 \227\206 Be sure that your child goes to school each day. \227\206 Help your child identify stress at home and at school. \227\206 Provide attention and special activities on days when your child does not have stomach aches. \227\206 Limit activities and interactions on sick days. \227\206 Avoid talking about any pains or illness you have. \227\206 Support your child in practicing their pain coping strategies (e.g. relaxation, distraction). of key messages to parents regarding behavioral pain manage- ment. Parents and children are engaged in a collaborative partner- ship where parents can both model and supportively \200\230coach \200\231 their child during treatment and for relapse prevention (Noel et al. , 2012b; Palermo et al., 2009; Robins et al., 2005). CBT treatment protocols diff er in the type and extent of parental involvement required, with some requiring joint attendance of the parent at a portion of treatment sessions (Robins et al., 2005) and others deliv- ering content separately and concurrently to parents and children (Noel et al., 2012a; Palermo e t al., 2009; for further discussion of CBT see Logan et al., Chapter 50, this volume). A ra ndomized con- trolled trial comparing CBT to standard medical care for children with recurr ent abdominal pain and their parents reported signifi - cantly reduced child pain and schoo l absences for the CBT group immediately post-treatment and at 1-year follow-up (Robins et al., 2005). Signifi cant reductions in parent pain-promoting behaviors were reported aft er a CBT intervention with parental involvement for children with recurrent abdominal pain (N oel et al., 2012a). Children with chronic pain and parents participating in an 8-week famil y CBT intervention online similarly reported signifi cant reduced pain and activity limitat ions as compared with a wait-list control immediately post-treatment and maintained at 3-mo nth follow-up (Palermo et al., 2009). Although some interventions address the importance of parents \200\231 own mental health (Noel et al., 2012a; Palermo et al., 2009), most do not assess parent psychoso- cial functioning. One study evaluating an interdisciplinary CBT pr ogram reported signifi cant improvements in parent anxi- ety, depression, and stress post-t reatment that was maintained at 3-month follow-up (Eccleston et al., 2003). Children attend ing this program also showed improvements in physical function and disability, anxiety, pai n catastrophizing, somatic awareness, and school attendance (Eccleston et al., 2003). References Bandura, A. (1977). Social learning theory. Englewood Cliff s, NJ: Prentice- Hall Inc. 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(1991). Parents \200\231 diff erential socialization of boys and girls: a meta-analysis. Psychol Bull , 109, 267 \200\223296. Goubert, L., Vervoort, T., Crombez, G., Cano, A., Craig, K. D., and de C. Williams, A. C. ( 2006). Response to letter to the editor regarding our manuscript \200\230Facing others in pain: the eff ects of empathy \200\231. Pain , 122, 328 \200\223330. Maciver, D., Jones, D., and Nicol, M. (2010). Parents \200\231 experiences of caring for a child with chronic pain. Qual Health Res , 20, 1272 \200\2231282. McGrath, P. J. (2008). Th e family is the crucible. Pain , 137, 471 \200\223472. McMurtry, C. M., Chambers, C. T., McGrath, P. J., and Asp, E. (2010). When \200\230don \200\231t worry \200\231 communicate s fear: children \200\231s perceptions of parental reassurance and distraction during a pai nful medical procedure. Pain , 150, 52 \200\22358. Goubert, L., Vervoort, T., Sullivan, M. J. L., Verhoeven, K., and Crombez, G. (2008). Paren tal emotional responses to their child \200\231s pain: the role of dispositional empathy an d catastrophizing about their child \200\231s pain. J Pain , 9, 272 \200\223279. SECTION 3 social and psychological basis of pediatric pain 118 McMurtry, C. M., McGrath, P. J., and Chambers, C. T. (2006). Reassurance can hurt: parental behavior and painful medical procedures. J Pediatr , 148, 560 \200\223561. Scharff , L., Langan, N., Rotter, N., Scott-Sutherland, J., Schenck, C., Tayor, N., et al . (2005). Psychological, behavioral, and family characteristics of pediatric patients with c hronic pain: a 1-year retrospective study and cluster analysis. Clin J Pain , 21, 432 \200 \223438. Moon, E. C., Chambers, C. T., Larochette, A. C., Hayton, K., Craig, K. D., and McGrath, P. J. (2008). Sex diff erences in parent and child pain ratings during an experimental child p ain task. Pain Res Manag , 13, 225 \200\223230. Moon, E. C., Chambers, C. T., and McGrath, P. J. (2011). \200\230He says, she says \200\231: a comparison of fathers \200\231 and mot hers \200\231 verbal behavior during child cold pressor pain. J Pain , 12, 1174 \200\223118 1. Simons, L. E., Claar, R. L., and Logan, D. L. (2008). Chronic pain in adolescence: parental responses, adolescent coping, and their impact on adolescent \200\231s pain behaviors. J P ediatr Psychol , 33, 894 \200\223904. St Laurent-Gagnon, T., Bernard-Bonin, A. C., and Villeneuve, E. (1999). Pain evaluation in preschool children and by their parents. Acta Paediatr , 88, 422 \200\223427. Myers, C. D., Riley, J. L., and Robinson, M. E. (2003). Psychosocial contributions to sex-c orrelated diff erences in pain. Clin J Pain , 19, 225 \200\223232. Stevens, B. J., Abbott, L. K., Yamada, J., Harrison, D., Stinson, J., Taddio, A., et al . ( 2011). Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ , 183, E403 \200\223410. Noel, M., Chambers, C. T., McGrath, P. J., Klein, R. 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Earl y parental and child predictors of recurrent abdominal pain at school age: results of a lar ge population-based study. J Am Acad Child Adolesc Psychiatry , 45, 729 \200\223736. Walker, L. S., Williams, S. E., Smith, C. A., Garber, J., Van Slyke, D. A., and Lipani, T. A. (2006). Parent attention versus distraction: impact on symptom complaints by children wi th and without chronic functional abdominal pain. Pain , 122, 43 \200\22352. Reid, G. J., McGrath, P. J., and Lang, B. A. (2005). Parent-child interactions among childr en with juvenile fi bromyalgia, arthritis, and healthy controls. Pain , 113, 201 \200\22321 0. Wicksell, R. K. (2007). Values-based exposure and acceptance in the treatment of pediatric chronic pain: from symptom reduction to valued living. Pediatr Pain Lett , 9, 13 \200\22320 . Robins, P. M., Smith, S. M., Glutting, J. J., and Bishop, C. T. (2005). A randomized contro lled trial of a cognitive-behavioral family intervention for pediatric recurrent abdominal pain. J Pediatr Psychol, 30, 397 \200\223408. Saunders, K., Korff , M. V., Leresche, L., an d Mancl, L. (2007). Relationship of common pain conditions in mothers and children. Clin J Pain, 23, 204 \200\223213. Wicksell, R.K. (2008). Acceptance and commitment therapy for pediatric chronic pain. In L. A. Greco and S. C. Hayes (eds) Acceptance and mindfulness treatments for children and adole scents: a practitioners guide , pp. 89 \200\223113. Oakland, CA: New Harbringer Publication s Inc. Schanberg, L. E., Anthony, K. K., Gil, K. M., Lefebvre, J. C., Kredich, D. W., and Macharon i, L. M. (2001). Family pain history predicts child health status in children with chronic rheumatic disease. Pediatrics , 108, 1 \200\2237. Williams, S. E., Blount, R. L., and Walker, L. S. (2010). children \200\231s pain threat ap praisal and catastrophizing moderate the impact of parent verbal behavior on children \200 \231s symptom complaints. J Pediatr Psychol , 36, 55 \200\22363. CHAPTER 13 Pain, social relationships, and school Paula Forgeron and Sara King Summary Although recurrent and chronic pain impacts the whole life of a child and or adoles cent, little research has been conducted on social con- sequences of chronic pain for child ren and adolescents. Emerging research suggests that (1) peer relationships, including clos e friend- ships, of children and adolescents with chronic pain may be negatively impacted b y pain and (2) social reactions from others can negatively impact the child or adolescent \200\231s pain experience. School functioning may also be impaired as a result of chronic p ain. Clinicians should understand the challenges experienced by children with chronic pain and should attend to the social and school consequences of pain when working with this popu lation. Although little research has examined interventions to manage the eff ects of chron ic pain on school and social functioning, researchers have identifi ed helpful strategies t hat may mitigate the negative consequences to social and school func- tioning associated wi th chronic pain. Th e goals of this chapter are: (1) to review the literature on social and school functioni ng for children and adolescents with chronic pain; (2) discuss strategies to ameliorate dif fi culties; and (3) high- light directions for future research. Social communication model of pain Th e social communication model (SCM) of pain (Craig 200 2, 2009) suggests that pain is a social phenomenon that is experi- enced within a social co ntext. Th is model underscores the rela- tionship between a child \200\231s or adolescent \200\231s chronic pain experience and their relationship with peers, friends, and school fu nctioning. According to this model, the individual \200\231s pain expression is an iter- at ive social process. Th us, peer, friend, and teacher responses to an adolescent \200\231s p ain expression may impact either positively or nega- tively on the adolescent \200\231s pai n experience. Conversely, the expres- sion of pain by the child or adolescent may have an i mpact on his or her peers \200\231, friends \200\231, and teachers \200\231 interpretation and response to pain. Th is cycle of pain expression, interpretation, and subsequent pain e xpression may be as infl uential in the social interactions of children and adolescents wit h chronic pain as individual pain fac- tors such as pain intensity. Th e SCM is reviewed in depth by Pillai Riddell et al. (Chapter 9, this volume). Introduction Peer relationships and close friendships are a fundamental part of child devel opment and become increasingly important as children approach adolescence. Peer relationshi ps provide a milieu through which adolescents develop self-identity and values in the absen ce of adult monitoring (Rubin et al., 2005). Indeed, positive peer relationships and close friendships are associated with lower lev- els of depression and loneliness (Nangle et al., 2003), and positive school adjustment (Ladd et al., 1997). Close friendships can buff er t he negative eff ects of peer victimization (Hodges et al., 1999) and negative family enviro nments (Gauze et al., 1996). Background Peers and friends Research examining the relationship between peers, friends, an d pain experience is in its infancy. Most research is based on gen- eral peer relationships (i.e. peer acceptance) as opposed to close friendships. When examining peer relationships of children and adolescents, it is necessary to diff erentiate between peer acceptance and close friendships. Peer acceptance (also defi ned as popularity) is a measure of general pe er relationships based on unilateral lik- ing and results in a feeling of belonging and inc lusion (Buhrmester and Furman, 1986). Close friendships are based on mutual liking and prov ide one with intimacy and reliable alliance (Bagwell et al., 2001). Sullivan (1953) suggest s that the need for peer acceptance is stronger for younger children, whereas the need for close friend- ships surpasses the need for general peer acceptance in adolescence. Th us, p sychosocial adjustment in children may be linked more to School functioning is essential for positive development, as it has been linked to both aca demic and social success. Peer acceptance and close friendships have an impact on social fu nctioning regard- less of context, whereas teacher acceptance plays a critical role in scho ol functioning for children and adolescents? Although typically developing children and ado lescents oft en experience challenges in both school and social functioning, diffi culties can be compounded for children and adolescents with chronic pain. Despite the impor- tance of the relations between and among peers, friends, and school functioning for positive deve lopment, little is known about the impact of recurrent and chronic pain on these areas of f unctioning. SECTION 3 social and psychological basis of pediatric pain 120 peer acceptance whereas for adolescents it may be linked more to close friendships (Erdley et al., 2001). explained in the interpretation of non-supportive social situations. Adolescents with chron ic pain may have a heightened sensitivity to negative social situations, as these situation s may have the potential to negatively impact their pain experience. According to the SCM, adolescents with chronic pain who have experienced unsupportive social situations involving their friends may try to avoid these situ- ations to avoid feeling uncared for by their fr iends. Th ese situations may then be interpreted with heightened sensitivity in the future, due to the possibility of experiencing negative consequences. In other studies, adolescent s with chronic pain described their friends as unable to understand their pain condition, a lluding to the notion that their friends were unsupportive (Carter et al., 2002; Forgeron a nd McGrath, 2008). One of the reasons that friends might not fully understand an adolescent \200\231s pain condition is the unpredictable nature of pain. Th ere are times when adoles cents with chronic pain are able to socially engage much like their healthy peers and other times when pain interferes signifi cantly with physical and social functioning. Additional ly, as most chronic pain conditions are not visible, healthy friends may not always provide the level of support desired by the adolescent with chronic pain. Th us, adolescents with chronic pain may experience feelings of loneliness, even when they do engage with friends, if they feel they cannot fully share their pain experience with others. Pain fi rst begins to interfere with social functioning by inter- rupting regular physical activities, leisure activities, and school attendance (Logan et al., 2008; Roth-Isigkeit et al., 2005). Missing physical and leisure activities in addition to missing school presents challenges for establishing and maintaining friendships, as these venues provide most of t he opportunities for children and adoles- cents to interact with peers. Interruptions to ac tivities and school absence can be problematic from a social functioning perspective, but t he extent to which this is the case is not clear, as impact var- ies between individuals. I ndeed, children and adolescents with chronic pain have fewer friends compared to healthy pe ers, but it is not clear whether this diff erence is signifi cant (see Forgeron et al., 201 0 for a review). Typically developing children and adolescents have an average of three to four close friends (Berndt and Hoyle, 1985). Although children and adolescents with chronic pain have been found to have fewer friends the actual number of friends they have compared to typically developing peers remains unknown (Forgeron et al., 2010). Perhaps more import ant is that it is not clear whether children and adolescents with chronic pain are at highe r risk for having no close friends. Although spending time with peers is necessary to foster friend- ships, time spent together may not be suffi cient for good social functioning or the development of close friendships . For exam- ple, structured leisure activities have been linked to lower levels of aggressi ve behavior (Mahoney and Stattin, 2000) and assist in the development of self-identity (Coa tsworth et al., 2005). Th erefore, adolescents with chronic pain who have withdrawn from st ructured leisure and sport activities may struggle with self-identifi cation in relation to their friends and peers. Chronic ponain was found to be a catalyst for adolescents to reth ink their identity (Forgeron et al., 2011a). For example, children and adolescents with chr onic pain may no longer identify themselves as a \200\230dancer \200\231 or \200\230footb all player \200\231, which may have a negative eff ect on self-identity. Recent research le nds credence to this argument, as adolescents with chronic pain report lower self-esteem sc ores, increased loneliness, and depressed mood scores compared to healthy peers. However, t he precise rea- sons are somewhat unclear (Forgeron et al., 2011b). It is possible that hav ing a negative self-image contributes to feeling unequal to others in a group and to decrea sed participation in sport and leisure activities. Even when these adolescents spend time w ith friends, they may feel diff erent and unequal to their friends, which can dis- rupt the establishment of close friendships. Carter and colleagues (2002) reported that adolescents with chronic pain oft en describe \200\230sunny day friends \200\231 as friends who are only present when pain is not problem atic. Interestingly, adoles- cents with chronic pain described some of their friends as hav ing changed, as opposed to changing themselves. Th is fi nding points to a potential dichot omy between adolescents with chronic pain and their friends. Healthy friends may perceive t he adolescent with chronic pain as the one who has changed. Not only does pain inter- fere with leisure and sport activities, but it can also contribute to dis- rupted sleep and irri tability. One participant in a study by S llfors and colleagues (2002) described classma tes being shocked as she became more irritable when she was in pain. Th us, fatigue and irr i- tability (a form of pain expression) may explain why some healthy friends only wish to i nteract with the adolescent with chronic pain when pain expression is minimal. Children and adolescents with chronic pain expressed diffi culty when their friends did not believe the m, and felt as though they were being blamed for their condition (Forgeron and McGrath, 200 8; S llfors et al., 2002). Friends of children and adolescents with chronic pain continue to have friendship needs, re gardless of whether the child or adoles- cent with chronic pain is able or willing to engag e in various social activities. Healthy children and adolescents may develop additional fri endships to buff er their own loneliness when their friend with chronic pain is not in scho ol or unable to participate in social activ- ities. It is not clear if or how friendships c hange over time when a child or adolescent has chronic pain. Healthy friends may be more un derstanding when the pain fi rst begins but over time may need to fi nd alternative friends to fi ll their own friendship needs. Close friends Th e majority of the research on close friendships and pain has been conducte d with adolescent populations. Th is is understandable, as the prevalence of chronic pain t ends to increase around or aft er puberty (King et al., 2011; Stanford et al., 2008). Adole scents with chronic pain have identifi ed close friends as being both helpful and unhelpful in coping with chronic pain (Forgeron and McGrath, 2008). In a recent study, Forgeron and colleagues (2011b) found that adolescents with chronic pain rated narrative vignettes depic t- ing a non-supportive social interaction between an adolescent with chronic pain and a cl ose friend as more unsupportive compared to healthy peers. Although adolescents with chroni c pain had higher rates of loneliness and depressed mood and lower self-es- teem, scores on these measures did not contribute to the variance Support from friends has a self-reported positive impact on social functioning (Carter et a l., 2002; Forgeron and McGrath, 2008; S llfors et al., 2002). Friends have been describe d as provid- ing distraction, understanding, companionship (Carter et al., 2002; Forgeron a nd McGrath, 2008; S llfors et al., 2002), and emotional and academic support to adolesce nts with chronic pain. Although close friends can provide positive support, it is unlikely that they provide support in every situation. In the narrative vignette study CHAPTER 13 pain, social relationships, and school 121 Peers Peer acceptance (unilateral liking/popularity) has been studied more extensively than close friendships in children and adolescents with chronic pain; however, results of studi es completed to date have been inconclusive. Some researchers suggest there are no dif- fer ences in peer acceptance of children and adolescents with chronic pain (Guite et al., 2000; Noll et al., 2008, 2010), whereas others sug- gest that there are diff erences (Kashikar-Z uck et al., 2007; Vanetta et al., 2008). Kashikar-Zuck and colleagues, using a classroom ra t- ing approach compared likeability ratings of adolescents with juve- nile fi bromyalgia w ith age-matched controls from the same class, found that peers rated the adolescent with ju venile fi bromyalgia as less likable than classmates (Kashikar-Zuck et al., 2007). However, Noll and colleagues using the same classroom rating approach did not fi nd any diff erence s in likeability between adolescents with juvenile arthritis and age-matched classmates (No ll et al., 2000). It remains uncertain which factors may contribute to the contrasting fi n dings reported in these two studies. described earlier (Forgeron et al., 2011b), adolescents with chronic pain and healthy contr ols listed alternative responses to the healthy character \200\231s response depicted in th e vignettes. Th e responses were coded as inclusive/helpful or not inclusive/helpful. Th er e were no diff erences between the two groups with respect to the number of inclusive/helpf ul alternatives that were listed across the 12 vignettes. However, adolescents with chronic pain endorsed signifi cantly more inclusive/helpful alternatives when asked to describe wh at they would have done if they had been the healthy character in the vignette. Even when h ealthy peers know what might be supportive to a friend with chronic pain, they may not feel skilled or prepared to provide that support in all situations. Alternatively, adolescents with chronic pain may have expectations that are above and beyond what another adolescent i s capable of providing. Th ere are several caveats that should accompany the research previously described. First, positive alternative behaviors were coded as supportive if they ensured the inclusion/help for the adolescent with chronic pain. It remains unclear, however, if pro- viding such supp ort would improve the social functioning of an adolescent with chronic pain. Being overly s olicitous may result in less competent social functioning, as it may enforce the belief tha t the adolescent with chronic pain believes his or her needs have priority over others. Nev ertheless, even if participation in social activities is not increased by supportive friend ship behav- iours, perceived support may help an adolescent with chronic pain feel valued a s a friend. Additionally, close friends are reciprocal in nature, therefore it may be impor tant to ensure that adolescents with chronic pain remain empathic to the needs of their hea lthy friends. Second, sex diff erences in friendships exist in typically developing childre n and adolescents. Specifi cally, male friendships are characterized by more physical prese nce and female friend- ships are characterized by more emotional sharing (Benenson and Chri stakos, 2003). Although the vignettes included both physical activity situations and emotio nal sharing situations, there were not suffi cient numbers of both to analyze separately. I t is unclear if there are diff erences in the types of situations perceived by ado- lescent s with chronic pain as non-supportive based on their sex. Th ere is no research that examin es the types of support off ered by a friend and the pain coping and social functioning of children and adolescents with chronic pain.