The association between children’s chronic pain, depression, and anxiety

symptoms: the mediating effect on the quality of life

Qihui Zhao1△, Yulin Wang1△, Xinyi Luo2, Wanchun Leng3, Qiongyue Hu3, Yanqing Xu1, Jin
Zhang1, Zezhi Li4,5*, Daqian Zhu1 *

1. Department of Psychology, Children's Hospital of Fudan University, National Children's

Medical Center, Shanghai 201102, China
2. University of Rochester, Rochester, NY 14627, USA
3. Qingdao Mental Health Center, Qingdao, China
4. Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University,
Guangzhou 510370, China
5. Guangdong Engineering Technology Research Center for Translational Medicine of Mental
Disorders, Guangzhou 510370, China

△
These authors have contributed equally to this work and share first authorship

*Correspondence:
Zezhi Li: Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical
University, Guangzhou, 510370, China.
E-mail address: biolpsychiatry@126.com.

Daqian Zhu: Department of Psychology, Children's Hospital of Fudan University, National

Children's Medical Center, Shanghai, China
E-mail address:zhudaqian2003@163.com

Funding:
This study was supported by funding from the program to Pediatric Chronic Pain
Multidisciplinary Team (MDT) at Children’s Hospital of Fudan University, Managing Cancer
and Living Meaningfully (CALM) in Pediatric Oncology Multidisciplinary Standardized
Management from Clinical Innovation Program of Shanghai Hospital Development Center
(SHDC22020212), and the special project on Aging and Maternal-Child Health from Shanghai
healthcare system (2020YJZX0211).

Abstract
Background:

The median prevalence range of pediatric chronic pain is 11% to 38%. Depression, anxiety

disorder, and chronic pain are closely associated with the quality of life of the patient, but only a

handful of studies have been conducted to delineate the cross-talks of these factors.

Objective:

The purpose of this study was to explore the association between pain intensity, depression, and

anxiety symptoms in children with chronic pain, and how the quality of life might affect these

interactions as a mediator.

Methods:

A total of 88 children with chronic pain were recruited for this study. The Children's Depression

Inventory (CDI), Screen for Child Anxiety Related Emotional Disorders (SCARED), Numerical

Rating Scales (NRS), and Pediatric Quality of Life Inventory (PedsQL4.0) were used to measure

the depression and anxiety symptoms, pain intensity, and quality of life, respectively.

Results:

The pain intensity was positively correlated with depression symptoms and anxiety symptoms

but negatively correlated with the quality of life.The mediating effect of quality of life between

children's pain and depressive symptoms was significant (95%CI=[0.18, 1.66]), accounting for

60.8% of the total effect. The mediating effect of quality of life on children's pain and anxiety

symptoms was also significant (95%CI=[0.24, 2.88]), accounting for 42.9% of the total effect.

Conclusion:

The quality of life has a mediating effect on pain intensity, depression, and anxiety symptoms in

children with chronic pain. Children may experience fewer depression and anxiety symptoms if

their quality of life can be improved.

Key words: Pediatric chronic pain; Depressive symptoms; Anxiety symptoms; Mediating effect

1. Introduction

Chronic pain refers to any recurrent pains lasting for at least three consecutive months.

Chronic pain can lead to a wide range of physiological and social impairments, including

physical discomforts, perturbed daily physical activities, social withdrawal, educational

hindrance, sleep disorders, attention deficits, and emotional problems, affecting the quality of life

in children (Forgeron et al., 2011; Kashikar-Zuck et al., 2011; Mckillop & Banez, 2016; Miller et

al., 2018; Voerman et al., 2017). Furthermore, chronic pain symptoms in childhood may induce

the onset of complicated health conditions, somatic symptoms, and neuropsychiatric diseases in

adulthood (Horst et al., 2014; Palermo et al., 2010). In children, the median prevalence range of

chronic pain is usually 11% to 38%, with 8% of children experiencing severe and frequent pain

symptoms (Fisher et al., 2018; King et al., 2011). Headache and stomach pain are the most

common pain conditions observed in these child subjects. Notably, an international study on

adolescents from 28 countries has reported that the incidence rates of headache and stomach pain

are 54.1%, and 49.8%, respectively (Swain et al., 2014).

Several etio-pathological risk factors could be associated with chronic pain in childhood,

such as biological susceptibility, individual psychological factors, and family environment

factors. Both age and gender are considered strong components of the biological susceptibility to

the presence of chronic pain. Interestingly, females and adolescents have been found at a high

risk of developing chronic pain (Huguet et al., 2016; Speretto et al., 2015). Moreover, a family

history of pain symptoms can also predict the onset of chronic pain pathology in childhood and
adolescence (Mckillop & Banez, 2016). In terms of an individual’s psychological factors, stress

and negative life events, as well as negative coping styles (dependence, denial, and

catastrophizing) are closely related to the occurrence and ongoing continuation of pain symptoms

(Helgeland et al., 2010; Miller et al., 2018). Regarding the family environment, studies have

shown that parenting style is one of the crucial indicators of pain symptoms. Parental pain

catastrophizing and protective responses can also lead to socio-psychological impairments in

children, ultimately transforming into chronic pain in their adulthood (Anno et al., 2015;

Donnelly et al., 2020; Logan et al., 2012).

Furthermore, there is a multitude of correlative relationships between depression, anxiety,

chronic pain, and quality of life in child subjects. In most cases, children suffering from chronic

pain show increased symptoms of depression, anxiety, and emotional agitations that often disturb

their daily school activities, like missing out on classes and taking leave for a relatively long

period, compared to the general population of students (Rousseau-Salvador et al., 2014; Soltani

et al., 2019; Tegethoff et al., 2015; Tran et al., 2016).

Depression and anxiety symptoms play vital roles in transitioning acute pain into chronic

pain(Lewandowski et al., 2017; Soltani et al., 2019). Children with chronic pain exhibiting

depressive symptoms have been shown to have higher rates of negative prognosis as well as pain

recurrence compared to their counterparts without any depressive symptoms (Sinclair et al.,

2016; Blaauw et al., 2015). Current studies suggest that depression, anxiety disorder, and chronic

pain are closely associated with the quality of life of the patient, but only a handful of studies

have been conducted to delineate the cross-talks of these pathological factors. Therefore, we

attempted to explore the disease-modifying effect of chronic pain on depression and anxiety

symptoms in children using the quality of life as a mediator variable. This study, thus, provides
us with evidence for strategies to lessen symptoms of depression and anxiety, and improve socio-

behavioral functions in children with chronic pain.

2. Methods

2.1 Subject selection

Eighty-eight children with chronic pain who were seen in the Psychology Department of

the Children’s Hospital of Fudan University from March 2021 to November 2021 were recruited

to the study. Most children were mainly referred by gastroenterologists, neurologists, and

rheumatologists. Their perceived pain or the functional impairment caused by that pain neither

matched the clinical disease symptoms nor was alleviated by standard treatments. The inclusion

criteria of patients were: (1) ages ranging from 8-18 years; (2) suffering from chronic or

recurrent pain (lasting for more than three months), and (3) the subject was capable of

understanding and answering questionnaires. Children with severe mental disorders or

intellectual disabilities were excluded from the study (Kashikar-Zuck et al., 2011). The study

was approved by the Ethics Committee of the Children’s Hospital of Fudan University (batch

number: No. 2021-461).

2.2 Assessment procedures

2.2.1 Key components of the assessment team

The assessment team consisted of psychotherapists from the Department of Psychology

of the Children’s Hospital of Fudan University. All team members were well-qualified

psychometrists. Children were assessed one-on-one in a separate room to ensure uninterrupted

completion of the interview and questionnaire processes. The assessment team members first

explained the study and guidelines to child subjects in a simple and understandable format before

recording their answers to the questionnaire.

2.2.2 Children’s Depression Inventory (CDI)

For this study, the Chinese version of the CDI (CDI-C) was used to assess depressive

symptoms in children. CDI has a wide application in the clinic and has been proven to be a valid

and efficient tool for assessing depressive symptoms in children with a Cronbach’s alpha

coefficient of 0.84 (Smucker et al., 1986). The Chinese version was translated from the English

version of the CDI scale, provided by Professor Abela from the Department of Psychology at

McGill University, Canada, and tested for reliability by Wu et al. (2010). The Chinese translation

was carried out by three psychology professionals from the Second Xiangya Hospital Central

South University, and then back-translated into English by bilingual experts from McGill

University to collate the semantic consistency of the Chinese translation with the original

English version of CDI. The CDI-C showed accepted levels of reliability and validity with an

internal consistency Cronbach’s alpha coefficient of 0.88, and a re-test reliability of 0.81 (Wu et

al., 2010).

The CDI consists of 27 items within 5 subscales: anhedonia, negative mood, negative

self-esteem, ineffectiveness, and interpersonal problems. Each entry has three options describing

different levels of depressive symptoms and is rated on a 3-point Likert scale, where 0 indicates

the least depressive symptoms, and 2 indicates the most depressive symptoms. The total score on

the CDI scale is 54, with higher scores indicating more severe depression.

2.2.3 The Screen for Child Anxiety Related Emotional Disorders (SCARED)

The Chinese version of the SCARED (SCARED-C) was used to assess anxiety symptoms

in children. The scale was developed by Birmaher et al. (1997) and revised in 1999. SCARED is

considered an effective screening tool for the clinical diagnosis of anxiety disorders in child

subjects (Birmaher et al., 1997; Birmaher et al., 1999).

 SCARED was translated into Chinese by Wang et al. and back-translated into English by

a professor at the English Training Center of Xiangya School of Medicine. It was confirmed that

there was no difference between the Chinese and English versions of SCARED. The Cronbach’s

alpha coefficient ranged from 0.43 to 0.89, with a sensitivity of 0.74 and a specificity of 0.79 for

diagnosing anxiety disorders (Wang et al., 2002).

SCARED consists of 41 items and 5 factors: panic disorder or significant somatic

symptoms, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and

significant school avoidance. Each entry has three options describing different levels of anxiety

and is rated on a 3-point Likert scale, with higher scores indicating greater anxiety symptoms.

2.2.4 Numerical Rating Scale (NRS)

NRS is used to rate the severity of pain symptoms and consists of four entries, namely

current, best, worst, and average pain experienced over the past 24 hours. Each entry is rated on

a scale of 0-10, with higher values indicating more severe pain. The average value of these four

entries is the composite score of pain intensity. NRS has been proven to be a valid and reliable

screening tool for assessing pain severity in children and adolescents (Castarlenas et al., 2017;

Makino et al., 2013).

2.2.5 The Pediatric Quality of Life Inventory 4.0 (PedsQL)

The Chinese version of PedsQL 4.0 (PedsQL-C) was used to assess the health-related

quality of life factors in children and adolescents. PedsQL 4.0 is widely used in many countries

and has been proven to be a clinically valid tool for assessing the quality of life with a

Cronbach’s alpha coefficient of 0.89 (Varni et al., 2003).

The PedsQL-C scale was translated and revised by Lu et al.(2008) in strict accordance

with the translation steps following internationally accepted procedures of translation and back-
translation with cultural adaptions. PedsQL-C, as a valid tool with Cronbach’s alpha coefficient

ranging from 0.74 to 0.82 and a comparative fit index of 0.92, is shown to be effective in

assessing the quality of life parameters in children and adolescents (Lu et al., 2008).

The PedsQL-C scale consists of 23 items and is divided into four dimensions, such as

physical functioning, emotional functioning, social functioning, and school functioning. Each

entry gathers information about the frequency of an event during the last month. The response

options are divided into five levels from 0 to 4, and the scoring is transformed into a score of 100

to 0 accordingly. Better living quality is indicated by higher scores (Lu et al., 2008).

2.3 Statistical analysis

A database was created and analyzed statistically using SPSS version 24.0 software.

Demographic characteristics of the samples were reported using descriptive statistics. The t-test

and analysis of variance (ANOVA) were used to analyze the effect of age and pain symptoms on

the degree of depression and anxiety in children. Pearson’s correlation analysis was used to

investigate correlations between pain intensity, depressive symptoms, anxiety symptoms, quality

of life, age, and duration of illness in children.

Analysis of the mediating effects was performed using PROCESS macro for the SPSS plug-

in developed by Preacher and Hayes. Based on the correlation analysis, a stepwise method was

used to test the relationship between pain intensity and child depression and anxiety symptoms

using linear regression with quality of life as the mediator variable (Baron & Kenny, 1986). The

significance of quality of life as a mediator variable was tested using the bootstrapping method,

in which 1000 bootstrap samples were repeatedly and randomly selected from the original

dataset to estimate a 95% of confidence interval (CI) for the mediating effect. The mediating

effect was indicated as significant if 95%CI did not include 0 (Preacher & Hayes, 2004).
3 Results
3.1 Sociodemographic characteristics
The average age of participating children was 11.0±1.83 years. The biological sex of the
participants was equally distributed between boys and girls (50% vs. 50%). The sites of chronic
pain included the abdomen (39.78%), head (14.77%), joint (14.77%), and other (chest, muscle,
etc.) (11.36%). Besides, 3.40% of the participants reported chronic pain in multiple sites in the
body. On average, chronic pain symptoms persisted for 16.78±15.75 months. The
sociodemographic characteristics of the samples are shown in Table 1.

Table 1 Sociodemographic characteristics of the sample

item Total(M±SD)/n Male(M±SD)/n Female(M±SD)/n t/X2 p
n=88 n=44 n=44

Age 11.10±1.83 11.09±1.70 11.11±1.98 -0.06 0.95

Pain Duration 16.78±15.75 15.41±14.42 18.16±17.04 -0.82 0.42

Pain Intensity 4.18±2.11 4.57±1.89 3.78±2.26 1.76 0.08

Pain Locations 4.04 0.40

Abdomen 35 18 17

Head 27 16 11
Joint 13 6 7

Other 10 4 6

Multiple sites 3 3 0

3.2 Effects of gender and pain locations on children’s anxiety, depression, and quality of life
The results of the independent sample t-test showed that there were no significant
differences between different genders for depressive symptoms (t=1.09, p>0.05), and quality of
life (t=0.29, p>0.05). However, females reported more severe anxiety symptoms than their male
counterparts (t=3.13, p<0.01) (Table 2).
 Table 2 Comparative analysis of depression, anxiety symptoms, and quality of life scores
between males and females (M±SD)
Total Female Male t P
CDI 20.45±9.18 21.52±9.81 19.39±8.48 1.09 0.28

SCARED 28.95±19.67 35.20±21.03 22.70±16.14 3.13** 0.00

PedsQL 63.96±17.52 64.50±17.01 63.41±18.19 0.29 0.77

**P<0.01

The results of the ANOVA indicated that there were no significant differences in the
effects of pain locations on depressive symptoms (F=0.47, p>0.05), anxiety symptoms (F=0.46,
p>0.05), and quality of life (F=1.45, p>0.05) in children (Table 3).

Table 3 Comparative analysis of depressive symptoms, anxiety symptoms, and quality of

life scores at different pain locations (M±SD)
Abdomen Head Joint Pain Other Multiple F p
Sites
CDI 21.08±8.69 21.11±8.69 20.62±12.48 17.10±7.06 17.67±12.6 0.47 0.76
6
SCARED 31.23±19.96 29.89±20.20 25.69±22.63 22.80±14.79 28.67±18.1 0.46 0.76
5
PedsQL 63.20±14.56 64.54±17.40 56.27±22.83 72.39±16.15 72.83±25.3 1.45 0.23
3

3.3 Correlation analysis of age, pain duration, pain intensity, quality of life, depressive
symptoms, and anxiety symptoms
The results of Pearson’s correlation analysis revealed that the pain intensity was negatively
correlated with quality of life (r=-0.24, p<0.05) but positively correlated with depressive
symptoms (r=0.29, p<0.01) and anxiety symptoms (r=0.28, p<0.01). Furthermore, quality of life
exhibited negative correlations with depressive symptoms (r=-0.80, p<0.01), and anxiety
symptoms (r=-0.65, p<0.01). Both age and pain duration were not significantly correlated with
either pain intensity, quality of life, depressive symptoms, or anxiety symptoms.
Table 4 Correlation analysis of age, pain duration, pain intensity, quality of life, depressive
symptoms, and anxiety symptoms
1 2 3 4 5 6
1 Pain Intensity 1 -0.24* 0.29** 0.28** -0.16 -0.13

2 Quality of life 1 -0.80** -0.65** -0.11 0.07

(PedsQL)
3 Depressive 1 0.80** 0.11 -0.00
symptoms (CDI)
4 Anxiety symptoms 1 0.18 0.03
(SCARED)
5 Age 1 0.05

6 Pain Duration 1

*p<0.05; **p<0.01

3.4 Mediation analysis

Gender, age, pain duration, and pain locations were included as the control variables in
this model. The first step of the analysis tested the significance of the regression coefficient of
pain intensity on depression and anxiety symptoms in children. The results revealed that pain
intensity was a significant predictor of child depressive symptoms (t=3.17, p<0.01), and anxiety
symptoms (t=3.93, p<0.01). The second step examined the significance of the regression
coefficient of pain intensity on quality of life, revealing that pain intensity was a significant
predictor of the quality of life (t=-2.4, p<0.05). The third step measured the significance of the
regression coefficients of pain intensity and quality of life on children's depression and anxiety
symptoms showing an increase in the R2 value. Additionally, the quality of life was a significant
predictor of depressive symptoms (t=-12.08, p<0.01), and anxiety symptoms (t=-8.75, p<0.01),
as well, in children. Although the predictive effects of pain intensity on depressive symptoms
(t=2.00, p<0.05) and anxiety symptoms (t=3.03, p<0.01) in children remained significant,
respective coefficient β values were decreased. The significance of the mediating effect was
further tested using the bootstrap method. The results indicated a significant mediating effect on
the quality of life between the pain intensity and depressive symptoms in children (95%CI =
0.18-1.66), where the mediating effect accounted for 60.8% of the total effect. The mediating
effect of quality of life between the pain intensity and anxiety symptoms in children was
significant (95%CI = 0.24-2.88) as well, accounting for 42.9% of the total effect (See Table 5,
Table 6; Figure 1, Figure 2).

Table 5 The relationship between the pain intensity and depressive symptoms in children, using
quality of life as a mediating variable
Index(β) Standard R2 t p 95% Confidence
Error Interval
(SE) Lower Upper
Limit Limit
Step 1
Pain intensity 1.48 0.47 0.15 3.17** 0.002 0.55 2.41
depressive
symptoms (c)
Step 2
Pain intensity -2.17 0.90 0.12 -2.40* 0.019 -3.96 -0.37
quality of life (a)
Step 3
Pain intensity, 0.70
quality of life
depressive
symptoms
Quality of life -0.42 0.03 -12.08** 0.000 -0.48 -0.35
depressive
symptoms (b)
Pain intensity 0.58 0.29 2.00* 0.049 0.00 1.15
depressive
 symptoms (c’)
Bootstrap
Pain intensity 0.90 0.38 0.18 1.66
quality of life
depressive
symptoms (a*b)
*p<0.05; **p<0.01

Figure 1 The relationship between pain intensity and depressive symptoms in children,
using quality of life as a mediating variable
a=-2.17 b=-0.42
Quality of life

c=1.48, c’=0.58
Pain intensity Depressive symptoms in Children

Table 6 The relationship between pain intensity and anxiety symptoms in children, using quality
of life as a mediating variable

Index Standard R2 t p 95% Confidence

(β) Error Interval
(SE) Lower Upper
Limit Limit
Step 1
Pain intensity 3.57 0.91 0.30 3.93** 0.000 1.76 5.38
anxiety
symptoms (c)
Step 2
Pain intensity -2.17 0.90 0.12 -2.40* 0.019 -3.96 -0.37
quality of life (a)
Step 3
 Pain intensity, 0.64
quality of life
anxiety
symptoms
Quality of life -0.71 0.08 -8.75** 0.000 -0.87 -0.55
anxiety
symptoms (b)
Pain intensity 2.05 0.68 3.03** 0.003 0.70 3.39
anxiety
symptoms (c’)
Bootstrap
Pain intensity 1.53 0.65 0.24 2.88
quality of life
anxiety
symptoms (a*b)
*p<0.05; **p<0.01

Figure 2 The relationship between pain intensity and anxiety symptoms in children, using
quality of life as a mediating variable
a=-2.17 b=-0.71
Quality of life

c=3.57, c’=2.05
Pain intensity Anxiety symptoms in Children

4. Discussion
Chronic pain-associated avoidance behaviors and social problems may lead to a reduced
quality of life and increased occurrences of depression and anxiety symptoms. Here, we reported
the characteristics of chronic pain symptoms in Chinese children. Furthermore, we showed that
quality of life had a mediating effect between pain intensity and depression and anxiety
symptoms in these children.
 Moreover, we observed a high incidence of abdominal pain and headache among these
children with chronic pain, which was consistent with previous reports (King et al., 2011; Swain
et al., 2014). However, the incidence rate of multi-site pain was significantly lower in this study,
with only 3 of 88 subjects reporting pain at multiple sites in the body, which was, in fact,
contradictory to the observations reported by Swain et al. (2014). This difference might be
attributed to the different analysis methods used in these two studies. In this study, information
was ascertained in an interrogative manner, and children’s responses were focused on the areas
of pain that bothered them the most. In contrast, Swain et al. used a questionnaire that asked
children if they had pain in a particular location, which might have inadvertently influenced
children’s responses to report on any or all recent discomforts. Additionally, the average age of
the children surveyed by Swain et al. was 13.6 ± 1.7 years, while that was 11.10 ± 1.83 years in
this study. It has been shown that, compared to younger children, adolescents tend to report
multiple sites of pain more often (Swain et al., 2014), which might also explain the lower
incidence of multiple sites of pain in this study.
There were no significant differences in terms of gender for pain intensity, depressive
symptoms, and quality of life, which were consistent with previous studies (Kashikar-Zuck et al.,
2011; Logan et al., 2012). However, females reported anxiety symptoms more frequently than
males. This might be because female subjects were more sensitive to anxiety symptoms
compared to males (Mahrer et al., 2012).
Impaired quality of life in children includes school absence, social problems, and
impaired daily activities. We found that children's quality of life was significantly and negatively
associated with their degrees of depressive symptoms, anxiety symptoms, and pain intensities.
These results were consistent with those of previous studies (Gibler et al., 2019; Logan et al.,
2012; Mckillop & Banez, 2016; Sil et al., 2015; Sinclair et al., 2016). Children with chronic
headaches and frequently recurring pain symptoms are four times more likely to miss more than
one month of school than children with paroxysmal headaches (Rousseau-Salvador et al., 2014).
Children with fibromyalgia reported more fear of movement and depressive symptoms than
others (Sil et al., 2015). Children with more severe pain intensities were more likely to suffer
from sleeping disorders and insomnia, which in turn can lead to a range of mental health
complications (Pavlova et al., 2017).
 There were mediating effects between the quality of life, pain intensity, depression, and
anxiety symptoms in children with chronic pain. The results indicated that quality of life could
mediate 60.8% of the total effect between the pain intensity and depressive symptoms; and
42.9% of the total effect between the pain intensity and anxiety symptoms in children.
Pain intensity has a predictive effect on the quality of life (t=-2.04, p<0.05). Moreover,
pain intensity was found to be a predictive factor of child anxiety symptoms (t=3.93, p<0.01).
The direct effect of pain intensity on children’s anxiety symptoms remained significant, even
after controlling the mediating effect of quality of life (t=3.03, p<0.01), suggesting that a high
pain intensity may lead to anxiety symptoms in children. This finding validated the hypothesis of
the fear-avoidance model of chronic pain, which suggests that chronic pain psychologically
influences children to be afraid of pain, and the anxiety symptoms synergistically lead to a
significant avoidance attitude, ultimately resulting in a poorer quality of life (Cousins et al.,
2015; Miller et al., 2018; Simons, 2012). High levels of pain intensity can also limit daily
activities in adolescent patients (Rabbitts et al., 2014). In children, an increase in anxiety
symptoms and avoidance behaviors due to an increase in chronic pain symptoms can restrain the
subject towards normal daily activities, leading to a reduced quality of life.
The decrease in quality of life could further predict the degree of children's anxiety
symptoms (t=-8.75, p<0.01) and depressive symptoms (t=-12.08, p<0.01). After controlling the
mediating effect of quality of life, the predictive coefficient β of pain intensity on children's
anxiety symptoms decreased from 3.57 to 2.05, but the significance remained at the 0.01 level.
The predictive coefficient β for pain intensity on depressive symptoms in children decreased
from 1.48 to 0.58, and the significance level changed from 0.01 to a marginally significant level.
Thus, decreased quality of life had a greater impact on depressive symptoms than anxiety
symptoms in children. This might be due to children's catastrophizing perceptions and
interpersonal problems. Children with chronic pain present reduced peer interactions and are
more prone to interpersonal problems due to impaired psycho-social functioning and increased
school absences. Usually, these children tend to have fewer friends, prefer to remain in seclusion,
and are more likely to be bullied (Forgeron et al., 2010). These children are also more sensitive
to potentially unsupportive environments (Forgeron et al., 2011). When peer interaction is
reduced due to chronic pain, children are more likely to feel excluded, which further exacerbates
their depression and anxiety symptoms. Impaired academic and social functioning, as well as
reduced quality of life due to chronic pain, may lead to the development of catastrophic
perceptions and feelings of helplessness, which can lead to depressive symptoms in children
(Miller et al., 2018).
This study established the fact that psychological interventions are highly required for
children with chronic pain. Cognitive-behavioral interventions can shape children's
catastrophizing perceptions, help them learn coping skills, reduce avoidance behaviors, and
restore social functioning, thereby improving their depression and anxiety symptoms.
This study has certain limitations that should be considered during the interpretation of
the results. Being a cross-sectional study, it limited us from drawing more definite conclusions
about the cause-and-effect relationships between pain intensity, quality of life, depression, and
anxiety symptoms, which should be further clarified through longitudinal studies and follow-up
studies in the future. Furthermore, the specific effects of pain intensity, children's and parents'
catastrophizing perceptions, parents' protective behaviors, and children's avoidance behaviors on
children's quality of life, depression, and anxiety symptoms could be included in future studies
allowing for more complex models being validated.
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