Orthopedic and musculoskeletal conditions in adolescence: The role of psychological screening in clinical care

Table 1 Provisional comparison of selected psychological measures relevant to adolescent musculoskeletal care

Instrument	Main construct/use	Approximate burden	Evidence context	Essential caveat
PHQ-2	Initial screening for depressive symptoms	2 items	Pediatric and adolescent clinical settings[17,90,92]	A positive result requires further assessment and is not diagnostic
PHQ-9	Assessment of depressive symptom severity after an initial concern or positive brief screen	9 items	Used in adolescent orthopedic and pediatric subspecialty workflows[17,88,94]	Any endorsement of item 9 requires prompt direct safety clarification regardless of the total score
GAD-2/GAD-7	Initial assessment and quantification of anxiety symptoms	2 or 7 items	General adolescent and pediatric mental-health populations[16,89,90]	Orthopedic-specific validation and optimal thresholds remain limited
PROMIS pediatric measures	Anxiety, depressive symptoms, pain interference, physical function, and related domains	Short forms or computerized adaptive testing	Pediatric and selected MSK populations[89,95,96]	Use the scoring documentation and reference population applicable to the selected version
Pain catastrophizing scale for children	Catastrophic thoughts and feelings related to pain	13 items	Pediatric chronic-pain populations[58,59,91,92]	Reference values are not universal diagnostic or referral thresholds
Fear of pain questionnaire for children	Pain-related fear and activity avoidance	24 items	Pediatric chronic-pain populations[91,93]	Interpretation should distinguish adaptive caution from persistent function-limiting avoidance

It is intended as a provisional clinical orientation rather than a prescribing guide. The instruments have not been uniformly validated across adolescent orthopedic diagnoses, languages, cultures, or treatment settings. Before implementation, clinicians should verify the official version, age range, scoring instructions, translation status, licensing or registration requirements, and locally appropriate response pathways. Cutoff values should not be transferred across populations without validation. PHQ: Patient Health Questionnaire; GAD: Generalized Anxiety Disorder; PROMIS: Patient-Reported Outcomes Measurement Information System; MSK: Musculoskeletal.

Table 2 Clinical interpretation of the evidence linking psychological factors and adolescent musculoskeletal care

Evidence domain	Predominant design/context	Principal finding	Interpretation	Ref.
Association: Scoliosis	Cross-sectional studies and reviews in adolescents with idiopathic scoliosis	Body image dissatisfaction and psychological distress are frequently associated with poorer self-reported quality of life	Direct adolescent evidence; associations are repeatedly reported, but causality and temporal direction remain uncertain	Feddema et al[12], Al Hajaj et al[13], Balboni et al[14], Bertuccelli et al[15], Gallant et al[21], Belli et al[22], Wang et al[23], Schwieger et al[24], Sanders et al[25], Kaya et al[26], Auerbach et al[45], Bertuccelli et al[46]
Association: Chronic MSK pain	Cross-sectional, cohort, and review evidence in adolescents with chronic MSK pain	Anxiety, depressive symptoms, catastrophizing, sleep disturbance, and pain interference frequently coexist with disability	Predominantly direct or adjacent pediatric evidence; findings vary across populations, measures, and study designs	Andias and Silva[35], Harte et al[36], Ocay et al[37], Phillips et al[38], Owiredua et al[39], Groenewald et al[40], Sherwood et al[41], Wolock et al[49], Forgeron et al[50], Jahre et al[51], Bateman et al[52], Feinstein et al[57], Miller et al[58], Guite et al[59]
Association: Sports injury	Observational studies and reviews involving adolescent athletes	Injury may be accompanied by poorer mental health, while pre-existing psychological difficulties may also be associated with injury vulnerability or recovery	Direct and adjacent adolescent evidence supporting a potentially reciprocal relationship rather than a single causal pathway	Putukian et al[27], Chow et al[28], Park et al[29], Nyland and Pyle[30], Brewer and Chatterton[31], Piussi et al[44]
Prognostic value	Prospective studies of adolescents undergoing surgery, rehabilitation, or recovery from MSK pain	Selected psychological factors may predict pain, disability, adherence, recovery, or return to sport	Direct evidence is limited and heterogeneous; prognostic associations do not demonstrate that modifying the factor will improve outcomes	Holley et al[56], Ramo et al[60], Hooten[65], Li et al[66], Pagé et al[67], Rabbitts et al[68], Fisher et al[69], Sapienza et al[70], Flanigan et al[71], Gennarelli et al[72], Richard et al[73], Li et al[74], Thorsell Cederberg et al[75]
Screening feasibility in orthopedic care	Implementation studies in pediatric orthopedic and sports clinics	Brief self-report or electronic screening can be completed during routine encounters and may identify previously unrecognized risk	Direct adolescent orthopedic evidence supporting feasibility and case identification, but not improved orthopedic outcomes	Colon-Morillo et al[17], Iturralde et al[88], Catanzano et al[94], Matthews et al[117]
Screening feasibility in adjacent pediatric care	Implementation studies in rheumatology, prosthetics, primary care, and chronic-disease services	Screening is generally acceptable and can be incorporated into outpatient workflows when response pathways are available	Adjacent pediatric evidence that informs implementation but cannot be treated as orthopedic outcome-effectiveness evidence	Milatz et al[16], James et al[18], Marshall et al[19], Marshall et al[20], Wissow et al[85], Martel et al[98], Quittner et al[99], Patel et al[100]
Psychological intervention	Trials and reviews in pediatric chronic pain populations	Psychological interventions may improve selected pain, disability, or coping outcomes, whereas effects on anxiety and depression are variable	Adjacent pediatric evidence; results should not be generalized automatically to all adolescent orthopedic populations	Palermo[77], Harrison et al[113], Maynard et al[115], Salerno et al[116], Birnie et al[122], Fisher et al[123], Palermo et al[124]
Integrated care	Pilot studies, implementation research, and evidence from pediatric chronic illness, trauma, rehabilitation, and adult MSK care	Coordinated models may improve access, engagement, and continuity of psychosocial care	Mostly adjacent or indirect evidence; direct evidence for improved adolescent orthopedic outcomes remains limited	Marshall et al[20], Reichman et al[106], Yonek et al[107], Teixeira et al[108], American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues and American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues[118], Alsulami et al[119], Davidson et al[120], Marani et al[121]

It provides a descriptive synthesis of representative evidence domains and does not constitute a formal grading of evidence certainty. “Direct evidence” refers to studies conducted in adolescent orthopedic or musculoskeletal populations; “adjacent evidence” refers to related pediatric specialties; and “indirect evidence” refers to adult or other-specialty populations. Descriptors such as “frequently reported,” “limited,” and “heterogeneous” summarize the characteristics of the reviewed literature and are not evidence-grade categories. MSK: Musculoskeletal.

Table 3 Psychological risk and protective factors in adolescents with orthopedic and musculoskeletal disorders

Domain	Risk factors or contextual markers	Protective factors
Psychological	Depressive symptoms; anxiety; pain catastrophizing; FA behaviors; low self-efficacy; negative body image; poor sleep quality; previous trauma or psychiatric disorder	Psychological flexibility; pain acceptance; adaptive coping strategies; high self-efficacy; emotional regulation capacity; optimism
Pain-related and neurobiological	CS symptoms; impaired conditioned pain modulation; high pain sensitivity; somatosensory hypersensitivity; altered pain-modulation profiles	Preserved pain modulation; adequate sleep; adaptive stress-response processes
Developmental, demographic, and structural context	Female sex; older adolescent age; racial or ethnic minority status, public insurance, and lower socioeconomic position as markers of structural inequity, discrimination, differential access to care, material disadvantage, and unequal exposure to social stressors rather than intrinsic biological vulnerability	Equitable access to healthcare; adequate health literacy; culturally responsive services; continuity of care; stable social and material support; opportunities for safe physical and social participation
Family and social	Parental pain catastrophizing; parental anxiety or depression; overprotective responses; poor family functioning; social isolation; peer victimization; low peer acceptance	Strong family support; positive family functioning; peer support; social connectedness; supportive school environment
Condition-related and treatment-related	Greater pain intensity; multisite or persistent pain; strong or exclusive athletic identity following sports injury; visible physical difference; prolonged or burdensome treatment; brace-related distress; preoperative psychiatric history; previous unfavorable treatment experiences	Earlier recognition and treatment; realistic expectations; positive therapeutic alliance; access to multidisciplinary support; adaptive athletic identity; positive previous treatment experiences
Clinical and healthcare-system factors	Absence of an established psychological assessment pathway; unclear referral procedures; fragmented care; provider stigma; limited psychosocial support; inadequate preoperative preparation; insufficient referral capacity; lack of follow-up after a concerning screening result	Clinically appropriate psychological screening; trained staff; defined interpretation and referral pathways; co-located or coordinated mental health services where available; interdisciplinary care; patient-centered communication; shared decision-making; timely assessment and follow-up

Racial or ethnic minority status, insurance status, and socioeconomic position should not be interpreted as intrinsic biological risk factors. Their associations with psychological and clinical outcomes may reflect structural inequities, discrimination, differential access to healthcare, material disadvantage, and unequal exposure to social stressors. The factors presented in this table are intended to support multidimensional clinical assessment and should not be used as stand-alone diagnostic criteria or universal referral thresholds. FA: Fear-avoidance; CS: Central sensitization.