Flourishing among adolescents living with chronic pain and their parents: A scoping review

Abstract Evidence exists regarding the impact of flourishing in individuals living with chronic pain, but there are currently no reviews which collate the literature on flourishing in adolescents living with chronic pain and their parents. Therefore, the aim of this scoping review was to map and review the current literature, to document how flourishing is defined and understood in the literature, and to identify gaps in the field. Six databases were searched (Web of Science, Medline, Embase, APA PsycNet and the Cochrane Central Register of Controlled Trials). In addition, a limited gray literature search was conducted. The resulting data were collated and reported in relation to the review questions, by examining the included papers to search for the presence of flourishing. Database searches resulted in 7326 papers after duplicate removal, with eight remaining papers being assessed for full‐text eligibility. Following full‐text screening, a final four papers were included in the review. Within the papers, flourishing was defined in relation to commonalities of benefit finding, enhanced maturity and growth, and social support. Gaps in the literature and directions for future research are considered. This review suggests that there is a dearth of knowledge and research regarding flourishing among adolescents living with chronic pain and their parents, despite aspects of flourishing identified in limited literature. This warrants further investigation.


| INTRODUC TI ON
Chronic pain (recurring or persistent pain lasting longer than 3 months 1 ) is a common experience in childhood and beyond. A meta-analysis by King et al. 2 found that 11%-38% of young people report experiencing chronic pain, with rates of chronic pain typically increasing during adolescence. Such rates alongside a high number of adolescents (35%) reporting the experience of chronic pain into adulthood has identified adolescent chronic pain as a public health concern. 3,4 The impact of chronic pain on adolescent life is wide-ranging and often deleterious, affecting familial, emotional, social, physical, school, and developmental functioning. [5][6][7][8][9][10][11] However, despite a dominant focus on disability in the chronic pain literature, some evidence exists regarding flourishing while living with chronic pain. 8 For example, a study by Trompetter et al. 12 conducted with two adult chronic pain samples concluded that those living with chronic pain are able to flourish, while a qualitative study by Umberger and Risko 13 observed positive growth in children and adolescents of parents living with chronic pain. The experiences of these children and adolescents led to growth in areas such as improved understanding and skills, and stronger character development and spirituality. It is likely that similar findings may be applicable to adolescents living with chronic pain and/or their parents.
There is currently no single agreed upon conceptualization of flourishing. 14 In the context of mental health, Keyes 15,16 considers flourishing to be achieved when high levels of psychological, social, and emotional well-being are experienced together, while Huppert and So 17 conceptualize flourishing as "life going well." Taking a slightly different approach, Goubert and Trompetter 8 describe the construct of sustainability (used interchangeably with flourishing) as long-term positive outcomes and optimal well-being despite adversity. For the purposes of this review, we use flourishing as an umbrella term to describe positive changes in functioning and include related constructs such as benefit finding, hope, optimism, resilience, pain self-efficacy, psychological flexibility, and acceptance, 8,18 or Post-Traumatic Growth 19 under this umbrella term. Therefore, our definition of flourishing extends beyond a simple reduction of negative outcomes and into the realm of positive change, either as a result of, or despite, chronic pain. However, despite our suggested definition, given the heterogeneity in how flourishing is recognized in the literature, within this review, we also include an investigation of how flourishing is defined and understood.
To fully understand flourishing in adolescents living with chronic pain, it is also important to acknowledge the wider social context in which they live. This includes the importance of considering the influence of parents and peers on adolescent chronic pain. A strong relationship with friends and adaptive parents may positively affect adolescent pain outcomes, 20 while studies have found that higher family conflict and reduced adolescent autonomy are associated with increased depression and functional impairment, 21,22 which may also impact flourishing. Parents can serve as important role models in the context of pain 3 and a key means of support can include strong family relationships. 23 In addition to positive outcomes for adolescents due to strong family relationships, parenting an adolescent with chronic pain may also have a positive impact on parental well-being by means of a bi-directional relationship between adolescent and parent. 24 To our knowledge, no reviews currently exist which report and synthesize the literature on flourishing in adolescents living with chronic pain and their parents. This collation may serve to broaden our understanding of the current literature and prove useful to inform future studies. Additionally, gaining a better understanding of flourishing in chronic pain could be useful to improve and expand on chronic pain interventions 12 which promote growth and positive change over time. 13 In particular, a positive focused approach could be especially useful to expand treatments in the context of a more typically deficits-based approach to care for individuals living with chronic pain. Therefore, the overall aim of this scoping review was to identify, map, and review the current literature, as well as identify gaps in the field. 25 Using original methodological guidance provided by Arksey and O'Malley 26 and updated guidance provided by Peters et al. 27 for further consideration, we devised broad research questions which would enable us to generate appropriate breadth of coverage.
Consequently, this review aimed to address the following research questions which considered flourishing in the context of adolescents who experience chronic pain and their parents:

| Approach to the scoping review
This scoping review followed published methodological procedures as outlined in Arksey and O'Malley. 26 The methodology includes a five-stage process; (1) identifying the research questions, (2) identifying relevant studies, (3) study selection, (4) charting the data, and lastly (5) collating, summarizing, and reporting the results. Although not necessarily required for a scoping review, 26 it is good practice to include a quality appraisal to facilitate a robust review. 28 Therefore, the quality of the included studies was evaluated during data extraction using an appraisal tool. 29 The protocol for this scoping review is registered with the Open Science Framework (OSF) database: https://osf.io/xrhnm/ ?view_only=49b4b 1b4b5 e44f7 a83ca da1e0 edee784.  Table 1 for full list of search terms used). An example of a search strategy from APA PsycNet is shown in Table 2. Searches were limited to English only and no limits were placed on dates of publication.

| Study selection
Following completion of all database searches, references were imported into reference management software, Zotero (www.zotero. org), where duplicates were removed. Remaining references were imported into Covidence (www.covid ence.co.uk), a specialized software used for managing review data for screening. After further duplicates were removed, all remaining papers were screened against title and abstract by the first author (RP). A total of 60% of papers were double screened by trained research assistants (CH, AD, AO), a process that has been followed in other research ( 10 : 50% double screened). Any conflicts were resolved by co-author AJ.
At the title and abstract screening stage, papers were included if they were related to adolescents aged 10-24 years old (congruent with a recent extended definition of adolescence of 10-24 years 30 ) who live with chronic pain conditions as their primary concern, or parents of such adolescents, and addressed findings which explicitly related to flourishing in adolescents with chronic pain. For the purposes of our database search and study selection, we adopted a broad definition of flourishing in order to include as many papers as possible to enable us to best address our research questions. The definition used was as follows: 'Flourishing in this review describes any positive changes as a result of living with chronic pain, beyond only an absence of negative outcomes. The positive aspect should not only be a result of an intervention or treatment but rather naturally occur due to the person's experience with chronic pain'. Eligible papers included those which adopted a qualitative, quantitative, or mixed method approach, were longitudinal, cross-sectional or intervention/experimental (randomized controlled trials) studies. Additionally, eligible papers were required to be published primary research studies which reported on original findings in peer-reviewed journal articles, conference abstracts, or unpublished theses. Papers were excluded if they were related to adolescents, or parents of such adolescents, who were not aged 10-24 years old, who only had pain which appeared to be a secondary concern, who had pain which was due to cancer (due to the potential life-threatening aspect of cancer and the unique causes of pain associated with cancer, for example, tumor pressing on nerves or nerve damage due to cancer treatment), or if papers did not address findings which explicitly related to flourishing in adolescent chronic pain. Studies were also excluded if they were editorials, commentaries, case studies, review papers, letters, books, or book chapters. Papers were retained for further full-text consideration if it was not possible to infer suitability for inclusion or exclusion based on title and abstract screening alone.
Following the title and abstract screening stage, remaining papers were assessed for full-text eligibility. As guided by Arksey and O'Malley, 26 these papers were all double screened by the first author (RP) and a fully trained research assistant (SG) using the same inclusion and exclusion criteria as at the title and abstract screening stage. Conflicts were resolved by co-author, JM.

| Charting the results
Data extraction for the included papers was conducted by the first author (RP) using a data extraction template devised by Peters, Godfrey, et al. 31 Data extracted was also completed independently by a trained research assistant (AD) and compared with RP to ensure accuracy of the data extracted for each eligible study. According to this template, data were extracted for the following: author(s), year of publication, study aims/purpose/objective, origin/country of origin, participant characteristics and sample size if applicable (age, gender, racial, cultural), type of pain, duration of pain, methodology

Age
Child* OR Adoles* OR "Late Childhood" OR "Young Adult" OR "Early Adulthood" OR "Young People" OR Young* OR Youth* OR "Young Person" OR Paediatric OR Pediatric OR Teen* OR Juveni* OR Minor* Or Pubesc* Chronic pain "Chronic Pain" OR Pain* OR "Long-Term Pain" OR "Persistent Pain" OR "Recurrent Pain" Flourishing Flourish* OR "Positive Change" OR Grow* OR Thriv* OR Benefit OR Goal OR "Emotional Development" OR Well-Being OR Well Being OR Adjustment OR Silver Lining OR Silver-Lining OR Social OR Change OR Optimism OR Hope OR "Plans for Future" OR Self-Efficacy OR Self Efficacy OR "Sense of Control" OR "Positive Affect" OR Sustain* OR Independence OR Identity OR "Developmentally Ahead" OR Acceptance OR Autonomy OR Character OR Spirit* OR "Treatment of Others" OR Engaged OR "Purpose in Life" OR Adjustment OR Optimism OR "Engagement in Meaningful Activities" OR "Quality of Life" OR "Fulfilling Life" OR Asset* OR "Mood" OR "Post Traumatic Growth" OR "Post-Traumatic Growth" OR "Adversarial Growth" OR Satisf* Positive associations Flexib* OR Resilien* OR Positiv* OR Enhanc* OR Develop* OR Increas* OR Improv* OR "Better" OR Strong* OR "Enhanced Maturity" OR "Increased Well-Being" OR "Improved Interpersonal Relationships" OR "Improved Relationship" OR "Better Adjustment" OR "Improved Social Relationships" OR "Increased Self-Efficacy" OR "Increased Independence" OR "Improved Identity" OR "Increased Acceptance" OR "Increased Autonomy" OR "Stronger Character" OR "Nurtured Spirituality" OR "Engaged Living" OR "Better Adjustment" OR "Life Satisfaction" OR "Valued Activities" OR parent* OR Caregiver OR Care-Giver (e.g., self-report, interview), study design (qualitative, quantitative, or mixed methods), and duration of the study. In addition, outcome data particularly relevant to the research questions were extracted for the following: key outcomes which relate to flourishing in adolescents with chronic pain, such as definitions, impact, assessment, gaps, and future research. Following data extraction, a narrative synthesis was conducted to analyze findings from the eligible papers, as part of the process of charting the data. 26 This synthesis focused on generating codes which identified important features of the included papers. These codes were subsequently examined and collated to identify commonalities among the papers. Following this, commonalities were compared with the data to identify final patterns present across the papers, moving beyond merely a description of each individual study (such as the approach taken by Hynes et al. 32 ). The data from the final four papers were further collated and reported in relation to the review questions, by examining the included papers to search for common findings and the occurrence of flourishing.

| Quality assessment
To ensure rigor, data were subjected to quality assessment using a tool developed by Alderfer et al. 29 This assessment was undertaken by the first author (RP) and a research assistant (AD) at the point of data extraction. A maximum of 16 quality criteria were used (quantitative methods studies rated on 9 criteria, qualitative methods studies rated on 11 criteria and mixed methods studies rated on 16 criteria), with a rating of between 1 (low quality, little to no evidence of guideline fulfillment) and 3 (high quality, good evidence of guideline fulfillment). Ratings were then averaged to obtain a total scientific merit score for each paper.

| Scope of the literature (research question 1)
The results of the review indicate that the scope of the current literature on flourishing in pediatric chronic pain is highly limited, with only four papers matching the search criteria. The papers were included in the scoping review based on their characteristics, which are summarized in Table 3.  were identified among the four papers. These commonalities may prove useful in supplementing our definition of flourishing in adolescent chronic pain and included: benefit finding, enhanced maturity and growth, and social support.

| Benefit finding
A dominant commonality within the eligible papers was benefit finding in the context of living with adolescent chronic pain. Benefit finding may be considered an important aspect of flourishing and is defined by Soltani et al. 35 as the perception of positive consequences despite adversity.
All four studies observed benefit finding among participants.
While Soltani et al. 35 was primarily focused on benefit finding, the remaining three papers were primarily focused on other variables but observed aspects of benefit finding in line with the above definition. Three of the papers observed benefit finding among adolescents, 6,33,35 while one paper observed parental (paternal) benefit finding. 34 Benefit finding in two of the papers 6,35 was observed using quantitative self-report measures such as the Benefit and Burden Scale for Children 36 used in Soltani et al. 35 Conversely, benefit finding was reported in the remaining two papers 33,34 in qualitative interview data with adolescents and parents.
In the Soltani et al. 35 paper, the researchers found that benefit finding was significantly positively associated with anxiety Although some of these results may appear surprising, Soltani et al. 35 offer the explanation that these results may reflect the complexity of chronic pain, and that past literature on chronic pain recognizes both highs (resilience) and lows (distress), which may change over the course of treatment. 37 A common finding relating to benefit finding in adolescent chronic pain was identified among two of the papers 33,34 in this review. Namely, that individuals adopted a more positive outlook due to living with their chronic pain. In Cartwright et al., 33   It is important to note, however, that participants rated themselves developmentally ahead of their peers in only this one item out of 11 items measured, while participants rated themselves as either developmentally similar to (five items) or behind (five items) their peers for the remaining items in this study.

| Social support
Social support was identified as a commonality among three of the papers. 6 The main positive outcome noted in Eccleston et al. 6 of maturity in dealing with problems was likewise attributed to the adolescent's experience of coping, which was linked to a social aspect with peers.
Three factors of social development were self-perceived in adolescents with chronic pain; emotional adjustment (made up of three items associated with adolescent's behavior regarding competence and emotional problem solving), identity formation (made up of four items associated with adolescent's socially assured behavior), and independence (made up of four items associated with adolescent's behavior independent of parents). Across these three factors, strong peer relations appeared to play a protective role and were associated with positive judgments of the adolescent's social development. Further resources may be provided by parents who promote coping, pain management and adjustment in their child 40 to encourage these adaptive behaviors. Social support from family and friends can also lead to perceived positive outcomes such as a greater awareness of love and support, as well as the direct benefit of strengthened friendships. In addition, this support may provide a coping resource and lead to hope, a concept linked to flourishing. 41 As indicated in one of the papers included in this review, strong friendships may also lead to perceived strengthened social development, and strong relationships with peers have been linked to positive emotional adjustment and independence in adolescents living with chronic pain. 6 The link found in this review between social support and positive by developing our understanding of everyday experiences and subjectivity in chronic pain. In addition to interview studies, diary studies may be used as a way of capturing details of everyday experiences related to chronic pain, while avoiding recall issues with methods that require retrospective recall. 45 Another methodological approach which may be considered is Q-methodology.
Q-methodology is a robust methodology and could be used to further explore subjectivity in relation to flourishing in adolescent chronic pain by investigating dominant shared viewpoints across multiple stake holders associated with adolescent chronic pain (e.g., the adolescent, their parents, their peers, and healthcare professionals who are involved in their care and treatment). There is also a lack of longitudinal studies in the literature, which would be useful to examine the construct of flourishing over time and its predictors. Additionally, it may also be useful to investigate flourishing in particular conditions, as there may be differences in levels of flourishing experienced based on different causes of chronic pain and their related severity and intensity. Finally, we note the potential important influence co-occurring mental health symptoms may have on adolescent chronic pain. 46 These symptoms may influence the relationship between flourishing and chronic pain, as adolescents with chronic have been shown to be twice as likely to report high emotional distress than those not living with chronic pain. 5 Future research should consider flourishing in adolescents living with co-occurring chronic pain and diagnosable mental health conditions, and the specific nature of the relationship between flourishing and mental health factors.
There were also some limitations in our review. Firstly, our search only included papers published in the English language.
Due to a lack of capacity to translate papers in other languages, it is possible that relevant results to our searches may have been missed or overlooked. Secondly, we were unable to retrieve the full paper (if written) for a potentially relevant conference abstract which was identified as potentially eligible for inclusion in the review.
Further studies examining flourishing could be used to explore and build on this overlooked but potentially valuable resource in supporting adolescents living with chronic pain. Results from such studies could be useful to inform treatment strategies based on Positive Psychology for adolescents with chronic pain and their parents, which draw on existing strengths and capabilities to support the self-management of chronic pain among adolescents. Positive Psychology interventions have been shown to be beneficial for adults living with chronic pain 47,48 and successful positive interventions have been effective in other related areas such as psychological flexibility and acceptance. 18,49 This research could be further developed or drawn upon, to support adolescents living with chronic pain in self-management of their pain symptoms.
In conclusion, this review, although based on a limited number of studies, suggests that there is a lack of research into flourishing among adolescents living with chronic pain and parents of such adolescents. Despite this, it is clear from the four papers identified in this review that adolescents living with chronic pain can indeed experience positive outcomes along with the predominant negative outcomes usually associated with living with chronic pain.
This warrants further investigation to further explore flourishing, not only for the individual adolescent, but also for their wider social environment.

ACK N OWLED G M ENTS
We would like to thank Alice Denman (AD), Chloe Hsu (CH), Agata Olszewska (AO), and Saz Guscott (SG) for their assistance with paper screening and/or data extraction, and librarians, Kirsten McCormick and Justin Hodds, for their assistance with search strategy development.