Two study characteristics were explored to assess their impact on the mean effect size: (1) whether or not samples included any participants older than 18 years, and (2) whether or not samples contained any participants reporting pain duration less than 3 months. Mean effect sizes were estimated including and excluding studies with these characteristics (ie, participants older than 18 and participants with pain <3 months). As seen in Table 9, minimal differences in mean effect sizes were observed between the total study sample and the subgroups, indicating that these study characteristics did not substantially influence the results.
Pain duration and pain diagnosis were also not supported as moderators, which suggests that the catastrophizing–pain nexus is not altered by the length of time or the specific pain diagnosis a child/adolescent has been experiencing. However, it bears noting that the number of studies included in specific pain diagnoses subgroups was low (all Ns < 6), thus reducing confidence in the reliability of the null finding. Finally, pain catastrophizing measure did not explain significant heterogeneity in the observed relationships. Nevertheless, both Q and I2 values were substantially reduced within categorical moderation subgroups for catastrophizing measure and pain diagnosis, indicating a reduction of variability in effect size heterogeneity between studies.49
Several limitations should be acknowledged. The majority of studies used clinical data, which introduces several forms of error, including selection bias and unsystematic administration of measures.93 In addition, clinical data sets are often used repeatedly for various publications, a detail that is not specifically and consistently disclosed, making it difficult to guarantee samples and corresponding effect sizes are unique. Furthermore, the variability in outcome measures used to assess a particular outcome (eg, physical functioning) may influence effect sizes. Another limitation, common in meta-analyses, is the file drawer problem.80 Although the results of fail-safe analyses instill confidence in the meta-analytic findings for all of our primary outcome variables, we cannot rule out the existence of unpublished studies that would have changed these findings had they been included. This meta-analysis only included a selection of outcomes that may be associated with catastrophizing. Unfortunately, other potentially important outcomes, such as school performance, are not commonly reported in the pediatric pain literature and thus were not included herein. Finally, all measures were self-reported and used similar item-response formats, thus, increasing the possibility that common method bias contributed to the observed associations.
Future studies should aim to elucidate possible moderators of the relationship between catastrophizing and pain outcomes because the current results indicate considerable between-study variability in the nature of this relationship. Future research may also investigate the effectiveness of current interventions in reducing catastrophic thinking and the magnitude of these effects over time. These findings would serve to enhance the individualization of treatments for chronic pain in children. The role of parents is important to examine as well. Many studies have reported significant relationships between parental catastrophizing and child pain outcomes,37,67,74 but these relationships are yet to be meta-analytically quantified.
The authors have no conflict of interest to declare.
This research was partially supported by the National Institutes of Health under award number T32 AR055855. We confirm that there have been no closely related manuscripts that have been submitted for simultaneous consideration to this or another journal.
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