Adaptive functioning of children and adolescents with persistent pain: associations with sensory modulation and attachment ​​​​​​​

Abstract

Current interdisciplinary pain management treatment relieves pain and restores function for many children and adolescents with persistent pain; however, for some, treatment is not successful, and the pain and dysfunction remain. Pain has an ecological context: as children and adolescents engage in their daily lives, receiving sensation through multiple sensory modalities, the perception of uncertain threat can evoke pain and protective responses. Children with disordered patterns of sensory modulation (i.e., those who do not effectively filter irrelevant sensory stimuli, or appropriately adjust arousal to organise a response graded to sensory input) have been shown to report higher pain intensity and duration, lower engagement in daily activities, and are vulnerable to developing insecure attachment. Sensory modulation may contribute to higher pain intensity and reduced function for children and adolescents with persistent pain, and limit the effectiveness of treatment; however, sensory modulation has not yet been investigated in relation to children and adolescents with persistent pain.The purpose of this thesis is to investigate the sensory modulation patterns of children and adolescents with persistent pain. To address the ecological context of pain, the thesis is guided by nonlinear dynamic systems theory (NDST); an ecological framework that serves to explain how neurobiological processes, social relationships, and environmental circumstances interact to influence an individual’s response to daily life and potential danger. The aims of the thesis are to consider: (1) the sensory modulation patterns of children and adolescents with persistent pain, (2) whether or not sensory modulation affects their pain and quality of life/capacity to function in daily life, (3) the associations between sensory modulation, attachment insecurity, quality of life/functional ability, and pain, and (4) whether sensory modulation and/or attachment insecurity impact the outcomes of interdisciplinary team treatment. A further aim is to explore the impact of sensory modulation and attachment style on the occupational patterns of children and adolescents with persistent pain, within social and physical contexts, so as to inform occupational therapy clinical reasoning processes.Three studies were undertaken to address the aims of the thesis: (1) a cross-sectional quantitative study investigating the associations between sensory modulation and attachment patterns, pain intensity, and the functional abilities/quality of life of children and adolescents with persistent pain, (2) an ecological momentary assessment study to explore the lived experience of persistent pain for children and adolescents, and (3) a prospective cohort study to investigate whether sensory modulation or attachment patterns of children with persistent pain predicted the outcomes of interdisciplinary team treatment.Findings of the cross-sectional study demonstrated that adolescents with persistent pain were more likely to be sensory over- and under-responsive, and were lower in sensation seeking, compared to a published normative sample. Extreme patterns of sensory modulation were associated with higher disability and poorer quality of life (QOL) for children and adolescents with persistent pain, but were not associated with pain intensity. Pain catastrophising mediated the relationship between higher sensory sensitivity (sensory over-responsiveness) and functional disability. Low registration (a sensory modulation pattern consistent with under-responsiveness) was associated with anxious and avoidant attachment. Anxious attachment was directly related to lower school-related QOL, and mediated the relationship between low registration and lower school-related QOL.Information obtained from the ecological momentary assessment study informed two case studies that demonstrated application of NDST to assist occupational therapists to: (1) identify contributors to complex persistent pain for children and adolescents, (2) understand the adaptive functional responses of children and adolescents with various sensory modulation and attachment patterns within unique environmental contexts, and (3) identify treatment targets and strategies.The prospective cohort study found that children and adolescents with typical sensory modulation were more likely to achieve functional improvement following three months of interdisciplinary pain management treatment. Those with atypical sensory sensitivity and sensory avoiding did not achieve these functional gains. Higher sensory seeking predicted improved functional ability; however, this relationship was not retained when parent depression was controlled for statistically. Parent responses to pain were not associated with insecure attachment, yet were correlated with poorer quality of life following three months of treatment, as was child/adolescent anxious attachment.This research is the first to demonstrate associations between sensory modulation and: insecure attachment, functional impairment, poorer quality of life, and poorer treatment outcomes for children and adolescents with persistent pain. Knowledge of how these variables manifest in different clinical presentations offers practical guidance for the occupational therapist working in this field. The results suggest that therapies addressing an individual’s sensory modulation and attachment patterns, integrated with the ecological context of his or her daily life, may improve treatment outcomes for children and adolescents with persistent pain, and warrant further investigation.