In sum, the available evidence suggests that observing their child in pain may initially el icit positive attention or care in parents. Over time, however, repeated exposure to their catastrophizing child \200\231s pain complaints may become a source of frustration and dis- tress. In addition, the way in which high-catastrophizing children communicate their distr ess and demand help may impact parent responses. Lastly, diff erences found between mothers and fathers underscore the importance of examining each parent, rather that restricting ou r understanding of this complex phenomena to only mothers (Hechler et al., 2011). Clearly m ore research is needed in this burgeoning area of inquiry. One might argue that some level of parental worry is necessary as children depend upon pare ntal care and protection. In this context, it might be useful to redefi ne catastrophizing as (more) extreme levels of parental worry. Indeed, very low levels of parental worry may f ail to elicit parental care. Very high levels of parental worry, on the other hand, may rel ate to \200\230catastrophizing \200\231, with its maladap- tive consequences for child out comes. Future research may disen- tangle which levels of worry are most adaptive with the p ossibility that moderate levels of parental worry are most adaptive and pro- mote eff ectiv e child self-regulation of distress, while at the same time facilitating empathic concern a nd attention for the needs of the child (Caes et al., 2011). Fear-avoidance beliefs in parents Beyond investigating the type of responses pain catastrop hizing in children elicits in others and how these responses impact upon the child \200\231 s future pain experience, it is also important to investigate who is likely to be less or m ore sensitive and responsive to height- ened pain displays in the child (i.e. the receptive side) (Goubert et al., 2005; Hadjistavropoulos et al., 2011). Not only characteristics of the child, such as the extent to which the child engages in pain expression, but also chara cteristics of the observer and contextual variations are important here. Th ese diff erent infl uences are clearly described within a recent model of empathy and pain (Goubert Parental beliefs about pain and parental behaviors may not only infl uence children \200 \231s pain and disability in a direct way, but may also have an indirect impact by means of observational learning proc- esses. Observational learning has been defi ned as changes in pat- terns of behavior that are a consequence of observing the behavior of others (Goubert et al., 2011). In the context of pain, a child may acquire information about a particular situation and about the con- sequences of specifi c actions in that situation through obser vation of another \200\231s behavior (e.g. parent) in that particular situation. For exampl e, children who observe their parents displaying fear and avoidance reactions to back-stres sing activities, such as lift ing heavy SECTION 3 social and psychological basis of pediatric pain 98 objects, may adjust their appreciation of that particular situation ( \200\230back-stressin g activities are dangerous \200\231) and the behavioral con- sequences ( \200\230avoidance of back-stressing activities reduces pain \200\231). Th is information may translate into c hanges in attitudes and behavior immediately, e.g. acquisition of catastrophizing thoughts related to certain activities, or later when the child experiences pain him/her- self. In t his way, how parents perceive pain and cope with pain may impact children \200\231s beliefs and behavioral repertoire (Goubert et al., 2011). Although early studies have found eviden ce for social mod- elling eff ects, indicating that observational learning infl uences both observable expression of pain as well as subjective experience (Craig, 1986), the evidence in the context of pediatric pain is limited. Few available studies suggest that families m ay infl uence children \200\231s expe- riences of pain through family members \200\231 own experiences/history of pain and use of coping strategies in dealing with their own pain and their child \200\231s pain (e.g. Th astum et al., 1997). To our knowledge, only one experi mental study in children and their mothers showed that children displayed lower pain thresh olds for a cold water task when their mother had voluntarily exaggerated her pain (Goodman and McGrath, 2003). Further research is needed to investigate the role of observational lea rning processes in the development of catastrophiz- ing thoughts and pain-related fear in c hildren. in the normal child \200\231s development. Indeed, prioritized pursuit of pain control goal s may hinder the pursuit of developmentally appropri- ate goals, such as the achievement of new academic and social skills. Children who endorse high levels of worrisome thoughts abo ut pain (i.e. catastrophize) may be likely to become entrapped into a vicious cycle of pain , fear, and prolonged disability (see Figure 10.1 ). Child pain, however, takes place in a social context, of which parents are most infl uentia l agents. On the expressive side, a child encodes its internal experience in an overt displ ay of pain, with high catastrophizing children engaging in an indiscriminate display of pai n. On the receptive side, a parent decodes the child \200\231s pain sig- nals, which may gi ve rise to their own emotional and behavioral responses. Parents \200\231 catastrophizing t houghts about their child \200\231s pain may impact the decoding of the child \200\231s pai n, fueling pain-related fears, and motivating toward (over)protective behaviors. Th ese par ental responses, may, in turn, impact the child \200\231s pain-related cognitions, fears, a nd behavior, and may promote child disability. Furthermore, when the child \200\231s pain b ecomes chronic, parents may become continuously focused upon the goal of alleviating their child \200\231s pain, which might interfere with other personal goals they have (e.g. work performance). Th is may lead to frustration, feel- ings of incompetence, and eventually dep ressive feelings in parents, which might, in turn, impact the child (see Figure 10.1). As mentioned previously, more research is needed to understand the diff erential infl uence of mothers and fathers. In some cases, fathers may counteract the impact of mothers, who h ave generally been found to ruminate more about their child \200\231s pain than fathers (He chler et al., 2011). For example, while both mothers and fathers with high levels of catast rophizing have been found to report a stronger inclination to engage in solicitous behavior s, only cata- strophizing fathers also reported a stronger tendency to engage in behaviors discouraging child \200\231s pain expression or distracting child \200\231s attention from pain (Goubert et al., 2012; Hechler et al., Interpersonal fear avoidance model of pain Based upon current evidence, the present chapter proposes a model involving pain-specifi c cognitive processes to understand how acute pedi atric pain may evolve into chronic problems. Recent evidence suggests that a key determinan t of adverse child outcomes may be a child \200\231s prioritized focus upon pain relief res ulting in avoidance of daily activities (e.g. school, hobbies), motivated by fearful and ca ta- strophic thoughts about pain. Prolonged avoidance of daily activities may result in lon g-term disability, child depression, and even delays Child internal pain experience Child pain expression Parent interpretation Pain stimulus Child consequences (disability, depression) Parent consequences (depression, interference of personal goals) Child pain catastrophizing Parent pain catastrophizing Parent (protective) behavior Child avoidant behaviors Child pain- related fears Parent pain- related fears Figure 10.1 Interpersonal Fear Avoidance Model of Pain. CHAPTER 10 cognitive styles and processes in pediatric pain 99 2011). Furthermore, given the impact of both child and parent vari- ables in determining ch ild outcomes, it is reasonable to assume that child and parent catastrophizing may have a c umulative impact; i.e. children who catastrophize about pain, and have pain-related fears, whose parents also have catastrophic thoughts about child pain might be at highest risk for longstanding problems. and pain-related behaviors interact in determining child pain outcomes, with trait-like cog nitive styles (e.g. neuroticism, opti- mism) acting as a vulnerability or resilience factor to develop- ing catastrophic thoughts about pain and pain-related fears. Our understanding of childhood pain/disability may further benefi t by focusing in future research on the mo tivational context of child and parent fear-avoidant behaviors. When pain persists, pain co ntrol may become the most dominant goal for children and parents who engage in catastrophic and fearful cognitions at the expense of other valuable life goals, resulting in persisten t disability and/or depres- sion (see Crombez et al., 2012). Child and parent may become fr us- trated because of experienced confl icts between pain-related goals (i.e. goals related to the reduction of pain) and other (e.g. social, academic/work) goals, potentially result ing in feelings of incompe- tence, and eventually depressive feelings. When attempts to sol ve the pain problem have repeatedly failed, adequate functioning and the successful attainm ent of developmental goals may depend upon the adjustment of unattainable goals (e.g. no ex clusive focus on pain elimination) and the engagement in new goals (e.g. learning to func- tion despite pain) by both child and parent. Evidence is accumulat- ing that the ability to disengage from and adjust unattainable goals is positively associated with quality of life (Crombez et al., 2012). Future study is warranted regarding the goals parents and children pursue when faced with child pain, the concordance in the goals parent and child value, an d the eff ect upon a child \200\231s functioning. Finally, contextual variables may modulate child and parent responses. A pertinent contextu al variable may be the situational threat value of pain. For example, pain of unknown origi n (i.e. functional pain) may be particularly threatening for parents (Williams et al., 2009 ), motivating parents (especially, those who already have cata- strophizing thoughts about their child \200\231s pain) to engage in protective behaviors (Goubert et al., 2012). Furth ermore, information a family receives regarding pain and its management (e.g. by a physicia n) may impact how child and parent cope with it. Research examining the role of contextual variables beyond child and parent pain-related cog- nitions/fears is an emerging and import ant area of inquiry. Clinical implications Extensive evidence points to the usefulness of cognitive-behavioral i nterventions in targeting catastrophic thoughts and pain-related fears in adults (Smeets et al., 2006). In children and adolescents, cog- nitive-behavioral approaches are also gainin g support (Eccleston et al., 2002; Logan and Simons, 2010). Further research is needed to e xamine whether targeting catastrophic thoughts in parents is an effi cient way to promote b etter pain outcomes in children. Furthermore, when families become trapped in a vicious cyc le of pain, catastrophizing, fears, and disability, and the pain prob- lem dominates family life at the cost of other important life goals, acceptance-based therapies may help famili es to give up the domi- nant search for a defi nitive cure for pain and reorient their atte ntion toward positive everyday activities and other rewarding aspects of life (McCracken an d Eccleston, 2003). Although most research on acceptance-based strategies has taken place i n the context of adult pain (Veehof et al., 2011), two treatment studies among adolescents using an approach combining exposure and acceptance-based strategies support its eff ective ness in adolescents (Wicksell et al., 2007, 2009). Th ese studies found that pain-related f ear, in addition to pain and disability, reduces following treatment. Case example Molly is an athletic 13-year-old girl who suff ered a hyperextension injury to her non-domi nant left wrist when she fell backward try- ing to head a ball while playing in a soccer to urnament. Working under the presumed diagnosis of a fracture, Molly underwent a series of c astings, splints, and physical therapy. Notably, Molly reported intense pain throughout. Se veral months aft er her initial injury, she was diagnosed with complex regional pain syndro me, type II and underwent a left supraclavicular brachial plexus block and left ulnar nerve block. She reported only transient relief with this treatment. Shortly aft er the block Mo lly was evaluated in a multidisciplinary pain clinic by a physician, physical therapist, an d clinical psychologist. To prevent the initiation of a vicious interpersonal cycle of fear- avoidance beliefs and t he development of chronic pain problems, screening for vulnerability factors, such as high neuroticism may be useful. However, it has been suggested that individuals with an increase d vulnerability may be less changeable in their fear-avoid- ance beliefs compared with indi viduals without pre-existing vul- nerabilities (Leeuw et al., 2007). Molly and her mother presented for the evaluation in signifi cant distress. Molly \200\231s mother indicated that in the past 6 months Molly \200\231s symptoms had only worsened and stated that \200\230something had to be done immediately \200\231 to help her daughter. Th roughout the evalu- ation, Molly \200\231s mother would oft en quickly respond to question s directed at Molly. At the time of evaluation Molly described her pain as 7 to 8/10 in her left wrist and forearm. She described burn- ing, sharp shooting, and throbbing pain from h er fi ngers to her left shoulder. She also described pins and needles, weakness, and muscle twitching. She reported increased pain with activity and at rest. She described associated color changes of her left hand and wrist to blue and purple, as well as increased oedema, sweating, and hair growth. Molly had signifi cantly limited her involvement in sports, no l onger participating in basketball or lacrosse (her favorite sport). She continued to play s occer, with a splint on the left wrist. Molly missed several days of school due to pain and her sleep was signifi cantly disrupted. With regards to social history, Molly lives at hom e with her mother, father, and three younger Finally, further research is needed regarding variables that buff er against the developmen t of catastrophizing thoughts and pain-related fear (e.g. optimism). Given that optimism ma y foster confi dence to overcome stressful situations (Hood et al., 2012), interventions pr o- moting positive optimistic beliefs in children and parents may have potential in the pre vention or recovery from chronic pain problems. Conclusion and future challenges In this chapter, we outlined how child and parental cognit ive styles and processes may impact the development and the maintenance of chronic pain com plaints. Child and parent beliefs about pain SECTION 3 social and psychological basis of pediatric pain 100 References Caes, L., Vervoort, T., Eccleston, C., Vandenhende, M., and Goubert, L. (2011). Parental catastrophizing about child \200\231s pain and its relationship with activity rest riction: the mediating role of parental distress. Pain , 152 , 212 \200\223222 . siblings (brother aged 12, sister 10, sister 7). Prior to her injury, it was expected that Molly would regularly help to care for her three younger siblings. Her father is in sales a nd mother is a stay-at- home mom, who played lacrosse in college and coaches Molly \200\231 s lacrosse team. Recommendations at the evaluation included con- tinued medication manageme nt of gabapentin Neurontin, three times weekly physical therapy, and initiation of biofeedb ack/relax- ation training. Charles, S., Gatz, M., Kato, K., and Pedersen, N. L. (2008). Physical health 25 years later : the predictive ability of neuroticism. Health Psychol, 27 , 369 \200\223378 . Craig, K. D . (1986). Social modeling infl uences on pain. In R. A. Sternbach (ed.) Th e psychology of pain (2nd edn) , pp. 67 \200\22396 . New York : Raven Press . Crombez, G., Bijttebier, P., Eccleston, C., Mascagni, T., Mertens, G., Goubert, L., et al . (2003). Th e child version o f the pain catastrophizing scale (PCS-C): a preliminary validation. Pain, 104 , 639 \200 \223646 . For the next 9 months, Molly struggled with her pain symp- toms with multiple follow-up med ical appointments, medical tests, and three subsequent sympathetic blocks. She attended lim ited sessions of biofeedback training. Notably, Molly and her mother presented very distres sed at appointments and expressed signifi cant frustration that her pain did not seem to be resolving. Without physician direction, Molly \200\231s mother weaned her from all medicat ions. Molly did experience periods of improved func- tioning during a spring vacation to Fl orida and multiple weeks in the summer while vacationing at the family \200\231s summer hom e. Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W. S., and Karoly, P. (2012). Th e f ear avoidance model of chronic pain: the next generation. Clin J Pain, 28(6), 475 \200\2234 83. Eccleston, C., Morley, S., Williams, A., Yorke, L., and Mastroyannopoulou, K. (2002). Syste matic review of randomized controlled trials of psychological therapy for chronic pain in c hildren and adolescents, with a subset meta- analysis of pain relief. Pain, 99 , 157 \200 \223165 . Geers, A. L., Wellman, J. A., Heifer, S. G., Fowler, S. L., and France, C. R. (2008). Dispo sitional optimism and thoughts of well-being determine sensitivity to an experimental pain task. Ann Behav Med, 36 , 304 \200\223313 . Goodman, J. E. and McGrath, P. J. (2003). Mothe rs \200\231 modeling infl uences Aft er a period of improved symptoms, Molly experienced a fl are in her symptoms approximat ely 18 months aft er her initial injury, shortly before the start of the lacrosse season. M olly presented frus- trated and sad. Her sleep was signifi cant disrupted and she was arriv ing to school late or missing the day entirely most days. She had almost completely stopped using her left arm and complained of intense, constant pain. Aft er re-evaluation at the p ain clinic, she underwent an additional sympathetic block and re-initiated psycho- logical treatment. In addition to a focus on biofeedback and relaxa- tion training, Molly set goals to: (1) attend a full week of school, (2) play in a soccer game, (3) deal with her frustra tion better with fam- ily members, (4) spend more time with friends, and (5) improve her mo od. Molly was introduced to \200\230radical acceptance \200\231 of her pain symptoms versu s the internal struggle with her pain in an eff ort to diff use some of the anger and frust ration that she had towards her pain and increase her ability to tolerate her physical disc omfort. Molly also explored her values in each domain of her life and noted how little pain had to do with her valued life directions. Th e patient was able to eloquently describe th e diff erence between \200\230acceptance \200\231 and \200\230giving up. \200\231 She tal ked about living a meaningful and enjoyable life regardless of the presence of pain. Althou gh the pressure of per- forming in lacrosse was discussed and explored, Molly denied that t his played any role in her symptoms. In collaboration with Molly \200\231s mother, Molly be gan attending school full-time again. Th is initially increased Molly \200\231s pain and fr ustration and Molly \200\231s mother strug- gled to tolerate her daughter \200\231s distres s, leading her to question the treatment plan. Th rough multiple family meetings with Molly and her mother centered on re-emphasizing Molly \200\231s valued life direc- tions, treatm ent alliance was re-strengthened and Molly continued to make gain in her functioning. At th e conclusion of psychological treatment, Molly was able to increase the frequency and inten sity of her physical therapy treatment and she was playing soccer (scoring the winning goal for her team at a recent game). children \200\231s pain during a cold pressor task. Pain, 104 , 559 \200\223565 . Goubert, L., Craig, K. D., Vervoort, T., Morley, S., Sullivan, M. J. L., de C. Williams A., et al . (2005). Facing others in pain: the eff ects of empathy. Pain, 118 , 285 \200\22328 8 . Goubert, L., Crombez, G., and Van Damme, S. (2004). Th e role of neuroticism, pain catastro phizing and pain-related fear in vigilance to pain: a structural equations approach. Pain, 107 , 234 \200\223241 . Goubert, L., Eccleston, C., Vervoort, T., Jordan, A., and Crombez, G. (2006). Parental cata strophizing about their child \200\231s pain. Th e parent version of the Pain Catastrophizi ng Scale (PCS-P): a preliminary validation. Pain, 123 , 254 \200\223263 . Goubert, L., Vervoort, T., and Craig, K. D. (2013). Empathy and pain. In R. F. Schmidt and G. F. Gebhart (eds) Encyclopedia of pain (2nd edn). Heidelberg : Springer-Verlag . Goubert, L., Vervoort, T., De Ruddere, L., and Crombez, G. (2012). Th e impact of parental gender, catastrophizing, and situational threat upon parental behavior to child pain: a vig nette study. Eur J Pain, 16(8), 1176 \200\2231184. Goubert, L., Vlaeyen, J. W. S., Crombez, G., and Craig, K. D. (2011). Learning about pain from others: an observational learning ac count. J Pain, 12 , 167 \200\223174 . Goubert, L., Craig, K. D., and Buysse, A. (2009). Perceiving others in pain: experimental a nd clinical evidence on the role of empathy. In W. Ickes and J. Decety (eds) Th e social ne uroscience of empathy , pp. 153 \200\223165 . Cambridge, MA : Th e MIT Press . Guite, J. W., McCue, R. L., Sherker, J. L., Sherry, D. D., and Rose, J. B. (2011). Relation ships among pain, protective parental responses, and disability for adolescents with chroni c musculoskeletal pain: the mediating role of pain catastrophizing. Clin J Pain , 27, 775 \200\22381 . Hadjistavropoulos, T., Craig, K. D., Duck, S., Cano, A. M., Goubert, L., Jackson, P., et al . (2011). A biopsychosocial formulation of pain communication. Psychol Bull, 137 , 910 \200\223939 . Hechler, T., Vervoort, T., Hamann, M., Tietze, A. L., Vocks, S., Goubert, L., Hermann, C., et al . (2011). Parental catastrophizing about their child \200\231s chronic pain: are moth ers and fathers diff erent and does this matter for the child? Eur J Pain, 15 , 515. e1 \200\223515.e9 . Hermann, C., Hohmeister, J., Zohsel, K., Ebinger, F., and Flor, H. (2007). Th e assessment of pain coping and pain-related cognitions in children and adolescents: current methods and further development. J Pain, 8 , 802 \200\223813 . Hood, A., Pulvers, K., Carrillo, J., Me rchant, G., and Th omas, M. D. (2012). Positive traits linked to less pain through lower pa in catastrophizing. Pers Indiv Diff , 52 , 401 \200\223405 . Acknowledgements We would like to thank Melissa Pielech for her graphical work. Work was su pported by the National Institutes of Health grant HD067202 (LS). CHAPTER 10 cognitive styles and processes in pediatric pain 101 physical and cognitive-behavioral treatment in chronic low back pain. J Pain, 7 , 261 \200 \223271 . Huguet, A. and Miro, J. (2008). Th e severity of chronic pediatric pain: an epidemiological study. J Pain, 9 , 226 \200\223236 . Sullivan, M. J. L., Th orn, B., Haythornthwaite, J., Keefe, F., Martin, M., Bradley, L., an d Lefebvre, J. C. (2001). Th eoretical perspectives on the relation between catastrophizing and pain. Clin J Pain, 17 , 52 \200\22364 . Keefe, F. J., Lipkus, I., Lefebvre, J. C., Hurwitz, H., Clipp, E., Smith, J., et al . (2003 ). Th e social context of gastrointestinal cancer pain: a preliminary study examining the r elation of patient pain catastrophizing to patient perceptions of social support and caregi ver stress and negative responses. Pain, 103 , 151 \200\223156 . Th astum, M., Zachariae, R., Sch ler, M., Bjerring, P., and Herlin, T. (1997). Cold pres sor pain: comparing responses of juvenile arthritis patients and their parents. Scand J Rhe um, 26 , 272 \200\223279 . King, S., Chambers, C. T., Huguet, A., MacNevin, R. C., McGrath, P. J., Parker, L., et al . (2011). Th e epidemiology of chronic pain in children and adolescents revisited: a systema tic review. Pain, 152 , 2729 \200\2232738 . Leeuw, M., Goossens, M. E. J. B., Linton, S. J. , Crombez, G., Boersma, K., and Vlaeyen, J. W. S. (2007). Th e fear-avoidance model of musc uloskeletal pain: current state of scientifi c evidence. J Behav Med, 30 , 77 \200\22394 . Veehof, M. M., Oskam, M., Schreurs, K. M. G., and Bohlmeijer, E. T. (2011). Acceptance-base d interventions for the treatment of chronic pain: a systematic review and meta-analysis. P ain , 152 , 533 \200\223542 . Vervoort, T., Caes, L., Trost, Z., Sullivan, M. J. L., Vangronsveld, K., and Goubert, L. (2 011a). Social modulation of facial pain display in high- catastrophizing children: An obser vational study in schoolchildren and their parents. Pain, 152 , 1591 \200\2231599 . Linton, S. J., Buer, N., and Vlaeyen, J. W. S. (2000). Are fear-avoidance beliefs related t o the inception of an episode of back pain? A prospective study. Psychol Health, 14 , 1051 \200\2231060 . Vervoort, T., Eccleston, C., Goubert, L., Buysse, A., and Crombez, G. (2010). Children \200 \231s catastrophic thinking about their pain predicts pain and disability 6 months later. E ur J Pain, 14 , 90 \200\22396 . Logan, D. E., Simons, L. E., and Carpino, E. (2012). Too sick for school? Parent infl uence s on school functioning among children with chronic pain. Pain, 153(2), 437 \200\223443 . Vervoort, T., Eccleston, C., Goubert, L., Vandenhende, M., Claeys, O., Clarke, J., et al . (2009). Pain catastrophizing and expressive dimensions of pain: an observational study in a dolescents with chronic pain. Pain, 146 , 170 \200\223176 . Vervoort, T., Goubert, L., Eccl eston, C., Bijttebier, P., and Crombez, G. (2006). Catastrophic thinking about pain is inde pendently associated with pain severity, disability, and somatic complaints in school child ren and children with chronic pain. J Ped Psychol, 31 , 674 \200\223683 . Logan, D. E., and Simons, L. E. (2010). Development of a group intervention to improve scho ol functioning in adolescents with chronic pain and depressive symptoms: a study of feasibi lity and preliminary effi cacy. J Ped Psychol, 35 , 823 \200\22336 . Mannix, M. M., Feldman, J. M., and Moody, K. (2009). Optimism and health- related quality o f life in adolescents with cancer. Child Care Health Dev, 35 , 482 \200\223488 . Vervoort, T., Goubert, L., Eccleston, C., Verhoeven, K., De Clercq, A., and Crombez, G. (20 08). Th e eff ects of parental presence upon the facial expression of pain: the moderating role of child pain catastrophizing. Pain, 138 , 277 \200\223285 . Martin, A. L., McGrath, P. A., Brown, S. C., and Katz, J. (2007). Anxiety sensitivity, fear of pain and pain-related disability in children and adolescents with chronic pain. Pain Re s Manag , 12 , 267 \200\223272 . Vervoort, T., Huguet, A., Verhoeven, K., and Goubert, L. (2011b). Mothers \200\231 and fath ers \200\231 responses to their child \200\231s pain moderate the relationship between the child \200\231s pain catastrophizing and disability. Pain, 152 , 786 \200\223793 . Merlijn, V. P. B. M., Hunfeld, J. A. M., van der Wouden, J. C., Hazebroek- Kampschreur, A. A. J. M., Koes, B. W., and Passchier, J. (2003). Psychosocial factors associated with chron ic pain in adolescents. Pain , 10 1, 33 \200\22343 . McCracken, L. M. and Eccleston, C. (20 03). Coping or acceptance: what to Watson, D. and Pennebaker, J. W. (1989). Health complaints, stress, and distress: exploring the central role of negative aff ectivity. Psychol Rev , 96 , 234 \200\22354 . Wicksell, R . K., Melin, L., Lekander, M., and Olsson, G. L. (2009). Evaluating the eff ectiveness of e xposure and acceptance strategies to improve functioning and quality of life in longstandin g pediatric pain \200\224a randomized controlled trial. Pain , 141 , 248 \200\223257 . do about chronic pain? Pain, 105 , 197 \200\223204 . Muris, P., Meesters, C., van den Hout, A., Wessels, S., Franken, I., and Rassin, E. (2007). Personality and temperament correlates of pain catastrophizing in young adolescents. Child Psychiatry Hum Dev , 38, 171 \200\223181 . Page, M. G., Campbell, F., Isaac, L., Stinson, J., Martin-Pichora, A. L., and Katz, J. (201 1). Reliability and validity of the Child Pain Anxiety Symptoms Scale (CPASS) in a clinical sample of children and adolescents with acute postsurgical pain. Pain , 152 , 1958 \200 \2231965 . Wicksell, R. K., Melin, L., and Olsson. G. L. (2007). Exposure and acceptance in the rehabi litation of adolescents with idiopathic chronic pain \200\224a pilot study. Eur J Pain , 11 , 267 \200\223274 . Williams, N. A., Davis, G., Hancock, M., and Phipps, S. (2010). Optimism and pessimism in c hildren with cancer and healthy children: confi rmatory factor analysis of the Youth Life O rientation Test and relations with health-related quality of life. J Ped Psychol, 35 , 672 \200\223682 . Perquin, C. W., Hunfeld, J. A. M., Hazebroek-Kampschreur, A. A. J. M., van Suijlekom-Smit, L. W. A., Passchier, J., Koes, B. W., et al . (2003). Th e natural course of chronic benign pain in childhood and adolescence: a two-year population-based follow-up study. Eur J Pain , 7 , 551 \200\223559 . Peterson, C. C. and Palermo, T. M. (2004). Parental reinforcement o f recurrent pain: the moderating impact of child depression and anxiety on functional disab ility. Pain , 131 , 132 \200\223141 . Williams, S. E., Smith, C. A., Bruehl, S. P., Gigante, J., and Walker, L. S. (2009). Medica l evaluation of children with chronic abdominal pain: impact of diagnosis, physician practi ce orientation, and maternal trait anxiety on mothers \200\231 responses to the evaluation. Pain, 146 , 283 \200\223292 . Piira, T., Taplin, J. E., Goodenough, B., and von Baeyer, C. L. (2002). Cognitive-behaviora l predictors of children \200\231s tolerance of laboratory- induced pain: implications for clinical assessment and future directions. Behav Res Th er , 40 , 571 \200\223584 . Wilson, A. C., Lewandowski, A. S., and Palermo, T. M. (2011). Fear-avoidance beliefs and pa rental responses to pain in adolescents with chronic pain. Pain Res Manage, 16 , 178 \200 \223182 . Rocha, E. M. and Prkachin, K. M. (2007). Temperament and pain reactivity predict health beh avior seven years later. J Ped Psychol, 32 , 393 \200\223399 . Sieberg, C. B., Williams, S. , and Simons, L. E. (2011). Do parent protective responses mediate the relation between par ent distress and child functional disability among children with chronic pain? J Ped Psycho l, 36 , 1043 \200\2231051 . Simons, L. E., Claar, R. L., and Logan, D. L. (2008). Chronic p ain in adolescence: parental responses, adolescent coping, and their impact on adolescent \200\231s pain behaviors. J Ped Psychol, 33 , 894 \200\223904 . Wolff , N., Darlington, A. S., Hunfeld, J., Verhulst, F., Jaddoe, V., Hofman, et al . (2010 ). Determinants of somatic complaints in 18-month-old children: the Generation R study. J P ed Psychol, 35 , 306 \200\223316 . Zeman, J. and Garber, J. (1996). Display rules for anger, sadness, and pain: it depends on who is watching. Child Dev, 67, 957 \200\223973 . Online supplementary materials Figure 10.2 Example of interpersonal fear avoidance model of pain worksheet Simons, L. E., Sieberg, C. B., Carpino, E., Logan, D., and Berde, C. (2011). Th e Fear of P ain Questionnaire (FOPQ): assessment of pain-related fear among children and adolescents wi th chronic pain. J Pain, 12 , 677 \200\223686 . Smeets, R. J. E. M., Vlaeyen, J. W. S., Kes ter, A. D. M., and Andre-Knottnerus, J. (2006). Reduction of pain catastrophizing mediates the outcome of both Figure 10.3 Example of completed interpersonal fear avoidance model of pain worksheet CHAPTER 11 Pain in cultural and communicative contexts Ignasi Clemente Summary Pain and culture are complex and multifactorial phenomena. Th ey defy objectifi cat ion, isolation, and simplifi cation. Th ey can neither be defi ned nor measured easily, sin ce they intersect with the bio- logical, psychological, and social realms. Taking into acco unt the intrinsic multidimensionality of each phenomenon, we are only beginning to understa nd the myriad of ways in which culture may infl uence pain. As a consequence, (1) the study of the relationship between culture and pain is fraught with methodological and theo- reti cal challenges; and (2) there is no conclusive evidence to sup- port specifi c guidelines o n how to assess and treat pain of specifi c cultural groups. used (experimental, interview, self-report, and observational). Th e examination of pediatr ic pain in cultural context is followed by a synoptic description of the sociomedical and s ocioeconomic con- texts of pediatric pain, with a focus on professional cultures and health disparities. Th e chapter closes with a discussion of the com- municative, environmental, or situational factors that impact chil- dren \200\231s acute and chronic pain experiences. Introduction Over the last 50 years we have learned that pain is a multidimen- sional, comp lex, and subjective (sensory and emotional) experience (Charlton, 2005; Merskey and Bogduk, 1994). Cultural and com- municative factors are consistently acknowledged by pain research , yet elusively studied, perhaps because of the inherent complexity of the two phenomena. Pain in children is too oft en underestimated and undermanaged (Craig and Riddell, 2003). T h e situation is worse for cultural \200\223ra- cial \200\223ethnic minority children, who are marginalized, relegated to the lowest socioeconomic status, and with multiple barriers that reduce or block their access to health care. Th e signifi cant health disparities that minority children experience aggravate ever further their vulnerability (Kristjansdottir e t al., 2012): their pain is persist- ently underassessed and undertreated. Key concepts: culture, race, and ethnicity Culture, oft en confused with the terms \200 \230ethnicity \200\231 and \200\230race \200\231 (Edwards et al., 2001; Finley et al., 200 9; Kagawa-Singer, 2001), is as complex and multifactorial as pain. Culture is \200\230an e thereal concept with a multitude of defi nitions \200\231 (Bernstein and Patcher, 2003, p. 142). Defi ning culture, ethnicity, and race is challenging. Operationalizing them is even more diffi cult, since these categories cannot be isolated and formulated into discrete ind ependent vari- ables (Clay, 2009; Craig and Pillai Riddell, 2003). Th ey infl uence and are infl uenced by gender, age, and socioeconomic class to name a few. Furthermore, they are d ynamic, socially and historically changing phenomena. Culture, ethnicity, and race are no d iff erent than defi nitions of pain and childhood, which have also changed historically (Bo nica and Loeser, 2001; Edwards et al., 2001; James and James, 2004; Unruh, 1992). Evidence emerging from multiple methodological approaches reveals that cultural factors may infl uence specifi c aspects of pain experiences more than others. While it is unclear how the sensory aspects of pain may be aff ected by culture, the evidence illustrates how cult ure aff ects pain response, even at an early stage in an infant \200\231s life. In addition to cultural factors across diff erent settings, pain expe- riences are also aff ected by the communicative factors specifi c to a particular environment or situation in w hich pain responses, self-report assessments, and descriptions occur. Pain is highly sus- c eptible to its immediate communicative environment in subtle ways. Clinicians need to becom e aware of their own cultural biases, assumptions, and beliefs. A place to start is to obse rve and talk to the pediatric patient and his/her family. Culture is \200\230the collection of malleable, adaptive strategies that groups of people have developed to survive in their ecologic niche \200\231 (Kagawa-Singer, 2001, p. 228). C ulture is: (1) adaptive , dynami- cally ever-changing to meet social and environmental chan ges; and (2) heterogeneous : cultural groups have internal or intracultural variation in te rms of socioeconomic class, gender, age, education, rural/urban setting, religion, and so f orth. Such signifi cant inter- nal variation can be found throughout this chapter, for inst ance, I begin the chapter by defi ning three key concepts (culture, eth- nicity, and race), and b y presenting the methodological and theo- retical problems of the research on pain and cult ure. Th e chapter proceeds with an examination of the evidence on the relationship between pediatric pain and culture, organized by the methodology CHAPTER 11 pain in cultural and communicative contexts 103 regarding the diff erences within the label of the \200\230Asian \200\231 child between Ja panese, Chinese, Isan Th ai, central and southern Th ai, and south- ern Taiwanese. Rigid an d deterministic defi nitions of culture found in health and social policy research oft en i gnore individuals \200\231 ability to act and change, as well as obscure similarities and e mphasize dif- ferences between cultural groups (Ahmad, 1996). intersubjective nature of pain experiences. For the interested clini- cian, a selected list of publications is included in the online sup- plementary materials, which also includes p atients \200\231 own published accounts. Pediatric pain in cultural context As in research with adults, fi ndings on the relationshi p of culture and pain in children are inconclusive and do not support specifi c clinical re commendations (Bernstein and Patcher, 2003; Finley et al., 2009; Pfeff erbaum et al., 1990; Rosmus et al., 2000; Zeltzer and LeBaron, 1985). Determining cultural infl uences on pedia tric pain is more complex because of the additional variability intro- duced by parent \200 \223child relationships (e.g. development, socializa- tion, and family context). Th ere is a scarcity of research studies examining the relationship between culture \200\223ethnicity and pain in children, and a total dearth of work that examines culture \200\223ethnicity a mong pediatric chronic pain patients, despite the importance of the social context for its treatment (Fortier et al., 2009). In addition, only one study has examined cross-cultural d iff erences on children \200\231s pain perceptions with an experimental methodology (Evans et al., 2008). In what follows, for the sake of clarity and despite the res- ervations that I have raised, I use the ethnic \200\223cultural \200\223racial labels that the authors th emselves use.