- Email: [email protected]
Adolescent social development and chronic pain
Available online at www.sciencedirect.com
European Journal of Pain 12 (2008) 765–774 www.EuropeanJournalPain.com
Adolescent social development and chronic pain Christopher Eccleston a,b,*, Sarah Wastell a,b, Geert Crombez c, Abbie Jordan a,b a Pain Management Unit, The University of Bath, Level 7, Wessex House, Bath BA2 7AY, United Kingdom The Royal National Hospital for Rheumatic Diseases NHS Trust, Upper Borough Walls, Bath, BA2 7AY, United Kingdom c Faculty of Psychology and Educational Sciences, Ghent University, Henri Dunantlaan 2, 9000 Gent, Belgium, United Kingdom b
Received 30 May 2007; received in revised form 16 October 2007; accepted 9 November 2007 Available online 11 January 2008
Abstract Adolescents with chronic pain report disability, distress and reduced social functioning. A clinical sample of 110 adolescents, with a mean four year history of pain, was investigated for the psychosocial impact of pain on social development. All participants completed a range of self-report measures of pain intensity, disability, distress, social and family functioning. Also completed was the Bath Adolescent Pain Questionnaire, including its development subscale. The development subscale measures the extent to which adolescents perceive themselves to be ahead or behind their peers on 11 aspects of social development. Three related analyses were undertaken. First, over 50% of adolescents reported themselves to be less developed than their peers on four or more aspects. The item with the highest endorsement of being ahead compared with peers was ‘‘dealing with problems”. Second, factor analyses revealed three factors of adolescent social development labelled ‘independence’, ‘emotional adjustment’ and ‘identity formation’. Third, regression analyses revealed that peer support had a positive effect on all three factors, disability and anxiety had a negative effect on perceptions of independence, greater family dysfunction had a negative effect on emotional adjustment, and depressive mood had a negative effect on identity formation. Pain intensity had a negative effect on all three factors. Findings suggest that adolescents with chronic pain judge themselves to be less developed than their peers. Pain intensity has a negative effect on this perception, but peer relations may play a protective role: strong peer relationships are associated with positive social comparisons of the level of social development. Ó 2007 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. Keywords: Adolescent; Chronic pain; Development; Peers; Social comparison
1. Introduction Adolescence is a period characterized by rapid and extensive social, psychological and physical maturation. Important is the emergence of autonomous behaviour, the reduction of dependence on parents, the increase in peer dependence, experimentation with identity, and the development of emotional skills. Adolescence can *
Corresponding author. Address: Pain Management Unit, The University of Bath, Level 7, Wessex House, Bath BA2 7AY, United Kingdom. Tel.: +44 0 1225 473427; fax: +44 0 1225 383622. E-mail address: [email protected] (C. Eccleston).
be considered as a sustained period of personal exploration and change. Autonomy in behaviour is related to opportunities for social exposure. Through exploration of likes and dislikes one’s identity is shaped and choices about identity are made (Marcia, 2000; Adams et al., 1992). Peers and social networks are a crucial part of identity exploration, with challenges to this process hampering the development of emotional regulation skills (Grotevant, 1987). Adolescent chronic illness and chronic pain are examples of sustained challenges to development (Yoder, 2000). The negative psychosocial impact of adolescent chronic pain is well documented. Disability (Fichtel and
1090-3801/$34 Ó 2007 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejpain.2007.11.002
766
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Larsson, 2002), distress (Eccleston et al., 2004), social functioning and parental protectiveness (Huygen et al., 2000; Walker et al., 2006) are all increased. Diminished, are quality of life (Hunfeld et al., 2001), school attendance (Roth-Isigkeit et al., 2005), and peer-group participation (Merlijn et al., 2003). Although we know that the experience of prolonged pain has detrimental effects on adolescent life, few studies have examined the relationship between chronic pain and the defining feature of adolescence, social development. One exception is a study conducted by Palermo et al. (2007) in which low levels of adolescent autonomy and adaptive family functioning were found to be predictive of poor adolescent functioning. Whilst clinical observation suggests that chronic pain affects the adolescent developmental trajectory, little is known about the nature of this impact or the enduring implications of actual or perceived developmental lag. As chronic pain results in emotional, social and physical restrictions, one might expect that such experience will affect adolescents’ opportunities to explore identity and to experiment with social and emotional skills. In this paper we are interested primarily in peer comparison. The lifeworld of the adolescent is dominated by the desire for acceptance in a shared peer group identity (Kistner et al., 2007). A critical developmental task is to negotiate identity, and to practice autonomy, in relation to significant other adolescents. We want to know whether adolescents judge themselves to be more or less developed than their peers. For this investigation we are uninterested in objective measures of development, and focus on adolescent self-perception. First we ask: how do adolescents with chronic pain judge their own developmental progress in comparison with their peers? Because of the socially restrictive effects of pain we hypothesized that adolescents would judge themselves to be behind their peers in all aspects of development. Second, we ask: what are the components of social development that are important for adolescents who experience ongoing pain? Third, we ask how these components of social development are related to psychosocial variables including disability, anxiety, depression, family and peer functioning, in addition to pain severity? We hypothesized that judgements of comparative development would be associated with disability, family coping and pain severity.
2. Method 2.1. Participants Adolescents were recruited from a multidisciplinary outpatient Pain Management clinic. Adolescents were approached at the time of assessment and invited to participate in the study. For inclusion participants were
required to be aged between 11 and 18 years old, with pain of over three months duration. All the adolescents approached met the inclusion criteria. Of these, six did not wish to take part in the research. Of the 117 who consented, seven failed to return completed questionnaires. These data are taken from a larger study on adolescent chronic pain (e.g., Eccleston et al., 2005; Gauntlett-Gilbert and Eccleston, 2007) in which a larger sample of 222 adolescents were recruited from two outpatient tertiary care centres, a Pain Management clinic (n = 110) and a Rheumatology clinic (n = 112). As discussed in the earlier paper, differences were observed between the two samples, with adolescents in the Pain Management sample being significantly older, experiencing more non-inflammatory pain, of a higher intensity and in a larger number of locations than adolescents in the Rheumatology sample (Eccleston et al., 2005). Given that the focus of the present study is on examining the issue of social development in the context of non-inflammatory, complex chronic pain, this study concerns itself only with the 110 adolescent participants recruited from the Pain Management clinic. Full clinical and biographical details of the sample are summarised in Table 1. A chronic pain syndrome diagnostic system was used (Malleson and Clinch, 2003) for the purposes of classification. 2.2. Measures 2.2.1. Pain intensity Adolescents rated their average pain intensity over the previous week on a 10 cm Visual Analogue Scale (VAS; 0 cm = ‘no pain’ and 10 cm = ‘worst pain possible’) (Varni et al., 1987). Table 1 Description of adolescent chronic pain sample (N = 110) Mean [SD] or (%) Age Mean pain duration (years) Sex Male Female Primary diagnosis at presentation CRPS type 1a RAPb Low back pain Chronic headache Multiple site idiopathic pain Site of primary pain Limb Back Hip Head Abdomen Total body Notes: a Complex Regional Pain Syndrome Type 1. b Recurrent Abdominal Pain.
15.1 [1.9] 4.1 [3.8] 30 (27.3%) 80 (72.7%) 41 (37.3%) 6 (5.5%) 7 (6.4%) 9 (8.2%) 47 (42.7%) 22 (20.0%) 11 (10.0%) 1 (0.9%) 11 (10.0%) 9 (8.2%) 55 (50.0%)
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
2.2.2. Pain duration Adolescents were asked to report their age in years and months at pain onset. A measure of pain duration was calculated by subtracting total age at pain onset in months from total current age in months. 2.2.3. Bath Adolescent Pain Questionnaire The Bath Adolescent Pain Questionnaire (BAPQ; Eccleston et al., 2005) is a self-report assessment tool designed specifically for use with adolescents who experience chronic pain. The BAPQ consists of 61 items in seven subscales of functioning affected by pain: Social functioning (9 items) (e.g. ‘‘I go out and meet friends”), physical functioning (9 items) (e.g. ‘‘I need help with dressing or bathing”), depression (6 items) (e.g. ‘‘I feel hopeless about the future”), general anxiety (7 items) (e.g. ‘‘I worry about the future”), pain specific anxiety (7 items) (e.g. ‘‘ I worry about my pain problem”), family functioning (12 items) (e.g. ‘‘Family life is stressful”) and self-perception of development (11 items) (e.g. ‘‘My plans for the future”). Each subscale is rated on a fivepoint frequency scale. All items are rated on a scale from zero (never) to four (always) except for the self-perception of development subscale (see Section 2.2.4). To obtain a result the necessary items are reversed and each subscale is calculated. A score of 0 indicates no impairment and the highest achievable score of 44 represents maximum impairment. The BAPQ was found to have good validity and test–retest reliability on all of the seven subscales. The inventory has been found to be a reliable and valid assessment tool in samples of adolescents with chronic pain recruited from both a chronic pain clinic and rheumatology clinic (Eccleston et al., 2005). 2.2.4. Comparative development To measure social development the self-perception of development subscale of the BAPQ was used. The selfperception of development subscale has 11 items that cover aspects of adolescent social development identified as important domains for adolescents in chronic pain (see Table 3 for a full list of items). Participants are asked to ‘‘read each statement carefully and think of each one in relation to other people of your age”. The scale is scored on a five point scale. Scores range from zero (very behind) to four (very ahead). 2.2.5. Disability The Functional Disability Inventory (FDI; Walker and Greene, 1991) is a self-report inventory for children that measures perceived difficulty in performing activities in the domains of school, home, recreation and social interactions. It comprises 15 items which respondents are asked to rate on a five-point frequency scale, ranging form zero (no trouble) to four (impossible) and uses a time frame of ‘the last few days’. Items ask about perceived difficulty in performing specific tasks
767
due to physical health reasons (e.g. ‘going shopping’). The FDI has proven to be reliable and is valid for disability across the range of chronic pain populations (Walker and Heflinger, 1998). 2.2.6. Depression The Children’s Depression Inventory Short Form (CDI-S; Kovacs, 1981) is a self-report inventory that assesses symptoms and severity of depressive mood in children and adolescents. It has good validity and acceptable reliability. The CDI-S consists of 10 items that are rated using a three-point scale (zero-two; e.g. I am sad many times). The raw scores are transformed to age and gender normed T-scores (M = 50, SD = 10). It has also been used with other paediatric chronic pain populations, facilitating comparison (e.g. Kashikar-Zuck et al., 2001; Zeltzer et al., 2002). 2.2.7. Anxiety The Spence Children’s Anxiety Scale (SCAS; Spence, 1994) is a self-report instrument measuring DSM-IV defined anxiety symptoms in young people. It consists of 38 anxiety items (e.g. ‘I would feel afraid of being on my own at home’) to be rated on a five-point frequency scale ranging from zero (never) to four (always). The SCAS also contains six filler items and an open ended non-scored item. It provides an overall measure of anxiety and six subscales. The measure is well used in adolescent populations and has good validity and reliability. Spence (1998) has provided a good summary of the psychometric properties of the SCAS in addition to useful norms. 2.2.8. Social Functioning The Child and Adolescent Social and Adaptive Functioning Scale (CASAFS; Price et al., 2002) is a self report inventory which provides an assessment of social functioning in young people. The CASAFS consists of 24 items (e.g. ‘‘I go out to places with my friends”) rated on a four point frequency scale, ranging from one (never) to four (always), with an additional ‘non applicable’ response for three relevant items. It provides an overall measure of social functioning in addition to measurement of four subscales; family relationships, peer relationships, school performance and home duties/self care. The CASAFS has good validity and acceptable reliability but has never been tested exclusively in chronic pain samples. 2.2.9. Analyses 2.2.9.1. Factor analysis. The data from the 11 item BAPQ development subscale were analysed using Principal Component Analysis (PCA) with oblique rotation. 2.2.9.2. Confirmatory factor analysis. To further test the stability of the three factor solution we undertook a
768
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
confirmatory factor analysis. For this purpose, the statistical package AMOS 5.0 was used (Arbuckle, 1995–1999, 2003). The model fit was assessed using (a) v2 divided by the degrees of freedom (CMIN/DF); (b) the root mean square error of approximation (RMSEA), and (c) the goodness of fit index (GFI). A statistically significant v2 indicates that a significant amount of observed covariance between items remains unexplained by the model, whereas a non-significant v2 implies a good fit to the data. This index is, however, highly sensitive to sample size, which is a disadvantage. One of the first fit statistics to address this problem was the v2/degrees of freedom or CMIN/DF ratio, which is the minimum sample discrepancy divided by degrees of freedom (Wheaton et al., 1977). Marsh and Hocevar (1985) recommend using ratios as low as 2 or as high as 5 to indicate a reasonable fit. A RMSEA value of 0.05 indicates a close fit and values up to 0.08 represent reasonable errors of approximation in the population (Browne and Cudeck, 1993). A GFI value greater than 0.90 indicates an adequate fit (Bentler, 1990; Tanaka and Huba, 1985). 2.2.9.3. Stepwise regression. A series of three multiple regression analyses was performed with the three factors of independence, emotional adjustment and identity formation as dependent variables to assess the unique contribution of adolescent variables on comparative social development. In a first step age and gender were entered to control for demography. In a second step pain duration and pain intensity were entered to control for pain severity. In a subsequent step, general anxiety, depressive mood, functional disability, family functioning and peer relationships were entered as independent variables using a stepwise method. This series was entered for both ‘independence’ and ‘identity formation’. Emotional adjustment differed slightly because the independent variable ‘peer relationship scale’ consisted of one item that had similar content as the dependent variable. A hierarchical multiple regression was run using the full peer relationship scale and the analysis showed the inde-
pendent variable had a unique value in explaining emotional adjustment (b = 0.36, R2 change = 0.12, F = 13.49, P < 0.001). To ensure that the item overlap was not influencing the outcome of the preliminary analysis the peer relationships scale was abbreviated (i.e., the item which overlapped was removed and the scale was recalculated). A multiple regression was run using the abbreviated scale which showed that the value of peer relationships in explaining emotional adjustment remained (b = 0.36, R2 change = 0.12, F = 12.76, P < 0.001).
3. Results 3.1. Descriptive statistics Table 2 provides a summary of the descriptive statistics for the Pain Management sample. Data from the previously mentioned Rheumatology sample in the earlier paper (Eccleston et al., 2005) is provided solely for comparison purposes. High levels of disability were observed with more than 90% of the adolescents scored in the moderate to high range (FDI-score > 10; Kashikar-Zuck et al., 2001). The results indicate that the adolescents are also emotionally distressed. With regard to depression as measured by the total score of the CDIS, 38% of adolescents scored within the normal limits (T-score of 50 or less), 25 % reported mildly elevated symptoms of depression (T-score between 51 and 65), 18% reported moderately elevated symptoms of depression (T-score between 66 and 79) and 4% reported severely elevated symptoms of depression (T-score of 80 or greater; Kashikar-Zuck et al., 2001). The mean score for anxiety as measured by the SCAS (25.83), was higher than the mean scores of two non-clinical groups (Spence, 1998: n = 20, M = 18.8, SD = 9.7; Muris et al., 2002; n = 521, M = 16.9, SD = 13.1). Adolescents rated themselves as similar to non-clinical controls on the measure of social role functioning
Table 2 Descriptive statistics for the Pain Management sample (n = 110) and the Rheumatology sample (n = 112) Clinic site
Descriptive statistic
BAPQa development
Pain intensity
FDIb
CDIc
SCASd
CASAFSe
Pain Management
Mean Standard deviation Range
24.18 6.46 6.0–39.0
7.53 2.24 0.0–10.0
26.35 11.58 0.0–53.8
5.10 3.69 0.0–16.0
25.83 15.65 2.0–65.0
72.81 8.72 52.0–93.0
Rheumatologyf
Mean Standard deviation Range
20.54 6.78 4.0–10.0
6.08 2.47 0.0–10.0
16.52 12.15 0.0–45.0
3.54 3.41 0.0–14.0
23.73 13.75 2.0–69.0
73.76 8.90 53.0–91.0
Notes: a Bath Adolescent Pain Questionnaire. b Functional Disability Inventory. c Children’s Depression Inventory. d Spence Children’s Anxiety Scale. e Child and Adolescent Social and Adaptive Functioning Scale. f Data on the Rheumatology sample is provided from the earlier paper (Eccleston et al., 2005), for comparative purposes.
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
(CASAFS total = 72.8; non-clinical mean = 71.4; Price et al., 2002). This is an unexpected finding considering that clinical impressions are that these patients present with severe problems in this domain. 3.2. Comparative social development Initial analyses focused on examining how many adolescents considered themselves different from their peers in terms of social development and used the self-perception of development subscale of the BAPQ. A total of 90% of the sample reported the perception that they were developmentally behind in at least one item, and 51% of these adolescents perceived themselves as developmentally behind in four or more items. The 10% of the sample who did not consider themselves to be behind on any items perceived themselves as developmentally ahead on at least one item. Table 3 summarizes the frequency of the samples perceived developmental level on each item listed in the BAPQ developmental subscale. Categories were collapsed to provide overall estimates of adolescent perceptions of feeling ‘ahead’ or ‘behind’ their peers for each item. For 5 of the 11 items the most frequent endorsements were of a perception of being developmentally behind (items relating to school progress, overall independence, social confidence, activity without parents and dating). The latter item was the most highly endorsed item with regard to adolescents perceptions of being ‘very behind’ their peers (29.6%). For 5
769
of the 11 items the most frequent endorsements were of a perception of being developmentally similar (items relating to future planning, handling feelings, identity and choosing one’s own clothes). In only one item was there a majority endorsement of the perception of being developmentally ahead of peers: ‘How I deal with problems’. 3.3. Factor analyses Examining the scree plot, four factors were identified as possible with an eigen value greater than one, accounting for 66% of the variance. The Kaiser– Meyer–Olkin (KMO) test of sampling adequacy was met, KMO = 0.764 and Bartlett’s test of sphericity yielded a X2 of 265.7, df = 55, p < 0.001 indicating significant relationships among the variables and the suitability of the data for PCA. However the fourth factor was determined by three items (‘‘my plans for the future”, ‘‘how often I choose my own clothes and personal belongings”, ‘‘my progress in school”), of which the first two listed items loaded more highly onto factor three. Consequently factor four was considered unstable. The analysis was rerun using a three factor solution. Each factor had an eigen value greater than 1.5. The three factor solution accounted for 56.9% of the variance in the BAPQ development subscale. With regard to variance, factors one, two and three accounted for 34.7%, 12.1% and 10.1% of the variance respectively. The factor loadings can be seen in Table 4.
Table 3 Descriptive statistics and frequency (%) of perceived developmental level on each item Perceived developmental level (%)
My progress in school My overall confidence around other people My plans for the future How often I do things without my parents around My overall independence How often I choose my own clothes and other personal items My ability to go on dates with boyfriends/girlfriends The development of my own sense of identity My ability to handle my own feelings My ability to fit in with friends How I deal with problems
Mean (SD)
N
Behind
Same
Ahead
2.47 (1.13) 2.40 (0.97) 2.08 (1.08) 2.47 (1.07) 2.47 (1.09) 1.79 (0.80) 2.66 (1.11) 1.90 (0.80) 1.92 (0.92) 2.25 (0.90) 1.76 (1.00)
102
56 (54.9%) 51 (47.6%) 29 (27.4%) 50 (47.2%) 52 (49.5%) 13 (12.1%) 51 (52%) 18 (17.2%) 22 (21.6%) 37 (34.9%) 22 (20.8%)
22 (21.6%) 38 (35.5%) 44 (41.5%) 40 (37.7%) 36 (34.3%) 66 (61.7%) 37 (37.8%) 61 (58.1%) 58 (54.2%) 54 (50.9%) 40 (37.7%)
24 (23.5%) 18 (16.8%) 33 (31.1%) 16 (15.1%) 17 (16.2%) 28 (26.2%) 10 (10.2%) 26 (24.8%) 27 (25.2%) 15 (14.2%) 44 (41.5%)
107 106 106 105 107 98 105 107 106 106
770
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Judging oneself to be less independent than one’s peers was predicted by greater pain intensity (b = 0.33, R2 change = 0.15, F = 6.57, P < 0.01) greater disability (b = 0.30, R2 change = 0.08, F = 9.32, P < 0.01) and greater anxiety (b = 0.19, R2 change = 0.03, F = 4.20, P < 0.05). Judging oneself to be less emotionally adjusted than one’s peers was predicted by greater pain intensity (b = 0.33, R2 change = 0.10, F = 5.09, P < 0.01) and great family dysfunction (b = 0.26, R2 change = 0.06, F = 7.14, P < 0.01). And, judging oneself to be less developed in one’s identity was predicted by greater pain intensity (b = 0.29, R2 change = 0.104, F = 5.09, P < 0.01) and greater depression (b = 0.26, R2 change = 0.05, F = 5.65, P < 0.05). Strong peer relationships predicted positive judgements of independence (b = 0.43, R2 change = 0.16, F = 17.91, P < 0.001), emotional adjustment (b = 0.36, R2 change = 0.12, F = 13.49, P < 0.001), and identity formation (b = 0.46, R2 change = 0.19, F = 22.98, P < 0.001).
The first factor was labelled ‘‘independence” and was made up of four items dominated by behaviour in school and with peers independent from parents (with a Cronbach’s alpha of.70). The second factor was labelled ‘‘emotional adjustment” and was dominated by behaviour associated with emotional problem solving and competence (with a Cronbach’s alpha of .75). The third factor was labelled ‘‘identity formation” and was dominated by socially assured behaviour (with a Cronbach’s alpha of .61). All three factors are intercorrelated. Table 5 shows the correlation coefficients of the three factors of perceived development and the pain related variables and other study variables. Of note is the significant inverse association between perceived development and pain intensity: the greater the pain intensity, the less developed adolescents perceived themselves to be in all three areas. Also worth noting is the finding that the positive peer relationships is associated with greater perceived social development in all three factors (independence r = 0.39, emotional adjustment r = 0.36, identity formation r = 0.47). The confirmatory factor analysis model fit indices indicated a reasonable fit (Chi Square (41) = 62.66, p < 0.02; CMIN/DF = 1.528; RMSEA = 0.071; GFI = 0.90). All items loaded significantly upon the hypothesized latent variable, except one item: ‘My progress in school’. Subsequent analyses revealed that this item did also not load significantly upon the other two latent factors. Future research will have to resolve whether this item is a valid indicator of the factor ‘‘independence”.
4. Discussion A sample of adolescent chronic pain patients with a four year history of chronic pain reported high pain, disability, and distress. Almost 51% of adolescents judged that when compared with their peers they were behind in four or more of the domains of adolescent social development. The most common perception of developmental lag was in school progress and independence. The most common perception of developmental advancement was in dealing with problems. Three factors of self-perception of social development were identified and labelled as ‘independence’, ‘emotional adjustment’, and ‘identity formation’. For all three factors pain intensity had a negative influence. Family dysfunction had a negative affect on emotional adjustment, and depressive mood had a negative affect on identity. However, across all three factors of social development, strong peer relations played a protective
3.4. Predictors of adolescent comparative social development The results of this series of multiple regressions are shown in Table 6. Variance inflation factors in all three regression analyses were small, indicating that there was no problem of co-linearity.
Table 4 Factors loadings for the BAPQ development subscale items (three factor solution) Factor loadings Independence How often I do things without my parents around My overall independence My progress in school My ability to go on dates with boyfriends/girlfriends How I deal with problems My ability to handle my own feelings My ability to fit in with friends The development of my own sense of identity My overall confidence around other people My plans for the future How often I choose my own clothes and other personal items Note: The highest factor loading for each item is provided in bold type.
0.83 0.75 0.54 0.53 0.02 0.10 0.16 0.29 0.10 0.19 0.06
Emotional adjustment 0.04 0.31 0.06 0.06 0.88 0.80 0.54 0.20 0.01 0.23 0.12
Identity formation 0.09 0.00 0.05 0.31 0.031 0.01 0.26 0.76 0.70 0.68 0.50
Table 5 Correlations between psychosocial variables and social development
1. Independence 2. Emotional adjustmentd 3. Identity formationd 4. Age 5. Gender 6. Pain duration 7. Pain intensity 8. School performancee 9. Peer relationshipse 10. Family relationshipse 11. Home duties/self caree 12. Physical functioningf 13. Depressionf 14. General anxietyf 15. Family functioningf 16. Pain specific anxietyf 17. Social functioningf a b c d e f
91 105 104 110 110 102 106 101 106 105 107 108 110 108 108 109 109
Mean 9.91 5.92 8.10 14.65 0.73 49.12 6.49 17.02 17.59 19.81 15.75 15.94 11.83 11.29 17.37 14.01 14.62
SD 3.17 2.30 2.51 1.88 0.44 45.78 2.69 3.85 3.25 2.83 3.14 8.18 4.50 5.07 7.18 5.64 6.75
2
3 b
0.43 –
4 b
0.46 0.43b –
5 0.04 0.07 0.10 –
6 0.02 0.10 0.09 0.02 –
7 0.21 0.01 0.10 0.21a 0.17 –
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed). Correlation is significant at the 0.001 level (2-tailed). Factors from the development subscale of the Bath Adolescent Pain Questionnaire. Subscale of the Child and Adolescent Social and Adaptive Functioning Scale. Subscale of the Bath Adolescent Pain Questionnaire.
8 b
0.36 0.31b 0.26b 0.02 0.20a 0.01 –
9 a
0.24 0.30b 0.22a 0.03 0.14 0.01 0.24a –
10 b
0.39 0.36b 0.47b 0.03 0.19a 0.05 0.07 0.17 –
0.03 0.26b 0.08 0.06 0.01 0.14 0.06 0.30b 0.10 –
11 0.17 0.02 0.22a 0.19 0.05 0.04 0.04 0.25a 0.14 0.25b –
12
13 b
0.50 0.15 0.26b 0.01 0.01 0.10 0.33b 0.17 0.26b 0.01 0.28b –
14 b
0.31 0.31b 0.35b 0.31b 0.03 0.05 0.40b 0.30b 0.26b 0.28b 0.21a 0.33b –
15 b
0.28 0.31b 0.23a 0.12 0.02 0.06 0.22a 0.23a 0.13 0.19 0.20a 0.33c 0.61b –
0.21 0.33b 0.20a 0.14 0.04 0.04 0.24a 0.32b 0.15 0.50b 0.32b 0.17 0.52b 0.43b –
16
17 0.51c 0.41c 0.49c 0.04 0.10 0.12 0.24a 0.29b 0.64c 0.21a 0.17 0.46c 0.54c 0.30b 0.31c 0.23a
0.11 0.16 0.08 0.02 0.02 0.10 0.29b 0.06 0.05 0.06 0.01 0.34c 0.47c 0.54c 0.36c –
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
N d
771
772
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Table 6 Results of the hierarchical regression analyses for developmental factors Criterion variable
Step
Predictor
B
R2 change
R2
Independence
1
Age Gender Pain duration Pain intensity Peer relationshipsa Physical functioningb General anxietyb
0.022 0.012 0.210 0.333d 0.429e 0.301d 0.194c
0.001
0.001
0.147d
0.148
0.103
0.164e 0.077d 0.033c
0.312 0.389 0.422
0.266 0.340 0.367
Age Gender Pain duration Pain intensity Peer relationshipsa Family functioningb
0.089 0.093 0.010 0.332d 0.361e 0.257d
0.014
0.014
0.104d
0.119
0.078
0.121e 0.060d
0.239 0.299
0.195 0.249
Age Gender Pain duration Pain intensity Peer relationshipsa Depressiona
0.050 0.127 0.063 0.290d 0.459e 0.256c
0.020
0.020
0.084c
0.105
0.062
0.192e 0.045c
0.297 0.342
0.255 0.294
2 3 4 5 Emotional adjustment
1 2 3 4
Identity formation
1 2 3 4
Adj. R2 0.025
0.008
0.002
The reported standardized bs are those from the final step in the regression analysis. a Physical functioning subscale of the Bath Adolescent Pain Questionnaire. b Family functioning subscale of the Bath Adolescent Pain Questionnaire. c P < 0.05. d P < 0.01. e P < 0.001.
role, being associated with positive judgements of development. Reduced social contact and poor peer relationships are related to judgements of poor social development. Chronic pain appears to have direct effects on reducing opportunities for social exposure and normative developmental experience (e.g., school and peer group involvement) but also increases exposure to dependent relationships in the home setting. Chronic pain not only produces immediate effects on adolescent current experience but also critically changes the social environment within which adolescents develop. It is possible that adolescents who perceive themselves to lag behind their peers may feel unable to undertake normative tasks such as those of higher education study, employment or moving away from the family home. The longer term adult consequences of perceived social developmental delay remain unknown. Perhaps more positive was the finding that adolescents also report that their experience of coping with chronic pain has led to comparative maturity in problem solving. It remains possible that such a perceived advancement may be either a further burden or a protective advantage for later coping. The mechanism(s) by which peer relationships and family coping are related to perceptions of comparative development are unknown. Harter and Whitesell (2003) argue that self-worth and the development of stable selfesteem are important precursors for later adult adjustment. The protective influence of peer relationships on
comparative judgements may be mediated by intrapersonal characteristics such as self-esteem or judgements of self-worth. Similarly, Harter et al. (1998) have found that such judgements are often contextually specific. It remains to be investigated whether positive self-judgements are more protected by peer relations in some situations (e.g., school) compared with other situations (e.g., family home). There is a number of limitations to this study. First, although the self-perception of development subscale of the BAPQ asks specifically about developmental issues affected by pain, there are no normative data from this measure. Therefore we have no way of knowing if the pattern of results is typical of adolescents with or without pain. Second, our access to judgements of development was via adolescent comparison with unknown peers. We were very clear that this adolescent ‘perception’ of development was our focus, but care should be taken when discussing whether chronic pain affects development without further empirical testing. Social comparison biases may affect these judgements, and we have no objective measure of peer development as a control for any biases. Third, the content of the self-perception of development subscale could benefit from revision. In particular, missing is any content referring to sexual maturation, considered by some a core aspect of adolescent development. Fourth, these data are crosssectional and hence caution is necessary when considering the direction of observed relationships between
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
self-perceived adolescent social development and the experience of adolescent chronic pain. Fifth, it is possible that factors, other than the experience of chronic pain may be responsible for adolescent perceptions of developmental delay in comparison to peers. For example, depression is associated with cognitive distortion in adolescent populations (Marcotte et al., 2006) and this may be characterised by perceptions of the self as less competent than others. There is preliminary evidence for this in the statistically predictive relationship of depression to identity development. Sixth, the sample is somewhat smaller than ideally desired for use with analytical methods such as stepwise regression. Replication of these analyses with larger samples would be of benefit. Finally, these data are from a specific group of very disabled and distressed chronic pain patients. Data from other centres and other chronic pain patients are necessary, particularly samples comprising large adolescent populations with specific diagnoses (e.g. headache, recurrent abdominal pain). A number of areas could be usefully investigated further. First, as indicated, replicate data from other research centres, normative data from school or community samples comprising adolescents without chronic pain, and data from other patient groups would be extremely helpful. Interesting would be objective data of social development and other-reported data (for example, comparative data from peers and from parents). Second, development is by definition a dynamic (ie. temporally sensitive) concept. What is needed are longitudinal data relating to the effect of pain on different stages or key tasks of development. Third, pain intensity had robust effects across all three factors. It is not clear in what way pain intensity is related to perceived social development, whether directly in the repeated exposure to a negative aversive experience, or indirectly through restricted social participation. Predictive and mediation analyses will be helpful to investigate these relationships further. Fourth, an intriguing finding of this study was the seemingly protective effect of positive peer relationships on social development. There is very little work on the importance of peers to the development of coping in chronic pain, and this finding strongly suggests that further research on friendship, and peer support is warranted. References Adams GR, Gullotta TP, Montemayor R. Adolescent identity formation. In: Hosek SG, Harper GW, Robinson L, editors. Identity development in adolescents living with HIV. J Adolescence 1992;25:355–64. Arbuckle JL. Amos 5.0 update to the Amos user’s guide. Chicago (IL): SPSS; 2003. Arbuckle JL, Wothke W. Amos 4.0 user’s guide. Chicago (IL): SPSS; 1995, 1999.
773
Bentler PM. Comparative fit indexes in structural models. Psychol Bull 1990;107:238–46. Browne MW, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Long JS, editors. Testing structural equation models. Newbury Park (CA): Sage; 1993. Eccleston C, Jordan A, McCracken LM, Sleed M, Connell H, Clinch J, et al. The Bath Adolescent Pain Questionnaire (BAPQ): development and preliminary psychometric evaluation of an instrument to assess the impact of chronic pain on adolescents. Pain 2005;118:263–70. Eccleston C, Crombez G, Scotford A, Clinch J, Connell H. Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents. Pain 2004;108:221–9. Fichtel A, Larsson B. Psychosocial impact of headaches and comorbidity with other pains among Swedish school adolescents. Headache 2002;42:766–75. Gauntlett-Gilbert J, Eccleston C. Disability in adolescents with chronic pain: patterns and predictors across different domains of functioning. Pain 2007;131:132–41. Grotevant HD. Toward a process model of identity formation. J Adolescent Res 1987;2:203–22. Harter S, Waters P, Whitesell NR. Relational self-worth: differences in perceived worth as a person across interpersonal contexts among adolescents. Child Dev 1998;69:756–66. Harter S, Whitesell NR. Beyond the debate: Why some adolescents report stable self-worth over time and situation, whereas others report changes in self-worth? J Person 2003;71:1027–58. Hunfeld JAM, Perquin CW, Duivenvoorden HJ, Hazebroek-Kampschreur AAJM, Passchier J, van Suijlekam-Smit LWA, et al. Chronic pain and its impact on quality of life in adolescents and their families. J Pediatr Psychol 2001;26(3):145–53. Huygen ACJ, Kuis W, Sinnema G. Psychological, behavioural, and social adjustment in children and adolescents with juvenile chronic arthritis. Ann Rheum Dis 2000;59:276–82. Kashikar-Zuck S, Goldschneider KR, Powers SW, Vaught MH, Hershey AD. Depression and functional disability in chronic paediatric pain. Clin J Pain 2001;17:341–9. Kistner J, David C, Repper K. Self-enhancement of peer acceptance: implications for children’s self-worth and interpersonal functioning. Soc Dev 2007;16:24–44. Kovacs M. Rating scales to assess depression in school aged children. Acta Paedopsychiatr 1981;46:305–15. Malleson PN, Clinch J. Pain syndromes in children. Curr Opin Rheumatol 2003;15:572–80. Marcia J. Development and validation of ego-identity status. In: Gullotta TP, Adams GR, Markstrom CA, editors. The adolescent experience. 4th ed. London: Academic Press; 2000. p. 79–81. Marcotte D, Le´vesque N, Fortin L. Variations of cognitive distortions and school performance in depressed and non-depressed high school adolescents: a two-year longitudinal study. Cognit Ther Res 2006;30:211–25. Marsh HW, Hocevar D. Application of confirmatory factor analysis to the study of self-concept: first- and higher-order factor models and their invariance across groups. Psychol Bull 1985;97:562–82. Merlijn VPBM, Hunfeld JAM, Van der Wouden JC, HazebroekKampschreur AAJM, Koes BW, Passchier J. Psychosocial factors associated with chronic pain in adolescents. Pain 2003;101: 33–43. Muris P, Merckelbach H, Ollendick T, King N, Bogie N. Three traditional and three new childhood anxiety questionnaires: their reliability and validity in a normal adolescent sample. Behav Res Ther 2002;40:753–72. Palermo T, Putnam J, Armstrong G, Daily S. Adolescent autonomy and family functioning are associated with headache-related disability. Clin J Pain 2007;23:458–65.
774
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Price CS, Spence SH, Sheffield J, Donovan C. The development and psychometric properties of a measure of social and adaptive functioning for children and adolescents. J Clin Child Adoles Psychol 2002;31:111–22. Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J, Schmucker P. Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics 2005;115(2):483–4. Spence SH. The Spence Children’s Anxiety Scale (SCAS). In: Sclare I, editor. The child psychology portfolio. Windsor: Nfer Nelson; 1994. Spence SH. A measure of anxiety symptoms among children. Behav Res Ther 1998;36:545–66. Tanaka JS, Huba GJ. A fit index for covariance structure models under arbitrary GLS estimation. Brit J Math Stat Psy 1985;38:197–201. Varni JW, Thompson KL, Hanson V. The Varni/Thompson pediatric pain questionnaire. Chronic musculoskeletal pain in juvenile rheumatoid arthritis. Pain 1987;28:27–38. Walker LS, Greene JW. The Functional Disability Inventory: measuring a neglected dimension of child health status. J Pediatr Psychol 1991;16:39–58.
Walker LS, Williams SE, Smith CA, Garber J, Van Slyke DA, Lipani TA. Parent attention versus distraction: impact on symptom complaints by children with and without chronic functional abdominal pain. Pain 2006;122:43–52. Walker LS, Heflinger CA. Quality of life predictors of outcome in pediatric abdominal pain patients: findings at initial assessment and at 5 year follow up. In: Drotar D, editor. Measuring health related quality of life in children and adolescents: implications for research and practice. Mahwah (NJ): Lawrence Erlbaum; 1998. p. 237–52. Wheaton B, Muthe´n B, Alwin D, Summers G. Assessing reliability and stability in panel models. In: Heise DR, editor. Sociological methodology 1977. San Francisco: Jossey-Bass; 1977. Yoder AE. Barriers to ego identity status formation: a contextual qualification of Marcia’s identity status paradigm. J Adolescence 2000;23:95–106. Zeltzer LK, Tsao JCI, Stelling C, Powers M, Levy S, Waterhouse M. A phase I study on the feasibility and acceptability of an acupuncture/-hypnosis intervention for chronic pain. J Pain Symptom Manage 2002;24:437–46.
European Journal of Pain 12 (2008) 765–774 www.EuropeanJournalPain.com
Adolescent social development and chronic pain Christopher Eccleston a,b,*, Sarah Wastell a,b, Geert Crombez c, Abbie Jordan a,b a Pain Management Unit, The University of Bath, Level 7, Wessex House, Bath BA2 7AY, United Kingdom The Royal National Hospital for Rheumatic Diseases NHS Trust, Upper Borough Walls, Bath, BA2 7AY, United Kingdom c Faculty of Psychology and Educational Sciences, Ghent University, Henri Dunantlaan 2, 9000 Gent, Belgium, United Kingdom b
Received 30 May 2007; received in revised form 16 October 2007; accepted 9 November 2007 Available online 11 January 2008
Abstract Adolescents with chronic pain report disability, distress and reduced social functioning. A clinical sample of 110 adolescents, with a mean four year history of pain, was investigated for the psychosocial impact of pain on social development. All participants completed a range of self-report measures of pain intensity, disability, distress, social and family functioning. Also completed was the Bath Adolescent Pain Questionnaire, including its development subscale. The development subscale measures the extent to which adolescents perceive themselves to be ahead or behind their peers on 11 aspects of social development. Three related analyses were undertaken. First, over 50% of adolescents reported themselves to be less developed than their peers on four or more aspects. The item with the highest endorsement of being ahead compared with peers was ‘‘dealing with problems”. Second, factor analyses revealed three factors of adolescent social development labelled ‘independence’, ‘emotional adjustment’ and ‘identity formation’. Third, regression analyses revealed that peer support had a positive effect on all three factors, disability and anxiety had a negative effect on perceptions of independence, greater family dysfunction had a negative effect on emotional adjustment, and depressive mood had a negative effect on identity formation. Pain intensity had a negative effect on all three factors. Findings suggest that adolescents with chronic pain judge themselves to be less developed than their peers. Pain intensity has a negative effect on this perception, but peer relations may play a protective role: strong peer relationships are associated with positive social comparisons of the level of social development. Ó 2007 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. Keywords: Adolescent; Chronic pain; Development; Peers; Social comparison
1. Introduction Adolescence is a period characterized by rapid and extensive social, psychological and physical maturation. Important is the emergence of autonomous behaviour, the reduction of dependence on parents, the increase in peer dependence, experimentation with identity, and the development of emotional skills. Adolescence can *
Corresponding author. Address: Pain Management Unit, The University of Bath, Level 7, Wessex House, Bath BA2 7AY, United Kingdom. Tel.: +44 0 1225 473427; fax: +44 0 1225 383622. E-mail address: [email protected] (C. Eccleston).
be considered as a sustained period of personal exploration and change. Autonomy in behaviour is related to opportunities for social exposure. Through exploration of likes and dislikes one’s identity is shaped and choices about identity are made (Marcia, 2000; Adams et al., 1992). Peers and social networks are a crucial part of identity exploration, with challenges to this process hampering the development of emotional regulation skills (Grotevant, 1987). Adolescent chronic illness and chronic pain are examples of sustained challenges to development (Yoder, 2000). The negative psychosocial impact of adolescent chronic pain is well documented. Disability (Fichtel and
1090-3801/$34 Ó 2007 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejpain.2007.11.002
766
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Larsson, 2002), distress (Eccleston et al., 2004), social functioning and parental protectiveness (Huygen et al., 2000; Walker et al., 2006) are all increased. Diminished, are quality of life (Hunfeld et al., 2001), school attendance (Roth-Isigkeit et al., 2005), and peer-group participation (Merlijn et al., 2003). Although we know that the experience of prolonged pain has detrimental effects on adolescent life, few studies have examined the relationship between chronic pain and the defining feature of adolescence, social development. One exception is a study conducted by Palermo et al. (2007) in which low levels of adolescent autonomy and adaptive family functioning were found to be predictive of poor adolescent functioning. Whilst clinical observation suggests that chronic pain affects the adolescent developmental trajectory, little is known about the nature of this impact or the enduring implications of actual or perceived developmental lag. As chronic pain results in emotional, social and physical restrictions, one might expect that such experience will affect adolescents’ opportunities to explore identity and to experiment with social and emotional skills. In this paper we are interested primarily in peer comparison. The lifeworld of the adolescent is dominated by the desire for acceptance in a shared peer group identity (Kistner et al., 2007). A critical developmental task is to negotiate identity, and to practice autonomy, in relation to significant other adolescents. We want to know whether adolescents judge themselves to be more or less developed than their peers. For this investigation we are uninterested in objective measures of development, and focus on adolescent self-perception. First we ask: how do adolescents with chronic pain judge their own developmental progress in comparison with their peers? Because of the socially restrictive effects of pain we hypothesized that adolescents would judge themselves to be behind their peers in all aspects of development. Second, we ask: what are the components of social development that are important for adolescents who experience ongoing pain? Third, we ask how these components of social development are related to psychosocial variables including disability, anxiety, depression, family and peer functioning, in addition to pain severity? We hypothesized that judgements of comparative development would be associated with disability, family coping and pain severity.
2. Method 2.1. Participants Adolescents were recruited from a multidisciplinary outpatient Pain Management clinic. Adolescents were approached at the time of assessment and invited to participate in the study. For inclusion participants were
required to be aged between 11 and 18 years old, with pain of over three months duration. All the adolescents approached met the inclusion criteria. Of these, six did not wish to take part in the research. Of the 117 who consented, seven failed to return completed questionnaires. These data are taken from a larger study on adolescent chronic pain (e.g., Eccleston et al., 2005; Gauntlett-Gilbert and Eccleston, 2007) in which a larger sample of 222 adolescents were recruited from two outpatient tertiary care centres, a Pain Management clinic (n = 110) and a Rheumatology clinic (n = 112). As discussed in the earlier paper, differences were observed between the two samples, with adolescents in the Pain Management sample being significantly older, experiencing more non-inflammatory pain, of a higher intensity and in a larger number of locations than adolescents in the Rheumatology sample (Eccleston et al., 2005). Given that the focus of the present study is on examining the issue of social development in the context of non-inflammatory, complex chronic pain, this study concerns itself only with the 110 adolescent participants recruited from the Pain Management clinic. Full clinical and biographical details of the sample are summarised in Table 1. A chronic pain syndrome diagnostic system was used (Malleson and Clinch, 2003) for the purposes of classification. 2.2. Measures 2.2.1. Pain intensity Adolescents rated their average pain intensity over the previous week on a 10 cm Visual Analogue Scale (VAS; 0 cm = ‘no pain’ and 10 cm = ‘worst pain possible’) (Varni et al., 1987). Table 1 Description of adolescent chronic pain sample (N = 110) Mean [SD] or (%) Age Mean pain duration (years) Sex Male Female Primary diagnosis at presentation CRPS type 1a RAPb Low back pain Chronic headache Multiple site idiopathic pain Site of primary pain Limb Back Hip Head Abdomen Total body Notes: a Complex Regional Pain Syndrome Type 1. b Recurrent Abdominal Pain.
15.1 [1.9] 4.1 [3.8] 30 (27.3%) 80 (72.7%) 41 (37.3%) 6 (5.5%) 7 (6.4%) 9 (8.2%) 47 (42.7%) 22 (20.0%) 11 (10.0%) 1 (0.9%) 11 (10.0%) 9 (8.2%) 55 (50.0%)
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
2.2.2. Pain duration Adolescents were asked to report their age in years and months at pain onset. A measure of pain duration was calculated by subtracting total age at pain onset in months from total current age in months. 2.2.3. Bath Adolescent Pain Questionnaire The Bath Adolescent Pain Questionnaire (BAPQ; Eccleston et al., 2005) is a self-report assessment tool designed specifically for use with adolescents who experience chronic pain. The BAPQ consists of 61 items in seven subscales of functioning affected by pain: Social functioning (9 items) (e.g. ‘‘I go out and meet friends”), physical functioning (9 items) (e.g. ‘‘I need help with dressing or bathing”), depression (6 items) (e.g. ‘‘I feel hopeless about the future”), general anxiety (7 items) (e.g. ‘‘I worry about the future”), pain specific anxiety (7 items) (e.g. ‘‘ I worry about my pain problem”), family functioning (12 items) (e.g. ‘‘Family life is stressful”) and self-perception of development (11 items) (e.g. ‘‘My plans for the future”). Each subscale is rated on a fivepoint frequency scale. All items are rated on a scale from zero (never) to four (always) except for the self-perception of development subscale (see Section 2.2.4). To obtain a result the necessary items are reversed and each subscale is calculated. A score of 0 indicates no impairment and the highest achievable score of 44 represents maximum impairment. The BAPQ was found to have good validity and test–retest reliability on all of the seven subscales. The inventory has been found to be a reliable and valid assessment tool in samples of adolescents with chronic pain recruited from both a chronic pain clinic and rheumatology clinic (Eccleston et al., 2005). 2.2.4. Comparative development To measure social development the self-perception of development subscale of the BAPQ was used. The selfperception of development subscale has 11 items that cover aspects of adolescent social development identified as important domains for adolescents in chronic pain (see Table 3 for a full list of items). Participants are asked to ‘‘read each statement carefully and think of each one in relation to other people of your age”. The scale is scored on a five point scale. Scores range from zero (very behind) to four (very ahead). 2.2.5. Disability The Functional Disability Inventory (FDI; Walker and Greene, 1991) is a self-report inventory for children that measures perceived difficulty in performing activities in the domains of school, home, recreation and social interactions. It comprises 15 items which respondents are asked to rate on a five-point frequency scale, ranging form zero (no trouble) to four (impossible) and uses a time frame of ‘the last few days’. Items ask about perceived difficulty in performing specific tasks
767
due to physical health reasons (e.g. ‘going shopping’). The FDI has proven to be reliable and is valid for disability across the range of chronic pain populations (Walker and Heflinger, 1998). 2.2.6. Depression The Children’s Depression Inventory Short Form (CDI-S; Kovacs, 1981) is a self-report inventory that assesses symptoms and severity of depressive mood in children and adolescents. It has good validity and acceptable reliability. The CDI-S consists of 10 items that are rated using a three-point scale (zero-two; e.g. I am sad many times). The raw scores are transformed to age and gender normed T-scores (M = 50, SD = 10). It has also been used with other paediatric chronic pain populations, facilitating comparison (e.g. Kashikar-Zuck et al., 2001; Zeltzer et al., 2002). 2.2.7. Anxiety The Spence Children’s Anxiety Scale (SCAS; Spence, 1994) is a self-report instrument measuring DSM-IV defined anxiety symptoms in young people. It consists of 38 anxiety items (e.g. ‘I would feel afraid of being on my own at home’) to be rated on a five-point frequency scale ranging from zero (never) to four (always). The SCAS also contains six filler items and an open ended non-scored item. It provides an overall measure of anxiety and six subscales. The measure is well used in adolescent populations and has good validity and reliability. Spence (1998) has provided a good summary of the psychometric properties of the SCAS in addition to useful norms. 2.2.8. Social Functioning The Child and Adolescent Social and Adaptive Functioning Scale (CASAFS; Price et al., 2002) is a self report inventory which provides an assessment of social functioning in young people. The CASAFS consists of 24 items (e.g. ‘‘I go out to places with my friends”) rated on a four point frequency scale, ranging from one (never) to four (always), with an additional ‘non applicable’ response for three relevant items. It provides an overall measure of social functioning in addition to measurement of four subscales; family relationships, peer relationships, school performance and home duties/self care. The CASAFS has good validity and acceptable reliability but has never been tested exclusively in chronic pain samples. 2.2.9. Analyses 2.2.9.1. Factor analysis. The data from the 11 item BAPQ development subscale were analysed using Principal Component Analysis (PCA) with oblique rotation. 2.2.9.2. Confirmatory factor analysis. To further test the stability of the three factor solution we undertook a
768
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
confirmatory factor analysis. For this purpose, the statistical package AMOS 5.0 was used (Arbuckle, 1995–1999, 2003). The model fit was assessed using (a) v2 divided by the degrees of freedom (CMIN/DF); (b) the root mean square error of approximation (RMSEA), and (c) the goodness of fit index (GFI). A statistically significant v2 indicates that a significant amount of observed covariance between items remains unexplained by the model, whereas a non-significant v2 implies a good fit to the data. This index is, however, highly sensitive to sample size, which is a disadvantage. One of the first fit statistics to address this problem was the v2/degrees of freedom or CMIN/DF ratio, which is the minimum sample discrepancy divided by degrees of freedom (Wheaton et al., 1977). Marsh and Hocevar (1985) recommend using ratios as low as 2 or as high as 5 to indicate a reasonable fit. A RMSEA value of 0.05 indicates a close fit and values up to 0.08 represent reasonable errors of approximation in the population (Browne and Cudeck, 1993). A GFI value greater than 0.90 indicates an adequate fit (Bentler, 1990; Tanaka and Huba, 1985). 2.2.9.3. Stepwise regression. A series of three multiple regression analyses was performed with the three factors of independence, emotional adjustment and identity formation as dependent variables to assess the unique contribution of adolescent variables on comparative social development. In a first step age and gender were entered to control for demography. In a second step pain duration and pain intensity were entered to control for pain severity. In a subsequent step, general anxiety, depressive mood, functional disability, family functioning and peer relationships were entered as independent variables using a stepwise method. This series was entered for both ‘independence’ and ‘identity formation’. Emotional adjustment differed slightly because the independent variable ‘peer relationship scale’ consisted of one item that had similar content as the dependent variable. A hierarchical multiple regression was run using the full peer relationship scale and the analysis showed the inde-
pendent variable had a unique value in explaining emotional adjustment (b = 0.36, R2 change = 0.12, F = 13.49, P < 0.001). To ensure that the item overlap was not influencing the outcome of the preliminary analysis the peer relationships scale was abbreviated (i.e., the item which overlapped was removed and the scale was recalculated). A multiple regression was run using the abbreviated scale which showed that the value of peer relationships in explaining emotional adjustment remained (b = 0.36, R2 change = 0.12, F = 12.76, P < 0.001).
3. Results 3.1. Descriptive statistics Table 2 provides a summary of the descriptive statistics for the Pain Management sample. Data from the previously mentioned Rheumatology sample in the earlier paper (Eccleston et al., 2005) is provided solely for comparison purposes. High levels of disability were observed with more than 90% of the adolescents scored in the moderate to high range (FDI-score > 10; Kashikar-Zuck et al., 2001). The results indicate that the adolescents are also emotionally distressed. With regard to depression as measured by the total score of the CDIS, 38% of adolescents scored within the normal limits (T-score of 50 or less), 25 % reported mildly elevated symptoms of depression (T-score between 51 and 65), 18% reported moderately elevated symptoms of depression (T-score between 66 and 79) and 4% reported severely elevated symptoms of depression (T-score of 80 or greater; Kashikar-Zuck et al., 2001). The mean score for anxiety as measured by the SCAS (25.83), was higher than the mean scores of two non-clinical groups (Spence, 1998: n = 20, M = 18.8, SD = 9.7; Muris et al., 2002; n = 521, M = 16.9, SD = 13.1). Adolescents rated themselves as similar to non-clinical controls on the measure of social role functioning
Table 2 Descriptive statistics for the Pain Management sample (n = 110) and the Rheumatology sample (n = 112) Clinic site
Descriptive statistic
BAPQa development
Pain intensity
FDIb
CDIc
SCASd
CASAFSe
Pain Management
Mean Standard deviation Range
24.18 6.46 6.0–39.0
7.53 2.24 0.0–10.0
26.35 11.58 0.0–53.8
5.10 3.69 0.0–16.0
25.83 15.65 2.0–65.0
72.81 8.72 52.0–93.0
Rheumatologyf
Mean Standard deviation Range
20.54 6.78 4.0–10.0
6.08 2.47 0.0–10.0
16.52 12.15 0.0–45.0
3.54 3.41 0.0–14.0
23.73 13.75 2.0–69.0
73.76 8.90 53.0–91.0
Notes: a Bath Adolescent Pain Questionnaire. b Functional Disability Inventory. c Children’s Depression Inventory. d Spence Children’s Anxiety Scale. e Child and Adolescent Social and Adaptive Functioning Scale. f Data on the Rheumatology sample is provided from the earlier paper (Eccleston et al., 2005), for comparative purposes.
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
(CASAFS total = 72.8; non-clinical mean = 71.4; Price et al., 2002). This is an unexpected finding considering that clinical impressions are that these patients present with severe problems in this domain. 3.2. Comparative social development Initial analyses focused on examining how many adolescents considered themselves different from their peers in terms of social development and used the self-perception of development subscale of the BAPQ. A total of 90% of the sample reported the perception that they were developmentally behind in at least one item, and 51% of these adolescents perceived themselves as developmentally behind in four or more items. The 10% of the sample who did not consider themselves to be behind on any items perceived themselves as developmentally ahead on at least one item. Table 3 summarizes the frequency of the samples perceived developmental level on each item listed in the BAPQ developmental subscale. Categories were collapsed to provide overall estimates of adolescent perceptions of feeling ‘ahead’ or ‘behind’ their peers for each item. For 5 of the 11 items the most frequent endorsements were of a perception of being developmentally behind (items relating to school progress, overall independence, social confidence, activity without parents and dating). The latter item was the most highly endorsed item with regard to adolescents perceptions of being ‘very behind’ their peers (29.6%). For 5
769
of the 11 items the most frequent endorsements were of a perception of being developmentally similar (items relating to future planning, handling feelings, identity and choosing one’s own clothes). In only one item was there a majority endorsement of the perception of being developmentally ahead of peers: ‘How I deal with problems’. 3.3. Factor analyses Examining the scree plot, four factors were identified as possible with an eigen value greater than one, accounting for 66% of the variance. The Kaiser– Meyer–Olkin (KMO) test of sampling adequacy was met, KMO = 0.764 and Bartlett’s test of sphericity yielded a X2 of 265.7, df = 55, p < 0.001 indicating significant relationships among the variables and the suitability of the data for PCA. However the fourth factor was determined by three items (‘‘my plans for the future”, ‘‘how often I choose my own clothes and personal belongings”, ‘‘my progress in school”), of which the first two listed items loaded more highly onto factor three. Consequently factor four was considered unstable. The analysis was rerun using a three factor solution. Each factor had an eigen value greater than 1.5. The three factor solution accounted for 56.9% of the variance in the BAPQ development subscale. With regard to variance, factors one, two and three accounted for 34.7%, 12.1% and 10.1% of the variance respectively. The factor loadings can be seen in Table 4.
Table 3 Descriptive statistics and frequency (%) of perceived developmental level on each item Perceived developmental level (%)
My progress in school My overall confidence around other people My plans for the future How often I do things without my parents around My overall independence How often I choose my own clothes and other personal items My ability to go on dates with boyfriends/girlfriends The development of my own sense of identity My ability to handle my own feelings My ability to fit in with friends How I deal with problems
Mean (SD)
N
Behind
Same
Ahead
2.47 (1.13) 2.40 (0.97) 2.08 (1.08) 2.47 (1.07) 2.47 (1.09) 1.79 (0.80) 2.66 (1.11) 1.90 (0.80) 1.92 (0.92) 2.25 (0.90) 1.76 (1.00)
102
56 (54.9%) 51 (47.6%) 29 (27.4%) 50 (47.2%) 52 (49.5%) 13 (12.1%) 51 (52%) 18 (17.2%) 22 (21.6%) 37 (34.9%) 22 (20.8%)
22 (21.6%) 38 (35.5%) 44 (41.5%) 40 (37.7%) 36 (34.3%) 66 (61.7%) 37 (37.8%) 61 (58.1%) 58 (54.2%) 54 (50.9%) 40 (37.7%)
24 (23.5%) 18 (16.8%) 33 (31.1%) 16 (15.1%) 17 (16.2%) 28 (26.2%) 10 (10.2%) 26 (24.8%) 27 (25.2%) 15 (14.2%) 44 (41.5%)
107 106 106 105 107 98 105 107 106 106
770
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Judging oneself to be less independent than one’s peers was predicted by greater pain intensity (b = 0.33, R2 change = 0.15, F = 6.57, P < 0.01) greater disability (b = 0.30, R2 change = 0.08, F = 9.32, P < 0.01) and greater anxiety (b = 0.19, R2 change = 0.03, F = 4.20, P < 0.05). Judging oneself to be less emotionally adjusted than one’s peers was predicted by greater pain intensity (b = 0.33, R2 change = 0.10, F = 5.09, P < 0.01) and great family dysfunction (b = 0.26, R2 change = 0.06, F = 7.14, P < 0.01). And, judging oneself to be less developed in one’s identity was predicted by greater pain intensity (b = 0.29, R2 change = 0.104, F = 5.09, P < 0.01) and greater depression (b = 0.26, R2 change = 0.05, F = 5.65, P < 0.05). Strong peer relationships predicted positive judgements of independence (b = 0.43, R2 change = 0.16, F = 17.91, P < 0.001), emotional adjustment (b = 0.36, R2 change = 0.12, F = 13.49, P < 0.001), and identity formation (b = 0.46, R2 change = 0.19, F = 22.98, P < 0.001).
The first factor was labelled ‘‘independence” and was made up of four items dominated by behaviour in school and with peers independent from parents (with a Cronbach’s alpha of.70). The second factor was labelled ‘‘emotional adjustment” and was dominated by behaviour associated with emotional problem solving and competence (with a Cronbach’s alpha of .75). The third factor was labelled ‘‘identity formation” and was dominated by socially assured behaviour (with a Cronbach’s alpha of .61). All three factors are intercorrelated. Table 5 shows the correlation coefficients of the three factors of perceived development and the pain related variables and other study variables. Of note is the significant inverse association between perceived development and pain intensity: the greater the pain intensity, the less developed adolescents perceived themselves to be in all three areas. Also worth noting is the finding that the positive peer relationships is associated with greater perceived social development in all three factors (independence r = 0.39, emotional adjustment r = 0.36, identity formation r = 0.47). The confirmatory factor analysis model fit indices indicated a reasonable fit (Chi Square (41) = 62.66, p < 0.02; CMIN/DF = 1.528; RMSEA = 0.071; GFI = 0.90). All items loaded significantly upon the hypothesized latent variable, except one item: ‘My progress in school’. Subsequent analyses revealed that this item did also not load significantly upon the other two latent factors. Future research will have to resolve whether this item is a valid indicator of the factor ‘‘independence”.
4. Discussion A sample of adolescent chronic pain patients with a four year history of chronic pain reported high pain, disability, and distress. Almost 51% of adolescents judged that when compared with their peers they were behind in four or more of the domains of adolescent social development. The most common perception of developmental lag was in school progress and independence. The most common perception of developmental advancement was in dealing with problems. Three factors of self-perception of social development were identified and labelled as ‘independence’, ‘emotional adjustment’, and ‘identity formation’. For all three factors pain intensity had a negative influence. Family dysfunction had a negative affect on emotional adjustment, and depressive mood had a negative affect on identity. However, across all three factors of social development, strong peer relations played a protective
3.4. Predictors of adolescent comparative social development The results of this series of multiple regressions are shown in Table 6. Variance inflation factors in all three regression analyses were small, indicating that there was no problem of co-linearity.
Table 4 Factors loadings for the BAPQ development subscale items (three factor solution) Factor loadings Independence How often I do things without my parents around My overall independence My progress in school My ability to go on dates with boyfriends/girlfriends How I deal with problems My ability to handle my own feelings My ability to fit in with friends The development of my own sense of identity My overall confidence around other people My plans for the future How often I choose my own clothes and other personal items Note: The highest factor loading for each item is provided in bold type.
0.83 0.75 0.54 0.53 0.02 0.10 0.16 0.29 0.10 0.19 0.06
Emotional adjustment 0.04 0.31 0.06 0.06 0.88 0.80 0.54 0.20 0.01 0.23 0.12
Identity formation 0.09 0.00 0.05 0.31 0.031 0.01 0.26 0.76 0.70 0.68 0.50
Table 5 Correlations between psychosocial variables and social development
1. Independence 2. Emotional adjustmentd 3. Identity formationd 4. Age 5. Gender 6. Pain duration 7. Pain intensity 8. School performancee 9. Peer relationshipse 10. Family relationshipse 11. Home duties/self caree 12. Physical functioningf 13. Depressionf 14. General anxietyf 15. Family functioningf 16. Pain specific anxietyf 17. Social functioningf a b c d e f
91 105 104 110 110 102 106 101 106 105 107 108 110 108 108 109 109
Mean 9.91 5.92 8.10 14.65 0.73 49.12 6.49 17.02 17.59 19.81 15.75 15.94 11.83 11.29 17.37 14.01 14.62
SD 3.17 2.30 2.51 1.88 0.44 45.78 2.69 3.85 3.25 2.83 3.14 8.18 4.50 5.07 7.18 5.64 6.75
2
3 b
0.43 –
4 b
0.46 0.43b –
5 0.04 0.07 0.10 –
6 0.02 0.10 0.09 0.02 –
7 0.21 0.01 0.10 0.21a 0.17 –
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed). Correlation is significant at the 0.001 level (2-tailed). Factors from the development subscale of the Bath Adolescent Pain Questionnaire. Subscale of the Child and Adolescent Social and Adaptive Functioning Scale. Subscale of the Bath Adolescent Pain Questionnaire.
8 b
0.36 0.31b 0.26b 0.02 0.20a 0.01 –
9 a
0.24 0.30b 0.22a 0.03 0.14 0.01 0.24a –
10 b
0.39 0.36b 0.47b 0.03 0.19a 0.05 0.07 0.17 –
0.03 0.26b 0.08 0.06 0.01 0.14 0.06 0.30b 0.10 –
11 0.17 0.02 0.22a 0.19 0.05 0.04 0.04 0.25a 0.14 0.25b –
12
13 b
0.50 0.15 0.26b 0.01 0.01 0.10 0.33b 0.17 0.26b 0.01 0.28b –
14 b
0.31 0.31b 0.35b 0.31b 0.03 0.05 0.40b 0.30b 0.26b 0.28b 0.21a 0.33b –
15 b
0.28 0.31b 0.23a 0.12 0.02 0.06 0.22a 0.23a 0.13 0.19 0.20a 0.33c 0.61b –
0.21 0.33b 0.20a 0.14 0.04 0.04 0.24a 0.32b 0.15 0.50b 0.32b 0.17 0.52b 0.43b –
16
17 0.51c 0.41c 0.49c 0.04 0.10 0.12 0.24a 0.29b 0.64c 0.21a 0.17 0.46c 0.54c 0.30b 0.31c 0.23a
0.11 0.16 0.08 0.02 0.02 0.10 0.29b 0.06 0.05 0.06 0.01 0.34c 0.47c 0.54c 0.36c –
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
N d
771
772
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Table 6 Results of the hierarchical regression analyses for developmental factors Criterion variable
Step
Predictor
B
R2 change
R2
Independence
1
Age Gender Pain duration Pain intensity Peer relationshipsa Physical functioningb General anxietyb
0.022 0.012 0.210 0.333d 0.429e 0.301d 0.194c
0.001
0.001
0.147d
0.148
0.103
0.164e 0.077d 0.033c
0.312 0.389 0.422
0.266 0.340 0.367
Age Gender Pain duration Pain intensity Peer relationshipsa Family functioningb
0.089 0.093 0.010 0.332d 0.361e 0.257d
0.014
0.014
0.104d
0.119
0.078
0.121e 0.060d
0.239 0.299
0.195 0.249
Age Gender Pain duration Pain intensity Peer relationshipsa Depressiona
0.050 0.127 0.063 0.290d 0.459e 0.256c
0.020
0.020
0.084c
0.105
0.062
0.192e 0.045c
0.297 0.342
0.255 0.294
2 3 4 5 Emotional adjustment
1 2 3 4
Identity formation
1 2 3 4
Adj. R2 0.025
0.008
0.002
The reported standardized bs are those from the final step in the regression analysis. a Physical functioning subscale of the Bath Adolescent Pain Questionnaire. b Family functioning subscale of the Bath Adolescent Pain Questionnaire. c P < 0.05. d P < 0.01. e P < 0.001.
role, being associated with positive judgements of development. Reduced social contact and poor peer relationships are related to judgements of poor social development. Chronic pain appears to have direct effects on reducing opportunities for social exposure and normative developmental experience (e.g., school and peer group involvement) but also increases exposure to dependent relationships in the home setting. Chronic pain not only produces immediate effects on adolescent current experience but also critically changes the social environment within which adolescents develop. It is possible that adolescents who perceive themselves to lag behind their peers may feel unable to undertake normative tasks such as those of higher education study, employment or moving away from the family home. The longer term adult consequences of perceived social developmental delay remain unknown. Perhaps more positive was the finding that adolescents also report that their experience of coping with chronic pain has led to comparative maturity in problem solving. It remains possible that such a perceived advancement may be either a further burden or a protective advantage for later coping. The mechanism(s) by which peer relationships and family coping are related to perceptions of comparative development are unknown. Harter and Whitesell (2003) argue that self-worth and the development of stable selfesteem are important precursors for later adult adjustment. The protective influence of peer relationships on
comparative judgements may be mediated by intrapersonal characteristics such as self-esteem or judgements of self-worth. Similarly, Harter et al. (1998) have found that such judgements are often contextually specific. It remains to be investigated whether positive self-judgements are more protected by peer relations in some situations (e.g., school) compared with other situations (e.g., family home). There is a number of limitations to this study. First, although the self-perception of development subscale of the BAPQ asks specifically about developmental issues affected by pain, there are no normative data from this measure. Therefore we have no way of knowing if the pattern of results is typical of adolescents with or without pain. Second, our access to judgements of development was via adolescent comparison with unknown peers. We were very clear that this adolescent ‘perception’ of development was our focus, but care should be taken when discussing whether chronic pain affects development without further empirical testing. Social comparison biases may affect these judgements, and we have no objective measure of peer development as a control for any biases. Third, the content of the self-perception of development subscale could benefit from revision. In particular, missing is any content referring to sexual maturation, considered by some a core aspect of adolescent development. Fourth, these data are crosssectional and hence caution is necessary when considering the direction of observed relationships between
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
self-perceived adolescent social development and the experience of adolescent chronic pain. Fifth, it is possible that factors, other than the experience of chronic pain may be responsible for adolescent perceptions of developmental delay in comparison to peers. For example, depression is associated with cognitive distortion in adolescent populations (Marcotte et al., 2006) and this may be characterised by perceptions of the self as less competent than others. There is preliminary evidence for this in the statistically predictive relationship of depression to identity development. Sixth, the sample is somewhat smaller than ideally desired for use with analytical methods such as stepwise regression. Replication of these analyses with larger samples would be of benefit. Finally, these data are from a specific group of very disabled and distressed chronic pain patients. Data from other centres and other chronic pain patients are necessary, particularly samples comprising large adolescent populations with specific diagnoses (e.g. headache, recurrent abdominal pain). A number of areas could be usefully investigated further. First, as indicated, replicate data from other research centres, normative data from school or community samples comprising adolescents without chronic pain, and data from other patient groups would be extremely helpful. Interesting would be objective data of social development and other-reported data (for example, comparative data from peers and from parents). Second, development is by definition a dynamic (ie. temporally sensitive) concept. What is needed are longitudinal data relating to the effect of pain on different stages or key tasks of development. Third, pain intensity had robust effects across all three factors. It is not clear in what way pain intensity is related to perceived social development, whether directly in the repeated exposure to a negative aversive experience, or indirectly through restricted social participation. Predictive and mediation analyses will be helpful to investigate these relationships further. Fourth, an intriguing finding of this study was the seemingly protective effect of positive peer relationships on social development. There is very little work on the importance of peers to the development of coping in chronic pain, and this finding strongly suggests that further research on friendship, and peer support is warranted. References Adams GR, Gullotta TP, Montemayor R. Adolescent identity formation. In: Hosek SG, Harper GW, Robinson L, editors. Identity development in adolescents living with HIV. J Adolescence 1992;25:355–64. Arbuckle JL. Amos 5.0 update to the Amos user’s guide. Chicago (IL): SPSS; 2003. Arbuckle JL, Wothke W. Amos 4.0 user’s guide. Chicago (IL): SPSS; 1995, 1999.
773
Bentler PM. Comparative fit indexes in structural models. Psychol Bull 1990;107:238–46. Browne MW, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Long JS, editors. Testing structural equation models. Newbury Park (CA): Sage; 1993. Eccleston C, Jordan A, McCracken LM, Sleed M, Connell H, Clinch J, et al. The Bath Adolescent Pain Questionnaire (BAPQ): development and preliminary psychometric evaluation of an instrument to assess the impact of chronic pain on adolescents. Pain 2005;118:263–70. Eccleston C, Crombez G, Scotford A, Clinch J, Connell H. Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents. Pain 2004;108:221–9. Fichtel A, Larsson B. Psychosocial impact of headaches and comorbidity with other pains among Swedish school adolescents. Headache 2002;42:766–75. Gauntlett-Gilbert J, Eccleston C. Disability in adolescents with chronic pain: patterns and predictors across different domains of functioning. Pain 2007;131:132–41. Grotevant HD. Toward a process model of identity formation. J Adolescent Res 1987;2:203–22. Harter S, Waters P, Whitesell NR. Relational self-worth: differences in perceived worth as a person across interpersonal contexts among adolescents. Child Dev 1998;69:756–66. Harter S, Whitesell NR. Beyond the debate: Why some adolescents report stable self-worth over time and situation, whereas others report changes in self-worth? J Person 2003;71:1027–58. Hunfeld JAM, Perquin CW, Duivenvoorden HJ, Hazebroek-Kampschreur AAJM, Passchier J, van Suijlekam-Smit LWA, et al. Chronic pain and its impact on quality of life in adolescents and their families. J Pediatr Psychol 2001;26(3):145–53. Huygen ACJ, Kuis W, Sinnema G. Psychological, behavioural, and social adjustment in children and adolescents with juvenile chronic arthritis. Ann Rheum Dis 2000;59:276–82. Kashikar-Zuck S, Goldschneider KR, Powers SW, Vaught MH, Hershey AD. Depression and functional disability in chronic paediatric pain. Clin J Pain 2001;17:341–9. Kistner J, David C, Repper K. Self-enhancement of peer acceptance: implications for children’s self-worth and interpersonal functioning. Soc Dev 2007;16:24–44. Kovacs M. Rating scales to assess depression in school aged children. Acta Paedopsychiatr 1981;46:305–15. Malleson PN, Clinch J. Pain syndromes in children. Curr Opin Rheumatol 2003;15:572–80. Marcia J. Development and validation of ego-identity status. In: Gullotta TP, Adams GR, Markstrom CA, editors. The adolescent experience. 4th ed. London: Academic Press; 2000. p. 79–81. Marcotte D, Le´vesque N, Fortin L. Variations of cognitive distortions and school performance in depressed and non-depressed high school adolescents: a two-year longitudinal study. Cognit Ther Res 2006;30:211–25. Marsh HW, Hocevar D. Application of confirmatory factor analysis to the study of self-concept: first- and higher-order factor models and their invariance across groups. Psychol Bull 1985;97:562–82. Merlijn VPBM, Hunfeld JAM, Van der Wouden JC, HazebroekKampschreur AAJM, Koes BW, Passchier J. Psychosocial factors associated with chronic pain in adolescents. Pain 2003;101: 33–43. Muris P, Merckelbach H, Ollendick T, King N, Bogie N. Three traditional and three new childhood anxiety questionnaires: their reliability and validity in a normal adolescent sample. Behav Res Ther 2002;40:753–72. Palermo T, Putnam J, Armstrong G, Daily S. Adolescent autonomy and family functioning are associated with headache-related disability. Clin J Pain 2007;23:458–65.
774
C. Eccleston et al. / European Journal of Pain 12 (2008) 765–774
Price CS, Spence SH, Sheffield J, Donovan C. The development and psychometric properties of a measure of social and adaptive functioning for children and adolescents. J Clin Child Adoles Psychol 2002;31:111–22. Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J, Schmucker P. Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics 2005;115(2):483–4. Spence SH. The Spence Children’s Anxiety Scale (SCAS). In: Sclare I, editor. The child psychology portfolio. Windsor: Nfer Nelson; 1994. Spence SH. A measure of anxiety symptoms among children. Behav Res Ther 1998;36:545–66. Tanaka JS, Huba GJ. A fit index for covariance structure models under arbitrary GLS estimation. Brit J Math Stat Psy 1985;38:197–201. Varni JW, Thompson KL, Hanson V. The Varni/Thompson pediatric pain questionnaire. Chronic musculoskeletal pain in juvenile rheumatoid arthritis. Pain 1987;28:27–38. Walker LS, Greene JW. The Functional Disability Inventory: measuring a neglected dimension of child health status. J Pediatr Psychol 1991;16:39–58.
Walker LS, Williams SE, Smith CA, Garber J, Van Slyke DA, Lipani TA. Parent attention versus distraction: impact on symptom complaints by children with and without chronic functional abdominal pain. Pain 2006;122:43–52. Walker LS, Heflinger CA. Quality of life predictors of outcome in pediatric abdominal pain patients: findings at initial assessment and at 5 year follow up. In: Drotar D, editor. Measuring health related quality of life in children and adolescents: implications for research and practice. Mahwah (NJ): Lawrence Erlbaum; 1998. p. 237–52. Wheaton B, Muthe´n B, Alwin D, Summers G. Assessing reliability and stability in panel models. In: Heise DR, editor. Sociological methodology 1977. San Francisco: Jossey-Bass; 1977. Yoder AE. Barriers to ego identity status formation: a contextual qualification of Marcia’s identity status paradigm. J Adolescence 2000;23:95–106. Zeltzer LK, Tsao JCI, Stelling C, Powers M, Levy S, Waterhouse M. A phase I study on the feasibility and acceptability of an acupuncture/-hypnosis intervention for chronic pain. J Pain Symptom Manage 2002;24:437–46.