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 support when they experience pain and that women show increased health care utilization for pain compared to men (e.g. Chang et al., 2006; Gibbs et al., 2003). Robinson and colleague s (2001) suggested that there may be a greater response cost involved when men report their pain because men are expected to be stoic in response to pain. Acting in a way that is inc ongruent with this expectation may cause men anx- iety and embarrassment. It is possible th at the pattern of observed adult sex diff erences in experimental but not clinical pain set tings may be because the relatively mild experimental pain makes it eas- ier for men to con form to male gender-role expectations (Myers et al., 2003). Clinical pain that is intense e nough for men to seek medical treatment may override the desire to conform to the stere- ot ypical male gender role. Case example: Maggie Maggie was 14 and had a long history of abdominal pain, but not menstrual cramps or menstru al pain. She was referred to the pain clinic from gastroenterology. Maggie was started on g abapentin and amitriptyline following an unsuccessful trial of NSAIDs. At a follow-up asses sment, it was observed that Maggie \200\231s abdominal pain increased about the time of her menses. When NSAIDs were added to her regimen for the several days before its onset, her o ngoing abdominal pain and its fl are at menses improved. Th ese cases illustrate the way in which sex and gender may interact with pain in the clini cal setting. Mathew hid his pain and his emotional reaction to it under a stoic demeanor. C linicians initially interpreted his reticence to engage clinically as disinter- est in trea tment. Sonia \200\231s pain was interpreted as a social and prob- ably psychological proble m when there was no physical fi nding to point to a cause. Maggie \200\231s abdominal pain was due to other issues than menstruation, but her menstrual cycle produced fl ares that ch anged treatment needs. For clinicians, it is important to consider that gender role expecta tions may shape the way in which a child or adolescent will communicate about their pain, a s well as their own perceptions of this communication. Similarly, biological fac- tors may intersect with gender and aff ect pain in clinical settings, particularly aft er puberty. Th ere has been substantial criticism that pain in women is more likely to be interpreted a s a psychological problem (e.g. Hoff mann and Tarzian, 2001; Unruh, 1996) but this issue ha s not been exam- ined in studies of child or adolescent pain. Th e greater willingness of g irls to express their pain to others may increase this risk. Clinical implications of sex and gender Th e ways in which sex and gender may be manifested in children and adolescents in a pain clinic are illustrated in the following three case s cenarios. Th e cases have been modifi ed but refl ect issues that have been clinically pres ented. Recommendations for future research Sex and gender diff erences are not usually the focus o f pain research. Instead, sex is typically included as a demographic variable that may or m ay not be examined and reported. As noted by Unruh (1996), the results of studies that do n ot identify sex as a variable of primary interest a priori must be interpreted with caution because the power of these studies to detect sex diff erences is unclear. Pain researchers need to look beyond descriptive sex diff erences to examine how the psychosocial variable of gender aff ects child and adult pain responses. To date, only a handful of studies have exam- ined gender diff erences in child and adult pain. Th is area is in great need of expa nsion. Fathers need to be included in research on sex and gender diff erences in child pain . With the exception of a few studies, fathers tend to be overlooked. In fact, 91% of child health psychology studies (including child pain), published from 1996 to 2003, involved on ly mothers or collapsed data from both parents (Phares et al., 2005). Particularly in resea rch about sex and gen- der, the impact of parent gender on socialization cannot be ignored without compromising the meaningfulness of outcomes. Case example: Matthew Matthew was 17 when he came to the pain clinic with his mother. He seemed to be coping well with his pain and was generally dis- interested in treatment. His mother was more concerne d about his pain than he was. Nevertheless, when he was later seen by the school guidance c ounselor for behavior problems at school, it was apparent that Matthew was extremely distre ssed by his severe pain and did not know what to do with his anger and frustration about it . Case example: Sonia At 15, Sonia was seen by an orthopedic surgeon for widespread pain that had originated 1 ye ar earlier with back pain. As the imaging results were all negative, the surgeon told Sonia \200\231s par- ents that there was nothing wrong with Sonia. He told Sonia that if she fou nd a nice boyfriend she would get better. By the time Sonia was seen at the pain clinic she had missed 8 months of school due to severe pain. As non-steroidal anti-infl ammatory drug s (NSAIDs) had been ineff ective in the past, and her sleep was poor, Sonia was started on gabapentin and amitriptyline. Th e psychologist saw her for pain-specifi c cognitive-behavi oral therapy. A very slow pacing program was initiated. Over the Conclusion Although the study of sex diff erences in child pain is not as advanced as the a dult pain literature, evidence for sex diff erences in child and adolescent pain has accumu lated in the past decade. Studies of sex diff erences in children \200\231s responses to ex perimentally SECTION 3 social and psychological basis of pediatric pain 132 induced pain have largely focused on the cold pressor pain para- digm and have generally no t uncovered sex diff erences. In con- trast, epidemiological data indicate that girls are a t an increased risk of a number of chronic pain conditions. Findings from child clinical pa in studies are inconsistent, but generally suggest that boys and girls give comparable pain ratings. Findings from recent studies of needle pain are mixed but indicate that girls may give higher pain aff ect ratings. Postoperative pain fi ndings are equivocal, with some st udies indicating greater pain intensity in girls and others reporting no sex diff erences. Findings on sex diff erences in child pain coping strategies are remarkably similar to fi n dings with adults. Girls appear to seek more social support for pain whereas boys are more likely to engage in distraction. Similar to the adult literature, some data also suggest th at girls may be more likely than boys to catastrophize in response to pain. Although gender infl uences adult pain responses, the study of gender diff erences in child pain has not b een exten- sive. Researchers have only just begun to delineate the impact of biological, fa mily, and sociocultural factors on sex and gender diff erences in pain. Inconsistent fi ndi ngs highlight the need for further expansion of this fi eld. Chang, L., Toner, B. B., Fukudo, S., Guthrie, E., Locke, G. R., Norton, N. J., et al . (200 6). Gender, age, society, culture, and the patient \200\231s perspective in the functional gastrointestinal disorders. Gastroenterology, 130 , 1435 \200\2231446 . Cohen, L. L., Blount, R. L., Cohen, R. J., and Johnson, V. C. (2004). Dimensions of pediatr ic procedural distress: children \200\231s anxiety and pain during immunizations. J Clin Ps ychol Med S, 11 , 41 \200\22347 . Cohen, L. L., Manimala, R., and Blount, R. L. (2000). Easier said than done: what parents s ay they do and what they do during children \200\231s immunizations. Child Health Care, 29 , 79 \200\22386 . Coldwell, S. E., Kaakko, T., Gartner-Makihara, A. B., Williams, T., Milgrom, P., Weinstein, P., et al . (2002). Temporal information reduces children \200\231s pain reports during a multiple-trial cold pressor procedure. Behav Th er, 33 , 45 \200\22363 . Derbyshire, S. W., Nichols, T. E., Firestone, L., Townsend, D. W., and Jones, A. K. (2002). Gender diff erences in patterns of cerebral activation during equal experience of painful laser stimulation. J Pain, 3 , 401 \200\223411 . Edwards, R. R., Haythornthwaite, J. A., Sullivan, M. J., and Fillingim, R. B. (2004). Catas trophizing as a mediator of sex diff erences in pain: diff erential eff ects for daily pain versus laboratory-induced pain. Pain, 111 , 335 \200\223341 . Evans, S., Tsao, J. C. I., and Zeltzer, L. K. (2008). Relationship of child perceptions of maternal pain to children \200\231s laboratory and nonlaboratory pain. Pain Res Manag, 13 , 211 \200\223218 . Fillingim, R. B. and Edwards, R. R. (2001). Th e association of hormone in Acknowledgements Th e authors acknowledge the assistance of Dr Paula Forgeron, University o f Ottawa, in the preparation of the case examples. replacement postemenopausal women. Pain, 92 , 229 \200\223234 . therapy with experimental pain responses Fillingim, R. B., King, C. D., Ribeiro-Dasilva, M. C., Rahim-Williams, B., and Riley, J. 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Par ent and child anxiety sensitivity: relationship to children \200\231s experimental pain res ponsivity. J Pain, 7 , 319 \200\223326 . Zeman, J. and Shipman, K. (1996). Children \200\231s expression of negative aff ect: reasons and methods. Dev Psychol, 32 , 842 \200\223849 . CHAPTER 15 Sleep and pain in children and adolescents Bruce D. Dick , Penny Corkum, Manisha Witmans , and Christine T. Chambers Summary Ongoing pain is a problem that aff ects a large number of chil- dren and adolescent s. It has been well documented that recurrent and chronic pain are associated with many dif fi culties related to both physical and psychological function. A major diffi culty that ma ny young people with chronic or recurrent pain experience is disrupted sleep. Sleep problem s have been reported to exist in as many as 50% or more of children with chronic illnesses (Owens, 2007). In many cases, pain is reported by the suff erers to cause sleep fragmentati on as well as signifi cant diffi culties with delayed sleep onset. As well, there is increa sing evidence that disrupted sleep is associated with increased pain. Both pain and sleep d is- ruption further complicate the patient \200\231s overall clinical picture by making it more diffi cult for children and teens to cope with health problems and associated diffi cu lties. Further, there is evidence that childhood sleep problems can have important negative eff ects on adult sleep patterns and, thereby, infl uence health status later in life (Fri cke-Oerkermann et al., 2007; Sivertsen et al., 2009). Th is chapter will address the preval ence, importance, and consequences of sleep problems in children and adolescents with pain. First, the prevalence and possible relationship between pain and sleep will be discussed. Next, we will highlight the assessment of sleep with a specifi c focus on assessment of sle ep in pediatric pain populations. We will then review established and emerging medical and psycho- logical treatment strategies used to eff ectively treat these important diffi culti es. Practical suggestions will also be provided as a general and basic guide for treatment of children and teens with pain and sleep problems. relatively short-term basis. Recurrent or persistent pain can have a useful function but of t en results in prolonged and more signifi cant impairment. Chronic pain can become highly disruptive of func- tion but generally tends not to have a useful or adaptive function, som etimes resulting in a complex web of negative outcomes that can have widespread eff ects on a young person \200\231s life. Clinically, when pain becomes disruptive of function, it is fre- quently reported by child and adolescent suff erers to result in a range of negative outcomes. Th ese negative eff ec ts include impairment of physical function and activity levels, decreased school attendance and academic performance, cognitive interruption, mood prob- lems, particularly anxiety an d depression, decreased social activity including negative eff ects on friendships, and poo rer quality of life (Dick and Pillai Riddell, 2010; Forgeron et al. 2011). Th e nature and severity of the eff ects of these problems can interact with each other and can be associat ed with several negative vicious cycles.