Dyadic analysis of child and parent trait and state pain catastrophizing in the process of children's pain communication

The Influence of Children's Pain-Related Attention Shifting Ability and Pain Catastrophizing Upon Negatively Biased Pain Memories in Healthy School Children

The current study investigated the influence of children's ability to flexibly shift attention toward and away from pain information on the development of negatively biased pain memories, thereby employing a direct measure of attention control reliant on behavioral responses in the context of pain (ie, an attention switching task). The direct influence of children's attention-shifting ability and pain catastrophizing as well as the moderating role of this shifting ability in the relationship between pain catastrophizing and the development of negatively biased pain memories was examined. Healthy school children (N = 41; 9-15 years old) received painful heat stimuli and completed measures of state and trait pain catastrophizing. They then performed an attention-switching task wherein they had to shift attention between personally relevant pain-related and neutral cues. Two weeks after the painful task, children's pain-related memories were elicited via telephone. Findings indicated that children's reduced ability to disengage attention away from pain information predicted more fear memory bias 2 weeks later. Children's pain-related attention-shifting ability did not moderate the relationship between children's pain catastrophizing and negatively biased pain memories. Findings highlight the contribution of children's attention control skills in the development of negatively biased pain memories. PERSPECTIVE: Results of the current study indicate that children with a reduced ability to shift attention away from pain information are at risk for developing negatively biased pain memories. Findings can inform interventions to minimize the development of these maladaptive negatively biased pain memories by targeting pain-relevant attention control skills in children.

A dyadic analysis of parent and child pain catastrophizing and health-related quality of life in pediatric sickle cell disease

ABSTRACT

The purpose of this study was to examine the dyadic and individual level effects of parent and child pain catastrophizing on child health-related quality of life (HRQOL) in pediatric sickle cell disease. Questionnaires assessing child pain frequency, child and parent pain catastrophizing, and child HRQOL were completed by youth and their primary caregiver. A Common Fate Model was estimated to test the dyadic level relationship between parent and child pain catastrophizing and child HRQOL. An Actor-Partner-Common Fate Model hybrid was estimated to test the relationship between child HRQOL and individual-level child pain catastrophizing and parent pain catastrophizing, respectively. In each model, child HRQOL was modelled as a dyadic variable by factoring parent and child ratings. Patients (N = 100, M age = 13.5 years, 61% female) and their caregivers (M age = 41.8 years, 86% mothers) participated. Dyad-level pain catastrophizing was negatively associated with child HRQOL, demonstrating a large effect (β = -0.809). Individual-level parent and child pain catastrophizing were each uniquely negatively associated with child HRQOL, demonstrating small to medium effects (β = -0.309, β = -0.270). Individual level effects were net of same-rater bias, which was significant for both parents and children. Both the unique and the overlapping aspects of parent and child pain catastrophizing are significant contributors to associations with child HRQOL, such that higher levels of pain catastrophizing are associated with worse child HRQOL. Findings suggest the need for multipronged intervention targeting factors common to parent-child dyads and factors unique to parents and children, respectively.

The association of spouse interactions and emotional learning in interference related to chronic back pain

Social interactions affect individual behaviours, preferences, and attitudes. This is also critical in the context of experiencing pain and expressing pain behaviours, and may relate to learned emotional responses. In this respect, individual variability in the medial prefrontal cortex (mPFC), which is involved in adjusting an organism's behaviour to its environment by evaluating and interpreting information within the context of past experiences, is important. It is critical for selecting suitable behavioural responses within a social environment and may reinforce maladaptation in chronic pain. In our study, we used brain imaging during appetitive and aversive pavlovian conditioning in persons with chronic back pain (CBP), subacute back pain (SABP), and healthy controls (HC), together with information on spouse responses to pain behaviours. We also examined the relationship of these responses with pain-related interference in the patients. Our findings yielded a significant negative association between mPFC responses to appetitive and aversive learning in CBP. We also observed a significant negative association for mPFC responses during aversive learning and distracting spouse responses, and a significant positive association between mPFC responses during appetitive learning and solicitous spouse responses in CBP. Both significantly predicted pain-related interference in the CBP group (explained variance up to 53%). Significant associations were not found for SABP or HC. Our findings support an association between appetitive and aversive pavlovian learning, related brain circuits and spouse responses to pain in CBP, where appetitive and aversive learning processes seem to be differentially involved. This can inform prevention and early intervention in a mechanistic approach.

A Brief Mindfulness Intervention for Parents and Children before Pediatric Venipuncture: A Randomized Controlled Trial

BACKGROUND

Routine needle procedures can be distressing for parents and children. Mindfulness interventions may be helpful for parents and children but have not been examined for pediatric needle procedures despite showing benefits in the context of pediatric chronic pain and in lab-based pain tasks.

METHODS

This preregistered (NCT03941717) two-arm, parallel-group randomized controlled trial examined the effects of a 5 min mindfulness intervention before pediatric venipuncture for parents and children (aged 7-12) compared to a control group on primary outcomes of child pain and fear, secondary outcomes of parent distress, and tertiary outcomes of parent ratings of child pain and fear. Moderators of parent and children's responses to the intervention were examined: state catastrophizing, trait mindfulness, and experiential avoidance.

RESULTS

Sixty-one parent-child dyads were randomized (31 mindfulness; 30 control). Parents and children completed measures, listened to a 5 min audio recording (mindfulness or control), and parents accompanied their child during routine venipuncture. The mindfulness intervention involved breathing and encouraging nonjudgmental attention to one's experiences, while the control condition involved an unfocused attention task. Three between-subject MANCOVAs assessed for group differences. Child pain and fear rated by children and their parents did not differ between groups. Parents in the mindfulness group were less distressed during the venipuncture than the controls. Parent state catastrophizing may have moderated the intervention effects, such that parents with moderate and high catastrophizing levels had lower distress following the mindfulness intervention versus control.

CONCLUSIONS

The intervention did not reduce child pain or fear but reduced parent distress. It appeared most helpful for parents catastrophizing about their child's pain, which is noteworthy as these children are prone to worse outcomes.

The Effect of Robot-Led Distraction during Needle Procedures on Pain-Related Memory Bias in Children with Chronic Diseases: A Pilot and Feasibility Study

The current study evaluated the feasibility and preliminary clinical impact of robot-led distraction during needle procedures in children with chronic diseases on pain-related memories. Participants were 22 children (8−12 years old) diagnosed with a chronic disease (e.g., chronic immune deficiency) and undergoing a needle procedure as part of their routine treatment. Children were randomized to the experimental group (i.e., robot-led distraction) or control group (i.e., usual care). For feasibility, we evaluated study- and needle-procedure-related characteristics, intervention fidelity and acceptability, and nurse perceptions of the intervention. Primary clinical outcomes included children’s memory bias for pain intensity and pain-related fear (1 week later). Results indicated that intervention components were >90% successful. Overall, the robot-led distraction intervention was perceived highly acceptable by the children, while nurse perceptions were mixed, indicating several challenges regarding the intervention. Preliminary between-group analyses indicated a medium effect size on memory bias for pain intensity (Hedges’ g = 0.70), but only a very small effect size on memory bias for pain-related fear (Hedges’ g = 0.09), in favor of the robot-led distraction intervention. To summarize, while feasible, certain challenges remain to clinically implement robot-led distraction during needle procedures. Further development of the intervention while accounting for individual child preferences is recommended.

Time for Action: Understanding Health Care Professionals Views on Pain and Pain Management in a Pediatric Hospital

BACKGROUND

Children admitted to the hospital experience pain. ChildKind International (CKI) is an organization dedicated to improving the quality of pediatric pain care worldwide. In 2019, BC Children hospital (BCCH) clinicians set out to achieve this certification. A qualitative study was performed in order to fully comprehend the current state of pain assessment and management at BCCH.

AIM

The objective of this study is to characterize the perceptions of health care professionals (HCPs) about pediatric pain and pain management in a pediatric hospital.

METHODS

We choose a quantitative methodology as it allows us to delve more deeply into the HCPs' personal experience with pain and pain management of children in the hospital. We interviewed 31 pediatric healthcare professionals (N = 31).

RESULTS

HCPs believe there is a significant lack of resources, especially educational resources, to adequately assess and treat pain in children. There is a lack of time to evaluate each patient appropriately and use pain tools consistently for both verbal and non-verbal children. HCPs varied in their opinions as to whether a procedure is painful or uncomfortable, and this opinion often differs from the perception of the child. Additionally, staff recognize that cultural diversity of both staff and patients can influence pain assessment and management in children. Therefore, there is a need for increased cultural diversity training for staff.

CONCLUSIONS

Pain management and treatment of children in the hospital remain inconsistent and inadequate. ChildKind certification will help hospitals to address this gap in their clinical practice.

Using the Parent Risk Screening Measure (PRISM) to Assess Pain-Related Risk Factors in Parents of Youth Seeking Treatment for Acute Musculoskeletal Pain

OBJECTIVES

The Parent Risk Screening Measure (PRISM) rapidly assesses parent distress, psychosocial function, and behaviors associated with child pain-related dysfunction in parents of youth with chronic pain. Recognizing the importance of parent pain-related cognitions and responses to pain during the acute pain period, the current study examined the utility of the PRISM in screening parents of youth with acute pain.

METHODS

Participants were 175 parent-youth dyads taking part in a larger study examining risk and resilience in youth with acute musculoskeletal pain. Parents completed the PRISM and a battery of measures reporting on their child's pain-related disability and cognitions and behaviors in response to their child's pain. Youth reported on their pain, pain-related disability, pain-related fear, catastrophizing, and pain self-efficacy.

RESULTS

PRISM total scores ( M =2.55, SD=2.77) were correlated with many parent and child report measures (eg, protectiveness, catastrophizing, and pain-related fear), with higher scores associated with greater symptoms. Using published PRISM cutoffs, 86.9% of parents were classified as low and 13.13% as elevated risk. t tests revealed significant differences between elevated and low-risk groups on several measures. Moreover, youth of parents in the elevated risk group were more likely to meet clinical cutoffs on pain catastrophizing and fear avoidance measures.

DISCUSSION

Findings suggest the PRISM is useful in screening for parent distress and behaviors associated with elevated pain symptomatology in a pediatric acute musculoskeletal pain sample. The important next steps are to identify the ideal time for administering the PRISM and to examine the associations among PRISM scores and pain outcomes over time.

Pain science education for children living with and beyond cancer: Challenges and research agenda

Pain in children living with and beyond cancer is understudied and undertreated. Pain science education (PSE) is a conceptual change strategy facilitating patients' understanding of the biopsychosocial aspects of pain. Preliminary studies on the adaptation of PSE interventions to adults with and beyond cancer provide a foundation for pediatric research. PSE could help childhood cancer survivors experiencing persistent pain and pain-related worry after active treatment. PSE may also help children receiving cancer treatment, providing them with a foundation of adaptive pain beliefs and cognitions, and preparing them for procedural and treatment-related pain. We direct this paper toward pediatric oncology clinicians, policy makers, and researchers working with children living with and beyond cancer. We aim to (a) identify challenges in adapting PSE for children living with and beyond cancer, (b) offer possible solutions, and (c) propose research questions to guide the implementation of PSE for children living with and beyond cancer.

Biopsychosocial Contributors to Parent Behaviors during Child Venipuncture

Children's needle-related distress is strongly related to parental verbal behaviors. Yet, empirical data supporting theorized contributors to parent behaviors in this context remain limited. This is the first study to collectively measure biological (heart rate variability; HRV), psychological (catastrophizing, anxiety), and social (child behaviors) contributors to parent verbal behaviors throughout pediatric venipuncture. HRV was used as a measure of emotion regulation capacity and examined as a moderator in the associations between parent psychological factors and their behaviors, and between child and parent behaviors. Sixty-one children aged 7 to 12 years who presented at an outpatient blood lab for venipuncture and a parent participated. Parent baseline HRV, state catastrophizing, and anxiety were measured prior to venipuncture. The procedure was video-recorded for later coding of pairs' verbal behaviors. Strong associations emerged between child behaviors and parent behaviors. Baseline HRV moderated the association between parent catastrophizing and behavior. Social factors remain a strong influence related to parent behaviors. Psychologically, parent negative cognitions differentially related to parent behaviors based on their emotion regulation capacity. Biologically, low baseline HRV may increase the risk that certain parents engage in a constellation of behaviors that simultaneously direct their child's attention toward the procedure and inadvertently communicate parental worry, fear, or concern.

Design and implementation of a novel patient-centered empowerment approach for pain optimisation in children undergoing major surgery

Background

Paediatric surgery is a stressful experience for patients and caregivers. While standardised protocols are the norm, patient-centred approaches are needed to empower patients/caregivers for an optimal perioperative pain experience. To address this gap, we employed a patient-centred approach using design thinking (DT) methodology to develop insights, map processes, identify opportunities and design solutions for individualised empowerment tools.

Methods

In consultation with DT experts, a multidisciplinary team of stakeholders (healthcare providers, patients who underwent pectus excavatum/scoliosis surgery and their caregivers), were invited to participate in surveys, interviews and focus groups. The project was conducted in two sequential stages each over 24 weeks—involving 7 families in stage 1 and 16 patients/17 caregivers in stage 2. Each stage consisted of three phases: design research (focus groups with key stakeholders to review and apply collective learnings, map processes, stressors, identify influencing factors and opportunities), concept ideation (benchmarking and co-creation of new solutions) and concept refinement.

Results

In stage 1, mapping of stress/anxiety peaks identified target intervention times. We identified positive and negative influencers as well as the need for consistent messaging from the healthcare team in our design research. Current educational tools were benchmarked, parent-child engagement dyads determined and healthcare-based technology-based solutions conceived. The ‘hero’s journey’ concept which has been applied to other illness paradigms for motivation successfully the was adapted to describe surgery as a transformative experience. In stage 2, patient and caregiver expectations, distinct personas and responses to perioperative experience were categorised. Educational tools and an empowerment tool kit based on sensorial, thinking, relaxation and activity themes, tailored to parent/child categories were conceptualised.

Conclusion

DT methodology provided novel family centred insights, enabling design of tailored empowerment toolkits to optimise perioperative experience. Adapting the hero’s journey call to adventure may motivate and build resilience among children undergoing surgery.

The influence of contextual factors on children's communication of pain during pediatric Haematopoietic Stem Cell Transplantation: A qualitative case study

PURPOSE

The aim of this study was to describe how contextual factors related to the clinical setting of a pediatric HSCT unit influenced children's communication of pain to their health-care providers and parents during hospitalization.

DESIGN AND METHODS

A qualitative case study design was conducted in two-phases in a tertiary level pediatric HSCT unit. The Social Communication Model of Pain provided the conceptual framework for the study. In phase one participants were parents and phase two participants were health-care providers and children in a pediatric HSCT unit. Parents participated in semi-structured interviews at 30- and 90-days post-transplantation regarding their child's communication of pain. Naturalistic observations of children receiving clinical care were conducted and health-care providers participated in semi-structured interviews.

RESULTS

Children extensively denied pain to their parents and health-care providers. When children did communicate pain, they were motivated by a need to seek interventions for their pain. Children's willingness to communicate pain was influenced by the physiological impact of HSCT therapy, their previous experiences of pain, their relationship with parents and health-care providers and parents and an environment of fear and uncertainty.

CONCLUSIONS

There is a pressing need for child-centric approaches to support children to communicate their pain experiences to overcome the limitations imposed by the complexity of their medical treatment and the clinical environment in which they receive healthcare.

PRACTICE IMPLICATIONS

In the context of HSCT therapy children may not communicate pain until pain is severe, and no longer bearable, or outright deny the presence of pain.

Parental Pain Catastrophizing, Communication Ability, and Post-surgical Pain Outcomes Following Intrathecal Baclofen Implant Surgery for Patients With Cerebral Palsy

There is strong evidence that psychosocial variables, including pain catastrophizing, influence parental and child ratings of pain, pain expression, and long-term outcomes among children with chronic pain. The role of these factors among children who have communication deficits due to cerebral palsy (CP) and other intellectual and developmental disabilities is currently unclear. In this study, parental pain catastrophizing was assessed before intrathecal baclofen (ITB) pump implantation for spasticity management in 40 children and adolescents with CP, aged 4 to 24 years. Pain was assessed before and after surgery with two methods: a parent-reported pain interference scale, and behavioral pain signs during a standardized range of motion exam. Linear mixed models with clinical/demographic factors and scores from the Pain Catastrophizing Scale for Parents (PCS-P), and child spoken language ability as predictors and the pain variables as the outcomes were implemented. On average, both pain outcomes improved after surgery. Only child spoken language ability predicted change in behavioral reactivity scores, with children with phrase speech showing an increase in reactivity at follow-up compared to pre-surgery levels, on average. A significant interaction between PCS-P scores and spoken language ability on change in pain interference scores over time showed that dyads with children with phrase speech whose parents reported high PCS-P scores reported the least improvement in pain interference at follow-up. Due to the preliminary nature of the study, future work is needed to investigate the parental behaviors that mediate the relationships between parental catastrophizing and pain outcomes in this population.

A Pilot Randomized Controlled Trial of Virtual Reality Distraction to Reduce Procedural Pain During Subcutaneous Port Access in Children and Adolescents With Cancer

OBJECTIVES

We aimed to determine the feasibility of virtual reality (VR) distraction for children with cancer undergoing subcutaneous port (SCP) access. We also aimed to estimate preliminary treatment effects of VR compared with an active distraction control (iPad).

MATERIALS AND METHODS

A single-site pilot randomized controlled trial comparing VR to iPad distraction was conducted. Eligible children and adolescents were aged 8 to 18 years undergoing treatment for cancer with upcoming SCP needle insertions. Intervention acceptability was evaluated by child, parent, and nurse self-report. Preliminary effectiveness outcomes included child-reported pain intensity, distress, and fear. Preliminary effectiveness was determined using logistic regression models with outcomes compared between groups using preprocedure scores as covariates.

RESULTS

Twenty participants (mean age 12 y) were randomized to each group. The most common diagnosis was acute lymphocytic leukemia (n=23, 58%). Most eligible children and adolescents (62%) participated, and 1 withdrew after randomization to the iPad group. Nurses, parents, and children reported the interventions in both groups to be acceptable, with the VR participants reporting significantly higher immersion in the distraction environment (P=0.0318). Although not statistically significant, more VR group participants indicated no pain (65% vs. 45%) and no distress (80% vs. 47%) during the procedure compared with the iPad group. Fear was similar across groups, with ~60% of the sample indicating no fear.

DISCUSSION

VR was feasible and acceptable to implement as an intervention during SCP access. Preliminary effectiveness results indicate that VR may reduce distress and distress compared with iPad distraction. These data will inform design of a future full-scale randomized controlled trial.

The Moderating Role of Attention Control in the Relationship Between Pain Catastrophizing and Negatively-Biased Pain Memories in Youth With Chronic Pain

The present study examined the role of attention control in understanding the development of negatively-biased pain memories as well as its moderating role in the relationship between pain catastrophizing and negatively-biased pain memories. Youth with chronic pain (N = 105) performed a cold pressor task (CPT) and completed self-report measures of state/trait pain catastrophizing and attention control, with the latter comprising both attention focusing and attention shifting. Two weeks after the CPT, youth's pain-related memories were elicited via telephone allowing to compute pain and anxiety memory bias indices (ie, recalling pain intensity or pain-related anxiety, respectively, as higher than initially reported). Results indicated no main effects of attention control and pain catastrophizing on pain memories. However, both components of attention control (ie, attention focusing and attention shifting) moderated the impact of pain catastrophizing on youth's memory bias, with opposite interaction effects. Specifically, whereas high levels of attention shifting buffered the influence of high pain catastrophizing on the development of pain memory bias, high levels of attention focusing strengthened the influence of high pain catastrophizing on the development of anxiety memory bias. Interaction effects were confined to trait catastrophizing (ie, not state catastrophizing). Theoretical and clinical implications are discussed. PERSPECTIVE: This article investigates the role of attention control in the development of negatively-biased pain memories in children with chronic pain. Findings underscore the importance of targeting differential components of attention control and can inform intervention efforts to minimize the development of negatively biased pain memories in youth with chronic pain.

What is pain: Are cognitive and social features core components?

Pain is a universal experience, but it has been challenging to adequately define. The revised definition of pain recently published by the International Association for the Study of Pain addressed important shortcomings of the previous version; however, it remains narrow in its focus on sensory and emotional features of pain, failing to capture the substantial roles of cognitive and social core components of the experience and their importance to advances in pain management. This paper reviews evidence and theoretical models for the significant role social and cognitive factors play in pain experience and we argue that without explicit recognition of these core components in the definition, significant nuances are lost at a cost to understanding and clinical management of pain. A focus on sensory and emotional features perpetuates biomedical interventions and research, whereas recognition of cognitive and social features supports a multidimensional model of pain, advances in interdisciplinary care, and the benefits of cognitive behavioral therapy and self‐management interventions. We also explore the six Key Notes that accompany the new definition of pain, discuss their application to the understanding of pain in childhood, and, in doing so, further explore social and cognitive implications. Considerations are also described for assessment and treatment of pain in pediatric populations.

Parent-Child Dyadic Coping and Quality of Life in Chronically Diseased Children

Different forms of dyadic coping are associated with positive outcomes in partner relationships, yet little is known about dyadic coping in parent-child relationships. The current research explored the association between parent-child dyadic coping and children’s quality of life in 12–18-year old children with a chronic disease (i.e., cystic fibrosis, autoimmune diseases, and children post-cancer treatment). In a sample of 105 parent-child dyads, self-reported forms of dyadic coping (i.e., stress communication, problem-oriented, emotion-oriented, and negative dyadic coping) and children’s quality of life were assessed. Children reported more stress communication and negative dyadic coping than their parents, while parents reported more problem-oriented dyadic coping and emotion-oriented dyadic coping than their children. More stress communication of the child was associated with more emotion-oriented dyadic coping and less negative dyadic coping of the parent. More negative dyadic coping of the child was associated with less stress communication, problem-oriented dyadic coping and emotion-oriented dyadic coping of the parent. Additionally, both children’s and parents’ negative dyadic coping were associated with lower self-reported pediatric quality of life and parents’ emotion-oriented dyadic coping was associated with higher pediatric quality of life. These findings emphasize that children and their parents mutually influence each other and that dyadic coping is associated with children’s quality of life. Theoretical and practical implications are discussed.

Parental Catastrophizing and Goal Pursuit in the Context of Child Chronic Pain: A Daily Diary Study

Background: Despite daily variability in children's chronic pain experiences, little is known about how parents' emotions and goals toward their child's pain are influenced by these daily changes. This diary study examined how daily child pain intensity (as perceived by parents) moderates the associations between parental catastrophic thoughts about child pain on the one hand, and daily parental distress and parents' goals with regard to their child's pain (pain control vs. activity engagement) on the other hand.

Method: Participants were 25 parents of 20 different children (N = 18; 90% girls). Children, aged 8–14 years (M = 9.5, SD = 2.09), experienced either chronic headache or functional abdominal pain with an average pain duration of 22.5 months (SD = 24.5 months). Daily parental responses (i.e., perceived child pain intensity, distress and goal endorsement) were collected through a 3-week daily diary (resulting in 413 valid diary reports). Parents completed the Pain Catastrophizing Scale for Parents prior to starting the diary (PCS-P general) and a daily measure (PCS-P daily) included in the diary. To account for the interdependence of the data, the data were analyzed using multilevel modeling.

Results: Perceived daily child pain intensity moderated the impact of parental general and daily catastrophic thoughts on parents' daily distress. Only for parents experiencing low general catastrophic thoughts an increase in distress was observed on days when they perceived their child's pain intensity as high. For all parents, high levels of perceived child pain intensity were related to more distress on days where parents reported high levels of catastrophic thinking (i.e., PCS-P daily). Perceived daily child pain intensity also moderated the impact of parental general catastrophic thinking on parents' daily endorsement of goals. Parents with high levels of general catastrophic thinking reported a lower focus on child pain control on days when child pain intensity was perceived to be low. Parents with low general catastrophic thinking reported lower endorsement of the activity engagement goal on days where the child's pain intensity was perceived to be low.

Conclusion: These findings highlight the complexity of daily fluctuations in parental distress and goals regarding their child's pain. Clinical implications and future directions are critically assessed.

The effect of a pain educational video intervention upon child pain-related outcomes: A randomized controlled study

BACKGROUND

Pain neuroscience education (PNE) has received increasing research attention demonstrating beneficial effects on pain-related outcomes in adults. Conversely, studies on the effectiveness of PNE in children are scarce.

METHODS

This study investigated the effect of a pain educational video intervention on child pain-related outcomes (i.e. experienced pain intensity, pain-related fear and catastrophic worry about pain, pain threshold and pain knowledge) in healthy children undergoing an experimental pain task. Furthermore, the moderating role of children's demographic (i.e. sex and age) and psychological (i.e. baseline pain knowledge and anticipated pain intensity, pain-related fear and catastrophic worry) characteristics was examined. Participants were 89 children (M_age  = 11.85, SD = 1.78), randomly assigned to either a condition whereby they were instructed to watch a brief pain educational video (i.e. experimental group) or to a control condition whereby they did not watch any video.

RESULTS

Study findings revealed that accurate pain knowledge and pain threshold were higher amongst children in the experimental group compared to the control group. In contrast with expectations, no main effects of the video intervention were observed for experienced pain intensity, pain-related fear and catastrophic worry. Moderation analyses indicated that the video intervention contributed, in comparison with the control condition, to higher levels of pain knowledge amongst younger children only and to higher pain thresholds amongst boys only.

CONCLUSIONS

Further investigation is needed to optimize pain educational video interventions and to determine whether more beneficial outcomes can be found in clinical (i.e. non-experimental) situations and in children with persistent or recurring pain problems.

SIGNIFICANCE

Examining the impact of pain educational interventions within a non-clinical setting is deemed particularly important given that adaptive pain coping strategies likely play an important role in preventing the development and maintenance of future maladaptive pain-related behaviour. Further, study findings provide preliminary evidence of baseline and demographic (i.e. age and sex) characteristics explaining differences in the effect of a pain educational video intervention in pain knowledge and pain-related experiences during experimental pain.

Longitudinal Impact of Parental Catastrophizing on Child Functional Disability in Pediatric Amplified Pain

Objective

Children with amplified musculoskeletal pain (AMPS) experience significant functional disability, with impairment in their ability to participate in age-appropriate activities of daily living. Parental factors play an important role in a child’s pain symptoms and treatment outcomes, with parental pain catastrophizing and protective behaviors linked to several maladaptive outcomes for children. Aims of the current study were to examine how parental pain catastrophizing, child pain catastrophizing, and parental protective behaviors longitudinally impacted functional disability for children with AMPS.

Methods

Archival data were examined from parent-child dyads presenting to a tertiary pain clinic for treatment of AMPS. Over 1 year, parents completed measures assessing the level of pain catastrophizing, common behavioral responses to child pain, and child functional disability. Children completed measures of pain catastrophizing and functional disability. Measures were collected at initial evaluation, 6-months, and 12-months. Latent growth models (LGM) were conducted to examine how to study variables longitudinally impacted the rate of change in child functional disability.

Results

Examining a comprehensive LGM of study variables, parental catastrophizing emerged as the sole contributing factor to slower improvement in functional disability.

Conclusions

The strong influence of parental pain catastrophizing on functional disability may relate to parents limiting behaviors that promote adaptive coping in children with pain. As such, parents who catastrophize may benefit from specific interventions to increase their use of adaptive behavioral responses, such as redirecting children to complete functional activities and encouraging the use of positive coping skills for pain-related distress.

A Multi-Method Approach to Understand Parent Behaviors During Child Acute Pain

Abstract. Parent behaviors strongly predict child responses to acute pain; less studied are the factors shaping parent behaviors. Heart rate variability (HRV) is considered a physiological correlate of emotional responding. Resting or “trait” HRV is indicative of the capacity for emotion regulation, while momentary changes or “state” HRV is reflective of current emotion regulatory efforts. This study aimed to examine: (1) parent state HRV as a contributor to parent verbal behaviors before and during child pain and (2) parent trait HRV as a moderator between parent emotional states (anxiety, catastrophizing) and parent behaviors. Children 7–12 years of age completed the cold pressor task (CPT) in the presence of a primary caregiver. Parents rated their state anxiety and catastrophizing about child pain. Parent HRV was examined at 30-second epochs at rest (“trait HRV”), before (“state HRV-warm”), and during their child’s CPT (“state HRV-cold”). Parent behaviors were video recorded and coded as coping-promoting or distress-promoting. Thirty-one parents had complete cardiac, observational, and self-report data. A small to moderate negative correlation emerged between state HRV-cold and CP behaviors during CPT. Trait HRV moderated the association between parent state catastrophizing and distress-promoting behaviors. Parents experiencing state catastrophizing were more likely to engage in distress-promoting behavior if they had low trait HRV. This novel work suggests parents who generally have a low (vs. high) HRV, reflective of low capacity for emotion regulation, may be at risk of engaging in behaviors that increase child distress when catastrophizing about their child’s pain.

Communicating with Youth about Pain: Developmental Considerations

BACKGROUND

Pain experiences can negatively impact children and adolescents, leading to trauma symptoms and nonadherence to important health behaviors. Developmentally-tailored communication strategies may mitigate this risk.

METHODS

This article reviews cognitive and linguistic developmental factors, within the familial and cultural context, that are important to consider when communicating with youth about acute, procedural, and/or chronic pain.

RESULTS

Youth undergoing acute or procedural pain benefit from pain education, truthful information about the procedure, and advance preparation. The use of analogies may be particularly helpful for patient understanding of chronic pain development, maintenance, and treatment. Youth with developmental disabilities may express pain differently than their normative peers, requiring adaptation of communication strategies.

CONCLUSION

Developmentally-tailored pain communication is an important tool for caregivers and healthcare providers that may foster adaptive functioning in youth who experience pain.

Testing the intergenerational model of transmission of risk for chronic pain from parents to their children: an empirical investigation of social transmission pathways

Children of parents with chronic pain have higher rates of pain and internalizing (eg, anxiety and depressive) symptoms than children of parents without chronic pain. Parental modeling of pain behaviour and reinforcement of child pain have been hypothesized to underlie these relationships. These mechanisms were tested in a sample of 72 parents with chronic pain and their children (aged 8-15 years). Standardized measures were completed by parents (pain characteristics, pain interference, and child internalizing) and children (pain catastrophizing, pain over previous 3 months, and internalizing). In a laboratory session, children completed the cold pressor task in the presence of their parent, and parent-child verbalizations were coded. Significant indirect effects of parental pain interference on child self-reported (B = 0.12, 95% confidence interval [CI]: 0.01-0.29) and parent-reported (B = 0.16, 95% CI: 0.03-0.40) internalizing symptoms through child pain catastrophizing were found (parental modeling mechanism), and were not moderated by child chronic pain status. Significant indirect effects were found between parent pain-attending verbalizations and child self-reported (B = 2.58, 95% CI: 1.03-5.31) and parent-reported (B = 2.18, 95% CI: 0.93-4.27) cold pressor task pain intensity and tolerance (B = -1.02, 95% CI: -1.92 to -0.42) through child pain-attending verbalizations (parental reinforcement mechanism). Although further understanding of the temporal relationships between these variables is needed, the current study identifies constructs (eg, parent pain interference, child pain catastrophizing, and parent reinforcement of child pain) that should be further examined as potential targets for prevention and intervention of pain and internalizing symptoms in children of parents with chronic pain.

The gender context of pain

Pain is a major source of global suffering, with women bearing the greatest burden. Alongside biology, psychological and social factors, including gender, help explain these differences. However, there has been no direct attempt to develop a unified social psychological model of men and women's pain. By drawing on approaches to both gender and pain, a gender context model of pain is presented. It proposes that pain is partly influenced by the gender context in which it occurs, which operates at both individual and interpersonal levels. The model is used to structure an appraisal of the existing evidence around gender and pain, and explore whether the model helps explain why such variation occurs. It is argued that despite evidence for an association between gender and pain, there are empirical gaps that need to be addressed. Implications and directions for future investigations into sex, gender and pain are considered.

Disentangling trait versus state characteristics of the Pain Catastrophizing Scale and the PHQ-8 Depression Scale

BACKGROUND

Research on the role of trait versus state characteristics of a variety of measures among persons experiencing pain has been a focus for the past few decades. Studying the trait versus state nature of the Pain Catastrophizing Scale (PCS) and the Patient Health Questionnaire (PHQ-8) depression scale would be highly informative given both are commonly measured in pain populations and neither scale has been studied for trait/state contributions.

METHODS

The PHQ-8 and PCS were obtained on persons undergoing knee arthroplasty at baseline, 2-, 6- and 12-month post-surgery (N = 402). The multi-trait generalization of the latent trait-state model was used to partition trait and state variability in PCS and PHQ-8 item responses simultaneously. A set of variables were used to predict trait catastrophizing and trait depression.

RESULTS

For total scores, the latent traits and latent states explain 63.2% (trait = 43.2%; state = 20.0%) and 50.2% (trait = 29.4%; state = 20.8%) of the variability in PCS and PHQ-8, respectively. Patients with a high number of bodily pain sites, high levels of anxiety, young patients and African-American patients had high levels of trait catastrophizing and trait depression. The PCS and the PHQ-8 consist of both enduring trait and dynamic state characteristics, with trait characteristics dominating for both measures.

CONCLUSION

Clinicians and researchers using these scales should not assume the obtained measurements solely reflect either trait- or state-based characteristics.

SIGNIFICANCE

Clinicians and researchers using the PCS or PHQ-8 scales are measuring both state and trait characteristics and not just trait- or state-based characteristics.

Maternal Pain Management at Home in Children with Cancer: A Turkish Sample

PURPOSE

The purpose of the present study was to examine maternal pain management in children with cancer and the associated factors.

DESIGN AND METHODS

The present work is a descriptive and cross-sectional study. Data for the study were obtained from mothers of children in the age group of 0 to 18 years undergoing treatment for solid tumors in Pediatric Oncology Service and Outpatient Clinics (n = 112). We used a questionnaire on parental pain management practices at home, the knowledge about pain and analgesic drugs, Spielberger State-Trait Anxiety Inventory (STAI), and Pain Catastrophizing Scale (PCS) to collect the data.

RESULTS

Several mothers taking part in the study reported various misconceptions about the assessment of children's pain, analgesic drugs, and usage of limited non-pharmacological methods for managing pain in children with cancer. No significant relationships were found between mothers' pain management practices, knowledge of pain assessment and analgesic drugs, and mothers' and children's sociodemographic characteristics or mothers' pain catastrophizing and anxiety about their own pain.

CONCLUSIONS

The findings of the study revealed that the majority of mothers of children with cancer had misconceptions regarding knowledge of pain assessment and analgesic drugs; these misconceptions potentially lead to manage children's pain associated with cancer ineffectively. Findings indicate mothers' information and support needs for children's cancer pain management in the home settings.

PRACTICE IMPLICATIONS

A further understanding of barriers to parental pain management in children with cancer in the home setting will contribute immensely in developing appropriate management practices.

When "a headache is not just a headache": A qualitative examination of parent and child experiences of pain after childhood cancer

OBJECTIVE

Today, more than 80% of children diagnosed with cancer are expected to survive. Despite the high prevalence of pain associated with the diagnosis and treatment of childhood cancer, there is a limited understanding of how having cancer shapes children's experience and meaning of pain after treatment has ended. This study addresses this gap by exploring childhood cancer survivors' (CCS') experiences of pain from their perspective and the perspective of their parents.

METHODS

Twenty semi-structured interviews were completed with CCS (50% female; mean age = 13.20 y, range = 8-17 y) and their parents (90% mothers). Data were analyzed using interpretive phenomenological analysis.

RESULTS

Analyses revealed three superordinate themes present in the data: (a) pain is a changed experience after childhood cancer; (b) new or ambiguous pains may be interpreted by CCS and parents as a threat of disease recurrence, late effects, or a secondary cancer; and (c) pain interpretation occurs within the broader context of how CCS and parents appraise their cancer experience. Parents generally appraised their child's cancer and pain as more threatening and were influential in guiding their child's interpretations.

CONCLUSIONS

The cancer experience played an important role in shaping CCS' and their parents' experience and interpretation of pain in survivorship. This study provides novel data to inform the development and refinement of new and existing conceptual models of pain and symptom perception after cancer. The results also point to key areas for future investigation and clinical intervention to address the issue of pain in cancer survivorship.

Dyadic analysis of siblings' relationship quality, behavioural responses, and pain experiences during experimental pain

Research on family factors in paediatric pain has primarily focused on parents; the role of siblings has been largely ignored. This study examined whether sibling relationship quality was related to siblings' behaviours during experimental pain, and whether the behaviours of an observing sibling were related to children's pain outcomes. Ninety-two sibling dyads between 8 and 12 years old completed both observational and questionnaire measures of sibling relationship quality. Children took turns completing the cold-pressor task (CPT) in a counterbalanced order with their sibling present. Pain outcomes (intensity, fear, and tolerance) were recorded for each sibling, and the behaviour of the observing and participating siblings during the CPT were coded as attending, nonattending, and coping/encouragement. Structural equation modelling, using the actor-partner interdependence model, was conducted to analyse the dyadic data. While participating in the CPT with their sibling present, greater levels of warmth and positivity in the sibling relationship were related to children engaging in more nonattending behaviours and less attending behaviours. Greater levels of attending behaviours by the observing child was related to the sibling having a lower pain tolerance, and greater levels of coping/encouragement behaviours by the observing child was related to the sibling reporting greater pain intensity and fear during the CPT. Children with warmer/positive sibling relationships were more likely to respond to acute pain by shifting the focus away from their pain experience (eg, through distraction) when a sibling was present. Pain-focused behaviours by an observing sibling are related to greater child pain and fear during experimental pain.

Scaling properties of pain intensity ratings in paediatric populations using the Faces Pain Scale-revised: Secondary analyses of published data based on the item response theory

BACKGROUND

The Faces Pain Scale-revised (FPS-r) has been developed as an interval scale. For other pain measurement instruments, several studies found evidence for and against an interval level of measurement.

OBJECTIVES

The primary aim of the current study was to evaluate the scale properties of the FPS-r using an item response theory approach.

DESIGN

Secondary analysis of published data.

SETTING

Three studies; Study 1 and study 2: One university hospital; Study 3: international pain registry.

PARTICIPANTS

Study 1: n = 246, female: 41%, age: 11-18 years, 3 pain items; Study 2: n = 240, female: 43%, age: 11-18 years, 9 pain items; Study 3: n = 2266, female: 41%, age: 4-18 years, 3 pain items.

METHODS

The rating scale model (interval scale), the graded response model (no interval scale, ordered response categories) and the partial credit model (no interval scale) were used to scale the data.

RESULTS

In all three studies, the rating scale model was outperformed by the graded response model or the partial credit model in terms of model fit. Overlapping response categories were found in items associated with less pain. Response category widths were wider for categories associated with low pain intensity and smaller for categories associated with high pain intensities. Smallest response categories were 1%-67% smaller compared to the widest response category of the same item.

CONCLUSION

According to these findings, the interval scale properties of the FPS-r may be questioned. Item response theory methods may help to solve the problem of missing linearity in pain intensity ratings using FPS-r.

A Multi-Informant Multi-Method Investigation of Family Functioning and Parent-Child Coping During Children's Acute Pain

Objective

To explore relations between family functioning and child acute pain, including pain ratings, coping, and parent–child behaviors.

Methods

Community sample of 171 dyads including one child aged 8–12 years (52% girls) and one parent (79% mothers). Family functioning was assessed via child and parent self-report, and observation during a conflict discussion task. Children and parents rated pain catastrophizing at baseline, and child pain and distress following a cold pressor task (CPT). Parent–child interactions during the CPT were coded for observed behaviors during child pain.

Results

Self-report of poorer family functioning predicted greater child and parent pain catastrophizing, and parent distress. Less observed family negativity/conflict and cohesiveness, and greater family focus of problems and parent emotional support predicted more child symptom complaints. Family functioning was not associated with child pain or distress.

Conclusions

Family functioning influenced parent and child coping and child behavioral responses, but not the experience, of acute pain.

Child and parent pain catastrophizing and pain from presurgery to 6 weeks postsurgery: examination of cross-sectional and longitudinal actor-partner effects

Child and parent pain catastrophizing are reported preoperative risk factors for children's acute and persistent postsurgical pain. This study examined dyadic relations between child and parent pain catastrophizing and child and parent ratings of child pain prior to (M = 4.01 days; "baseline") and following surgery (M = 6.5 weeks; "acute follow-up"), as well changes in pain catastrophizing during this time in 167 youth (86% female; Mage = 14.55 years) undergoing spinal fusion surgery and 1 parent (89% mothers). Actor-partner interdependence models assessed cross-sectional and longitudinal intra- and interpersonal effects. Cross-sectionally, child pain catastrophizing was positively associated with child pain at baseline and acute follow-up (actor effects: βbaseline = 0.288 and βfollow-up = 0.262; P < 0.01), and parents' ratings of child pain at baseline (partner effect: βbaseline = 0.212; P < 0.01). Parent pain catastrophizing was not cross-sectionally associated with ratings of child pain. Longitudinally, higher pain catastrophizing at baseline predicted higher pain catastrophizing at acute follow-up for children (actor effect: β = 0.337; P < 0.01) and parents (actor effect: β = 0.579; P < 0.01) with a significantly smaller effect for children (respondent × actor interaction: β = 0.121; P < 0.05). No longitudinal partner effects for catastrophizing were observed. Baseline child and parent pain catastrophizing did not predict child pain at acute follow-up. In conclusion, child, not parent, pain catastrophizing was associated with children's pre- and postsurgical pain, and showed significantly less stability over time. There is a need to better understand contributors to the stability or changeability of pain catastrophizing, the prospective relation of catastrophizing to pain, and contexts in which child vs parent pain catastrophizing is most influential for pediatric postsurgical pain.

Psychosocial factors and their influence on the experience of pain

Over the past 20 years, our understanding of social factors on pain experience has increased. Edwards et al observed that the presence of a friend resulted in an increased pain threshold and tolerance to experimentally induced pain (cold pressor test and pressure algometry). Having a male friend present had the most prominent effect on male participants' reporting of pain. However, the effects of psychosocial traits known to effect pain experience (eg, catastrophising) were not considered.

Evidence-Based Psychological Interventions for the Management of Pediatric Chronic Pain: New Directions in Research and Clinical Practice

Over the past 20 years our knowledge about evidence-based psychological interventions for pediatric chronic pain has dramatically increased. Overall, the evidence in support of psychological interventions for pediatric chronic pain is strong, demonstrating positive psychological and behavioral effects for a variety of children with a range of pain conditions. However, wide scale access to effective psychologically-based pain management treatments remains a challenge for many children who suffer with pain. Increasing access to care and reducing persistent biomedical biases that inhibit attainment of psychological services are a central focus of current pain treatment interventions. Additionally, as the number of evidence-based treatments increase, tailoring treatments to a child or family’s particular needs is increasingly possible. This article will (1) discuss the theoretical frameworks as well as the specific psychological skills and strategies that currently hold promise as effective agents of change; (2) review and summarize trends in the development of well-researched outpatient interventions over the past ten years; and (3) discuss future directions for intervention research on pediatric chronic pain.

Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints

Primary pain disorders (formerly "functional pain syndromes") are common, under-diagnosed and under-treated in children and teenagers. This manuscript reviews key aspects which support understanding the development of pediatric chronic pain, points to the current pediatric chronic pain terminology, addresses effective treatment strategies, and discusses the evidence-based use of pharmacology. Common symptoms of an underlying pain vulnerability present in the three most common chronic pain disorders in pediatrics: primary headaches, centrally mediated abdominal pain syndromes, and/or chronic/recurrent musculoskeletal and joint pain. A significant number of children with repeated acute nociceptive pain episodes develop chronic pain in addition to or as a result of their underlying medical condition "chronic-on-acute pain." We provide description of the structure and process of our interdisciplinary, rehabilitative pain clinic in Minneapolis, Minnesota, USA with accompanying data in the treatment of chronic pain symptoms that persist beyond the expected time of healing. An interdisciplinary approach combining (1) rehabilitation; (2) integrative medicine/active mind-body techniques; (3) psychology; and (4) normalizing daily school attendance, sports, social life and sleep will be presented. As a result of restored function, pain improves and commonly resolves. Opioids are not indicated for primary pain disorders, and other medications, with few exceptions, are usually not first-line therapy.