Topical Review: Getting into the head of youth with chronic pain: how theory of mind deficits may relate to the development and maintenance of pediatric pain

Abstract

Objective

Theory of mind (ToM) is the ability to understand the thoughts, feelings, and mental states of others and is critical for effective social and psychological functioning. ToM deficits have been associated with various psychological disorders and identified in adult pain populations. For youth with chronic pain, ToM deficits may underlie the biological, psychological, and social factors that contribute to their experience of pain, but this remains poorly understood.

Methods

This topical review explored the extant literature in the areas of ToM and chronic pain, particularly for pediatric populations, with respect to biological, psychological, and social elements of the biopsychosocial model of pain.

Results

ToM deficits may be present alongside previously identified biological, psychological, and social correlates of pediatric pain, as a vulnerability, mechanism, and/or consequence. Biologically, ToM deficits may relate to cortisol abnormalities and neurobiological substrates of pain processing. Psychologically, ToM deficits may stem from pain-focused cognitions, thus impacting relationships and fueling impairment. Socially, chronic pain may preclude normative development of ToM abilities through social withdrawal, thereby exacerbating the experience of pain.

Conclusion

Taken together, ToM deficits may be associated with increased risk for the development and/or maintenance of pediatric chronic pain, and pediatric chronic pain may similarly confer risk for ToM deficits. Future research should investigate the nature of ToM abilities in youth with chronic pain to test these hypotheses and ultimately inform ToM-focused and pain-based interventions, as this ability has been demonstrated to be modifiable.

Theory of mind (ToM), sometimes referred to as “perspective-taking,” is a multifaceted, social-cognitive process that represents the ability to understand the thoughts, feelings, and mental states of others (Premack & Woodruff, 1978). ToM is foundational to social functioning, as ToM deficits are associated with lack of social engagement, lack of social communication, and increased loneliness (Braak et al., 2022). Prior research has documented dysfunction in ToM in several psychological disorders, most notably autism spectrum disorders (ASD) (Baron-Cohen, 2000), for which hallmark symptoms include challenges with understanding others and engaging in reciprocal social communication. More recent work has also investigated associations between ToM and depression (Nestor et al., 2022), anxiety (Banerjee & Henderson, 2001), and suicidality (Nestor & Sutherland, 2022), with results generally indicating ToM deficits in each clinical presentation.

In the pain literature, ToM abilities have been assessed primarily in adults with pain or pain-related disorders (Silveri et al., 2022; Zunhammer et al., 2015), though less so in youth with chronic pain (YCP). Prior studies in the adult literature have begun to identify deficits in adult samples with pain and pain-related disorders. For example, adults with functional movement disorders (Silveri et al., 2022), chronic somatoform conditions (Zunhammer et al., 2015), fibromyalgia (Di Tella et al., 2015), high somatic symptoms (Stonnington et al., 2013), chronic migraines (Raimo et al., 2022), and complex regional pain syndrome all have demonstrated decreased ToM as compared to healthy adults.

For YCP, ToM deficits have not been investigated, though they may relate to the biopsychosocial factors that contribute to and/or exacerbate the pain experience, and in turn, long-term well-being. Indeed, psychologically, changes in mood, affect, and anxiety can both contribute to and emerge from the experience of pain (Meints & Edwards, 2018), and social factors, including disrupted social relationships, negative interpersonal interactions, and non-supportive social environments (e.g., peers, teachers), are also critical to the experience of pain (Forgeron et al., 2010). Investigating ToM as a factor that may underlie biopsychosocial processes in YCP is critical as it holds promise for responsiveness to intervention through direct skills-training (Hofmann et al., 2016).

Drawing from the biopsychosocial model of pain (Gatchel et al., 2007), this topical review aims to incorporate ToM-specific findings into previously identified biological, psychological, and social aspects of a biopsychosocial model of pediatric chronic pain. Specifically, we reviewed the extant literature in the areas of ToM and chronic pain. Search terms included phrases such as “theory of mind,” “chronic pain,” “health outcomes,” “pediatric,” and “social functioning and pain.” Only studies that reported findings specific to pediatric samples were included. Below we integrate our ToM-related findings into relevant biological, psychological, and social aspects of pediatric pain. Figure 1 provides a visual depiction of our proposed conceptualization of the role of ToM in biopsychosocial influences on pediatric pain.

Figure 1.

Incorporating ToM into a biopsychosocial model of pediatric chronic pain.

 

Biological factors

Due to more tenuous and preliminary current evidence linking ToM to biological substrates of pain, we chose to focus this topical review on psychological (Heleniak & McLaughlin, 2020) and social (Astington & Jenkins, 1995) aspects of pain, for which ToM is most readily identified as a correlate. However, we do note briefly that some work does point to associations between ToM and biological factors of pain, particularly with respect to neuroendocrine (i.e., cortisol abnormalities) (Rogan et al., 2023) and neurobiological functioning (Apkarian et al., 2005). Although yet to be investigated in YCP, cross-sectional work in healthy adolescents has shown that increased cortisol levels are associated with decreased ToM abilities (Pluck et al., 2021), suggesting that a heightened state of stress may make deciphering mental states a more challenging task. Other neurobiological evidence shows that neural networks (e.g., amygdala and insula) required for processing pain partially overlap with those required for processing of others’ emotional states (i.e., affective ToM) (Apkarian et al., 2005), with further evidence in adult fibromyalgia patients revealing alterations in these regions (Burgmer et al., 2009; Gracely & Ambrose, 2011). In line with this, previous researchers have speculated that for individuals with chronic pain, hyperactivity in the pain neural network may lead to an increased demand on the amygdala and insula, thereby depleting their available resources for other functions such as affective ToM (Di Tella et al., 2015). Future work should investigate associations between ToM and markers of neurobiological pain markers in YCP.

Psychological factors

Prior research underscores the psychological comorbidity observed in YCP (Dorn et al., 2003), and the increased incidence of ACEs in this population (Nelson et al., 2018). In parallel research, psychological comorbidity and ACEs in childhood have also been linked to adulthood ToM deficits (Germine et al., 2015), which may position ToM as a transdiagnostic factor cutting across varying psychological and physical presentations. Irrespective of pain, youth with ToM deficits also experience poor mental health, particularly anxiety and depression (Banerjee & Henderson, 2001; Nestor et al., 2022). Several potential temporal pathways may be relevant to these associations. First, ToM deficits could lead to psychological challenges YCP. That is, individuals with ToM deficits may have fewer effective social interactions which may lead to worry or low mood (Pemberton & Tyszkiewicz, 2016), which may increase vulnerability to later pain developmental (Meints & Edwards, 2018). Second, psychological challenges, often comorbid with pain, could lead to later ToM deficits such that worry and low mood may make individuals less attuned to others’ mental states, due to anxiety or depressive symptoms, such as hypervigilance or self-focused attention (Ingram, 1990). ToM deficits also may compound mental health issues in YCP. For example, prior work identified deficits in ToM in adults with high levels of somatization, which authors suggested may be due to disruptions in emotional processing, exacerbated by anxiety, leading to psychosomatic symptomatology (Stonnington et al., 2013). Future longitudinal investigations should clarify these relations in YCP.

Specific subpopulations of neurodivergent youth may be particularly vulnerable to ToM deficits and chronic pain. Estimates from a nationally representative sample of youth indicate the prevalence of chronic pain to be nearly double for youth with ASD (Whitney & Shapiro, 2019). Other estimates suggest that over a quarter of YCP may also experience comorbid neurodevelopmental disorders (Lipsker et al., 2018), and that for YCP, ASD, and ADHD symptoms are positively associated with greater pain interference (Balter et al., 2021). Researchers speculate that challenges with social communication (McKeown et al., 2022) and the chronic stress that may emerge due to ongoing social difficulties secondary to neurodivergent conditions (Low Kapalu et al., 2018) may place such subgroups of youth at greater risk for development of pain. Given the established ToM deficits in youth with neurodivergence, future research should investigate more the role of ToM in YCP and neurodevelopmental disorders.

Other specific cognitive factors related to ToM deficits also may be implicated in pediatric chronic pain. For example, the deployment of pain-focused cognitive resources including pain-related rumination (Fisher et al., 2018) may make it more challenging to attend to and interpret social cues (Beck et al., 2011), impacting the ability of YCP to interpret others’ thoughts, feelings, and preferences. Prior work also suggests YCP interpret non-supportive behavior from peers as significantly more negative than youth without chronic pain (Forgeron et al., 2010), suggesting inaccurate ToM. These parallel findings suggest that pain and ToM deficits may reinforce each other, but minimal research has investigated this.

Further, ToM may be particularly relevant to executive functioning (EF) and emotion regulation (ER) in association with treatment engagement. Prior research has established ToM is associated with EF, and inhibition, compared to other components of EF, is most associated with age-related differences in ToM across adolescence (Vetter et al., 2013). This suggests that inhibiting one’s own perspective is necessary for understanding others’ thoughts and feelings. Inhibition has also been identified as integral to the development of ER across adolescence (Luciana, 2013). Specific to chronic pain, recent work has highlighted how reciprocal deficits in EF and ER may impact the self-management strategies necessary for pediatric pain treatment (Caes et al., 2021). For example, engagement in multidisciplinary pediatric pain treatment often requires a wide variety of skills, including attention and adherence (i.e., EF) to a rehabilitation plan, as well as regulating thoughts, moods, and emotions (i.e., ER). Deficits in these abilities can exacerbate disability and the impact of pain on functioning (Caes et al., 2021). Further exploration of the role of ToM deficits in these areas, particularly related to treatment engagement in YCP, is necessary.

ToM deficits may also relate to diagnostic uncertainty (Pincus et al., 2018) in YCP. Diagnostic uncertainty, or the perception that a proper label for pain is inaccurate or missing, is a common experience that significantly impacts patient “buy-in” to treatment (Neville et al., 2019). YCP and ToM deficits may be more susceptible to challenges understanding their diagnosis, prognosis, and relevant treatment approaches, which may be due to difficulty (1) reasoning about or taking the perspective of their providers or (2) understanding that their thoughts about their pain (e.g., initiating or maintaining factors) may differ from those of their providers. Relatedly, prior research shows that cognitive flexibility—to understand others’ perspectives—is related to ToM and chronic pain (Kashdan & Rottenberg, 2010). YCP may then exhibit cognitive rigidity and struggle to consider the viewpoints of others, thus hindering their engagement in treatment to improve functioning and symptoms. How ToM deficits relate to diagnostic uncertainty and treatment “buy-in” should be further investigated as it may hold promise for optimizing treatment outcomes.

Social factors

YCP face numerous social challenges, including fewer reciprocated friendships, increased loneliness, and less popularity at school (Forgeron et al., 2010), with many of these challenges stemming from pain-related disruptions in youth’s typical social routines. YCP also report significant negative interactions with peers that can result in distress and loss of friendships (Forgeron & McGrath, 2008). These social challenges have further been shown to initiate, maintain, and exacerbate the experience of chronic pain for youth (Varni et al., 1996). For individuals without chronic pain, ToM deficits are widely associated with increased social challenges. For example, ToM deficits in children have been shown to be predictive of negative social interactions into adolescence, including peer victimization (Shakoor et al., 2012). In contrast, effective ToM is associated with better reported social functioning in children, including less social rejection (Banerjee & Henderson, 2001).

Due to the observed associations between social challenges and pediatric pain, as well as between ToM deficits and social challenges, ToM may be relevant to the social dysfunction in pediatric pain. Misidentifying or misunderstanding how another person thinks and feels may be related to confusion and conflict within a social relationship, and such problems may also be associated with exacerbated pain. On the other hand, being able to accurately identify a person’s thoughts and feelings and respond in a way that reflects that understanding can allow for increased closeness, affiliation, and support in that relationship; importantly, close friendship can be a marker of resilience for YCP (Ross et al., 2018). Future research should consider whether social withdrawal from typical activities may make YCP “out of practice” of using ToM skills with their social partners (Porcelli et al., 2019). ToM deficits may also predispose youth to chronic pain and related difficulties. That is, youth who struggle to understand the thoughts and feelings of others may begin to socially withdraw due to their ineffective social interactions and thus avoid future social interactions (Porcelli et al., 2019), potentially placing them at risk for poorer pain-related outcomes. Research has yet to directly examine these associations.

Recommendations

Adolescence represents an important window of psychological and social change, as well as a period of vulnerability to the onset of chronic pain (Perquin et al., 2000). Investigating ToM as a transdiagnostic mechanism that may cut across psychological and social factors of pediatric chronic pain is a critical next step for research aimed at identifying targeted interventions for YCP. Importantly, ToM deficits may also be modifiable through targeted intervention (Hofmann et al., 2016).

Future research should first embark on cross-sectional investigations to assess the nature of ToM abilities in YCP. If ToM deficits emerge, cross-sectional and longitudinal investigations should examine ToM alongside biopsychosocial factors of pediatric chronic pain to better parse whether such deficits may precipitate the emergence of pain or occur secondary to pain onset. Moderator and mediator analyses can further investigate whether ToM deficits impact the degree to which pain relates to functional outcomes and whether ToM deficits explain, partially or fully, how pain impacts functional outcomes. From a resiliency lens, we also suggest investigations that explore ToM prowess as a potentially buffering effect against the development and onset of pediatric pain. Finally, due to the heterogeneity within the construct of ToM, we also recommend exploratory analysis into specific components (i.e., reasoning vs decoding or cognitive versus affective).

Several task-based and self-report measures exist that provide age-appropriate assessment of ToM. Considered the gold-standard of ToM assessment is the Reading the Mind in the Eyes Test, which requires instantaneous identification of mental states of others by seeing their eyes only (Baron-Cohen et al., 2001). This measure has been used as a valid and reliable assessment of ToM for adolescents. Other frequently used assessments of ToM require youth to determine character’s intentions, thoughts, and feelings in different social scenarios, such as the Movie for the Assessment of Social Cognition (Dziobek et al., 2006). Finally, self-report measures, including the Perspective-Taking scale of the Interpersonal Reactivity Index can be implemented to assess youths’ own perceptions of their understanding of others’ mental states (Davis, 1983). These measures can be readily incorporated into research and clinical practice to assess baseline ToM skill and monitor changes.

Clinically, future work holds promise for the treatment of chronic pain through ToM-focused interventions. Identifying ToM as a treatment target for YCP may help improve functional outcomes and decrease the impact of pain. ToM appears to be a skill sensitive to training and intervention. A meta-analysis revealed that ToM training interventions in children significantly improved their ToM as compared to control interventions, with a moderate-large effect size (Hofmann et al., 2016). This work, however, has not yet been explored in adolescents, and the clinical value (e.g., social decision-making or decreased internalizing symptoms) of improved ToM skills remains largely understudied.

Importantly, cultural considerations must be acknowledged in this research area. The literature on social factors and ToM is quite lacking, with very few studies examining how race, ethnicity, language, or socioeconomic status may relate to ToM. Moreover, reviewed findings in the current article were significantly limited by samples lacking demographic diversity (i.e., English-speaking, majority-White samples), thus hampering generalizability to other, more diverse groups of youth (Table 1). Hallmark findings of perspective-taking from a sociological lens may provide insight into this research area. Sociological research suggests individuals in lower positions (or in more subordinate roles) may be socialized to take the perspectives of others more readily (Fiske, 2010), perhaps making them more skilled at ToM. Research also indicates that less powerful individuals are actually better at taking the perspective of others and knowing how they themselves appear, which may to be born of a societal pressure to understand how high-power individuals are stereotyping them. This is further evidenced as those in lower positions, as compared to higher-power counterparts, orient more strongly toward gathering information to process the intentions of those in higher positions (Zink et al., 2008) to better facilitate their social-cognitive processes underlying ToM. These sociological findings may suggest YCP with more marginalized identities may demonstrate better ToM than their more privileged counterparts. We recommend future ToM research consider diverse pediatric pain samples to investigate these relations.

Table 1.

Demographic descriptions for reviewed studies of pediatric pain.

Study	Sample	Age range; gender	Race/ethnicity	Language	Type of study
Apkarian et al. (2005)	NA	NA	NA	NA	Review
Balter et al. (2021)	n = 47 diagnosed CP, outpatient, types NR	8–18 years; 70.2% female	NR	English	Intervention; Self-Report Measures
Burgmer et al. (2009)	n = 17 FMS; n = 17 HC	NR (adult); 100% female	NR	German	Cross-Sectional; fMRI paradigm; Self-Report Measures
Caes et al. (2021)	NA	NA	NA	NA	Review
Dorn et al. (2003)	n = 14 recurrent abdominal pain; n = 14 anxiety; n = 14 HC	8–16 years; 59.5% female	85.7% White; 7.1% African-American; 7.1% Hispanic	English	Cross-Sectional; Self-Report Measures
Fisher et al. (2018)	NA	NA	NA	NA	Review and Meta-Analysis
Forgeron & McGrath (2008)	NA	NA	NA	NA	Review
Forgeron et al. (2010)	NA	NA	NA	NA	Review
Gracely & Ambrose (2011)	NA	NA	NA	NA	Review
Kashdan & Rottenberg (2010)	NA	NA	NA	NA	Review
Lipsker et al. (2018)	n = 146 diagnosed CP, outpatient, types NR	8–17 years; 69.9% female	NR	Swedish	Cross-Sectional; Self-Report Measures
Low Kapalu et al. (2018)	n = 94 diagnosed CP beginning IIPT, 79% widespread	10–18 years; 85.1% female	86.2% White; 9.6% Black; 3.2% Biracial; 2.1% Hispanic	English	Cross-Sectional; Self-Report Measures
McKeown et al. (2022)	NA	NA	NA	NA	Commentary
Meints & Edwards (2018)	NA	NA	NA	NA	Review
Nelson et al. (2018)	n = 141 diagnosed with CP, outpatient, 63% musculoskeletal	9–19 years; 79.4% female	83% White; 2.8% Black; 2.8% Asian; 5% Multiracial; 9% Other	English	Cross-Sectional; Self-Report Measures
Neville et al. (2019)	n = 20 youth diagnosed CP; 30% CRPS	10–18 years; 75% female	90% White; 5% Latin American; 5% NR	English	Cross-Sectional; Qualitative; Thematic Analysis
Porcelli et al. (2019)	NA	NA	NA	NA	Review
Ross et al. (2018)	n = 238 adolescents diagnosed with CP, outpatient, 22.7% jaw pain	12–18 years; 78.9% female	61.8% White, 10.1% Asian; 3.8% African-American; 24.4% Other; 20.6% Hispanic	English	Cross-Sectional; Self-Report Measures
Schechter et al. (2021)	NA	NA	NA	NA	Viewpoint
Varni et al. (1996)	n = 160 youth with rheumatic diseases	5–16 years; 69.4% female	76.3% White; 10.6% Hispanic; 8.1% African-American; 3.1% Asian; 1.3% Native American	English	Cross-Sectional; Self-Report Measures
Whitney & Shapiro (2019)	n = 48,591 without ASD; n = 1,158 ASD	6–17 years; 49% female	50% White, non-Hispanic; 13% Black, non-Hispanic; 25% Hispanic; 10% Multiracial (weighted % estimates)	English	Cross-Sectional; National Survey of Children’s Health; Self-Report Measures

Note. ASD = autism spectrum disorders; CP = chronic pain; CRPS = complex regional pain syndrome; fMRI = functional magnetic resonance imaging; FMS = fibromyalgia syndrome; IIPT = intensive interdisciplinary pain treatment; NA = not applicable; NR = not reported; RA = rheumatoid arthritis. Largest type of reported chronic pain condition indicated when study provided such details. All racial and ethnic information is presented as reported in respective studies.

Author Contributions

Bridget A. Nestor (Conceptualization [equal], Data curation [lead], Investigation [lead], Writing—original draft [lead], Writing—review & editing [lead]), Joe Kossowsky (Conceptualization [equal], Writing—review & editing [equal]) and Sarah M. Nelson (Conceptualization [equal], Writing—review & editing [equal])

Funding

This study was supported by the National Center for Complementary and Integrative Health-NCCIH 1K23AT010643 (to SMN).

Conflicts of interest: None declared.

Data availability

No new data were generated or analyzed in support of this research.