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Pain severity and pain catastrophizing predict functional disability in youth with inflammatory bowel disease Andrea A. Wojtowicz a , Rachel Neff Greenley a , , Amitha Prasad Gumidyala a , Andrew Rosen a , Sara E. Williams b a Department of Psychology, Rosalind Franklin University of Medicine & Science, 3333 Green Bay Road, North Chicago, IL 60064, United States b Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, United States Received 3 December 2013; received in revised form 5 February 2014; accepted 14 February 2014 KEYWORDS Functional disability; Inflammatory bowel disease; Pediatrics; Pain Abstract Background: Abdominal pain is commonly reported by youth with IBD. In a significant subset of youth, pain severity and pain catastrophizing (i.e., unhelpful thoughts related to the pain) may contribute to more negative outcomes and greater impairment in functioning. This study aimed to examine relationships of pain severity and pain catastrophizing with functional disability among a sample of youth with inflammatory bowel disease (IBD). Methods: Seventy-five youth aged 11 to 18 years completed ratings of abdominal pain severity, pain catastrophizing, and functional disability using validated measures. Disease activity was rated by treating physicians. Results: Over half of participants reported abdominal pain in the past two weeks, and pain was present among those with and without clinical disease activity. Nearly one-third of youth reported mild to moderate functional disability. After controlling for gender, pain severity accounted for 15% of the variance in patient functional disability. Moreover, pain catastrophizing contributed significant variance to the prediction of functional disability (approximately 7%) beyond the role of pain severity. Data previously presented at the National Conference in Pediatric Psychology, New Orleans, LA, April 1113, 2013. Corresponding author at: Department of Psychology, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064, United States. Tel.: +1 847 578 8751; fax: +1 847 578 8765. E-mail addresses: [email protected] (A.A. Wojtowicz), [email protected] (R.N. Greenley), [email protected] (A.P. Gumidyala), [email protected] (A. Rosen), [email protected] (S.E. Williams). http://dx.doi.org/10.1016/j.crohns.2014.02.011 1873-9946/© 2014 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. Available online at www.sciencedirect.com ScienceDirect Journal of Crohn's and Colitis (2014) xx, xxxxxx CROHNS-00971; No of Pages 7 Please cite this article as: Wojtowicz AA, et al, Pain severity and pain catastrophizing predict functional disability in youth with inflammatory bowel disease, J Crohns Colitis (2014), http://dx.doi.org/10.1016/j.crohns.2014.02.011

Pain severity and pain catastrophizing predict functional disability in youth with inflammatory bowel disease

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ScienceDirect

Journal of Crohn's and Colitis (2014) xx, xxx–xxx

CROHNS-00971; No of Pages 7

Pain severity and pain catastrophizing predictfunctional disability in youth withinflammatory bowel disease☆

Andrea A. Wojtowicz a, Rachel Neff Greenleya,⁎, Amitha Prasad Gumidyala a,Andrew Rosena, Sara E. Williamsb

a Department of Psychology, Rosalind Franklin University of Medicine & Science, 3333 Green Bay Road, North Chicago,IL 60064, United Statesb Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati,OH 45229, United States

Received 3 December 2013; received in revised form 5 February 2014; accepted 14 February 2014

☆ Data previously presented at the N⁎ Corresponding author at: Departme

Chicago, IL 60064, United States. Tel.:E-mail addresses: andrea.wojtowic

[email protected] (A.P. Gu

http://dx.doi.org/10.1016/j.crohns.201873-9946/© 2014 European Crohn's an

Please cite this article as: Wojtowicz Abowel disease, J Crohns Colitis (2014)

KEYWORDSFunctional disability;Inflammatory boweldisease;Pediatrics;Pain

Abstract

Background: Abdominal pain is commonly reported by youth with IBD. In a significant subset ofyouth, pain severity and pain catastrophizing (i.e., unhelpful thoughts related to the pain) maycontribute to more negative outcomes and greater impairment in functioning. This study aimedto examine relationships of pain severity and pain catastrophizing with functional disabilityamong a sample of youth with inflammatory bowel disease (IBD).

Methods: Seventy-five youth aged 11 to 18 years completed ratings of abdominal pain severity,pain catastrophizing, and functional disability using validated measures. Disease activity wasrated by treating physicians.Results: Over half of participants reported abdominal pain in the past two weeks, and pain waspresent among those with and without clinical disease activity. Nearly one-third of youth reportedmild to moderate functional disability. After controlling for gender, pain severity accounted for15% of the variance in patient functional disability. Moreover, pain catastrophizing contributedsignificant variance to the prediction of functional disability (approximately 7%) beyond the role ofpain severity.

ational Conference in Pediatric Psychology, New Orleans, LA, April 11–13, 2013.nt of Psychology, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North+1 847 578 8751; fax: +1 847 578 [email protected] (A.A. Wojtowicz), [email protected] (R.N. Greenley),midyala), [email protected] (A. Rosen), [email protected] (S.E. Williams).

14.02.011d Colitis Organisation. Published by Elsevier B.V. All rights reserved.

A, et al, Pain severity and pain catastrophizing predict functional disability in youth with inflammatory, http://dx.doi.org/10.1016/j.crohns.2014.02.011

2 A.A. Wojtowicz et al.

Please cite this article as: Wojtowicz Abowel disease, J Crohns Colitis (2014)

Conclusions: Greater attention to the role of pain catastrophizing in contributing to functionaldisability in youth with IBD may be important given that pain-related cognitions are modifiablevia intervention.© 2014 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

A, et al, Pain severity and pain, http://dx.doi.org/10.1016/j.

1. Introduction

Abdominal pain is common among youth with inflammatorybowel disease (IBD). It may result from gastrointestinal tractinflammation due to disease activity, IBD-related proceduresor surgical interventions, treatment side effects, or intestinalobstruction.1 Among youth with IBD participating in onerecent study, over half reported abdominal pain, and ofthose reporting pain, the majority had no evidence of clinicaldisease activity.2 Functional abdominal pain (FAP) refersto recurrent pain resulting from visceral hypersensitivity oroveractive nerves in the GI tract in the absence of anyidentifiable organic disease.3 In a study of 307 youth withCrohn's disease (CD), 13% of those endorsing abdominal painmet criteria for FAP, providing evidence that FAP is a comorbidcondition in a subset of youth with CD.4

Regardless of whether or not an underlying organicexplanation can be identified, abdominal pain adverselyimpacts physical functioning and health related qualityof life (HRQoL) in affected youth.5,2,6 Several aspects ofthe abdominal pain experience may influence functioningincluding pain severity, pain duration, and one's thoughtsrelated to the pain experience. For example, regarding theduration of abdominal pain, youth with IBD who reported thepresence of abdominal pain at two time points over a six-monthperiod had significantly lower HRQoL than those reporting noabdominal pain at either time point. Moreover, the youth withIBD reporting abdominal pain at both time points were morelikely to have clinical impairments in their HRQoL compared toeither youth reporting abdominal pain at just one time pointor youth without abdominal pain at either time point.2

In addition to the role of abdominal pain severity andduration, thoughts related to the abdominal pain experiencehave also been associated with functional disability. Paincatastrophizing refers to a tendency to magnify or exaggeratethe threat value or seriousness of pain sensations.7 In youth,catastrophizing can be thought of as extreme worry about thepain.8 Greater pain catastrophizing has been consistentlyassociated with greater physical and psychosocial disabilityamong patients with various pain conditions.9–14 However, therole of pain catastrophizing in predicting functional disabilityhas yet to be explored in a pediatric IBD population.

Studying the role of the abdominal pain experience,including pain severity and pain catastrophizing, is impor-tant because a significant subset of youth with chronicpain experience a downward spiral of increasing functionaldisability, such as lack of participation in age appropriateactivities (e.g., sports, social events), poor school atten-dance, and limited interaction with peers.15 For youth withIBD, examining relationships of both abdominal pain severityand catastrophizing with functional disability are importantfor several reasons. First, abdominal pain is an inherent part ofIBD, and as such, youth with IBD are expected to experience at

catcro

least intermittent abdominal pain throughout their lives.Moreover, because “curing” all episodes of abdominal pain isnot a realistic goal in the context of IBD, identification ofmodifiable factors that may reduce the negative impact ofabdominal pain on daily functioning is important. Cognitionsrelated to abdominal pain have the potential to be modifiedand consequently, documenting their associations withfunctional disability is of value in maximizing adjustment inthe context of pediatric IBD.16–18 Thus, the current studyexplored the role of both pain severity and pain catastrophizingin relation to functional disability within a pediatric IBDsample. Specifically, this study aimed to: (1) describe rates ofabdominal pain and functional disability among youth withIBD; and (2) to examine the role of both pain severity andpain catastrophizing in accounting for significant variance infunctional disability. It was hypothesized that abdominal painwould be prevalent in this sample. Additionally, we expectedthat both pain severity and pain catastrophizing would bepositively associated with functional disability in regressionmodels, given findings supporting such associations within thepediatric chronic pain literature.

2. Materials & method

2.1. Study design

This study utilized baseline data from an adherence-promotionrandomized clinical trial (RCT). Seventy-five participants wererecruited from two Midwestern children's hospitals. Patientsmeeting inclusion criteria were approached during scheduledoutpatient gastroenterology clinic appointments by a researchassistant. Interested families provided informed consent/assent and then completed a home assessment visit. Duringthis visit, at least one parent/guardian completed a measureof demographic information. Youth completed measures ofabdominal pain, pain catastrophizing, and functional disability.Medical records were reviewed for disease information.

Inclusion criteria were: (a) medically confirmed IBD diagno-sis; (b) prescribed daily oral IBD maintenance medication;(c) age 11 to 18; and (d) at least one parent or guardian willingto participate. Inclusion criteria (b) and (c) related to the aimsof the parent study which were to examine efficacy of anintervention to improve oral medication adherence amongadolescents. Exclusion criteria were: (a) patient cognitiveimpairment that would preclude questionnaire completion;and (b) no English fluency.

2.2. Measures

2.2.1. Demographic informationParents provided the following demographic informationat baseline: youth age, gender, race/ethnicity, and familyannual income.

astrophizing predict functional disability in youth with inflammatoryhns.2014.02.011

Table 1 Summary of intercorrelations on gender, clinicaldisease activity, Abdominal Pain Index (API), Pain CatastrophizingScale (PCS), and Functional Disability Inventory (FDI).

Variable 1 2 3 4 5

1. Gender – −0.11 −0.33 ⁎⁎

−0.24 ⁎

−0.34 ⁎⁎

2. Clinical diseaseactivity

−0.11 – 0.31 ⁎⁎ 0.26 ⁎ 0.40 ⁎⁎

3. API −0.33 ⁎⁎

0.31 ⁎⁎ – 0.31 ⁎⁎ 0.55 ⁎⁎

4. PCS-C −0.24 ⁎

0.26 ⁎ 0.31 ⁎⁎ – 0.44 ⁎⁎

5. FDI −0.34 ⁎⁎

0.40 ⁎⁎ 0.55 ⁎⁎ 0.44 ⁎⁎ –

Note. API = Abdominal Pain Index; PCS-C = Pain CatastrophizingScale for Children; FDI = Functional Disability Inventory.⁎ p b 0.05.⁎⁎ p b 0.01.

3Pain severity and pain catastrophizing predict functional disability in youth with IBD

2.2.2. Disease informationMedical record reviews were conducted to obtain informationabout type of IBD (i.e., Crohn's disease, ulcerative colitis, orindeterminate colitis), length of IBD diagnosis, level of clinicaldisease activity at time of study enrollment, and medicationsprescribed for IBD treatment. Clinical disease activity wasassessedwith the Physician Global Assessment (PGA) scale,19 asingle-item measure that was completed by the treatingpediatric gastroenterologist at the time of the medical visitcoinciding with study enrollment. The PGA is a validatedglobal assessment of clinical disease activity. Patients areassigned a rating of no clinical disease activity/clinicalremission (0), mild (1), moderate (2), or severe (3) clinicaldisease activity.

2.2.3. Pain catastrophizingThe Pain Catastrophizing Scale — Child Version (PCS-C)9 is a13-item measure of thoughts and feelings children mayexperience when in pain. Youth rate their agreement witheach statement using a 5-point Likert scale ranging from“not at all” (0) to “extremely” (4). The PCS-C yields a TotalScore that can range from 0 to 52. Higher scores indicategreater pain catastrophizing. The PCS-C is reliable andvalid in community and clinical samples (α = 0.90).9 In thecurrent sample, internal consistency of the Total Score wasexcellent (α = 0.95).

2.2.4. Functional disabilityThe Functional Disability Inventory (FDI)20 is a well-validated15-item self-report measure that assesses functional limita-tions of youth with a variety of pediatric conditions. Youthprovide ratings on each item using a 5-point Likert scaleranging from “no trouble” (0) to “impossible” (4). Total Scoresare computed by summing the ratings for each item. Higherscores indicate greater perceived functional disability. TheFDI has high internal consistency in previous studies (αs = 0.86to 0.91)21 and in the current sample (α = 0.93).

2.2.5. Abdominal painThe Abdominal Pain Index (API)22 is a well-validated, 5-itemmeasure of youth intensity, frequency, and duration ofabdominal pain during the past 2-weeks. Youth rate painintensity using a 10-point scale ranging from “no pain” to “themost pain possible.” Youth provide ratings on the frequency ofpain using a 6-point scale ranging from “not at all” to “everyday.” The duration of pain episodes is rated using a 9-pointscale (ranging from “a few minutes” to “all day”). Responsesare standardized and summed to create the API Index Score,which is expressed as a measure of pain severity in Z scoreunits. Internal consistency scores range from α = 0.78 toα = 0.93 in previous research.22,23 For this study, internalconsistency was α = 0.88.

2.3. Data analysis plan

Preliminary analyses examined distributional propertiesof study variables. The PCS-C Total Score was significantlyskewed, as were the API Index Score and FDI Total Score.A log linear transformation successfully normalized eachvariable's distribution. Transformed variables were used inanalyses; however, descriptive statistics are reported with

Please cite this article as: Wojtowicz AA, et al, Pain severity and pain catbowel disease, J Crohns Colitis (2014), http://dx.doi.org/10.1016/j.croh

non-transformed values for ease of interpretation. Descriptiveanalyses were conducted to evaluate Aim 1. Aim 2 examinedthe impact of pain catastrophizing (using the Total PCS-CScore as the dependent variable) on functional disabilityafter controlling for pain severity using hierarchical regressionanalyses. In the regression model, the relative contribution ofpain catastrophizing to functional disability was evaluatedafter controlling for pain severity. Additionally, because initialanalyses demonstrated a significant association betweengender and functional disability (r = 0.28, p = 0.02), genderwas included as a covariate. See Table 1 for intercorrelationsof study variables.

2.4. Ethical considerations

The Institutional Review Boards of participating institutionsapproved this study prior to any patient enrollment. All researchteam members completed ethical training in human subjectresearch prior to becoming involved in the study. Interestedfamilies provided informed consent/assent at the time ofenrollment. Parents provided written consent for their ownparticipation as well as the minor child's participation. Youthaged 18 provided written consent for their own participation.Youth of ages 11–17 provided written assent for their ownparticipation. Those under age 14 signed a simplified assentform, while those of ages 14–17 provided assent by signing anassent line on the consent form.

3. Results

3.1. Descriptive analyses

See Table 2 for demographic and disease-related informationabout the current sample. Of the 132 families approached, 75consented to participate (57%). Participants did not differfrom nonparticipants in age (t (114) = 0.44, p = 0.661) orsex (ɸ = 0.02, p = 0.794). Families were compensated forparticipation.

astrophizing predict functional disability in youth with inflammatoryns.2014.02.011

Table 2 Means and standard deviations of the Pain Catastrophizing Scale, Abdominal Pain Index, and Functional DisabilityInventory Scores.

Variable Mean (SD) Range Percentage

Age 14.5 (1.7) 11–18GenderFemale 45%Male 55%

Race/ethnicityCaucasian 88%African American 7%Hispanic 1%Other 4%

Median family income $120,000–$139, 00DiagnosisCrohn's disease (CD) 73%Ulcerative colitis (UC) 24%Indeterminate colitis (IC) 3%

Duration of disease 3.45 (3.27) 0.18–17.39Medications prescribed for IBDImmunomodulators 60%Corticosteroids 7.9%Aminosalicylates 45%Antibiotics 5.3%Methotrexate 5.3%

PCS-C Total Score 14.93 (12.19) 0–50Abdominal Pain Index (z-scores) 0.00 (0.88) −0.93–2.42Functional Disability Inventory Total Score 2.84 (4.98) 0–28.93

Note. PCS-C = Pain Catastrophizing Scale for Children.

4 A.A. Wojtowicz et al.

3.2. Frequency of pain, pain catastrophizing, andfunctional disability

The mean PCS-C Total Score was M = 14.93. Forty-nineparticipants (55%) reported abdominal pain during the past2 weeks, with a mean pain intensity of 4.12 (SD = 2.18).Abdominal pain was present in 61% of youth with no evidence

Figure 1 Presence of abdominal pain in patients wit

Please cite this article as: Wojtowicz AA, et al, Pain severity and pain catbowel disease, J Crohns Colitis (2014), http://dx.doi.org/10.1016/j.cro

of clinical disease activity and among 75% of youth withevidence of clinical disease activity (See Fig. 1). Because painwas present among youth with and without clinical diseaseactivity, all participants were included in subsequent analyses.

Fifty-five percent of the sample (n = 41) endorsed somefunctional disability. Based on previously established clinicalcutoffs,24 8% of the total sample reported mild to moderate

h and without evidence of clinical disease activity.

astrophizing predict functional disability in youth with inflammatoryhns.2014.02.011

5Pain severity and pain catastrophizing predict functional disability in youth with IBD

levels of functional disability (an FDI total score range from13 to 29). The remainder of the sample (92%) had FDI totalscores below 13. None of the youth without abdominal painscored above the clinical cutoff, whereas, 12% of youth withabdominal pain scored above the clinical cutoff.

3.3. Role of abdominal pain severity and paincatastrophizing in functional disability

Results of the regression analysis are presented in Table 3. In ahierarchical multiple regression analysis, abdominal painseverity accounted for 15% of the variance in FDI Total Scores,after controlling for gender. These findings were statisticallysignificant, of medium effect size magnitude, and consistentwith hypotheses. With regard to pain catastrophizing, PCS-CTotal Scores accounted for an additional 7% of the variance infunctional disability, beyond that accounted for by abdominalpain severity (R2Δ = 0.07, FΔ (3, 71) = 8.14, p b 0.01). Thesefindings were consistent with prediction.

4. Discussion

The current findings suggest that functional disability ispresent among youth with IBD, with 8% of the samplereporting mild or moderate functional disability. Moreover,

Table 3 Summary of hierarchical regression analyses forvariables predicting functional disability.

Predictor B SE B β t c

Step 1Gender −0.28 0.09 −0.34 −3.05 ⁎⁎

Step 2Gender −0.14 0.08 −0.17 −1.70Abdominal pain severity 0.93 0.19 0.49 4.79 ⁎⁎

Step 3Gender −0.11 0.08 −0.13 −1.34Abdominal pain severity 0.79 a 0.19 0.42 b 4.14 ⁎⁎

PCS-C Total Score 0.25 0.09 0.28 2.85 ⁎⁎

Note. B = Unstandardized partial regression coefficient. SEB = standard error of the unstandardized partial regressioncoefficient. β = standardized partial regression coefficient.PCS-C = Pain Catastrophizing Scale for Children. PCS-C Total ScoreModel: R2 = 0.11 for Step 1; R2 = 0.33 and ΔR2 = 0.21 for Step 2;R2 = 0.40 and ΔR2 = 0.07.a Both B and β represent the unique effect of a given predictor

variable on the dependent variable, partialling out the effect ofother predictor variables in the model at the given step. B isinterpreted in the original units of measurement (i.e, for every 1point increase in abdominal pain, functional disability increasesby 0.79 points, after partialling out the effects of gender andPSC-C scores).b β is expressed in standard deviation units (i.e., for every 1

standard deviation increase in abdominal pain, functionaldisability increases by 0.42 standard deviation units, afterpartialling out the effects of gender and PSC-C scores).c The t test examines whether B and β significantly differ from

zero. A significant t statistic indicates that there is support for agiven independent variable accounting for significant variance infunctional disability scores, after partialling out the effects ofother variables entered in that step.⁎⁎ p b 0.01.

Please cite this article as: Wojtowicz AA, et al, Pain severity and pain catbowel disease, J Crohns Colitis (2014), http://dx.doi.org/10.1016/j.croh

all youth experiencing functional disability endorsedabdominal pain during the last two weeks, suggesting thatthis is a group at particular risk for functional disability. Boththe severity of abdominal pain endorsed and the presence ofhigher levels of catastrophic thinking each independentlypredicted functional disability in our sample. However, sincecatastrophizing effect sizes were relatively small, ourfindings suggest the importance of examining pain from amultidimensional perspective including, but not limited to,pain-related cognitions. Theoretical models suggest thatwhile cognitions play an important role in predicting outcomessuch as disability, other cognitive, emotional, and socialconstructs (e.g., family, school) also contribute to a youth'sexperience with chronic pain.25–27

The current findings are informative in several respects.First, they serve to replicate findings related to associations ofpain severity and catastrophizing with functional disabilityfrompast researchwith other pediatric illness groups includingyouth with chronic pain in a pediatric IBD sample. 12,13 Thisis informative insofar as it suggests that these constructs arerelevant to the understanding of functional disability evenamong youth whose abdominal pain may be related to anorganic rather than functional etiology. Second, identificationof pain catastrophizing as a correlate of functional disability isparticularly important given that pain-related cognitions arepotentially modifiable via intervention, whereas pain severitymay not be as amenable to treatment. Specifically, abdominalpain is a characteristic symptom of IBD during times of diseaseremission, and as such, elimination of all abdominal painamong youth with IBD may be an unrealistic treatment goal.However, cognitions associatedwith abdominal pain, includingthe extent to which pain is perceived as threatening (i.e., paincatastrophizing) are potentially modifiable through cognitivebehavioral interventions.28 Given the associations betweencatastrophizing and functional disability, the current findingssuggest that reducing pain catastrophizing has the potential todecrease functional disability in this population.

4.1. Study limitations and future research directions

Although these findings contribute to the understanding ofabdominal pain in youth with IBD, the present study is notwithout limitations. Several limitations regarding the samplecharacteristics limit generalizability of the current findingsto the full population of youth with IBD. Specifically, thepresent sample had limited ethnic diversity, was primarily ofmiddle to upper middle class socioeconomic background,and had low levels of disease activity. However, the ethnicdistribution of participants in this sample was similar to thatof the population of youth with IBD in the region,29 and thesocioeconomic status is comparable to the typical populationof families participating in IBD research.30,31 Additionally,the current analyses utilized data drawn from the baselineassessment of an adherence promotion RCT that requiredyouth to have been prescribed an oral IBD maintenancemedication. Thus, youth on other IBD treatment regimens(i.e., injection or infusion-based regimens) were excludedfrom this study, further limiting generalizability to thosegroups. In future research, a larger and more diverse samplewould provide additional support for generalizability of thesefindings. In addition, inclusion of a sample with a greater

astrophizing predict functional disability in youth with inflammatoryns.2014.02.011

6 A.A. Wojtowicz et al.

range of disease activity and functional disability may be ofvalue. Our study relied on a brief assessment of clinical diseaseactivity (i.e., the PGA), which may be less precise thanmeasures of disease activity based on laboratory inflammatorymarkers or mucosal biopsy, and may have contributed to agreater proportion of patients being labeled has having nodisease activity. That said, since the goal of IBD treatmentis to induce remission of symptoms and promote optimal dailyfunctioning, identification of youth with severe diseaseactivity will require multisite studies that oversample forthese characteristics. In addition, in such future studies itwould be beneficial to include more precise measures ofdisease activity that incorporate inflammatory or mucosaldisease markers. One possible way to do so would be to enrollpatients at the time of endoscopy for a similar trial. Regardingthe design, the current study employed a cross-sectionaldesign, which did not allow for examination of changes in paincatastrophizing or functional disability over time. Futureresearch which employs a longitudinal design would allow formore sophisticatedmodeling of trajectories of abdominal painand pain catastrophizing over time and their impact onfunctional disability. Finally, the contribution of additionalfactors on functional disability of youth with IBD should also beconsidered for future research in this area given the modestamount of variance accounted for by pain severity and paincatastrophizing. Examining the role of parent and familyfactors such as parent catastrophizing on functional disabilitymay be one productive avenue for future research.

4.2. Clinical implications

The current findings have several implications for clinicalpractice. Since abdominal pain is both inherently subjectiveand a characteristic symptom of IBD and its treatment,eliminating the presence of abdominal pain may be anunrealistic strategy for enhancing the functioning of affectedyouth. However, enhancing functioning via reduction ofdysfunctional cognitions associated with abdominal pain isconsistent with the cognitive behavioral model of pain. Thus,routine assessment of pain catastrophizing among youth withIBD may identify youth at risk for functional impairments.Given the brevity of the pain catastrophizing measure, thefeasibility of implementation into clinical practice is high. Foryouth endorsing high levels of catastrophizing in the context oftheir abdominal pain, referral to a behavioral health specialistfor participation in interventions aimed at reducing levels ofpain catastrophizing may be useful in decreasing functionaldisability.

Financial disclosure statement

The authors have no financial relationships relevant to thisarticle to disclose.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Please cite this article as: Wojtowicz AA, et al, Pain severity and pain catbowel disease, J Crohns Colitis (2014), http://dx.doi.org/10.1016/j.cro

Acknowledgment

This research was funded by the Crohn's and Colitis Foundationof America (Senior Research Award #2838 to R.G.). Wegratefully acknowledge the assistance of participating fami-lies, the support of health care providers in the participatinggastroenterology clinics, and the assistance of undergraduateresearch assistants at Marquette University and graduatestudents at Rosalind Franklin University of Medicine andScience in assistance with data collection and data entry.AAW participated in the collection of the data, data analyses,and writing of the manuscript. RNG conceived the study,participated analysis of the data, and writing of themanuscript. APG participated in the collection of the data,analysis of the data, and writing of the manuscript. ARparticipated in the collection of the data, analysis of the data,and writing of the manuscript. SEW provided input on dataanalyses and critical review of the manuscript.

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