\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. Race is an ideological construct that has been associated with colonialism, inequality, and the imposition of a hierarchy of domi- nant people over dominated others. Race as a scient ifi c category is a myth (Kagawa-Singer, 2001). Th e American Anthropological Association ( 1998) and the American Association of Physical Anthropology (1996) underscore that \200 \230race \200\231 is not a scientifi c cat- egory based on clearly demarcated and consisten tly distinct \200\230racial \200\231 biological groupings. Phenotypic diff erences, for in stance, diff er- ences in skin color, do not match genetic diff erences (Craig and Pillai R iddell, 2003; Kagawa-Singer, 2001). Most genetic varia- tion (94% of the human DNA) lies wi thin the so-called racial groups, whereas only 6% occurs between racial groups (American An thropological Association, 1998). Ethnicity simply denotes differences between two groups. Ethnicity is not culture, since cu lture refers to ways of doing, think- ing, feeling, and being. Unlike essentialist \200 \230racial \200\231 diff erences based on purportedly biological diff erences, ethnic diff erences depend on nationality, tribe, religion, language, culture, history, experience, anc estry, and beliefs (Craig and Pillai Riddell, 2003; Edwards et al., 2001; Kagawa-Singer, 20 01). Th e term ethnicity is misused when: (1) some kind of ethnic purity is assumed, withou t contemplating the possibility that an individual may self-identify with multiple ethnic g roups or none; (2) it is applied ethnocentrically exclusively to others (i.e. the others ar e the ones with weird customs); and (3) it is used to mask a \200\230diff erence \200\231 that is in fact inequality, subjugation, and discrimination of minorities. Children \200\231s pain perceptions and experimental pain Regarding the infl uence of cultu re on pain perception in experi- mental and non-experimental pain research, our current und er- standing can be summarized as follows. First, numerous studies are plagued with theoret ical and methodological problems. Second, no agreement exists on how culture may infl uence pain perception, and on what aspects of pain perception may be infl uenced. Th ird, adult experimental and clinical pain research show that non-sensory aspects of pain, such as unpl easantness, tolerance, and intensity, may be susceptible to ethnic \200\223cultural infl ue nces, but no cross-cul- tural evidence has been found in the neurophysiologic detection of pain (Edwards et al., 2001; Green et al., 2003; Zatzick and Dimsdale, 1990: 554). Finally, despite the abundant literature with adults, only one study has examined ethnic \200\223rac ial diff erences with children in a laboratory setting. In this study of three pain tasks w ith 123 healthy children (mean age was 12.9 years) in the US, Evans et al. (2008) found tha t African American children were no more or no less sensitive to pain than Caucasian Americ an children, and no more likely to use a specifi c coping strategy. However, when coping (a ttending versus distracting) and race were considered together, signifi cant diff erences e merged. For African American children, attending was associated with lower levels of pain a nd lower pain sensitivity, while for Caucasian Americans, distracting was associ- ated with lower levels of pain and lower pain sensitivity. A signifi cant problem in pain research is the stereotypical, meth- odologically inconsiste nt, and widely diverse use of racial \200\223ethnic \200\223 cultural labels (Bernstein and Patcher, 2003; Finley et al., 2009; LeResche, 2001; McGrath and Finley, 2003; Zatzick and Dimsdale, 1990). In a critique of some \200\230classic \200\231 research studies on pain a nd culture, psychiatrist and anthropologist Kleinman and colleagues (1992, p. 2) argue that these labels are dehumanizing, create cari- catures instead of people, and fail to address pain as \200\230an intimate feature of lived experience of individuals in the context of their local social world and historic epoch \200\231. Widely used racial \200\223ethnic \200\223 cultural labels are nation-state labels (e.g. \200\230Chinese \200\231 with 1.6 b il- lion people), designating thousands of millions of individuals who have little in commo n other than politically and militarily draft ed international borders. Th e same applies t o pan-ethnic labels such as Hispanic or Latino, which are contested and yet used as politic al maneuvers to provide health care to minorities that cannot aff ord them otherwise (Duany , 2011; Santiago-Irizarry, 2001). In addition to a general lack of theoretical frameworks i n studies of culture and pain (Kristjansdottir et al., 2012), the diffi culties in systemat ically delineating ethnic groups make it challenging to develop compara- tive meta-analyzes of fi ndings, synthetic summary statements, and clinical guidelines (Bernstein and Patcher , 2003; Finley et al., 2009; Garro, 1990; Zatzick and Dimsdale, 1990). Finally, because of its clinical orientation, this chapter is not representative of contem- porary work on pain in the humanities and the social sciences, which has abandoned a cross-cultural comparativ e perspective and has instead focused on the deeply personal, subjective and Children \200\231s descriptions and understandings of pain elicited in interview studies Wi th the exception of Abu-Saad \200\231s research (1984a, 1984b, 1984c), most interview studi es of children \200\231s pain descriptions and under- standings in clinical and non-clinica l contexts have taken a devel- opmental perspective without consideration to cultural diff erences, despite the fact they have oft en been conducted in various countries. Th e lack o f a cross-cultural perspective makes it unclear whether reported non-developmental diff ere nces are due to culture, context SECTION 3 social and psychological basis of pediatric pain 104 of the study, or the methods used. Gaff ney and Dunne \200\231s study (1987) illustrates th is diffi culty: the authors reported that some Irish schoolchildren viewed pain as punishme nt. However, because such views of pain have not been found by other studies, research- ers have speculated that it may have to do with the religious context of the schools in the st udy or with some aspect of the test procedure (Esteve and Marquina-Aponte, 2011; McGrath, 1 995). may be acknowledged in Western countries but ignored in non- Western ones. Th ey illustrate the importance of avoiding cultural stereotypes such as \200\230Children from culture X f eel Y pain no matter what situation, what happens, what is said, who is present, what age, what gender, and so on and so forth \200\231 (see the later discussion of situational facto rs in acute pediatric pain). Children \200\231s clinical pain score scale rating self-report studies Th ree studies reve al minor cultural diff erences: Zeltzer and LeBaron \200\231s (1985) study of Anglo America n and Mexican American adolescents (ages 10 \200\22321) with cancer in the US, Pfeff erbaum et al. \200\231s (1990) study of Anglo and Hispanic children (ages 3 \200\22315) with canc er in the US, and Alwugyan et al. \200\231s (2007) study of Kuwaiti children (ages 6 \200 \22312) from countries in the Gulf (Kuwait and Kingdom of Saudi Arabia), Egypt, and the Lev ant (Lebanon, Syria, Jordan, and Palestine). At the same time, all three studies report int racultural diff erences: Zeltzer and LeBaron report diff erences between the two groups of Mexican Americans (e.g. rural versus urban lifestyles, and clinic diff erences between trea tment centers); Pfeff erbaum et al. report diff erences between Hispanic children and their parents; and Alwugyan et al. report diff erences according to socioeconomic factors, such as family income and educational level of the mother. Abu-Saad \200\231s infl uential research has examined cross-cultural dif- ferences in child ren \200\231s pain descriptions and understandings with Arab American, Asian (Chinese) Amer ican, Latin American, and Dutch schoolchildren (Abu-Saad, 1984a, 1984b, 1984c, 1990; Abu- S aad et al., 1990). Overall, Abu-Saad and colleagues found that the range of physical and ps ychological causes of pain did not diff er widely amongst cultural groups. Some cross-cultu ral diff erences were found in the use of sensory, aff ective and evaluative terms to descr ibe pain; the description of the causes of pain; and the types of aches reported. Intracult ural diff erences were also found, for instance, in the intensity scores assigned to pain d escriptions by children with and without hospital experience. Revealing a more complex desc ription, Abu-Saad also identifi ed similar and recur- ring intracultural gender diff erence s in several cultural \200\223ethnic groups. Within their respective cultural \200\223ethni c group, Arab and Asian American girls reported more frequently psychological causes of pai n, diff erent feelings when in pain (e.g. girls reported more oft en feeling embarrassed) a nd diff erent pain coping mecha- nisms (e.g. girls preferred to be comforted). Th e intracultural diff erences in the three studies raise a critical issue that underlies much of the research on children \200\231s pain and culture, namely the need to provide a c omplex description of the social context in which children are socialized and acculturated (e.g. assimilation into the majority group). Child development does not occur in a social v acuum. From the moment of birth, an infant inhabits a sociocultural world (Pillai Riddell e t al., 2007; Pillai Riddell and Racine, 2009), a fact illustrated by research showing that infants as young as 2 or 4 months old show cultural diff erences in acute pain responses (L ewis et al., 1993; Rosmus et al., 2000). Furthermore, children are not raised by parents wi thin a self-contained family context, but within and in rela- tion to social contexts such as the village/city, the school, the peer group, extended family, the state, and the socioe conomic forces that aff ect parents and families in terms of income, occupation, and educat ion. Consequently, socialization/acculturation is not a unilineal process, but one that res ults from children interacting with parents, relatives, children and teachers in school, th e public media, health practitioners, and other individuals and institutions (Craig and Pil lai Riddell, 2003). In conclusion, these studies fi nd no signifi cant intercultural diff e rences in clinical pain reports and instead identify intracultural diff erences, such as ge nerational, rural/urban setting, socioeconomics, minority group member- ship, and the insti tutional culture of each clinic. Th ree recent studies of children \200\231s pain experiences and descrip- tions have focuse d on smaller populations and situations. As with previous research, they have revealed mino r cultural diff erences. Cheng \200\231s (2003) study of southern Taiwanese children \200 \231s pain expe- riences reports that crying does not necessarily involve vocaliza- tions, but may be limited to facial expressions. Cheng relates this fi nding to cultural norms tha t vocal crying is inappropriate in southern Taiwan. Cheng also reports that some Taiwanese chil- dren perceived that their parents lied to them about the possibility of experiencing pain during hospitalization. Jongudomkarn and colleagues \200\231 (2006) study of north-eas tern Th ai-Isan children liv- ing with pain found that Th ai-Isan children oft en described their pain as torturing, and that their pain experiences may not be extrapolated to childr en of diff erent cultures in central and south- ern Th ailand. Finally, and also involving Th ai children but with a Th ailand versus US cross-cultural comparative design, McCarty et al. (1999) analyzed six stressful situations in terms of cultural diff erences, coping goa ls, and type of coping (overt versus covert). Th e authors reported that culture did not ha ve a monolithic eff ect on child coping, but interacted with other variables such as stres- sor situation, gender, and age. Th e two groups diff ered in some situational contexts mor e than others, depending on the cultural salience of the situation. Taken together, the evidence emerging from cultural studies of children \200\231s pain desc riptions, experiences, and understanding of pain reveals more cross-cultural similarities t han diff erences, and points to signifi cant intracultural diff erences depending on gender , age, stressor, and situation. Culture is not a monolithic infl uence on the totality of t he pain experience: specifi c cultural practices interact with other variables to infl uenc e particular components of the pain experience. In addition, these studies debunk the wrong ly assumed internal cultural homogeneity within nation-states and ethnic groups, and expose the ease in which cultural diversity Children \200\231s pain responses and observational measures Observational studies of child ren \200\231s pain responses provide similar fi ndings. Th ere are no signifi cant overall cross-cultural diff erences, but minor diff erences emerge when an abstract defi nition of culture is abandoned, and culture is considered as interacting with other factors, such as the training of health care professionals, ethnicity of the observer/pain rater, parental s ocioeconomic class, parental level of literacy, and phase of the medical procedure. CHAPTER 11 pain in cultural and communicative contexts 105 Some cross-cultural design observational studies found no remarkable cultural diff erences, such as Pfeff erbaum et al. \200\231s (1990), while others have found some minor diff eren ces. In an study exam- ining Dutch and US children with cancer undergoing bone marrow aspir ations (age 8 months to 18 years 7 months) in their respective countries, van Aken et al. ( 1989) found subtle diff erences between the two groups according to phase of the medical pr ocedure (pre- paratory, bone marrow aspiration, recovery). Th e authors discuss several exp lanations to account for these subtle diff erences, includ- ing cultural and contextual fac tors (i.e. diff erences in hospital set- ting, presence/absence of parents, and adult behav iors). that Japanese infants are not less aff ected by stress. Instead, they suggested two potenti al explanations for the diff erences in pain reactivity, one biological (i.e. genetic basis of temperament) and one cultural explanation related to socialization (i.e. Japanese infan ts are kept in close proximity to the parents, which may lead to a smaller need of signalin g of distress). Rosmus et al. \200\231s (2000) examination of the behavioral pain response of Chinese and n on-Chinese Canadian 2-month-old infants undergoing routine immunizations found that Chinese Canadian infants showed a higher degree of behavioral reactivity than non- Chinese. Rosmus et al. \200\231s fi ndings go in the opposite direction of Lewis et al. \200\231s fi nding s (non-Japanese infants showed increased reactivity), demonstrating that a globalizing cate gory of \200\230Asian \200\231 is unsuitable. Bohannon (1995) examined pre- and post-surgery pain diff er- ences between African American and Anglo American children (ages 3 \200\2237) in the US using behavioral, self-assessment , and physio- logical measures. Bohannon found that African American children were signifi cantly rated lower on observed pain behaviors, despite the fact that children rated their p ain similarly. Bohannon discussed diff erent interpretations: (1) non-linguistic based pain scores may be less subject to cultural \200\223ethnic diff erences or may indicate uni- ve rsal aspects of pain; (2) African American children may express their pain diff erently whe n compared to Anglo American children; (3) the observational measure (Children \200\231s On tario Pain Scale) may be better suited to detect pain behaviors of Anglo American chil- dre n; (4) the examiners, whose ethnicity was not controlled, may have exhibited a bias. Rosmus et al. underscored that the Chinese/non-Chinese groups also diff ered signifi cantly according to socioeconomic status (i.e. parental education and occupation). Th e authors c onducted an impressive discussion that brings together cultural, socioeconomic, communicati on styles, and situational factors, to account for the diff erences in infant pain reactivi ty. For instance, infant arousal state may be infl uenced by the mother \200\231s communica tion style, which in turn, may be infl uenced by the mother \200\231s socioeconomic status. Since mothers may feel that their infant \200\231s behavior refl ects on how good/bad a mo ther she is, mothers of varying occupation and education will likely hold diff erent values and expectations about how to present their infants to (unknown) others. Furthermore, pare ntal education and occupation may interact with situational factors related to the logistic s of the study, such as the ability (or lack thereof) to read, write, and give reports. In brief, Rosmus et al. \200\231s study demonstrated that cultural diff erences are already pr esent at a very early age, and, in line with studies discussed earlier, that cul- ture does not have a monolithic eff ect on child pain behavior, but intersects with other variables such socioeconomic status, commu- nication style, and situational factors. Th ree studies relied on Blount et al. \200\231s original or revised Child Adult Medical Pr ocedure Interaction Scales (CAMPIS) (Blount et al., 1989, 1990, 1997) to examine procedural pain with children from diff erent cultural backgrounds. However, the lack of a cross- cul tural design requires caution when interpreting the results. Overall, authors found great c onsistency between their fi nd- ings and previous research. Salmon and colleagues \200\231 (2002) study of Australian children (ages 2 \200\2237) of European, Middle Eastern, Asian, and Pacifi c Island descent undergoing voiding cystourethro- grams found no cultural diff e rences. Pedro et al. \200\231s (2010) study of Portuguese children (ages 3 \200\2236) under going routine immunizations found some diff erences. However, underscoring the exploratory nature of their study, Pedro et al. contemplated that these diff er- ences could be due to cultural diff erences and/or lack of specifi c training of professionals and parents. Mahon ey et al. \200\231s (2010) study of venipunctures among mostly white European children (age s 7 \200\22316) in the UK found that humor and non-procedural talk were more common in the UK when compared to studies in the US. Furthermore, they found that adult behaviors such as apologiz- ing, criticizing, and making empathic comments were rare; and children \200\231s verbalized pain and fear were common. Mahoney et al. \200\231s fi ndings raise an interest ing issue: the possibility that cultural diff er- ences may not necessarily involve diff er ent behaviors, but diff er- ent distributions and diff erent frequencies of similar behavio rs. Th e sociomedical and socioeconomic contexts of pediatric pain If culture is an ethereal co ncept that is diffi cult to defi ne, the con- sequences of cultural diff erences are palpab le in the specifi c socio- medical and socioeconomic contexts of pediatric pain. Specifi ca lly, I discuss the impact of professional and institutional cultures, as well as health car e disparities, on children \200\231s pain. Regarding its sociomedical context, the assessment and treatment of pediatric pain are cont ingent on parents \200\231 and health profession- als \200\231 attitudes and beliefs (Post et al., 1996). Pain assessment varies according to whom is observing it, in clinical practi ce (Davitz et al., 1976) and in research (Bernstein and Patcher, 2003; Neuman, 1996; Post e t al., 1996; Zatzick and Dimsdale, 1990). Furthermore, health professionals are not acultur al beings, but have their own specifi c cultural \200\223ethnic \200\223religious backgroun d (Free, 2002). Finally, physi- cians and nurses are also members of specifi c professional cultures, having undergone a professional socialization process (Cicourel, 1987; Good, 199 5), which makes them members of the particular subculture of a specifi c hospital/clinic/un it within the culture of a specifi c health care center. Finally, Rosmus et al. \200\231s (2000) and Lewis et al. \200\231s (1993) cross- cultural d esign observational studies of infant pain provide a new understanding of cultural diff ere nce and infant pain response. Th ey highlight that cross-cultural variation may occur earli er in life than previously assumed. In a study of 4-month-old Japanese and American Caucasi an infants undergoing routine immunizations in the US Lewis et al. (1993) found that Caucas ian and Japanese infants did not diff er in pre- and post-inoculation cortisol increase, bu t Caucasian American infants were more behaviourally reactive to pain than the Japanese cou nterparts. Th e authors emphasized In Western and non-Western hospitals, institutional cultures and clinicians \200\231 belief s oft en are the barriers to optimal pain manage- ment (Finley et al., 2009; McGrath and Un ruh, 2007) in both devel- oped and developing countries (Cohen and MacLaren, 2007; Craig et al., 1996; Finley et al., 2008; Forgeron et al., 2006, 2009; McCarthy SECTION 3 social and psychological basis of pediatric pain 106 et al., 2004; Pillai Riddell et al., 2008). As Finley et al. (2008) note on the erroneous m isconceptions about pain and opioid addiction, there is nothing Arab or Middle Eastern spec ifi c to them. examine also what they are communicating verbally and non-ver- bally, when, who, to whom, w here, and how (Table 11.1 ). Pediatric chronic pain and communication Children with chronic pain oft en feel that clinic ians do not hear, understand, or believe them (Carter, 2002; Nutkiewicz, 2008). In an inter view study of 32 adolescents with non-malignant chronic pain (ages 14 \200\22318) in the US , Nutkiewicz (2008) remarked that clinicians ignore the experiential component of the pain and the child \200\231s lived experience, and are not attentive to information that may not be dis- cernibly or explicitly clinical. In addition, adolescents fi nd themselves continu ally re-telling their pain stories in multiple unrelated visits to diff erent clinicians. C hildren \200\231s perceived lack of physician understand- ing reinforces their frustration, loss of potential, sense of isolation and diff erence from peers; and lowers even further their expectations that clinicians or parents can help them (Meldrum et al., 2009). In terms of the socioeconomic context of pediatric pain, cul- tural \200\223ethnic \200\223 racial diff erences place minority children as a vulner- able population when it comes to p ain assessment and treatment (Kristjansdottir et al., 2012). Minoritized communities face o ver- lapping problems such as racism, poverty, limited education, low income, limited profi ciency in the majority language, lack of health insurance, high mobility due to migrant pa tterns associated with temporary jobs, and legal/illegal immigrant status. Furthermore, the y have to overcome signifi cant diffi culties in access to care, in terms of fi nancial aff ordability, living far from health care centers, and/or lacking transportation. Health car e disparities have been qualifi ed as a national and pervasive problem in the US (Williams and Organizing Committee of the Pain Disparities Special Interest Group of the American Pai n Society, 2005). Although studies of sociodemographic disparities in pediatric pain manage ment have yielded inconsistent results (see Ezenwa and Huguet, Chapter 65, this volume), di sparities in adult pain (Green et al., 2003) and gen- eral health care disparities for mino rity children have been docu- mented. Th us, it is not far-fetched to assume that minority children share the health care disadvantages of their parents. In a narrative study of children with chronic pain and their fam- ilies in the UK, Carter ( 2002, 2004) described how children experi- ence \200\230referral fatigue \200\231 in their \200\230diagnostic quest \200\231 (see also Lillrank, 2003; Ong et al., 2004), from one s pecialist to the next, as well as professional \200\230ventriloquism, \200\231 where \200 \230the child \200\231s words are reinter- preted and mistranslated through the professiona ls \200\231 own paradig- matic understanding of the narrative \200\231 (Carter, 2002, p. 36 ). Disparities in children \200\231s health have been reported within three common pediatric h ealth conditions: asthma, oral health, and obesity/type 2 diabetes (Fuemmeler et al., 2009) . Access to health care is also an obstacle for uninsured children, who are dispro- portion ally minority children. Fuemmeler et al. also report that Hispanic children are more than t wice as likely to be non-insured in the US. Hispanic children are also the least likely to be insured with the numerous risk factors and consequences (Flores et al., 2006). In a revi ew study of barriers to health care for Latino children in the US, Flores and Vegas (1998) reported that Latino children are more likely to be poor, the most uninsured, and have pare nts with the lowest education attainment. In addition, Latino children experi- enced provid er-related barriers such as reduced screening, missed vaccination opportunities, decreased likelihood of receiving pre- scriptions, suboptimal management plans, inadequate communi- c ation and patient education, and perceptions of negative attitudes. It is fundamental then to acquiesce that social inequalities and racism, and not culture per se, are oft en the cu lprits of profoundly unjust health disparities. Children \200\231s negative experiences of communication inside the clinic/hospital are mis sed opportunities to incorporate the richness of children \200\231s own pain narratives int o clinical decisions. Based on a qualitative analysis of the narratives of 45 children with chronic pain attending a US multidisciplinary tertiary care specializing in pain, Meldrum et al. (2009) identifi ed fi ve common themes in children \200\231s narratives: hiding pain from parents and friends; a sense of isolation and diff erence from peers and classmates; pain as an obstacle to personal activities; fears about how pain will aff ect the future; a nd perceived lack of physician understanding. Th ese themes are articulated in six diff ere nt narratives or plotlines: the constant patient, the invalid, the weary soldier, the stoic , the posi- tive thinker, and the decision-maker. Meldrum et al. (2008) also identifi ed a functioning strategy developed by the children them- selves, \200\230getting on with life \200\231, which involves ignoring the pain and trying to keep going. Th ese authors also pr ovide additional sup- port to two self-developed strategies identifi ed by Hunfeld et al. ( 2001): \200\230planning ahead, \200\231 which involves deliberatively organiz- ing activit ies while reducing stress, and \200\230body awareness, \200\231 which involves becoming aw are of one \200\231s body while distracting oneself from the pain. A further discussion of persisting pain can be found in Chapter 32 by Mherekumombe and Collins. Pediatric pain in communicative context Pediatric acute pain and communication In the same way that culture and ethnicity infl uence children \200\231s pain experiences, a number of contextual factors \200\224also referred to as situ- ational or environmental \200\224infl uence pain experiences. Contextual factors are discussed elsewhere in this volume in chapte rs on dis- traction (Cohen et al., Chapter 53), pain and the family (Birnie et al., Chapter 12), and the various measurement chapters \200\224especially with non-verbal populations ( e.g. Lee and Stevens, Chapter 35; Chorney and McMurtry, Chapter 37). However, a way to reme mber key con- textual factors includes using interrogatives (what, when, who, whom, where, and how). Adult (parent and staff ) and child behaviors are highly interactive, aff ecting each other in subtle, susceptible, and almost-immediate ways. Because of this, current and future studies are moving beyond who is present during a painful procedure, to Conclusion In this chapter, the complexity of examining the relationships between culture a nd pain, and communication and pain has been highlighted. Neither pain nor culture and comm unication are ame- nable to \200\230easy answers and fi xes. \200\231 Indeed, \200\230eas y answers and fi xes \200\231 lead to ignoring or stereotyping cultural and communicative d iff er- ences. On the contrary, the variability of cultural and communica- tive contextual factors only adds to the variability of subjective and deeply personal pain experiences. We are beginning to understand how cultural and communica- tive factors infl uence pain and what aspects of pain they infl uence. Cultural and communicative factors aff ecting pain a re characterized CHAPTER 11 pain in cultural and communicative contexts 107 Table 11.1 Contextual variables based on interrogatives What a Praising the child is neither related to child coping nor distress Empathic and apologetic statements are positively related to child distress Reassurances fail to diminish displays of child and infant distress, and may magnify them Adult promoted attention manipulation (e .g. passive and active distraction) are bene \201 cial in child coping and reducing pain W hen the distraction intervention requires too much attention, the distress may interfere wi th the child \200\231s ability to focus on the distraction When Children \200\231s distress is likely to be preceded and followed by adult distress promoti ng behaviors (e.g. reassurances) in what seems a circular relationship Children \200\231s e ngagement in coping behaviors, such talk unrelated to the painful procedure, humor and copi ng statements, is also preceded and followed by adult coping-prompting behaviors Child dist ress and coping, and adult behaviors change according to the phase of the medical procedure Type of adult coping promoting and child coping behaviors correlate within a speci \201 c phase, but not across phases Who Nurses \200\231 increased coping promoting behaviors are associated with an increase in par ental coping promoting behaviors Whereas nurses \200\231 and physicians \200\231 behaviors are uniformly negatively associated with child distress, some parental behaviors are associ ated with child distress Whom Whereas the same behavior of adult non-procedural talk to another adult is neutral, when ad dressed to the child, non-procedural talk is child coping promoting Despite the development al changes in children \200\231s pain expression, it remains to be determined whether obser vational measures of children \200\231 procedural pain need to be aged-normed Observational measures have shown good evidence supporting their validity from early childhood through l ate adolescence Where