The Fear Avoidance Model of Chronic Pain: Examination for Pediatric Application

  • Laura E. Simons
    Address reprint requests to Laura E. Simons, PhD, Children’s Hospital Boston, 21 Autumn St, Boston, MA 02115.
    Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, Massachusetts

    Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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  • Karen J. Kaczynski
    Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, Massachusetts

    Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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      The current study examined the Fear Avoidance (FA) model of chronic pain in pediatric chronic pain patients. Multiple structural equation models were tested in the current study with pairwise parameter comparisons made between younger children (8–12 years) and adolescents (13–17 years). Within a sample of 350 children and adolescents, we examined functional disability and depressive symptoms in separate models with the following predictor variables—pain, pain catastrophizing, fear of pain, and avoidance of activities—after controlling for duration of pain. For a subset of patients (n = 151), we also tested a brief prospective outcome model with baseline predictor variables and functional disability at 1-month follow-up. The FA models predicting functional disability concurrently and prospectively were an excellent fit to the data. The theorized FA model for depression was a poor fit. When the model was modified to include direct pathways from the cognitive processes of pain catastrophizing and fear of pain to depressive symptoms, the model fit was significantly improved. In the examination of developmental differences between younger children and adolescent patients, duration of pain contributed to the model for younger children, whereas pain-related fears were more influential for adolescent patients.


      The FA model of chronic pain appears to be applicable for pediatric patients with some modification to account for developmental differences across childhood. We discuss the developmental, theoretical, and clinical implications of these results.

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