Neuropsychiatric Symptoms in Pediatric Chronic Pain and Outcome of Acceptance and Commitment Therapy

Abstract

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy (ACT) treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children and adolescents aged 8-18 years (N = 47) were recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities (i.e., pain interference, sleep, and physical and school functioning), socioemotional functioning (i.e., depressive symptoms, emotional, and social functioning), psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key.

Keywords: acceptance and commitment therapy; attention-deficit hyperactivity disorder; autism spectrum disorder; pediatric chronic pain; socioemotional functioning.

Figure 1

Significant Pearson correlations of pretreatment functioning with autism traits (A–C) and with ADHD symptoms (D–F). Non-significant correlations are shown in Table 2 and Supplementary Figure 1.

Figure 2

Pre- to post-ACT changes for all outcome measures. Values on the y-axes are mean scores pre- and post-ACT. Errors bars represent standard error of the mean. ***p < 0.001, **p < 0.01, *p < 0.001.

Figure 3

Pre- (white triangles) and post-ACT scores (dark gray squares) are plotted on the primary (left) y-axis for each patient for insomnia (A), emotional functioning (B), and pain interference (C). Black circles on secondary y-axis represent individual autism scores (presented from the lowest to the highest score). The right panel (D–F) shows significant correlations between autism traits and change score (from pre- to post-ACT) for insomnia (D) emotional functioning (E), and pain interference (F). Negative insomnia severity/pain interference change scores indicate greater improvements in insomnia/pain interference. Positive emotional functioning change scores indicate greater improvements in emotional functioning.