Neuropsychological Functioning of Youth Receiving Intensive Interdisciplinary Pain Treatment

Neuropsychological Functioning of Youth Receiving Intensive Interdisciplinary Pain Treatment Abstract Objective Chronic pain is associated with school difficulties; however, there is limited published evidence on the cognitive or neuropsychological functioning of youth with chronic pain. Method When beginning intensive interdisciplinary pain treatment, 94 youth (age = 10–18) with chronic pain completed neuropsychological assessment (e.g., intelligence, academic skills, learning and recall, and attention) and clinical questionnaires (e.g., pain and physical and psychological functioning). We compared neuropsychological scores with test norms and with clinical questionnaires. Results Youth with chronic pain had higher verbal comprehension and full scale IQ scores than expected, below-average nondominant hand dexterity, and difficulty with visual recall. Self-reported difficulties with executive functioning were associated with small-to-moderate difficulties with objectively measured attention. Performance on neuropsychological measures was generally not associated with pain, impairment, anxiety, or depression, though catastrophizing was negatively correlated with perceptual reasoning. An expected number of these youth had learning disorders (14%); however, more than expected had an autism spectrum disorder (9%) or attention deficit hyperactivity disorder (18%), and nearly a quarter demonstrated characteristics of nonverbal learning disability (22%). Conclusions Some of these cognitive findings may be a consequence of chronic pain, and others may reflect subtle neurodevelopmental differences that may predate or be comorbid with pain. Regardless of etiology, with more than half the current sample experiencing some type of learning challenge, often undiagnosed, pediatric psychologists evaluating youth with chronic pain may wish to screen for comorbid learning difficulties. adolescents, chronic pain, cognitive assessment, neuropsychology Introduction Chronic pain is persistent or recurrent, can be associated with a disease (e.g., arthritis or sickle cell disease) or can be idiopathic, and is always a biopsychosocial phenomenon (American Pain Society, 2012; Gatchel, Peng, Peters, Fuchs, & Turk, 2007). Chronic pain affects more than 30% of adults (Johannes, Le, Zhou, Johnston, & Dworkin, 2010) and up to 37% of adolescents, with about 5% of youth experiencing moderate-to-severe chronic pain (Huguet & Miró, 2008). Youth with chronic pain experience impairments in physical, social, emotional, and family functioning (Hunfeld et al., 2001; Palermo, 2000), which can persist into adulthood and affect social, educational, and vocational outcomes (Kashikar-Zuck et al., 2014). During middle and high school, youth with chronic pain report significant impairment in academic performance (Logan, Simons, & Kaczynski, 2009; Logan, Simons, Stein, & Chastain, 2008). However, there is limited published evidence on the cognitive or neuropsychological functioning of adolescents with chronic pain. The Distracting Effects of Pain Cognitive impairment may be a consequence of pain, which causes distraction by placing demands on attention and other neurological systems (Eccleston, 1994; Eccleston & Crombez, 1999; Grigsby, Rosenberg, & Busenbark, 1995). Consistent with this, adults with chronic pain experience difficulties with executive functioning and cognition, particularly in the areas of processing speed (Antepohl, Kiviloog, Andersson, & Gerdle, 2003), learning and memory (Dick & Rashiq, 2007), and attention (Dick, Eccleston, & Crombez, 2002; Dick & Rashiq, 2007; Eccleston, 1994). Further, adults with chronic pain perform poorly on tasks of working memory (Antepohl et al., 2003; Luerding, Weigand, Bogahn, & Schmidt-Wilcke, 2008), long term memory (Luerding et al., 2008), and recognition memory (Park, Glass, Minear, & Crofford, 2001), when compared with controls. Less is known about the cognitive effects of chronic pain in youth. A recent systematic review identified only nine studies directly investigating cognitive function in youth with chronic pain (Dick & Riddell, 2010). This review generally concluded that youth with chronic pain have at least average intelligence but perceive both cognitive dysfunction (Bell, Bell, & Cheney, 1994) and academic impairment (Logan, Simons, Stein, and Chastain, 2008). Attention-related difficulties may underlie this perceived impairment. For example, two studies using physiological measures of attention suggest that adolescents with chronic pain have difficulty shifting their attention away from painful stimuli (Buodo, Palomba, Sarlo, Naccarella, & Battistella, 2004; Zohsel et al., 2008). Indeed, attending to pain is hardwired into the brain, with areas such as the amygdala and frontal cortex directly implicated (Simons, Elman, & Borsook, 2014). Unfortunately, and despite the importance of this area of investigation (Dick & Riddell, 2010), research in this area has waned, and there has been no recent systematic investigation of the neuropsychological function of youth with chronic pain. Cognitive Problems as a Chronic Stressor, Predisposing One to Pain As stress is a known contributor to the development of chronic pain (Hoffart & Wallace, 2014; Li & Hu, 2016; McEwen & Kalia, 2010; Melzack, 1999; Sherry & Weisman, 1988), it is also possible that preexisting psychological, cognitive, or learning problems lead to stress, which predisposes a person to the later development of health symptoms. Indeed, in adults with chronic pain, depression and self-reported distress are related both to the report of cognitive complaints (McCracken & Iverson, 2001) and to objective performance on cognitive measures (Grace, Nielson, Hopkins, & Berg, 1999; Landrø, Stiles, & Sletvold, 1997). Depression also plays a role in school functioning for youth (Logan, Simons, & Kaczynski, 2009). However, psychological symptoms do not generally predate the development of pain in youth (Lynch, 1992). On the other hand, youth have been found to have various patterns of cognitive strengths and weaknesses. These cognitive patterns could potentially result in increased stress for adolescents who experience an academic “mis-fit” between the manner in which they are taught and their own learning style. One study, for example, found that adolescents with chronic musculoskeletal pain had average overall IQs on the Wechsler Intelligence Scale for Children—Revised (WISC-R) but frequently demonstrated a significant difference between performance and verbal IQ scores (Sherry, McGuire, Mellins, Salmonson, Wallace, & Nepom, 1991). In this study, 42% of the sample had a significant split between verbal and performance scores, with two-thirds demonstrating higher performance IQ. This pattern would not be expected to be caused by pain and could present a learning style contributing to specific and relatively difficult-to-detect academic challenges. In a study comparing the cognitive functioning of adolescents with migraine headaches without aura (MoA) and tension-type headaches and controls using the WISC-R, the MoA group was found to score the lowest on total and verbal IQ scores, though no differences in performance IQ were detected (Parisi et al., 2010). Finally, Sherry and colleagues (1991) also reported that seven of the 37 youth in their study with normal IQ reported low school achievement scores, potentially suggestive of a learning disability. However, not all studies have identified differences, and in a third example, adolescents with chronic pain were found to demonstrate higher verbal and nonverbal reasoning skills, higher word reading and math reasoning, and no differences in reading comprehension, arithmetic computation, spelling, and written expression when compared with test norms (Ho et al., 2009). Another study found no significant differences in sequential or simultaneous information processing when adolescents with chronic migraines were compared with sibling controls (Haverkamp et al., 2002). In addition, instead of cognitive challenges, adolescents with chronic pain tend to have average (Sherry et al., 1991) or above-average cognitive functioning (Ho, Bennett, Cox, & Poole, 2009; Parisi et al., 2010). Thus, it remains unclear the extent to which youth with pain may experience underlying cognitive and academic difficulties that may be unrelated to pain, and yet create a situation that may predispose them to developing pain. The Present Study In short, the current understanding of neurocognitive performance in youth with chronic pain is limited, and research examining the neurocognitive profile of youth with chronic pain may improve our understanding of both causes and consequences of chronic pain in young people. The overall aim of this study was to describe the neurocognitive profile of a medium-sized sample of youth with chronic pain who were beginning intensive interdisciplinary pain treatment (IIPT). In this description, we include findings that may (a) be related to the distracting effects of pain (e.g., continuous performance) or (b) suggest preexisting cognitive findings that may cause stress and thus contribute to pain (e.g., verbal and academic abilities). To achieve these aims, we compared scores from standardized cognitive instruments with the normative samples published with these instruments. Owing to literature demonstrating the importance of psychological factors to cognitive performance, we evaluated whether psychological factors like depression, anxiety, and catastrophizing are associated with neuropsychological functioning. Finally, we compared preexisting diagnoses and those made during assessment with base rates for attention deficit hyperactivity disorder (ADHD), autism, traditional learning disabilities such as dyslexia and dyscalculia, and nonverbal learning disability (NLD). Method Participants Potential participants included 99 youth beginning an IIPT program at a regional children’s hospital between March 2013 and December 2015. Of 99 consecutively enrolled participants, 94 completed neuropsychological assessment. Reasons for not completing this assessment included recent outside assessment through school or private psychologist (n = 3), significant developmental delay with existing services (n = 1), and English not being the patient’s primary language (n = 1). The five excluded patients did not differ on age, race, pain diagnosis, or pain intensity (ps > .05); however, they tended to have a shorter pain history (median = 1.1 vs. 2.5 years; Mann–Whitney U = 96.5, p < .05). Participants consisted of 80 female youth and 14 male youth between 10 and 18 years of age at the time of testing (Table I). Participants in this program present with both localized (e.g., complex regional pain syndrome) and widespread (e.g., juvenile fibromyalgia and amplified pain syndrome) chronic pain conditions. Comorbid conditions (e.g., arthritis and diabetes) were required to be well-controlled before program admission. Before entering the program, patients were removed from any pain medications (typically months before beginning the program). To be included in IIPT, patients had previously attempted traditional outpatient treatment of chronic pain. Table I. Demographics and Questionnaire Data (N = 94) Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Table I. Demographics and Questionnaire Data (N = 94) Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Procedures This investigation was approved by the hospital institutional review board as a component of a project designed to describe demographic characteristics and treatment outcomes of participants in a specific IIPT program. Assent was obtained from minor patients and permission from their parents, and consent was obtained from adult patients (age 18). On approximately their first day of IIPT, participants completed an abbreviated neuropsychological assessment, caregiver and self-report measures of executive functioning, and self-report of pain, functioning, and psychological symptoms. The first day of the program was selected because this day includes evaluation from all disciplines and avoids intense exercise that might bias observed results. Occasionally, testing was completed before therapies on the morning of the second or third day of the program. Neuropsychological testing was completed by a licensed psychologist or graduate-level psychology trainee under the in-person supervision of a licensed psychologist. A board certified neuropsychologist was consulted in developing the brief battery. Measures Most measures were administered to all patients; however, we include two measures that were only given to a subset of participants, as these were systematically given over a period, rather than selected based on patient characteristics (the Wechsler Intelligence Scale for Children, Fourth Edition [WISC-IV] Processing Speed Index [PSI] and the Conners’ Continuous Performance Test, Second Edition [CPT-II]). Cognitive ability Cognitive ability was measured using the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II; Wechsler, 2011) for all participants. The WASI-II provide a short and reliable measure of intelligence, and scores are based on a norm group of 2,300 individuals matched to U.S. Census data for gender, race/ethnicity, education, and region of the country within each age-group. Cognitive ability is calculated using all four subtests. These four subtests are further divided into two composite areas, verbal comprehension (VCI) and perceptual reasoning (PRI), based on characteristics of the subtests and what they measure. Internal consistency for the overall scale and subtests used ranged from 0.87 to 0.96. The WISC-IV (Wechsler, 2003) PSI was later added to the battery to more objectively evaluate processing speed (n = 52). The WISC-IV norm group consists of 2,200 children and adolescents age 6:0 to 16:11, with race/ethnicity matching U.S. Census data, equal male and female participants, balanced recruitment across the United States, and stratified for parent education level. Both the PSI standard score and the two subtest scaled scores were used for data analysis; internal reliability is 0.88 for the PSI. Academic achievement Academic achievement was measured using standard scores from the math computation and word reading subtests from the Wide Range Achievement Test, Fourth Edition (WRAT-4; Wilkinson & Robertson, 2006). The WRAT-4 reading subtest provides an untimed measure of letter and word decoding, and math computation measures an individual’s ability to compute basic to more advanced math problems in 15 min. The normative sample includes 3,021 individuals from across the United States carefully matched (and weighted as needed) to align to U.S. Census data. Internal consistency is 0.92 for word reading and 0.89 for math computation. Dexterity The Grooved Pegboard Test (GPT; Lafayette Instruments, 1989) was used to assess motor dexterity bilaterally. This test requires the participant to rotate and place pegs into 25 holes with randomly positioned slots, requiring dexterity and visual–motor coordination. Raw scores (time to completion) were converted to T-scores using normative data provided in the manual (total norm group of 744 between age 9 and 19, gleaned from existing studies). Higher T-scores indicate slower performance. Motor preference was evaluated by self-report, and lateral preference was evaluated on writing tasks. Verbal learning and recall The California Verbal Learning Test, Children’s Version (CVLT-C; Delis, Kramer, Kaplan, & Ober, 1998) or California Verbal Learning Test, Second Edition (CVLT-II; Delis, Kramer, Kaplan, & Ober, 2000) was administered to assess verbal learning and recall. The CVLT-C was administered for youth from the age of 10 years through 16 years, whereas the CVLT-II was administered for participants 17 years and older. Both of these tests provide subjects five trials to learn a list of words, then a single trial of a different list, followed a short-delay free and cued recall of the first list. Approximately 20 min later, a long-delay free and cued recall trial are administered, followed by a recognition trial in which the participant identifies which words were on the initial list. The CVLT-II normative sample included 1,087 adults, carefully matched to U.S. Census data for gender, age, race, ethnicity, education, and region of the country; the CVLT-C normative sample includes 920 children with an IQ range that closely approximated that of the U.S. population of children. Internal consistency is 0.94 for the CVLT-II and 0.88 for the CVLT-C, and test–retest reliabilities were as expected, given the nature of these tasks. Z scores were calculated for each measure and analyzed for both free and cued recall on both short- and long-delay trials. In addition, recognition trials were examined. Visuospatial construction and memory The Rey Complex Figure Test (RCFT; Meyers & Meyers, 1996) was administered to assess visual construction and visual memory. This test prompts the copy and then recall of a complex figure and has a long history of use to assess visuospatial construction ability, with validity established through observed differences in across many samples of patients with known brain injuries. The normative samples include 601 adults from various urban, suburban, and university settings in the Western and Midwestern United States and Canada, and 505 children and adolescents enrolled in various school in the Midwestern United States. Scoring has been further delineated in the current edition of the test, and interrater reliability ranges from 0.93 to 0.99, with test–retest correlations ranging from 0.76 to 0.89 across 6 months. Immediate recall, delayed recall, and delayed recognition T-scores were included in the analysis. Attention/executive functioning The CPT-II (Conners, 2004), Version 5, was administered to objectively assess sustained attention, vigilance, and inhibition in a subset of participants (n = 55). The CPT-II requires participants to press a computer key each time a stimulus is presented, unless the stimulus is “X.” The test lasts 14 min and provides a variety of comparisons with the norm groups, which consist of 1,920 individuals without attention problems, 378 with ADHD, and 223 with other neurological impairments. The omissions, commission errors, reaction time, variability, detectability, and perseveration T-scores were used in analyses. Self- and parent-report versions of the Behavior Rating Inventory of Executive Functioning (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) were used to assess perceptions of executive dysfunction in adolescents with chronic pain. The self-report BRIEF consists of 80 items in which participants rated various behaviors related to executive functioning using a 3-point scale (never, sometimes, and often). The parent-report BRIEF consists of 86 items and uses the same rating scale, and T-scores are calculated based on a norm group consisting of 1,419 parent ratings. Internal consistency ratings for clinical scales and composite scores range from .72 to .96. Pain and impairment The 100-mm Visual Analogue Scale for pain was completed by the participants. The participants were asked to rate their average pain intensity using a visual scale that consists of a horizontal line with two descriptors (i.e., “no pain” and “worst pain imaginable”) on each end that serve as anchors for the scale. The line measures 100 mm in length, and the distance in millimeters from the far left end of the scale to the participant’s response is the participant’s score on this measure. Participants also completed the Functional Disability Index (FDI) to assess the impact of chronic pain on every day functioning. Respondents provide ratings on 15 items using a 5-point Likert rating scale with scores ranging from “no trouble” to “impossible.” Internal consistency for the FDI was good (α = .86). Coping and psychological functioning A number of rating scales were used to assess patient coping and psychological functioning. These measures included the Pediatric Anxiety, Depression, and Peer Relationships subscales of the Patient-Reported Outcomes Measurement Information System (Irwin et al., 2010), the catastrophizing subscale of the Pain-Related Cognitions Questionnaire for Children (Hermann, Hohmeister, Zohsel, Ebinger, & Flor, 2007), and the school functioning score from the Pediatric Quality of Life Inventory (PedsQL 4.0; Varni, Seid, & Kurtin, 2001). All measures were completed by participants on their first day, before participation in IIPT. Internal consistency for these measures ranged from acceptable for the PedsQL school functioning score (α = .73) to excellent for the other measures (anxiety: α = .92; depression: α = .96; peer relationships: α = .91; catastrophizing: α = .90). Analytic Strategy The sample was evaluated for outliers before performing statistical analyses using the outlier labeling rule, and outliers were replaced with less extreme values with a g value of 2.2 (Hoaglin & Iglewicz, 1987). This resulted in the correction of 27 values (0.6% of total observations). Independent samples t-tests (with or without assuming equal variances, as appropriate) were completed to identify any significant differences between male and female participants on neuropsychological measures. As differences were not statistically significant, data were not weighted to correct for unequal gender distribution in the sample. First, one-sample z test statistics were used to compare participant scores with test norm groups for standardized neuropsychological assessments and questionnaires (Ho et al., 2009). Test norms are considered comparable with population means; thus, these comparisons may reveal a pattern of “typical” strengths and weaknesses across teens with chronic pain. As a number of z tests were completed for this analysis, only z test results significant at the p ≤ 0.01 level will be interpreted to minimize type I error, while still identifying potential meaningful associations, given the exploratory nature of this analysis. Second, neuropsychological data were correlated with pain-related and questionnaire data of interest. Measures of pain, impairment, depression, anxiety, catastrophizing, peer relationships, and school functioning were correlated with objective neuropsychological data, using Pearson product–moment correlations. Correlations significant at the p ≤ 0.01 level were interpreted to minimize type I error rate without overly increasing type II error. Third, we evaluated the rate of learning-related diagnoses (preexisting and those made during neuropsychological assessment) observed in our sample compared with published epidemiological rates. The targeted diagnoses included ADHD, autism spectrum disorders (ASD), specific learning disability such as dyslexia or dyscalculia (LD), and NLD. Criteria previously used by Petti, Voelker, Shore, and Hayman-Abello (2003) were used to identify those with NLD. To be categorized as NLD, participants must meet three criteria, including (a) verbal IQ at least 12 points higher than performance IQ, (b) verbal IQ greater than math achievement by at least 1 SD, and (c) verbal IQ of at least 85. Results Cognitive and Achievement Scores Youth with chronic pain scored significantly higher on the full scale IQ (z = 5.63, p < .001) when compared with test norms. They also scored higher on the WASI-II VCI (z = 7.30, p < .001) and both the vocabulary (z = 8.04, p < .001) and similarities (z = 5.63, p < .001) subtests when compared with test norms. They performed similar to test norms on the WASI-II PRI (z = 2.30, p = .021); for subtests within the PRI, youth with chronic pain scored within the normative range on the block design subtest (z = −0.87, p = .382) and better than test norms on the matrix reasoning subtest (z = 5.17, p < .001). Teens who completed the WISC-IV PSI (n = 52) had processing speed comparable with test norms (z = 0.71, p = .477). Teens with chronic pain scored similar to test norms on the WRAT-4 math calculation (z = 0.61, p = .541) and word reading (z = 1.77, p=.077) subtests. See Table II for a full list of z tests along with observed means and effect sizes. Table II. Z-Tests Comparing Neuropsychological Performance of Adolescents With Chronic Pain With Test Normative Samples Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 a Score types. b ISI: interstimulus interval. *** significant at 0.001 level; **significant at 0.005 level; *significant at 0.01 level. Abbreviations: SS: standard score (M = 100, SD = 15); S: scaled score (M = 10, SD = 3); T: T-score (M = 50, SD = 10); Z: z-score (M = 0, SD = 1). Measures: WASI-II: Wechsler Abbreviated Scale of Intelligence—Second Edition; WISC-IV: Wechsler Intelligence Scale for Children—Fourth Edition; GPT: Grooved Pegboard Test; CVLT-C: California Verbal Learning Test—Children’s Version; CVLT-II: California Verbal Learning Test—Second Edition; RCFT: Rey Complex Figure Test; WRAT-4: Wide Range Achievement Test—Fourth Edition; CPT-II: Conners’ Continuous Performance Test II, Version 5; BRIEF: Behavior Rating Inventory of Executive Function (parent-report and self-report versions). Table II. Z-Tests Comparing Neuropsychological Performance of Adolescents With Chronic Pain With Test Normative Samples Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 a Score types. b ISI: interstimulus interval. *** significant at 0.001 level; **significant at 0.005 level; *significant at 0.01 level. Abbreviations: SS: standard score (M = 100, SD = 15); S: scaled score (M = 10, SD = 3); T: T-score (M = 50, SD = 10); Z: z-score (M = 0, SD = 1). Measures: WASI-II: Wechsler Abbreviated Scale of Intelligence—Second Edition; WISC-IV: Wechsler Intelligence Scale for Children—Fourth Edition; GPT: Grooved Pegboard Test; CVLT-C: California Verbal Learning Test—Children’s Version; CVLT-II: California Verbal Learning Test—Second Edition; RCFT: Rey Complex Figure Test; WRAT-4: Wide Range Achievement Test—Fourth Edition; CPT-II: Conners’ Continuous Performance Test II, Version 5; BRIEF: Behavior Rating Inventory of Executive Function (parent-report and self-report versions). Dexterity Youth with chronic pain scored below average on the grooved peg task for their nondominant hand (z = 3.65, p < .001) and average for their dominant hand (z = 1.56, p = .118) compared with test norms. Of note, youth with hand/arm (n = 28) pain did not perform differently for the dominant, t(90) = .70, p = .484, or the nondominant, t(90) = .11, p = .912, hand when compared with those without hand/arm pain. Verbal and Nonverbal Learning and Recall Teens with chronic pain scored within normal limits on all verbal learning and recall tasks. Specifically, scores were comparable with test norms for free (z = −0.99, p = .321) and cued (z = 2.596, p = .009) short-delay recall tasks, for free (z = 1.52, p = .130) and cued (z = 1.35, p = .176) long-delay recall tasks, and recognition discriminability (z = −0.192, p=.848) of the CVLT. Conversely, youth with chronic pain performed significantly worse on the immediate (z = −3.79, p < .001) and delayed recall (z = −4.81, p < .001) tasks of the RCFT compared with test norms. They performed as expected on the recognition trial of this measure (z = −.8675, p = .386). Attention/Executive Functioning Youth with chronic pain demonstrated a greater number of commission errors (z = 3.25, p = .001), elevated detectability scores (z = 2.84, p = .004), and slower reaction times (z = 4.43, p < .001) on the CPT-II compared with test norms. They demonstrated similar levels of omission rates (z = 2.07, p = .039), variability (z = 0.274, p = .784), and perseveration (z = −0.75, p = .454). Parent report on the BRIEF was significantly higher than tests norms for the Global Executive Composite (GEC, z = 7.36. p < .001) and across all scales, with the exception of inhibition. Self-report on the BRIEF also produced significant elevations on the GEC (z = 4.80, p < .001) and on all scales except inhibition, monitoring, and organization when compared with test norms (Table II). The greatest elevations for both parent- and self-report were on the subscales Shift (average T-score for parent report = 61.3, self-report = 57.9) and Working Memory (average T-score for parent-report = 60.4, self-report = 57.4). Relationship Between Neuropsychological Performance and Psychological Variables Pain intensity was not significantly correlated with performance on any objective neuropsychological measure (all ps > .01). Similarly, youth report of functional disability, depression, peer relationships, and school-based quality of life was not correlated with objective neuropsychological data for youth with chronic pain (all ps > .01). Anxiety was negatively correlated with WASI-II Matrix Reasoning, r(94) = −.273, p < .01, only. Catastrophizing was negatively correlated with WASI-II Full Scale IQ, r(94) = −.319, p < .01, with WASI-II PRI, r(92) = −.298, p < .01, and with both perceptual reasoning subtests including block design, r(92) = −.282. p < .01, and matrix reasoning, r(92) = −.271, p < .01. Catastrophizing was not significantly correlated with WASI-II VCI or Verbal subscales, nor with any other neuropsychological measure. Diagnoses An expected number of participants had learning disorders (n = 13, 14%) based on published population base rates (between 5% and 15%; American Psychiatric Association, 2013). However, more participants than expected had ASD (n = 8, 9%, compared with a population base rate of 1%–2%; American Psychiatric Association, 2013; Blumberg et al., 2013) or ADHD (n = 17, 18%, compared with a population base rate of 5%–8%; American Psychiatric Association, 2013; Froehlich et al., 2007). Further, a very high percentage of our sample demonstrated a pattern consistent with NLD (n = 21, 22%, compared with an estimated population base rate of between 0.1% and 1%; Molenaar-Klumper, 2002). Although there were some patients with more than one diagnosis, 49 of the 94 (52%) had at least one of these diagnoses. All diagnoses were made or confirmed by a licensed psychologist with experience treating chronic pain. Discussion The experience of chronic pain is thought to directly result in certain cognitive impacts, often related to processing speed (Antepohl et al., 2003), learning and memory (Dick & Rashiq, 2007), and attention (Dick et al., 2002, Dick and Rashiq, 2007; Eccleston, 1994); this may be particularly important for the youth in this sample with disability sufficient to warrant IIPT. Consistent with this, the current sample had mild impulsivity, slower reaction times, poor visual retrieval, and self-reported difficulty with working memory. In this way, current results extend findings from studies using physiological measures of attention (Buodo et al., 2004; Zohsel et al., 2008) and suggest that difficulty shifting attention away from painful stimuli may have performance consequences relevant to academic functioning. On the other hand, the current sample differs from existing research in that inattention did not result in omission errors or difficulty with verbal encoding and retrieval, and the sample had average processing speed. Certain other differences in this sample from normative groups would not be expected to be a consequence of experiencing pain, such as the relative strength for verbal processing as compared with spatial cognition, lateralizing motor signs (i.e., significantly higher dominant hand speed of completion versus nondominant hand), and difficulty with unexpected change (self- and parent report of “shift” on the BRIEF). It is possible that these characteristics may predate the onset of chronic pain. Indeed, it is compelling that fully 50% of the sample had at least some type of learning issue when considering ADHD, ASD, traditional learning disabilities, and NLD. Most of the youth in this sample had been functioning with minimal or no academic accommodations for these symptoms and (anecdotally) often reported that they had been working harder than peers for the same level of achievement at school. As has been noted, various stressors can contribute to the development and maintenance of pain (Melzack, 1999; Sherry & Weisman, 1988). Thus, it is possible that teens with subtle neurodevelopmental differences (e.g., inattention, difficulties with perceptual reasoning and visual memory, nondominant hand dexterity, executive functioning, or high functioning ASD), when combined with relatively high verbal intelligence, may initially be successful in school but struggle as academic and social demands increase. Their strong vocabulary and verbal reasoning skills may mask these concerns, preventing the implementation of appropriate interventions and accommodations, and leading to greater academic stress. In line with this hypothesis, although typical learning disabilities were comparable with epidemiological estimates, we found rates of ASD, ADHD, and nonverbal learning disorder between 2 and 20 times higher in the present sample than the national average. NLD may be an excellent example of this sort of mild neurodevelopmental difference, which acts as a chronic stressor, making academic work and social interaction more difficult (Cornoldi et al., 1999, Chow & Skuy, 1999), and over time puts teens at greater risk for chronic pain conditions. Shared Pathways for Pain and Cognitive Problems Another possible explanation for the association between pain and cognitive problems is a shared biological etiology for chronic pain and learning issues whereby some people have the predisposition toward both, and indeed some of the current results suggest brain-based differences may exist. For example, the current sample of youth with chronic pain had deficits on measures of visual retrieval (immediate and delayed recall of the RCFT) and motor dexterity (nondominant performance significantly lower than dominant hand performance), suggesting deficits lateralized to the non-language-dominant (typically right) hemisphere. In addition, our data show certain deficits in visual attention (on self-report and visual continuous performance testing), which also have associations with the non-language-dominant hemisphere of the brain (right frontal and parietal; Posner & Peterson, 1990). To expand on this point, visual-spatial cognition is thought to be composed of functions mediated by the predominantly right-hemisphere network that includes parietal lobes, lateral prefrontal cortex, medial temporal lobes, inferior temporal cortex, occipital cortex, basal ganglia, and white matter tracts, and these areas are implicated in how we interact with our environment more broadly involving perception, selection, organization, and visual-spatial/perceptual processing (Possin, 2010). Also, the middle cingulate cortex is highly implicated in attention and has reciprocal connections with the lateral prefrontal cortex, parietal cortex, premotor, and supplementary motor areas (Devinsky, Morrell, & Vogt, 1995; Peyron et al., 1999). Further, research documents an association between chronic pain and changes in the middle cingulate and the posterior parietal cortex (Buckalew, Haut, Morrow, & Weiner, 2008), and gray matter changes are observed specifically in the somatosensory cortex of adults with chronic back pain (Schmidt-Wilcke et al., 2006). In youth with chronic pain, neuroimaging has revealed interesting differences such as diminished emotional processing of fear, suggesting a potential role of brain “wiring” as a risk factor both for pain and differences in neural processing (Simons et al., 2016). Finally, given the increased incidence of both ASD and NLD in this sample, one might speculate that pain could be related to longstanding sensory issues recognized in both of these populations. It is also worth noting that somatosensory functioning has been shown to be related to parietal lobe functioning. However, investigation into the underlying neurobiology of chronic pain in youth is in its infancy, and no research has prospectively or even concurrently investigated the association between NLD or other neurodevelopmental differences and chronic pain. Limitations By eliminating medications before assessment, this study may better identify associations between pain and neurocognitive functions without the potentially confounding factor of medication side effects. However, the current study is still limited by the lack of a control group, such as a group without pain, or even a previous assessment of these youth before onset of pain. The study is also limited by the cross-sectional nature of these data, and suggestions about symptoms predating pain are speculation that would benefit from further research. Another limitation is the lack of variance in pain intensity, as these youth tended to have very high pain scores overall, which may obscure differences on cognitive measures due to current levels of pain. Related to this, these youth represent a select group of teens with high disability who have already failed multiple other treatment attempts for pain; the characteristics of this group do not necessarily reflect broader groups of youth with chronic pain, and it is quite possible that the higher prevalence of some of the learning disabilities may partly result from the inability of these youth to benefit from less-intensive treatments. Finally, there is no agreed-upon diagnostic criteria for NLD. After reviewing relevant research, we used a set of empirically derived criteria for which we had sufficient data; however, use of other criteria may change the size of the sample identified with NLD. Future Research and Clinical Implications Given the need to not only treat chronic pain in youth but also foster better overall quality of life (i.e., return to school and better adaptive functioning within the academic, family, and social settings), further research into cognitive causes and consequences of pain is critical. Future studies should determine if the present results generalize to other samples of youth with chronic pain; whether these findings differ based on pain type, location, or diagnosis; and whether the findings hold with other measures of cognitive functioning, attention, executive functioning, and memory. In addition, it is important to further evaluate whether youth with chronic pain have higher prevalence rates of learning differences as compared with youth in medical settings without a history of chronic pain. Further investigation of the uniquely high rate of NLD and ASD found in our sample is particularly important. If replicated, there are definite clinical implications for the screening of all types of learning disabilities in pain clinics, and follow-up to determine if earlier identification helps to promote better outcomes is critical to improving overall quality of life in this patient population. Future directions for research include imaging studies to help elucidate structural differences in the brain that may predispose individuals to chronic pain. Treatment outcome studies that investigate changes in brain structure and neuropsychological functioning for youth with chronic pain following an IIPT program are also of the utmost importance. Also, given the often extensive school absences observed in many youth with chronic pain, evaluation of the impact of absence on certain types of assessment (e.g., academic achievement) may be a clinically relevant research focus. Related to this, these results suggest that evaluation of cognitive functioning may be particularly important for youth participating in IIPT due to a potentially higher prevalence of learning concerns, school absence before the program, and the explicit plan for youth to resume school after completing the program. Conclusions In conclusion, the youth in this study (who were beginning IIPT) have certain cognitive impairments that are likely a consequence of chronic pain, such as difficulties with attention and working memory, and these impairments are not strongly related to psychological factors such as anxiety and depression. These youth may also have a higher prevalence of subtle neurodevelopmental differences (e.g., inattention, NLD and associated difficulties with visuospatial processing, nondominant hand dexterity, executive functioning, or high functioning ASD) that, particularly when combined with relatively high verbal intelligence, may lead to increased academic and social stress. Given these findings, and the observation that more than half the current sample was experiencing some type of (often-undiagnosed) learning difficulty, psychologists working with youth with chronic pain may wish to include more specific screening related to ADHD, high functioning ASD, learning disabilities, and in particular NLD. Conflicts of interest: None declared. References American Pain Society . ( 2012 ). Assessment and management of children with chronic pain. Retrieved from http://americanpainsociety.org/uploads/get-involved/pediatric-chronic-pain-statement.pdf Retrieved 26 December 2017. 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Neuropsychological Functioning of Youth Receiving Intensive Interdisciplinary Pain Treatment

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© 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
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Abstract

Abstract Objective Chronic pain is associated with school difficulties; however, there is limited published evidence on the cognitive or neuropsychological functioning of youth with chronic pain. Method When beginning intensive interdisciplinary pain treatment, 94 youth (age = 10–18) with chronic pain completed neuropsychological assessment (e.g., intelligence, academic skills, learning and recall, and attention) and clinical questionnaires (e.g., pain and physical and psychological functioning). We compared neuropsychological scores with test norms and with clinical questionnaires. Results Youth with chronic pain had higher verbal comprehension and full scale IQ scores than expected, below-average nondominant hand dexterity, and difficulty with visual recall. Self-reported difficulties with executive functioning were associated with small-to-moderate difficulties with objectively measured attention. Performance on neuropsychological measures was generally not associated with pain, impairment, anxiety, or depression, though catastrophizing was negatively correlated with perceptual reasoning. An expected number of these youth had learning disorders (14%); however, more than expected had an autism spectrum disorder (9%) or attention deficit hyperactivity disorder (18%), and nearly a quarter demonstrated characteristics of nonverbal learning disability (22%). Conclusions Some of these cognitive findings may be a consequence of chronic pain, and others may reflect subtle neurodevelopmental differences that may predate or be comorbid with pain. Regardless of etiology, with more than half the current sample experiencing some type of learning challenge, often undiagnosed, pediatric psychologists evaluating youth with chronic pain may wish to screen for comorbid learning difficulties. adolescents, chronic pain, cognitive assessment, neuropsychology Introduction Chronic pain is persistent or recurrent, can be associated with a disease (e.g., arthritis or sickle cell disease) or can be idiopathic, and is always a biopsychosocial phenomenon (American Pain Society, 2012; Gatchel, Peng, Peters, Fuchs, & Turk, 2007). Chronic pain affects more than 30% of adults (Johannes, Le, Zhou, Johnston, & Dworkin, 2010) and up to 37% of adolescents, with about 5% of youth experiencing moderate-to-severe chronic pain (Huguet & Miró, 2008). Youth with chronic pain experience impairments in physical, social, emotional, and family functioning (Hunfeld et al., 2001; Palermo, 2000), which can persist into adulthood and affect social, educational, and vocational outcomes (Kashikar-Zuck et al., 2014). During middle and high school, youth with chronic pain report significant impairment in academic performance (Logan, Simons, & Kaczynski, 2009; Logan, Simons, Stein, & Chastain, 2008). However, there is limited published evidence on the cognitive or neuropsychological functioning of adolescents with chronic pain. The Distracting Effects of Pain Cognitive impairment may be a consequence of pain, which causes distraction by placing demands on attention and other neurological systems (Eccleston, 1994; Eccleston & Crombez, 1999; Grigsby, Rosenberg, & Busenbark, 1995). Consistent with this, adults with chronic pain experience difficulties with executive functioning and cognition, particularly in the areas of processing speed (Antepohl, Kiviloog, Andersson, & Gerdle, 2003), learning and memory (Dick & Rashiq, 2007), and attention (Dick, Eccleston, & Crombez, 2002; Dick & Rashiq, 2007; Eccleston, 1994). Further, adults with chronic pain perform poorly on tasks of working memory (Antepohl et al., 2003; Luerding, Weigand, Bogahn, & Schmidt-Wilcke, 2008), long term memory (Luerding et al., 2008), and recognition memory (Park, Glass, Minear, & Crofford, 2001), when compared with controls. Less is known about the cognitive effects of chronic pain in youth. A recent systematic review identified only nine studies directly investigating cognitive function in youth with chronic pain (Dick & Riddell, 2010). This review generally concluded that youth with chronic pain have at least average intelligence but perceive both cognitive dysfunction (Bell, Bell, & Cheney, 1994) and academic impairment (Logan, Simons, Stein, and Chastain, 2008). Attention-related difficulties may underlie this perceived impairment. For example, two studies using physiological measures of attention suggest that adolescents with chronic pain have difficulty shifting their attention away from painful stimuli (Buodo, Palomba, Sarlo, Naccarella, & Battistella, 2004; Zohsel et al., 2008). Indeed, attending to pain is hardwired into the brain, with areas such as the amygdala and frontal cortex directly implicated (Simons, Elman, & Borsook, 2014). Unfortunately, and despite the importance of this area of investigation (Dick & Riddell, 2010), research in this area has waned, and there has been no recent systematic investigation of the neuropsychological function of youth with chronic pain. Cognitive Problems as a Chronic Stressor, Predisposing One to Pain As stress is a known contributor to the development of chronic pain (Hoffart & Wallace, 2014; Li & Hu, 2016; McEwen & Kalia, 2010; Melzack, 1999; Sherry & Weisman, 1988), it is also possible that preexisting psychological, cognitive, or learning problems lead to stress, which predisposes a person to the later development of health symptoms. Indeed, in adults with chronic pain, depression and self-reported distress are related both to the report of cognitive complaints (McCracken & Iverson, 2001) and to objective performance on cognitive measures (Grace, Nielson, Hopkins, & Berg, 1999; Landrø, Stiles, & Sletvold, 1997). Depression also plays a role in school functioning for youth (Logan, Simons, & Kaczynski, 2009). However, psychological symptoms do not generally predate the development of pain in youth (Lynch, 1992). On the other hand, youth have been found to have various patterns of cognitive strengths and weaknesses. These cognitive patterns could potentially result in increased stress for adolescents who experience an academic “mis-fit” between the manner in which they are taught and their own learning style. One study, for example, found that adolescents with chronic musculoskeletal pain had average overall IQs on the Wechsler Intelligence Scale for Children—Revised (WISC-R) but frequently demonstrated a significant difference between performance and verbal IQ scores (Sherry, McGuire, Mellins, Salmonson, Wallace, & Nepom, 1991). In this study, 42% of the sample had a significant split between verbal and performance scores, with two-thirds demonstrating higher performance IQ. This pattern would not be expected to be caused by pain and could present a learning style contributing to specific and relatively difficult-to-detect academic challenges. In a study comparing the cognitive functioning of adolescents with migraine headaches without aura (MoA) and tension-type headaches and controls using the WISC-R, the MoA group was found to score the lowest on total and verbal IQ scores, though no differences in performance IQ were detected (Parisi et al., 2010). Finally, Sherry and colleagues (1991) also reported that seven of the 37 youth in their study with normal IQ reported low school achievement scores, potentially suggestive of a learning disability. However, not all studies have identified differences, and in a third example, adolescents with chronic pain were found to demonstrate higher verbal and nonverbal reasoning skills, higher word reading and math reasoning, and no differences in reading comprehension, arithmetic computation, spelling, and written expression when compared with test norms (Ho et al., 2009). Another study found no significant differences in sequential or simultaneous information processing when adolescents with chronic migraines were compared with sibling controls (Haverkamp et al., 2002). In addition, instead of cognitive challenges, adolescents with chronic pain tend to have average (Sherry et al., 1991) or above-average cognitive functioning (Ho, Bennett, Cox, & Poole, 2009; Parisi et al., 2010). Thus, it remains unclear the extent to which youth with pain may experience underlying cognitive and academic difficulties that may be unrelated to pain, and yet create a situation that may predispose them to developing pain. The Present Study In short, the current understanding of neurocognitive performance in youth with chronic pain is limited, and research examining the neurocognitive profile of youth with chronic pain may improve our understanding of both causes and consequences of chronic pain in young people. The overall aim of this study was to describe the neurocognitive profile of a medium-sized sample of youth with chronic pain who were beginning intensive interdisciplinary pain treatment (IIPT). In this description, we include findings that may (a) be related to the distracting effects of pain (e.g., continuous performance) or (b) suggest preexisting cognitive findings that may cause stress and thus contribute to pain (e.g., verbal and academic abilities). To achieve these aims, we compared scores from standardized cognitive instruments with the normative samples published with these instruments. Owing to literature demonstrating the importance of psychological factors to cognitive performance, we evaluated whether psychological factors like depression, anxiety, and catastrophizing are associated with neuropsychological functioning. Finally, we compared preexisting diagnoses and those made during assessment with base rates for attention deficit hyperactivity disorder (ADHD), autism, traditional learning disabilities such as dyslexia and dyscalculia, and nonverbal learning disability (NLD). Method Participants Potential participants included 99 youth beginning an IIPT program at a regional children’s hospital between March 2013 and December 2015. Of 99 consecutively enrolled participants, 94 completed neuropsychological assessment. Reasons for not completing this assessment included recent outside assessment through school or private psychologist (n = 3), significant developmental delay with existing services (n = 1), and English not being the patient’s primary language (n = 1). The five excluded patients did not differ on age, race, pain diagnosis, or pain intensity (ps > .05); however, they tended to have a shorter pain history (median = 1.1 vs. 2.5 years; Mann–Whitney U = 96.5, p < .05). Participants consisted of 80 female youth and 14 male youth between 10 and 18 years of age at the time of testing (Table I). Participants in this program present with both localized (e.g., complex regional pain syndrome) and widespread (e.g., juvenile fibromyalgia and amplified pain syndrome) chronic pain conditions. Comorbid conditions (e.g., arthritis and diabetes) were required to be well-controlled before program admission. Before entering the program, patients were removed from any pain medications (typically months before beginning the program). To be included in IIPT, patients had previously attempted traditional outpatient treatment of chronic pain. Table I. Demographics and Questionnaire Data (N = 94) Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Table I. Demographics and Questionnaire Data (N = 94) Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Descriptor Frequency Percent Gender  Female 80 85.1  Male 14 14.9 Ethnicity  Non-Hispanic 91 96.8  Hispanic 2 2.1 Race  White 81 86.2  Black 9 9.6  Biracial 3 3.2 Pain type  Widespread 79 84.0  Complex regional pain syndrome or localized 15 16.0 M SD Min Max Age (years) 15.41 1.96 10 18 Average pain intensity (0–100) 58.22 16.09 23 99 Pain duration (years) 3.91 3.91 0.3 15.6 Impairment (FDI, 0–60) 26.59 9.56 3 48 Depression (0–32) 13.60 9.52 0 32 Anxiety (0–32) 14.90 7.30 0 32 Catastrophizing (1–5) 3.17 1.10 1 5 Peer relationships (0–32) 20.88 7.46 0 32 School functioning (0–100) 42.42 19.74 0 90 Procedures This investigation was approved by the hospital institutional review board as a component of a project designed to describe demographic characteristics and treatment outcomes of participants in a specific IIPT program. Assent was obtained from minor patients and permission from their parents, and consent was obtained from adult patients (age 18). On approximately their first day of IIPT, participants completed an abbreviated neuropsychological assessment, caregiver and self-report measures of executive functioning, and self-report of pain, functioning, and psychological symptoms. The first day of the program was selected because this day includes evaluation from all disciplines and avoids intense exercise that might bias observed results. Occasionally, testing was completed before therapies on the morning of the second or third day of the program. Neuropsychological testing was completed by a licensed psychologist or graduate-level psychology trainee under the in-person supervision of a licensed psychologist. A board certified neuropsychologist was consulted in developing the brief battery. Measures Most measures were administered to all patients; however, we include two measures that were only given to a subset of participants, as these were systematically given over a period, rather than selected based on patient characteristics (the Wechsler Intelligence Scale for Children, Fourth Edition [WISC-IV] Processing Speed Index [PSI] and the Conners’ Continuous Performance Test, Second Edition [CPT-II]). Cognitive ability Cognitive ability was measured using the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II; Wechsler, 2011) for all participants. The WASI-II provide a short and reliable measure of intelligence, and scores are based on a norm group of 2,300 individuals matched to U.S. Census data for gender, race/ethnicity, education, and region of the country within each age-group. Cognitive ability is calculated using all four subtests. These four subtests are further divided into two composite areas, verbal comprehension (VCI) and perceptual reasoning (PRI), based on characteristics of the subtests and what they measure. Internal consistency for the overall scale and subtests used ranged from 0.87 to 0.96. The WISC-IV (Wechsler, 2003) PSI was later added to the battery to more objectively evaluate processing speed (n = 52). The WISC-IV norm group consists of 2,200 children and adolescents age 6:0 to 16:11, with race/ethnicity matching U.S. Census data, equal male and female participants, balanced recruitment across the United States, and stratified for parent education level. Both the PSI standard score and the two subtest scaled scores were used for data analysis; internal reliability is 0.88 for the PSI. Academic achievement Academic achievement was measured using standard scores from the math computation and word reading subtests from the Wide Range Achievement Test, Fourth Edition (WRAT-4; Wilkinson & Robertson, 2006). The WRAT-4 reading subtest provides an untimed measure of letter and word decoding, and math computation measures an individual’s ability to compute basic to more advanced math problems in 15 min. The normative sample includes 3,021 individuals from across the United States carefully matched (and weighted as needed) to align to U.S. Census data. Internal consistency is 0.92 for word reading and 0.89 for math computation. Dexterity The Grooved Pegboard Test (GPT; Lafayette Instruments, 1989) was used to assess motor dexterity bilaterally. This test requires the participant to rotate and place pegs into 25 holes with randomly positioned slots, requiring dexterity and visual–motor coordination. Raw scores (time to completion) were converted to T-scores using normative data provided in the manual (total norm group of 744 between age 9 and 19, gleaned from existing studies). Higher T-scores indicate slower performance. Motor preference was evaluated by self-report, and lateral preference was evaluated on writing tasks. Verbal learning and recall The California Verbal Learning Test, Children’s Version (CVLT-C; Delis, Kramer, Kaplan, & Ober, 1998) or California Verbal Learning Test, Second Edition (CVLT-II; Delis, Kramer, Kaplan, & Ober, 2000) was administered to assess verbal learning and recall. The CVLT-C was administered for youth from the age of 10 years through 16 years, whereas the CVLT-II was administered for participants 17 years and older. Both of these tests provide subjects five trials to learn a list of words, then a single trial of a different list, followed a short-delay free and cued recall of the first list. Approximately 20 min later, a long-delay free and cued recall trial are administered, followed by a recognition trial in which the participant identifies which words were on the initial list. The CVLT-II normative sample included 1,087 adults, carefully matched to U.S. Census data for gender, age, race, ethnicity, education, and region of the country; the CVLT-C normative sample includes 920 children with an IQ range that closely approximated that of the U.S. population of children. Internal consistency is 0.94 for the CVLT-II and 0.88 for the CVLT-C, and test–retest reliabilities were as expected, given the nature of these tasks. Z scores were calculated for each measure and analyzed for both free and cued recall on both short- and long-delay trials. In addition, recognition trials were examined. Visuospatial construction and memory The Rey Complex Figure Test (RCFT; Meyers & Meyers, 1996) was administered to assess visual construction and visual memory. This test prompts the copy and then recall of a complex figure and has a long history of use to assess visuospatial construction ability, with validity established through observed differences in across many samples of patients with known brain injuries. The normative samples include 601 adults from various urban, suburban, and university settings in the Western and Midwestern United States and Canada, and 505 children and adolescents enrolled in various school in the Midwestern United States. Scoring has been further delineated in the current edition of the test, and interrater reliability ranges from 0.93 to 0.99, with test–retest correlations ranging from 0.76 to 0.89 across 6 months. Immediate recall, delayed recall, and delayed recognition T-scores were included in the analysis. Attention/executive functioning The CPT-II (Conners, 2004), Version 5, was administered to objectively assess sustained attention, vigilance, and inhibition in a subset of participants (n = 55). The CPT-II requires participants to press a computer key each time a stimulus is presented, unless the stimulus is “X.” The test lasts 14 min and provides a variety of comparisons with the norm groups, which consist of 1,920 individuals without attention problems, 378 with ADHD, and 223 with other neurological impairments. The omissions, commission errors, reaction time, variability, detectability, and perseveration T-scores were used in analyses. Self- and parent-report versions of the Behavior Rating Inventory of Executive Functioning (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) were used to assess perceptions of executive dysfunction in adolescents with chronic pain. The self-report BRIEF consists of 80 items in which participants rated various behaviors related to executive functioning using a 3-point scale (never, sometimes, and often). The parent-report BRIEF consists of 86 items and uses the same rating scale, and T-scores are calculated based on a norm group consisting of 1,419 parent ratings. Internal consistency ratings for clinical scales and composite scores range from .72 to .96. Pain and impairment The 100-mm Visual Analogue Scale for pain was completed by the participants. The participants were asked to rate their average pain intensity using a visual scale that consists of a horizontal line with two descriptors (i.e., “no pain” and “worst pain imaginable”) on each end that serve as anchors for the scale. The line measures 100 mm in length, and the distance in millimeters from the far left end of the scale to the participant’s response is the participant’s score on this measure. Participants also completed the Functional Disability Index (FDI) to assess the impact of chronic pain on every day functioning. Respondents provide ratings on 15 items using a 5-point Likert rating scale with scores ranging from “no trouble” to “impossible.” Internal consistency for the FDI was good (α = .86). Coping and psychological functioning A number of rating scales were used to assess patient coping and psychological functioning. These measures included the Pediatric Anxiety, Depression, and Peer Relationships subscales of the Patient-Reported Outcomes Measurement Information System (Irwin et al., 2010), the catastrophizing subscale of the Pain-Related Cognitions Questionnaire for Children (Hermann, Hohmeister, Zohsel, Ebinger, & Flor, 2007), and the school functioning score from the Pediatric Quality of Life Inventory (PedsQL 4.0; Varni, Seid, & Kurtin, 2001). All measures were completed by participants on their first day, before participation in IIPT. Internal consistency for these measures ranged from acceptable for the PedsQL school functioning score (α = .73) to excellent for the other measures (anxiety: α = .92; depression: α = .96; peer relationships: α = .91; catastrophizing: α = .90). Analytic Strategy The sample was evaluated for outliers before performing statistical analyses using the outlier labeling rule, and outliers were replaced with less extreme values with a g value of 2.2 (Hoaglin & Iglewicz, 1987). This resulted in the correction of 27 values (0.6% of total observations). Independent samples t-tests (with or without assuming equal variances, as appropriate) were completed to identify any significant differences between male and female participants on neuropsychological measures. As differences were not statistically significant, data were not weighted to correct for unequal gender distribution in the sample. First, one-sample z test statistics were used to compare participant scores with test norm groups for standardized neuropsychological assessments and questionnaires (Ho et al., 2009). Test norms are considered comparable with population means; thus, these comparisons may reveal a pattern of “typical” strengths and weaknesses across teens with chronic pain. As a number of z tests were completed for this analysis, only z test results significant at the p ≤ 0.01 level will be interpreted to minimize type I error, while still identifying potential meaningful associations, given the exploratory nature of this analysis. Second, neuropsychological data were correlated with pain-related and questionnaire data of interest. Measures of pain, impairment, depression, anxiety, catastrophizing, peer relationships, and school functioning were correlated with objective neuropsychological data, using Pearson product–moment correlations. Correlations significant at the p ≤ 0.01 level were interpreted to minimize type I error rate without overly increasing type II error. Third, we evaluated the rate of learning-related diagnoses (preexisting and those made during neuropsychological assessment) observed in our sample compared with published epidemiological rates. The targeted diagnoses included ADHD, autism spectrum disorders (ASD), specific learning disability such as dyslexia or dyscalculia (LD), and NLD. Criteria previously used by Petti, Voelker, Shore, and Hayman-Abello (2003) were used to identify those with NLD. To be categorized as NLD, participants must meet three criteria, including (a) verbal IQ at least 12 points higher than performance IQ, (b) verbal IQ greater than math achievement by at least 1 SD, and (c) verbal IQ of at least 85. Results Cognitive and Achievement Scores Youth with chronic pain scored significantly higher on the full scale IQ (z = 5.63, p < .001) when compared with test norms. They also scored higher on the WASI-II VCI (z = 7.30, p < .001) and both the vocabulary (z = 8.04, p < .001) and similarities (z = 5.63, p < .001) subtests when compared with test norms. They performed similar to test norms on the WASI-II PRI (z = 2.30, p = .021); for subtests within the PRI, youth with chronic pain scored within the normative range on the block design subtest (z = −0.87, p = .382) and better than test norms on the matrix reasoning subtest (z = 5.17, p < .001). Teens who completed the WISC-IV PSI (n = 52) had processing speed comparable with test norms (z = 0.71, p = .477). Teens with chronic pain scored similar to test norms on the WRAT-4 math calculation (z = 0.61, p = .541) and word reading (z = 1.77, p=.077) subtests. See Table II for a full list of z tests along with observed means and effect sizes. Table II. Z-Tests Comparing Neuropsychological Performance of Adolescents With Chronic Pain With Test Normative Samples Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 a Score types. b ISI: interstimulus interval. *** significant at 0.001 level; **significant at 0.005 level; *significant at 0.01 level. Abbreviations: SS: standard score (M = 100, SD = 15); S: scaled score (M = 10, SD = 3); T: T-score (M = 50, SD = 10); Z: z-score (M = 0, SD = 1). Measures: WASI-II: Wechsler Abbreviated Scale of Intelligence—Second Edition; WISC-IV: Wechsler Intelligence Scale for Children—Fourth Edition; GPT: Grooved Pegboard Test; CVLT-C: California Verbal Learning Test—Children’s Version; CVLT-II: California Verbal Learning Test—Second Edition; RCFT: Rey Complex Figure Test; WRAT-4: Wide Range Achievement Test—Fourth Edition; CPT-II: Conners’ Continuous Performance Test II, Version 5; BRIEF: Behavior Rating Inventory of Executive Function (parent-report and self-report versions). Table II. Z-Tests Comparing Neuropsychological Performance of Adolescents With Chronic Pain With Test Normative Samples Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 Measure (domain) Scorea N M SD Z p Cohen’s d WASI-II (intelligence)  Full-scale IQ (FSIQ) SS 94 108.71 12.85 5.630*** <.001 0.581  Verbal Comprehension Index (VCI) SS 94 111.29 12.82 7.297*** <.001 0.753  Vocabulary subscale T 94 58.35 9.28 8.036*** <.001 0.835  Similarities subscale T 94 55.60 9.60 5.429*** <.001 0.560  Perceptual Reasoning Index (PRI) SS 94 103.56 13.47 2.301 .021 0.237  Block Design subscale T 94 49.10 10.46 −0.873 .382 −0.090  Matrix Reasoning subscale T 94 55.33 8.38 5.168*** <.001 0.533 WISC-IV (processing speed)  PSI SS 52 101.48 13.73 0.712 .477 0.099  Coding subscale S 52 9.31 2.80 −1.659 .097 −0.230  Symbol Search subscale S 52 11.08 2.77 2.596* .009 0.360 GPT (dexterity)  Dominant hand T 92 51.63 12.10 1.563 .118 0.163  Nondominant hand T 92 53.80 15.11 3.645*** <.001 0.380 CVLT-C/CVLT-II (verbal learning and recall)  Total learning T 93 50.47 10.05 0.453 .650 0.047  Short-delay, free recall Z 93 −0.10 1.06 −0.993 .321 −0.103  Short-delay, cued recall Z 71 0.20 0.99 1.685 .092 0.200  Long-delay, free recall Z 92 0.16 0.94 1.515 .130 0.158  Long-delay, cued recall Z 92 .14 1.01 1.352 .176 0.141  Recognition memory Z 92 −0.02 0.72 −0.192 0.848 −0.020 RCFT (visual construction and recall)  Immediate recall T 89 45.98 11.58 −3.792*** <.001 −0.402  Delayed recall T 87 44.84 12.20 −4.813*** <.001 −0.516  Recognition memory T 87 49.07 11.35 −0.867 .385 −0.093 WRAT-4 (academic achievement)  Math computation SS 93 100.95 15.07 0.611 .541 0.063  Word reading SS 93 102.75 12.15 1.768 .077 0.183 CPT-II (attention, vigilance, inhibition)  Omissions T 55 52.80 12.89 2.069 .039 0.279  Commissions T 55 54.38 9.61 3.248*** .001 0.438  Reaction time T 55 55.97 10.82 4.430*** <.001 0.597  Reaction time standard error T 55 51.21 11.76 0.897 .370 0.121  Variability of standard error T 55 50.37 11.70 0.274 .784 0.037  Detectability T 55 53.83 7.25 2.840** .004 0.383  Response style T 55 49.14 6.76 −0.638 .524 −0.086  Perseverations T 55 48.99 4.95 −0.749 .454 −0.101  Reaction time by block T 55 48.86 7.51 −0.838 .402 −0.113  Standard error by block T 55 51.49 9.03 1.105 .269 0.149  Reaction time by ISIb T 55 50.05 9.40 0.036 .972 0.005  Standard error by ISI T 55 49.89 10.82 −0.081 .936 −0.011 BRIEF (parent report of executive function)  Global Executive Composite T 88 57.84 12.64 7.355*** <.001 0.784  Behavioral Regulation Index T 86 57.77 12.07 7.206*** <.001 0.777  Inhibit T 89 50.97 10.39 0.915 .360 0.097  Shift T 89 61.29 13.37 10.650*** <.001 1.129  Emotional control T 89 58.64 12.29 8.151*** <.001 0.864  Metacognition index T 86 58.15 12.04 7.560*** <.001 0.815  Initiate T 89 58.31 11.76 7.840*** <.001 0.831  Monitor T 89 54.18 11.23 3.943*** <.001 0.418  Working memory T 89 60.42 13.61 9.830*** <.001 1.042  Plan/organize T 89 55.81 12.14 5.481*** <.001 0.581  Organization of materials T 89 53.54 9.73 3.340*** <.001 0.354 BRIEF-SR (self-report of executive function)  Global Executive Composite T 85 55.21 11.89 4.803*** <.001 0.521  Behavioral Regulation Index T 84 54.68 11.92 4.289*** <.001 0.468  Inhibit T 86 49.76 10.12 −0.226 .821 −0.024  Shift T 86 57.91 12.74 7.335*** <.001 0.791  Emotional control T 86 56.80 13.04 6.306*** <.001 0.680  Monitor T 86 51.73 11.79 1.604 .109 0.173  Metacognition Index T 84 54.74 12.58 4.344*** <.001 0.474  Working memory T 86 57.36 12.69 6.825*** <.001 0.736  Plan/organize T 86 53.02 11.88 2.801** 0.005 0.302  Organization of materials T 86 50.64 11.67 0.594 .553 0.064  Task completion T 86 54.84 11.82 4.488*** <.001 0.484 a Score types. b ISI: interstimulus interval. *** significant at 0.001 level; **significant at 0.005 level; *significant at 0.01 level. Abbreviations: SS: standard score (M = 100, SD = 15); S: scaled score (M = 10, SD = 3); T: T-score (M = 50, SD = 10); Z: z-score (M = 0, SD = 1). Measures: WASI-II: Wechsler Abbreviated Scale of Intelligence—Second Edition; WISC-IV: Wechsler Intelligence Scale for Children—Fourth Edition; GPT: Grooved Pegboard Test; CVLT-C: California Verbal Learning Test—Children’s Version; CVLT-II: California Verbal Learning Test—Second Edition; RCFT: Rey Complex Figure Test; WRAT-4: Wide Range Achievement Test—Fourth Edition; CPT-II: Conners’ Continuous Performance Test II, Version 5; BRIEF: Behavior Rating Inventory of Executive Function (parent-report and self-report versions). Dexterity Youth with chronic pain scored below average on the grooved peg task for their nondominant hand (z = 3.65, p < .001) and average for their dominant hand (z = 1.56, p = .118) compared with test norms. Of note, youth with hand/arm (n = 28) pain did not perform differently for the dominant, t(90) = .70, p = .484, or the nondominant, t(90) = .11, p = .912, hand when compared with those without hand/arm pain. Verbal and Nonverbal Learning and Recall Teens with chronic pain scored within normal limits on all verbal learning and recall tasks. Specifically, scores were comparable with test norms for free (z = −0.99, p = .321) and cued (z = 2.596, p = .009) short-delay recall tasks, for free (z = 1.52, p = .130) and cued (z = 1.35, p = .176) long-delay recall tasks, and recognition discriminability (z = −0.192, p=.848) of the CVLT. Conversely, youth with chronic pain performed significantly worse on the immediate (z = −3.79, p < .001) and delayed recall (z = −4.81, p < .001) tasks of the RCFT compared with test norms. They performed as expected on the recognition trial of this measure (z = −.8675, p = .386). Attention/Executive Functioning Youth with chronic pain demonstrated a greater number of commission errors (z = 3.25, p = .001), elevated detectability scores (z = 2.84, p = .004), and slower reaction times (z = 4.43, p < .001) on the CPT-II compared with test norms. They demonstrated similar levels of omission rates (z = 2.07, p = .039), variability (z = 0.274, p = .784), and perseveration (z = −0.75, p = .454). Parent report on the BRIEF was significantly higher than tests norms for the Global Executive Composite (GEC, z = 7.36. p < .001) and across all scales, with the exception of inhibition. Self-report on the BRIEF also produced significant elevations on the GEC (z = 4.80, p < .001) and on all scales except inhibition, monitoring, and organization when compared with test norms (Table II). The greatest elevations for both parent- and self-report were on the subscales Shift (average T-score for parent report = 61.3, self-report = 57.9) and Working Memory (average T-score for parent-report = 60.4, self-report = 57.4). Relationship Between Neuropsychological Performance and Psychological Variables Pain intensity was not significantly correlated with performance on any objective neuropsychological measure (all ps > .01). Similarly, youth report of functional disability, depression, peer relationships, and school-based quality of life was not correlated with objective neuropsychological data for youth with chronic pain (all ps > .01). Anxiety was negatively correlated with WASI-II Matrix Reasoning, r(94) = −.273, p < .01, only. Catastrophizing was negatively correlated with WASI-II Full Scale IQ, r(94) = −.319, p < .01, with WASI-II PRI, r(92) = −.298, p < .01, and with both perceptual reasoning subtests including block design, r(92) = −.282. p < .01, and matrix reasoning, r(92) = −.271, p < .01. Catastrophizing was not significantly correlated with WASI-II VCI or Verbal subscales, nor with any other neuropsychological measure. Diagnoses An expected number of participants had learning disorders (n = 13, 14%) based on published population base rates (between 5% and 15%; American Psychiatric Association, 2013). However, more participants than expected had ASD (n = 8, 9%, compared with a population base rate of 1%–2%; American Psychiatric Association, 2013; Blumberg et al., 2013) or ADHD (n = 17, 18%, compared with a population base rate of 5%–8%; American Psychiatric Association, 2013; Froehlich et al., 2007). Further, a very high percentage of our sample demonstrated a pattern consistent with NLD (n = 21, 22%, compared with an estimated population base rate of between 0.1% and 1%; Molenaar-Klumper, 2002). Although there were some patients with more than one diagnosis, 49 of the 94 (52%) had at least one of these diagnoses. All diagnoses were made or confirmed by a licensed psychologist with experience treating chronic pain. Discussion The experience of chronic pain is thought to directly result in certain cognitive impacts, often related to processing speed (Antepohl et al., 2003), learning and memory (Dick & Rashiq, 2007), and attention (Dick et al., 2002, Dick and Rashiq, 2007; Eccleston, 1994); this may be particularly important for the youth in this sample with disability sufficient to warrant IIPT. Consistent with this, the current sample had mild impulsivity, slower reaction times, poor visual retrieval, and self-reported difficulty with working memory. In this way, current results extend findings from studies using physiological measures of attention (Buodo et al., 2004; Zohsel et al., 2008) and suggest that difficulty shifting attention away from painful stimuli may have performance consequences relevant to academic functioning. On the other hand, the current sample differs from existing research in that inattention did not result in omission errors or difficulty with verbal encoding and retrieval, and the sample had average processing speed. Certain other differences in this sample from normative groups would not be expected to be a consequence of experiencing pain, such as the relative strength for verbal processing as compared with spatial cognition, lateralizing motor signs (i.e., significantly higher dominant hand speed of completion versus nondominant hand), and difficulty with unexpected change (self- and parent report of “shift” on the BRIEF). It is possible that these characteristics may predate the onset of chronic pain. Indeed, it is compelling that fully 50% of the sample had at least some type of learning issue when considering ADHD, ASD, traditional learning disabilities, and NLD. Most of the youth in this sample had been functioning with minimal or no academic accommodations for these symptoms and (anecdotally) often reported that they had been working harder than peers for the same level of achievement at school. As has been noted, various stressors can contribute to the development and maintenance of pain (Melzack, 1999; Sherry & Weisman, 1988). Thus, it is possible that teens with subtle neurodevelopmental differences (e.g., inattention, difficulties with perceptual reasoning and visual memory, nondominant hand dexterity, executive functioning, or high functioning ASD), when combined with relatively high verbal intelligence, may initially be successful in school but struggle as academic and social demands increase. Their strong vocabulary and verbal reasoning skills may mask these concerns, preventing the implementation of appropriate interventions and accommodations, and leading to greater academic stress. In line with this hypothesis, although typical learning disabilities were comparable with epidemiological estimates, we found rates of ASD, ADHD, and nonverbal learning disorder between 2 and 20 times higher in the present sample than the national average. NLD may be an excellent example of this sort of mild neurodevelopmental difference, which acts as a chronic stressor, making academic work and social interaction more difficult (Cornoldi et al., 1999, Chow & Skuy, 1999), and over time puts teens at greater risk for chronic pain conditions. Shared Pathways for Pain and Cognitive Problems Another possible explanation for the association between pain and cognitive problems is a shared biological etiology for chronic pain and learning issues whereby some people have the predisposition toward both, and indeed some of the current results suggest brain-based differences may exist. For example, the current sample of youth with chronic pain had deficits on measures of visual retrieval (immediate and delayed recall of the RCFT) and motor dexterity (nondominant performance significantly lower than dominant hand performance), suggesting deficits lateralized to the non-language-dominant (typically right) hemisphere. In addition, our data show certain deficits in visual attention (on self-report and visual continuous performance testing), which also have associations with the non-language-dominant hemisphere of the brain (right frontal and parietal; Posner & Peterson, 1990). To expand on this point, visual-spatial cognition is thought to be composed of functions mediated by the predominantly right-hemisphere network that includes parietal lobes, lateral prefrontal cortex, medial temporal lobes, inferior temporal cortex, occipital cortex, basal ganglia, and white matter tracts, and these areas are implicated in how we interact with our environment more broadly involving perception, selection, organization, and visual-spatial/perceptual processing (Possin, 2010). Also, the middle cingulate cortex is highly implicated in attention and has reciprocal connections with the lateral prefrontal cortex, parietal cortex, premotor, and supplementary motor areas (Devinsky, Morrell, & Vogt, 1995; Peyron et al., 1999). Further, research documents an association between chronic pain and changes in the middle cingulate and the posterior parietal cortex (Buckalew, Haut, Morrow, & Weiner, 2008), and gray matter changes are observed specifically in the somatosensory cortex of adults with chronic back pain (Schmidt-Wilcke et al., 2006). In youth with chronic pain, neuroimaging has revealed interesting differences such as diminished emotional processing of fear, suggesting a potential role of brain “wiring” as a risk factor both for pain and differences in neural processing (Simons et al., 2016). Finally, given the increased incidence of both ASD and NLD in this sample, one might speculate that pain could be related to longstanding sensory issues recognized in both of these populations. It is also worth noting that somatosensory functioning has been shown to be related to parietal lobe functioning. However, investigation into the underlying neurobiology of chronic pain in youth is in its infancy, and no research has prospectively or even concurrently investigated the association between NLD or other neurodevelopmental differences and chronic pain. Limitations By eliminating medications before assessment, this study may better identify associations between pain and neurocognitive functions without the potentially confounding factor of medication side effects. However, the current study is still limited by the lack of a control group, such as a group without pain, or even a previous assessment of these youth before onset of pain. The study is also limited by the cross-sectional nature of these data, and suggestions about symptoms predating pain are speculation that would benefit from further research. Another limitation is the lack of variance in pain intensity, as these youth tended to have very high pain scores overall, which may obscure differences on cognitive measures due to current levels of pain. Related to this, these youth represent a select group of teens with high disability who have already failed multiple other treatment attempts for pain; the characteristics of this group do not necessarily reflect broader groups of youth with chronic pain, and it is quite possible that the higher prevalence of some of the learning disabilities may partly result from the inability of these youth to benefit from less-intensive treatments. Finally, there is no agreed-upon diagnostic criteria for NLD. After reviewing relevant research, we used a set of empirically derived criteria for which we had sufficient data; however, use of other criteria may change the size of the sample identified with NLD. Future Research and Clinical Implications Given the need to not only treat chronic pain in youth but also foster better overall quality of life (i.e., return to school and better adaptive functioning within the academic, family, and social settings), further research into cognitive causes and consequences of pain is critical. Future studies should determine if the present results generalize to other samples of youth with chronic pain; whether these findings differ based on pain type, location, or diagnosis; and whether the findings hold with other measures of cognitive functioning, attention, executive functioning, and memory. In addition, it is important to further evaluate whether youth with chronic pain have higher prevalence rates of learning differences as compared with youth in medical settings without a history of chronic pain. Further investigation of the uniquely high rate of NLD and ASD found in our sample is particularly important. If replicated, there are definite clinical implications for the screening of all types of learning disabilities in pain clinics, and follow-up to determine if earlier identification helps to promote better outcomes is critical to improving overall quality of life in this patient population. Future directions for research include imaging studies to help elucidate structural differences in the brain that may predispose individuals to chronic pain. Treatment outcome studies that investigate changes in brain structure and neuropsychological functioning for youth with chronic pain following an IIPT program are also of the utmost importance. Also, given the often extensive school absences observed in many youth with chronic pain, evaluation of the impact of absence on certain types of assessment (e.g., academic achievement) may be a clinically relevant research focus. Related to this, these results suggest that evaluation of cognitive functioning may be particularly important for youth participating in IIPT due to a potentially higher prevalence of learning concerns, school absence before the program, and the explicit plan for youth to resume school after completing the program. Conclusions In conclusion, the youth in this study (who were beginning IIPT) have certain cognitive impairments that are likely a consequence of chronic pain, such as difficulties with attention and working memory, and these impairments are not strongly related to psychological factors such as anxiety and depression. These youth may also have a higher prevalence of subtle neurodevelopmental differences (e.g., inattention, NLD and associated difficulties with visuospatial processing, nondominant hand dexterity, executive functioning, or high functioning ASD) that, particularly when combined with relatively high verbal intelligence, may lead to increased academic and social stress. Given these findings, and the observation that more than half the current sample was experiencing some type of (often-undiagnosed) learning difficulty, psychologists working with youth with chronic pain may wish to include more specific screening related to ADHD, high functioning ASD, learning disabilities, and in particular NLD. Conflicts of interest: None declared. References American Pain Society . ( 2012 ). Assessment and management of children with chronic pain. Retrieved from http://americanpainsociety.org/uploads/get-involved/pediatric-chronic-pain-statement.pdf Retrieved 26 December 2017. 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Journal of Pediatric PsychologyOxford University Press

Published: Sep 1, 2018

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