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

Introduction: 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. Methods: 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. Results: 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 ( rs =0.4–0.52, ps < 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 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 nonsignificant (c=–2.99, P =0.14), consistent with a suppression pattern. Discussion: 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.