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 . Grunau, R. E. (2006). Long-term consequences of pain in human neonates. Semin Fetal Neonatal Med , 11 (4), 268 \200\223275 . Hadjistavropoulos, T., Craig, K. D., Duck, S., Cano, A., Goubert, L., Jackson, P. L., et al . (2011). A biopsychosocial formulation of pain communication. Psychol Bull , 137 (6), 910 \200\223939 . doi:10.1037/a0023876 Conclusion A child \200\231s experience of pain is an important area of focus within the br oader pursuit of understanding human suff ering. Developing bio- logical and psychological capacities and social interactions distinguish infant, children, and adolescent experiences from those of the mature adult. Th e social contexts of pain, which interact with the chil d \200\231s bio- logical and psychological action tendencies, are defi ned strongly by the impact of direct caregivers such as parents. Existing models in the fi eld primarily descri bes these relationships separately for acute and chronic pain \200\224integration is necess ary. Future models could benefi t by careful consideration of developmental stage factors. Hohmeister, J., Kroll, A., Wollgarten-Hadamek, I., Zohsel, K., Demirak a, S., Flor, H., et al . (2010). Cerebral processing of pain in school-aged children with neonatal nocicepti ve input: an exploratory fMRI study. Pain , 150 (2), 257 \200\223267 . doi:10.1016/j.pain.2 010.04.004 Kazak, A. E. and Kunin-Batson, A. (2001). Psychological and integrative interventions in pe diatric procedure pain in infants and children, pp. 77 \200\223100 . Seattle, WA : IASP Pre ss. 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\2232138 . doi: 10.1016/j.pain.2011.07.016 Melzack, R. (1996). Gate control theory: on the evolution of pain concepts. Key recommendations Having reviewed current biopsychosocial models of pediatric pain, key r ecommendations stemming from this work can be made: Pain Forum , 5, 128 \200\223138 . doi:10.1016/S1082-3174(96)80050-X Melzack, R. (1999). From the gate to the neuromatrix. Pain (Suppl. 6), S121 \200\223126 . Melzack, R. and Wall, P. D. (1965). Pain mechanisms: a new theory. Science , 150, 971 \200\223979 . (1) Biological, psychological, and social dimensions are useful constructs that encapsulate the key factors in \202 uencing paedi- atric pain. Osborne, R. B., Hatcher, J. W., and Richtsmeler, A. J. (1989). Th e role of social modeling in unexplained pediatric pain. J Pediatr Psychol , 14, 43 \200\22361 . doi:10.1093/jpepsy/ 14.1.43 (2) These dimensional in \202 uences are not static, but rather are dynamic, not only over the child \200\231s development, but also over the course of a discrete painful event or e pisode. Page, L. and Blanchette, J. A. (2009). Social learning theory: toward a unifi ed approach o f pediatric procedural pain. Int J Behav Consult Th er , 5, 124 \200\223141 . Palermo, T. M. (2012). Th e problem of chronic pain in children and adolescents. In T. Pale rmo (ed.) Cognitive-behavioral therapy for chronic pain in children and adolescents , pp. 5 \200\22316 . New York : Oxford University Press. (3) More work that acknowledges how factors within a dimension impact on the child differen tially over different developmental stages will prove theoretically and pragmatically bene \201 cial. SECTION 3 social and psychological basis of pediatric pain 94 Rickard, K. (1988). Th e occurrence of maladaptive health-related behaviors and teacher-rat ed conduct problems in children of chronic low back pain patients. J Behav Med , 11, 107 \200\223116 . doi:10.1007/BF00848259 Palermo, T. M. and Chambers, C. T. (2005). Parent and family factors in pediatric chronic p ain and disability: an integrative approach. Pain , 119, 1 \200\2234 . Sameroff , A. (2010). A unifi ed theory of development: a dialectic integration Pillai Riddell, R. (2009). Keynote award address to Canadian pain society 2009 annual meeti ng: dependent yet developing: new theorizing on the unique social context of infant pain. P ain Res Manag , 14 (2), 143 . of nature and nurture. Child Dev , 81, 6 \200\22322 . Taddio, A., Katz, J., Ilersich, A. L., and Koren, G. (1997). Eff ect of neonatal circumcisi on on pain response during subsequent routine vaccination. Lancet , 349, 599 \200\223603 . Pillai Riddell, R., Campbell, L., Flora, D., Racine, N., Din Osmun, L., Greenberg, S., et a l . (2011). Caregiver sensitivity and infant pain: the relative relationships between infan t behaviors and caregiver sensitivity over the fi rst year of life. Pain , 152, 2673 \200 \2232896. Turk, D., Flor, H., and Rudy, T. (1987). Pain and family. I. Etiology, maintenance and psychosocial impact. Pain , 30, 3 \200\22327 . Pillai Riddell, R. and Racine, N. (2009). Assessing pain in infancy: the von Baeyer, C. (2011). Interpreting the high prevalence of pediatric chronic pain revealed in community surveys. Pain , 152, 2683 \200\2232684 . doi: 10.1016/j.pain.2011.08.023 caregiver context. Pain Res Manag , 14, 27 \200\22332. Pillai Riddell, R., Stevens, B. J., Cohen, L. L., Flora, D. B., and Greenberg, S. (2007). P redicting maternal and behavioral measures of infant pain: the relative contribution of mat ernal factors. Pain , 133 (1 \200\2233), 138 \200\223149 . doi:10.1016/j.pain.2007.03.020 Walker, L. S., and Zeman, J. L. (1992). Parental response to child illness behavior. J Pedi atr Psychol , 17 (1), 49 \200\22371 . doi:10.1093/jpepsy/17.1.4 Williams, S., Blount, R. an d Walker, L. (2011). Children \200\231s pain threat appraisal and catastrophizing moderate the impact of parent verbal behavior on children \200\231s symptom complaints. J Pediatr Ps ychol , 36 (1), 55 \200\22363 . doi: 10.1093/jpepsy/jsq043 Pillai Riddell, R. R., Flora, D. B., Stevens, S. A., Stevens, B. J., Cohen, L. L., Greenber g, S., et al . (2013). Variability in infant acute pain responding meaningfully obscured by averaging pain responses. Pain , 154, 714 \200\223721. Woolf, C. (2010). What is this thing called pain? J Clin Invest , 120 (11), 3742 \200\223 Racine, N., Pillai Riddell, R., Flora, D., Garfi eld, H., and Greenberg, S. (2012). A longi tudinal examination of verbal reassurance during infant immunization. J Pediatr Psychol , 3 7(8), 935 \200\223944. 3744 . doi:10.1172/JCI45178 Young, K. D. (2005). Pediatric procedural pain. Ann Emerg Med , 45, 160 \200\223171 . doi: 10.1016/j.annemergmed.2004.09.019 CHAPTER 10 Cognitive styles and processes in pediatric pain Liesbet Goubert and Laura E. Si mons Summary Chronic pain is prevalent in children and adolescents. Th e current chapter outline s an interpersonal perspective on child pain, demon- strating the central role of child and parent pain-related cognitions in the development and maintenance of chronic pain in child hood. Pain takes place within a social context: children \200\231s expressions of pain (e.g . facial pain displays) are observed and decoded by others (parents), eliciting emotional a nd behavioral responses. Parents \200\231 responses may impact child outcomes in two ways, directly by imposing activity limitations/encouraging activity engagement or indirectly thr ough observational learning. Although personality and temperamental factors may predispose children and parents to perceive pain as more or less threatening to deal with, the model p resented in this chapter focuses on proximal pain-related cognitive processes and associate d behaviors that contribute to pain-related disability in children. Recent evidence suggest s that perceptions of pain as highly threatening (i.e. catastrophizing) may lead to fearful reactions to pain, activity avoidant behaviors, and more disability. In parents, catastrop hizing thoughts about child pain are associated with higher levels of child disability, wit h recent evidence implicat- ing parent protective behaviors as a mediating mechanism. Setting the stage: personality and temperament Since the introduction of the gate control t heory of pain, it has been increasingly acknowledged that the way individuals perceive and interpret pain is a determinant of pain outcomes. Early studies dem- onstrated that people \200\231s personality or characteristic ways of thinking impact how they process pain. Most studies focused upon the role of neuroticism \200\224i.e. the trait-like tendency to exper ience a broad range of negative feelings such as distress or worry \200\224which has been a ssociated with a heightened experience of bodily sensations (Watson and Pennebaker, 1989), and, in particular, pain (Charles et al., 2008). In the context of pediatric pain, a fearfu l temperament has been identifi ed as a predictor of somatic complaints 1 year later (Wolff et al., 2010) and 7 years later (Rocha and Prkachin, 2007). Furthermore, adolescents suff ering from chronic pain have been found to be more vulnerable than healthy peers in terms o f neuroti- cism (Merlijn et al., 2003). Originating from the positive psychology movement, the concept of optimism \200\224i.e. the generalized expect- ancy of positive outcomes \200 \224has received increasing attention in the context of pain. In particular, optimism has b een linked with lower pain reports in adults (Geers et al., 2008) and adolescents (Mannix e t al., 2009; Williams et al., 2010). In children with cancer, Williams et al. (2010) demons trated that optimism primarily related to lower self-report of pain and better emotional fu nctioning, while pessi- mism was linked to poorer mental health. Introduction Chronic and recurrent pain is prevalent in children and adoles- cents, with me dian prevalence rates ranging from 11% to 38% (King et al., 2011). A study in 987 children recruited from the gen- eral population showed that one-third of children and adolescents w ho were experiencing chronic pain at baseline reported chronic pain at 1-year and 2-year fo llow-up (Perquin et al., 2003). Most children seem to function well despite pain, although a minority (5%) are moderately or severely disabled across several domains of functioning ( Huguet and Miro, 2008). Th e central question is why some children easily recover from pain and resume daily activities, while others seem to experience it as a major burden, hinderi ng them in pursuing daily activities. Th is chapter will outline an inter- personal perspec tive on the development and maintenance of child chronic pain complaints, describing the ro le of cognitive processes in children and parents. Additionally, challenges for future rese arch will be discussed. Although these studies indicate that temperament and personal- ity traits have a direct eff ect upon pain outcomes, other research has suggested that personality variables are better viewed as vulner- ability or resilience factors, impacting on pain outcomes through more p roximal variables involving pain-specifi c cognitive proc- esses (Goubert et al., 2004; Hoo d et al., 2012; Leeuw et al., 2007; Muris et al., 2007; Vervoort et al., 2006). Pain-speci \201 c cognitive processes A cognitive process which has received ample attenti on in the pain literature is catastrophic thinking about pain, characterized by an individu al \200\231s tendency to focus on, and exaggerate, the threat value of painful stimuli and negatively evaluate one \200\231s own ability to deal SECTION 3 social and psychological basis of pediatric pain 96 with pain (Sullivan et al., 2001). Extensive evidence is available that catastrophizing abo ut pain relates to more intense pain and higher disability (Leeuw et al., 2007), and also i s predictive of the persist- ence of pain and disability (e.g. Linton et al., 2000). Catast rophic thinking has been shown to give rise to an excessive fear of pain/ injury (Goubert e t al., 2004), which, in turn motivates individu- als to escape or avoid activities thought to induce pain. Numerous studies have shown that catastrophizing thoughts about pain and pa in-related fear (i.e. fear-avoidance beliefs) exert their eff ects upon pain experience and pain-related disability through longstanding avoidance behaviors and physical inactivity ( Leeuw et al., 2007). In line with the vulnerability hypothesis, several studies have dem- o nstrated that neuroticism impacts on pain outcomes through cata- strophizing about pain, in adults (Goubert et al., 2004) and children (Vervoort et al., 2006). Furthermore, a study i n young adolescents showed that reactive temperament traits (involving fear and anger- frus tration) were positively associated with pain catastrophizing, whereas regulative traits (i .e. attention and inhibitory control) were negatively associated with catastrophizing about pain (Muris et al., 2007). Interestingly, a recent study in healthy adults demonstrated th at the protective link between optimism and pain perception operates through lower catastro phizing thoughts about pain, sug- gesting that individuals who are lower in optimism are mo re likely to ruminate, magnify or feel helpless about their pain experience, resulting in h igher pain (Hood et al., 2012). Given the bulk of evi- dence supporting the proximal link o f pain-specifi c cognitive proc- esses on outcomes, the remainder of the chapter will prima rily focus upon the role of fear-avoidance beliefs in children and parents. was associated with a decrease in functional disability, suggesting that a decline in pain- related fear corresponds with a resumption of daily activities. Th is study also examined t he relationship between pain catastrophizing and pain-related fear. As expected, these sequ entially linked variables were highly related to one another. At present, no studies have e xamined the sequential predictive role of pain catastrophizing to pain-related fear to pain -related outcomes in children. Proceeding from a cognitive-behavioral model of pain (see Le euw et al., 2007), pain-related fear and escape or avoid- ance behaviors are expected to me diate the association between catastrophizing and the chronifi cation of pain. Children \200\231s fear-avoidance beliefs in a social context It has become increasingly cl ear that child pain does not exist in a social vacuum. Th e biopsychosocial model of pain c ommunica- tion of Hadjistavropoulos and colleagues (2011) outlines how pain becomes a socia l experience. Following a pain stimulus, a child encodes its internal experience of pain in to an expressive display of pain (e.g. facial pain behavior), observable to others (e.g. pa r- ents). Th ese expressive displays demand attention from others, which are then decoded ( i.e. discriminated and interpreted), and may elicit emotional (e.g. distress) and behaviora l responses (e.g. comforting) in the parent (Goubert et al., 2005). In turn, parents \200 \231 responses may impact the child \200\231s experience and expression of pain. A comprehe nsive understanding of pain as a social experi- ence (i.e. the dynamic interplay between a child \200\231s pain experience and the social environment in which pain emerges) thus requ ires consideration of expressive (i.e. how is pain communicated to oth- ers) and receptive features (i.e. how is pain perceived by others) of pain (Hadjistavropoulos et al., 2011). Fear-avoidance beliefs in children: catastrophizing and pain-related fear In recent years r esearch has accumulated demonstrating the impor- tance of fear-avoidance beliefs in the con text of pediatric pain. Although the available evidence is markedly smaller than in adults, the fi ndings are consistent with the adult literature. Child pain cata- strophizing has b een found to be related to higher pain intensity in samples of healthy school children and children with chronic pain (e.g. Hermann et al., 2007) and to lower pain tolerance (Piira e t al., 2002). High catastrophizing children with chronic pain also report having more diffi culty performing daily activities in home, school, recreational and social domains (Crombe z et al., 2003; Guite et al., 2011). To our knowledge, only one prospective study of pain c ata- strophizing is available in children (Vervoort et al., 2010), indicating that it contr ibutes to increased pain and disability 6 months later. On the expressive side, studies have indicated that children are able to modulate their exp ression of pain. An important determi- nant of pain expression is the intensity of pain exp erienced. Yet, pain intensity only explains a small to moderate amount of the variance in c hildren \200\231s pain expression (Vervoort et al., 2009). A child \200\231s display of pai n may vary according to the way a child is socialized to think and behave when in pain. Stu dies have shown that children \200\231s expression of pain depends on the beliefs endorsed about pain and the child \200\231s perceived ability to cope with it. Specifi cally, in lin e with research in adults (e.g. Keefe et al., 2003), recent fi ndings revealed that chil- d ren who endorse high levels of catastrophizing about pain express high levels of pain, rega rdless of the intensity of pain experienced (Vervoort et al., 2009). Furthermore, contextua l factors, such as the presence of others, may be critical in understanding varying levels of child pain expression (Hadjistavropoulos et al., 2011). Children may consider the potent ial response from the other when deciding to express or hide pain. For example, children as young as 9 years old report being less likely to express pain in front of a peer than in p resence of their parent because they expect more negative reactions from peers compared to parents following pain disclosure (Zeman and Garber, 1996). Furthermore, the social context may interact with children \200\231s beliefs in the impact upon child \200\231s pain expre ssion. Of interest in this regard are studies from Vervoort et al. (2008, 2011a), investiga ting the impact of diff erent types of observers in the rela- tionship between child pain c atastrophizing and child \200\231s display of pain. An interesting fi nding from these stud ies is that children who perceive the pain as threatening (i.e. catastrophize) indiscrimina tely Research examining the theorized consequent of pain catastro- phizing, pain-related fear, h as gained support in relation to pain-re- lated outcomes. In a small pilot study, Martin an d colleagues (2007) found that pain-related fear accounted for 40% of the variance in pain- related disability. In another study, child pain-related fear pre- dicted physical activity limitations beyond the infl uence of pain and depressive symptoms (Wilson et al., 2011). F urthermore, in a recent study among pediatric patients experiencing acute post-surgical pai n, pain-related fear was associated with pain unpleasantness and functional disability 2 we eks aft er surgery (Page et al., 2011). In pediatric patients with persistent pain, Simons et al. (2011) found higher levels of pain-related fear to be associated with more frequent physician visits and higher levels of functional disability. In addition, a decrease in pai n-related fear over a 1-month period CHAPTER 10 cognitive styles and processes in pediatric pain 97 display their pain, regardless whether they are alone, with a stranger, or with a parent. I n contrast, low-catastrophizing children modu- lated their expression depending on whether a solicitous response is more likely (e.g. higher expression in presence of parent compared with when alone or in presence of a stranger). et al., 2005, 2009, 2013). When a child displays an internal expe- rience of pain, others a ttend to, discriminate, and interpret pain signals, which may give rise to emotional (e.g. distress) and behav- ioural responses (e.g. comforting), with strongest reactions elicited by more intense pain displays. Yet, child pain expression is not the only source of informa tion for others. Both characteristics of the observer (such as beliefs about the pain) and characteristics of the context may be important here. Yet, it is still largely unknown why children who catastrophize express more pain, and the impact upon others. Th e fi ndings of Vervoort et al. (2008, 2011a) support the suggestion of Sullivan et al. (2001), that catastrophizing about pain has an interpersonal func- tion. In particular, it has been suggested that, through a heightened display of distress, indiv iduals who catastrophize may be maximiz- ing the probability that potential caregivers will maintain proximity or off er support or assistance (Sullivan et al., 2001). To truly under - stand the dynamics of children \200\231s pain catastrophizing in a social con- text, unde rstanding the nature of the interaction between the child in pain and those able to provide care is essential. It is still unclear what type of responses high catastrophizing childre n elicit in others and how, in turn, these responses infl uence the child \200\231s future pain experience. Research in adult populations has indicated that others \200\231 responses toward high catastrophizers can vary substantially; cata- strophizing appears to elicit po sitive responses such as the provi- sion of instrumental support as well as negative respon ses such as criticizing the suff erer in pain or responding punitively (Keefe et al., 2003) . In the context of pediatric pain, a recent study suggests that child catastrophizing may not always elicit solicitous responses, but also discouraging responses (e.g. criticism), a lthough this associa- tion was only found for mothers (Vervoort et al., 2011b). Th is study also indicated that the negative eff ects of child catastrophizing upon pain outcomes may be reduced when parents promote well behav- iours in their child. Only one pilot study coul d be found that has examined the relationship between child pain-related fears and par- ent responses to pain. Wilson et al. (2011) found that child pain-re- lated fear and parent pr otective responses to pain were signifi cantly correlated, with child pain-related fear med iating the relationship between protective parent responses and child activity limitations. In line with the cognitive-aff ective model of pain (Leeuw et al., 2007), it is likely that parents who perceive their child \200\231s pain as highly threatening (i.e. have catastrop hic thoughts) may experience high dis- tress, and, accordingly, feel motivated to engage in behaviors aimed at the reduction or avoidance of pain in their child, at the expense of ot her important domains (e.g. school performance) in the child \200\231s life. For example, i t is reasonable to assume that parents, who perceive the child \200\231s pain as highly thr eatening and dangerous, may keep their child home from school more frequently. Preliminary evidence is available. Studies have shown that more protective behaviors from parents are a ssociated with higher child disability (Peterson and Palermo, 2004; Simons et al., 2008). F urthermore, it was found that higher parental catastrophizing about their child \200\231s p ain is related to higher parental distress (Caes et al., 2011; Goubert et al., 2006), highe r child disabil- ity and lower school attendance (Goubert et al., 2006), and a higher tende ncy to restrict their child \200\231s pain-inducing activity (Caes et al., 2011). When exam ining parent catastrophizing and protective parent behaviors together, protective behaviors mediated the relationship between parent catastrophizing and child school functioning (Log an et al., 2012) and partially mediated the relationship between catastro- phizing and func tional disability (Sieberg et al., 2011). Additionally, parent pain-related fears are relat ed to higher levels of child func- tional disability and child healthcare utilization (Simo ns et al., 2011). More insight into these mechanisms is expected to be of crucial clinical signifi cance, as it will enable us to identify those parents who negatively infl uence chi ldren \200\231s vulnerability to deal with pain, and, as such, increase children \200\231s risk for delays in academic or social skills due to persistent pain problems. 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.