Young people with and without chronic pain: The role of anxiety

Everyday pain is common during childhood and adolescence. However, pain that persists is associated with poorer functioning including missed developmental milestones, disrupted emotional functioning, and social isolation. Children and adolescents with chronic pain often report high levels of anxiety. Anxiety, the cognitive, physiological, and behavioural reaction to a threatening stimulus, is associated with disability and poor functioning within this population. Anxiety is common during childhood and adolescence beyond a context of pain. Adolescence is a time of change and autonomy and experiencing long-term pain can inhibit those goals. Youth with higher levels of anxiety also experience higher levels of social isolation and poorer coping skills. Yet psychological interventions do not typically target anxiety to improve the functioning of children and adolescents. My primary research aim is to investigate the role of anxiety within the context of pain for adolescents. Specifically, I investigate the effect of anxiety on functioning and behaviour, and determine the characteristics of anxiety between adolescents with and without chronic pain. Finally, it is important to assess whether anxiety can be reduced in children and adolescents with chronic pain through psychological interventions and I investigate the efficacy of psychological treatments for children and adolescents with chronic pain for the outcomes anxiety, pain, disability, depression, and sleep. First, in Chapter One I review the current literature with a specific focus on anxiety within a paediatric population with chronic pain, identifying the gaps in the current research. In Chapters 2-4, I present one secondary data analysis study and two empirical studies that investigate the role of anxiety. In Chapter Two, I investigate the effect of anxiety experienced during early adolescence on the development of chronic pain, pain- related anxiety, and pain- related disability in later adolescence. This study showed that higher general anxiety at 13 years of age, and higher pain-related anxiety at 17 years of age in adolescence were associated with pain-related disability. Having established the importance of anxiety in Chapter Two, I next investigate the characteristics of anxiety in adolescents, and further identify differences of anxiety characteristics between adolescents with and without chronic pain in Chapter Three. I found that adolescent’s worry was predominantly 8 about personal competence: being criticised, being perceived negatively, and selfcriticism. There were no differences between adolescent with and without chronic pain. In Chapter Four, I adopt a more motivational stance, to investigate how the role of goals and anxiety promote approach and avoidance of activities when in pain. Goals promoted the approach of activities when in pain but only when high pain intensity vignettes were presented. Anxiety about pain, but not general anxiety predicted avoidance of activities due to pain. The findings from these three studies demonstrate the detrimental impact of elevated anxiety and therefore, it was next important to investigate whether anxiety can be reduced by psychological interventions in children and adolescents with chronic pain. I conduct two systematic reviews in Chapter Five that investigate how efficacious psychological therapies are at reducing anxiety within a paediatric population. Analyses revealed that psychological therapies were not beneficial at reducing anxiety in this population, but were beneficial at reducing pain and disability, particularly posttreatment. Finally, in Chapter Six, I present my discussion and conclusions. Collectively, my findings from this thesis show that anxiety is an important variable to consider when investigating and treating pain in children and adolescents. Higher levels of anxiety experienced early in life are important to identify and treat. Nevertheless, adolescents with and without chronic pain have similar worries and characteristics of worry in later adolescence, and anxiety about pain is most detrimental to functioning when in pain. Finally, psychological interventions for children and adolescents with chronic pain do not frequently target anxiety and systematic reviews do not show a reduction in anxiety after receiving psychological therapies in this population. I conclude with a new model of how anxiety contributes to disability in this population and provide implications for research and practice.