An estimated 25% of children and adolescents report having pain that persists for more than 3 months, with severe and disabling pain affecting 8% of this population.1 As is the case in other age groups with chronic pain, these individuals face a number of physiological, psychological, and social challenges with varying degrees of resilience.
In a review published in Pain Research and Management, Annina Riggenbach, PhD, of the Family and Development Center at the University of Lausanne, Switzerland, and colleagues examined the evidence regarding the role of 3 basic psychological needs — autonomy, competence, and relatedness — in the modulation of disease-related disability in adolescents with chronic pain.1
According to the Self-Determination Theory proposed by the review authors, the satisfaction of these needs “would be essential for psychological growth, subjective well-being, and optimal human functioning, whereas their frustration would lead to maladjustment and the development of psychopathology.” Some researchers have postulated that need frustration may be associated with reduced motivation.2
Other studies indicate that environmental factors play an important role in modulating need satisfaction and well-being. For pediatric patients, these factors include parenting style. Studies support the notion that autonomy-supportive parenting may predict need satisfaction, and that controlling parenting may predict need frustration.1
The frustration of basic needs “may explain why chronic pain is predictive of diminished goal pursuit, disability, and functional diﬃculties, hence playing a mediating role,” according to the review authors. “At the same time, the contextual support of [the patients’] needs may play a moderating role…. [as a] …resilience factor that explains why some adolescents do well… even under conditions of high pain.”
Conclusions from studies in which factors that underlie adaptive functioning in adolescents were examined and are summarized below.
Autonomy. The Self-Determination Theory defines autonomy as “volitional functioning” rather than independence. In a 2014 study, teachers’ support of autonomy in adolescent patients with chronic pain was linked with higher school functioning (ie, greater attendance, better grades, and fewer instances of being bullied by peers).3 In other research, support of autonomy by partners and healthcare providers was associated with positive effects on adjustment, treatment adherence, and treatment outcomes in adults with chronic pain.1
Competence. As reported in a review published in 2016, feelings of incompetence in “adolescents with chronic pain were associated with increased activity avoidance and disability and limited the development of adequate strategies to manage pain.”1,4
“Prolonged avoidance and absenteeism might in turn intensify the feeling of incompetence and decrease the motivation to attend school or any other activity, thus creating a downward spiral,” noted the current review authors.
In addition, self-efficacy, an aspect of competence, has been linked with higher quality of life and self-esteem, lower levels of pain, and fewer behavioral and psychological symptoms.5,6 Overall, support of adolescents’ need for competence by teachers, parents, and peers is thought to be associated with fewer somatic symptoms, better functioning, higher school attendance, a lower likelihood of avoidance mechanisms use, and reduced disability.
Relatedness. The need for relatedness in adolescents with chronic pain may be thwarted by the social challenges that are particular to this population (eg, low acceptance by peers, isolation, and victimization by peers). Positive social interaction is thought to be associated with a lower risk for social isolation, improved pain management, lower likelihood of using avoidance mechanisms, and higher quality of life and functional ability in these patients.
Developmental models could “provide important information to understand resilience mechanisms to [living] adaptively with chronic pain” in adolescents, the review authors concluded.1 The Self-Determination Theory “may provide a developmental framework that can foster our understanding of why adolescents with chronic pain are likely to adopt avoidant behaviors or, by contrast, to pursue personal goals and live adaptively.”
Clinical Pain Advisor interviewed Gerard Banez, PhD, pediatric psychologist and program director of the Cleveland Clinic Pediatric Pain Rehabilitation Program, to further discuss the points made in this review.
Clinical Pain Advisor: What does this review add to our understanding of adolescents’ adaptation to chronic pain?
Dr Banez: The paper encourages us to consider adaptation to chronic pain within a developmental framework, with particular attention to how the satisfaction of basic psychological needs contributes to adaptive functioning despite pain. According to Riggenbach and colleagues, the satisfaction of our basic psychological needs for autonomy, competence, and relatedness provides resilience against the negative impact of pain and contributes to normal functioning in the face of pain.
The paper also highlights the important role of contextual support of these needs. Kids who have family and friends that support the satisfaction of these needs will handle their pain better.
Clinical Pain Advisor: Based on the Self-Determination Theory, the authors suggest that the “satisfaction of one’s basic psychological needs and their contextual support are important resources for adolescents to live adaptively with chronic pain.” Do you agree? What are some ways in which clinicians can advocate for these goals in their adolescent patients with chronic pain?
Dr Banez: I absolutely agree. Clinicians can advocate for these goals in many ways. One way is by promoting a self-management approach to chronic pain, emphasizing that kids can learn to manage their pain effectively and independently and maintain normal, age-appropriate functioning despite their pain. To help with a sense of competence, self-esteem enhancement strategies and promoting a sense of control are important. For example, clinicians could say: “It’s time for you to take control of your life and not let pain dictate what you can and cannot do.” Social skills and social problem-solving training, as well as encouraging increased interpersonal activity, can improve relatedness.
Clinical Pain Advisor: What are some relevant treatment recommendations?
Dr Banez: Family members — particularly parents — and friends play an important role in helping kids with chronic pain function adaptively. To promote a self-management approach, I always tell parents that their role is to help their kids learn to help themselves. They can do this by teaching their kids how to make decisions on their own and encouraging independent decision making.
Meaningful praise and reinforcement can help build self-esteem, and confidence-building strategies are important. Parents should support social activity even when kids are not feeling well, as the potential benefits and rewards outweigh the discomfort and concerns.
Clinical Pain Advisor: What should be the next steps in this area in terms of research?
Dr Banez: Next steps would include direct testing of the role that these psychological needs play in adaptation to chronic pain. Research on contextual influences on the satisfaction of these needs —such as parental support of autonomy — will also be important. Clinically, development and evaluation of child-parent treatment programs that promote psychological need satisfaction will be most useful.
1. Riggenbach A, Goubert L, Van Petegem S, Amouroux R. Topical review: basic psychological needs in adolescents with chronic pain-a self-determination perspective. Pain Res Manag. 2019;2019:8629581.
2. Haerens L, Aelterman N, Vansteenkiste M, Soenens B, Van Petegem S. Do perceived autonomy-supportive and controlling teaching relate to physical education students’ motivational experiences through unique pathways? Distinguishing between the bright and dark side of motivation. Psychol Sport Exerc. 2015;16(3):26-36.
3. Vervoort T, Logan DE, Goubert L, De Clercq B, Hublet A. Severity of pediatric pain in relation to school-related functioning and teacher support: an epidemiological study among school-aged children and adolescents. Pain. 2014;155(6):1118-1127.
4. Sinclair CM, Meredith P, Strong J, Feeney R. Personal and contextual factors affecting the functional ability of children and adolescents with chronic pain: a systematic review. J Dev Behav Pediatr. 2016;37(4):327-342.
5. Libby CJ, Glenwick DS. Protective and exacerbating factors in children and adolescents with fibromyalgia. Rehabil Psychol. 2010;55(2):151-158.
6. Bursch B, Tsao JCI, Meldrum M, Zeltzer LK. Preliminary validation of a self-efficacy scale for child functioning despite chronic pain (child and parent versions). Pain. 2006;125(1-2):35-42.
This article originally appeared on Clinical Pain Advisor