Pediatric Pain Screening Identifies Youth at Risk for Chronic Pain in Sickle Cell Disease

Introduction: Chronic pain related to pediatric sickle cell disease (SCD) contributes to high healthcare use and poor quality of life. Factors that contribute to the transition from acute to chronic pain in SCD remain largely unknown. Thus, chronic SCD pain remains a challenging problem that is difficult to manage due to the complex interaction of biological, psychological, and social determinants that contribute to its onset and maintenance. Common sequelae of chronic SCD pain in children and adolescents include functional impairment, frequent school absences, elevated depressive symptoms, and high levels of anxiety or catastrophic thinking. Early identification of youth who are at risk of developing chronic SCD pain is needed to help prevent the onset and exacerbation of chronic pain. This study aimed to identify youth at increased risk for chronic SCD pain and its sequelae through the integration of a brief psychosocial pain screening tool. Children and adolescents with SCD identified as "high risk" on the pain screening tool were expected to demonstrate a psychosocial profile consistent with chronic SCD pain, including increased pain frequency and duration, high levels of functional impairment, elevated anxiety and depressive symptoms, and reduced quality of life.

Methods: Children and adolescents with SCD presenting to a pediatric SCD clinic completed the Pediatric Pain Screening Tool, a brief 9-item self-report questionnaire developed for rapid identification of risk in youth with pain complaints. Youth also completed a battery of surveys about their pain characteristics (pain frequency and duration), pain burden (SCD Pain Burden Interview for Youth), functional impairment (PROMIS Pain Interference), anxiety (Pain Catastrophizing Scale-Child; Fear of Pain Questionnaire), depressive symptoms (Children's Depression Inventory -2), and quality of life (Pediatric Quality of Life-SCD Module).

Results: Youth (n=45) were on average 13.5 years old (SD = 4.4), 89% Black or African American, 80% HbSS, 85.5% prescribed hydroxyurea, and 16.7% receiving chronic transfusions. Youth were classified into Low (n=15, 33.3%), Medium (n=15, 33.3%), and High (n=15, 33.3%) risk groups based on pain screening. Risk groups did not significantly differ by age, race, hemoglobin type, or treatment with hydroxyurea or chronic transfusions. Multivariate Analysis of Variance (MANOVA) showed significant risk group differences on pain characteristics, pain burden, functional impairment, anxiety and depressive symptoms, and quality of life (Wilks' λ = 0.13, F_{16, 54} = 6.02, p < .001). Post-hoc univariate tests revealed that youth in the High Risk group had significantly higher pain frequency (M=15.2 days/month, SD= 2.2) and duration (over 1 year) compared to the Low (M=1.8, SD= 2.3; duration 1.2 months) and Medium (M=7.6, SD= 2.3; duration 2.5 months) Risk groups. The High Risk group also had significantly higher pain burden, functional impairment, catastrophic thinking, depressive symptoms, and poorer quality of health compared to the Low and Medium Risk groups. The High Risk group had significantly higher levels of fear of pain relative to the Low Risk group, but there was no significant difference in fear of pain between the Medium and High Risk groups.

Conclusions: Brief psychosocial pain screening may be a helpful tool to support the early identification of youth at risk for chronic SCD pain. Youth classified as High Risk based on pain screening demonstrated a psychosocial profile consistent with other pediatric chronic pain conditions. Additionally, the High Risk group reported high pain frequency and duration that is consistent with the primary diagnostic criteria for chronic SCD pain (i.e., ≥15 days of pain per month, lasting ≥ 6 months). Further validation with a larger sample of children and adolescents with SCD is needed to support the utility of the Pediatric Pain Screening Tool in identifying youth at risk of transitioning from acute to chronic pain.

Supported by NCATS Award UL1TR000454. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.