Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Parental narrative style moderates the relation between pain-related attention and memory biases in youth with chronic pain

ABSTRACT

Negatively biased pain memories robustly predict maladaptive pain outcomes in children. Both attention bias to pain and parental narrative style have been linked with the development of these negative biases, with previous studies indicating that how parents talk to their child about the pain might buffer the influence of children's attention bias to pain on the development of such negatively biased pain memories. This study investigated the moderating role of parental narrative style in the relation between pain-related attention and memory biases in a pediatric chronic pain sample who underwent a cold pressor task. Participants were 85 youth-parent dyads who reminisced about youth's painful event. Eye-tracking technology was used to assess youth's attention bias to pain information, whereas youth's pain-related memories were elicited 1 month later through telephone interview. Results indicated that a parental narrative style using less repetitive yes-no questions, more emotion words, and less fear words buffered the influence of high levels of youth's attention bias to pain in the development of negatively biased pain memories. Opposite effects were observed for youth with low levels of attention bias to pain. Current findings corroborate earlier results on parental reminiscing in the context of pain (memories) but stress the importance of matching narrative style with child characteristics, such as child attention bias to pain, in the development of negatively biased pain memories. Future avenues for parent-child reminiscing and clinical implications for pediatric chronic pain are discussed.

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

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.

Assessment of postoperative pain in children with computer assisted facial expression analysis

PURPOSE

The present study was conducted to evaluate the use of computer-aided facial expression analysis to assess postoperative pain in children.

DESIGN AND METHODS

This was a methodological observational study. The study population consisted of patients in the age group of 7-18 years who underwent surgery in the pediatric surgery clinic of a university hospital. The study sample consisted of 83 children who agreed to participate and met the sample selection criteria. Data were collected by the researcher using the Wong Baker Faces pain rating scale and Visual Analog Scale. Data were collected from the child, mother, nurse, and one external observer. Facial action units associated with pain were used for machine estimation. OpenFace was used to analyze the child's facial action units and Python was used for machine learning algorithms. The intraclass correlation coefficient was used for statistical analysis of the data.

RESULTS

The pain score predicted by the machine and the pain score assessments of the child, mother, nurse, and observer were compared. The pain assessment closest to the self-reported pain score by the child was in the order of machine prediction, mother, and nurse.

CONCLUSIONS

The machine learning method used in pain assessment in children performed well in estimating pain severity.It can code facial expressions of children's pain and reliably measure pain-related facial action units from video recordings.

APPLICATION TO PRACTICE

The machine learning method for facial expression analysis assessed in this study can potentially be used as a scalable, standard, and valid pain assessment method for nurses in clinical practice.

Does past/current pain change pain experience? Comparing self-reports and pupillary responses

Introduction

For decades, a substantial body of research has confirmed the subjective nature of pain. Subjectivity seems to be integrated into the concept of pain but is often confined to self-reported pain. Although it seems likely that past and current pain experiences would interact and influence subjective pain reports, the influence of these factors has not been investigated in the context of physiological pain. The current study focused on exploring the influence of past/current pain on self-reporting and pupillary responses to pain.

Methods

Overall, 47 participants were divided into two groups, a 4°C-10°C group (experiencing major pain first) and a 10°C-4°C group (experiencing minor pain first), and performed cold pressor tasks (CPT) twice for 30 s each. During the two rounds of CPT, participants reported their pain intensity, and their pupillary responses were measured. Subsequently, they reappraised their pain ratings in the first CPT session.

Results

Self-reported pain showed a significant difference (4°C-10°C: p = 0.045; 10°C-4°C: p < 0.001) in the rating of cold pain stimuli in both groups, and this gap was higher in the 10°C-4°C group than in the 4°C-10°C group. In terms of pupillary response, the 4°C-10°C group exhibited a significant difference in pupil diameter, whereas this was marginally significant in the 10°C-4°C group (4°C-10°C: p < 0.001; 10°C-4°C: p = 0.062). There were no significant changes in self-reported pain after reappraisal in either group.

Discussion

The findings of the current study confirmed that subjective and physiological responses to pain can be altered by previous experiences of pain.

The relation between children's attention bias to pain and children's pain-related memory biases is moderated by parental narrative style

Children's heightened attention to pain and parental narrative style have been linked to the development of negatively-biased pain memories in children (i.e., recalling higher levels of pain and fear than initially reported, which robustly predicts maladaptive pain outcomes). However, the interplay between child attention bias and parental narrative style remains to be assessed. This study aims to fill this gap using enhanced paradigms assessing children's cognitive biases for cues signaling actual pain. Healthy school children (N = 63; 9-15 years old) received painful heat stimuli while performing a spatial cueing task measuring attention bias to cues signaling actual pain. Parent-child interaction upon completion of the painful task, was coded for parental narrative style (i.e., elaboration, repetition and evaluation). Children's pain-related memories were elicited two weeks later. Findings indicated that children showed an attention bias to cues signaling pain. Furthermore, children who were hypervigilant to pain cues benefitted from parents elaborating more about the pain experience, while children who avoided pain cues developed more negatively-biased pain memories if parents had a more elaborative style compared to a more evaluative parental style. In conclusion, this study suggests that optimal ways to talk about children's pain depend upon child characteristics (i.e., children's attention bias to pain).

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.

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.

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.

A child in pain: A psychologist’s perspective on changing priorities in scientific understanding and clinical care

My research and clinical career followed a trajectory of increasing appreciation for the importance of social factors as determinants of pain experience and expression. The social contexts of children’s lives determine whether infants and children are exposed to pain, how socialization in family and ethnocultural contexts lead to pain as a social experience, comprised of thoughts and feelings as well as sensory input, how others shape pain experience and expression, less so for automatic/reflexive features than purposeful representations, and how other's appraisals of children’s pain reflect the observer's unique background and capacities for intervening in the child’s interests. A greater understanding of the social dimensions of pain, as reflected in the social communication model of pain, would support innovation of psychological and social interventions.