Chronic pain during childhood and adolescence can lead to persistent pain problems and mental health disorders into adulthood. Posttraumatic stress disorders and depressive and anxiety disorders are mental health conditions that co-occur at high rates in both adolescent and adult samples, and are linked to heightened impairment and disability. Comorbid chronic pain and psychopathology has been explained by the presence of shared neurobiology and mutually maintaining cognitive-affective and behavioral factors that lead to the development and/or maintenance of both conditions. Particularly within the pediatric chronic pain population, these factors are embedded within the broader context of the parent–child relationship. In this review, we will explore the epidemiology of, and current working models explaining, these comorbidities. Particular emphasis will be made on shared neurobiological mechanisms, given that the majority of previous research to date has centered on cognitive, affective, and behavioral mechanisms. Parental contributions to co-occurring chronic pain and psychopathology in childhood and adolescence will be discussed. Moreover, we will review current treatment recommendations and future directions for both research and practice. We argue that the integration of biological and behavioral approaches will be critical to sufficiently address why these comorbidities exist and how they can best be targeted in treatment.

Background Pediatric chronic pain often emerges in adolescence and cooccurs with internalizing mental health issues and sleep impairments. Emerging evidence suggests that sleep problems may precede the onset of chronic pain as well as anxiety and depression. Studies conducted in pediatric populations with pain-related chronic illnesses suggest that internalizing mental health symptoms may mediate the sleep-pain relationship; however, this has not been examined in youth with primary pain disorders. Objective To examine whether anxiety and depressive symptoms mediated relationships between sleep quality and pain outcomes among youth with chronic pain. Methods Participants included 147 youth (66.7% female) aged 8–18 years who were referred to a tertiary-level chronic pain program. At intake, the youth completed psychometrically sound measures of sleep quality, pain intensity, pain interference, and anxiety and depressive symptoms. Results As hypothesized, poor sleep quality was associated with increased pain intensity and pain interference, and anxiety and depressive symptoms mediated these sleep-pain relationships. Discussion For youth with chronic pain, poor sleep quality may worsen pain through alterations in mood and anxiety; however, prospective research using objective measures is needed. Future research should examine whether targeting sleep and internalizing mental health symptoms in treatments improve pain outcomes in these youth.

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Pediatric pain is common, and memory for it may be distressing and have long-lasting effects. Children who develop more negatively biased memories for pain (ie, recalled pain is higher than initial pain report) are at risk of worse future pain outcomes. In adolescent samples, higher child and parent catastrophic thinking about pain was associated with negatively biased memories for postsurgical pain. This study examined the influence of child and parent anxiety on the development of younger children's postsurgical pain memories. Seventy-eight children undergoing a tonsillectomy and one of their parents participated. Parents reported on their anxiety (state and trait) before surgery, and trained researchers observationally coded children's anxiety at anaesthesia induction. Children reported on their postsurgical pain intensity and pain-related fear for 3 days after discharge. One month after surgery, children recalled their pain intensity and pain-related fear using the same scales previously administered. Results revealed that higher levels of postsurgical pain and higher parent trait anxiety predicted more negatively biased memories for pain-related fear. Parent state anxiety and child preoperative anxiety were not associated with children's recall. Children who developed negatively biased pain memories had worse postsurgical pain several days after surgery. These findings underscore the importance of reducing parental anxiety and effective postsurgical pain management to potentially buffer against the development of negatively biased pain memories in young children.

Negatively biased memories for pain (ie, recalled pain is higher than initial report) robustly predict future pain experiences. During early childhood, parent–child reminiscing has been posited as playing a critical role in how children's memories are constructed and reconstructed; however, this has not been empirically demonstrated. This study examined the role of parent–child reminiscing about a recent painful surgery in young children's pain memory development. Participants included 112 children (Mage = 5.3 years; 60% boys) who underwent a tonsillectomy and one of their parents (34% fathers). Pain was assessed in hospital and during the recovery phase at home. Two weeks after surgery, parents and children attended a laboratory visit to participate in a structured narrative elicitation task wherein they reminisced about the surgery. Four weeks after surgery, children completed an established pain memory interview using the same previously administered scales through telephone. Narratives were coded for style (elaboration) and content (pain and emotion) based on coding schemes drawn from the developmental psychology literature. Findings revealed that a more elaborative parental reminiscing style in addition to greater use of emotional words predicted more accurate/positively biased pain memories. Greater parental use of pain words predicted more negatively biased pain memories. Although there were no sex and parent-role differences in pain memory biases, mothers and fathers differed in how they reminisced with their boys vs girls. This research underscores the importance of parent–child reminiscing in children's pain memory development and may be used to inform the development of a parent-led memory reframing intervention to improve pediatric pain management.

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From the first days of life, children frequently encounter pain. Given the highly subjective nature of pain and the powerful modulating influence that one's cognitions, emotions, and behaviours can have on how pain is experienced, pain is a fascinating field for psychological inquiry. One particularly important aspect of pain phenomenology is memory for pain. Pain memory is a critical cognitive requirement for children to selfreport on their pain and invariably shapes how they cope with pain in the future. How individuals remember pain from childhood can set the stage for future pain and health behaviours well into adulthood, and may underlie the development of chronic pain. Importantly, pain memories are malleable, particularly in childhood, and can be harnessed in psychological interventions to reframe memories to be more accurate or positive to improve pain experiences. This article provides a narrative review of the literature on children's memory for pain to build upon previous reviews on this topic. In light of advances in neuroimaging techniques and research in pediatric pain, we summarise relevant literature on the neurobiology of pain memories to stimulate future interdisciplinary research in this area. Finally, additional directions for future research and clinical practice are discussed.

In terms of cross-sectional correlations, higher levels of baseline pain intensity and interference were associated with higher levels of baseline PTSS (rs = .35 and .36, ps < .001, respectively), more severe insomnia (r = .22, p < .05 and r = .48, p < .001, respectively), and poorer sleep quality (r = -.20, p < .05 and r = -.40, p < .001, respectively), ps < .05. Higher levels of baseline PTSS were associated with poorer sleep quality (r = -.36, p < .001) and more severe insomnia (r = .49, p < .001). Higher pain interference at follow-up was associated with higher levels of follow-up pain intensity (r = .52, p < .001) and 3-month PTSS (r = .25, p < .05). Longer sleep duration was associated with better sleep quality (r = .20, p < .01). Correlations between objectively assessed sleep duration and most of self-report variables were small and nonsignificant (rs ranged from |.02| to |.16|, ps > .05).With regards to longitudinal correlations, higher levels of pain intensity, pain interference, and PTSS at baseline correlated with higher pain intensity, pain interference, and PTSS at follow-up (rs ranged from .24 to .72, ps < .05). Similarly, more severe insomnia and poorer sleep quality at baseline were associated with higher pain intensity, pain interference, and PTSS at follow-up (rs ranged from |.23| to |.43|, ps < .05). Additional Analyses: Child PTSD Symptom scale (CPSS-5) subscales