Validation and Clinical Application of a Biopsychosocial Model of Pain Intensity and Functional Disability in Patients with a Pediatric Chronic Pain Condition Referred to a Subspecialty Clinic
Background. Pediatric chronic pain is considered to be a multidimensional construct that includes biological, psychological, and social components. Methods. The 99 enrolled study patients (mean age 13.2 years, 71% female, 81% Caucasian) and an accompanying parent completed a series of health-related questionnaires at the time of their initial appointment in a pediatric chronic pain medicine clinic. Results. Significant correlations ( , ) were observed between pediatric chronic pain intensity and patient anxiety, patient depression, patient pain coping, parent chronic pain intensity, and parent functional disability. Pediatric chronic pain intensity was significantly associated with patient anxiety ( ). Significant correlations ( , ) were observed between pediatric functional disability and patient chronic pain intensity, patient anxiety, patient depression, patient pain coping, parent chronic pain intensity, parent functional disability, parent anxiety, parent depression, and parent stress. Pediatric functional disability was significantly associated with patient chronic pain intensity ( ), patient anxiety ( ), patient pain coping ( ), and parent functional disability ( ). Conclusions. These findings provide empirical support of a multidimensional Biobehavioral Model of Pediatric Pain. However, the practical clinical application of the present findings and much of the similar previously published data may be tenuous. 1. Introduction Pediatric chronic pain has extensive and often sustained detrimental effects on the health, development, and quality of life of young people, with a concomitant adverse impact on all those invested in their well-being [1–6]. A Delphi poll of professionals with a specific interest in chronic pain in children and adolescents was undertaken to reach a consensus as to the factors associated with pediatric chronic pain and disability [7]. Factors deemed most important in the development of pediatric chronic pain and disability included (a) child’s psychological characteristics: the child’s tendency to somaticize, depressed personality, and anxious personality; (b) parent’s psychological characteristics: parental emotional instability; (c) characteristics of the pain experience: suffering from constant pain and a family history of chronic pain; (d) characteristics of pain management: an excessive use of healthcare services for the child pain complaints, an inappropriate consumption of medicines to relieve the pain, doctor searching for the pain problem without finding anything wrong, and a low compliance with the healthcare
References
[1]
J. I. Gold, A. K. Yetwin, N. E. Mahrer et al., “Pediatric chronic pain and health-related quality of life,” Journal of Pediatric Nursing, vol. 24, no. 2, pp. 141–150, 2009.
[2]
A. L. Jordan, C. Eccleston, and M. Osborn, “Being a parent of the adolescent with complex chronic pain: an interpretative phenomenological analysis,” European Journal of Pain, vol. 11, no. 1, pp. 49–56, 2007.
[3]
R. Slover, G. L. Neuenkirchen, S. Olamikan, and S. Kent, “Chronic pediatric pain,” Advances in Pediatrics, vol. 57, no. 1, pp. 141–162, 2010.
[4]
G. Cucchiaro, “Pain in children,” in Biobehavioral Approaches to Pain, R. Moore, Ed., pp. 149–194, Springer, New York, NY, USA, 2009.
[5]
D. Maciver, D. Jones, and M. Nicol, “Parents' experiences of caring for a child with chronic pain,” Qualitative Health Research, vol. 20, no. 9, pp. 1272–1282, 2010.
[6]
J. A. M. Hunfeld, C. W. Perquin, A. A. J. M. Hazebroek-Kampschreur, J. Passchier, L. W. A. Van Suijlekom-Smit, and J. C. Van der Wouden, “Physically unexplained chronic pain and its impact on children and their families: the mother's perception,” Psychology and Psychotherapy, vol. 75, no. 3, pp. 251–260, 2002.
[7]
J. Miró, A. Huguet, and R. Nieto, “Predictive factors of chronic pediatric pain and disability: a delphi poll,” Journal of Pain, vol. 8, no. 10, pp. 774–792, 2007.
[8]
D. C. Turk and H. Flor, “Chronic pain: a biobehavioral perspective,” in Psychosocial Factors in Pain: Critical Perspectives, R. J. Gatchel and D. C. Turk, Eds., pp. 18–34, The Guilford Press, New York, NY, USA, 1999.
[9]
D. C. Turk and E. S. Monarch, “Biopsychosocial perspective on chronic pain,” in Psychological Approaches to Pain Management: A Practitioner’s Handbook, D. C. Turk and R. J. Gatchel, Eds., pp. 3–29, Guilford Press, New York, NY, USA, 2nd edition, 2002.
[10]
K. Kozlowska, D. Rose, R. Khan, S. Kram, L. Lane, and J. Collins, “A conceptual model and practice framework for managing chronic pain in children and adolescents,” Harvard Review of Psychiatry, vol. 16, no. 2, pp. 136–150, 2008.
[11]
B. D. Carter and B. M. Threlkeld, “Psychosocial perspectives in the treatment of pediatric chronic pain,” Pediatric Rheumatology, vol. 10, no. 1, p. 15, 2012.
[12]
J. W. Varni, “Pediatric pain: a decade biobehavioral perspective,” Behavioral Therapist, vol. 18, pp. 65–70, 1995.
[13]
J. W. Varni, M. A. Rapoff, S. A. Waldron, R. A. Gragg, B. H. Bernstein, and C. B. Lindsley, “Effects of perceived stress on pediatric chronic pain,” Journal of Behavioral Medicine, vol. 19, no. 6, pp. 515–528, 1996.
[14]
J. W. Varni, R. L. Blount, S. A. Waldron, and A. J. Smith, “Management of pain and distress,” in Handbook of Pediatric Psychology, M. C. Roberts, Ed., pp. 105–123, Guilford Press, New York, NY, USA, 2nd edition, 1995.
[15]
M. G. Sawyer, J. A. Carbone, J. N. Whitham et al., “The relationship between health-related quality of life, pain, and coping strategies in juvenile arthritis—a one year prospective study,” Quality of Life Research, vol. 14, no. 6, pp. 1585–1598, 2005.
[16]
K. S. White and A. D. Farrell, “Anxiety and psychosocial stress as predictors of headache and abdominal pain in urban early adolescents,” Journal of Pediatric Psychology, vol. 31, no. 6, pp. 582–596, 2006.
[17]
US Census Bureau, State & County QuickFacts: Alabama, 2009, http://quickfacts.census.gov/qfd/states/01000.html.
[18]
T. R. Vetter, “Assessment tools in pediatric chronic pain: reliability and validity,” in Handbook of Pediatric Chronic Pain: Current Science and Integrative Practice, B. C. McClain and S. Suresh, Eds., pp. 63–85, Springer, New York, NY, USA, 2011.
[19]
G. A. Walco, H. Rozelman, and D. A. Maroof, “The assessment and management of chronic and recurrent pain in adolescents,” in Behavioral Approaches to Chronic Disease in Adolescence, W. T. O'Donohue, Ed., pp. 163–175, Springer, New York, NY, USA, 2009.
[20]
J. W. Varni, M. A. Rapoff, S. A. Waldron, R. A. Gragg, B. H. Bernstein, and C. B. Lindsley, “Chronic pain and emotional distress in children and adolescents,” Journal of Developmental and Behavioral Pediatrics, vol. 17, no. 3, pp. 154–161, 1996.
[21]
L. L. Cohen, K. Lemanek, R. L. Blount et al., “Evidence-based assessment of pediatric pain,” Journal of Pediatric Psychology, vol. 33, no. 9, pp. 939–955, 2008.
[22]
L. S. Walker and J. W. Greene, “The functional disability inventory: measuring a neglected dimension of child health status,” Journal of Pediatric Psychology, vol. 16, no. 1, pp. 39–58, 1991.
[23]
H. Zhou, P. Roberts, and L. Horgan, “Association between self-report pain ratings of child and parent, child and nurse and parent and nurse dyads: meta-analysis,” Journal of Advanced Nursing, vol. 63, no. 4, pp. 334–342, 2008.
[24]
R. L. Claar and L. S. Walker, “Functional assessment of pediatric pain patients: psychometric properties of the functional disability inventory,” Pain, vol. 121, no. 1-2, pp. 77–84, 2006.
[25]
T. M. Palermo, A. C. Long, A. S. Lewandowski, D. Drotar, A. L. Quittner, and L. S. Walker, “Evidence-based assessment of health-related quality of life and functional impairment in pediatric psychology,” Journal of Pediatric Psychology, vol. 33, no. 9, pp. 983–996, 2008.
[26]
S. Kashikar-Zuck, S. R. Flowers, R. L. Claar et al., “Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain,” Pain, vol. 152, no. 7, pp. 1600–1607, 2011.
[27]
M. Kovacs, “Rating scales to assess depression in school-aged children,” Acta Paedopsychiatrica, vol. 46, no. 5-6, pp. 305–315, 1981.
[28]
M. Kovacs, “The Children's depression, inventory (CDI),” Psychopharmacology Bulletin, vol. 21, no. 4, pp. 995–998, 1985.
[29]
C. Eccleston, G. Crombez, A. Scotford, J. Clinch, and H. Connell, “Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents,” Pain, vol. 108, no. 3, pp. 221–229, 2004.
[30]
K. D. Rudolph and S. F. Lambet, “Child and adoescent depression,” in Assessment of Childhood Disorders, E. J. Mash and R. A. Barkley, Eds., pp. 213–252, Guilford Press, New York, NY, USA, 4th edition, 2007.
[31]
G. N. Holmbeck, A. W. Thill, P. Bachanas et al., “Evidence-based assessment in pediatric psychology: measures of psychosocial adjustment and psychopathology,” Journal of Pediatric Psychology, vol. 33, no. 9, pp. 958–980, 2008.
[32]
P. J. McGrath, G. A. Walco, D. C. Turk et al., “Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations,” Journal of Pain, vol. 9, no. 9, pp. 771–783, 2008.
[33]
S. Kashikar-Zuck, K. R. Goldschneider, S. W. Powers, M. H. Vaught, and A. D. Hershey, “Depression and functional disability in chronic pediatric pain,” Clinical Journal of Pain, vol. 17, no. 4, pp. 341–349, 2001.
[34]
C. R. Reynolds and B. O. Richmond, Revised Children's Manifest Anxiety Scale, Western Psychological Services, Los Angeles, Calif, USA, 2nd edition, 2008.
[35]
C. Eccleston, A. L. Jordan, and G. Crombez, “The impact of chronic pain on adolescents: a review of previously used measures,” Journal of Pediatric Psychology, vol. 31, no. 7, pp. 684–697, 2006.
[36]
M. A. Southam-Gerow and B. F. Chorpita, “Anxiety in children and adolescents,” in Assessment of Childhood Disorders, E. J. Mash and R. A. Barkley, Eds., pp. 347–397, Guilford Press, New York, NY, USA, 4th edition, 2007.
[37]
D. E. Logan, R. L. Claar, and L. Scharff, “Social desirability response bias and self-report of psychological distress in pediatric chronic pain patients,” Pain, vol. 136, no. 3, pp. 366–372, 2008.
[38]
G. J. Reid, C. A. Gilbert, and P. J. McGrath, “The pain coping questionnaire: preliminary validation,” Pain, vol. 76, no. 1-2, pp. 83–96, 1998.
[39]
M. A. Rapoff, “Pediatric measures of pain. The Pain Behavior Observation Method, Pain Coping Questionnaire (PCQ), and Pediatric Pain Questionnaire,” Arthritis and Rheumatism, vol. 49, no. 5, pp. S90–S95, 2003.
[40]
R. L. Blount, L. E. Simons, K. A. Devine et al., “Evidence-based assessment of coping and stress in pediatric psychology,” Journal of Pediatric Psychology, vol. 33, no. 9, pp. 1021–1045, 2008.
[41]
C. Hermann, J. Hohmeister, K. Zohsel, F. Ebinger, and H. Flor, “The assessment of pain coping and pain-related cognitions in children and adolescents: current methods and further development,” Journal of Pain, vol. 8, no. 10, pp. 802–813, 2007.
[42]
G. J. Reid, B. A. Lang, and P. J. McGrath, “Primary juvenile fibromyalgia: psychological adjustment, family functioning, coping, and functional disability,” Arthritis and Rheumatism, vol. 40, no. 4, pp. 752–760, 1997.
[43]
G. J. Reid, P. J. McGrath, and B. A. Lang, “Parent-child interactions among children with juvenile fibromyalgia, arthritis, and healthy controls,” Pain, vol. 113, no. 1-2, pp. 201–210, 2005.
[44]
S. Kashikar-Zuck, M. H. Vaught, K. R. Goldschneider, T. B. Graham, and J. C. Miller, “Depression, coping, and functional disability in juvenile primary fibromyalgia syndrome,” Journal of Pain, vol. 3, no. 5, pp. 412–419, 2002.
[45]
M. Thastum, T. Herlin, and R. Zachariae, “Relationship of pain-coping strategies and pain-specific beliefs to pain experience in children with juvenile idiopathic arthritis,” Arthritis Care and Research, vol. 53, no. 2, pp. 178–184, 2005.
[46]
M. Thastum, R. Zachariae, and T. Herlin, “Pain experience and pain coping strategies in children with juvenile idiopathic arthritis,” Journal of Rheumatology, vol. 28, no. 5, pp. 1091–1098, 2001.
[47]
C. S. Cleeland, “Measurement of pain by subjective report,” in Issues in Pain Measurement, C. R. Chapman and J. D. Loeser, Eds., vol. 12, pp. 391–403, Raven Press, New York, NY, USA, 1989.
[48]
G. Tan, M. P. Jensen, J. I. Thornby, and B. F. Shanti, “Validation of the brief pain inventory for chronic nonmalignant pain,” Journal of Pain, vol. 5, no. 2, pp. 133–137, 2004.
[49]
C. Cleeland, “The brief pain inventory user guide,” 2009, http://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/symptom-research/symptom-assessment-tools/BPI_UserGuide.pdf.
[50]
A. Huguet, J. N. Stinson, and P. J. McGrath, “Measurement of self-reported pain intensity in children and adolescents,” Journal of Psychosomatic Research, vol. 68, no. 4, pp. 329–336, 2010.
[51]
A. T. Beck, C. H. Ward, M. Mendelson, J. Mock, and J. Erbaugh, “An inventory for measuring depression,” Archives of General Psychiatry, vol. 4, pp. 561–571, 1961.
[52]
A. T. Beck, R. A. Steer, R. Ball, and W. F. Ranieri, “Comparison of Beck depression inventories -IA and -II in psychiatric outpatients,” Journal of Personality Assessment, vol. 67, no. 3, pp. 588–597, 1996.
[53]
P. Richter, J. Werner, A. Heerlein, A. Kraus, and H. Sauer, “On the validity of the beck depression inventory. A review,” Psychopathology, vol. 31, no. 3, pp. 160–168, 1998.
[54]
R. Uher, A. Farmer, W. Maier et al., “Measuring depression: comparison and integration of three scales in the GENDEP study,” Psychological Medicine, vol. 38, no. 2, pp. 289–300, 2008.
[55]
P. A. Lowe and C. R. Reynolds, “Psychometric analyses of the Adult Manifest Anxiety Scale-Adult version among young and middle-aged adults,” Educational and Psychological Measurement, vol. 64, no. 4, pp. 661–681, 2004.
[56]
C. Reynolds, B. Richmond, and P. Lowe, The Adult Manifest Anxiety Scale Manual, Western Psychological Services, Torrance, Calif, USA, 2003.
[57]
B. H. Loyd and R. R. Abidin, “Revision of the parenting stress index,” Journal of Pediatric Psychology, vol. 10, no. 2, pp. 169–177, 1985.
[58]
M. E. Haskett, L. S. Ahern, C. S. Ward, and J. C. Allaire, “Factor structure and validity of the parenting stress index-short form,” Journal of Clinical Child and Adolescent Psychology, vol. 35, no. 2, pp. 302–312, 2006.
[59]
R. R. Abidin, Parenting Stress Index (PSI) Manual, Pediatric Psychology Press, Charlottesville, Va, USA, 3rd edition, 1995.
[60]
S. Evans, R. Taub, J. C. I. Tsao, M. Meldrum, and L. K. Zeltzer, “Sociodemographic factors in a pediatric chronic pain clinic: the roles of age, sex and minority status in pain and health characteristics,” Journal of Pain Management, vol. 3, no. 3, pp. 273–281, 2010.
[61]
A. Gelman and J. Hill, “Missing-data imputation,” in Data Analysis Using Regression and Multilevel/Hierarchical Models, pp. 529–544, Cambridge University Press, Cambridge, UK, 2006.
[62]
A. Szabova, J. Rose, and K. Goldschneider, “A guide to diagnoses, indications, and contraindications for interventions in pediatric chronic pain,” International Anesthesiology Clinics, vol. 50, no. 4, pp. 109–119, 2012.
[63]
B. Bursch, G. A. Walco, and L. Zeltzer, “Clinical assessment and management of chronic pain and pain-associated disability syndrome,” Journal of Developmental and Behavioral Pediatrics, vol. 19, no. 1, pp. 45–53, 1998.
[64]
L. Zeltzer, B. Bursch, and G. Walco, “Pain responsiveness and chronic pain: a psychobiological perspective,” Journal of Developmental and Behavioral Pediatrics, vol. 18, no. 6, pp. 413–422, 1997.
[65]
L. K. Zeltzer, J. P. Bush, E. Chen, and A. Riveral, “A psychobiologic approach to pediatric pain–part II. Prevention and treatment,” Current Problems in Pediatric and Adolescent Health Care, vol. 27, no. 7, pp. 264–284, 1997.
[66]
L. K. Zeltzer, J. P. Bush, E. Chen, and A. Riveral, “A psychobiologic approach to pediatric pain—part I. History, physiology, and assessment strategies,” Current Problems in Pediatric and Adolescent Health Care, vol. 27, no. 6, pp. 225–253, 1997.
[67]
T. R. Vetter, “Pediatric chronic pain,” in Handbook of Pain and Palliative Care, R. J. Moore, Ed., pp. 147–168, Springer, New York, NY, USA, 2012.
[68]
A. Lynch-Jordan and S. Kashikar-Zuck, “Chronic pain in adolescents: physiological and psychological bases for pain,” in Handbook of Adolescent Health Psychology, W. T. O'Donohue, L. T. Benuto, and L. Woodward Tolle, Eds., pp. 705–721, Springer, New York, NY, USA, 2013.
[69]
S. Yazdani and L. Zeltzer, “Treatment of chronic pain in children and adolescents,” Pain Management, vol. 3, no. 4, pp. 303–314, 2013.
[70]
T. M. Palermo and C. T. Chambers, “Parent and family factors in pediatric chronic pain and disability: an integrative approach,” Pain, vol. 119, no. 1–3, pp. 1–4, 2005.
[71]
D. E. Logan and L. Scharff, “Relationships between family and parent characteristics and functional abilities in children with recurrent pain syndromes: an investigation of moderating effects on the pathway from pain to disability,” Journal of Pediatric Psychology, vol. 30, no. 8, pp. 698–707, 2005.
[72]
D. E. Logan, J. W. Guite, D. D. Sherry, and J. B. Rose, “Adolescent-parent relationships in the context of adolescent chronic pain conditions,” Clinical Journal of Pain, vol. 22, no. 6, pp. 576–583, 2006.
[73]
T. M. Palermo and C. Eccleston, “Parents of children and adolescents with chronic pain,” Pain, vol. 146, no. 1-2, pp. 15–17, 2009.
[74]
L. E. Simons, R. L. Claar, and D. L. Logan, “Chronic pain in adolescence: parental responses, adolescent coping, and their impact on adolescent's pain behaviors,” Journal of Pediatric Psychology, vol. 33, no. 8, pp. 894–904, 2008.
[75]
B. Kr？ner-Herwig, L. Morris, and M. Heinrich, “Biopsychosocial correlates of headache: what predicts pediatric headache occurrence?” Headache, vol. 48, no. 4, pp. 529–544, 2008.
[76]
S. Kashikar-Zuck, A. M. Lynch, S. Slater, T. B. Graham, N. F. Swain, and R. B. Noll, “Family factors, emotional functioning, and functional impairment in juvenile fibromyalgia syndrome,” Arthritis Care and Research, vol. 59, no. 10, pp. 1392–1398, 2008.
[77]
T. M. Palermo and A. Holley, “The importance of the family environment in pediatric chronic pain,” Archives of Pediatrics and Adolescent Medicine, 2012.
[78]
L. Scharff, N. Langan, N. Rotter et al., “Psychological, behavioral, and family characteristics of pediatric patients with chronic pain: a 1-year retrospective study and cluster analysis,” Clinical Journal of Pain, vol. 21, no. 5, pp. 432–438, 2005.
[79]
A. S. Lewandowski, T. M. Palermo, J. Stinson, S. Handley, and C. T. Chambers, “Systematic review of family functioning in families of children and adolescents with chronic pain,” Journal of Pain, vol. 11, no. 11, pp. 1027–1038, 2010.
[80]
N. E. Mahrer, Z. Montano, and J. I. Gold, “Relations between anxiety sensitivity, somatization, and health-related quality of life in children with chronic pain,” Journal of Pediatric Psychology, vol. 37, no. 7, pp. 808–816, 2012.
[81]
G. B. Hoftun, P. R. Romundstad, and M. Rygg, “Association of parental chronic pain with chronic pain in the adolescent and young adult: family linkage data from the HUNT study,” Archives of Pediatrics and Adolescent Medicine, vol. 167, no. 1, pp. 61–69, 2013.
[82]
C. Eccleston, T. M. Palermo, A. C. D. C. Williams, et al., “Psychological therapies for the management of chronic and recurrent pain in children and adolescents,” Cochrane Database of Systematic Reviews, no. 12, Article ID CD003968, 2012.
[83]
C. Eccleston, T. M. Palermo, A. C. D. C. Williams, A. Lewandowski, and S. Morley, “Psychological therapies for the management of chronic and recurrent pain in children and adolescents,” Cochrane Database of Systematic Reviews, no. 2, Article ID CD003968, 2009.
[84]
R. L. Claar and L. E. Simons, “Adolescents' pain coping profiles: expectations for treatment, functional outcomes and adherence to psychological treatment recommendations,” Pain Research and Management, vol. 16, no. 3, pp. 192–196, 2011.
[85]
D. E. Logan, C. Conroy, C. B. Sieberg, and L. E. Simons, “Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program,” Pain, vol. 153, no. 9, pp. 1863–1870, 2012.
[86]
L. E. Simons, D. E. Logan, L. Chastain, and M. Cerullo, “Engagement in multidisciplinary interventions for pediatric chronic pain: parental expectations, barriers, and child outcomes,” Clinical Journal of Pain, vol. 26, no. 4, pp. 291–299, 2010.
[87]
S. King, C. T. Chambers, A. Huguet et al., “The epidemiology of chronic pain in children and adolescents revisited: a systematic review,” Pain, vol. 152, no. 12, pp. 2729–2738, 2011.
[88]
C. W. Perquin, A. A. J. M. Hazebroek-Kampschreur, J. A. M. Hunfeld et al., “Pain in children and adolescents: a common experience,” Pain, vol. 87, no. 1, pp. 51–58, 2000.
[89]
C. W. Perquin, J. A. M. Hunfeld, A. A. Hazebroek-Kampschreur et al., “The natural course of chronic benign pain in childhood and adolescence: a two-year population-based follow-up study,” European Journal of Pain, vol. 7, no. 6, pp. 551–559, 2003.
[90]
J. A. M. Hunfeld, C. W. Perquin, W. Bertina et al., “Stability of pain parameters and pain-related quality of life in adolescents with persistent pain: a three-year follow-up,” Clinical Journal of Pain, vol. 18, no. 2, pp. 99–106, 2002.
[91]
C. L. Von Baeyer, “Interpreting the high prevalence of pediatric chronic pain revealed in community surveys,” Pain, vol. 152, no. 12, pp. 2683–2684, 2011.
[92]
G. B. Hoftun, P. R. Romundstad, J.-A. Zwart, and M. Rygg, “Chronic idiopathic pain in adolescence—high prevalence and disability: the young HUNT study 2008,” Pain, vol. 152, no. 10, pp. 2259–2266, 2011.
[93]
T. Hechler, A. Martinl, M. Blankenburgl, et al., “Specialized multimodal outpatient treatment for children with chronic pain: treatment pathways and long-term outcome,” European Journal of Pain, vol. 15, no. 9, pp. 976–984, 2011.
[94]
T. Hechler, M. Blankenburg, M. Dobe, J. Kosfelder, B. Hübner, and B. Zernikow, “Effectiveness of a multimodal inpatient treatment for pediatric chronic pain: a comparison between children and adolescents,” European Journal of Pain, vol. 14, no. 1, pp. 97.e1–97.e9, 2010.
[95]
T. Hechler, M. Dobe, J. Kosfelder et al., “Effectiveness of a 3-week multimodal inpatient pain treatment for adolescents suffering from chronic pain statistical and clinical significance,” Clinical Journal of Pain, vol. 25, no. 2, pp. 156–166, 2009.
[96]
A. Gupta, N. Weber, and M. Duwell, “Implementing a public health approach to the management of chronic pain in the USA,” Pain Management, vol. 3, no. 4, pp. 315–319, 2013.
[97]
J. W. Guite, D. E. Logan, E. A. Ely, and S. J. Weisman, “The ripple effect: systems-level interventions to ameliorate pediatric pain,” Pain Management, vol. 2, no. 6, pp. 593–601, 2012.
[98]
D. E. Logan, L. E. Simons, and E. A. Carpino, “Too sick for school? Parent influences on school functioning among children with chronic pain,” Pain, vol. 153, no. 2, pp. 437–443, 2012.
[99]
D. E. Logan and J. A. Curran, “Adolescent chronic pain problems in the school setting: exploring the experiences and beliefs of selected school personnel through focus group methodology,” Journal of Adolescent Health, vol. 37, no. 4, pp. 281–288, 2005.
[100]
J. Boutilier and S. King, “Missed opportunities: school as an undervalued site for effective pain management,” Pediatric Pain Letter, vol. 15, no. 1, pp. 9–15, 2013.
[101]
M. A. Fortier, C. T. Anderson, and Z. N. Kain, “Ethnicity matters in the assessment and treatment of children's pain,” Pediatrics, vol. 124, no. 1, pp. 378–380, 2009.
[102]
D. E. Logan, L. E. Simons, and K. J. Kaczynski, “School functioning in adolescents with chronic pain: the role of depressive symptoms in school impairment,” Journal of Pediatric Psychology, vol. 34, no. 8, pp. 882–892, 2009.
[103]
T. R. Vetter, “A clinical profile of a cohort of patients referred to an anesthesiology-based pediatric chronic pain medicine program,” Anesthesia and Analgesia, vol. 106, no. 3, pp. 786–794, 2008.
