socioeconomic status, school environment, and characteristics of the health care system, we re recognized as providing context for the more proximal family and parent social factors. A novel aspect of this model is close examination of the role of health habits (such as sle ep, physical activity, substance use) play in pediatric chronic pain and disability. Explic itly making stable health habits salient highlights the importance of assessing these perip heral but fun- damental behaviors because of their potential role in moderating pain and di sability, particularly in older children and adolescents. Th is model posits bidirectional relationships among biological, psy- chological, and social factors with biological factors nested within the psychological context of the child, which in turn is nested within socia l contexts. Health habits would develop on the basis of the interplay of all three factors. Developmental considerations are advanced in this model, with the biology of pubertal deve lop- ment highlighted as particularly important. Refl ective of current research in the bro ader fi eld of pediatric psychology, the innova- tion of including health habits are noted as particularly relevant in adolescent populations. Th e model is broad in scope and descri bes an interplay of diff erent aspects of the systems. However, while the comprehensiveness and representativeness of the model facilitates a broad inventory of potential factors in chronic pain, this appears to come at the cost of its specifi c predictive power. Specifi c hypoth- eses about how factors within diff erent systems interact for empiri- cal validati on purposes (e.g. mood, culture, and puberty) and the directionality of these relationships are not readily evident from the model descriptions. Palermo (2012) extended the theoretical foundation proposed by Palermo and Chambers (2005) by explicitly adding in new com- ponents to the model, namely: (1) biological processes, (2 ) the dimension of psychological factors infl uencing health habits, and (3) social factors that go beyond consideration of parents and the family. Th e \200\230guiding conceptual m odel for understanding paediat- ric chronic pain and disability \200\231 (see Figure 9.1 ) is therefore more comprehensive in its scope. In terms of the biological levels of infl u- ence, consideration was given to ontogenetic maturation, includ- ing genetic factors, centr al nervous system functioning, sex, and pubertal status. Psychological variables proposed a s important in pediatric chronic pain include individual beliefs, coping, mood/ aff ect, an xiety, and fear. Broader social variables, such as culture, As discussed earlier, integrative models in the area of pediatric chronic pain are still in their early stages, with modeling typically representing the product of a particular inves tigative group. In con- trast, pediatric models of acute pain began proliferating about a d ecade earlier and have had the benefi t of diverse viewpoints on the topic. Th e following section addresses a number of recent models. Biopsychosocial models of pediatric acute pain Contrary to the dearth of theoretical litera ture on pediatric chronic pain, several models that specifi cally address acute or pro- ced ural pediatric pain have been advanced in the pediatric pain SECTION 3 social and psychological basis of pediatric pain 88 literature. In all of these models, the proposed relationships and interplay between variab les are presented in the context of a par- ticular painful episode (e.g. a specifi c immuni zation or other pain- ful medical procedure). among features and determinants of the pain experience choosing rather to specifi cally out lay the directionality of certain relation- ships. However, with this model we see a diff e rent type of limitation in that while specifi c mechanisms are readily identifi able and te st- able, potential gaps in the conceptualization of relationships between variables are ev ident. For example, whereas it is hypothesized that child factors (such as coping behaviors ) or parent factors (such as anxiety) can modulate the child \200\231s short-term pain resp onse or long- term distress memories, the model does not explicitly propose that the child \200\231s short-term pain response or long-term distress memories would exert infl uence on the child \200\231s coping behaviors or the parent \200\231s anxiety. Moreover, it provide s only a surface treatment of biological variables and a more comprehensive integration of biological factors would improve its conceptual value. A social-ecological framework for understanding procedure pain Informed and laid out simila rly to Bronfenbrenner \200\231s (1977) social- ecological framework, Kazak and Kunin-Batson \200\231s (2001) model sit- uated the child in pain at the center of a series of nested co ncentric circles representing the increasingly broad social settings that have an impact on a child in pain and that exert bidirectional infl uences on the child. Contained in the fi rst circle of infl uence, the microsys- tem, are child-specifi c, or intrapersonal, factor s such as age, biology, coping, health, and the pain experience itself. In the mesosystem, or second circle of infl uence, are social factors in the child \200\231s immedi- ate life contexts, such as those relating to family, peers, school staff , and hospital staff , and the interrelationships between these social units. Finally, broader social environments are represented by the largest circle of infl uence or the exosystem, such as social networks of parents, ethnocultural infl uences, including cultural beliefs and practices, health car e systems, and public policy. Th e interpersonal meso- and exosystems are hypothesized to e xert a direct and indi- rect impact on the child in pain (the microsystem) and all three sy stems are expected to interact, a position this perspective shares with other models discus sed. Once again, the model, while compre- hensive in its scope and grounded in current rese arch, has limited impact beyond providing a comprehensive description of potential variable s related to procedural pain. In essence, specifi c hypothesis testing of the dynamic inter play of nested spheres is impossible because of the large number of interactive possibiliti es that diff er- ent factors within diff erent spheres present. Young \200\231s model of pediatric procedural pain Similarly to Cohen \200\231s model, Youn g \200\231s (2005; see Figure 9.2 ) biopsy- chosocial model contextualizes pediatric proced ural acute pain by fi rst breaking the time sequence of a procedural pain event into three phases: (1) pre-procedure, (2) procedure, and (3) post- procedure. Th is framework acknowle dges that while acute pain occurs in a distinct episode of time (procedure), it is substant ially infl uenced by pre-procedural factors, such as the mindset the child brings to the pr ocedure (memories of past pain, fear/anxiety, tem- perament), unique biological disposition s (such as pain receptor density, endogenous opioids), and social infl uences (such as pare n- tal modeling, cultural beliefs, media attention, peer infl uences). Furthermore, the cum ulative impact of both pre-procedural and procedural factors would continue to infl uence t he child aft er the procedure has been completed. Similar observations must apply to acute pain arising from injury. Importantly, this model stands alone from models reviewed thus fa r by including a specifi c feedback loop postulating that aft er the procedural pain respon se, long-term eff ects of pain and distress (such as memories of the acutely painful experi ence) will in turn directly impact on an individual \200\231s cognitive control and coping skills in the next painful experience. Stimulus \200\223response model of (pediatric) pain Th e \200\230stimulus \200\223response model of (pediatric) pain \200\231 (Cohen et al., 2008) takes a diff erent perspective by structuring the model around a linear sequence of events that follow a specifi c painful st imulus (e.g. injection, infl ammation). First, there is a short-term response phase in whic h pain, distress, and anxiety can be experienced, but also in which the opportunity to lear n, practice, cope, or be coached exists. Th e link between the painful stimulus and the sho rt- term response is hypothesized to be modulated by child factors (e.g. coping behaviors, prior experiences), parent factors (e.g. coaching behaviors, parent anxiety), medical staff factors (e.g. coaching behaviors, staff anxiety), and contextual factors (e.g. environment al factors, culture). Following this short-term response phase is the long-term response ph ase in which health atti- tudes/behaviors, distress memories, and expectations can develop, physiological changes can occur, and the opportunity to cope or be coached exists. Similar to the link between the painful stimulus and the short-term response phase, the link betwe en the short-term response phase and the long-term response phase is hypothesized to be mod ulated by the same child, parent, medical staff , and contex- tual factors discussed earlie r. In line with a biopsychosocial approach to understanding pediatric pain, this model addr esses biological, psychological, and social spheres of infl uence, as well as the inter- pl ay between the specifi c variables that subsume these three levels. Compared to earlier mod els discussed previously, this model does not overtly hypothesize a transactional, or bidir ectional, relationship In addition, the model explicitly incorporates Melzack and Wall \200\231s (1965) gate contr ol theory by noting that both individual (such as age, sex, development, and temperament) a nd other systemic fac- tors (such as ethnicity/psychobiological factors, cultural/familial factors, and societal/environmental factors) impact on central cor- tical control processes and descending inhibitory mechanisms of the pain gate, which in turn determine the pain re sponse (sensory, aff ective, and physiological). Given such a broad array of factors and clearly laid out inter- relationships, the potentia l for contributing to the development of the fi eld becomes readily apparent. When critical ly appraising the model, questions quickly arise regarding interactions among spe- cifi c s ubunits of the model. For example, why is a child \200\231s pain and distress presumed to o nly impact on individual factors but not psy- chobiological factors such as pain thresholds ? Additionally, given the integral role of ongoing threat appraisals in the actual pain res ponse, pain responding (in particular physiological responding) would also be directly impa cted upon by pre-procedural factors such as previous pain experiences, rather than solely b eing medi- ated by a child \200\231s cognitive abilities and schemas. It is notable that th e various mechanisms and constructs describing the pain response are laid out explicitly. H ence, this model provides clear avenues for empirical validation and its in-depth empirical basis is clearly CHAPTER 9 psychological theories and biopsychosocial models in pediatric pain 89 Societal and environmental factors, eg, Media, peers, school, secondary gain Cultural and familial factors, eg, Pain beliefs, symptom monitoring Ethnic and psychobiologic factors, eg, Pain receptor density, endogenous opicoids, anxiety Individual factors, eg, Age, sex, development, temperament, fear/anxiety, Prior pain experi ences e r u d e c o r p e r P d l i Pain attitudes, behaviors, role models h C Coping skills Cognitive control Parent and health care provider interactions with child Descending inhibition Interventions e r u d e c o r P Large and small \201bers Exposure: characteristics and appraisal of the procedure, immediate environment Open Pain response: Sensory: self-report A \200ective: behavior Physiologic Substantia gelatinosa (gate) T Cells Action system Figure 9.2 Model for conceptualizing and studying pediatric procedural pain (Young, 2005). Reprinted from Annals of Emergency Medicine , Volume 45, Issue 2, Kelly D. Young, Pediatric Procedural Pain, pp. 160 \200\223171, Copyright 2005, with permission from Elsevier, ht tp://www. sciencedirect.com/science/journal/01960644 e r u d e c o r p t s o P Close Long-term e \200ects of pain and distress laid out in the paper. One conceptual criticism of the model is that the caregiver of child in pain appears to be relegated to a periph- eral role during the procedural phase and is not acknowledged as having a direct impact on the child \200\231s construction of previous pain experiences. caregivers who, when deemed necessary, will take action to manage the pain. Th ese transactions between the child and persons in the social environment are explicitly examined during four sequenced, con- ceptually distinct but interactive stages following an initial painful event: (1) the child \200\231s pain experience, (2) the child \200\231s pa in expression, (3) assessment of pain by a caregiver, and (4) and actions taken (or not tak en) by others that would impact on the child \200\231s pain. Th e social communication model of pain In a hybrid approach that incorporates the sequenci ng of events in acute pain and yet acknowledges larger spheres of both inter- and intrapers onal infl uence, Craig and colleagues have taken a broader perspective that emphasizes soci al learning theory in how the child, the caregiver, and the relationship function in the pa in context (see Figure 9.3 ). Th e focus is upon dyadic interactions between the child and others, but consideration is given to the broader social ecological systems within which ch ild pain is suff ered. Having had the benefi t of over a decade of development, including e xplora- tion of its empirical and theoretical ramifi cations (e.g. Craig, 2009; Craig et al ., 1996; Hadjistavropoulos et al., 2011), the conceptual framework now provides by far the most developed biopsychoso- cial formulation of pediatric acute pain. It predates other mod els described here with the fi rst pediatric version released in the early 1990s when the i mportance of the social context to understanding children in pain was only beginning to be established. Th us, when tissue damage or trauma occurs, the noxious input is transduced into the child \200\231s perception of pain. Th e biological dis- positions triggered are the outcome of t he biological, personal, and social history of the child, not only the nociceptive sensory input. Th e experience includes both automatic/refl exive features as well as higher level processing refl ecting the learning history of the child. Th us, an understanding of the re action to a noxious event, whether acute tissue trauma or exacerbation of chronic pain, req uires con- sideration of both immediate and personal history events. Th e second stage concerns the complexities of how painful expe- rience becomes manifest in the expression of pain. Pain expression may be observed in infants vocally through crying or screaming, as well as through non-vocal expression, including facial expression and body actions. Depending on the developmental stage of the child, they may be able to use langua ge to communicate pain. Th ere are bidirectional relationships between pain experience and pain expression, whereby the child \200\231s pain experience will impact on pain expression , and a child \200\231s expression of pain will impact on how it is experienced. Th e disti nction between the experience and expres- sion of pain implicitly acknowledges they may be discordant. Th is complicates the challenge caregivers confront when attempting to assess a child \200\231s distress, with decisions about an appropriate course of action depending u pon this judgment. Important and relatively unique features of the SCM include the impact of socialization on child pain experience and expres- sion as well as the inclusion of persons other than the i ndividual experiencing the pain, caregivers in particular. Th is is particularly important in pediatric pain because vulnerable infants and chil- dren are heavily reliant on family, other adults, and professionals for caregiving, including assessment and relief from pain ( Pillai Riddell and Racine, 2009). Th e SCM as it relates to pediatric pain includes process es whereby the subjective pain experience of the child is transduced into a pain expression that can be assessed by Pain expression and caregiver assessments mutually infl u- ence each other. Pain expression primarily, but not exclusively, SECTION 3 social and psychological basis of pediatric pain 90 Child in Pain Caregiver Personal History, Biological Endowment Personal History, Biological Constraints Perfessional Training, Personal Judgment Intrapersonal In \202uences Sensitivity, Biases, Knowledge Pain Expression Personal Experience of Pain Pain Management Physical trauma, demonstrated or percieved Pain Assessment (nonverbal, self-report, physiological) (pharmaco- logical, psychological, environmental) (thoughts, feelings & sensations) (decoding) (encoding) Situational Context Context Clinical or Everyday Settings Relationship, Duties Interpersonal In \202uences (social & physical) (social & physical) Figure 9.3 Th e social communication model of pain. A conceptual biopsychosocial model depi cting the interaction between the child in pain and their caregiver. Reprinted with permiss ion from Craig, K. D., Th e social communication model of pain, Canadian Psychology , Volum e 50, pp. 22 \200\22332, Copyright 2009, American Psychological Association. DOI: 10.103 7/a0014772. interactions between the child in pain and her/his caregivers. Social learning approaches t o child development in a pain context, including both operant (e.g. Gatzounis et al., 2012) and observa- tional learning (e.g. Goubert et al., 2011) processes have proven particularl y useful in model refi ning. Second, the model examines a progression of four stages follow ing onset of painful events that fi rst concern the child and then the caregiver (see later ). Th ird, the SCM recognizes dynamic reciprocal relationships between the infant \200\231s or child \200\231s experience and communication of pain and the caregiver \200\231s interp retation and reaction to the pain-related distress. Finally, as the model developed, intrap ersonal and interpersonal factors unique to the biological and environmental history and cu r- rent status of the individual child and caregiver were shown to be crucial to understand ing the child and the caregiver, separately and interactively. determines the observer \200\231s pain assessment, and this reaction in turn will have an i mpact on the pain expression (and experience) depending upon the reaction. Th e component o f the model encom- passing child expression and caregiver assessment is at the heart of the model and exemplifi es the belief that pain is fundamentally a social experience. Pain was evolutionarily conserved as a biological adaptation, with expression and adult reactions t o the child playing no small part. Children modulate signals of pain and distress con- ting ent upon perception of the immediate context, including recep- tivity of the caregiver, and the caregiver would also attune sensitivity to signals based on their interpretation of th e child \200\231s expressivity. Parental and health practitioner sensitivity as social dete rminants of children \200\231s pain expression seem obvious and would not seem to require f urther illustration here. Finally, the caregiver \200\231s assessment of the urgency, intensity, and necessity of the pain signal determine whether the caregiver will take action and attempt to control pain. As with all phases of the process, caregiver judgements and decisions to provide care are m utually infl uential. Th e actions a caregiver takes may also impact on their assessment (e .g. if the actions are eff ective, the assessment might be that the pain is lower). Moreove r, how a caregiver manages a child \200\231s pain will also feed back to the beginning of t he sequence and impact on how a child \200\231s pain experience is constructed. Th ese four steps delineate the dynamic interaction between children and caregivers in the pediatric p ain context. As aforementioned, the SCM has provided rich fodder for empir- ical work in the fi eld tryi ng to elucidate the psychosocial infl uences on pediatric pain. However, in contrast to mor e focused models of pediatric procedural acute pain (such as Young \200\231s model), the SC M is not ideally suited to provide detailed guidance regarding spe- cifi c mechanisms subsu ming the interplay between components. It provides broader conceptual guidance postulating the general sequence of acute pain from painful trigger to caregiver manage- ment and outli ning the spheres of infl uence with specifi c mention of potential variables on each step o f the sequence. Th e diff ering approaches, while overlapping, tend to generate diff erent types of hypotheses. For example, while both models suggest previous Upon review, four key features of the model contribute to its explanatory value. First, the model characterizes important CHAPTER 9 psychological theories and biopsychosocial models in pediatric pain 91 pain history impacts on a child \200\231s pain response, the SCM postulates that it impacts on the experience of pain which in turn impacts on expression, while the Young model sugge sts a more specifi ed feedback loop such that previous experience impacts on current experi ence via the child \200\231s cognitive control exerted over the pain gate pathways and via the child \200\231s coping skills, which both in turn impact on current pain experience and then, subsequently, future pain experience. One fi nal criticism of all pediatric pain mod els presented to date, whether they focus on the sequence of events, the larger spheres of infl uence, or both, is the lack of specifi c attention to the developmental stage of the c hild \200\224a key variable in under- standing pediatric pain. or damage is then transduced into an initial pain reaction via nocic- eptive aff erents exc eeding noxious sensory thresholds. Rather than pursuing the infi nite challenge of operatio nalizing the non-verbal infant \200\231s subjective experience of the noxious stimulus, the model focuses on overtly measurable pain behaviors. Aft er an immediate automatic/refl exi ve peak response is manifest following the pain- ful event (observable via measures such as physiological or overt behavioral pain responses like cry, facial actions, or body move- m ents), the infant begins the process of self-regulation towards re-establishing homeostasis (measurable via the decrease in overt pain responding as the immunization appointment prog resses). Using complex, multifactorial modeling, emerging research on the OUCH cohort has c learly shown that the largest studied deter- minant of infant initial pain reactivity and p ain regulation is the infant \200\231s earlier pain behavior, either earlier in the specifi c immu- nization appointment or earlier in the life of the child. A biopsychosocial model speci \201 cally for infant pain: the DIAPR model An appreciation of the unique developmental stage of infancy in terms of both the inter- and intrapersonal infl uences inspired the creation of a new biopsychosocial model specifi cally constructed to provide a framework for understanding acute pain over the fi rst year of life: Th e \200\230development of infant acute pain responding \200\231 or DIAPR model (Pillai Riddell , 2009; see Figure 9.4 ). Acknowledging the SCM innovation of the primary role of the dynam ics between caregiver and child, this new model incorporates novel compo- nents that have n ot been seen in other models of pediatric acute pain to date, including the separate concep tualization of the initial pain reaction and ongoing pain regulation, the indirect infl uen ce of larger social contexts, and the hypothesis of three specifi c feedback loops involvin g either the infant, the caregiver, or both. Th e model is based on evidence gathered from a growing literature base gen- erated by the OUCH cohort (e.g. Ahola Kohut 2012; Pillai Rid dell et al., 2011, 2013; Racine et al., 2012). Th e OUCH cohort is an ongo- ing cohort sequ ential sample of over 750 healthy children and par- ents being followed through routine imm unization injections at 2, 4, 6, 12 months and/or most recently preschool age (with a subsa m- ple of 130 infants that was also followed at 12 \200\22318 months during a non-painful y et distressing parent \200\223child interaction procedure). Accordingly, over the fi rst year of life in a standard immunization setting where almost a ll younger infants were immunized on an examining table and older infants were being held d uring immuni- zation, specifi c caregiver factors (e.g. verbal reassurance, emotional avail ability, proximal soothing) have no to small relationships with infant pain behavior, thus, the relegation of caregiver factors to peripheral determinant roles (compared to actual in fant behavior) in this infant-specifi c model. Moreover, all larger spheres of social infl uence, such as the family (e.g. the spouse or siblings), hospi- tal ecology, or culture are speculated to exert infl uence indirectly through infl uencing the primary caregiver at th e time the infant is in pain. For example, during an immunization, the parent \200\231s int ernal cognitive schema for pain will be infl uenced by cultural beliefs, availability/accep tability of pharmaceuticals, general pain knowledge and beliefs, skills for coping with the child \200\231s pain, and societal expectations for an infant \200\231s pain response. Th is schema in turn will infl uence caregiver pain assessment and management which then direc tly infl uences infant pain regulation and reactiv- ity. Previous work confi rming that a p arent \200\231s recall of their child \200\231s painful immunization experiences was signif i cantly determined by potential cultural stress (Pillai Riddell et al., 2007) add credence to this hypothesis regarding the infl uence of larger spheres on pain assessment. Th e model begins with the chain of events arising from an acutely painful incident, typica lly conceptualized in terms of triggering bio- logical processes related to a nociceptive t hreshold. Th e tissue stress There are three feedback loops inherent in the model. Consideration of the infant respondin g self-regulatory loop (see interrelationships between boxes in the model in Figure 9.4) su g- gests that within an appointment, the actual stimulus and the infant \200\231s sensory t hresholds (infl uenced by previous pain experiences and genetic nociceptive thresholds) tri ggers an infant \200\231s initial pain reac- tion and that the initial pain reaction will c ontribute to determining regulation from the initial pain reaction. Moreover, it is postula ted that future pain responding, through modifi cation of pain thresh- olds, will be impact ed upon by past pain responding (both initial pain reaction and the infant \200\231s regula tion from it). Examination of the infant \200\223caregiver regulatory feedback loop (see in terrelation- ships between the boxes and the ovals in Figure 9.4) suggests that not only wi ll a caregiver \200\231s initial assessment and management of an infant \200\231s acute pai n be predicted by immediate pain reactivity, a feedback loop occurs relating to infant regu lation and subsequent caregiver assessment and management. Th us, how an infant is reg- ula ting following the pain event will impact ongoing assessment and management in a cyclical f ashion until the distress is no longer evident (i.e. infant regulation re-establishes homeo static balance). Genetic and Experiential In \202uences Pain Event Immediate Infant Pain and Distress Reactivity Infant \200\231s Noxious Sensory Threshold Non- Immediate Infant Pain and Distress Reactivity (Regulation) Caregiver Pain Assessment External Systems (e.g. Culture, Medical Clinic, Familial Demands Caregiver Pain Schemas Caregiver Pain Management Figure 9.4 Th e development of infant acute pain responding model (the DIAPR model). SECTION 3 social and psychological basis of pediatric pain 92 Finally, unique consideration must be given to the broader psy- chosocial systems of infanc y. A parent feedback loop (see relations between ovals in the model in Figure 9.4) acknowle dges that while an infant \200\231s pain responding (i.e. initial reactivity and regulation ) contributes to caregiver assessment and management of the infant \200\231s pain, informat ion arising directly from the infant is accommodated within existing parental schemas of th e situation, based on infl u- ences such as cultural norms, medical institution guidelines, and the familial demands. to explicitly bridge the theoretical gap that currently separates acute and chronic pain. T h e opportunity may be available in the study of biopsychosocial factors that are involved with the transition from acute to chronic pain. In children this must give consideration to the developing nervous system. A problematic tendency of most pediatric models has been to treat pain expression as a unit ary construct. Yet, as others have acknowledged in the more adult-centric theoretical liter ature (e.g. Hadjistavropoulos et al. 2011), there are both automatic-refl exive components and more controlled-cognitively mediated compo- nents to pain, with both refl ecting ontoge netic and socialization features of pain experience and expression. Pragmatically, one also could acknowledge this divide using a similar dichotomy based on pain reactivity (a child \200\231s immediate response to a painful event) ver- sus pain regulation (a child \200\231 s pain and distress temporally distal to the actual painful event as the child moves toward re-establishing homeostasis). It would follow that the strength of impact of biopsy- choso cial factors would vary, with more innate/refl exive factors (e.g. pain receptor density, t emperament) likely more prominent with pain reactivity and psychosocial factors (such as at tachment, cultural beliefs about the value of pain, gender biases) likely more important de terminants of how the child self-regulates subsequent to the painful event. Finally, to attempt to bring further awareness to the steep tra- jectory of development dur ing infancy, in Figure 9.4 dashed lines were used to portray those relationships that are h ypothesized to change in strength over the course of infancy. For example, simply comparing infants at 2 months versus 12 months, OUCH cohort research indicated that the infl uence o f parental factors, such as sensitivity or verbal reassurance, on pain responding was stron ger at 12 months of age than at 2 months of age. Moreover, the transi- tion and relationshi ps between pain responses (i.e. pain reactivity and pain regulation) changes according to d evelopmental stages within infancy. Solid arrows suggest that while changes may occur over time, this is likely to be not as strongly linked to the infant \200\231s development. Th u s, the model attempts to capture the interplay between and among infant and caregiver facto rs as they change over the fi rst year of life. Th e most important limitation of existing biopsychosocial mod- els of pediatric pain arise s from how development is handled. With a few focused exceptions, we know little about the developmental transformations in biological, psychological, and social bases of pain throug h infancy, childhood, and adolescence, particularly through longitudinal study. While all e xisting models acknowledge the importance of development, it is argued here that in biopsy- chosocial models the interplay of these dimensions must be recog- nized as diff erent acro ss childhood (defi ned here as from birth to adolescence). While attempting to capture observable inter- and intrapersonal factors to generate specifi c testable hypotheses regarding the infant, the model does not yet specifi cally outlay sp ecifi c caregiver sche- mas that may be fi ltering infl uences from larger spheres of cultu re, medical norms, etc. Understanding patterns regarding how these larger systems infl uenc e the parental schemas which in turn impact on their behavior towards their child in pain i s crucial in trying to target interventions. Critical review of pediatric pain models to date and future directions Pediatric pain emerg ed as a distinct area of study in its own right relatively recently. Th ere has been a prol iferation of conceptual models over the past two decades. Generally speaking, these mod- el s share similar explanatory purposes in trying to understand the interplay among biological , psychological, and social processes during children \200\231s painful events. Th ey postu late and emphasize diff erent dimensions in seeking features of children \200\231s pain tha t are potentially modifi able to reduce pain and suff ering in this vulner- able sector of society. Rather than confl icting with each other, the models refl ect a remarkable degree of concordance concerning the key factors involved. However, one stark diff erence is the p rimacy of the caregiver. Most models embed the infl uence of the caregiver in a social dime nsion \200\224only the SCM assigns caregivers a central role. Taken from the larger fi eld of child development, Arnold Sameroff \200\231s unifi ed theo ry of development (2010) provides an exem- plar for this position. At the core of this mode l is the tenet that while biological, psychological, and social factors are important in un derstanding all stages of the developing child, the magnitude of infl uence varies through infancy, childhood, adolescence, and adulthood. Factors external to the child increase in p rominence with age and exposure to ecological systems, such as those provided by parents, t he family, peers, and the community (including health care system and geopolitical contexts ). One can then discern that to the newborn infant larger psychosocial contexts (culture, c om- munity norms, institutional practices, etc.) outside the self are not directly conseque ntial (they likely indirectly impact on the infant through a caregiver \200\231s mediation of these factors). Th ese infl uences change over time as attachment bonds are formed with primary caregivers over early infancy and childhood and then as the child enters into new s ystems of psychosocial infl uence such as daycare, elementary, or university spheres. Interestingly, the biopsychosocial models presented here have chosen by design to either fo cus on acute or chronic pain. However, the formulations overlap. Th e models that examine t he sequence of events involved in an acute pain episode acknowledge that previous pain expe riences impact on current pain experiences. Th is provides an opportunity to examine relati onships between acute and chronic pain. As Palermo and colleagues \200\231 models of chroni c pain (2005, 2012) suggest, very similar aspects of the biology, psychology, and social en vironment (such as physical health, coping mechanisms, and culture) come into play, yet no models to date have attempted Although challenging, given the crucial nature that developmental stage plays in pediatric pain, it is imperative that this role is acknowl- edged more specifi cally because the rela tive weight of related factors change over time. One alternative would be to create models spe- cifi c to unique stages of life as in the DIAPR model. Biopsychosocial models could th en be more explicit and clearly elaborate on key fac- tors involved within the specifi ed a ge range, without fear of becom- ing convoluted. Potential developmental \200\230phases \200\231, based on key CHAPTER 9 psychological theories and biopsychosocial models in pediatric pain 93 References Ahola Kohut, S., Pillai Riddell, R. R., Flora, D., and Oster, H. (2012). A longi tudinal analysis of the development of infant facial expressions in responses to acute pain : immediate and regulatory expressions. Pain, 153(12), 2458 \200\2232465. Case example Leah is 4 years old and her parents would describe her as being \200\230sensitive \200\231 to tactile and noxious stimulation. She is about to have her preschool immunization. Her m other and 1-year-old brother are waiting with her in the examination room. She told her mot her earlier that she did not want to go to the doctor today because she hates needles. Her mother reminded her to behave because \200\230good girls don \200\231t make a fuss \200 \231. Her mother also reminded her that when she was a young girl her mother gave her a spa nking if she embarrassed the family by overreacting in public. Adding to her dismay about t he appointment, Leah had to miss her favorite period in junior kindergarten, music, to come to the doctor. Th e minute the doctor entered the room Leah started crying, which triggere d her younger brother \200\231s tears. Her mother soothed her young son and apologized to t he doctor for Leah \200\231s outburst. By the time the doctor could restrain Leah and quick ly insert the immunization needle, Leah expressed maximal pain behaviors and took a long ti me to calm down aft er the needle. Anand, K. J. (2000). Pain plasticity and premature birth: a prescription for permanent suff ering. Nat Med , 6, 971 \200\223973 . doi:10.1038/79658 Bandura, A. (1977). Social learning theory. Englewood Cliff s, NJ : Prentice-Hall. Bronfenb renner, U. (1977). Toward an experimental ecology of human 513 \200\223531 . doi:10.1037/00 03- development. 066X.32.7.513 Am Psychol , 32 (7), Chambers, C. T., Craig, K. D., and Bennett, S. M. (2002). Th e impact of maternal behavior on children \200\231s pain experiences: an experimental analysis. J Pediatr Psychol , 27, 2 93 \200\223301 . doi:10.1093/jpepsy/27.3.293 Cohen, L. L., MacClaren, J. E., and Lim, C. S. (2008). Pain and pain management. In R. G. Steele, D. T. Elkin, and M. C. Roberts (eds), H andbook of evidence-based therapies for children and adolescents , pp. 281 \200\223295 . Ne w York : Springer. Craig, K. D. (2009). Th e social communication model of pain. Can Psychol , 50, 22 \200\22332 . doi:10.1037/a0014772 Craig, K. D., Lilley, C. M., and Gilbert, C. A. (1996). Social barriers to optimal pain man agement in infants and children. Clin J Pain , 12, 232 \200\223242 . Fitzgerald, M. (2005). Th e development of nociceptive circuits. Nat Rev Acute immunization pain is just one type of pain that children face over the span of childh ood. As Leah \200\231s case helps illustrate, to best understand her pain experience and re sponding, one must take a biopsychosocial perspective. Neurosci , 6, 507 \200\223520 . Fordyce, W. (1976). Behavioral methods for chronic pain and illness. St. Louis, MI : Mosby. Gatzounis, R., Schrooten M. G., Crombez G., and Vlaeyen, J. W. (2012). Operant learning the ory in pain and chronic pain rehabilitation. Curr Pain Headache Rep , 16, 117 \200\223126 . doi:10.1007/s11916-012-0247-1 areas of development (e.g. reliance on parents versus peers, ability to self-report, biolog ical/physical changes), could be birth through infancy (0 \200\2232 years), early childhood (3 \200\223 6 years), middle childhood (7 \200\22312 years), and adolescence (13 \200\2231 8 years). Th is would allow for models that more precisely outline the relative contributio ns of fea- tures and roles of biology, psychology and the social environment. Goubert L., Vlaeyen, J. W. S., Cromvez, G., and Craig, K. D. (2011). Learning about pain fr om others: an observational leaning account. J Pain , 12, 167 \200\223174 .