Th e following academic accommodations have been identifi ed as helpful either from clinica l experience or the literature. First, regular communication between and among the health c are profes- sionals, school, and family is needed (Logan and Curran, 2005). Second, teacher s are more apt to provide requested academic accommodations if the health professional prov ides these sugges- tions in writing (Forgeron and McGrath, 2008; Logan and Curran, 2005). T h ird, academic accommodations that off set the negative cognitive consequences of chronic pain need to be individualized, as not all patients require every accommodation. Such accom mo- dations may include a combination of the following: (1) class notes (i.e. for missed wo rk or to reduce motor demand when in class), (2) spacing out of projects and tests to allow for the increase length of time to complete tasks, and (3) decreased workload (i.e. the qu ality should be the same but amount may need to be reduced). Finally, in our clinical exper ience, having one teacher (or guidance counsel- lor) to act as a student advocate within th e school has been helpful. Although chronic pain may negatively aff ect subjective reports of academic performance (Di ck and Pillai-Riddell, 2010), the exact processes remain elusive. Pain may negatively impac t concentra- tion and focus. However, negative academic performance may also be related to other pain related factors such as sleep disturbances. CHAPTER 13 pain, social relationships, and school 125 Changes in social relationships in the school setting (both with peers and teachers) may co ntribute to a decline in overall school performance and school absence may intensify or be a consequence of these factors. Research is needed to examine the processes that interfere with specifi c aspects of school performance (academic performance, social relationships, r estrictions on school involve- ment) along with designing and testing strategies that impro ve overall school performance. W. Nagle and C. A. Erdley (eds) Th e role of friendship in psychological adjustment , pp. 2 5 \200\22350. San Francisco, CA : Jossey-Bass . Bandura, A. (1993). Perceived self-effi cacy in cognitive development and functioning. Educ Psychol , 28, 117 \200\223148. Benenson, J. and Christakos, A. (2003). Th e greater fragility of females \200\231 versus males \200\231 closest same-sex friendships. Child Dev , 74 , 1123 \200\2231129 . Berndt, T. J. and Hoyle, S. G. (1985). Stability and change in childhood and adolescent friendships. Dev Psychol, 21 , 1007 \200\2231015 . Buhrmester, D. and Furman, W. (1986). Th e changing functions of friends in childhood: a ne o-Sullivanian perspective. In V. J. Derlega and B. A. Winstead (eds) Friendship and social interaction , pp. 41 \200\22345. New York : Springer-Verlag . Conclusion A clear understanding of the social and school functioning of chil- dren and ado lescents with chronic pain is an essential part of their clinical care. We have suggested s trategies on to support improved social functioning and school performance-based current re search. However, more research is needed to understand the processes underlying social func tioning and school performance so that more specifi c interventions can be designed and imp lemented, thereby allowing children and adolescents challenged by chronic pain to be as suc cessful as possible in the academic and social spheres. Carter, B., Lambrenos, K., and Th ursfi eld, J. (2002). A pain workshop: an approach to eli citing the views of young people with chronic pain. J Clin Nurs , 11 , 753 \200\223762 . Coatsworth, J. D., Sharp, E. H., Palen, A., Darling, N., Cumsille, P., and Marta, E. (2005) . Exploring adolescent self-defi ning leisure activities and identity experiences across th ree countries. Int J Behav Dev , 29 , 361 \200\223370 . Craig, K. (2009). Th e social communication model of pain. Can Psychol , 50, 22 \200\22332. Craig, K. D. (2002). Pain in infants and children: socio developmental variations on the th eme . In M. A. Giamberardino (ed), Pain 2002 \200\224an updated review, refresher course sy llabus, 10th World Congress on Pain, San Diego, CA , pp. 305 \200\223314. Seattle, WA: IASP Press. Case example Dick, B. and Pillai Riddell, R. (2010). Cognitive and school functioning in children and ad olescents with chronic pain: a critical review. Pain Res Manag , 15 , 238 \200\223244 . Jill is a 16-year-old girl who developed widespread body pain at the end of the school year and her pain intensity progressively increased over the summer months. She has seen severa l special- ists and all her diagnostic tests come back within normal limits. She rates her pain as 7 out of 10 most days with exacerbations up to 10 out of 10 at least once a week. T h e pain is keeping her from sleeping well; she fi nds it hard to fall asleep and wakes fre - quently thought the night because of pain. She started 10th grade 2 months ago, which mea nt a change in schools. She is missing about 2 to 3 days of school a week. Her classmates f rom last year are attending the same school but most are not in her classes. Erdley, C. A., Nangle, D. W., Newman, J. E., and Carpenter, E. M. (2001). Children \200\231 s friendship experiences and psychological adjustment: theory and research. In D. W. Nagle and C. A. Erdley (eds) Th e role of friendship in psychological adjustment , pp. 5 \200\223 24. San Francisco, CA : Jossey-Bass . Eccleston, C., Wastell, S., Crombez, G., and Jordan, A. (2008). Adolescent social development and chronic pain . Eur J Pain , 12 , 765 \200\223774 . Forgeron, P. A., King, S., Stinson, J., McGrath, P. J., MacDonald, A. J., and Chambers, C. T. (2010). Social functioning and peer relationships in children and adolescents with chron ic pain: a systematic review. Pain Res Manag , 15 , 27 \200\22341 . In grade 9 Jill was on the volleyball team and achieved straight As. Her parents are suppor tive but wonder why the doctors can- not fi nd anything wrong with Jill. Jill used to go ou t with her friends regularly and is described by her parents as being popu- lar. However, s ince developing the widespread pain, she has been home much more, hardly goes out with her friends on the week- end, did not try out for the volleyball team, and her marks are now in the Bs. Jill reports that getting up from her seat and going for a walk is helpful when he r pain becomes unbearable in class, but some of her teachers do not allow her to leave the classroom citing that she has missed so much time that she cannot aff ord to miss any more instruction. In private Jill mentions to you that she does not like to go out as she may ha ve pain when she is out socializing. She also mentions that her friends called a lot when s he fi rst became ill but have stopped calling her. Forgeron, P., and McGrath, P. J. (2008). Self-identifi ed needs of adolescents with chronic pain. J Pain Manag , 1 , 163 \200\223172 . Forgeron, P. A., McGrath, P., Evans, J., Stevens, B., and Finley, A. (2011a). My friends do n \200\231t really understand me: examining close friendships of adolescents with chronic p ain. PhD dissertation, Dalhousie University, Halifax. Forgeron, P. A., McGrath, P. J., Stevens, B., Evans, J., Dick, B., Finley, G. A., et al . ( 2011b). Social information processing in adolescents with chronic pain: my friends don \200 \231t really understand me. Pain , 152 , 2771 \200\2232780 . Gauze, C., Bukowski, W. M., Aquan-Assee, J., and Sippola, L. K. (1996). Interactions betwee n family environment and friendship and associations with self-perceived well-being during early adolescence. Child Dev , 67 , 2201 \200\2232216 . Greco, L. A., Freeman, K. E., and Duft on, L. M. (2007). Overt and relational victimization among children with frequent abdominal pain: links to social skills, academic functioning, and health service use . J Pediatr Psychol , 32 , 319 \200\223329 . Is Jill experiencing school avoidance? What would you suggest from an academic perspective? What would you suggest form a social perspective in terms of Guite, J. W., Walker, L. S., Smith, C. A., and Garber, J. (2000). Children \200\231s percep tions of peers with somatic symptoms: the impact of gender, stress, and illness. J Pediatr Psychol , 25 , 125 \200\223135 . school? Why do you think Jill \200\231s friends are no longer contacting her? Hodges, E. V. E., Boivin, M., Vitaro, F., and Bukowshi, W. M. (1999). Th e power of friends hip: protection against an escalating cycle of peer victimization. Dev Psychol , 35 , 94 \200\223101 . References Bagwell, C. L., Schmidt, M. E., Newcomb, A. F., and Bukowski, W. M. (2001). Frie ndship and peer rejection as predictors of adult adjustment. In D. Kashikar-Zuck, S., Lynch, A., Graham, B., Swain, N., and Mullen, S. A. (2007). Social funct ioning and peer relationships of adolescents with juvenile fi bromyalgia syndrome. Arthriti s Rheum , 57 , 474 \200\223480 . SECTION 3 social and psychological basis of pediatric pain 126 Perrin, E. C., Stein, R. E. K., and Drotar, D. (1991). Cautions in using the Child Behavior Checklist: observations based on research about children with a chronic illness . J Pediat r Psychol , 16 , 411 \200\223421 . King, S., Chambers, C. T., Huguet, A., MacNevin, R. C., McGrath, P. J., Parker, L., et al . (2011). Th e epidemiology of chronic pain in children and adolescents revisited: a systema tic review. Pain , 152 , 2729 \200\2232738 . Konijnenberg, A. Y., Uiterwaal, C. S. P. M., K impen, J. L. L., van der Hoeven, J., Buitelaar, J. K., and de Graeff -Meeder, E. R. (2005). Children with unexplained chronic pain: substantial impairment in everyday life. Arch Dis Child , 90, 680 \200\223686. Roeser, R. W., and Eccles, J. S. (1998). Adolescents \200\231 perceptions of middle school: relation to longitudinal changes in academic and psychological adjustment. J Rese Adolesc , 8 , 123 \200\223158 . Roth-Isigkeit, A., Th yen, U., St ven, H., Schwarzenberger, J., and Schmucker, P. (2005) . Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics , 11 , 3152 \200\2233162 . Ladd, G. W., Kochenderfer, B. J., and Coleman, C. C. (1997). Classroom peer acceptance, fri endship, and victimization: distinct relational systems that contribute uniquely to childre n \200\231s school adjustment? Child Dev , 68 , 1181 \200\2231197 . Rubin, K. H., Chen, X., Coplan, R., Buskirk, A., and Wojslawowicz, J. C. (2005). Peer relat ionships in childhood. In M. H. Bornstein and M. E. Lamb (eds) Developmental science: an ad vanced textbook (5th edn), pp. 469 \200\223512. Mahwah, NJ : Erlbaum . Larochette, A. C., Chambers, C. T., and Craig, K. D. (2006). Genuine, suppressed and faked facial expression of pain in children. Pain , 126 , 64 \200\22371 . S llfors, C., Fasth, A., and Hallberg, L.R. (2002). Oscillating between hope and despair \200\224a qualitative study. Child: Care, Health, Dev , 28 , 495 \200\223505 . Logan, D. E. and Curran, J. A. (2005). Adolescent chronic pain problems in the school setti ng: exploring the experiences of selected school personnel through focus group methodology. J Adolescent Health , 37 , 281 \200\223288 . Logan, D. E., Simmons, L. E., Stein, M. J., a nd Chastain, L. (2008). School Stanford, E. A., Chambers, C. T., Biesanz, J. C., and Chen, E. (2008). Th e frequency, traj ectories and predictors of adolescent recurrent pain: a population-based approach. Pain , 1 38 , 11 \200\22321 . impairment in adolescents with chronic pain. J Pain , 9 , 407 \200\223416 . Mahoney, J. L., and Stattin, H. (2000). Leisure activities and adolescent antisocial behavi or: the role of structure and social context. J Adolescences, 23 , 113 \200\223127 . Sullivan, H. S. (1953). Th e interpersonal theory of psychiatry. New York: W.W. Norton & Company . Van Dijk, A., McGrath, P. A., Pickett, W., and Van Den Kerkhof, E. (2008). Pain and self re ported health in Canadian children . Pain Res Manag , 13 , 407 \200\223411 . Nangle, D., Erdley, C. A., Newman, J. E., Mason, C. A., and Carpenter, E. M. (2003). Popula rity, friendship quantity, and friendship quality: interactive infl uences on children \200 \231s loneliness and depression. J Clin Child Adolesc Psychol , 52 , 546 \200\223555 . Vannatta, K. Getzoff , E. A., Gilman, D. K., Noll, R. B., Gerhardt, C. A., Powers, S. W., e t al . (2008). Friendships and social interactions of school-aged children with migraine. C ephalalgia , 28 , 734 \200\223743 . Natvig, G. K., Albrektsen, G., and Qvarnstrom, U. (2001). Psychosomatic symptoms among vict ims of school bullying. J Health Psychol , 6 , 365 \200\223377 . Noll, R. B., Kiska, R., Re iter-Purtill, J., Gerhardt, C. A., and Vannatta, K. (2010). A controlled, longitudinal stud y of the social functioning of youth with sickle cell disease. Pediatrics , 125, e1453 \200 \2231459. Walker, L. S., Garber, J., Smith, C. A., Van Slyke, A., and Claar R. L. (2001). Th e relati on of daily stressors to somatic and emotional symptoms in children with and without recurr ent abdominal pain. J Consult Clin Psychol , 69 , 85 \200\22391 . Noll, R. B., Kozlowski, K., Gerhardt, C., Vannatta, K., Taylor, J., and Passo, M. (2000). S ocial, emotional and behavioral functioning of children with juvenile rheumatoid arthritis. Arthritis Rheum , 46 , 1387 \200\2231396 . Online supplementary materials Figure 13.1 Example letter. Reproduced with permission from Forgeron, P. A. and McGrath, P. J, Distance Management of Pediatric Pain, in G. A. Walco an d K. R. Goldschneider (eds), Pediatric Pain Management in Primary Care: A Practical Guide, Humana Press, Totowa, New Jersey, USA, Copyright 2007. Noll, R. B., Reiter-Purtill, J., Vannatta, K., Gerhardt, C. A., & Short, A. (2007). Peer re lationships and emotional well-being of children with sickle cell disease: a controlled rep lication. Child Neuropsychol , 13 , 173 \200\223187 . Noll, R. B., Vannatta, K., Koontz, K. , and Kalinyak. K. (1996). Peer relationships and emotional well being of youngsters with s ickle cell disease. Child Dev , 67, 423 \200\223436. CHAPTER 14 Th e e \200 ects of sex and gender on child and adolescent pain Erin C. Moon an d Anita M. Unruh Summary As women enter adulthood, they are at an increased risk for a number of clinical pa in conditions and show higher experimen- tal pain sensitivity relative to men (e.g. Filling im et al., 2009). Th e feminine gender role encourages the expression of pain in both child ren and adults whereas the masculine gender role encourages stoicism in response to pain (e .g. Robinson et al., 2001; Zeman and Garber, 1996). Th e earlier work of Unruh (1996), Berk eley (1992, 1997), and LeResche (1997), demonstrated that sex and gender shaped the experie nce of pain and a subsequent body of research has continued to articulate their infl uence. In epidemiological studies worldwide, Fillingim et al. (2009) reported that neuropathic pai n, chronic musculoskeletal pain, abdominal pain, headache, and migraine were more prevalent in women compared to men, and women had pain in more anatomi- cal sites. Similarly, Tsang et al. (2008), in a study spanning 17 coun- tries, found that women reported a higher preva lence of common chronic pain conditions. Th ough sex diff erences are evident in experimental and epide- miological studies, in adul t clinical pain samples they are equivocal. In a study of pain ratings in fi ve samples of patients at chronic pain clinics, women were slightly more likely to give higher pain sever - ity ratings than men (Robinson et al., 1998). Other studies have not reported sex diff er ences (e.g. arthritis: Lander et al., 1990; temporo- mandibular pain: Bush et al., 1993; Wi lson et al., 1994). Before examining this literature, it is important to distinguish between the terms sex and gender. Sex usually refers to biological aspects and gender to the social or cultural dimen sions of being male or female (Owen Blakemore et al., 2009). Th e World Health Organization defi nes sex as \200\230the biological and physiological char- acteristics that defi ne m en and women \200\231 and gender as \200\230the socially constructed roles, behaviors, act ivities, and attributes that a given society considers appropriate for men and women \200 \231 (World Health Organization, n.d., para. 1). Findings on adult sex diff erences in medical procedure and postoperative pain are also inc onsistent. In a study of needle pro- cedures, women reported higher pain intensity (Ring et al., 2009). In a review of 15 studies of postoperative pain, Fillingim and col- leagues (2 009) concluded that women gave higher pain intensity ratings but noted that confl icting ou tcomes were also reported in some studies. Th is chapter will begin with a brief overview of sex and gender diff erences in adult pain to provide a context for then examining sex and gender diff erences in child and adolescen t pain. Th e chap- ter will continue with a discussion of the biological, family, and socio -cultural factors thought to contribute to sex and gender dif- ferences in child and adoles cent pain. Men and women may cope diff erently with pain. Th e most robust fi ndings are that women us e more social support to cope with pain and a greater number of pain coping strategies comp ared to men (Unruh, 1997). Although not all studies fi nd sex diff erences in cata- strophi zing (e.g. Unruh et al., 1999), there is evidence that women do catastrophize about pain mo re than men (Edwards et al., 2004; Jensen et al., 1994; Keefe et al., 2000). Sex and gender di \200 erences in adult pain Much of the early research on sex diff erence s in adult pain focused on experimental paradigms. A 1998 meta-analysis of these stud- ies concluded that women were more likely to report lower pain threshold and tolerance than men , with eff ect sizes of d = 0.55 for threshold and d = 0.57 for tolerance (Riley et al., 19 98). In an updated meta-analysis, Fillingim et al. (2009) concluded that there are reliable sex diff erences in pressure and electrical pain, with women reporting greater sensitivity than men. Th e largest study to date to assess sex diff erences in pain threshold using mu ltiple experimental modalities found that women have signifi cantly lower pain thresholds t han men (Rolke et al., 2006). Fewer studies have considered the impact of gender on adult pain. Existing studies show tha t higher scores on measures of mas- culine gender role stress increase systolic blood press ure reactivity to pain (indicating stress; e.g. Lash et al. 1990). Higher masculinity score s have also predicted higher pain tolerance and lower pain rat- ings (Otto and Dougher, 198 5; Th orn et al., 2004). Th ere is no critical age marking the onset of sex and gender dif- ferences in adult pain. A number of studies suggest that the sociali- zation mechanisms that shape gender role expe ctations of pain begin in childhood and that puberty is the biological catalyst for the ons et of the physiological mechanisms that contribute to sex diff erences in pain (Unruh and C ampbell, 1999). SECTION 3 social and psychological basis of pediatric pain 128 Sex di \200 erences in child and adolescent pain In 1999, Unruh and Campbell concluded tha t sex diff erences in studies of experimental pain in childhood and adolescence were not co nsistent but when they occurred, they were in the same direc- tion as in adult studies. Gir ls generally reported similar or lower pain thresholds and tolerance compared to boys. Th e experimental studies of child and adolescent pain published since 1999 are sum- marized in Tables 14.1 and 14.2 . range of the participants in the Blankenburg et al. study may help account for these diverg ent fi ndings. In a sample of 244 children, Lu and colleagues (2005) found no sex diff erences in heat pai n tolerance, but girls had a signifi cantly Table 14.2 Summary of recent child and adolescent cold pressor task studies reporting on se x di \200 erences Authors, year Age range Sex di \200 erence \201 ndings Chambers et al., 2002 8 \200\22312 years Pain intensity: no di \200 erences Two of these experimental studies used quantitative sensory test- ing (QST), a battery of s omatosensory processing tests that provide reliable and valid measures of sensory threshold s in children (Meier et al., 2001), with diff erent outcomes. Walker et al. (2009) used QST in a study of the long-term impact of early pain and injury on sen- sory perception. Th er e were no sex diff erences in mechanical (pres- sure) detection thresholds between children born premature (and now 11 years of age) and a control group of children born full-term. N evertheless, in the control group, boys were signifi cantly more sensitive to heat and cold detection than girls. In contrast, with a healthy sample of 6- to 16-year-olds, Blankenbur g and colleagues (2010) found that girls were more sensitive to heat and cold detec- tion, as well as heat and cold pain stimuli, than boys. Th e wider age Pain a \200 ect: no di \200 erences Pain tolerance: no di \200 erences Heart rate: no di \200 erences Facial activity: boys > girls Coldwell et al., 2002 8 \200\22311 years Pain intensity: no di \200 erences (sex not predictor in regression) Evans et al. 2008 8 \200\22318 years Pain intensity: no di \200 erences Goodman and McGrath, 2003 10 \200\22314 years Pain intensity: no di \200 erences Pain tolerance: no di \200 erences Pain threshold: no di \200 erences Table 14.1 Summary of recent child and adolescent experimental pain studies (paradigms othe r than cold pressor task) reporting on sex di \200 erences Facial activity: no di \200 erences Jaaniste et al., 2007 7 \200\22312 years Pain intensity: no di \200 erences Pain tolerance: no di \200 erences Authors, year Age range Sex di \200 erence \201 ndings Larochette et al., 2006 8 \200\22312 years Facial activity: no di \200 erences Quantitative sensory testing Moon et al., 2008 4 \200\22312 years Pain intensity: no di \200 erences Walker et al., 2009 11 years Mechanical detection threshold: no di \200 erences Heart rate: no di \200 erences Facial activity: no di \200 erences Heat detection threshold: in control group, boys more sensitive Myers et al., 2006 8 \200\22318 years Pain intensity: more boys than girls in \200\230low pain \200\231 group Cold detection threshold: in control group, boys more sensitive Pain a \200 ect: no di \200 erences Pain tolerance: no di \200 erences Blankenburg et al., 2010 6 \200\22316 years Mechanical detection threshold: no di \200 erences Pepino and Mennella, 2005 5 \200\22310 years Pain intensity: no di \200 erences Heat detection threshold: girls more sensitive Pain tolerance: no di \200 erences Cold detection threshold: girls more sensitive Piira et al., 2002 7 \200\22314 years Pain tolerance: no di \200 erences (age by sex interaction) Mechanical pain threshold: no di \200 erences Piira et al., 2006 7 \200\22314 years Pain intensity: no di \200 erences Heat pain threshold: girls more sensitive Pain tolerance: no di \200 erences Cold pain threshold: girls more sensitive Trapanotto et al., 2008 8 \200\22312 years Pain intensity: no di \200 erences Pressure pain Pain a \200 ect: no di \200 erences Lu et al., 2005 8 \200\22318 years Pain tolerance: boys > girls Pain tolerance: no di \200 erences Lu et al., 2007 8 \200\22318 years Pain intensity: no di \200 erences Tsao et al., 2002 8 \200\22310 years Pain intensity: no di \200 erences Pain unpleasantness: no di \200 erences Pain tolerance: no di \200 erences Heat pain Tsao et al., 2006a 8 \200\22318 years Pain intensity: no di \200 erences Lu et al., 2005 8 \200\22318 years Pain tolerance: no di \200 erences Tsao et al., 2006b 8 \200\22318 years Pain intensity: no di \200 erences Lu et al., 2007 8 \200\22318 years Pain intensity: no di \200 erences Pain unpleasantness: no di \200 erences Tsao et al., 2004 8 \200\22318 years Pain intensity: more boys than girls in \200\230low-pain \200\231 group CHAPTER 14 the effects of sex and gender on child and adolescent pain 129 lower pressure pain tolerance than boys. A mediation analysis indi- cated that this sex dif f erence was due to a higher pre-trial heart rate in girls (an indication of autonomic arou sal). With the same sample of children, Lu et al. (2007) reported no sex diff erences in pr essure or heat pain intensity or pain unpleasantness. similar to research with adults, sex diff erences in child postopera- tive pain are not cle ar. In one study, conducted with adolescents and young adults aged 12 to 20 years who had u ndergone elective surgery, girls gave higher pain intensity ratings than boys (Gillies et a l., 1999). In addition, more girls in this study requested pain medication than boys in the fi rst 24 hours aft er surgery. Another study, of children aged 5 to 13 years who had unde rgone minor surgery, found no sex diff erences in children \200\231s self-reports or par- e nts \200\231 and nurses \200\231 reports of child pain intensity (Chambers et al., 2005). S imilarly, in a study of children and young adults aged 8 to 21 years who had spinal fusion surgery, girls and boys gave similar postoperative pain intensity ratings and displayed sim ilar levels of pain behavior (Kotzer, 2000). Since the review by Unruh and Campbell (1999), 16 studies of cold pressor pain in children and adolescents have examined sex diff erences (see Table 14.2). With a few exceptions, mos t of these studies do not identify sex diff erences in pain intensity, pain toler- ance, pa in aff ect, or facial response to pain. Girls are at an increased risk of chronic pain. Based on data from population-based studies conducted in America (Stewart et al., 1991) and Germany (Kroner-Herwig et al., 2007), Fill ingim et al. (2009) concluded that while boys have an earlier onset of both migraine and no n-migraine headache, as adolescence approaches, incidence and prevalence rises more quickly in girls. Sex diff erences in the prevalence of child musculoskeletal pain are not as clea r. For example, a Finnish study (Mikkelsson et al., 1997) indicated an increased prevalence of chest and upper back pain in girls whereas a nationwide study of musculoskeletal pain i n Swedish students (Brun Sundblad et al., 2007) did not detect sex diff erences. In this Sw edish study, girls were twice as likely to have weekly abdominal pain as boys. Other epidem iological studies of child abdominal pain support the increased prevalence of abdominal pai n in girls (Kristjansdottir, 1996; Oh et al., 2004; Ramchandani et al., 2005; Stanford et a l., 2008). In a study of Canadian adolescents, girls had higher rates of all types of pain (e.g. headaches, stomach aches, and backaches) than boys (Stanford et al. 2008) and in a Eu ropean study, girls also reported more frequent chronic pain (Huguet and Mir , 2008). Regarding sex diff erences in coping with pain, data collected with child and adolescent sa mples parallels the fi ndings from adult samples (Unruh and Campbell, 1999). Like women, gi rls aged 8 to 18 years use more social support in response to pain than boys (Keogh and Ecc leston, 2006; Lynch et al., 2007). Boys in this age group use more behavioral distraction ( e.g. doing something enjoyable to take their mind off pain; Lynch et al., 2007; Reid et al. , 1998). Th e fi nding that boys are more likely than girls to distract themselves from pai n has been interpreted as a way for boys to minimize pain and thereby act in accordance wit h the male gen- der role (Reid et al., 1998). Similar to studies in the adult litera- ture, some studies with children and adolescents have not found sex diff erences in catastrophiz ing (Lynch et al., 2007; Reid et al., 1998) whereas other studies report that adolescent gi rls are more likely than boys to catastrophize in response to pain (Keogh and Eccleston, 20 06). Sex diff erences in clinical child pain have been explored in vari- ous studies but have no t yet been the subject of systematic review. In two clinical studies, girls reported higher current pain (Keogh and Eccleston, 2006) and more continuing pain and utilization of healt h care services (Martin et al., 2007). In a sample of adolescent cancer patients, Hechler a nd colleagues (2009) found that girls reported higher pain intensity in the past week and m onth, but boys and girls were similar in present pain intensity ratings. In two other studi es, present pain intensity ratings were comparable in girls and boys aged 8 to 18 years (Ka czynski et al., 2009; Lynch et al., 2007). Gender di \200 erences in child and adolescent pain Th e impact of gender on child pain ou tcomes has not been exten- sively studied but existing research suggests that masculinity m ay have an impact on some pain outcomes. Myers and colleagues (2006) measured the relations hip between self-reported gender- stereotyped personality traits and pain ratings in childr en aged 8 to 18 years using the Child Sex Role Inventory (CSRI; Boldizar, 1991). Children u nderwent three pain tasks: pressure, cold, and thermal. Masculinity scores for boys were un related to pain tolerance on all three tasks but signifi cantly inversely related to heat p ain intensity and pain aff ect ratings. For boys and girls aged 14 to 18 years, higher masc ulinity relative to femininity scores predicted lower cold and heat pain ratings. Surprisin gly, for boys and girls aged 8 to 13 years, higher masculinity relative to femininity score s predicted higher cold pain ratings. Otherwise healthy children frequently endure pain from medi- cal procedures such as immuniz ations and blood draws. Unruh and Campbell (1999) concluded that fi ndings on sex diff eren ces in children \200\231s needle pain were inconsistent. Since 1999, evidence continues to be mixed. Five recent studies that compared boys \200\231 and girls \200\231 immunization a nd venepuncture pain found no diff erences (Caprilli et al., 2007; Cohen et al., 2000, 2004 ; Goodenough et al., 1999a; Kleiber et al., 2007). In contrast, Chambers and colleagues (19 99) found that girls aged 5 to 12 years gave higher pain inten- sity ratings following vene puncture than boys. Similarly, sex diff er- ences were reported with older children (11 \200\22317 years; von Baeyer et al., 2009) and younger children (4 \200\2236 years; Sparks 2001) under- going immunizations. In another study of venepuncture pain, Goodenough et al. (1999b) discovered that girls gave signifi cantly higher pain unpleasantness ratings than b oys from the age of 8 years onwards. Th ese authors suggested that boys over the age of 8 y ears may be increasingly infl uenced by gender role expectations that boys should be stoic about pain. In a second study using the CSRI, Moon (2010) examined the relationship between parents \200\231 ratings of their children \200\231s gender- stereotyped personality traits and col d pressor pain outcomes in children aged 8 to 12 years. Similar to the fi ndings of Myers a nd colleagues (2006), child gender was not associated with cold pres- sor pain intensity, p ain aff ect, pain tolerance, or pain complaints. Nevertheless, for children under the age o f 13 years, Myers and col- leagues found that higher femininity, relative to masculinity, w as predictive of lower cold pressor pain intensity ratings. Th ey inter- preted these fi nd ings to mean that responses to cold pressor pain that are in keeping with gender-role stere otypes (i.e. higher mascu- linity being associated with lower pain ratings) may only emerge Data on sex diff erences in child postoperative pain have not been systematically reviewed. Th e available evidence suggests that SECTION 3 social and psychological basis of pediatric pain 130 aft er the age of 13 years. Th e fi ndings of the study by Moon are in keeping with this in terpretation. (1996) suggested that parents may teach their children to behave in accordance with gender- role stereotypes for pain by giving their daughters more attention when they express pain c ompared to their sons. Th is position was supported by an experimental pain study with 8- t o 16-year-old children in which parents tended to use more attention with their daughters a nd more distraction with their sons (Walker et al., 2006). Th ese fi ndings were not replic ated in a more recent experimental pain study with 8- to 12-year-olds (Moon et al., 2011). Factors that contribute to sex and gender di \200 erences in child and adolescent pain In order to better understand sex and gender diff erences in pain, researchers have begun to c onsider the relative contributions and interactions of biological, family, and sociocultura l factors. Until very recently, there have been few studies comparing and contrasting the socializatio n infl uence of mothers and fathers on child pain, but those that exist point to the import ance of compar- ing these parental roles. Kangaroo care (providing skin-to-skin care by the parent holding a nappy-clad infant against the bare chest) has a signifi cant impact on re ducing an infant \200\231s response to painful procedures (Johnston et al., 2011). Johnston and colleagues (2011) have shown that this eff ect is marginally but signifi cantly strong er for the mother than the father. (See Johnston and Campbell-Yeo, Chapter 58, this volume, for further discussion of mother care pain interventions.) Moon (2010) found that higher f emininity scores, relative to masculinity scores, were associated with fewer pain com- plai nts when girls underwent a cold pressor task with their fathers present, but not with their mothers present. In an intriguing study of the relationship between parental catastrophizi ng and pain intensity and disability in a children \200\231s pain clinic, Hechler et al. (2 011) found that maternal, not paternal, catastrophizing was related to child pain intensity . Surprisingly, in this study, child disability was not signifi - cantly related to materna l or paternal catastrophizing. In another recent study, parental catastrophizing and child pain intensity were associated with the perceived threat inherent in the child \200\231s pa in and the parent \200\231s need to control the child \200\231s pain, with the relationship stronger for mothers than fathers (Caes et al., 2012). Mothers have reported more use of n on-pharmacological methods than fathers to manage pain in their children (Gorodzinsky et al . 2011). Future studies in this domain will be important in determining the com- plex relat ionship between familial socialization processes and gen- der diff erences in child and ado lescent pain. Biological factors Sex hormones (mainly oestradiol, progesterone, and testosterone) play a role in men \200\231s and women \200\231s responses to experimental pain (e.g. Fillingim an d Edwards, 2001; Riley et al., 1999) and have an impact on pain across the menstrual cycle (Unruh, 1996). Furthermore, sex diff erences in some pain conditions such as migraine heada ches (Stewart et al., 1992) and temporomandibular disorders (LeResche, 1997) emerge only af t er puberty. Th ere are also sex and hormonally determined diff erences in neuroactive sub stances such as gamma- aminobutyric acid, opioid and non-opioid analgesia, nerve growth fac tor (involved in pain perception), and the sympathetic nervous system that may help explain sex diff erences in experimental pain (Berkley, 1997). Rodent models have been used to reduce the infl uence of socio- cultural variables inherent in studies of human sex diff erences in pain. Findings of this animal research have led to the generally- held conclusion that female rodents have a lower pain threshold (Hurley and Adams, 2008). Nevertheless, in a review of the litera- ture on sex diff erences in both hu man and animal pain, Hurley and Adams noted that the animal models with the most clinical r elevance for human pain (e.g. the Brennan et al. model of post-in- cisional pain in rodents ; Brennan et al., 1996) have not uncovered signifi cant diff erences between male and femal e animals. Some researchers have used brain imaging techniques such as positron emission tomography to study sex diff erences in human response to pain. Women have shown greater regional brain acti- vation of the thalamus, contralateral prefrontal cortex, and con- tralateral insula t han men following painful thermal stimulation (Paulson et al., 1998); however, in another s tudy, men had greater regional brain activation (Derbyshire et al., 2002). No signifi cant diff erence in brain activation has been reported using functional magnetic resonance imagi ng following thermal pain (Moulton et al., 2006). At present, it is premature to conclude t hat there are sex diff erences in brain activation in response to pain, and no stud- ies ha ve included child or adolescent samples. Sociocultural factors Research indicates that social roles support or permit pain expres- s ion for women but discourage it for men. Robinson and colleagues (2001) found that men and women expected men to have a higher level of pain endurance and a lower level of pain sensi tivity than women. Pool et al. (2007) also reported that men and women believed that the id eal man should tolerate more pain than the ideal woman. Results from cross-cultural researc h indicate that such gender-role expectations are not unique to North American samples (e.g . Nayak et al., 2000; see also Clemente, Chapter 11, this volume). Family factors Parental behavior has a powerful eff ect on child pain (Chambers et al., 200 3; see also Birnie et al., Chapter 12, this volume). A hand- ful of studies support the hyp othesis that sex diff erences in child pain may be partly explained by familial socializati on histories. Th ese studies provide evidence that the expression of pain in girls is encou raged whereas the expression of pain in boys is discouraged by neutral or negative parental reactions (e.g. Kankkunen et al., 2003; Schechter et al., 1991; Walker et al., 1995). Gender-role expectations for pain expression in children and adolescents have not been stud ied in detail. Still, a number of studies suggest that children, like adults, may behave ac cording to gender-role expectations that encourage girls and discourage boys from expressin g pain. In a widely cited early paper, Mechanic (1964) found that boys were signifi cantly more likely to report that they were not afraid of getting hurt and that they did not pay a tten- tion to pain. Zeman and Garber (1996) found that girls reported they would be signifi cantly more likely than boys to express pain in response to common pains. Girls were also more likely than boys to report that other people would understand and accept According to the operant model of chronic pain (Fordyce, 1976), receiving attention from ot hers about pain reinforces pain expres- sion. Applying this model to child pain, Zeman and Shipman CHAPTER 14 the effects of sex and gender on child and adolescent pain 131 their expressions of pain. Th ese fi ndings were echoed in a qualita- tive study of Canadia n adolescents (Hatchette et al., 2008). Girls reported feeling free to discuss their pain w ith peers whereas boys reported being reluctant to express their pain to peers. next 4 years, Sonia progressed from no attendance at school to full attendance. By 5 years, she was pain-free and off pain medi- cations. Sonia had many friends but in fact no boyfri end during these 5 years. Gender-stereotyped beliefs about pain help explain fi ndings that girls (Keogh and Ecclesto n, 2006; Lynch et al., 2007) and women (Unruh et al., 1999) are more likely to seek social