures. Furthermore, psychoeducation regarding the relationship between psychological and physical health is warranted as well, as youth with depression and pain may not be aware that it is both appropriate and important to report physical symptoms to their mental health provider. Lastly, familiarity with evidence-based treatments for youth with comorbid chronic pain and mental health concerns would be valuable for mental health clinicians working with youth (Fisher et al., 2014). Robust evidence exists supporting the efficacy of Cognitive-Behavioral Therapy (CBT) in treating pediatric chronic pain, which is rooted in a biopsychosocial framework, and can be used independently or in conjunction with pharmaco-therapy, and/or physical and occupational therapy (Palermo, 2012).
Although research concerning chronic pain and suicide in adolescents has greatly expanded in recent years, more targeted research is still needed to provide a more detailed understanding of the mechanisms through which depressive symptoms relate to SI among youth with pain. As such, we are currently conducting a longitudinal investigation of psychological and pain symptoms to track the relative development of physical and psychological symptoms over time, which we hope will inform more targeted prevention and intervention strategies for youth with chronic pain.
References:
Lewcun, B., Kennedy, T. M., Tress, J., Miller, K. S., Sherker, J., & Sherry, D. D. (2018). Predicting suicidal ideation in adolescents with chronic amplified pain: The roles of depression and pain duration. Psychological Services,15(3), 309-315. doi:10.1037/ser0000210
INTERNATIONAL RESEARCH SPOTLIGHT
Prevalence of Self‐reported Chronic Pain Among Adolescents: Evidence from 42 Countries and Regions
Inese Gobina(1) & Alina Cosma(2)
1 Department of Public Health and Epidemiology, Institute of Public Health, Rīga Stradinš University, Rīga, Latvia
2 Child and Adolescent Health Research Unit (CAHRU), School of Medicine, University of St Andrews, St Andrews, UK
Young adolescence between the age of 11-15 years is a time for much physical, psychological and social change and development. Along with all the positive development and growth, adolescents can also experience pain. Chronic pain can be an important, debilitating factor for young adolescents’ well-being. Existing studies show chronic pain is common not only among adolescents in clinical sub-groups but also in the general population. However, there is significant variation in chronic pain prevalence among adolescents across existing studies.
A team of European researchers, investigated the prevalence of single-site pain, as well as combined pain in representative samples of adolescents (aged 11-, 13-, and 15-year olds) from 42 countries. The data was collected as part of the Health Behaviour in School-aged Children (HBSC) study, which is one of the oldest and biggest WHO collaborative study that collects data every 4 years from more than 45 European countries. The specific aims of this study were:
(a) to describe and compare the prevalence of chronic single‐site (only headache or backache, or stomach‐ache) and multi‐site pain (pain reported in at least two sites) in adolescents cross‐nationally;
(b) to investigate the patterns of chronic pain by age and sex; and
(c) to examine country‐level effects on variation of chronic pain, and associations between pain and age.
The results show that the most frequent single-site pain reported by adolescents is headache, followed by backache and stomach-ache. In general, the odds of reporting localized chronic headaches and backaches increased with age during adolescence, whereas the prevalence of stomach‐ache was more likely to decrease with age; however, significant country variation exist.
On average, in comparison with different specific localized types of single‐site pain, the prevalence of multi‐site pain was more common varying from 13.2% in Armenia to 33.8% in Israel. The most consistent findings indicate that multi-site pain was more prevalent among girls across all countries and that the prevalence increased with age.
Despite having 42 countries included in the analysis, no consistent geographical patterns of pain prevalence in adolescents across different countries were observed. The international heterogeneity of chronic pain prevalence and differences in chronic pain patterns across countries shows that adolescents with chronic pain are not a homogenous group. Differences in chronic pain characteristics should be addressed in both clinical and public health practice in order to maximize the adolescent chronic pain management and prevention. Chronic pain in adolescents should be managed using a multidisciplinary approach by taking into account the multidimensionality and biopsychosocial development of pain, and the cross‐country differences in chronic pain prevalence.
References:
Gobina, I., Villberg, J., Välimaa, R., Tynjälä, J., Whitehead, R., Cosma, A., ... & Villerusa, A. (2018). Prevalence of self‐reported chronic pain among adolescents: evidence from 42 countries and regions. European Journal of Pain; https://doi.org/10.1002/ejp.1306.
CLINICAL SPOTLIGHT
Bringing the Comfort Ability Pain Management Program to Lurie Children’s Hospital
Bonnie Essner, PhD
Pediatric Psychologist, Ann & Robert H. Lurie Children’s Hospital of Chicago
Assistant Professor, Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine
“Yes, really, you can do that and it worked so well for my daughter!”
"Oh, I never thought about it that way…”
These are a few of the encouraging messages shared among parents of adolescents with chronic pain who were attending our first Comfort Ability workshop at Ann & Robert H. Lurie Children’s Hospital of Chicago. This group of parents was creating behavior plans to improve their teens’ functioning. Although I’d worked with many families on behavior plans in individual treatment, I found myself savoring the energy and enthusiasm in this room of supportive parents who were cheering on one another as only peers can. It was one of my first realizations that the Comfort Ability was going to be an important service for our pediatric chronic pain program.
The Comfort Ability program is a one-day, group-based workshop that introduces cognitive-behavioral principles to adolescents with chronic pain and their parents. In preliminary research, teen and parent attendees reported improvements in behavioral, emotional and psychological functioning immediately following the program and improved further in these domains over time (Coakley, Wihak, Kossowsky, Iversen, & Donado, 2018). Developed and overseen by Rachael Coakley, PhD and colleagues at Boston Children’s Hospital, the program is now offered at eleven academic medical centers in North America and the network of Comfort Ability sites continues to grow. My Lurie Children’s Hospital colleagues and I had heard enthusiastic reviews of the program from friends at other sites that had adopted Comfort Ability. We set out to integrate this brief program into our relatively small, pediatric chronic pain treatment service and were welcomed into a supportive team of pediatric chronic pain programs collaborating to make this program a success.
Adopting the Comfort Ability program was a team effort. From our initial phone consultation with Dr. Coakley, through our on-site training experience at Boston Children’s, further email and phone communications, to hosting our initial workshop and beyond, our Lurie Children’s team has benefited from the expertise of the Comfort Ability network. The Boston Children’s team provided resources and feedback for funding the program start-up and maintenance and they offered a package of materials for program marketing, participant registration and tracking, and program evaluation. Bolstered by this strong external support, our team generated enthusiasm internally among colleagues and administrators. We obtained a competitive, hospital-sponsored grant to fund our initial workshop and with instrumental support from chronic pain treatment program leadership, we obtained hospital-wide approval for our program and a business plan for ongoing sustainability of Comfort Ability. As a testament to our chronic pain treatment program’s support, several members of our multidisciplinary team – physical therapists, advanced practice nurses, and physicians – attended and volunteered time at our Comfort Ability workshop launch last spring. We’ve maintained this interest with our subsequent workshop; we’re establishing a stream of internal referrals and the program has sparked collaboration with other subspecialty programs that are focused on improving the pain services for their patients.
Overall, collaborating with Dr. Coakley’s team to host the Comfort Ability Pain Management Program has benefited our chronic pain treatment program and our patients. It’s a unique clinical program that has been eagerly-received by our colleagues and family participants. The workshop has enhanced our site’s clinical programming, offered a new opportunity for families to promote growth among one another, and connected our team to a community of chronic pain professionals and excellent resources. We look forward to many more of those moments of shared connection and enthusiasm that I recall from our first workshop, when parents excitedly cheered on one another and shared their confidence in improving their teens’ pain management.
*For more information about the Comfort Ability Pain Management Program, visit the program website: https://www.thecomfortability.com/.
*Special thanks to Natalie Seewald, APN and Sue Park, APN, co-facilitators of the Comfort Ability Pain Management Program at Ann & Robert H. Lurie Children’s Hospital of Chicago
References
Coakley, R., Wihak, T., Kossowsky, J., Iversen, C., & Donado, C. (2018). The Comfort Ability pain management workshop: A preliminary, nonrandomized investigation of a brief, cognitive, biobehavioral, and parent training intervention for pediatric chronic pain. Journal of Pediatric Psychology, 43(3), 252-265. doi: 10.1093/jpepsy/jsx112.
Pain in Child Health (PICH)
Pain in Child Health (PICH) is a transdisciplinary, international research training consortium that started in 2002 with the founding participation of five Canadian universities and the support of the CIHR Strategic Training Initiative in Health Research (STIHR) and other partners (e.g. Mayday Foundation). As of April 2018, PICH has transitioned from this funding structure. PICH was originally based at the IWK Hospital in Halifax and has moved to the Pain Centre at The Hospital for Sick Children in Toronto. The goal of PICH is to create a community of scholars in pediatric pain to improve child health outcomes.
PICH leadership is comprised of top researchers in pediatric pain that are divided into two committees: the National Collaborators Committee (PICH's core team of interdisciplinary faculty from across the country that will support and help lead PICH initiatives) and the Advisory Committee (former PICH leaders for over 15 years, they provide input on the ongoing activities of PICH and insight on new strategic directions). There are currently 69 active national trainees, 55 international trainees, and 41 faculty members in different research networks across 9 countries.
PICH has cultivated a tight-knit community of researchers and clinicians in the field of pediatric pain through different events targeted toward sharing knowledge and improving current research and clinical practices to minimize pain and suffering of children around the globe.
Some of our events and resources include:
- PICH2GO conferences. Educational and networking events co-hosted by PICH and local children’s hospitals with the goal of engaging, empowering, and educating families, trainees, clinicians and researchers.
- The PICH Pulse newsletter. Aimed to keep the PICH community and the public updated on all PICH-related matters, it is released three times a year
- An international mailing listserv where participants share news and ask questions.
- PICH webinars. Connecting with trainees and faculty across the globe, monthly PICH webinars are scheduled on a topic about pediatric pain. Usually, a trainee gives a live presentation about their research and a PICH faculty member serves as a moderator, asking questions and facilitating discussion.
If you have a faculty position, we have some good news for you: PICH is expanding and looking for researchers to join PICH as a faculty member. The faculty requirements are:
- Hold an academic appointment and are conducting pediatric pain research
- Supervise, or have the potential to supervise, students
- Have an active interest in being involved with PICH
- Have approval and support from a National Collaborator
If you are a trainee, we have good news for you as well: PICH is open to those with a commitment to research in pediatric pain or developmental aspects of pain, in any discipline and at any level in their training.
Interested to learn more about PICH or how to join our community? Click here for information re: how to apply to be a faculty or trainee member: http://www.sickkids.ca/PICH/key-info/how-to-apply/index.html
Questions? Send an email to: pain.childhealth@sickkids.ca