Should child pain anxiety be modeled as a multidimensional latent construct or as a network of interrelated symptoms? Apsychometric comparison in spanish clinical and community populations
Year: 2026
Type: article
Study design: Observational Study
Abstract: Background: Pain anxiety—an anxiety response specifically focused on pain and its anticipation—is a clinically significant psychological process in children and adolescents, predicting functional disability and poorer adjustment over and above pain intensity itself. How this construct is conceptualised and assessed therefore has direct implications for clinical evaluation and intervention. A long-standing question is whether the symptoms captured by pain anxiety scales reflect a single underlying latent trait or a network of directly interacting, mutually reinforcing symptoms—a distinction with both theoretical and clinical consequences that has never been examined in a paediatric pain instrument. Using the Spanish version of the Child Pain Anxiety Symptoms Scale (CPASS), we directly compared latent variable and psychometric network models to clarify how pain anxiety in children is best understood and measured. Methods: In 415 children and adolescents (8-18 years) from clinical (n=195) and community (n=220) settings, we applied a fully cross-validated pipeline: exploratory factor and exploratory graph analysis on a first random split, and confirmatory factor and confirmatory network estimation on the held-out split. Three competing latent models (two-factor, four-factor and second-order) and a confirmatory network model were compared on identical data using non-overlapping RMSEA confidence intervals and AIC. Measurement invariance and network-structure invariance were evaluated in parallel across sex, age and clinical status, and two estimation packages (lavaan and psychonetrics) were contrasted for ordinal data. Results: The methodological choice proved consequential. The confirmatory network model fitted better than every latent specification (highest CFI and TLI, lowest RMSEA with non-overlapping confidence intervals, and lowest AIC). Items that a four-factor solution would discard behaved as clinically meaningful bridge symptoms within the network, and both measurement and network invariance broke down between clinical and community samples—conclusions a conventional CFA-only evaluation would have missed. Within the latent framework, a parsimonious two-factor structure (ω=.90) showed the strongest cross-sample congruence. Conclusions: Pediatric pain anxiety is better characterised as a network of mutually reinforcing symptoms than as the passive reflection of a single latent trait, with highly central and bridge symptoms representing promising targets for clinical assessment and intervention. The Spanish CPASS is supported as a psychometrically sound measure of pain anxiety, best summarised by a parsimonious two-factor structure (Fear and Catastrophizing about Pain; Anxiety and Avoidance Response to Pain), although the breakdown of measurement and network invariance between clinical and community samples means that scores require contextualised interpretation across these populations. More broadly, directly comparing latent and network models—rather than defaulting to confirmatory factor analysis—can reshape the substantive and clinical conclusions drawn from a psychological assessment instrument.
Source: BMC Psychology
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $1,990
Funder: Universidad Francisco de Vitoria
OpenAlex ID: W7212701142