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. One factor may be explained versus unexplained pain. Recurrent and ongoing pain from juveni le fi bromyalgia is not as well under- stood compared to the pain from juvenile arthritis. In a hypotheti- cal vignette study, 4th and 5th grade children in the US rated same age pee rs with both explained and unexplained abdominal pain as equally likable as playmates (Guit e et al., 2000). Older children and adolescents may perceive unexplained pain more negative ly compared to younger children. Younger children may not have a biological understanding o f illness and therefore do not make judgements based on the underlying etiology of illness condition of a friend. Conversely, for older children and adolescents, the com- plexity of unexplained pain may not fi t with their biological under- standing of illness, which then contributes to judging children and adolescents with chronic pain as diff erent than peers and hence less compatible. Alternatively, peer likability of children or adolescents with unex- plained chronic pain m ay not be related to age but instead related to the diff erence between actual versus hypot hetical experiences of interacting with an adolescent with a chronic pain condition. In act ual in vivo interactions with peers, there may be a negative itera- tive process between th e pain behaviors expressed by the adoles- cent with chronic pain, the interpretation of the se behaviors by peers, and further expression of pain that negatively impact peers \200\231 perception of the adolescent with unexplained recurrent or chronic pain. In contrast to their healthy friends, adolescents with chronic pain may develop a diff eren t perspective on how they view friendships, support, and their place within relationships a s a result of their pain. Adolescents in several qualitative studies described pain as inte r- rupting their ability to be \200\230normal \200\231 (Carter et al., 2002; Forgeron and McGrath 2008; S llfors et al., 2002) and making them feel dif- ferent from their \200 \230normal \200\231 healthy friends. Adolescents who have not experienced chronic pain may not appreciate the challenges of living with a chronic condition. Chronic pain does not alw ays have an identifi able cause and there are no diagnostic tests that confi rm the existen ce of pain. Additionally, although most healthy chil- dren and adolescents have experienced some form of acute pain, these experiences would not prepare them with the knowledge and u nderstanding that adolescents with chronic pain feel they need from their friends. Not only could this diff erence in perspective lead to misunderstandings, but the invisible nature of chronic pain can add to confusion for healthy friends who do not understand how function ing can vary so much in their friend with chronic pain (Forgeron and McGrath, 2008; S ll fors et al., 2002). Th ere also are inherent limitations to the studies that compare peer relationships of chil dren and adolescents with pain conditions with healthy peers (Kashikar-Zuck et al., 2007; N oll et al., 1996, 2000, 2007; Vannatta et al., 2008). Th e majority of the previously discu ssed studies examined perceptions of children and adolescents with various chronic pain con ditions using a variety of sociometric measures. All researchers used classroom peers as th e only measure of acceptance or likeability and did not examine other friendships the child or adolescent might have outside the classroom or school. Limiting research to classroom s ociometric measures may be prob- lematic when studying adolescents in junior high and high school, as class composition generally changes from class to class, and ado- lescents have increased opportunities to make friends in other set- tings. Most of these researchers also focused on quantity compared to the quality or characteristics of the friendship; therefor e, it is SECTION 3 social and psychological basis of pediatric pain 122 School functioning School is central to the life of children and adolescents. Not only is s chool essential for academic learning, it also provides opportuni- ties for children and ad olescents to engage in social activities and relationships. Being exposed to diff erent typ es of social relation- ships helps children develop social knowledge and practice a broad r ange of social skills, thereby leading to competent social function- ing. However, school c an also be a place of stigma and discrimina- tion for children and adolescents with chronic pain. Chronic pain can negatively impact on academic performance and change rela- tionship s with teachers. unclear whether being viewed as accepted by classmates translates into deeper friendships f or children and adolescents with chronic pain. Finally, most of the researchers explored pe er relationships for a wide age range (i.e. 8 \200\22318 years); this is problematic, as pa tterns of peer relationships change as children age. Th erefore, the inclu- sion of both ch ildren and adolescents may not have provided the necessary power in these studies to fi nd subgroup diff erences. Since there were some interactions between pain and age of the child or adolescent, the separation of these developmental groups may be especially important. Some studies used standardized quantitative measures to exam- ine peer relationships of chi ldren and adolescents with chronic pain compared to healthy children and adolescents (Noll et al., 2000, 2007; Vannatta et al., 2008). Although using standardized measures is advisab le, these measures may not be robust for children with chronic illness, as they may lack co nstruct valid- ity for this population (e.g. Perrin et al., 1991). Adams and col- leagues ( 2002) note that a lack of normative data exists for some measures and clinical measures of child social functioning are generally designed to diff erentiate psychopathology versus a con- tinuum of function. For example, if a child with chronic illness is not picked as oft en for a sport team, does this truly represent classmates \200\231 negative perception of t he child or is this a refl ec- tion of classmates \200\231 recognition of the child \200 \231s limitations? Th ese measures also may not capture the true sense of perception of the ir peer relationships by the child or adolescent with a chronic pain condition. Academic achievement Pain can negatively impact school attendance, which can contribute to academic and social sequelae. Youth with chronic pain may miss 1 to 5 days of school per mo nth (Konijnenberg et al., 2005 Logan et al., 2008; Roth-Isigkeit et al., 2005); 20% of chil dren and adoles- cents with chronic pain recruited from a pain clinic, can be absent from s chool more than 50% of the time (Logan et al., 2008) and 14% may be totally absent from sch ool (Konijnenberg et al., 2005). However, absences alone do not account for all of the acad emic challenges faced by children and adolescents with chronic pain. Ho and colleagues (2008) found that children and adolescents with chronic pain did not diff er on standard cognitive tests in com- parison to healthy children and adolescents, sugges ting that intel- ligence is not negatively aff ected by the presence of a chronic pain cond ition. What may be aff ected, however, is an adolescent \200\231s ability to sustain the ne cessary focus and concentration to study and reach his or her academic potential. Logan and colleagues (2008) found 44.3% of adolescents with chronic pain and their parents reported a decrease in their grades since the onset of pain. Th e decline in grades ranged from one to four levels (i.e. a four-level change would mean that a student who generally achieves \200\230As \200\231 would now mostly achieve \200\230Cs \200\231). Adolescent participants in other studies have reiter- ated experiencing diffi culty in their academic ability due to chronic pain (Forgeron and McGrath, 2008). Several researchers report that children and adolescents with chronic pain are subjected to more peer victimization than healthy children (Greco et al., 2007; Natvig et al., 2001). H owever, no causal link has been established between peer victimization and recurrent or chr onic pain. Children and adolescents who experi- ence recurrent or chronic pain may be viewe d by their peers as more vulnerable than healthy children and therefore be preferred target s for more frequent bullying. Th e stress that results follow- ing peer victimization may s ubsequently increase a child \200\231s or adolescent \200\231s pain from a manageable to an unmanageable level. Relational victimization (i.e. aggression that impacts one \200\231s s ocial status) can result in children and adolescents with chronic pain feeling stigmatized for having pain. In a focus group study explor- ing the self-identifi ed needs of adolescen ts with chronic pain, one male participant described the experience of being asked personal questions from a non-friend peer and then subjected to cursing when he ignored her questio ns (Forgeron and McGrath, 2008). Th ere also may be sex diff erences in the types of victim ization children and adolescents with chronic pain are exposed to. For example, boys with a bdominal pain who reported peer victimiza- tion experienced both overt and relational forms of victimization whereas girls with abdominal pain only reported relational forms of victi mization (Greco et al., 2007). Th e signifi cance of this sex diff erence regarding victimi zation is unclear, but relational victim- ization may be more diffi cult to recognize. As a lready noted, no research describes the consequences of having fewer friends com- pared to typically developing peers. However, given that positive friendships have been found to buf f er the negative eff ects of peer victimization (Hodges et al., 1999) it is essential to u nderstand the relationship between chronic pain and the actual number of close friends as h aving fewer friends suggests that they may be more impacted by peer victimization actions. Chronic pain can have a signifi cant negative eff ect on academic achievement, and perhaps academic self-effi cacy. Bandura (1993) suggests that a student \200\231s perceived self-ef fi cacy in terms of ability to manage their learning and develop profi ciency in academic a ctivi- ties aff ects motivation, goals, and academic success. Chronic pain may change an ad olescent \200\231s self-effi cacy in the academic realm as a result of the decrease in grad es that oft en accompanies chronic pain. Logan and Curran (2005) note that that teachers face many chal- lenges when working with st udents experiencing chronic pain and subsequently need more information about chronic pain condi- tions from health care professionals, as well as guidance on how to manage pain symp toms and pain-related behaviors in school. In our experience, teachers indicate that they d esired ongoing dia- logue with health professionals in addition to receiving a formal let- ter informing them of the student \200\231s pain condition, similar to what has been suppor ted by others (Logan and Curran, 2005). Stress may add to school challenges for children and adolescents with chronic pain. Althoug h both healthy children and children with recurrent abdominal pain experience more stress a t school than outside of school, children with recurrent abdominal pain report greater dail y stressors and a stronger association between CHAPTER 13 pain, social relationships, and school 123 stressors and pain symptoms than healthy children (Walker et al., 2001). Pain has also been associated with unhappiness at school (van Dijk et al., 2008), but the specifi c causes of school unhappiness are not entirely clear. Classmates and teachers may not understand an a dolescent \200\231s pain and thus do not make necessary allowances for challenges that may arise in the school setting (Forgeron and McGrath, 2008). Classmates are oft en confused wh en children and adolescents with chronic pain are able to participate in physical activitie s one day but not another (S llfors et al., 2002). Additionally, teachers may question t he validity of an adolescent \200\231s pain condi- tion (Logan and Curran, 2005). For examp le, Logan and Curran (2005) examined teacher perceptions of students with chronic pain and found that some teachers were skeptical of the validity of these students \200\231 pain rep ort based on the association between context fac- tors and pain expression. Specifi cally, teachers were concerned that adolescents might use pain as an excuse (fake pain) to be excu sed from tests or to receive attention from peers. Th us, negative per- ceptions and reacti ons from others may be a factor contributing to inability to concentrate in the classroom, as well as overall school unhappiness in children and adolescents with chronic pain. or complete academic assignments elsewhere (e.g. the library or an empty classroom) so as t o protect themselves from standing out from their healthy peers. Adolescents describe feeling punished for their pain condition when teachers are unwilling to grant them academic accommoda- tions (Forgeron and McGrath, 2008). Th ese reactions (a r esponse to their pain expression) may increase their stress and perhaps even their pain int ensity (due to the relationship between stress and pain), which, in turn, aff ects their ab ility to attend school. However, when teachers modifi ed academic requirements, adoles- cen ts with chronic pain reported feeling supported and perceived these accommodations as ackno wledgement of their pain as real (Forgeron and McGrath, 2008). Many schools have restrictions on participation in committees, sports, and special school e vents based on either school attendance or grades. Adolescents with chronic pain feel furth er punished when they are unable to participate in these extracurricular events. Having the se restrictions waived for children and adolescents with chronic pain has a positive eff ec t on how they feel in the social context of school, which then has a positive eff ect on ho w these students feel in the academic context. Collaboration and dialog is necessary to obt ain a waiver of these restrictions and to help teachers understand how their reaction to a student with chronic pain can either result in the student feeling supported or add to the student \200\231s stress. Th ere is no evidence to suggest that students with pain fake their pain to reduce school a ssignments or to avoid tests and exams. Interestingly, there is evidence that parents are a ble to easily detect when their child is faking pain but have more diffi culty detecting wh en their child or adolescent is suppressing pain (Larochette et al., 2006). Th us, teachers may actually under-detect pain in the class- room, especially if a child or adolescent is suppressing his or her pain expression to blend in with classmates. When a student with chr onic pain encounters a teacher who gives the impression that he or she believes the student is \200\230faking \200\231 he or she may feel stigmatized by the school experience. Recommendations Although there are no intervention studies to date that identify the most u seful strategies to help children and adolescents with chronic pain manage peer relationshi ps and friendships, we propose inter- vention strategies that are informed by the research reviewed in this chapter. Social context of school When children and adolescents with chronic pain are absent from sc hool, they are also absent from their primary social environment and risk falling behind in the social knowledge and exchanges that take place during the school day. Specifi cally, t hey may not be aware of the social events from previous days and the topic of conversa- tio n, which may contribute to feeling alone despite being among peers. Th us, the process of r eturning to school aft er a period of absence can be challenging because of the negative im pact of their absence on academic skills and on their social knowledge. Clinical recommendations Clinicians must recognize that chronic pain may present challenges to peer relationships and friendships. Children and adolescents may be reticent to speak n egatively about their friends, as they acknowledge that many of their friends were supporti ve at times. Th us, ensuring a safe environment to discuss concerns is needed. Improving peer perceptions of children and adolescents with chronic pain is important, as p ositive peer relationships have been positively correlated with more positive perceptions o f social abilities of adolescents with chronic pain (Eccleston et al., 2008). Exploring sit uations in which peers and close friends have not been supportive may help the child or ado lescent with chronic pain, as non-supportive situations tend to be the most troubling for t his population and may lead to disengagement from friends. Th e clini- cian should work wit h the child or adolescent with chronic pain to determine an approach so the child or adoles cent could take con- trol of the situation. For example, they could practice the types of c onversations that may occur with their friends and learn the types of actions that are help ful and non-helpful in conversations with friends. Helping a child or adolescent understand that some of their pain behaviors may be diffi cult for their friends to understand may al so be needed. Th ese discussions, along with activities such as role playing, may help the adolescent practice how to take control and advocate for their friendship needs. However, t he adolescent with chronic pain must also understand that his or her needs should Children and adolescents with chronic pain may feel singled out and diff erent from their c lassmates (Forgeron and McGrath, 2008). Th is can be due to teachers and other students ask ing questions upon their return that make them feel unsupported and judged. Th ese question s may include asking for reasons for their absences, details about their medical conditions , justifi cation for academic or physical accommodations, and being outwardly teased by cla ss- mates. Additionally, in a study by S llfors et al. (2002), adolescents have noted th at it was oft en diffi cult to sit out of certain classes (i.e. physical education) and com plete academic assignments while their classmates were having fun. Clearly, being separated from classmates would serve to highlight their pain condition and the diff erences between adolescents with a pain condition and their healthy peers. Although children and adolescen ts with pain condi- tions may not be able to participate in classes such as physical edu- c ation, they may prefer to either take part in a modifi ed version of the physical activity (e.g. walking rather than running, if possible) SECTION 3 social and psychological basis of pediatric pain 124 be balanced with a willingness to listen to their friends \200\231 needs, as friendships ar e reciprocal. Taking control of these situations may improve friendship quality by not only securing the friendship needs of adolescents with chronic pain but also allowing friends t o discuss their friendship needs when the adolescent with chronic pain disengages from acti vities. Th is member of the teaching staff is someone the student can go to have issues resolved in stead of having to negotiate with several teachers at once. Some children and adolescents may require physical accom- modations such as the ability to leave their desk and walk around, have a private place outside of class (e.g. guidance or n urse offi ce) to use non-pharmacological pain-reducing strategies (e.g. relaxation exercise s such as deep breathing and guided imagery), or the use of an elevator pass or access to w ater in class (i.e. especially for chil- dren or adolescents on certain medications). Th es e physical accom- modations are aimed at helping to reduce pain in the moment so that the c hild or adolescent is able to remain in the school even if he or she must miss a class. In our clinical experience, once a child or adolescent leaves school due to their pain it is u nlikely that the student will return to school that day. Understanding one \200\231s pain condition has been linked to accept- ance and engagement i n treatment; therefore, pain education is oft en off ered to children and adolescents with chronic pain to help them understand their condition. However, pain education targeted at h elping the child or adolescent develop language to help explain their condition to others h as not been developed. It is necessary for a child or adolescent to understand his or her p ain condition in a way that they could translate to their friends to decrease the scep- tic ism they encounter. Future research should attempt to develop and evaluate interventions th at focus on developing appropriate language to describe pain to others. A formal request for the child or adolescent to be exempt from the attendance or grade requ irements to participate in school social life is also important. When excluded from school social life due to their pain condition, children and adolescents may feel as though they a re being punished as a result of their condition. Th e more excluded socially, the more lik ely they are to experience loneliness, and other associated psychosocial sequelae (e.g. anx iety or depres- sion). Children and adolescents with chronic pain may benefi t from health professionals having a discussion with teachers regarding the best ways to communicate with a student challenged by chronic pain. Children and adolescents do not want to stand out an d appear diff erent from their peers; therefore, it is important to remind school personnel to keep conversations about pain and health confi den- tial. A template of a school letter , developed and used at our clinic (IWK Health Center, Halifax, Nova Scotia \200\224where t he fi rst author was the clinical nurse specialist) is part of the online supplement of thi s chapter. An important component is a basic explanation of the physiology of chronic pain that may help teachers to reinforce the legitimacy of chronic pain to school personnel. We encourage other clinicians to use or modify this letter if they feel it would be useful in advocating for children and adolescents with chronic pain. Given the regularity that some adolescents with chronic pain are absent from school, their friends may not fi nd their absences unu- sual. Children and adolescents who miss school du e to pain may need to be proactive in contacting their friends to fi ll them in on the soci al activities of the day. Th is approach may help a child or adolescent with chronic pain w ho is absent from school regularly to remain informed of the social context and perhaps a f eeling of belonging when they do go back to school. Technology such as webcams and real-tim e chatting over the Internet could be off ered as helpful tools to allow children and adole scents with chronic pain to continue interacting with their peers remotely. School accommodations Academic accommodations may help adolescents with chronic pain to vie w their teachers as taking a more positive attitude towards them and believing in their pai n condition. Student perceptions of positive teacher regard have been linked to increases i n academic values, achievement, and feelings of academic competency (Roeser and Eccles, 199 8). Many of the adolescents in a study by Logan and colleagues (2008) had some form of acco mmodation in place; teachers rated students with more accommodations as being bet- ter adju sted to school compared to typical peers. Th erefore, even when chronic pain negatively imp acts academic performance the implementation of accommodations may help students perceive t hemselves as valued competent students. Research recommendations Th ere is limited research on the social consequences of chronic p ain for children and adolescents. Little is known about the proc- esses of how peer relatio nships or friendships impact the chronic pain experience and functioning of children and ad olescents, or the processes through which pain impacts friendships. It appears that withdra wal from activities and school absences are important factors but further research examinin g the relationship between pain expression and pain interpretation are needed to understand the impact of these factors. To date, most of the research focuses on peer relationships a nd needs to expand to include close friend- ships. Additionally, examining the relationship s of adolescents separately from children would allow developmental diff erences to be reve aled. Studies are also needed that account for diff erences between male and female friends hips. Finally, intervention studies to determine the best ways to maintain and strengthen c lose friend- ships are needed. 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 .