Abstract
Objective:
The purpose of this study is to determine the association between presence of chronic pain and school functioning among school aged children (6–17 years) using the most recent United States national data.
Methods:
Secondary data analyses of the 2016–2017 National Survey of Children’s Health. Parents (n=48,254) reported on whether their child had chronic pain over the past 12 months. Parents also reported on school functioning including (1) engagement with school, (2) number of school days missed, (3) problems at school, (4) repeating a grade, and (5) diagnosis of a learning disability. Children with chronic pain were compared to children without chronic pain using multivariate logistic regression models. We also stratified analysis according to age and sex.
Results:
In multivariate analyses, children with pain were more likely to have low school engagement (adjusted odds ratio (OR): 1.4, 95% confidence interval (CI): 1.0–1.9), be chronically absent (OR: 4.2, 95%CI: 3.0–5.8), have school related problems (OR: 1.9, 95%CI: 1.5–2.3), repeat a grade (OR: 1.4, 95%CI: 1.0–2.0), and be diagnosed with a learning disability (OR: 1.6, 95%CI: 1.1–2.5). In stratified analyses, associations between chronic pain and school measures were strongest among adolescents (15–17 years of age) and males.
Discussion:
This study extends evidence linking chronic pain status to poorer school functioning in a large, national sample. Poor school functioning is a pressing public concern affecting children with chronic pain. Health care providers, educators, policy makers, and families should work together to ensure that needs are met for this vulnerable population.
Keywords: Children and adolescents, Chronic pain, School, Absenteeism
Introduction
Chronic pain affects 15–25 % of school-aged children1, 2. Many of these children experience reduced daily functioning due to their pain, manifesting as poor academic performance and missed school days3. For example, Logan et al. examined school functioning in adolescents with chronic pain presenting to a tertiary care pain program4. Almost half of adolescents had missed at least one day of school a week, experienced a decline in academic performance, or reported that pain interfered with their school success. Since then, epidemiologic studies conducted outside of the United States have confirmed school-related problems associated with chronic pain in larger, non-clinical, samples: Vervoort et al. found that pain was associated with higher school absenteeism, increased school related pressure, reduced satisfaction and greater bullying experience in a school-based sample in Belgium1; while Huguet et al. found increased absenteeism among a large school-based sample in Spain2.
However, data from the United States are lacking. To our knowledge, the only national data linking chronic pain to school functioning is from the Medical Expenditure Panel Survey (MEPS). This study found that chronic pain was associated with 22 million days of missed school5, however data from the MEPS dataset is limited as it does not contain other information on school functioning. Indeed, beyond school absenteeism, the extant literature on school functioning in children with pain in the United States are limited to small geographical and clinical samples. Therefore, the extent to which chronic pain is associated with broader measures of school functioning such as school engagement, academic performance, and problems at school on a national level remains unknown. This is a gap in knowledge, that if filled, could lead to the development of national-level strategies aimed at improving school functioning in children with chronic pain. Such strategies could include cognitive-behavioral interventions or educational programming designed to meet the needs of children with chronic pain with the aim of mitigating long-term effects of pediatric chronic pain.
To address this gap in knowledge, the current study used data from a large, nationally representative sample with the primary aim of reporting associations between chronic pain and multiple aspects of school functioning, including (1) child school engagement, (2) chronic absenteeism, (3) child having problems at school, (4) repeating a grade, and (5) being diagnosed with a learning disability. We hypothesize that children with chronic pain will have poorer school functioning across all domains as compared to children without chronic pain. We also explored whether associations between school functioning and chronic pain differed by age and sex.
Materials and Methods:
Participants
This study was a secondary analysis of data from the 2016–2017 National Survey of Children’s Health (NSCH)6. The NSCH is an annual cross-sectional survey, conducted via in-person interviews of randomly sampled households, selected via a multistage process to represent the entire civilian, non-institutionalized population of the United States. NSCH is conducted by the United States Census Bureau with funding and direction from the Maternal and Child Health Bureau. The primary purpose of NSCH is to provide national estimates of the health status of the U.S. childhood population. For each family included in the NSCH, one child (aged 17 or younger) was selected to be the subject of the survey, while one parent with the most knowledge about the child responded to questionnaires. Surveys were conducted via telephone and in English, Spanish, and four Asian languages. We used data from the 2016 and 2017 samples, as these are the only samples with data on chronic pain among child participants. The total sample for 2016–2017 included 71,811 child-parent dyads. We excluded children < 6 years of age (n = 20,655), those with developmental delay or intellectual disability (n = 2,600), and those with incomplete data on the chronic pain measure (n = 302), leaving a final sample of 48,254 children for analysis. The data are publicly available and deidentified and was deemed exempt from review by our institutional review board.
Measures
Chronic pain status
Parents were asked, “During the past 12 months, has this child had frequent or chronic difficulty with repeated or chronic physical pain, including headaches or other back or body pain?” Those who responded “yes” were assigned to the chronic pain group.
School functioning
School engagement
Parents were asked 2 questions about their child’s engagement with school: whether their child cared about doing well in school and whether their child did all required homework during the past month (using a 3-point rating scale ranging from “definitely true” to “not true”). If caregivers responded “not true” to both questions, then the child was categorized as having low school engagement. This measure of school engagement has been used in earlier versions of the NSCH and with prior studies7.
Chronic absenteeism
School absence was based on the question: “During the past 12 months, about how many days did this child miss school because of illness or injury?” Chronic absenteeism was defined as missing more than 11 days of school during the past 12 months, which is consistent with the definition used by the United States Department of Education8.
School-reported problems
Parents were asked: “During the past 12 months, how many times has this child’s school contacted you or another adult in your household about any problems he or she is having with school?” Those who reported being called 2 or more times were classified as having school-related problems (consistent with previous research).7
Repeating a grade
Parents were asked : “Since starting Kindergarten, has this child repeated any grades?” (yes/no).
Learning disability
Parents reported whether a doctor, other health care provider, or educator had ever told them that their child had a learning disability (yes/no).
Covariates
Data were collected on the following socio-demographic variables: age, child sex (male versus female), child race/ethnicity (White, non-Hispanic, Black, non- Hispanic, Hispanic, and Other or multiracial), household income (<100% Federal Poverty Level (FPL), 100%–199% FPL, 200%–399% FPL, 400% or greater FPL), insurance status (private, public only, uninsured), census region (Northeast, Midwest, South, West), and parent education (less than high school, high school, more than high school). Previous studies have shown that depressive9 and anxiety10 symptoms are directly related to school functioning in children with chronic pain and therefore both of these variables were included in multivariate analysis. Participants with anxiety and/or depression were identified by parents responding “yes” to the question “Has a doctor or other health care provider ever told you that this child has anxiety?” and “Has a doctor or other health care provider ever told you that this child has depression?”.
Statistical Analyses:
Analyses were conducted with Stata version 14.2 (StataCorp, College Station, TX)11. Alpha level was set at .05. We adjusted for the complex survey design of NHIS using sampling weights, stratification, and clustering. Thus, our estimates are nationally representative of the non-institutionalized childhood population in the United States.
To address the primary aim, we used χ2 tests to compare prevalence rates of the 5 identified school measures among children with chronic pain to children without pain. We then performed multivariate logistic regression analysis to determine the odds ratios of each school functioning measure (regressed one at a time) associated with chronic pain, after controlling for sociodemographic and psychological (anxiety and depression) variables.
In addition to the total sample, we also estimated models by sex (male and female) and by school age groups: 6 – 11 years (elementary-school), 12 – 14 years (middle school), and 15 – 17 years (high school) to explore whether the associations between chronic pain and school functioning varied with sex and age.
Results:
Demographics
Among our sample, 8% (95% confidence interval, 7.5–8.6%) of children had chronic pain. Chronic pain was more common among 15–17-year-olds (as compared to younger age groups), females, and those from lower income levels (Table 1). Children with private insurance were less likely to have chronic pain compared to those with public insurance and the uninsured. Race, ethnicity and census region were not associated with chronic pain status. Chronic pain was more common among children with anxiety and depression.
Table 1.
Sample characteristics.
| Characteristic | Chronic pain | ||||
|---|---|---|---|---|---|
| Total in sample (N=48254) | Weighted % | No N=44299 (92%) | Yes N=3955 (8%) | p | |
| Age category | <0.0001 | ||||
| 6–11 years | 20243 | 49.8 | 51.4 | 31 | |
| 12–14 years | 12417 | 24.8 | 24.5 | 28.2 | |
| 15–17 years | 15594 | 25.4 | 24 | 40.8 | |
| Sex of the child | <0.0001 | ||||
| Male | 24230 | 50.2 | 50.8 | 43.2 | |
| Female | 24024 | 49.8 | 49.2 | 56.8 | |
| Race and ethnicity | NS | ||||
| White, non-Hispanic | 33883 | 51.1 | 51.2 | 49.7 | |
| Black, non-Hispanic | 2903 | 13.5 | 13.3 | 15.4 | |
| Hispanic | 5368 | 25.3 | 25.2 | 26.8 | |
| Other/Multi-racial, non-Hispanic | 6100 | 10.1 | 10.3 | 8.1 | |
| Poverty level (Federal poverty level) | <0.0001 | ||||
| <100% FPL | 4923 | 20.6 | 19.8 | 30.4 | |
| 100–199% FPL | 7360 | 21.9 | 21.8 | 23.4 | |
| 200–399% FPL | 14576 | 26.7 | 26.9 | 24.6 | |
| 400% FPL or greater | 21395 | 30.8 | 31.6 | 21.5 | |
| Insurance type | <0.0001 | ||||
| Private | 37372 | 63.4 | 64.3 | 52.1 | |
| Public only | 8230 | 29.9 | 29 | 39.8 | |
| Uninsured | 1884 | 6.8 | 6.6 | 8.1 | |
| Census region | NS | ||||
| Northeast | 9152 | 15.8 | 16 | 13.2 | |
| Midwest | 12256 | 21.2 | 21.1 | 21.7 | |
| South | 14566 | 38.9 | 38.8 | 40.1 | |
| West | 12280 | 24.2 | 24.1 | 25 | |
| Parent education | 0.0027 | ||||
| Less than High School | 1108 | 9.9 | 9.8 | 11.9 | |
| High School | 6136 | 20.3 | 19.9 | 24.7 | |
| More than High School | 40190 | 69.8 | 70.3 | 63.4 | |
| Anxiety | <0.0001 | ||||
| No | 43598 | 93 | 94.2 | 78.7 | |
| Yes | 4349 | 7 | 5.8 | 21.3 | |
| Depression | <0.0001 | ||||
| No | 46016 | 96.8 | 97.7 | 87.2 | |
| Yes | 2020 | 3.2 | 2.3 | 12.8 |
School functioning
The weighted prevalence of school measures in the total sample and subdivided by chronic pain status are presented in Table 2. Overall, 4.3% of children were reported as having poor school engagement, 3.3% were chronically absent, 10.5% had school-related problems, 5.5% had repeated a grade, and 4.3% were diagnosed with a learning disability by a health care provider. As compared to children without chronic pain, children with chronic pain had poorer school functioning across all measures, with higher rates of chronic absenteeism, poorer school engagement, more school reported problems, more likely to repeat a grade, and higher prevalence of learning disability (all p <0.0001, Table 2). After adjusting for covariates (sociodemographic factors, anxiety and depression), all measures of school functioning remained significantly associated with chronic pain (Table 3). The magnitude of the associations differed, with the strongest for chronic absenteeism (adjusted odds ratio (OR): 4.2, 95% confidence interval (CI): 3.0–5.8, p<0.0001). However, children with chronic pain had a nearly 90% increased odds of school reported problems (OR: 1.9, 95%CI: 1.5–2.3), a 60% increased likelihood of having a learning disability (OR: 1.6, 95%CI: 1.1–2.5), a 40% increased likelihood of poor school engagement (OR: 1.4, 95%CI: 1.0–1.9), and a 40% increased likelihood of repeating a grade at school (OR: 1.4, 95%CI: 1.0–2.0). With respect to the covariates, females and higher income families had lower odds of poorer school functioning (Table 3). Anxiety was significantly associated with all school measures, while depression was associated with poor school engagement, chronic absenteeism and school reported problems (Table 3).
Table 2.
Comparison of children with chronic pain and children without chronic pain on school measures.
| Total sample | No chronic pain | Chronic pain | |||||
|---|---|---|---|---|---|---|---|
| School measure | Weight % | 95% CI | Weighted % | 95% CI | Weighted % | 95% CI | |
| Poor school engagement | 4.3 | (3.9–4.8) | 3.9 | (3.5–4.4) | 8.7 | (7.2–10.5) | *** |
| Chronic absenteeism | 3.3 | (3.0–3.8) | 2.4 | (2.1–2.8) | 13.9 | (11.2–17.1) | *** |
| School reported problems | 10.5 | (9.9–11.1) | 9.5 | (8.9–10.1) | 21.5 | (18.9–24.3) | *** |
| Repeat grade | 5.5 | (5.0–6.0) | 5.1 | (4.7–5.7) | 9.1 | (7.1–11.6) | *** |
| Learning disability | 4.3 | (3.8–4.8) | 3.9 | (3.4–4.3) | 9.2 | (6.7–12.4) | *** |
p < .05,
p < .01,
p < .001.
Table 3.
Multivariate associations between chronic pain and school functioning among children 6–17 years of age captured in the 2016–2017 National Survey of Children’s Health.
| Poor school engagement | Chronically absent | School reported problems | Repeat a grade | Learning Disability | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| ORα | 95% CIβ | OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Chronic pain | ||||||||||
| No chronic pain | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| Chronic pain | 1.4 | (1.0–1.9) * | 4.2 | (3.0–5.8) *** | 1.9 | (1.5–2.3) *** | 1.4 | (1.0–2.0) * | 1.6 | (1.1–2.5) * |
| Age category | ||||||||||
| 6–11 years | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| 12–14 years | 1.6 | (1.2–2.1) *** | 1.4 | (1.0–2.0) * | 1.0 | (0.9–1.2) | 1.3 | (1.0–1.7) * | 1.4 | (1.0–1.8) |
| 15–17 years | 2.1 | (1.6–2.7) *** | 1.3 | (1.0–1.7) | 0.7 | (0.6–0.9) *** | 1.9 | (1.5–2.5) *** | 0.9 | (0.7–1.2) |
| Sex | ||||||||||
| Male | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| Female | 0.5 | (0.4–0.6) *** | 0.9 | (0.7–1.1) | 0.6 | (0.5–0.7) *** | 0.8 | (0.6–0.9) * | 0.6 | (0.5–0.8) ** |
| Race and ethnicity | ||||||||||
| White, non-Hispanic | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| Black, non-Hispanic | 0.9 | (0.6–1.3) | 0.8 | (0.5–1.2) | 1.9 | (1.5–2.3) *** | 1.2 | (0.9–1.6) | 1.0 | (0.7–1.4) |
| Hispanic | 1.0 | (0.7–1.3) | 0.8 | (0.6–1.2) | 0.8 | (0.7–1.1) | 1.3 | (0.9–1.7) | 0.9 | (0.6–1.3) |
| Other/Multi-racial | 1.0 | (0.7–1.4) | 1.0 | (0.6–1.5) | 0.9 | (0.8–1.1) | 1.1 | (0.8–1.5) | 0.8 | (0.5–1.3) |
| Poverty level | ||||||||||
| <100% FPL | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| 100–199% FPL | 0.9 | (0.7–1.3) | 0.6 | (0.4–0.9) ** | 0.7 | (0.6–0.9) ** | 0.8 | (0.6–1.1) | 0.7 | (0.5–1.1) |
| 200–399% FPL | 0.9 | (0.6–1.3) | 0.6 | (0.4–0.8) ** | 0.8 | (0.6–1.0) | 0.6 | (0.4–0.9) ** | 0.6 | (0.4–0.8) ** |
| 400% FPL or greater | 0.7 | (0.5–1) | 0.5 | (0.3–0.7) *** | 0.7 | (0.6–0.9) ** | 0.4 | (0.3–0.6) *** | 0.5 | (0.3–0.8) ** |
| Insurance | ||||||||||
| Private insurance | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| Public only | 1.9 | (1.4–2.6) *** | 1.2 | (0.9–1.8) | 1.4 | (1.2–1.7) *** | 1.2 | (0.9–1.7) | 1.3 | (0.9–1.8) |
| Uninsured | 1.1 | (0.7–1.6) | 0.9 | (0.5–1.6) | 1.0 | (0.7–1.4) | 1.2 | (0.8–2.0) | 0.9 | (0.5–1.5) |
| Region | ||||||||||
| Northeast | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| Midwest | 1.0 | (0.7–1.4) | 0.9 | (0.6–1.2) | 1.1 | (0.9–1.3) | 0.8 | (0.6–1.2) | 0.9 | (0.7–1.2) |
| South | 1.2 | (0.8–1.6) | 0.9 | (0.7–1.3) | 1.2 | (1.0–1.5) ** | 1.7 | (1.3–2.3) ** | 0.8 | (0.6–1) |
| West | 1.0 | (0.7–1.4) | 1.1 | (0.8–1.7) | 0.9 | (0.7–1.1) | 0.7 | (0.5–1.1) | 0.9 | (0.6–1.3) |
| Parents education | ||||||||||
| Less than High School | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| High School | 1.2 | (0.7–2.1) | 0.9 | (0.5–1.6) | 0.9 | (0.6–1.3) | 1.2 | (0.8–1.8) | 0.9 | (0.5–1.8) |
| More than High School | 1.3 | (0.8–2.2) | 1.1 | (0.6–2.1) | 0.9 | (0.6–1.3) | 0.8 | (0.5–1.2) | 0.9 | (0.4–1.7) |
| Anxiety | ||||||||||
| No | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| Yes | 3.2 | (2.2–4.7) *** | 3.0 | (2.1–4.4) *** | 3.3 | (2.7–4.1) *** | 1.5 | (1.1–2.1) * | 3.3 | (2.4–4.5) *** |
| Depression | ||||||||||
| No | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | |||||
| Yes | 1.9 | (1.3–2.9) *** | 2.1 | (1.4–3.3) ** | 3.4 | (2.6–4.5) *** | 0.8 | (0.6–1.2) | 1.4 | (0.9–2.2) |
p < .05,
p < .01,
p < .001.
Odds ratio’s adjusted for age, sex, race & ethnicity, poverty level, insurance, region, parent education, anxiety, and depression.
95% Confidence intervals.
Stratification by age and sex
Stratifying by age revealed that associations between chronic pain and school functioning was most pronounced among 15–17-year-olds as compared to younger age groups. For children 15–17 years, there were significant associations between chronic pain and all school measures except for school engagement (Table 4). Associations between chronic pain and school functioning were stronger among males as compared to females (Table 5). Specifically, males with chronic pain had significantly increased odds of having poor school engagement and learning disabilities, while females with chronic pain did not. Repeating a grade was not significant among either males or females.
Table 4.
Associations between chronic pain and school functioning stratified by age among children 6–17 years of age using the 2016 and 2017 National Survey of Children’s Health.
| School functioning by subgroup | OR (95% CI) |
|---|---|
| 6–11 y | |
| School engagement | 1.6 (0.9–3.0) |
| Chronically absent | 5.3 (3.6–8.0) *** |
| School problems | 1.8 (1.3–2.5) *** |
| Repeat a grade | 1.3 (0.8–2.2) |
| Learning disability | 1.3 (0.8–2.1) |
| 12–14 y | |
| School engagement | 1.7 (1.0–2.8) |
| Chronically absent | 5.6 (3.1–10) *** |
| School problems | 1.9 (1.3–2.7) ** |
| Repeat a grade | 1.4 (0.8–2.5) |
| Learning disability | 2.1 (1.0–4.5) |
| 15–17 y | |
| School engagement | 1.3 (0.9–1.9) |
| Chronically absent | 2.8 (1.9–4.3) *** |
| School problems | 2.1 (1.5–2.9) *** |
| Repeat a grade | 1.7 (1.0–2.8) * |
| Learning disability | 1.6 (1.1–2.3) * |
p < .05,
p < .01,
p < .001.
Table 5.
Associations between chronic pain and school functioning stratified by child sex among children 6–17 years of age using the 2016 and 2017 National Survey of Children’s Health.
| School functioning by subgroup | OR (95% CI) |
|---|---|
| Males | |
| School Engagement | 1.7 (1.2–2.5) ** |
| Chronically absent | 6.0 (3.8–9.4) *** |
| School problems | 1.6 (1.3–2.1) *** |
| Repeat a grade | 1.4 (0.9–2.0) |
| Learning disability | 2.1 (1.2–3.8) ** |
| Females | |
| School Engagement | 1.0 (0.6–1.7) |
| Chronically absent | 3.1 (2.1–4.5) *** |
| School problems | 2.2 (1.6–3.0) *** |
| Repeat a grade | 1.5 (0.9–2.5) |
| Learning disability | 1.2 (0.8–1.8) |
p < .05,
p < .01,
p < .001.
Discussion:
Using data from the 2016–2017 NSCH, we found that children with chronic pain had significantly worse school functioning compared to children without chronic pain on a national level. This association was present across all 5 measures captured in the NSCH, and remained significant even after controlling for sociodemographic factors, anxiety and depression. Furthermore, several of these associations were large, in particular there was a greater than 300% increased likelihood of chronic school absenteeism in children with versus without chronic pain. Associations between chronic pain and school functioning were most pronounced in males, and among 15–17-year olds.
Consistent with previous studies, we found that children and adolescents with chronic pain missed more school compared to their peers1–3. This has been described in clinical samples of children with chronic pain (abdominal pain12–14, juvenile arthritis15,9, widespread musculoskeletal pain16, lower back pain17, mixed pain conditions) and in epidemiologic studies.2, 3, 12, 18–21. One study found that almost half of all children with chronic pain missed more than 6 days of school in the previous 3 months, and 13% missed more than 35 days22. In the only other large, nationally representative study to date in the United States, children with chronic pain were 5 times more likely to be chronically absent compared to peers without chronic pain (6.1% vs. 1.3% missed 15 days or more)5. We confirm and extend this knowledge to a second large, national sample of children in the United States. Indeed, similar to the study using data from the Medical Expenditure Panel Survey, we found that rates of chronic absenteeism were about 5 times higher among children with chronic pain as compared to children without chronic pain (13.9% versus 2.4%). Chronic absenteeism is an indication of broader problems in overall performance at school and a strong risk factor for school dropout,23, 24 lower academic performance, and lower post-secondary enrollment25. Indeed, the US Department of Education considers chronic absenteeism an educational crisis26. Improving pediatric chronic pain management may play a role in reducing chronic absenteeism in the United States.
As hypothesized, we found that chronic pain was associated with poorer school engagement and increased risk for repeating a grade. Previous studies found that the onset of chronic pain was associated with a decline in children’s grades in a dose-dependent fashion3, 27. Not surprisingly, parents of children with pain also reported that they were more often contacted because of problems at school. We are not able to determine how these measures interact nor their directionality, however, it is likely that lack of engagement may contribute to poorer academic performance. In turn, poor school engagement and poor academic performance may be contributing factors that result in parents being contacted. On the other hand, each of these measures also encompass independent constructs. For example, school engagement is a global assessment that incorporates behavioral, affective and cognitive indices of the child28. While factors such as student behavior and teacher perception can contribute to engagement, the data remains sparse on the specific etiology of poor school engagement, and how it ultimately relates to poor academic performance.
Our finding that chronic pain was associated with an increased risk for having a learning disability diagnosis merits further research. Several studies have evaluated differences in intellectual functioning between children with chronic pain and their peers without pain, and none have identified significant differences29–31. It has been proposed that poor academic performance may be the result of more complex processes, such as difficulties with sustained attention, working memory, and attentional biases to pain32, 33. While there is no clear evidence that chronic pain affects cognitive function34, pain may reduce children’s ability to concentrate, socialize, and attend school, thereby worsening academic competence and outcomes34. Studies have not examined specific learning disabilities in children with chronic pain, however there is emerging evidence that children with chronic pain may have elevated risk of comorbid neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder35. This is clearly an area that warrants further investigations. Finally, chronic pain is often associated with other physical and psychological symptoms such as sleep disturbances, anxiety and depressive4 symptoms, which may further reduce cognition, emotional and physical functioning in school settings.
Recognizing that the epidemiology of pain differs with age and sex, we also examined possible differences in school functioning by these factors. Although results suggest that the association between chronic pain and school functioning is present early in elementary school, older adolescents (15–17-year olds) were most affected by chronic pain. Adolescence is a period of critical transition to adulthood and disruptions in schooling during this time may have significant consequences on lifelong educational and vocational attainment36. Unfortunately, for many youth, supports at school decrease in high school, which may increase vulnerability to negative school impact. Our results showed greater associations between chronic pain and school functioning in males as compared to females. As males are often underrepresented in clinical pain samples, there has been limited previous research exploring such sex differences in the negative effects of chronic pain. However, evidence suggests different pain coping strategies between males versus females, which may contribute to worse school-related outcomes among boys37. Girls are more likely to seek social support from family and teachers;. whereas boys are more likely to cope by behavioral distraction including acting out which may lead to school-related problems. Future research is needed to consider mechanisms that link pain with school functioning in males and females4, 22.
Given the high national prevalence of pediatric chronic pain, addressing school functioning should involve a comprehensive approach involving children, families, educators, and health policy makers. On the child and family level, resources and support for improving school attendance and academic success can be provided. This might involve expanded use of special education services for health impairments (including accommodations). as well as working with psychologists trained in chronic pain who can help with school re-entry, use of pain coping skills in the school setting, and parent-child expectations about school. On a school level, useful interventions may include information sharing from medical providers to help teachers and administrators understand the diagnosis of chronic pain and expectations in academic settings as well as continued support given for tailored educational plans. The subjective nature of chronic pain has been associated with negative judgement and stigma. Indeed, teachers often report a lack of knowledge and lack of specific guidelines as barriers to interacting with students with chronic pain38. Recognizing that supportive teachers can enhance school functioning, providing an understanding of strategies to support success in the classroom may be beneficial. On a national level, policy makers should consider strategies that provide education on a broader forum for children and families about chronic pain. Finally, a priority has to be placed on the development and testing of interventions specifically targeting school functioning in children with chronic pain39.
Several limitations of this study should be acknowledged. First, this is a cross-sectional analysis and the causal relationship between chronic pain and school functioning cannot be established. While chronic pain may directly lead to poorer school functioning, it is also plausible that poorer school functioning may lead to worsening pain symptoms in affected individuals. This question can only be addressed with a longitudinal design. Second, data captured in the NSCH are reported by parents. Due to social desirability bias, parents may underreport problems related to children’s pain or school functioning. To minimize bias, participants were told that their answers would be de-identified. Regardless, parent and child report of objective school functioning, specifically school engagement, may differ. Third, school measures were all completed retrospectively, relying on memory over the prior 12 months, which may be subject to recall bias. However a previous study found that parent and child self-report of school performance was consistent with objective school records3. Fourth, The NSCH did not include questions on the severity, frequency and duration of pain. Thus, the presence versus absence of chronic pain over the past 12 months was the only inclusion criteria, which means that children with a range of chronic pain conditions are likely represented in our sample40. Despite these limitations, there are significant strengths of our findings relative to the research in this area. First, the use of a large community based, nationally representative sample means that our results are generalizable to the entire school-aged population in the United States. Second, the survey was administered in participants’ homes and thus may more accurately reflect both the prevalence of pain and school functioning as compared with surveys administered in school (which require attendance at school to complete) or in specialist pain clinics.
In summary, we found that children with chronic pain in the United States have significantly poorer school-related functioning as compared to their peers. This highlights the emerging and urgent need for population-based approaches to address a vulnerable population at risk for poor educational and vocational attainment.
Funding source:
This work was partially funded by grants from the National Institutes of Health: (grant number K23HL138155 PI:CBG), (grant number K23DK118111 PI:SWT).
Footnotes
Financial Disclosure: The authors have no financial relationships relevant to disclose.
Conflict of interest: The authors have no conflicts of interest to disclose.
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