Dispositional Mindfulness and Its Relationship With Distress and Functioning in Adolescents With Chronic Pain and Low-Level Pain

Dispositional Mindfulness and Its Relationship With Distress and Functioning in Adolescents With... Abstract Objective Dispositional mindfulness is the general tendency to pay attention to present-moment awareness without judgment. The main aim of this cross-sectional study was to determine (a) whether dispositional mindfulness is associated with psychological distress in adolescents with chronic pain and low-level pain, and (b) whether it accounts for unique variance in distress after controlling for key variables from the pain literature. A secondary aim was to explore the relationship between dispositional mindfulness and functioning. Method 54 adolescents seeking help for chronic pain and 94 “healthy” adolescents with recent low-level pain from the general population completed the same battery of measures, including the Child and Adolescent Mindfulness Measure of dispositional mindfulness. Results As predicted, dispositional mindfulness was associated with mood and anxiety in both groups and also accounted for unique variance in mood and anxiety in standard regression models after controlling for group, age, pain-intensity, pain-catastrophizing, and pain-acceptance. Dispositional mindfulness did not differ significantly across the two groups and did not predict physical functioning. However, it did account for unique variance in social functioning. Conclusions Dispositional mindfulness may be an important construct to consider in the context of adolescents experiencing mood and anxiety problems in both low-level and chronic pain samples. Further research should aim to replicate these findings in larger clinical samples and explore the predictive power of dispositional mindfulness using longitudinal designs. chronic and recurring pain, mental health, psychosocial functioning Introduction Mindfulness is often defined as “paying attention on purpose, in the present moment, non-judgementally” (Kabat-Zinn, 2003, p. 145). Dispositional mindfulness can be thought about as a general “trait-like” tendency to abide in mindful states over time (Brown & Ryan, 2003). McCracken and colleagues have clearly outlined why mindfulness may be an important construct to consider in the field of adult chronic pain (McCracken, Gauntlett-Gilbert, & Vowles, 2007). They argue that observing (as opposed to reacting automatically to) physical sensations, emotions, and thoughts, that is, being more mindful, can lead to a more “balanced, non-reactive and realistic” relationship to pain experiences. Central to this is the idea that mindful awareness involves noticing and stepping back from, rather than being immersed in and controlled by, thoughts, emotions, and sensations (Shapiro, Carlson, Astin, & Freedman, 2006). The contribution of mindfulness to chronic pain was first supported by evidence that mindfulness training, leading to enhanced levels of mindfulness, was associated with the reduction of distress in the context of chronic pain (Kabat-Zinn, Lipworth, & Burney, 1985). More recently, in the adult chronic pain literature, a series of cross-sectional studies have indicated that natural variation in dispositional mindfulness can explain unique variance in distress after controlling for other key variables (Elvery, Jensen, Ehde, & Day, 2017; McCracken et al., 2007; McCracken & Keogh, 2009; Mun, Okun, & Karoly, 2014). Two of the established key variables are pain catastrophizing (an exaggerated mental set of rumination, magnification, and helplessness in the context of actual or anticipated pain) and pain-acceptance (experiencing pain without taking actions to control it and persisting with activity in the presence of pain). It may be that researchers now need to investigate the potential additive influence of the “non-pain-specific” construct dispositional mindfulness. If it is important, then chronic pain treatment programs might consider incorporating general mindfulness training (that can be of benefit to many areas of one’s life) in addition to targeting pain-specific cognitions. Relationships exist between pain-catastrophizing, pain-acceptance, and dispositional mindfulness; however, they may not be redundant (Elvery et al., 2017). With emerging evidence that the separate construct of dispositional mindfulness may play an important role in determining the nature of distress experienced by adults living with chronic pain, it is important to assess whether this also applies to adolescents. The adolescent literature has already demonstrated that pain-catastrophizing and pain-acceptance predict levels of distress in the context of chronic pain (Kalapurakkel, Carpino, Lebel, & Simons, 2015; Tran et al., 2015), but as yet, no studies have explored the potential role played by dispositional mindfulness in this context. However, there is evidence that dispositional mindfulness is positively associated with good mental health in the general adolescent population (Greco, Baer, & Smith, 2011; Pallozzi, Wertheim, Paxton, & Ong, 2017), whereas mindfulness training appears to help to reduce distress in the context of adolescent chronic pain (Gauntlett-Gilbert, Connell, Clinch, & McCracken, 2013). Dispositional mindfulness has also been found to account for unique variance in pain interference in healthy adolescents experiencing low-level pain typical of the general population (Petter, Chambers, McGrath, & Dick, 2013). The main aim of this cross-sectional study was therefore to determine (a) whether dispositional mindfulness is associated with psychological distress in adolescents with chronic pain and “healthy” adolescents with low-level pain, and (b) whether it accounts for unique variance in distress after controlling for key variables already established in the pain literature. To test this, both a chronic pain and a “healthy” low-level pain sample were recruited into the study and all adolescents were asked to complete the same battery of measures. Based on the research described earlier, our first hypothesis was that dispositional mindfulness would be significantly associated with anxiety and mood in both adolescents with chronic pain and “healthy” adolescents with low-level pain. Our second hypothesis was that dispositional mindfulness would account for unique variance in mood and anxiety after controlling for group, demographics, pain-intensity, pain-catastrophizing, and pain-acceptance. As an exploratory aim, we also examined the relationship between dispositional mindfulness and aspects of physical and social functioning, and whether there are differences between adolescents with chronic pain and “healthy” adolescents with low-level pain in terms of their levels of dispositional mindfulness. Inconsistent findings from the adult pain literature (McCracken et al., 2007; Schütze, Rees, Preece, & Schütze, 2010) and a dearth of research in the adolescent literature meant that only exploratory hypotheses could be generated with regard to these questions. We tentatively predicted that dispositional mindfulness would be positively associated with social and physical functioning (based on initial adult research reported by McCracken et al., 2007). We also tentatively predicted that levels of dispositional mindfulness would not differ significantly across the two groups (based on initial adult research reported by Schütze et al., 2010). Method Participants and Procedure Chronic Pain Group Potential patients aged 13–17 years presenting for assessment at three UK tertiary child and adolescent pain clinics between October 2016 and March 2017 were handed information and consent sheets by their assessing psychologist. Inclusion criteria included meeting local service criteria (persistent, distressing, nonmalignant chronic pain that had not responded to standard pediatric care) and sufficient English-language skills to complete the survey packs. Exclusion criteria included severe mental disorder, severe substance abuse, or known diagnosis of a terminal illness.1 Interested adolescents and their parents, for those < 16 years old, were given the choice to complete the consent process and study pack at the clinic (overseen by a clinician) or at home (overseen by the lead author via telephone). In total, 61 chronic pain patients participated (approximately 40% of those invited), but seven were excluded owing to incomplete data, yielding a final sample of 54 patients. In total, 94% of the participants in the chronic pain group were White-British, 72% were female, and the mean age was 14.6 years (range = 13–17, SD = 1.3). Reasons for declining participation were not recorded. All participants recruited into the chronic pain group were offered a £5 gift voucher as a token of appreciation. “Healthy” Low-level Pain Group Pupils from two classes in a state-funded UK secondary school (N = 51) and a convenience sample of adolescents attending a university open day to find out more about undergraduate degree programs (N = 53) were recruited. The lead author oversaw consent and participation procedures in person. Parents/carers of all school pupils were sent information sheets and opt-out slips in advance of the study. Parental consent was not needed for participants recruited from the university open day because they were ≥16 years old. Eight participants were excluded retrospectively (after completing the study pack) owing to reporting no pain over the past week, one was excluded retrospectively owing to reporting treatment for chronic pain, and one was excluded retrospectively because of incomplete data, yielding a final sample of 94 participants (50 from the secondary school and 44 from the university open day). In total, 80% of the participants in the general population group were White-British, 69% were female, and the mean age was 15.2 years (range = 13–17, SD = 1.8). Materials In addition to routine questions regarding demographics, all participants also completed the measures described next. Dispositional Mindfulness The Child and Adolescent Mindfulness Measure (CAMM; Greco et al., 2011) is a 10-item measure of dispositional mindfulness developed from the 39-item four-factor adult Kentucky Inventory of Mindfulness Skills (Baer, Smith, & Allen, 2004). Large samples of adolescents took part in the development studies providing feedback on the comprehensibility of the items (Greco et al., 2011). Factor analysis determined the single-factor structure of the CAMM, capturing both “present moment awareness” and “nonjudgment.” However, the CAMM does not include items measuring “describing” or “observing” because they were found to be developmentally inappropriate for the adolescent population. Convergent validity has been demonstrated by expected correlations with quality of life, academic competence, social skills, somatic complaints, internalizing, and externalizing. Incremental validity has been observed beyond measures of thought suppression and psychological inflexibility. The respondent is asked to rate each of the 10 reverse-scored items (e.g. “At school I walk from class-to-class without noticing what I’m doing,” “I get upset with myself for having feelings that don’t make sense”) on a 5-point Likert scale (0 = never true, 4 = always true). The CAMM has demonstrated good internal consistency (Cronbach’s alpha of .81) and construct validity in previous studies (Greco et al., 2011). The current study found alpha values of .81 and .85 in the chronic pain and “healthy” low-pain groups, respectively. Pain Factors Participants were asked to rate their average pain intensity experienced over the past week on a 0-10 Visual Analog Scale (VAS), with 0 representing no pain and 10 representing the worst pain possible (Varni, Thompson, & Hanson, 1987). Participants were asked to identify where in their body the pain was located (open text response allowing for multiple locations to be listed if appropriate), at what age they first noticed the pain, whether they were currently taking medication for their pain (yes/no response), and whether they had previously received any treatment for their pain (yes/no response). Data were not collected regarding pain frequency or duration of pain episodes. Distress and Functioning The Bath Adolescent Pain Questionnaire (BAPQ; Eccleston et al., 2005) subscales for depression, anxiety, social functioning, and physical functioning were used. The Depression subscale comprises six statements, such as “I feel sad.” The Anxiety subscale comprises seven statements, such as “I worry about the future.” The Social Functioning subscale comprises nine statements, such as “I go out to meet my friends.” The Physical Functioning subscale includes nine statements, such as “I need help dressing or bathing.” Respondents are asked to rate all statements on a 5-point Likert scale (0 = never, 4 = always). Each of these subscales has demonstrated good internal consistency (Cronbach's alpha values ranging from .80 to .83) and construct validity in previous studies (Eccleston et al., 2005). All Cronbach’s alpha values were above .70 in the current study, except for the Physical Functioning subscale when used with the “healthy” low-pain group (.66). Pain-catastrophizing The Pain Catastrophizing Scale for Children (PCS-C; Crombez et al., 2003) has 13 items (e.g. “When I have pain I feel I can’t stand it any more”), which the respondent rates on a 5-point Likert scale (0 = not at all, 4 = extremely). Recent evidence favors a single-factor structure (Pielech et al., 2014), with previous studies demonstrating good internal consistency (Cronbach’s alpha = .87) and construct validity (Crombez et al., 2003). The current study found alpha values of .94 and .92 for the chronic pain and “healthy” low-pain groups, respectively. Pain-acceptance The adolescent version of the Chronic Pain Acceptance Questionnaire (CPAQ-A; McCracken, Gauntlett-Gilbert, & Eccleston, 2010) has 20 items (e.g., “it’s ok to experience pain”), which the respondent rates on a 5-point Likert scale (0 = never true, 4 = always true). Evidence supports using the two subscales of “pain willingness” and “activity engagement.” Each subscale has demonstrated good internal consistency (Cronbach’s alpha = .75 and .86) and construct validity in previous studies (McCracken et al., 2010). The current study found alpha values ranging from .78 to .85 for the chronic pain and “healthy” low-pain groups. Design In this cross-sectional design, all participants completed the same set of measures at one time-point only. Chronic pain participants recruited from one of the clinics completed the CPAQ-A and the BAPQ as part of their routine assessment. Participants from another of the clinics completed the BAPQ as part of their routine assessment. Other participants completed all measures as part of the study pack. Ethical Approval Ethical approval was granted by a regional UK National Health Service (NHS) Research and Ethics Committee, the UK Health Research Authority, and the University of Bath Psychology Department Ethics Committee. Data Analysis All data were screened for outliers, as well as assumptions of normality, linearity, collinearity, homogeneity, and independent errors using graphical and statistical means. In terms of missing data, an a-priori decision was taken to replace a participant’s missing scale items with their mean scale or subscale score when a participant neglected to respond to up to two items of a scale (N = 14). Where a participant neglected to respond to more than two items of a scale, the scale was removed from analyses (N = 8). To test our first formal hypothesis, a series of Pearson’s coefficient bivariate correlations were planned to assess the relationship between dispositional mindfulness and distress (plus other key variables). To test our second formal hypothesis, a series of linear multiple regression analyses were planned to assess whether dispositional mindfulness accounted for unique variance in distress after controlling for other key variables. Related to the two exploratory hypotheses, an independent t-test was planned to assess group differences for dispositional mindfulness, and additional correlation and regression analyses were planned to investigate the relationship between dispositional mindfulness and functioning scores. Results Preliminary Analyses SPSS version 23 was used for all data analysis. Following initial screening, four extreme outliers caused by data entry mistakes were corrected. Parametric assumptions were not met for all variables; therefore, inferential statistics were conducted using the bias-corrected and accelerated (BCa) 95% bootstrapping method (set at 1,000 samples). This bootstrapping method helps to reduce error when estimating confidence intervals for data that do not meet all parametric assumptions. The process of sampling with replacement estimates properties of a statistic (e.g., confidence intervals) by taking the original data set and resampling from it (in this case 1,000 times). This provides an estimate of the modeled shape of distribution. The BCa method adjusts for bias and skewness in the distribution. In this article, we report BCa 95% bootstrapped confidence intervals for mean differences, Pearson’s r, and regression b values. Group Characteristics Pain was more commonly reported in all body locations by adolescents in the chronic pain group, except the head and chest. Overall, 74% of the adolescents in the chronic pain group reported pain across multiple sites, whereas this was only reported by 12% of the adolescents in the “healthy” low-pain group. The average number of years since first noticing the pain was 3.9 (SD = 2.8) in the chronic pain group and 2.2 (SD = 2.6) in the low-pain group. The proportion of participants reporting that they were currently taking medication for their pain was higher in the chronic pain group (57% vs. 10%), as was the proportion of participants reporting that they had previously received some form of medical treatment for their pain (85% vs. 51%). Table I provides means, standard deviations, independent t-test statistics, and BCa 95% mean difference confidence intervals for each of the key variables. Participants in the chronic pain group reported significantly higher pain intensity, pain-catastrophizing, depressive, and anxious symptomology. In contrast, participants in the “healthy” low-pain group reported significantly higher pain-acceptance, physical functioning, and social functioning. None of the BCa bootstrapped 95% confidence intervals for these mean differences crossed zero, indicating that these findings are likely to be reliable. Table I. Means, Standard Deviations, and Group Difference Statistics for Key Variables Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 aLevene’s test indicated that equal variances could not be assumed, perhaps indicating ceiling effects in the general population group. Table I. Means, Standard Deviations, and Group Difference Statistics for Key Variables Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 aLevene’s test indicated that equal variances could not be assumed, perhaps indicating ceiling effects in the general population group. Supporting our second exploratory hypothesis, dispositional mindfulness scores did not differ significantly across the two groups (and were also normally distributed in both groups). An independent samples t-test revealed that although closely matched, the mean ages of the two samples differed significantly, t(146) = 2.41, p < .05. Bivariate Correlations Table II provides an overview of all bivariate correlations for key variables per group. Medication use, pain duration, and gender were largely unrelated to other variables and so are not included (only two of 24 possible correlations reached significance). Confirming our first formal hypothesis, dispositional mindfulness was negatively associated with depression (r = −.58 and −.50) and anxiety (r = −.67 and −.59) in both groups. Dispositional mindfulness was also negatively associated with pain-catastrophizing (r = −.52 and −.41) and positively associated with pain-willingness (r = .37 and .42) in both groups. In the “healthy” low-pain group only, higher dispositional mindfulness was also positively associated with age (r = .27), activity engagement (r = .22), social functioning (r = .27), and physical functioning (r = .21). None of the BCa bootstrapped 95% confidence intervals for these r values crossed zero. However, the Cronbach’s alpha value was low for the physical functioning measure when used with the low-pain sample. Therefore, the latter of these findings may not be valid. Partly disconfirming our second exploratory hypothesis, dispositional mindfulness was not significantly associated with social functioning or physical functioning in the chronic pain group. In neither group was dispositional mindfulness associated with VAS pain-intensity. Table II. Correlations Between Mindfulness and Key Variables for Both Groups Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – *p < .05, **p < .01. Table II. Correlations Between Mindfulness and Key Variables for Both Groups Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – *p < .05, **p < .01. Regression All four regression analyses were conducted on the combined data pooled across the two samples. This provides a mixed group of adolescents who all reported recent experiences of pain (albeit some having chronic problems with this). This helps to ensure a wide range of values and to avoid floor-ceiling effects in groups of (a) relatively unimpaired “healthy” (low-pain) adolescents and (b) very impaired (chronic pain) adolescents. Each regression analysis aimed to assess whether dispositional mindfulness explained unique variance in the dependent variable after controlling for the other key predictors. The following predictors were entered simultaneously into each model: group, age, VAS pain intensity, pain-catastrophizing, pain-willingness, activity engagement, and dispositional mindfulness. Table III provides a summary of the findings, along with BCa 95% b confidence intervals. Table III. Combined Data Set Regression Models for Outcome Variables (N = 148) Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 *p < .05, **p < .01. Table III. Combined Data Set Regression Models for Outcome Variables (N = 148) Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 *p < .05, **p < .01. Supporting our second formal hypothesis, dispositional mindfulness accounted for unique variance in mood (b= −0.26) and anxiety (b = −0.35) after all other variables were controlled for (including group). Neither of the BCa bootstrapped 95% confidence intervals for these b values crossed zero, suggesting that these findings are reliable. On average, as dispositional mindfulness increased by one unit, depressive symptomology decreased by 0.26 units and anxiety symptomology decreased by 0.35 units (when all other variables were held constant). In terms of our first exploratory hypothesis, dispositional mindfulness was not found to account for unique variance in physical functioning, but it did account for unique variance in social functioning (b= 0.17). Discussion As predicted by our first formal hypothesis, dispositional mindfulness was significantly associated with mood and anxiety in adolescents with chronic pain and “healthy” adolescents with low-level pain. This replicates and extends previous studies (Greco et al., 2011; Petter et al., 2013) by demonstrating that dispositional mindfulness is positively associated with good mental health in the general adolescent population and also those experiencing chronic pain. As predicted by our second formal hypothesis, dispositional mindfulness also accounted for unique variance in mood and anxiety after controlling for group, age, pain-intensity, pain-catastrophizing, and pain-acceptance. Thus, recent results from the adult literature (Elvery et al., 2017; McCracken et al., 2007; McCracken & Keogh, 2009; Mun, Okun, & Karoly, 2014) suggesting that dispositional mindfulness may play a role in the experience of chronic pain appear to extend to the adolescent population. This may have significant theoretical implications for cognitive-behavioral models of chronic pain that emphasize the role of pain-specific cognitions (e.g., the Fear Avoidance Model: Simons & Kaczynski, 2012) but do not encompass the more generalized “trait-like” construct of dispositional mindfulness. Our results are also relevant to clinical treatment models. Many clinicians and researchers see it as essential to target pain-catastrophizing in treatment, particularly in widely used cognitive behavioral therapy approaches. However, the current study demonstrated that dispositional mindfulness was key in explaining psychological distress, perhaps more so than pain-catastrophizing. This is not necessarily an argument against conventional treatment, which has established positive effects (Bruce et al., 2017; Fisher et al., 2014), but our results should embolden researchers and clinicians to explore mindfulness interventions further with youth. For example, Gauntlett-Gilbert et al. (2013) demonstrated the benefits of a multidisciplinary treatment program for adolescent chronic pain that included mindfulness training throughout. Mindfulness and acceptance approaches start from the premise that pain, stress, and negative thinking are, to a degree, fundamentally uncontrollable. However, by showing that this uncontrollability is not necessarily a barrier to skillful management, they may offer a particularly hopeful and relevant approach for youth with challenging chronic health conditions. The first of our two exploratory hypotheses was partially supported. We found that dispositional mindfulness predicted social, but not physical, functioning after other variables had been controlled. This is neither consistent nor inconsistent with the adult literature, because some adult chronic pain studies have found dispositional mindfulness to predict functioning, whereas others have found this not to be the case (McCracken et al., 2007; Schütze et al., 2010). Finally, in support of our second exploratory hypothesis, we found no significant difference between adolescents with chronic pain and “healthy” adolescents with low-level pain in terms of their levels of dispositional mindfulness. Therefore, the current study suggests that high pain levels are not necessarily a barrier to the existence or development of mindfulness. This corroborates Schütze et al. (2010), who found that levels of adult dispositional mindfulness were not significantly lower in a chronic pain sample when compared with a general population sample. However, our finding that dispositional mindfulness was not associated with pain-intensity in either group is at odds with two adult chronic pain studies (McCracken et al., 2007; McCracken & Keogh, 2009) and one adolescent low-pain general population study (Petter et al. 2013). Each of these previous studies reported a negative association between dispositional mindfulness and pain-intensity. This needs further investigation, because although mindfulness theory would predict a negative association between dispositional mindfulness and psychological distress in the context of pain, it would not necessarily predict lower pain ratings from individuals experiencing higher levels of dispositional mindfulness. Our preliminary view is that adolescents with greater dispositional mindfulness will have less “judgment” attached to their pain experience, but also perhaps more “awareness” of their pain experience. Although one could argue that mindfulness explicitly increases the ability to encounter pain sensations with less resistance and struggle (perhaps resulting in a lower pain-intensity rating), being more aware of your pain experience could offset this. Although a “naïve” view of pain might presume tight associations between pain intensity and pain distress, mindfulness theory would point out that these may not be inevitably linked. This is a complicated issue requiring further exploration. Strengths of this study include the investigation of dispositional mindfulness in a chronic pain sample of adolescents, use of standardized measures, use of multiple recruitment sites, and comparison with a large “healthy” low-level pain sample. However, there are a number of limitations that need highlighting, particularly the small sample size of the chronic pain group, the differing sample sizes across the two groups, the lack of data on pain frequency and duration of pain episodes, and of course the single time point cross-sectional design. Finally, the Cronbach’s alpha value for the BAPQ Physical Functioning subscale was also low. Perhaps additional normative data are needed on this measure to understand its suitability in assessing functioning in healthy youth. In terms of future research, longitudinal studies (with larger chronic pain samples) will be required to further explore the role played by dispositional mindfulness in the adolescent experience of chronic pain, and the possibility that it might be a “resilience resource” as suggested by Cousins, Kalapurakkel, Cohen, and Simons (2015). Research suggests that dispositional mindfulness tends to predict changes in mood and anxiety (Ciarrochi, Kashdan, Leeson, Heaven, & Jordan, 2011), but the direction of causality cannot be inferred from the current study. Research will also need to elucidate the mechanisms or processes underlying the observed relationships between dispositional mindfulness, psychological distress, and social functioning. Finally, although it is encouraging that the CAMM demonstrated good internal consistency in both groups, it is a one-dimensional measure, and so, this study was not able to differentiate between the elements of “present-moment awareness” and “nonjudgment” that define the complex and broad construct of mindfulness (Brown & Ryan, 2003). This is important if we want to develop our understanding of how mindfulness could be added to models and treatments of adolescent chronic pain. In summary, despite these cautions, the current study can conclude that dispositional mindfulness accounted for unique variance in psychological distress (and social functioning) in adolescents with chronic pain and “healthy” adolescents with low-level pain. This provides some indirect support to the theoretical importance of dispositional mindfulness in adolescent contextualized cognitive-behavioral models such as acceptance and commitment therapy (ACT; Pielech, Vowles, & Wicksell, 2017), and suggests that further research could investigate the utility of mindfulness training, particularly for adolescents experiencing mood and anxiety problems (both in low-pain and chronic pain samples). There is no reason to presume that “dispositional mindfulness” cannot be changed by intervention. Despite the fact that this concept is framed as a “trait,” all mindfulness training aims to create sustained, daily improvements in levels of present moment awareness and acceptance, rather than experiences that last no longer than a meditation session (Kabat-Zinn, 2003). Evidence from adult meditators shows enduring brain changes associated with sustained practice (Fox et al., 2014), and ACT has emphasized the application of mindfulness across many aspects of daily life, rather than purely in the context of meditation (Hayes, Strosahl, & Wilson, 2011). Therefore, the potential benefits of incorporating mindfulness practice into adolescent pain treatment programs need further exploration. Footnotes 1 Severe mental disorder and severe substance abuse were not formally defined, but recruiting clinicians were asked to exclude on this basis if they felt that a young person’s mental disorder or substance abuse was so extreme that it would interfere with their ability to take part in the study. Acknowledgments The authors would like to express their gratitude to the young people who took part in this study, the clinicians who gave up their time to assist with recruitment, and also the Associate Editor and three anonymous reviewers for their constructive and thoughtful suggestions for revision. Funding This study received no specific funding. One of the authors (M.E.L.) is funded by the National Institute for Health Research. This report is independent research. The views expressed in this publication are those of the authors and not necessarily those of the NHS, The National Institute for Health Research, or the Department of Health. References Baer R. A. , Smith G. T. , Allen K. B. ( 2004 ). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills . Assessment , 11 , 191 – 206 . Google Scholar Crossref Search ADS PubMed Brown K. W. , Ryan R. M. ( 2003 ). The benefits of being present: Mindfulness and its role in psychological wellbeing . Jounral of Personality and Social Psychology , 84 , 822 – 848 . Google Scholar Crossref Search ADS Bruce B. K. , Ale C. M. , Harrison T. E. , Bee S. , Luedtke C. , Geske J. , Weiss K. E. ( 2017 ). Getting back to living: Further evidence for the efficacy of an interdisciplinary pediatric pain treatment program . Clinical Journal of Pain , 33 , 535 – 542 . Google Scholar Crossref Search ADS PubMed Ciarrochi J. , Kashdan T. B. , Leeson P. , Heaven P. C. L. , Jordan C. ( 2011 ). On being aware and accepting: A one-year longitudinal study into adolescent well-being . Journal of Adolescence , 34 , 695 – 703 . Google Scholar Crossref Search ADS PubMed Cousins L. A. , Kalapurakkel S. , Cohen L. L. , Simons L. E. ( 2015 ). Topical review: Resilience resources and mechanisms in pediatric chronic pain . Journal of Pediatric Psychology , 40 , 840 – 845 . Google Scholar Crossref Search ADS PubMed Crombez G. , Bijttebier P. , Eccleston C. , Mascagni T. , Mertens G. , Goubert L. , Verstraeten K. ( 2003 ). The child version of the pain catastrophizing scale (PCS-C): A preliminary validation . Pain , 104 , 639 – 646 . Google Scholar Crossref Search ADS PubMed Eccleston C. , Jordan A. , McCracken L. M. , Sleed M. , Connell H. , Clinch J. ( 2005 ). The Bath Adolescent Pain Questionnaire (BAPQ): Development and preliminary psychometric evaluation of an instrument to assess the impact of chronic pain on adolescents . Pain , 118 , 263 – 270 . Google Scholar Crossref Search ADS PubMed Elvery N. , Jensen M. P. , Ehde D. M. , Day M. A. ( 2017 ). Pain catastrophising, mindfulness, and pain-acceptance: What's The Difference? Clinical Journal of Pain , 33 , 485 – 495 . Google Scholar Crossref Search ADS PubMed Fisher E. , Heathcote L. , Palermo T. M. , Williams A. C. , Lau J. , Eccleston C. ( 2014 ). Systematic review and meta-analysis of psychological therapies for children with chronic pain . Journal of Pediatric Psychology , 39 , 763 – 782 . Google Scholar Crossref Search ADS PubMed Fox K. C. , Nijeboer S. , Dixon M. L. , Floman J. L. , Ellamil M. , Rumak S. P. , Sedlmeier P. , Christoff K. ( 2014 ). Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners . Neuroscience and Biobehavioral Reviews , 43 , 48 – 73 . Google Scholar Crossref Search ADS PubMed Gauntlett-Gilbert J. , Connell H. , Clinch J. , McCracken L. M. ( 2013 ). Acceptance and values-based treatment of adolescents with chronic pain: Outcomes and their relationships to acceptance . Journal of Pediatric Psychology , 38 , 72 – 81 . Google Scholar Crossref Search ADS PubMed Greco L. A. , Baer R. A. , Smith G. T. ( 2011 ). Assessing mindfulness in children and adolescents: Development and validation of the Child and Adolescent Mindfulness Measure (CAMM) . Psychological Assessment , 23 , 606 – 614 . Google Scholar Crossref Search ADS PubMed Hayes S. C. , Strosahl K. D. , Wilson K. G. ( 2011 ). Acceptance and commitment therapy: The process and practice of mindful change . New York, US : Guilford Press . Kabat-Zinn J. ( 2003 ). Mindfulness-based interventions in context: Past, present and future [commentary] . Clinical Psychology: Science and Practice , 10 , 144 – 156 . Google Scholar Crossref Search ADS Kabat-Zinn J. , Lipworth L. , Burney R. ( 1985 ). The clinical use of mindfulness meditation for the self-regulation of chronic pain . Journal of Behavioral Medicine , 8 , 163 – 190 . Google Scholar Crossref Search ADS PubMed Kalapurakkel S. , Carpino E. A. , Lebel A. , Simons L. E. ( 2015 ). “Pain can’t stop me”: Examining pain self-efficacy and acceptance as resilience processes among youth with chronic headache . Journal of Pediatric Psychology , 40 , 926 – 933 . Google Scholar Crossref Search ADS PubMed McCracken L. M. , Gauntlett-Gilbert J. , Eccleston C. ( 2010 ). Acceptance of pain in adolescents with chronic pain: Validation of an adapted assessment instrument and preliminary correlation analyses . European Journal of Pain , 14 , 316 – 320 . Google Scholar Crossref Search ADS PubMed McCracken L. M. , Gauntlett-Gilbert J. , Vowles K. E. ( 2007 ). The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability . Pain , 131 , 63 – 69 . Google Scholar Crossref Search ADS PubMed McCracken L. M. , Keogh E. ( 2009 ). Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: An analysis of anxiety sensitivity . Journal of Pain , 10 , 408 – 415 . Google Scholar Crossref Search ADS PubMed Mun C. J. , Okun M. A. , Karoly P. ( 2014 ). Trait mindfulness and catastrophizing as mediators of the association between pain severity and pain- related impairment . Personality and Individual Differences , 66 , 68 – 73 . Google Scholar Crossref Search ADS Pallozzi R. , Wertheim E. , Paxton S. , Ong B. ( 2017 ). Trait mindfulness measures for use with adolescents: A systematic review . Mindfulness , 8 , 110 – 125 . Google Scholar Crossref Search ADS Petter M. , Chambers C. T. , McGrath P. J. , Dick B. D. ( 2013 ). The role of trait mindfulness in the pain expeirence of adolescents . Journal of Pain , 14 , 1709 – 1718 . Google Scholar Crossref Search ADS PubMed Pielech M. , Ryan M. , Logan D. , Kaczynski K. , White M. T. , Simons L. E. ( 2014 ). Pain catastrophizing in children with chronic pain and their parents: Proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure . Pain , 155 , 2360 – 2367 . Google Scholar Crossref Search ADS PubMed Pielech M. , Vowles K. E. , Wicksell R. ( 2017 ). Acceptance and commitment therapy for pediatric chronic pain: Theory and application . Children , 4 , 10 – 22 . Google Scholar Crossref Search ADS Schütze R. , Rees C. , Preece M. , Schütze M. ( 2010 ). Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain . Pain , 148 , 120 – 127 . Google Scholar Crossref Search ADS PubMed Shapiro S. L. , Carlson L. E. , Astin J. A. , Freedman B. ( 2006 ). Mechanisms of mindfulness . Journal of Clinical Psychology , 62 , 373 – 386 . Google Scholar Crossref Search ADS PubMed Simons L. E. , Kaczynski K. J. ( 2012 ). The fear avoidance model of chronic pain: Examination for pediatric application . Journal of Pain , 13 , 827 – 835 . Google Scholar Crossref Search ADS PubMed Tran S. T. , Mano K. E. J. , Hainsworth K. R. , Medrano G. R. , Khan K. A. , Weisman S. J. , Davies W. H. ( 2015 ). Distinct influences of anxiety and pain catastrophizing on functional outcomes in children and adolescents with chronic pain . Journal of Pediatric Psychology , 40 , 744 – 755 . Google Scholar Crossref Search ADS PubMed Varni J. W. , Thompson K. L. , Hanson V. ( 1987 ). The Varni/Thompson Pediatric Pain Questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis . Pain , 28 , 27 – 38 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Pediatric Psychology Oxford University Press

Dispositional Mindfulness and Its Relationship With Distress and Functioning in Adolescents With Chronic Pain and Low-Level Pain

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Abstract

Abstract Objective Dispositional mindfulness is the general tendency to pay attention to present-moment awareness without judgment. The main aim of this cross-sectional study was to determine (a) whether dispositional mindfulness is associated with psychological distress in adolescents with chronic pain and low-level pain, and (b) whether it accounts for unique variance in distress after controlling for key variables from the pain literature. A secondary aim was to explore the relationship between dispositional mindfulness and functioning. Method 54 adolescents seeking help for chronic pain and 94 “healthy” adolescents with recent low-level pain from the general population completed the same battery of measures, including the Child and Adolescent Mindfulness Measure of dispositional mindfulness. Results As predicted, dispositional mindfulness was associated with mood and anxiety in both groups and also accounted for unique variance in mood and anxiety in standard regression models after controlling for group, age, pain-intensity, pain-catastrophizing, and pain-acceptance. Dispositional mindfulness did not differ significantly across the two groups and did not predict physical functioning. However, it did account for unique variance in social functioning. Conclusions Dispositional mindfulness may be an important construct to consider in the context of adolescents experiencing mood and anxiety problems in both low-level and chronic pain samples. Further research should aim to replicate these findings in larger clinical samples and explore the predictive power of dispositional mindfulness using longitudinal designs. chronic and recurring pain, mental health, psychosocial functioning Introduction Mindfulness is often defined as “paying attention on purpose, in the present moment, non-judgementally” (Kabat-Zinn, 2003, p. 145). Dispositional mindfulness can be thought about as a general “trait-like” tendency to abide in mindful states over time (Brown & Ryan, 2003). McCracken and colleagues have clearly outlined why mindfulness may be an important construct to consider in the field of adult chronic pain (McCracken, Gauntlett-Gilbert, & Vowles, 2007). They argue that observing (as opposed to reacting automatically to) physical sensations, emotions, and thoughts, that is, being more mindful, can lead to a more “balanced, non-reactive and realistic” relationship to pain experiences. Central to this is the idea that mindful awareness involves noticing and stepping back from, rather than being immersed in and controlled by, thoughts, emotions, and sensations (Shapiro, Carlson, Astin, & Freedman, 2006). The contribution of mindfulness to chronic pain was first supported by evidence that mindfulness training, leading to enhanced levels of mindfulness, was associated with the reduction of distress in the context of chronic pain (Kabat-Zinn, Lipworth, & Burney, 1985). More recently, in the adult chronic pain literature, a series of cross-sectional studies have indicated that natural variation in dispositional mindfulness can explain unique variance in distress after controlling for other key variables (Elvery, Jensen, Ehde, & Day, 2017; McCracken et al., 2007; McCracken & Keogh, 2009; Mun, Okun, & Karoly, 2014). Two of the established key variables are pain catastrophizing (an exaggerated mental set of rumination, magnification, and helplessness in the context of actual or anticipated pain) and pain-acceptance (experiencing pain without taking actions to control it and persisting with activity in the presence of pain). It may be that researchers now need to investigate the potential additive influence of the “non-pain-specific” construct dispositional mindfulness. If it is important, then chronic pain treatment programs might consider incorporating general mindfulness training (that can be of benefit to many areas of one’s life) in addition to targeting pain-specific cognitions. Relationships exist between pain-catastrophizing, pain-acceptance, and dispositional mindfulness; however, they may not be redundant (Elvery et al., 2017). With emerging evidence that the separate construct of dispositional mindfulness may play an important role in determining the nature of distress experienced by adults living with chronic pain, it is important to assess whether this also applies to adolescents. The adolescent literature has already demonstrated that pain-catastrophizing and pain-acceptance predict levels of distress in the context of chronic pain (Kalapurakkel, Carpino, Lebel, & Simons, 2015; Tran et al., 2015), but as yet, no studies have explored the potential role played by dispositional mindfulness in this context. However, there is evidence that dispositional mindfulness is positively associated with good mental health in the general adolescent population (Greco, Baer, & Smith, 2011; Pallozzi, Wertheim, Paxton, & Ong, 2017), whereas mindfulness training appears to help to reduce distress in the context of adolescent chronic pain (Gauntlett-Gilbert, Connell, Clinch, & McCracken, 2013). Dispositional mindfulness has also been found to account for unique variance in pain interference in healthy adolescents experiencing low-level pain typical of the general population (Petter, Chambers, McGrath, & Dick, 2013). The main aim of this cross-sectional study was therefore to determine (a) whether dispositional mindfulness is associated with psychological distress in adolescents with chronic pain and “healthy” adolescents with low-level pain, and (b) whether it accounts for unique variance in distress after controlling for key variables already established in the pain literature. To test this, both a chronic pain and a “healthy” low-level pain sample were recruited into the study and all adolescents were asked to complete the same battery of measures. Based on the research described earlier, our first hypothesis was that dispositional mindfulness would be significantly associated with anxiety and mood in both adolescents with chronic pain and “healthy” adolescents with low-level pain. Our second hypothesis was that dispositional mindfulness would account for unique variance in mood and anxiety after controlling for group, demographics, pain-intensity, pain-catastrophizing, and pain-acceptance. As an exploratory aim, we also examined the relationship between dispositional mindfulness and aspects of physical and social functioning, and whether there are differences between adolescents with chronic pain and “healthy” adolescents with low-level pain in terms of their levels of dispositional mindfulness. Inconsistent findings from the adult pain literature (McCracken et al., 2007; Schütze, Rees, Preece, & Schütze, 2010) and a dearth of research in the adolescent literature meant that only exploratory hypotheses could be generated with regard to these questions. We tentatively predicted that dispositional mindfulness would be positively associated with social and physical functioning (based on initial adult research reported by McCracken et al., 2007). We also tentatively predicted that levels of dispositional mindfulness would not differ significantly across the two groups (based on initial adult research reported by Schütze et al., 2010). Method Participants and Procedure Chronic Pain Group Potential patients aged 13–17 years presenting for assessment at three UK tertiary child and adolescent pain clinics between October 2016 and March 2017 were handed information and consent sheets by their assessing psychologist. Inclusion criteria included meeting local service criteria (persistent, distressing, nonmalignant chronic pain that had not responded to standard pediatric care) and sufficient English-language skills to complete the survey packs. Exclusion criteria included severe mental disorder, severe substance abuse, or known diagnosis of a terminal illness.1 Interested adolescents and their parents, for those < 16 years old, were given the choice to complete the consent process and study pack at the clinic (overseen by a clinician) or at home (overseen by the lead author via telephone). In total, 61 chronic pain patients participated (approximately 40% of those invited), but seven were excluded owing to incomplete data, yielding a final sample of 54 patients. In total, 94% of the participants in the chronic pain group were White-British, 72% were female, and the mean age was 14.6 years (range = 13–17, SD = 1.3). Reasons for declining participation were not recorded. All participants recruited into the chronic pain group were offered a £5 gift voucher as a token of appreciation. “Healthy” Low-level Pain Group Pupils from two classes in a state-funded UK secondary school (N = 51) and a convenience sample of adolescents attending a university open day to find out more about undergraduate degree programs (N = 53) were recruited. The lead author oversaw consent and participation procedures in person. Parents/carers of all school pupils were sent information sheets and opt-out slips in advance of the study. Parental consent was not needed for participants recruited from the university open day because they were ≥16 years old. Eight participants were excluded retrospectively (after completing the study pack) owing to reporting no pain over the past week, one was excluded retrospectively owing to reporting treatment for chronic pain, and one was excluded retrospectively because of incomplete data, yielding a final sample of 94 participants (50 from the secondary school and 44 from the university open day). In total, 80% of the participants in the general population group were White-British, 69% were female, and the mean age was 15.2 years (range = 13–17, SD = 1.8). Materials In addition to routine questions regarding demographics, all participants also completed the measures described next. Dispositional Mindfulness The Child and Adolescent Mindfulness Measure (CAMM; Greco et al., 2011) is a 10-item measure of dispositional mindfulness developed from the 39-item four-factor adult Kentucky Inventory of Mindfulness Skills (Baer, Smith, & Allen, 2004). Large samples of adolescents took part in the development studies providing feedback on the comprehensibility of the items (Greco et al., 2011). Factor analysis determined the single-factor structure of the CAMM, capturing both “present moment awareness” and “nonjudgment.” However, the CAMM does not include items measuring “describing” or “observing” because they were found to be developmentally inappropriate for the adolescent population. Convergent validity has been demonstrated by expected correlations with quality of life, academic competence, social skills, somatic complaints, internalizing, and externalizing. Incremental validity has been observed beyond measures of thought suppression and psychological inflexibility. The respondent is asked to rate each of the 10 reverse-scored items (e.g. “At school I walk from class-to-class without noticing what I’m doing,” “I get upset with myself for having feelings that don’t make sense”) on a 5-point Likert scale (0 = never true, 4 = always true). The CAMM has demonstrated good internal consistency (Cronbach’s alpha of .81) and construct validity in previous studies (Greco et al., 2011). The current study found alpha values of .81 and .85 in the chronic pain and “healthy” low-pain groups, respectively. Pain Factors Participants were asked to rate their average pain intensity experienced over the past week on a 0-10 Visual Analog Scale (VAS), with 0 representing no pain and 10 representing the worst pain possible (Varni, Thompson, & Hanson, 1987). Participants were asked to identify where in their body the pain was located (open text response allowing for multiple locations to be listed if appropriate), at what age they first noticed the pain, whether they were currently taking medication for their pain (yes/no response), and whether they had previously received any treatment for their pain (yes/no response). Data were not collected regarding pain frequency or duration of pain episodes. Distress and Functioning The Bath Adolescent Pain Questionnaire (BAPQ; Eccleston et al., 2005) subscales for depression, anxiety, social functioning, and physical functioning were used. The Depression subscale comprises six statements, such as “I feel sad.” The Anxiety subscale comprises seven statements, such as “I worry about the future.” The Social Functioning subscale comprises nine statements, such as “I go out to meet my friends.” The Physical Functioning subscale includes nine statements, such as “I need help dressing or bathing.” Respondents are asked to rate all statements on a 5-point Likert scale (0 = never, 4 = always). Each of these subscales has demonstrated good internal consistency (Cronbach's alpha values ranging from .80 to .83) and construct validity in previous studies (Eccleston et al., 2005). All Cronbach’s alpha values were above .70 in the current study, except for the Physical Functioning subscale when used with the “healthy” low-pain group (.66). Pain-catastrophizing The Pain Catastrophizing Scale for Children (PCS-C; Crombez et al., 2003) has 13 items (e.g. “When I have pain I feel I can’t stand it any more”), which the respondent rates on a 5-point Likert scale (0 = not at all, 4 = extremely). Recent evidence favors a single-factor structure (Pielech et al., 2014), with previous studies demonstrating good internal consistency (Cronbach’s alpha = .87) and construct validity (Crombez et al., 2003). The current study found alpha values of .94 and .92 for the chronic pain and “healthy” low-pain groups, respectively. Pain-acceptance The adolescent version of the Chronic Pain Acceptance Questionnaire (CPAQ-A; McCracken, Gauntlett-Gilbert, & Eccleston, 2010) has 20 items (e.g., “it’s ok to experience pain”), which the respondent rates on a 5-point Likert scale (0 = never true, 4 = always true). Evidence supports using the two subscales of “pain willingness” and “activity engagement.” Each subscale has demonstrated good internal consistency (Cronbach’s alpha = .75 and .86) and construct validity in previous studies (McCracken et al., 2010). The current study found alpha values ranging from .78 to .85 for the chronic pain and “healthy” low-pain groups. Design In this cross-sectional design, all participants completed the same set of measures at one time-point only. Chronic pain participants recruited from one of the clinics completed the CPAQ-A and the BAPQ as part of their routine assessment. Participants from another of the clinics completed the BAPQ as part of their routine assessment. Other participants completed all measures as part of the study pack. Ethical Approval Ethical approval was granted by a regional UK National Health Service (NHS) Research and Ethics Committee, the UK Health Research Authority, and the University of Bath Psychology Department Ethics Committee. Data Analysis All data were screened for outliers, as well as assumptions of normality, linearity, collinearity, homogeneity, and independent errors using graphical and statistical means. In terms of missing data, an a-priori decision was taken to replace a participant’s missing scale items with their mean scale or subscale score when a participant neglected to respond to up to two items of a scale (N = 14). Where a participant neglected to respond to more than two items of a scale, the scale was removed from analyses (N = 8). To test our first formal hypothesis, a series of Pearson’s coefficient bivariate correlations were planned to assess the relationship between dispositional mindfulness and distress (plus other key variables). To test our second formal hypothesis, a series of linear multiple regression analyses were planned to assess whether dispositional mindfulness accounted for unique variance in distress after controlling for other key variables. Related to the two exploratory hypotheses, an independent t-test was planned to assess group differences for dispositional mindfulness, and additional correlation and regression analyses were planned to investigate the relationship between dispositional mindfulness and functioning scores. Results Preliminary Analyses SPSS version 23 was used for all data analysis. Following initial screening, four extreme outliers caused by data entry mistakes were corrected. Parametric assumptions were not met for all variables; therefore, inferential statistics were conducted using the bias-corrected and accelerated (BCa) 95% bootstrapping method (set at 1,000 samples). This bootstrapping method helps to reduce error when estimating confidence intervals for data that do not meet all parametric assumptions. The process of sampling with replacement estimates properties of a statistic (e.g., confidence intervals) by taking the original data set and resampling from it (in this case 1,000 times). This provides an estimate of the modeled shape of distribution. The BCa method adjusts for bias and skewness in the distribution. In this article, we report BCa 95% bootstrapped confidence intervals for mean differences, Pearson’s r, and regression b values. Group Characteristics Pain was more commonly reported in all body locations by adolescents in the chronic pain group, except the head and chest. Overall, 74% of the adolescents in the chronic pain group reported pain across multiple sites, whereas this was only reported by 12% of the adolescents in the “healthy” low-pain group. The average number of years since first noticing the pain was 3.9 (SD = 2.8) in the chronic pain group and 2.2 (SD = 2.6) in the low-pain group. The proportion of participants reporting that they were currently taking medication for their pain was higher in the chronic pain group (57% vs. 10%), as was the proportion of participants reporting that they had previously received some form of medical treatment for their pain (85% vs. 51%). Table I provides means, standard deviations, independent t-test statistics, and BCa 95% mean difference confidence intervals for each of the key variables. Participants in the chronic pain group reported significantly higher pain intensity, pain-catastrophizing, depressive, and anxious symptomology. In contrast, participants in the “healthy” low-pain group reported significantly higher pain-acceptance, physical functioning, and social functioning. None of the BCa bootstrapped 95% confidence intervals for these mean differences crossed zero, indicating that these findings are likely to be reliable. Table I. Means, Standard Deviations, and Group Difference Statistics for Key Variables Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 aLevene’s test indicated that equal variances could not be assumed, perhaps indicating ceiling effects in the general population group. Table I. Means, Standard Deviations, and Group Difference Statistics for Key Variables Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 Measure Chronic pain group (N = 54) General population group (N = 94) T-test statistic Mean difference BCa 95% CI VAS Pain intensity (0–10) 6.9 (1.9) 3.4 (2.0) t(146) = 10.80, p < .001 2.9, 4.2 CPAQ-A total (0–80) 35.2 (10.7) 59.9 (11.0) t(143) = 13.20, p < .001 20.8, 28.2 CPAQ-A activity engagement (0–44) 22.2 (7.0) 34.8 (6.2) t(143) = 11.36, p < .001 10.2, 14.7 CPAQ-A pain willingness (0–36) 13.0 (6.0) 25.0 (6.8) t(143) = 10.68, p < .001 9.7, 14.2 PCS-C (0–52) 31.4 (11.5) 16.6 (9.1) t(144) = 8.59, p < .001 10.8, 17.8 BAPQ Physical functioninga (0–36) 20.8 (7.5) 30.9 (3.5) t(62) = 9.04, p < .001 7.9, 12.4 BAPQ Social functioning (0–36) 18.3 (6.5) 24.6 (5.2) t(146) = 6.36, p < .001 4.1, 8.1 BAPQ Depression (0–24) 14.1 (4.5) 10.1 (4.2) t(145) = 5.43, p < .001 2.5, 5.4 BAPQ Anxiety (0–28) 14.6 (4.3) 12.9 (4.8) t(144) = 2.38, p < .05 0.1, 3.3 CAMM (0–40) 20.0 (7.5) 22.0 (8.0) t(146) = 1.72, p = .09 0.7, 4.7 aLevene’s test indicated that equal variances could not be assumed, perhaps indicating ceiling effects in the general population group. Supporting our second exploratory hypothesis, dispositional mindfulness scores did not differ significantly across the two groups (and were also normally distributed in both groups). An independent samples t-test revealed that although closely matched, the mean ages of the two samples differed significantly, t(146) = 2.41, p < .05. Bivariate Correlations Table II provides an overview of all bivariate correlations for key variables per group. Medication use, pain duration, and gender were largely unrelated to other variables and so are not included (only two of 24 possible correlations reached significance). Confirming our first formal hypothesis, dispositional mindfulness was negatively associated with depression (r = −.58 and −.50) and anxiety (r = −.67 and −.59) in both groups. Dispositional mindfulness was also negatively associated with pain-catastrophizing (r = −.52 and −.41) and positively associated with pain-willingness (r = .37 and .42) in both groups. In the “healthy” low-pain group only, higher dispositional mindfulness was also positively associated with age (r = .27), activity engagement (r = .22), social functioning (r = .27), and physical functioning (r = .21). None of the BCa bootstrapped 95% confidence intervals for these r values crossed zero. However, the Cronbach’s alpha value was low for the physical functioning measure when used with the low-pain sample. Therefore, the latter of these findings may not be valid. Partly disconfirming our second exploratory hypothesis, dispositional mindfulness was not significantly associated with social functioning or physical functioning in the chronic pain group. In neither group was dispositional mindfulness associated with VAS pain-intensity. Table II. Correlations Between Mindfulness and Key Variables for Both Groups Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – *p < .05, **p < .01. Table II. Correlations Between Mindfulness and Key Variables for Both Groups Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – Measure Chronic pain group (N = 54) General population group (N = 94) 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 10 1. CAMM −.22 .24 .52** .02 .37** .17 .11 −.58** −.67** .41** .02 −.41** .22* .42** .27** .21* −.50** −.59** 2. Age − −.07 −.13 .05 .24 .27 .33* −.12 .16 – −.04 .47** −.14 −.42** −.11 −.17 .25* .27** 3. VAS pain intensity – −.05 −.16 −.07 .14 −.35** −.02 −.05 – −006 −.06 −.08 .11 −.22* .11 −.01 4. PCS-C – −.39** −.72** −.24 −.24 .48** .46** − −.48** −.71** −.21* −.37** .41** .36** 5. CPAQ-A Activity engagement – .37** .40** .34* −.37** −.02 – .52** .12 .38** −.25* −.30** 6. CPAQ-A Pain willingness – .19 .20 −.37** −.28 – .09 .26* −.31** −.31** 7. BAPQ Social functioning – .36** −.55** −.24 – .15 −.55** −.45** 8. BAPQ Physical functioning – −.41** −.05 – −.24* −.18 9. BAPQ Depression – .66** – .66** 10. BAPQ Anxiety – – *p < .05, **p < .01. Regression All four regression analyses were conducted on the combined data pooled across the two samples. This provides a mixed group of adolescents who all reported recent experiences of pain (albeit some having chronic problems with this). This helps to ensure a wide range of values and to avoid floor-ceiling effects in groups of (a) relatively unimpaired “healthy” (low-pain) adolescents and (b) very impaired (chronic pain) adolescents. Each regression analysis aimed to assess whether dispositional mindfulness explained unique variance in the dependent variable after controlling for the other key predictors. The following predictors were entered simultaneously into each model: group, age, VAS pain intensity, pain-catastrophizing, pain-willingness, activity engagement, and dispositional mindfulness. Table III provides a summary of the findings, along with BCa 95% b confidence intervals. Table III. Combined Data Set Regression Models for Outcome Variables (N = 148) Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 *p < .05, **p < .01. Table III. Combined Data Set Regression Models for Outcome Variables (N = 148) Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 Outcome and predictor variables B β BCa 95% CI for B Depression (R2 = .48)  Group −0.01 −0.01 −1.83, 1.80  Age −0.21 −0.07 −0.62, 0.24  VAS pain intensity 0.30 0.17 −0.01, 0.64  PCS-C 0.12** 0.31 0.01, 0.23  CPAQ-A pain-willingness 0.09 0.16 −0.07, 0.26  CPAQ-A activity engagement −0.11* −0.22 −0.23, 0.02  CAMM −0.26** −0.43 −0.36, −0.15 Anxiety (R2 = .43)  Group 0.71 0.07 −1.59, 3.13  Age −0.04 −0.01 −0.48, 0.44  VAS pain intensity 0.19 0.11 −0.12, 0.55  PCS-C 0.07 0.19 −0.02, 0.18  CPAQ-A pain-willingness 0.07 0.14 −0.07, 0.23  CPAQ-A activity engagement −0.07 −0.12 −0.17, 0.03  CAMM −0.35** −0.59 −0.46, −0.24 Social functioning (R2 = .31)  Group 4.08* 0.31 1.15, 7.04  Age 0.46 0.12 −0.25, 1.13  VAS pain intensity 0.29 0.12 −0.23, 0.75  PCS-C −0.07 −0.13 −0.21, 0.08  CPQ-A pain-willingness −0.10 −0.14 −0.34, 0.12  CPQ-A activity engagement 0.21* 0.29 0.03, 0.36  CAMM 0.17* 0.20 0.03, 0.30 Physical functioning (R2 = .58)  Group 3.43* 0.23 0.82, 6.15  Age 0.45 0.10 0.01, 0.93  VAS pain intensity −0.70** −0.25 −1.07, −0.34  PCS-C −0.12* −0.20 −0.23, 0.01  CPQ-A pain-willingness −0.08 −0.10 −0.30, 0.12  CPQ-A activity engagement 0.21** 0.26 0.06, 0.37  CAMM 0.09 0.09 −0.03, 0.21 *p < .05, **p < .01. Supporting our second formal hypothesis, dispositional mindfulness accounted for unique variance in mood (b= −0.26) and anxiety (b = −0.35) after all other variables were controlled for (including group). Neither of the BCa bootstrapped 95% confidence intervals for these b values crossed zero, suggesting that these findings are reliable. On average, as dispositional mindfulness increased by one unit, depressive symptomology decreased by 0.26 units and anxiety symptomology decreased by 0.35 units (when all other variables were held constant). In terms of our first exploratory hypothesis, dispositional mindfulness was not found to account for unique variance in physical functioning, but it did account for unique variance in social functioning (b= 0.17). Discussion As predicted by our first formal hypothesis, dispositional mindfulness was significantly associated with mood and anxiety in adolescents with chronic pain and “healthy” adolescents with low-level pain. This replicates and extends previous studies (Greco et al., 2011; Petter et al., 2013) by demonstrating that dispositional mindfulness is positively associated with good mental health in the general adolescent population and also those experiencing chronic pain. As predicted by our second formal hypothesis, dispositional mindfulness also accounted for unique variance in mood and anxiety after controlling for group, age, pain-intensity, pain-catastrophizing, and pain-acceptance. Thus, recent results from the adult literature (Elvery et al., 2017; McCracken et al., 2007; McCracken & Keogh, 2009; Mun, Okun, & Karoly, 2014) suggesting that dispositional mindfulness may play a role in the experience of chronic pain appear to extend to the adolescent population. This may have significant theoretical implications for cognitive-behavioral models of chronic pain that emphasize the role of pain-specific cognitions (e.g., the Fear Avoidance Model: Simons & Kaczynski, 2012) but do not encompass the more generalized “trait-like” construct of dispositional mindfulness. Our results are also relevant to clinical treatment models. Many clinicians and researchers see it as essential to target pain-catastrophizing in treatment, particularly in widely used cognitive behavioral therapy approaches. However, the current study demonstrated that dispositional mindfulness was key in explaining psychological distress, perhaps more so than pain-catastrophizing. This is not necessarily an argument against conventional treatment, which has established positive effects (Bruce et al., 2017; Fisher et al., 2014), but our results should embolden researchers and clinicians to explore mindfulness interventions further with youth. For example, Gauntlett-Gilbert et al. (2013) demonstrated the benefits of a multidisciplinary treatment program for adolescent chronic pain that included mindfulness training throughout. Mindfulness and acceptance approaches start from the premise that pain, stress, and negative thinking are, to a degree, fundamentally uncontrollable. However, by showing that this uncontrollability is not necessarily a barrier to skillful management, they may offer a particularly hopeful and relevant approach for youth with challenging chronic health conditions. The first of our two exploratory hypotheses was partially supported. We found that dispositional mindfulness predicted social, but not physical, functioning after other variables had been controlled. This is neither consistent nor inconsistent with the adult literature, because some adult chronic pain studies have found dispositional mindfulness to predict functioning, whereas others have found this not to be the case (McCracken et al., 2007; Schütze et al., 2010). Finally, in support of our second exploratory hypothesis, we found no significant difference between adolescents with chronic pain and “healthy” adolescents with low-level pain in terms of their levels of dispositional mindfulness. Therefore, the current study suggests that high pain levels are not necessarily a barrier to the existence or development of mindfulness. This corroborates Schütze et al. (2010), who found that levels of adult dispositional mindfulness were not significantly lower in a chronic pain sample when compared with a general population sample. However, our finding that dispositional mindfulness was not associated with pain-intensity in either group is at odds with two adult chronic pain studies (McCracken et al., 2007; McCracken & Keogh, 2009) and one adolescent low-pain general population study (Petter et al. 2013). Each of these previous studies reported a negative association between dispositional mindfulness and pain-intensity. This needs further investigation, because although mindfulness theory would predict a negative association between dispositional mindfulness and psychological distress in the context of pain, it would not necessarily predict lower pain ratings from individuals experiencing higher levels of dispositional mindfulness. Our preliminary view is that adolescents with greater dispositional mindfulness will have less “judgment” attached to their pain experience, but also perhaps more “awareness” of their pain experience. Although one could argue that mindfulness explicitly increases the ability to encounter pain sensations with less resistance and struggle (perhaps resulting in a lower pain-intensity rating), being more aware of your pain experience could offset this. Although a “naïve” view of pain might presume tight associations between pain intensity and pain distress, mindfulness theory would point out that these may not be inevitably linked. This is a complicated issue requiring further exploration. Strengths of this study include the investigation of dispositional mindfulness in a chronic pain sample of adolescents, use of standardized measures, use of multiple recruitment sites, and comparison with a large “healthy” low-level pain sample. However, there are a number of limitations that need highlighting, particularly the small sample size of the chronic pain group, the differing sample sizes across the two groups, the lack of data on pain frequency and duration of pain episodes, and of course the single time point cross-sectional design. Finally, the Cronbach’s alpha value for the BAPQ Physical Functioning subscale was also low. Perhaps additional normative data are needed on this measure to understand its suitability in assessing functioning in healthy youth. In terms of future research, longitudinal studies (with larger chronic pain samples) will be required to further explore the role played by dispositional mindfulness in the adolescent experience of chronic pain, and the possibility that it might be a “resilience resource” as suggested by Cousins, Kalapurakkel, Cohen, and Simons (2015). Research suggests that dispositional mindfulness tends to predict changes in mood and anxiety (Ciarrochi, Kashdan, Leeson, Heaven, & Jordan, 2011), but the direction of causality cannot be inferred from the current study. Research will also need to elucidate the mechanisms or processes underlying the observed relationships between dispositional mindfulness, psychological distress, and social functioning. Finally, although it is encouraging that the CAMM demonstrated good internal consistency in both groups, it is a one-dimensional measure, and so, this study was not able to differentiate between the elements of “present-moment awareness” and “nonjudgment” that define the complex and broad construct of mindfulness (Brown & Ryan, 2003). This is important if we want to develop our understanding of how mindfulness could be added to models and treatments of adolescent chronic pain. In summary, despite these cautions, the current study can conclude that dispositional mindfulness accounted for unique variance in psychological distress (and social functioning) in adolescents with chronic pain and “healthy” adolescents with low-level pain. This provides some indirect support to the theoretical importance of dispositional mindfulness in adolescent contextualized cognitive-behavioral models such as acceptance and commitment therapy (ACT; Pielech, Vowles, & Wicksell, 2017), and suggests that further research could investigate the utility of mindfulness training, particularly for adolescents experiencing mood and anxiety problems (both in low-pain and chronic pain samples). There is no reason to presume that “dispositional mindfulness” cannot be changed by intervention. Despite the fact that this concept is framed as a “trait,” all mindfulness training aims to create sustained, daily improvements in levels of present moment awareness and acceptance, rather than experiences that last no longer than a meditation session (Kabat-Zinn, 2003). Evidence from adult meditators shows enduring brain changes associated with sustained practice (Fox et al., 2014), and ACT has emphasized the application of mindfulness across many aspects of daily life, rather than purely in the context of meditation (Hayes, Strosahl, & Wilson, 2011). Therefore, the potential benefits of incorporating mindfulness practice into adolescent pain treatment programs need further exploration. Footnotes 1 Severe mental disorder and severe substance abuse were not formally defined, but recruiting clinicians were asked to exclude on this basis if they felt that a young person’s mental disorder or substance abuse was so extreme that it would interfere with their ability to take part in the study. Acknowledgments The authors would like to express their gratitude to the young people who took part in this study, the clinicians who gave up their time to assist with recruitment, and also the Associate Editor and three anonymous reviewers for their constructive and thoughtful suggestions for revision. Funding This study received no specific funding. One of the authors (M.E.L.) is funded by the National Institute for Health Research. This report is independent research. The views expressed in this publication are those of the authors and not necessarily those of the NHS, The National Institute for Health Research, or the Department of Health. References Baer R. A. , Smith G. T. , Allen K. B. ( 2004 ). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills . Assessment , 11 , 191 – 206 . Google Scholar Crossref Search ADS PubMed Brown K. W. , Ryan R. M. ( 2003 ). The benefits of being present: Mindfulness and its role in psychological wellbeing . Jounral of Personality and Social Psychology , 84 , 822 – 848 . Google Scholar Crossref Search ADS Bruce B. K. , Ale C. M. , Harrison T. E. , Bee S. , Luedtke C. , Geske J. , Weiss K. E. ( 2017 ). Getting back to living: Further evidence for the efficacy of an interdisciplinary pediatric pain treatment program . Clinical Journal of Pain , 33 , 535 – 542 . Google Scholar Crossref Search ADS PubMed Ciarrochi J. , Kashdan T. B. , Leeson P. , Heaven P. C. L. , Jordan C. ( 2011 ). On being aware and accepting: A one-year longitudinal study into adolescent well-being . Journal of Adolescence , 34 , 695 – 703 . Google Scholar Crossref Search ADS PubMed Cousins L. A. , Kalapurakkel S. , Cohen L. L. , Simons L. E. ( 2015 ). Topical review: Resilience resources and mechanisms in pediatric chronic pain . Journal of Pediatric Psychology , 40 , 840 – 845 . Google Scholar Crossref Search ADS PubMed Crombez G. , Bijttebier P. , Eccleston C. , Mascagni T. , Mertens G. , Goubert L. , Verstraeten K. ( 2003 ). The child version of the pain catastrophizing scale (PCS-C): A preliminary validation . Pain , 104 , 639 – 646 . Google Scholar Crossref Search ADS PubMed Eccleston C. , Jordan A. , McCracken L. M. , Sleed M. , Connell H. , Clinch J. ( 2005 ). The Bath Adolescent Pain Questionnaire (BAPQ): Development and preliminary psychometric evaluation of an instrument to assess the impact of chronic pain on adolescents . Pain , 118 , 263 – 270 . Google Scholar Crossref Search ADS PubMed Elvery N. , Jensen M. P. , Ehde D. M. , Day M. A. ( 2017 ). Pain catastrophising, mindfulness, and pain-acceptance: What's The Difference? Clinical Journal of Pain , 33 , 485 – 495 . Google Scholar Crossref Search ADS PubMed Fisher E. , Heathcote L. , Palermo T. M. , Williams A. C. , Lau J. , Eccleston C. ( 2014 ). Systematic review and meta-analysis of psychological therapies for children with chronic pain . Journal of Pediatric Psychology , 39 , 763 – 782 . Google Scholar Crossref Search ADS PubMed Fox K. C. , Nijeboer S. , Dixon M. L. , Floman J. L. , Ellamil M. , Rumak S. P. , Sedlmeier P. , Christoff K. ( 2014 ). Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners . Neuroscience and Biobehavioral Reviews , 43 , 48 – 73 . Google Scholar Crossref Search ADS PubMed Gauntlett-Gilbert J. , Connell H. , Clinch J. , McCracken L. M. ( 2013 ). Acceptance and values-based treatment of adolescents with chronic pain: Outcomes and their relationships to acceptance . Journal of Pediatric Psychology , 38 , 72 – 81 . Google Scholar Crossref Search ADS PubMed Greco L. A. , Baer R. A. , Smith G. T. ( 2011 ). Assessing mindfulness in children and adolescents: Development and validation of the Child and Adolescent Mindfulness Measure (CAMM) . Psychological Assessment , 23 , 606 – 614 . Google Scholar Crossref Search ADS PubMed Hayes S. C. , Strosahl K. D. , Wilson K. G. ( 2011 ). Acceptance and commitment therapy: The process and practice of mindful change . New York, US : Guilford Press . Kabat-Zinn J. ( 2003 ). Mindfulness-based interventions in context: Past, present and future [commentary] . Clinical Psychology: Science and Practice , 10 , 144 – 156 . Google Scholar Crossref Search ADS Kabat-Zinn J. , Lipworth L. , Burney R. ( 1985 ). The clinical use of mindfulness meditation for the self-regulation of chronic pain . Journal of Behavioral Medicine , 8 , 163 – 190 . Google Scholar Crossref Search ADS PubMed Kalapurakkel S. , Carpino E. A. , Lebel A. , Simons L. E. ( 2015 ). “Pain can’t stop me”: Examining pain self-efficacy and acceptance as resilience processes among youth with chronic headache . Journal of Pediatric Psychology , 40 , 926 – 933 . Google Scholar Crossref Search ADS PubMed McCracken L. M. , Gauntlett-Gilbert J. , Eccleston C. ( 2010 ). Acceptance of pain in adolescents with chronic pain: Validation of an adapted assessment instrument and preliminary correlation analyses . European Journal of Pain , 14 , 316 – 320 . Google Scholar Crossref Search ADS PubMed McCracken L. M. , Gauntlett-Gilbert J. , Vowles K. E. ( 2007 ). The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability . Pain , 131 , 63 – 69 . Google Scholar Crossref Search ADS PubMed McCracken L. M. , Keogh E. ( 2009 ). Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: An analysis of anxiety sensitivity . Journal of Pain , 10 , 408 – 415 . Google Scholar Crossref Search ADS PubMed Mun C. J. , Okun M. A. , Karoly P. ( 2014 ). Trait mindfulness and catastrophizing as mediators of the association between pain severity and pain- related impairment . Personality and Individual Differences , 66 , 68 – 73 . Google Scholar Crossref Search ADS Pallozzi R. , Wertheim E. , Paxton S. , Ong B. ( 2017 ). Trait mindfulness measures for use with adolescents: A systematic review . Mindfulness , 8 , 110 – 125 . Google Scholar Crossref Search ADS Petter M. , Chambers C. T. , McGrath P. J. , Dick B. D. ( 2013 ). The role of trait mindfulness in the pain expeirence of adolescents . Journal of Pain , 14 , 1709 – 1718 . Google Scholar Crossref Search ADS PubMed Pielech M. , Ryan M. , Logan D. , Kaczynski K. , White M. T. , Simons L. E. ( 2014 ). Pain catastrophizing in children with chronic pain and their parents: Proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure . Pain , 155 , 2360 – 2367 . Google Scholar Crossref Search ADS PubMed Pielech M. , Vowles K. E. , Wicksell R. ( 2017 ). Acceptance and commitment therapy for pediatric chronic pain: Theory and application . Children , 4 , 10 – 22 . Google Scholar Crossref Search ADS Schütze R. , Rees C. , Preece M. , Schütze M. ( 2010 ). Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain . Pain , 148 , 120 – 127 . Google Scholar Crossref Search ADS PubMed Shapiro S. L. , Carlson L. E. , Astin J. A. , Freedman B. ( 2006 ). Mechanisms of mindfulness . Journal of Clinical Psychology , 62 , 373 – 386 . Google Scholar Crossref Search ADS PubMed Simons L. E. , Kaczynski K. J. ( 2012 ). The fear avoidance model of chronic pain: Examination for pediatric application . Journal of Pain , 13 , 827 – 835 . Google Scholar Crossref Search ADS PubMed Tran S. T. , Mano K. E. J. , Hainsworth K. R. , Medrano G. R. , Khan K. A. , Weisman S. J. , Davies W. H. ( 2015 ). Distinct influences of anxiety and pain catastrophizing on functional outcomes in children and adolescents with chronic pain . Journal of Pediatric Psychology , 40 , 744 – 755 . Google Scholar Crossref Search ADS PubMed Varni J. W. , Thompson K. L. , Hanson V. ( 1987 ). The Varni/Thompson Pediatric Pain Questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis . Pain , 28 , 27 – 38 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Pediatric PsychologyOxford University Press

Published: Oct 1, 2018

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