Executive Function Deficits Common in Pediatric Patients With Chronic Pain

Chronic pain in pediatric patients can lead to cognitive processing weaknesses and reduced executive dysfunction.

Youth living with chronic pain are more likely to experience cognitive processing weaknesses due to decreased executive functions. These results, from a cross-sectional survey, were published in The Clinical Journal of Pain.

Adolescents aged 13 to 17 years were recruited from 2 tertiary care clinics in Western Canada. Twenty-six participants had chronic pain (mean age 15.5 years); 30 were healthy controls (mean age, 14.9 years). Participants were assessed for demographic parameters and for pain and functioning characteristics by several diagnostic instruments including the PROMIS v1.1 Pediatric Profile 25 (PROMIS), Pediatric Quality of Life Inventory 4.0 Short Form (PedsQL-SF15), and Adolescent Sleep Wake Scale-Short Version (ASWS-S), among others.

Most participants with chronic pain (92.3%) had some limitation due to pain. Most (53.8%) did not know the source of their pain, 15.4% reported pain associated with a known illness, 11.5% had genetic-related pain, 11.5% had a sports injury, and 7.7% were involved in an accident. The pain diagnoses included migraine, juvenile idiopathic arthritis, lupus, scoliosis, amplified musculoskeletal pain syndrome, myofascial pain syndrome, chronic reginal pain syndrome, and postural orthostatic tachycardia syndrome.

Those with chronic pain reported having trouble paying attention, sleeping, and walking significantly more compared with the healthy controls (t[54], 7.66; P <.001) as well as reduced physical function (t[54], -6.79 and 6.19; P <.001 for both) and increased fatigue (t[54], 5.09; P <.001).

Those who had chronic pain also reported having poorer emotional control (PedsQL-SF15: t[54], -5.98; P <.001), increased symptoms of worry (PROMIS: t[54], 4.23; P <.001), reduced school function (PedsQL-SF15: t[54], -4.89; P <.001), and more sleep difficulties (ASWS-S: t[54], -5.23; P <.001).

Those who were living with chronic pain performed significantly worse on tests of working memory speed, word inhibition, and design fluency (P <.001 for all).

Parents of these adolescents rated their child’s executive functioning differently. Patients with chronic pain were rated as having decreased emotional control (F[1,54], 20.09; P <.001), self-monitoring (F[1,54], 4.47; P =.039), planning and organization (F[1,54], 14.68; P <.001), and working memory (F[1,54], 24.51; P <.001), among others.

The observed differences of executive function perception among parents of those with chronic pain were significantly correlated with depressive symptoms (F[1,53], 22.77; P <.001), sleep quality (F[1,53], 21.57; P <.001), fatigue (F[1,53], 10.31; P =.002), and anxiety symptoms (F[1,53], 9.83; P =.003). These cofactors for the youth’s self-rated executive function deviations correlated with sleep quality (F[1,53], 9.26; P =.004), depression (F[1,53], 8.79; P =.005), and symptoms of anxiety (F[1,53], 5.81; P =.019).

This study was limited by its cross-sectional design which did not allow for relating significant observations with causal factors. Future studies are needed in order to unravel the causative factors of the depressed executive functions among youth with chronic pain.

“This is the first study to demonstrate that youth with chronic pain have greater [executive functioning] difficulties across multiple performance-based and behavior ratings…compared to youth without chronic pain,” the researchers concluded. “These findings emphasize risk for specific cognitive processing deficits…and support recent calls in the literature to investigate [executive functioning] among pediatric chronic pain populations.”


Turner KM, Wilcox G, Nordstokke DW, Dick B, Schroeder M, Noel M. Executive functioning in youth with and without chronic pain: A comparative analysis. Published online November 5, 2020. Clin J Pain. doi: 10.1097/AJP.0000000000000895