The Role of Psychological Stress in the Relationship Between Chronic Pain and School Functioning

Pediatric chronic pain is linked to higher school absenteeism, academic struggles, and social stressors, which may further exacerbate pain. Stress is thought to be a key mechanism in this relationship. This study tested whether psychological stress mediates the association between chronic pain and school functioning.

Adolescents with chronic pain (ACP) at a tertiary hospital in the northeastern United States and adolescents without chronic pain (AWCP) completed self-report measures of psychological stress and school functioning. Analyses included t tests, Spearman's correlations, and mediation models controlling for age, gender, and race.

The sample comprised 488 adolescents (63.11% female, M age =16.05, SD=1.23): 274 (56.14%) ACP and 214 (43.85%) AWCP. ACP reported significantly higher psychological stress ( P <0.001) and greater school-related interpersonal discomfort ( P =0.013) com p ared to AWCP. After covariate adjustment, the difference in interpersonal discomfort was no longer significant. Psychological stress correlated with poorer school functioning across all subscales ( r =0.4-0.52, P < 0.05). In the mediation model, chronic pain strongly predicted higher stress (a=9.70, P <0.001), stress predicted poorer school functioning (b=0.99, P <0.001), and the indirect effect was large and statistically significant (ab=9.62, 95% CI [7.06,12.45], P <0.001). After accounting for stress, the direct link between chronic pain and school functioning became negative and statistically significant (c'=-12.61, 95% CI [-16.09,-9.13], P <0.001), while the total effect remained not statistically significant (c=-2.99, P =0.14), consistent with a suppression pattern.

Psychological stress mediates the relationship between chronic pain and school functioning. Interventions targeting stress may improve school outcomes for adolescents with chronic pain even if pain symptoms persist.