Abstract
Previous research indicates elevated levels of clinically significant traits and symptoms of autism spectrum disorder and attention-deficit hyperactivity disorder (ADHD) in children with chronic pain, but associations with functioning and depression are yet unclear. The current study examined the relationships of autistic traits and ADHD symptoms with pain interference, depression, and health-related quality of life, as well as the mediating roles of insomnia and psychological inflexibility, in children with chronic pain (n = 146, 8–17 years, 102 girls) presenting at a tertiary pain clinic. Children completed measures of pain intensity, depression, pain interference, health-related quality of life, insomnia, and psychological inflexibility. Parents (n = 146, 111 mothers) completed measures to assess autistic traits and ADHD symptoms in their children. Children with clinically significant autistic traits and ADHD symptoms presented with significantly higher levels of depressive symptoms and pain interference, and significantly lower health-related quality of life, than did the other children. Autistic traits and ADHD symptoms contributed significantly to the prediction of pain interference and depressive symptoms, as well as health-related quality of life. Psychological inflexibility mediated the relationships between ADHD symptoms and autistic traits on the one hand and depression, pain interference, and health-related quality of life on the other, while insomnia mediated the relationships between ADHD symptoms and depression, pain interference, and health-related quality of life. All analyses were adjusted for demographics and pain intensity. Results suggest the utility of screening for neurodevelopmental disorders in children with chronic pain. Furthermore, the findings may indicate insomnia and skills related to psychological flexibility as potential treatment targets in interventions aiming at improving functioning and health-related quality of life in children with chronic pain and co-occurring symptoms of neurodevelopmental disorders.
Highlights
Pediatric chronic pain conditions are prevalent and associated with impaired functioning across physical, emotional, and social domains (Konijnenberg et al, 2005; Petersen et al, 2009b; Hoftun et al, 2011)
In a recent study including a clinical sample of children and adolescents with debilitating chronic pain, we found elevated levels of clinically significant traits and symptoms of the neurodevelopmental disorders autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) compared to healthy populations
Number of bootstrap resamples = 5000; Covariates in all analyses: age, gender, pain intensity; LLCI/ULCI, Lower/Upper Level Confidence Interval; C3, Conners 3; symptoms (C3) and autistic traits (SRS), The Social Responsiveness Scale; pain interference (PII), Pain Interference Index; CES-DC, Center for Epidemiological Studies – Depression Scale Children; PedsQL, Pediatric Quality of Life Inventory. aThe indirect effect is statistically significant when the confidence interval (LLCI – ULCI) does not include zero (99% equals p < 0.01 level significance). *p < 0.05 and **p < 0.01
Summary
Pediatric chronic pain conditions are prevalent and associated with impaired functioning across physical, emotional, and social domains (Konijnenberg et al, 2005; Petersen et al, 2009b; Hoftun et al, 2011). The widely recognized biopsychosocial model of chronic pain (Edwards et al, 2016) emphasizes how biological, psychological, and social factors interplay, vary significantly between individuals, and may influence the development and maintenance of chronic debilitating pain in different ways (Liossi and Howard, 2016) This pattern suggests that some factors may constitute a risk to chronic pain development and functional disability in youth, while others may be protective and promote resilience (Gmuca et al, 2019). Chronic pain has been found to be more common in girls in both community and clinical samples (Konijnenberg et al, 2005; Huguet and Miro, 2008; King et al, 2011; Holmstrom et al, 2015) As these data show, there is a large body of research of specific risk factors that may contribute to pediatric chronic pain and pain-related impairments. The study of factors that can prevent development of severe functional impairments in pediatric chronic pain, and constitute resilience factors, is still, a neglected research area (Gmuca et al, 2019; Lee et al, 2020)
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