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Abstract

Chronic pain is believed to have substantial negative effects on children’s school outcomes. However, there is currently no research regarding the impact of chronic pain on children in England. Educational differences between countries may mean the impact of chronic pain cannot be generalised between countries, indicating the need for a study in England exploring this relationship. The current cross-sectional study collected scores for Standardised Assessment Tests (SAT), attendance rates, and mental health data from 148 parents of children with and without chronic pain aged 11–14 years via an online survey. Results show children with chronic pain scored lower on the SATs, had higher absence rates, and poorer mental health than children without chronic pain after controlling for gender, SES and SEND. These findings have implications for the education system in how to support children with chronic pain to achieve their educational potential.

Keywords

paediatric chronic pain teacher response standardised assessment tests SATs education

Introduction

Pain, an unpleasant sensory experience (Raja et al., 2020), is considered chronic for children when it persists or recurs for more than 3 months (Merskey, 1986). Chronic pain can occur as a primary disorder, secondarily to an underlying health condition, or without identifiable injury, illness or abnormality (Rolfe, 2019). It is a substantial international issue, with up to 35% of children globally and between 6 and 25% in the UK living with chronic pain (King et al., 2011; Perquin et al., 2000; van Dijk et al., 2006).

Chronic pain has considerable effects on children, negatively impacting social functioning (Murray et al., 2020), mental health outcomes (Jastrowski Mano, 2017), and cognitive function (Weiss et al., 2018). These areas may in turn influence school functioning which is a multi-dimensional concept, covering a wide array of school life from friendships and attendance rates to academic achievement and grades (Haraldstad et al., 2011).

Chronic pain has been linked with increased absences and reduced classroom engagement, with one study reporting approximately half of their sample of adolescents with chronic pain were absent for at least a quarter (25%) of school days (Logan et al., 2008). In addition, pain-related fatigue, difficulty concentrating, and side-effects from medication can make it harder for children to focus on tasks and retain information (Armbrust et al., 2016), which can lead to them falling behind in schoolwork. Physical limitations due to pain also represent barriers to physical activities like sports and PE class, essential for both health and social integration (Chan et al., 2005). Consequently, exclusion from these activities may lead children to feel isolated, impacting their social and emotional health. This is further exaggerated by the observation that children with chronic pain struggle to maintain friendships and experience up to 1.5 times more bullying than non-chronic pain peers (Voerman et al., 2015). The associated lack of social support can contribute to mental issues (Dudeney et al., 2024) which further affect children’s interactions with teachers and peers, as well as their overall school experience and grades. Finally, worry about pain episodes at school can exacerbate existing stress, negatively impacting school performance (Forgeron et al., 2013). It is therefore reasonable to assume chronic pain negatively affects school functioning.

Whereas there is abundant research on the effect of chronic pain on attendance and social aspects there are few studies focusing on academic achievement. Grimby-Ekman et al. (2018) used teacher-based non-standardised assessments comparing grades between children with and without chronic pain in Sweden. They found children with chronic pain achieved lower grades at 15–16 years old compared to non-chronic pain peers. Although this indicates a negative effect of chronic pain on grades, issues such as lack of objectivity and comparability across assessors are associated with teacher-based assessments (Marlow et al., 2014). Furthermore, differences between countries in terms of educational structure, policies, cultural attitudes towards education, variability in teacher training and resources, and differences in socio-economy and health suggest such findings may not translate well between countries (Morris, 2011).

These differences demonstrate the need for additional studies to elucidate whether and if so, which aspects of school functioning are negatively affected by chronic pain. Outcomes from this research could then be used to direct future research objectives appropriately to ensure better outcomes for children living with chronic pain. Therefore, we aimed to elucidate the relationship between chronic pain, mental health, school absences and educational achievement among 11–14-year-old children in England. We hypothesised children with chronic pain would (1) score lower on standardised assessment tests (SATs) taken by all mainstream, state-funded school children in Year 6; (2) experience anxiety symptoms more frequently and score higher on a measure of depression; and (3) report more days of absence than their non-chronic pain peers.

Method

Design

A cross-sectional online survey design was used to determine the association between chronic pain and scores on SATs. The study was pre-registered on aspredicted.org and the protocol can be accessed here: https://aspredicted.org/v8jp-ybhg.pdf.

STROBE cross-sectional reporting guidelines were used in the reporting of this study (von Elm et al., 2007).

Participants

Sample size estimation was based on a GPower (Faul et al., 2009) calculation of a small-medium effect size grounded in similar research investigating the relationship between chronic pain and educational outcomes (Ragnarsson et al., 2022; Tegethoff et al., 2015) with an alpha level of 0.05 and beta of 0.80. This calculation indicated a sample of 250 participants, with the aim to collect an equal number of responses from parents of children with and without chronic pain.

Participants were parents or guardians of children living in England who took their SATs in 2022, 2023 or 2024. The exclusion criterion was inadequate proficiency in the English language, which prevented appropriate engagement with the survey.

Participants were recruited over an 8-month period by contacting secondary schools local to the researcher, advertising on chronic pain social media pages, and word of mouth. A standardised recruitment poster was used. Additionally, participants were recruited via Prolific.com, an online recruitment platform. In two rounds of recruitment, Prolific users in England were first asked to complete a screening questionnaire consisting of two questions: ‘Do you have a child/children in Year 7 or 8 of secondary school?’ and ‘Does your child have chronic pain?, that is, pain that has lasted or recurred for longer than 3 months. This can be diagnosed or suspected. Examples are fibromyalgia, chronic regional pain syndrome or chronic headaches?’. We acknowledge that chronic regional pain syndrome has been misspelled in the screening survey and should read chronic complex regional pain syndrome. Participants were reimbursed for participation in the screening survey and anyone answering yes to these questions was invited to participate in the main survey for which they were also reimbursed.

Three-hundred-and-three participants began the survey (207 from Prolific), of which 116 participants were excluded, as they did not complete the survey. Thirty-nine further participants were excluded due to not providing relevant SAT data, resulting in a final data set of 148 participants. No reasons were provided for non-provision of SAT data.

Measures

Demographics

Age and gender were recorded for parents and children. For parents, relationship status, relationship to child, and their region of residency in England were also collected. For children, ethnicity, Special Educational Needs and Disabilities (SEND) status and socioeconomic status (SES) (measured by eligibility for Free School Meals (FSM)) were collected. A child has SEND if they have significant difficulty learning at the same level as children of the same age, or they have a disability that prevents or hinders their access to general educational facilities in mainstream schools (Department for Education, 2015). Free School Meals is the provision of a healthy meal to disadvantaged pupils of school age (Department for Education, 2023a), and has been widely used as a proxy measure for SES (Taylor, 2017). Children are eligible if their parents claim certain benefits and earn under a particular threshold (under £7400 per year for Universal Credit and £16,190 for Child Tax Credit) (Department for Education, 2023a). Households in England are considered to be living in poverty if, after housing costs are paid, they are living on less than 60% of the median household income of that year (The House of Commons Library, 2023). The current median household income in England is £29,380 per year, 60% of which is £17,628. Therefore, if children are eligible for FSM, they may be considered to be living in poverty, indicating a lower SES.

Standardised assessment tests scores

Standardised Assessment Tests are taken by children in state-funded schools in England in Year 6 of primary school in the subjects of Maths, English, and Grammar Punctuation and Spelling (GPS) (Jerrim, 2021). Children sit six papers under exam conditions including spelling, arithmetic, and reading comprehension (Standards and Testing Agency, 2025). These tests, standardised across all schools, are designed to track children’s academic progress and are used as a marker of the quality of teaching at a school (Williams, 2024). Scores are scaled to between 80 and 120 points by teachers, before being provided to the children and parents. Children who score above 100 are said to be working at the level expected for their cohort (Standards and Testing Agency, 2019).

Parents were asked to report their child’s SAT scores for Maths, Reading and GPS and the year their child took the SAT to ensure data would be appropriate for comparison. Parents were reminded they might be able to find these scores on their child’s end of year reports.

Pain characteristics

To assess pain status, parents were asked to answer Yes or No to ‘Does your child suffer from, or do you suspect your child suffers from, chronic pain?’ (‘recurring or persistent pain beyond the expected time period of an acute or underlying condition, generally for over 3 months’). If parents indicated ‘No’, the survey took them to the next section of the questionnaire, so they did not provide answers to non-applicable questions. If the response was ‘Yes’, parents used a free text box to name their child’s pain condition, the duration of the pain (in months), and medication their child takes for pain. Parents also indicated where on the body their child experiences their pain.

School absences

To measure school absence rates, parents were asked to indicate, in a free text box, ‘In the year your child took their SATs, what was your child’s attendance rate (in percentage)?’. Parents were, again, directed to their child’s end of year report for this information. Additionally, parents of children with chronic pain were asked to estimate, using a tick box, how many days of absence were due to chronic pain (All (4/4), Majority (>3/4 ), Most (1/2–3/4), Some (1/4–1/2), Few (>0–<1/4), or None (0)). Parents of non-chronic pain children were asked to tick N/A for not applicable.

Mental health characteristics

Anxiety

To assess general anxiety, parents were asked to choose ‘Yes’, ‘No’, or ‘Not Sure’, to the question ‘In your opinion, does your child experience symptoms of anxiety such as difficulty sleeping, abnormal irritability or difficulty concentrating?’. Parents were also asked to write in a free text box how often they felt their child experienced these symptoms and were given examples such as ‘once per week’ or ‘once per day’. This measure was designed this way as the current measures used are often overly long (Ahlen et al., 2018). For the purpose of suitable length of the overall survey we decided a binary answer to presence of anxiety symptoms was appropriate.

To assess school anxiety, parents were asked to choose ‘Never, Sometimes, Often or Always’ to the question ‘In your opinion, how often does your child experience negative or bad feelings about attending school?’.

Depression

To assess depression, parents were asked to complete the Moods and Feelings Questionnaire—Parent Report (MFQ-PR) (Thapar and McGuffin, 1998), a 13-item questionnaire designed to identify clinical depression in children and adolescents. Parents indicate on a 3-point scale (‘True’, ‘Sometimes’ or ‘Not True’) their opinion of how their child has been feeling and acting in the past 2 weeks. Statements include: ‘S/he did not enjoy anything at all’, ‘S/he cried a lot’, and ‘S/he felt lonely’. Evidence suggests the MFQ-PR is a satisfactory parent-report screening tool for clinical depression (Thapar and McGuffin, 1998). The Cronbach’s alpha for this scale was 0.948, indicating a good internal consistency.

Procedure

Data were collected online using Gorilla Experiment Builder (https://gorilla.sc/). Ethics approval was gained from the University of Portsmouth’s ethics committee. Before starting the survey, participants were presented with a Participant Information Sheet (PIS) detailing the study summary, what participation involved, data confidentiality, advantages and disadvantages of participation, and contact details of the researcher. Once informed consent was established participants worked their way through the survey. Participants were able to stop and come back to the survey if needed. Once the survey was completed, participants were provided with a debrief sheet reminding them of the purpose of the survey, contact information for the researcher, and where to access further support as needed.

Data analysis

Analyses were conducted in SPSS (Version 28). To compare SAT scores (mathematics, reading, and GPS) between children with and without chronic pain a MANCOVA was used. In this analysis, the independent variable (IV) was chronic pain status (chronic pain or not chronic pain), and the dependent variables (DV) were SAT scaled scores for Maths, Reading, and GPS (80–120). The covariates entered into the analysis were child’s gender, SES, and SEND status. These covariates have been selected due to a demonstrated impact on SAT scores; historically, girls outperform boys on all aspects of the SAT. Children from lower SES background typically score lower than children from higher SES, and children with SEND typically score lower than those without (Department for Education, 2023b). Additionally, three logistic regressions, using the covariates above, were used to examine the relationship between the IV of chronic pain status and the binary DVs of Expected Standard Reached for Maths, Reading, and GPS (i.e., scoring above or below 100 on the SAT).

As noted in the preregistration, a Mann–Whitney U test and an ANOVA were to be conducted to explore the relationship between chronic pain and mental health. However, during the building of the survey an error occurred, so this could not be carried out. Once SAT and demographic data were collected, participants who selected ‘no’ to the chronic pain status question were directed to the end of the questionnaire instead of the mental health measures as intended. Therefore, a t-test was conducted using the mean score on the MFQ-PR for the chronic pain group and an age and gender comparable non-chronic pain non-depressed and a non-chronic pain depressed sample from Rhew et al. (2010). Furthermore, a comparison of frequencies of school anxiety feelings was carried out between the chronic pain group from the current study and the average non-chronic pain group from Rhew et al. (2010).

To explore the relationship between chronic pain and days absent from school, an Independent t-test was conducted with the IV of chronic pain status (chronic pain or non-chronic pain) and the DV of percentage of school days attended (from 0% to 100%).

Results

Descriptive statistics

Parent age ranged from 25 to 72 years old (M^age = 40.63 years, SD = 7.29). Three participants recorded ages below 18 years of age, likely erroneously reporting their child’s age, and so their data were excluded from the mean presented above. Further parent and child demographics are reported in Table 1. Children’s pain conditions are reported in Table 2. Pain duration was reported to be between 3 months and 8 years and a wide range of medication use was reported including oral painkillers, injections, and heat/cold patches.

Table 1.

Sociodemographic characteristics of parents and children.

Characteristic	n (total)	% (total)	n (CP^≠)	n (non-CP^≠)
Gender (parents)
Female	77	52	16	61
Male	71	48	23	48
Gender (children)
Female	65	43.9	19	46
Male	83	56.1	20	63
Relationship status
Single	7	4.7	0	7
Married	101	68.2	28	73
In a relationship (not cohabiting)	5	3.4	2	3
In a relationship (cohabiting)	25	16.9	6	19
Divorced	6	4.1	1	5
Separated	2	1.4	1	1
Prefer not to say	2	1.4	1	1
Region of Residency
South West	13	8.8	0	13
South East	27	18.2	7	20
Greater London	12	8.1	1	11
East of England	16	10.8	7	9
West Midlands	20	13.5	9	11
East Midlands	16	10.8	5	11
Yorkshire and Humber	10	6.8	2	8
North West	19	12.8	5	14
North East	10	6.8	2	8
Other*	5	3.4	1	4
Relationship to child
Mother	78	52.7	15	63
Father	65	43.9	20	45
Legal guardian	3	2.0	2	1
Other⁺	2	1.4	2	0
Resident with child
Yes	143	96.6	39	104
No	4	2.7	0	4
Other^{^}	1	0.7	0	1
Ethnicity
White^#	122	82.5	32	90
Asian/Asian British^##	19	6.0	3	16
Black^###	9	6.0	2	7
Mixed/multiple ethnic groups^####	8	5.5	1	7
Chronic pain status
Yes^~	39	26.4	39	0
No	109	73.6	0	109
Free school meal entitlement
Yes	41	27.7	14	27
No	107	72.3	25	82
SEND status
Yes^~	37	25	16	21
No	111	75	23	88
Year of SATs
2022	48	32.4	15	33
2023	95	64.2	24	71
2024	5	3.4	0	5
School absences due to pain^!
All (4/4)			5	1
Majority (>3/4)			9	0
Most (1/2 to 3/4)			8	0
Some (1/4 to1/2)			11	1
Few (>0 to<1/4			3	2
None (0/4)			0	24
N/A			-	81

Note. This table displays demographic details of the parents who completed the survey about their child (n = 148). Child demographics provided by parents.

≠

Chronic pain.

Northern Ireland x1, Wales x2, Scotland x2.

Stepmother x2.

Shared custody.

White British/English/Scottish/Northern Irish/Irish/Any other White background.

Indian/Pakistani/Bangladeshi/Chinese/Any other Asian background.

###

Black British/African/Caribbean/Any other Black background.

####

White and Black Caribbean/White and Black African/White and Asian/Arab/Any other mixed or multiple ethnic group.

Suspected or diagnosed.

N = 36 chronic pain participants. 3 did not provide an answer.

Table 2.

Parent reported chronic pain conditions for children.

Reported pain type	Percentage of sample*
Feet	2.6
Back	20.5
Stomach/intestinal	5.1
Bowel	12.8
Chronic fatigue	2.6
Musculoskeletal	17.9
Arthritis	5.1
Chest	5.1
Fibromyalgia	12.8
Migraine/headache	15.4

Chronic pain group sample size N = 39.

Mancova

A one-way between subjects MANCOVA was carried out to assess the impact of chronic pain status on SAT scores. Assumptions of homogeneity of variance-covariance matrices were confirmed using Box’s Test (p = 0.08). Equality of variance was measured using Levene’s Test and showed the assumption was violated for two of the three dependent variables (SATs_Reading, p < 0.001 and SATs_Maths, p = 0.002), whereas SATs_GPS was not p = 0.300). We applied blom transformation to the dependent variables, which resulted in the equality of variance for SATs_Reading and SATs_Maths no longer being violated. The results and interpretation did not change for any of the variables upon using the transformed variables, thus untransformed scores and original analyses were used and are reported in this section. The analysis with the transformed scores can be found in Appendix A. The MANCOVA showed a significant difference between the two groups on the combined DV ‘SAT Scaled Scores’ after accounting for the influence of gender, SES, and SEND status, F (3,141) = 6.12, p < 0.001; Wilks’ Lambda = 0.9, partial η² = 0.115. Analyses of each individual dependent variable, using a Bonferonni adjusted alpha level of 0.017, showed the two groups differed significantly on all three SAT results: Reading, F (1,143) = 16.96, p < 0.001, Maths, F (1,143) = 12.04, p < 0.001, and GPS, F (1,143) = 14.68, p < 0.001. The mean scores for the chronic pain group were lower for all three SAT parts (M^Reading = 98.66, SD = 11.32, M^Maths = 98.09, SD = 11.98, and M^GPS = 97.40, SD = 9.72) compared to the non-chronic pain group (M^Reading = 105.94, SD = 8.89, M^Maths = 104.47, SD = 9.157, and M^GPS = 104.05, SD = 9.31). Additionally, analyses of covariates showed SES had a significant effect on scores for all three SAT parts: Reading (F (1,141) = 9.98, p = 0.002), Maths (F (1,141) = 15.16, p < 0.001) and GPS (F(1,141) = 6.38, p = 0.013). Children who qualified for FSM had lower SAT scores compared to those who did not. Furthermore, analyses of covariates showed SEND status had a significant effect on scores for GPS (F(1,141) = 6.048, p = 0.015). Children with SEND had lower GPS scores than those without SEND.

Logistic regression

A total of 148 cases were included in the three logistic regressions to examine the impact of chronic pain, SES and SEND status on the likelihood of reaching the expected standards on the three SAT parts. For reading, the full model significantly predicted whether the expected standard was reached (omnibus chi-square = 27.08, df = 4, p < 0.001), as was the case for Maths (omnibus chi-square = 25.50, df = 4, p < 0.001), and GPS (omnibus chi-square = 25.88, df = 4, p < 0.001). In all three cases, having chronic pain significantly increased the risk of not reaching the expected standard. The variance accounted for by the model for expected standards reached in Maths was 21.7%, in Reading was 24.9%, and in GPS was 22.5%. Table 3 gives the coefficients, odds ratios, and probability values for each predictor variable for SATs Reading, Maths and GPS outcomes.

Table 3.

Coefficients, odds ratios and probability variables for child gender, socioeconomic status, and SEND status variables for SATs Reading, Maths and GPS score.

							95% C.I. for Exp(B)
Predictor variable	B	S.E.	Wald	df	Sig.	Exp (B)	Lower	Upper
SATs Reading
Chronic pain status^¥	−1.257	0.452	7.729	1	0.005	0.285	0.117	0.690
Gender^¥	1.196	0.483	6.132	1	0.013	3.306	1.283	8.519
FSM Eligibility*^¥	−1.281	0.446	8.260	1	0.004	0.278	0.116	0.665
SEND status^¥	−0.884	0.452	3.816	1	0.051	0.413	0.170	1.003
SATs Maths
Chronic pain status^¥	−.877	0.421	4.327	1	0.038	0.416	0.182	0.951
Gender^¥	0.198	0.385	0.265	1	0.607	1.219	0.573	2.591
FSM Eligibility*^¥	−1.599	0.405	15.59	1	<0.001	0.202	0.091	0.447
SEND status^¥	−0.462	0.429	1.159	1	0.282	0.630	0.272	1.461
SATs GPS
Chronic pain status^¥	−0.970	0.422	5.280	1	0.022	0.379	0.166	0.867
Gender^¥	0.574	0.408	1.980	1	0.159	1.775	0.798	3.946
FSM eligibility*^¥	−1.165	0.412	7.992	1	0.005	0.312	0.139	0.700
SEND status^¥	−1.107	0.423	6.839	1	0.009	0.331	0.144	0.758

Free school meals as measure of socioeconomic status.

Variable codes: 1 = Yes, 2 = No (Chronic pain status, FSM eligibility, SEND status) 1 = Female, 2 = Male (Gender).

T-Tests

Children with chronic pain had higher total scores for the MFQ-PR (M = 15.0, SD = 3.46) compared to a comparable sample (Rhew et al., 2010) of depressed children (M = 7.3, SD = 3.2) (t(68) = 6.90, p < 0.001) and non-depressed children (M = 3.1, SD = 5.8) (t(513) = 22.19, p < 0.001). Children with chronic pain scored on average above the cutoff of 11 (range 0–26) indicating possible clinical depression (Thapar and McGuffin, 1998). 61.5% of the chronic pain group reported experiencing anxiety symptoms between ‘a couple of times a month’ to ‘multiple times a day’. Additionally, 64.1% of the chronic pain group reported experiencing bad feelings about school sometimes, with 28.2% reporting bad feelings often or always.

Children with chronic pain had lower school attendance rates (M = 85.97%) compared to children without chronic pain (M = 94.54%). An independent t-test showed the difference between the groups was significant and the effect size was medium to large (t(123) = 2.95, p = 0.004, two-tailed, d = 0.611). Number of days of absence parents attributed to their children’s pain is detailed in Table 1.

Discussion

This study found children experiencing chronic pain in England achieve lower scores on the SAT in Reading, Maths, and Grammar, Punctuation and Spelling compared to children without chronic pain. Children with chronic pain are also less likely to meet the expected standard of achievement for their age for all three aspects of the SAT. This relationship persisted when known covariates (gender, SES, and SEND status) were accounted for. Additionally, this study showed that children with chronic pain experienced higher levels of school absenteeism compared to healthy peers. Furthermore, this study demonstrated children with chronic pain experienced levels of depression that reach the threshold for a clinical diagnosis, felt high levels of generalised anxiety, and experienced considerable levels of school-related anxiety.

This study is the first in England to examine the relationship between chronic pain on scores achieved on standardised tests taken by all children in mainstream schools aged 10 and 11. The results are consistent with other research such as Grimby-Ekman et al. (2018), who found children with chronic pain scored lower on teacher assessed grades than pain-free peers. The use of standardised test scores in the current study negates some of the possible biases that arise from the lack of consistency and individual teacher differences in teacher-based assessments (Marlow et al., 2014), adding to the robustness of the conclusions being drawn.

Chronic pain can impact school achievement in several ways. Children may struggle to access school buildings or classrooms if their pain condition prevents them from climbing stairs, sitting for long periods of time, or carrying heavy equipment such as rucksacks (Limon et al., 2004; Morton et al., 2016; Parcells et al., 1999). This puts them at increased risk of isolation, disengagement from lessons and falling behind academically. Children with chronic pain are also more likely to be absent from school than their pain-free peers (Logan et al., 2008), which we confirmed as well. Absence from school means children are not accessing the learning their peers are and have fewer opportunities to engage with extracurricular activities leading to poorer academic and social outcomes (Hill and Macartney, 2019).

Additionally, children with chronic pain often experience fatigue or sleep issues as part of their pain condition (Armbrust et al., 2016) which are associated with less restorative sleep and more daytime tiredness than pain-free peers (Valrie et al., 2013). Tiredness and fatigue may be exacerbated by the length of the school day and the cognitive demands required to complete lessons, making it difficult for children with chronic pain to engage in the whole school day. Furthermore, increased levels of tiredness and fatigue may lead to reduced concentration and poorer working memory skills, key indicators in academic achievement (Mifflin et al., 2016). Lastly, the very purpose of pain is to alert humans to danger, making identification and management of the pain a priority for the brain (Eccleston and Crombez, 1999). Thus, the brain shifts focus from ongoing cognitive tasks to the pain in order to manage it. The persistent nature of chronic pain means the disruptive effect occurs frequently, causing repeated interruptions to the task a child is attending to. This repeated interruptive effect has cumulative negative consequences for the learning children are engaging in at school. All of these factors negatively affect the learning achieved in the classroom leading to poorer academic outcomes for children with chronic pain. Strategies that improve children’s learning could target the physical environment (e.g. access to comfortable seating, considerate distribution of resources around the school), fatigue issues (e.g. implementing activity pacing (Antcliff et al., 2017) where children alternate rest and activity), or social issues such as how teachers and peers respond to children’s pain behaviours in school.

The average attendance of children with chronic pain in our sample was 85.97%, almost 10% lower than the average 94.54% attendance of those without chronic pain. This finding is in line with previous research that highlights the high levels of absenteeism experienced by children with chronic pain (Logan et al., 2008). Absenteeism in children with chronic pain may be due to several factors. Physical pain from their condition can make them unable to get out of bed and to school on time or at all. Concerns such as access to toilet facilities (Walker et al., 2004) or the increased stress of friendship maintenance (Forgeron and McGrath, 2008) also lead to increased likelihood of school refusal. Investigations show even small levels of absence reduce the likelihood of achieving the expected level for reading, writing, and maths (Department for Education, 2022). When absence levels reach persistent levels, that is, below 90% attendance (Department for Education, 2024), the likelihood of achieving the expected standards of learning is 40.2% compared to 83.9% for children attending school regularly. Klein et al. (2022) suggest children who experience absence because of ‘sickness behaviour’, as opposed to truancy or holiday absences, are impacted through a ‘health pathway’, where the child’s health condition has direct (school absence) and indirect (school engagement or mental health) effects on school outcomes. Additionally, children experiencing persistent absences are affected via a ‘psychosocial’ pathway as absences reduce their interactions with peers and teachers leading to isolation and exclusion from classroom activities. In the context of this study, where 61% of the parents reported their child’s pain as the cause for all, the majority, or most of their school absences, it is reasonable to assume these children are not only missing out on learning, but are at increased risk of isolation and exclusion from friends, their teachers, and school life in general. Future research might focus on the extent to which attendance has an impact on SAT scores for children with chronic pain.

Additionally, this study showed that almost two thirds of the children in the chronic pain group (61.5%) experience generalised and/or school-related anxiety regularly, and the average depression questionnaire score (15) was several points above the cut-off demarking clinical depression (11) on the MFQ-PR. These elevated levels of anxiety and depression echo findings from similar research (Khan et al., 2015). Furthermore, these findings highlight the considerable difference in prevalence of mental health issues for children with and without chronic pain; in 2020, 16% of 5–16 year olds were suffering from a mental health condition (Vizard et al., 2020), which is significantly lower than the prevalence rate of 61.5% in the current study. It is worth noting the directionality of the relationship between chronic pain and mental health is likely bi-directional (Bondesson et al., 2024), and for some children anxiety or depression may have a greater effect on SAT scores than chronic pain. Of note, the present study controlled for SEND status, which would include social, emotional, and mental health difficulties, as a covariate when assessing the impact of chronic pain on school achievement. Further research is needed to understand the mechanisms underlying this relationship.

Notably, lower SES negatively influenced scores for Reading, Maths and GPS. This is perhaps due to socioeconomically-related risk factors, such as economic hardship, access to educational opportunities, and parental characteristics, such as maternal mental health, parental education level, and exposure to stress, all of which can influence the frequency and responsivity of interactions between parents and their children (Conger et al., 1992; Davis-Kean et al., 2019). The cumulative negative effect of these risk factors perhaps means children from poorer socioeconomic backgrounds achieve worse reading and maths outcomes.

Finally, SEND status negatively affected scores for GPS but not Reading or Maths. This appears to substantiate research which suggests children with SEND achieve comparable attainment in maths and some language competencies but do not always achieve the same proficiency levels as children without SEND (Lenkeit et al., 2024). There may be a broad range of needs, strengths and difficulties between and within SEND conditions and therefore several social, emotional and cognitive factors might impact scores on the SAT for these children. Furthermore, some evidence suggests there is a relationship between SEND and SES (Strand and Lindsay, 2009) with a higher proportion of children from lower socioeconomic backgrounds being diagnosed with SEND and chronic pain than those from higher socioeconomic backgrounds (Bugdayci et al., 2005). Future research might focus on attitudes, understanding and training of educators regarding SEND (Mónico et al., 2020; Roberts and Simpson, 2016), parental and teacher judgements about children’s cognitive abilities (Pinquart and Ebeling, 2020), and the compounding effect of socioeconomic status on educational outcomes for children with chronic pain.

The findings in this study should be viewed in light of some limitations. Firstly, the error in data collection means a direct comparison between groups regarding mental health outcomes was not possible. This precluded us from running the pre-registered statistical analyses into differences in anxiety and depression levels and frequencies. Nevertheless, comparisons with existing data represent a meaningful alternative. Secondly, the use of parent-report measures might reduce the reliability of the findings. Studies have suggested low agreement between parents and children on depression symptoms and externalising anxiety symptoms (Orchard et al., 2019). Nevertheless, the depression questionnaire used in this study is well validated and shows suitable levels of sensitivity for distinguishing between clinical and non-clinical levels of depression when completed by parents (Thapar and McGuffin, 1998). Additionally, parental attributions for school absences might provide a source of bias. Parents might erroneously attribute all of their child’s absences to pain (Heathcote et al., 2018), perhaps limiting the validity of findings regarding the relationship between absence rates and chronic pain. Furthermore, we did not include ‘worrying’, a fundamental symptom of anxiety (Kertz et al., 2012), in our measure of anxiety. The included symptoms were deemed easy for parents to tangibly measure via a questionnaire. However, we acknowledge that parents may have changed their responses if ‘worrying’ was presented as an example of a symptom, which may affect the validity of our conclusions. Difficulties in participant recruitment, particularly participants with chronic pain, meant the sample size was not as large as pre-registered. This perhaps reduces the strength of the conclusions drawn. Finally, due to the cross-sectional nature of this study, we cannot definitively state the causal relationships between chronic pain, mental health, attendance, and SAT outcomes. Due to the increased risk of comorbid mental health disorders, depression and/or anxiety may be the primary influence on SAT scores for children with chronic pain. Nevertheless, the demonstration of a relationship between chronic pain and SAT outcomes in children in England, regardless of the mechanism, is informative. Notwithstanding these limitations, this study adds value to the evidence base in this field. The wide range of pain conditions and the heterogeneity of gender, location, ethnicity, and age in the sample increases the generalisability of these findings. The use of standardised test scores as an outcome measure means this study adds robust findings to the literature regarding chronic pain and school outcomes for children in England. Future research might seek to replicate the findings of this study using a larger sample size and using a comparison group for mental health outcome measures.

To summarise, this study found that children with chronic pain are more likely to score lower on standardised tests than children without chronic pain, are more likely to experience greater absenteeism, and experience generalised anxiety, school anxiety, and depression symptoms above clinical levels. Further research would benefit from exploring the experiences and perceptions of teachers and school personnel about chronic pain in the school setting. It would be helpful to understand what teachers and school personnel understand about the underlying mechanisms of chronic pain and its impact on children at school. Furthermore, exploring what teachers feel would help them to support children with chronic pain in their classrooms would be beneficial. This information could then be used to develop teacher training principles which help teachers validate children’s experiences whilst helping them learn appropriate coping strategies to reach their full potential academically.

Footnotes

Appendices

Tests of between-subjects effects.

Independent Variable	Dependent Variable	F	Sig	Partial eta squared
Chronic pain status	SATs_GPS	15.075	<0.001	0.096
	SATs_Reading	15.315	<0.001	0.097
	SATs_Maths	10.718	<0.001	0.070
SEND status	SATs_GPS	5.359	0.022	0.036
	SATs_Reading	0.137	0.712	0.001
	SATs_Maths	0.001	0.981	0.000
FSM status	SATs_GPS	6.088	0.015	0.041
	SATs_Reading	10.057	0.002	0.066
	SATs_Maths	12.970	<0.001	0.084
Gender	SATs_GPS	3.414	0.067	0.023
	SATs_Reading	7.538	0.007	0.050
	SATs_Maths	0.631	0.428	0.004

ORCID iDs

Claire Cornick

Iris Nomikou

Jessica Massonnie

Nils Niederstrasser

Ethical considerations

This study received favourable ethical approval from The Science and Health Faculty Ethics Committee Science and Health Faculty Office at the University of Portsmouth (Reference Number: SHFEC 2023-120).

Consent to participate

All participants read a participant information sheet and completed an online consent form before completing the survey. Participants could not access the survey until all the consent boxes were ticked.

Consent for publication

Consent for publication is not applicable to this article as it does not contain any identifiable data.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was conducted as part of a PhD by the primary investigator (Claire Cornick), which was funded by the South Coast Doctoral Training Partnership (SCDTP).

Declaration of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study are available in the University of Portsmouth’s institutional repository (PURE) available from

Pre-registration

The study was pre-registered on aspredicted.org and the protocol can be accessed here: .

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Chronic pain negatively affects children’s outcomes on the English Standardised Assessment Tests (SAT)

Abstract

Keywords

Introduction

Method

Design

Participants

Measures

Demographics

Standardised assessment tests scores

Pain characteristics

School absences

Mental health characteristics

Anxiety

Depression

Procedure

Data analysis

Results

Descriptive statistics

Mancova

Logistic regression

T-Tests

Discussion

Footnotes

Appendices

ORCID iDs

Ethical considerations

Consent to participate

Consent for publication

Funding

Declaration of conflicting interest

Data availability statement

Pre-registration

References