Perceived Injustice Is Associated With Pain and Functional Outcomes in Children and Adolescents With Chronic Pain: A Preliminary Examination

Abstract

Chronic pain is prevalent in children/adolescents and contributes to high healthcare utilization. Research suggests injustice perceptions about pain are important in adult patients and a possible treatment focus. We conducted a preliminary evaluation of the psychometric properties of the Injustice Experiences Questionnaire (IEQ) and the relationship between injustice perceptions, pain, and functioning in chronic pain patients (N=139, mean age=15 years, 72% female) presenting to a pediatric pain clinic. Patients completed measures assessing pain intensity, injustice perceptions about pain, catastrophizing, overall functional disability, emotional functioning, social functioning, and school functioning. The IEQ demonstrated good reliability and validity. Higher levels of perceived injustice were associated with higher levels of pain intensity, catastrophizing, and functional disability, and with poorer emotional, social, and school functioning. Additionally, perceived injustice remained significantly associated with pain intensity, functional disability, emotional functioning, social functioning, and school functioning after accounting for relevant demographic and clinical factors. This is the first study to suggest that injustice perceptions are important in the experience of pediatric chronic pain patients.Future studies should more thoroughly examine the psychometric properties of the IEQ in children/adolescents and elucidate the causal nature of these relationships, which will inform treatment efforts to improve pediatric pain care.Perspective: This initial investigation suggests that injustice perceptions about pain can be reliably and validly measured and are tied to important clinical outcomes in children/adolescents. Future studies that replicate and extend these preliminary results are necessary to determine the extent to which injustice perceptions are an important target for intervention.

Injustice perceptions about pain: parent–child discordance is associated with worse functional outcomes

“…Dyads where the child endorsed elevated injustice perceptions (concordant high and discordant high Clow P) were characterized by higher pain, stress, and disability, and poorer quality of life as reported by the child, compared to dyads where the child endorsed lower injustice perceptions. These findings align with research suggesting that negative pain appraisals are related to poor pain outcomes in children [18,21,22,25,35,36,44]. Catastrophizing, in particular, has been associated with negative outcomes including increased pain behaviors and depressive symptoms, and decreased functioning [21].…”

“…Data from a subset of this sample were analyzed in a previous study [22]; however, that study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 focused only on pediatric patients, did not include parents, and had different aims from the current study.…”

“…In addition to catastrophizing, pain-related injusticean appraisal cognition comprising elements of the severity of loss, blame, unfairness, and irreparability [40] has been identified as an important cognitive-emotional factor for adults [29,38,40] and, more recently, for children with pain [22]. High injustice perceptions are associated with elevated pain behavior, psychological distress, and poor functional outcomes in adults [29,38,40,40] and with elevated pain intensity, catastrophizing, and poorer physical, emotional, social, and school functioning in children [22]. To our knowledge, no study has investigated the pain-related injustice perceptions of important confidants (e.g., parent, spouse) to the pain sufferer.…”

Implications of parent and child injustice appraisals for child pain and functional outcomes

“…Parental ratings of injustice were correlated with poor child outcomes, but these effects were strongest among children with higher injustice ratings and, also in dyads containing children with high perceptions of injustice, specifically those in the 'concordant high' and 'discordant high child -low parent' groups. As the authors rightly suggest, these findings indicate that, consistent with the pattern of findings in the only other paediatric study [3] and within the adult literature in general, child appraisals of their own injustice are the primary drivers of pain and functional outcomes. Nevertheless, perhaps the most interesting finding is that among all concordant and discordant groups, the worst outcomes were observed in the discordant group where the child had a higher level of perceived injustice than their parent.…”

“…As indicated in the discussion, it will be useful in future to investigate whether these findings will be replicated with parents who do not have such significant ratings. 3 Although the authors explain their findings well in relation to relevant literature, interpretation is still somewhat precluded by the lack of key information on the characteristics of the participants. This includes facts about the gender of the parent, duration of diagnosis and number of clinic appointments attended, all of which could be hypothesised to influence pain-related injustice appraisals and associated child outcomes.…”