Objectives: Internalizing mental health issues co-occur with pediatric chronic pain at high rates and are linked to worse pain and functioning. Although the field has prioritized anxiety and posttraumatic stress disorder, little is known about co-occurring depression and chronic pain in youth, despite its high prevalence. The purpose of this narrative review was to examine the existing literature on the co-occurrence of pediatric chronic pain and depressive disorders and symptoms and propose a conceptual model of mutual maintenance to guide future research. Methods: The literature from both fields of pediatric pain and developmental psychology were searched to review the evidence for the co-occurrence of pediatric chronic pain and depression. Conceptual models of co-occurring mental health issues and chronic pain, as well as child depression, were reviewed. From both literatures, we provide evidence for a number of proposed child, parent, and neurobiological factors that may serve to mutually maintain both conditions over time. On the basis of this evidence, we propose a conceptual model of mutual maintenance and highlight several areas for future research in this area. Results: Evidence was found for the prevalence of depression in pediatric chronic pain as well as the co-occurrence of both conditions. The key mutually maintaining factors identified and proposed included neurobiological, intrapersonal (eg, cognitive biases, sleep disturbances, emotion regulation, and behavioral inactivation), and interpersonal (eg, parent mental health and pain, genes, and parenting) factors. Discussion: Given the dearth of research on mutual maintenance in this area, this review and conceptual model could drive future research in this area. We argue for the development of tailored treatments for this unique population of youth to improve outcomes.

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Findings suggest that benefit finding is associated with internalizing mental health symptoms, pain outcomes, and quality of life in youth with chronic pain. Future research examining this construct is warranted.

Youth with chronic pain and their parents face uncertainty regarding their diagnosis, treatment, and prognosis. Given the uncertain nature of chronic pain, and high comorbidity of anxiety among youth, intolerance of uncertainty (IU) may be critical to the experience of pediatric chronic pain. This study longitudinally examined major tenets of the Interpersonal Fear Avoidance Model of Pain, and included parent and youth IU as key factors in the model.Participants included 152 youth with chronic pain (Mage=14.23 years; 72% female) and their parents (93% female). At baseline, parents and youth reported on their IU and catastrophic thinking about youth pain; youth reported on their fear of pain, pain intensity, and pain interference; and parents reported on their protective responses to child pain. Youth reported on their pain interference three months later. Cross-lagged panel models, controlling for baseline pain interference, showed that greater parent IU predicted greater parent pain catastrophizing which, in turn, predicted greater parent protectiveness, greater youth fear of pain, and subsequently greater youth 3-month pain interference. Youth IU had a significant indirect effect on 3-month pain interference via youth pain catastrophizing and fear of pain. The results suggest that parent and youth IU contribute to increases in youth pain interference over time via increased pain catastrophizing, parent protectiveness, and youth fear of pain. Thus, parent and youth IU play important roles as risk factors in the maintenance of pediatric chronic pain over time and may be important targets for intervention.

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Attentional biases are posited to play a key role in the development and maintenance of chronic pain in adults and youth. However, research to date has yielded mixed findings and few studies have examined attentional biases in pediatric samples. The present study used eye-gaze tracking to examine attentional biases to pain-related stimuli in a clinical sample of youth with chronic pain and pain-free controls. The moderating role of attentional control was also examined. Youth with chronic pain (n = 102) and pain-free controls (n = 53) viewed images of children depicting varying levels of pain expressiveness paired with neutral faces while their eye gaze was recorded. Attentional control was assessed using both a questionnaire and a behavioural task.Both groups were more likely to first fixate on high pain faces but showed no such orienting bias for moderate or low pain faces. Youth with chronic pain fixated longer on all pain faces than neutral faces, whereas youth in the control group exhibited a total fixation bias only for high and moderate pain faces. Attentional control did not moderate attentional biases between or within groups. The results lend support to theoretical models positing the presence of attentional biases A

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During the coronavirus 2019 (COVID-19) pandemic youth with chronic pain have experienced additional barriers to accessing treatment and managing their pain. This study explored the experiences of youth with chronic pain and their parents during the COVID-19 pandemic. Individual semi-structured interviews were conducted with 20 youth with chronic pain (aged 13-20 years) and one of their parents, recruited from a tertiary level pediatric chronic pain program. Interviews occurred between the months of June-August 2020 and enabled participants to describe their experiences of the COVID-19 pandemic according to their own unique perspectives. Transcripts were analysed using inductive reflexive thematic analysis. Four themes were generated and labelled: ‘temporality, mental health, and pain’, ‘coping with pain during a global pandemic’, ‘impact on care’, and ‘re-appraisal in the context of development and pandemic life’. Across these themes, youth and parents described their unique challenges of living with pain as they adapted to changing circumstances of the COVID-19 pandemic. Notably, youth experienced increased difficulties managing their mental health and pain, which were intricately connected and related to social isolation, temporality, and uncertainty exacerbated by the COVID-19 pandemic. Restrictions due to the COVID-19 pandemic impacted youth's access to care and their abilities to engage in coping strategies to manage their pain. The COVID-19 pandemic was also perceived to have interrupted youth's development and growing autonomy, prompting youth to re-appraise their current circumstances and imagined futures. Perspective: This manuscript provides an in-depth understanding of the impact of the COVID-19 pandemic on youth with chronic pain and their parents. Youth and their parents perceived the COVID-19 pandemic to have impacted youth's mental health, pain, socio-emotional development, and access to care.