Fear-avoidance in adolescence with chronic pain - Society of ...

Anna C. Wilson, PhD
Assistant Professor
Anesthesiology and
Perioperative Medicine

Overview
Background and theory
Chronic pain in adolescence
Fear-avoidance beliefs in adolescence
Parent factors in adolescent chronic pain
Aims and methods of current study
Results and conclusions
Future directions

Chronic and Recurrent Pain is a
Significant Pediatric Health Problem
20-40% of children and adolescents in community
samples experience persistent pain (Perquin et al., 2000;
Stanford et al., 2008)
More severe persistent pain in 8%
Pain accompanied by moderate to severe disability in
5% (Huguet & Miro, 2008)
Most common locations: head, abdomen, limbs
Multiple pains are common
More commonly reported in girls than boys
Peak incidence: ages 14-15 years (Stanford et al., 2008)
Comorbid anxiety and depression common

Fear-avoidance beliefs
Cognitions (thoughts and beliefs) about pain being
linked to physical activity or movement
“Physical activity makes my pain worse” or “I cannot
do movements that make my pain worse”
Fear-avoidance beliefs are related to higher levels of
pain and disability: Well-supported in adults with
chronic low back pain (e.g., Jensen et al., 2001; Poiraudeau et
al., 2006)
Few measures of fear-avoidance beliefs that have
been used in children and adolescents

Vlaeyen & Linton, 2000

Cognitions and avoidance behaviors develop within
a family context
Parental responses to child pain may influence
cognitions about pain, including fear-avoidance
Children and parents play a role in appraising or
judging pain to be more or less threatening

Parent
behaviors
Vlaeyen & Linton, 2000

Specific parent responses to child pain behaviors
may serve to inadvertently reinforce or encourage
pain behaviors
Protective or solicitous responses to child pain
associated with higher pain intensity and disability
(Claar et al., Pain, 2008; Chambers et al., J Ped Psych, 2002)
Behaviors include:
Frequent attending to pain symptoms
Allowing activity withdrawal from less preferred
activities (e.g., chores, school attendance)
Giving special privileges or rewards

1. Describe fear-avoidance beliefs and correlates in
a sample of adolescents with chronic pain
2. Examine fear-avoidance beliefs and depressive
symptoms as predictors of disability
3. Test fear-avoidance beliefs as a potential
moderator and mediator of parental protectiveness

n = 42 adolescents with chronic pain (pain 1x/wk or
more, present for >3 months), recruited through
outpatient pediatric specialty care clinics at a university
children’s hospital (pain clinic, gastroenterology,
neurology)
Abdominal pain (n = 23)
Headache (n = 11)
Musculoskeletal pain (n = 8)
11-17 years old, Mean age 14.90 (SD = 2.11)
73.8% female
88.1% Caucasian; 7.1% Hispanic;

Pain characteristics
Usual pain intensity, 0-10 NRS
Pain frequency in last 3 months
Fear and Avoidance Beliefs Questionnaire –
Physical Activity 5-item subscale (FABQ-PA;
Waddell et al., 1993)
Depressive Symptoms: 10-item Major Depressive
Disorder subscale of Revised Children’s Anxiety and
Depression Scale (RCADS; Chorpita et al., 2005)

Parental Protectiveness: Adult Responses to
Children’s Symptoms 15-item Protect subscale (Van
Slyke & Walker, 2006)
Item examples: “When your child has aches and
pains, how often do you…pay more attention than
usual to your child; give your child special privileges;
bring your child special treats or little gifts”
Physical Activity Limitations: Child Activity
Limitations Interview (CALI; Palermo et al., 2004)
Assesses difficulty doing physical and routine
activities because of pain

Variable
M (SD)
Pain Intensity (0-10) 6.57 (1.74)
Depressive Symptoms 55.98 (13.50)
Disability (CALI):
Adolescent Report
Disability (CALI):
Parent report
19.86 (6.19)
21.05 (6.09)
Parental Protectiveness 1.79 (.51)

Adolescents reported moderate levels of fearavoidance
(FABQ-PA, M = 11.52)
Slightly lower than samples of adults with chronic low
back pain (FABQ-PA, M = 14.0-14.2)
FABQ-PA had slightly low internal consistency:
Chronbach’s alpha = .69

As hypothesized, the FABQ-PA was significantly
correlated with:
Parent-report disability (r = .42, p < .01)
Child-report disability (r = .44, p < .01)
Parental protectiveness (r = .47, p < .01)
FABQ-PA was not related to:
Depressive symptoms
Usual pain intensity
Pain location

CALI: Child report CALI: Parent report
∆R 2
β at final
step ∆R 2 β at final
step
Step 1:
.38***
.08
Household Income
Usual Pain Intensity
-.23
.47***
.09
.23
Step 2:
.00
.02
Depressive Symptoms
-.03
.05
Step 3:
.16**
.17**
Fear-avoidance Beliefs
.42**
43**
Total R 2 : .54*** .27*
* p < .05, ** p < .01, *** p < .001

Tested two models: fear-avoidance as a moderator
and as a mediator
Fear-Avoidance
Beliefs
Parental
Protectiveness
Child Activity
Limitations

Tested two models: fear-avoidance as a moderator
and as a mediator
Fear-Avoidance
Beliefs
Parental
Protectiveness
Child Activity
Limitations

Tested two models: fear-avoidance as a moderator
and as a mediator
Fear-Avoidance
Beliefs
Parental
Protectiveness
Child Activity
Limitations

Results: No support found for moderation model
The association between protectiveness and activity
limitations is not altered by child fear-avoidance
Fear-Avoidance
Beliefs
n.s.
Parental
Protectiveness
.29*
Child Activity
Limitations

Support for mediation model (Sobel z = 1.97, p = .05)
Fear-avoidance beliefs may serve as one pathway
through which parental protectiveness influences
activity limitations.
Fear-Avoidance
Beliefs
.51** .42*/.40*
Parental
Protectiveness
.29*/.05
Child Activity
Limitations:
Adol. report

As in adult chronic pain populations, fear-avoidance
beliefs play an important role in adolescent disability
Fear-avoidance beliefs seem to be important for
adolescents with a variety of pain problems
Fear-avoidance beliefs may be less tied to
depressive symptoms and pain intensity in
adolescents than in adults
Parental behaviors in response to adolescent pain
may influence adolescent cognitions and fears which
in turn increase activity limitations

Strengths:
Associations demonstrated across reporters
(adolescent and parent)
Fear-avoidance beliefs examined in a mixed pain
problem sample (not only back or
musculoskeletal pain)
Limitations:
Cross-sectional study limits our ability to draw
conclusions about the direction of these effects
Relatively small sample limited power to detect
moderation
Did not examine anxiety symptoms

Examine role of parental behaviors and cognitions in
shaping adolescent cognitions over time
Examine additional parental behaviors and beliefs:
Parent catastrophizing about their child’s pain
Parent modeling of pain behaviors
Enhance understanding of how adolescent fearavoidance
beliefs relate to other pain-related
cognitions such as catastrophizing
Both parent behaviors and adolescent fearavoidance
cognitions may be potential intervention
targets

Pediatric Health Pilot Project (PI: Wilson): Oregon
Clinical and Translational Research Institute (OCTRI),
grant # UL1 RR024140 from the National Center for
Research Resources (NCRR), a component of the
National Institutes of Health (NIH), and NIH Roadmap for
Medical Research
Colleagues and collaborators:
Tonya Palermo, PhD
Amy Lewandowski, PhD
Caitlin Murray, BA