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Poor functional outcomes in pediatric chronic pain – what’s catastrophizing got to do with it?



The 2024 Global Year will examine what is known about sex and gender differences in pain perception and modulation and address sex-and gender-related disparities in both the research and treatment of pain.

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Catastrophizing has long been implicated in many poor outcomes in chronic pain-related conditions in both adults and children [3,4,11,12,14,15,18,20,22,24,29]. Scholars have called for interventions to reduce catastrophizing in children with chronic pain with the hope of improving outcomes [1,16,36]. However, important unanswered questions remain such as: How strong and how consistent are the associations between catastrophizing, pain, and various functional outcomes? Finding answers to these questions may provide critical information that will optimize the distribution of limited clinical and financial resources to those likely to benefit.

We sought answers to these questions by systematically integrating and meta-analyzing existing studies that examined the relationships between catastrophizing, pain, and functional outcomes in pediatric pain. Included studies, published by March 27th, 2017, were identified in PsychInfo, MEDLINE, PubMed, and Embase. A total of 111 effect sizes from 28 cross-sectional studies were included to assess the strength and consistency of the relationship, prior to intervention, between pain catastrophizing and the following: 1) pain intensity, 2) physical functioning, 3) anxiety, 4) depression, and 5) quality of life. Additionally, sex (i.e., percentage of the sample that was female), average pain duration, pain diagnosis, and pain catastrophizing measures were investigated as moderators of the relationship between catastrophizing and pain and functional outcomes.

Our two primary findings were: 1) catastrophizing demonstrated a strong relationship with anxiety, depression, and quality of life, and 2) catastrophizing demonstrated a moderate relationship with physical functioning and pain intensity. All examined relationships were robust against publication bias and study quality variation. Additionally, sample sex, average pain duration, pain diagnosis, and pain catastrophizing measure did not function as moderators of the relationship between catastrophizing, pain, and functional outcomes [21].

Anxiety and depression demonstrated the strongest associations with catastrophizing. Individuals who catastrophize about their pain may be more likely to have general (i.e., not pain-specific) maladaptive thinking styles, thereby catastrophizing about non-pain specific situations. Previous studies show that maladaptive thinking styles are common among individuals with anxiety and depression [5,10,30]. The strong association may also be due to conceptual overlap among catastrophizing, anxiety, and depression. Based on the strong association between catastrophizing, anxiety and depression, it makes intuitive sense that improving catastrophic thinking about pain would alleviate anxiety and depressive symptoms. However, this reasoning has not been supported by evidence – specifically, changes in catastrophizing do not explain changes in depression symptoms following psychological treatment [17,35]. The mechanism by which catastrophizing is closely linked to anxiety and depression levels is yet to be revealed.

Catastrophizing was moderately related to physical functioning in our study. The fear-avoidance model provides one way to make sense of this finding [2,25,28]. In this model, catastrophizing about pain leads to fear of future pain, which then leads to activity avoidance aimed at preventing further pain. Ultimately, this cycle is thought to result in deconditioning of the body and a consequent self-perpetuating feedback loop [28]. The biopsychomotor model provides an alternative way to make sense of this finding [31]. The protective and social-relational aspects of this model seem particularly relevant. Children who catastrophize about their pain may demonstrate more protective pain behaviors (e.g., guarding and bracing); these behaviors have been linked to decreased physical functioning [32]. Additionally, these protective pain behaviors may elicit solicitous responses (“You look like you are hurting. Take it easy”) from parents, teachers, and peers, which reinforce physical disuse and subsequently worsen functional disability.

Quality of life, most commonly measured with the PedsQL, demonstrated a strong relationship with catastrophizing. One explanation for this strong association is the overlap between the domains (i.e., physical, emotional, social, and school domains) the PedsQL covers and our other outcomes of interest (i.e., physical functioning, anxiety, and depression) [33]. However, what remains to be determined is how much of the strong association between catastrophizing and quality of life is specific to social or school functioning – although children with chronic pain often report deficits in these domains, they have received much less attention in the literature [9,23].

Surprisingly, catastrophizing and pain intensity had the weakest relationship compared to other outcomes. While studies have posited both physiological and neural explanations for the association between catastrophizing and pain, most have included only adults [6,13,26,27]. However, the results of a recent study in children with pediatric complex regional pain syndrome suggest that pain catastrophizing may predispose children and adolescents to develop chronic pain, experience greater pain intensity when they do have pain, and engage in particular behavioral and emotional responses to that pain [7]. While contrary to the current findings, the strength of the relationship between catastrophizing and pain intensity may vary across pain diagnoses. In the current study, pain diagnosis was evaluated as a moderator of these relationships. However, sample sizes within each pain diagnosis were small.

Take-home message: catastrophizing has consistent and strong-to-moderate associations with poor functional outcomes in children with chronic pain. Cognitive-behavioral, relaxation, and acceptance-based interventions have demonstrated small effects in reducing pain catastrophizing in children [8,19,34]. Our meta-analytic results provide additional support for their use. Furthermore, our results suggest these interventions may lead to particular improvements in anxiety, depression, and overall QOL. Several important questions remain for future research – among them: 1) how long do these treatment effects last, and 2) what are their underlying mechanisms of action. Answers to these questions would provide insights for the further refinement of existing treatments and the formulation of new treatments to target catastrophic thinking and improve the function of children with pain.

About Megan M. Miller

Megan is a doctoral student in the Clinical Psychology PhD program (health psychology specialty) and a member of the Pain Research Laboratory at IUPUI. Her emerging program of research seeks to better understand: 1) psychosocial factors (e.g., pain-related injustice, coping, and resilience) that influence pain and functioning in children/adolescents with pain, and 2) sociocultural factors that facilitate and impede the delivery of guideline-concordant care for children/adolescents with pain. Her first line of research focuses on pain-related injustice appraisals and their relationship to functional outcomes in pediatric pain patients. She is also examining how caregiver factors, such as injustice appraisals and catastrophizing, influence children’s pain experience. Regarding her second line of research, she is using Virtual Human patients to examine how provider bias, provider empathy, and pediatric patient and parent characteristics (e.g., race, gender, and SES) individually and interactively affect pain care. In her spare time she dabbles in photography and confectionary creations. Her joys in life include spending time with her doggies, good music, great food, and tasty beverages.


[1] American Pain Society. Pediatric chronic pain: A position statement for the American Pain Society. American Pain Society Bulletin 2001 (Jan/Feb):10-12.

[2] Asmundson GJ, Noel M, Petter M, Parkerson HA. Pediatric fear-avoidance model of chronic pain: Foundation, application and future directions. Pain Res Manag 2012;17:397-405.

[3] Becker N, Thomsen AB, Olsen AK, Sjøgren P, Bech P, Eriksen,J. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain 1998;73:393-400.

[4] Brown GK. A causal analysis of chronic pain and depression. J Abnorm Psychol 1990;99: 127.

[5] Carleton RN, Sharpe D, Asmundson GJ. Anxiety sensitivity and intolerance of uncertainty: requisites of the fundamental fears?. Behav Res Ther 2007;45:2307-2316.

[6] Edwards RR, Kronfli T, Haythornthwaite JA, Smith MT, McGuire L, Page GG. Association of catastrophizing with interleukin-6 responses to acute pain. Pain 2008;140:135-144.

[7] Erpelding N, Simons L, Lebel A, Serrano P, Pielech M, Prabhu S, Becerra L, Borsook D. Rapid treatment-induced brain changes in pediatric CRPS. Brain Struct Funct 2016;221:1095-1111.

[8] Fisher E, Heathcote L, Palermo TM, Williams ACDC, Lau J, Eccleston C. Systematic review and meta-analysis of psychological therapies for children with chronic pain.J Pediatr Psychol 2014;39:763-782.

[9] Forgeron PA, King S, Stinson JN, McGrath PJ, MacDonald AJ, Chambers CT. Social functioning and peer relationships in children and adolescents with chronic pain: A systematic review. Pain Res Manag 2010;15:27-41.

[10] Garnefski N, Kraaij V. Relationships between cognitive emotion regulation strategies and depressive symptoms: A comparative study of five specific samples. Pers Individ Dif 2006:40:1659-1669.

[11] Gauntlett-Gilbert J, Eccleston C. Disability in adolescents with chronic pain: Patterns and predictors across different domains of functioning. Pain 2007;131:132-141.

[12] Huguet A, Miró J. The severity of chronic pediatric pain: An epidemiological study. J Pain 2008;9:226–36.

[13] Johansson AC, Gunnarsson LG, Linton SJ, Bergkvist L, Stridsberg M, Nilsson O, Cornefjord M. Pain, disability and coping reflected in the diurnal cortisol variability in patients scheduled for lumbar disc surgery. Eur J Pain 2008;12:633-640.

[14] Kashikar-Zuck S, Flowers SR, Claar RL, Guite JW, Logan DE, Lynch-Jordan AM, Palermo TM, Wilson AC. Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain. Pain 2011;152:1600-1607.

[15] Kashikar-Zuck S, Goldschneider KR, Powers SW, Vaught MH, Hershey AD. Depression and functional disability in chronic pediatric pain. Clin J Pain 2001;17:341-349.

[16] Kashikar-Zuck S, Ting TV, Arnold LM, Bean J, Powers SW, Graham TB, Passo MD, Schikler KN, Hashkes PJ, Spalding S, Lynch-Jordan AM, Banez G, Richards MM, Lovell DJ. Cognitive behavioral therapy for the treatment of juvenile fibromyalgia: A multisite, single-blind, randomized, controlled clinical trial. Arthritis Rheum 2012;64:297-305.

[17] Kashikar-Zuck S, Sil S, Lynch-Jordan AM, Ting TV, Peugh J, Schikler KN, Hashkes PJ, Arnold LM, Passo M, Richards MM, Powers SW, Lovell DJ. Changes in pain coping, catastrophizing, and coping efficacy after cognitive-behavioral therapy in children and adolescents with juvenile fibromyalgia. J Pain 2013;14:492-501.

[18] Logan DE, Scharff L. 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. J Pediatr Psychol 2005;30:698-707.

[19] Lonergan A. The effectiveness of cognitive behavioural therapy for pain in childhood and adolescence: a meta-analytic review.Ir J Psychol Med 2016;33:251-264.

[20] McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: An examination in a nationally representative sample. Pain 2003;106:127-133.

[21] Miller MM, Meints SM, Hirsh AT. Catastrophizing, pain, and functional outcomes for children with chronic pain: A meta-analytic review. Pain 2018;159: 2442-2460.

[22] Paananen M, Taimela S, Auvinen J, Tammelin T, Zitting P, Karppinen J. Impact of self-reported musculoskeletal pain on health-related quality of life among young adults. Pain Med 2011;12:9-17.

[23] Palermo TM. Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature. J Dev Behav Pediatr 2000;21:58-69.

[24] Peterson CC, Palermo TM. Parental reinforcement of recurrent pain: The moderating impact of child depression and anxiety on functional disability. J Pediatr Psychol 2004;29:331-341.

[25] Pincus T, Smeets RJ, Simmonds MJ, Sullivan MJ. The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin J Pain 2010;26:739-746.

[26] Quartana PJ, Burns JW, Lofland KR. Attentional strategy moderates effects of pain catastrophizing on symptom-specific physiological responses in chronic low back pain patients. J Behav Med 2007;30:221-231.

[27] Seminowicz DA, Davis KD. Cortical responses to pain in healthy individuals depends on pain catastrophizing. Pain 2006;120:297-306.

[28] Simons LE, Kaczynski KJ. The Fear Avoidance model of chronic pain: examination for pediatric application. J Pain 2012;13:827-835.

[29] Skevington SM. Investigating the relationship between pain and discomfort and quality of life, using the WHOQOL. Pain 1998;76:395-406.

[30] Starcevic V, Berle D. Cognitive specificity of anxiety disorders: a review of selected key constructs. Depress and Anxiety 2006;23:51-61.

[31] Sullivan MJ. Toward a biopsychomotor conceptualization of pain: implications for research and intervention. Clin J Pain 2008;24:281-290.

[32] Sullivan MJ, Thibault P, Savard A, Catchlove R, Kozey J, Stanish WD. The influence of communication goals and physical demands on different dimensions of pain behavior. Pain 2006;125:270-277.

[33] Varni JW, Burwinkle TM, Seid M, Skarr D. The PedsQL™* 4.0 as a pediatric population health measure: feasibility, reliability, and validity. Ambul Pediatr 2003;3:329-341.

[34] Wicksell RK, Melin L, Lekander M, Olsson GL Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain–a randomized controlled trial. Pain 2009;141:248-257.

[35] Wicksell RK, Olsson GL, Hayes SC. Mediators of change in acceptance and commitment therapy for pediatric chronic pain. Pain 2011;152:2792-2801.

[36] Zeltzer LK, Tsao JC, Bursch B, Myers CD. Introduction to the special issue on pain: From pain to pain-associated disability syndrome. J Pediatr Psychol 2006;31:661-666.

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