Th eoretical frameworks: families and pain Recent work has situated family factors and rela tionships as one of many important determinants in a biopsychosocial formulation of pain co mmunication (Hadjistavropoulos et al., 2011). Other broader theories related to parent \200 \223child interactions and the family environment have been applied to the pain context and have also guided research in the fi eld; most notably operant conditioning/ social learnin g theory (Bandura, 1977), theories of family systems (Turk et al., 1987), and attachment (P orter et al., 2007). Several pain-specifi c theories have also been proposed, such as the e mpa- thy model for others \200\231 pain (Goubert et al., 2005). An integrative model of parent and family factors in pediatric pain was proposed by Palermo and Chambers (2005). Th is model (Figure 12.1 ) emphasizes the importance of multiple leve ls of fam- ily assessment, and situates individual parenting variables (e.g. parenting styl e, parental reinforcement) within a broader context of dyadic variables (e.g. quality of pa rent \200\223child interaction), embed- ded within the global familial environment (e.g. fa mily function- ing). Th e model highlights reciprocal interactions of individual child and parent factors, with dyadic (parent \200\223child), and familial levels in infl uencing chi ldren \200\231s reported pain severity, associated Parental assessment of acute pain Children experience numerous acute painful events across child- hood, typically in the form of everyday minor injuries (Fearon et al., 1996). Oft en , it is the parent who assesses the child \200\231s pain and SECTION 3 social and psychological basis of pediatric pain 112 Family level variables (e.g., family environment, overall functioning) Pain Dyadic variables (e.g., parent-child interaction) Possible moderators/mediators: Child gender Child emotional symptoms Child age and developm ental status Child coping Parental pain history Individual variables (e.g., parenting style, parental reinforcement/ solicitousness) Figure 12.1 Integrative model of parent and family factors in pediatric pain. Reproduced fr om Palermo, T. M. and Chambers, C. T., Parent and family factors in pediatric chronic pain and disability: An integrative approach, PAIN , Volume 119, Issues 1 \200\2233, pp. 1 \200\2234, 2005. Th is \201 gure has been reproduced with permission of the International Association for the Study of Pain (IASP). Th e \201 gure may NOT be reproduced for any other purpose without permission. Functional Disability makes decisions regarding management. Children also frequently experience painful medical p rocedures, either for routine immu- nizations or as a result of diagnostic and/or treatment procedures (Stevens et al., 2011). While health professionals are involved in assessing th e child \200\231s pain in the medical setting, it is typically the parent who assumes the p rimary role in assessing their child \200\231s pain. Health professionals frequently rely o n parents to provide informa- tion relevant to pain assessment, for example, the extent to which the child \200\231s current (pain) behavior diff ers from their usual behav- iour. Th is information is particularly important when child self- report is not available. potential to signifi cantly impact children \200\231s later health care usage (Pate et al., 1996). Parent variables have played a critical role in children \200\231s coping and distr ess during painful medical procedures. It is now well accepted that parents should be prese nt with their child during painful medical procedures, and the focus of research is on how and why parents \200\231 behaviors during medical procedures relates to their children \200 \231s pain experiences. Blount and colleagues (Blount et al., 1990, 1991, 1997) investi- gated the relationship bet ween parent behaviors and child distress and coping by providing detailed coding of child a nd parent verbal- izations during painful medical procedures. Specifi c parent behav- iours are associated with decreases or increases in child distress, respectively classifi ed as \200\230coping promoting \200\231 or \200\230distress promot- ing \200\231. Behaviors cla ssifi ed as \200\230coping promoting \200\231 included non- procedural talk, suggestions o n how to cope, and use of humor. A well-established, but seemingly, counterintuitive relati onship between several parent behaviors and child distress was identi- fi ed (e.g. empathy, reassurance). Reassurance is the most common parent behavior exhibited during painful proc edures (Cohen et al., 2002); yet it has consistently been linked to higher levels of child pain and distress, both in clinical and experimental research (Chambers et al., 2002; Taylo r et al., 2011). Th e specifi c mechanisms through which reassurance promotes child distres s and pain dur- ing acute painful medical procedures are not known; however, it appears tha t parental reassurance serves as a signal to the child that the parent is anxious, thereby triggering distress and pain in the child (McMurtry et al., 2006). Children report higher f ear during parental reassurance than during parental distraction, and perceive their parent s as being fearful or worried when they are providing reassurance to the child, especially when it is off ered with a fear- ful facial expression and in a rising tone, indicative of uncertainty (McMurtry et al., 2010). Parents are typically asked to provide observer ratings using self- report pain assessment tools used with children (Stinson et al., 2006). Parents generally underestimate their chil dren \200\231s pain, although the reasons for this are not clear (Chambers and Craig 1999; Chambers et al., 1998; Goubert et al., 2009; Kelly et al., 2002; St Laurent- Gagnon et al., 1999). However, parents are generally more accurate in their estimation of children \200 \231s pain as compared to health profes- sionals, including physicians and nurses (Boerner et al., 2013). Th e extent that parents and children catastrophize about the child \200\231 s pain may play an important role in parental pain assessment. In parents, higher levels of pain catastrophizing have been related to higher child-pain ratings by parents, and better agreement between par- ent and child pain ratings (Goubert et al., 2009). In children, low er levels of pain catastrophizing have been related to better agreement in parent \200\223c hild pain ratings (Vervoort et al., 2009). Some situations may increase the challenge of pa in assessment for parents. For example, while parents are relatively good at detecting when their children are genuinely experiencing or pretending to have pain, they have diffi cult y in accurately detecting when their children are suppressing pain (Larochette et al., 2006 ). More research is needed examining the various psychological and contextual factors that infl uence parent acute pain assessment and to distill this work into measures and approach es maximizing parents \200\231 ability to provide important information about pain assessme nt. Th e tendency to catastrophize about pain has been proposed to play a role in parents \200 \231 responses to their children \200\231s pain. Caes and colleagues (2011) found that pare nts \200\231 catastrophic thoughts about their child \200\231s pain were associated with a higher tendency by parents to restrict their child \200\231s behavior (i.e. stop them from completing a painful experimental task). Th is relationship was mediated by parental distre ss, and was observed in parents of both healthy chil- dren and adolescents with chronic pai n (Caes et al., 2011). Parental non-attending pain talk (i.e. utterances which did not focu s on the Parental behavior and acute pain Children \200\231s experiences during acute painful events can have an impact on their memories of the painful experience and their reac- tions to fu ture painful events (Chen et al., 2000; Noel et al., 2010). Repeated negative interactions in the context of pain have the CHAPTER 12 families and pain 113 child \200\231s pain or the painful stimulus) was associated with increased facial displays of pain and self-reported pain in high pain catastro- phizing children, although this diff erence was not observed in low pain catastrophizing children (Vervoort et al., 2011). Chil d pain catastrophizing was related to parental responses to children \200\231s pain, and wa s moderated by parent \200\223child attachment (Vervoort et al., 2010). Future research in this area needs to utilize more sophisti- cated statistical techniques, such as sequential analysis and dyadic analysis, as well as consideration of parent non-verbal as well as verb al behavior. Box 12.1 Recommendations for parents for managing procedural pain in children \227\206 Prepare yourself and stay calm. \227\206 Prepare your child by using age-appropriate words and be honest; children 5 years old and older should be told about the procedure at least 1 day in advance. \227\206 Distract your child using age-appropriate strategies (e.g. toys, books, music, or videos). \227\206 Encourage your child to take slow, deep breaths (e.g. with bub- Th e role of fathers A major limitation of research on the role of the family in paedi- atr ic pain is the paucity of studies including fathers. Mothers are most oft en involved as th ey are accessible and are oft en identifi ed as the primary caregiver. However, fathers pla y an increasingly important role in their children \200\231s lives and health care and, as such, are important to include (Phares et al., 2005). Moon and colleagues (2008) found that fathers showed better agreement with children \200\231s pain ratings than mothers. Moon an d colleagues (2011) also exam- ined parent \200\231s verbal behavior while children complet ed the cold pressor task. Mothers and fathers generally did not diff er in their proportion s of attending and non-attending talk during children \200\231s pain; however, mothers used more non symptom-focused talk and commands, while fathers used more criticism (Moon et al. , 2011). Th is work focused exclusively on comparing mother-father verbal behavior; researc h is needed to also examine potential diff erences in use of non-verbal behavior. bles or pinwheels). \227\206 Avoid words that focus on the pain or the procedure (e.g. \200\230It \200\231ll be over soon \200\231 \200\230You \200\231ll be okay \200\231); it \200\231s better to tal k about things not related to the procedure. \227\206 Use other age-appropriate pain-relieving interventions, such as breastfeeding or sucrose for infants or topical anesthetic creams. \227\206 Aft er the procedure, praise your child for a job well done. procedures is also eff ective for reducing parental anxiety (Cohen et al., 1997). Parents c an be instructed in how to: (1) prepare them- selves and their child in advance of the proc edure, (2) distract their child during the procedure, (3) provide physical comfort and othe r pain-relieving interventions (e.g. breastfeeding, topical anaesthet- ics), and (4) praise the child aft er the procedure (Box 12.1 ). Sex diff erences exist in pain perception and responses to pain, which may be partially inf l uenced by gender socialization (Myers et al., 2003). Gender socialization suggests that, through social learning processes such as modeling and reinforcement, children learn gender -specifi c behaviors that infl uence their responses to pain (Myers et al., 2003). Parents play an important role in teach- ing their children gender-specifi c behaviors (Langlois an d Downs, 1980) and fathers tend to diff erentiate between male and female children more tha n mothers (Lytton and Romney, 1991). A sur- vey of Finnish parents \200\231 perceptions of children \200\231s postoperative pain found that fathers were more likely than mothers to b elieve that their child should be able to independently cope with their pain, think that pa in from surgery was acceptable, and believe that their children were capable of faking pain (Kankkunen et al., 2003). Additionally, boys were expected to tolerate more pain than girl s. Researchers need to continue examining the unique role of fathers in pediatric pain, and avoid drawing conclusions about parent fac- tors from research conducted primarily with mo thers. Chronic pain: families and pain Case example Lauren is a 13-year-old girl with a 5-year history of recurrent stomach aches. When Lauren is seen by the Complex Pain Consultation Service, she has missed the past 6 weeks of school and reports daily stomach aches with an average pain inten- sity of 7 out of 10. Lauren \200\231s parents, Melissa and Doug, report considerable concern about her pain as well as frustration over how to best support Lauren. At the time Lauren \200\231s stomach aches wor sened, Melissa was also home from work on disability as a result of a back injury she susta ined in the work place. However, Melissa had recently returned to work, leaving Lauren unsu per- vised during the day. Lauren spends a typical day watching tele- vision, which she say s helps to distract her from her pain. Melissa reported signifi cant anxiety about Lauren \200\231s pain, and that she is frequently troubled by thoughts that perhaps Lauren will al ways have pain and never be able to return to school. Doug reports a strong family history of gastrointestinal symptoms, and acknowl- edged that he suff ered from stomach aches as a child. Th e family reports considerable confl ict about how to best manage Lauren \200\231s pain. Melissa feels that Lauren cannot return to school until her pain has improved or res olved, while Doug feels that Lauren just needs to \200\230tough it out \200\231 and return to school. Melissa reports wak- ing up dreading the conversations they will have about Lau ren \200\231s pain and whether Lauren will feel well enough to return to school that day. Parents \200\231 roles in acute pain management Th e importance of appropriate pain managem ent for medical proce- dures in children has continued to receive attention. Clinical prac- tice guidelines identify evidence-based pharmacological, physical, and psychological strat egies for management of immunization pain in children (Taddio et al., 2010a, 2010b). System atic reviews of psy- chological interventions in pediatric procedural pain management (Cham bers et al., 2009; Uman et al., 2006, 2008) identify a number of eff ective cognitive-behav ioral strategies for reducing pain (e.g. distraction, deep breathing) that parents can enco urage or direct. Involving parents in coaching their child to cope during painful SECTION 3 social and psychological basis of pediatric pain 114 Aggregation of pain in families Research is mixed in understanding the relationship between paren- tal and child pain with some showing an increased risk of chronic pain for children who have a parent with chronic pain (Groholt et al., 2003; Saunders et al., 2007). Associa tions between parent and child pain may be site specifi c. Two large population-based studi es demonstrated that parental headache, abdominal pain, and back pain were predictive of th e same pain sites in children (Groholt et al., 2003; Saunders et al., 2007). Additionally, a dose \200\223response relationship in the number of pain sites reported by mothers was as sociated with a greater number of pain sites in children (Saunders et al., 2007). Th e infl uence of parental pain models may be sex spe- cifi c with a higher concordance rate of par ent \200\223child pain among mothers and daughters; however, data for fathers were incomple te (Evans et al., 2010). A prospective study supported a relationship between parent and ch ild pain experiences (Goodman et al., 1997); children of parents reporting four or more pai n incidents over a 7-day period were at signifi cantly increased risk for reporting a large number of total pain incidents, as well as clinically signifi - cant and disabling pain in cidents. Together, these studies suggest a familial predisposition to pain sensitivity and reactivity. experiences of fear, helplessness, and distress and describe parents as feeling powerless i n attempts to help their child despite seeking resources and intervention. Parental adjustm ent is partially related to individual child and pain-related factors, with parents report- ing higher levels of parenting stress with younger child age, pain chronicity, and child d epression (Eccleston et al., 2004). Greater daily intensity of the child \200\231s chronic pain was predictive of greater maternal social restrictions, personal strain, and coping (H unfeld et al., 2001). Parental factors, such as dispositional empathy and catastrophic thin king about their child \200\231s pain, also infl uenced parental distress in response to vi gnettes of children \200\231s pain expe- riences (Goubert et al., 2008). Addressing parents \200\231 psychologi- cal well-being is an area warranting greater research attention, as i mproved understanding of parental distress result in more eff ec- tive management of childr en \200\231s pain and related disability (Palermo and Eccleston, 2009). Siblings also worry about their sibling with chronic pain and became more considerate and c ompassionate toward them (Britton and Moore, 2002). Siblings reported confusion about their sick sibling \200\231s symptoms, wondering if they would develop chronic pain or what thei r own life would be like with chronic pain. Parents reported that siblings would sometimes compete for their atten- tion. Research suggests that parents may alter their behavior towa rd well siblings, excusing them from chores or off ering special treats to assuage parental guilt associated with lessened attention (Jordan et al., 2007). Parent and child psychosocial and environmental factors may also account for associations b etween parent and child pain. Longitudinal examination over the fi rst 6 years of life reve aled that parent anxiety and child temperament during the child \200\231s fi rst year were associated with later development of childhood recur- rent abdominal pain (Ramchandani et a l., 2006). Schanberg and colleagues (2001) reported associations between parental/familial pain history and current pain of children with chronic rheumatic disease were mediated by c hild pain catastrophizing. Maternal pain history has also been reported as a unique predict or of child functional impairment, although the impact of paternal pain his- tory has not b een examined (Kashikar-Zuck et al., 2008). Bruehl and colleagues (2005) found that children \200\231s recollections of parental pain signifi cantly predicted the child \200\231s own chronic pain status and number of pain locations in adulthood, while objective parental his tory of chronic pain did not. In \202 uence of parental beliefs, psychological functioning, and behaviors Parental belie fs, functioning, and behaviors reciprocally infl uence children \200\231s pain (Palermo and Chambers, 2005). Parental beliefs about the etiology of the child \200\231s chronic pain h ave infl uenced child pain outcomes and parent behaviors. Children whose parents sub- scrib ed to a biopsychosocial model of pain were more likely to have successfully resolved recurr ent abdominal pain than children whose parents cited physical cause only (Crushell et al., 2003). Children whose parents believed their pain was \200\230medical only \200\231 report ed the highest pain and functional disability (Guite et al., 2009). Altogether, fi ndings from these studies demonstrate the potential role of risk factors con tributing to parent and child pain, support- ing the complex ways pain aggregates within fa milies. Conclusions from these studies must be drawn cautiously as many are based on subjec tive retrospective report, employing varying defi nitions of intensity and frequency of par ental and pediatric pain. Future research should continue focusing on longitudinal prospect ive designs that assess the possible infl uence of genetic, psychosocial, and environmental as risk factors for chronic pain. Substantial research has focused on parental responses to chil- dren \200\231s pain. Th e A dult Responses to Children \200\231s Symptoms question- naire (Claar et al., 2010; Van Slyk e and Walker 2006) categorizes parental responses to children \200\231s chronic pain on thr ee factors: (1) protectiveness (e.g. limiting the child \200\231s activities and responsibi l- ities), (2) minimization of pain (e.g. criticizing), and (3) encourag- ing and monitorin g (e.g. reassuring, distracting the child). Parental protectiveness has been associated wit h increased pain-related dis- ability, child depressive symptoms, and longer pain duration (Claar et al., 2010). Parental protectiveness predicted greater somatic complaints among ad olescents with chronic pain; as well as greater physical disability for adolescents who rep orted infrequent use of passive coping strategies (Simons et al., 2008). Impact of child pain on the family Pediatric chronic pain significantly impacts on the fami ly. Parents of children with chronic pain report high levels of paren- tal role stress, anx iety and depressive symptoms, and social impact (Palermo and Eccleston, 2009). Rates of anx iety, depression, and somatoform disorders are higher among mothers of children with chroni c pain as compared to mothers of healthy children (Campo et al., 2007; Evans et al., 2008b; Kashikar-Zuck et al., 2008). Parent \200\223child interactions during painful activities provide addi- tional support fo r the infl uence of parental behaviors on children \200\231s pain. Sequential analysis of a dolescents with chronic pain and their parents during an exercise task revealed that when p arents made statements that discouraged child coping, the child was less likely to remain o n task, which was signifi cantly associated with func- tional disability and school absence s (Reid et al., 2005). Similarly Several studies have qualitatively explored parents \200\231 experiences caring for a child with chronic pain (Jordan et al., 2007; Maciver et al., 2010; van Tilburg et al., 2006). T h ese studies describe parents \200\231 CHAPTER 12 families and pain 115 to healthy children, children with chronic pain exhibited more symptom complaints during an experimental pain task when their parents attended to their pain, as opposed to when they distracted them (Walker et al., 2006). Clinical and experimental studies sup- port the powe rful infl uence of operant conditioning strategies of positive and negative reinforcement, whereby children \200\231s adoption of a sick role is continuously strengthened leading to increased dis- ability and maladaptive coping. in pediatric chronic pain. Child autonomy, in particular, has predicted greater functional impairment among adolescents with chronic pain aft er controlling for pubertal status, pain intensity, and depressive symptoms (Palermo et al., 2007). Greater parent \200\223 adolesc ent confl ict, poorer family functioning, and less age-ap- propriate autonomy predicted gre ater depressive symptoms for adolescents with chronic headaches (Lewandowski and Palermo, 2 009). Interviews with children with chronic pain and their moth- ers suggested that limited autonomy reduced the child \200\231s sense of self-effi cacy for pain and non-pain related activities, as well as decreased the likelihood of regular attendance at school and other activities (Evans et al., 2010). Poorer psychological functioning of parents has been reported to negatively impact the chil d \200\231s reported pain and related disability (Logan and Scharff 2005; Palermo and Eccle ston 2009), as well as infl uence parent behavior. Mothers with greater psychological dis- tress were more likely to seek physician consultation with child report of abdominal pain ( Levy et al., 2006). Parental worry about the child \200\231s physical health was signifi ca ntly related to child functional disability and parents \200\231 engagement in pain promoti ng behaviors (Guite et al., 2009). Additionally, greater maternal worry has been associated with higher perceived pain threat and limitations in family activities as a result of the child \200\231s pain (Lipani and Walker, 2006). Greater parent \200\223adolescent relationship distress was related to increased adolescent distress and lower pain intensity, but not to adolescent functional disability (Logan et a l., 2006). Parents reported closer relationships with their adolescent than healthy norms ( Logan et al., 2006), a fi nding supported by interviews with parents and children with chro nic pain (Jordan et al., 2007). Th is intensive parenting role is more akin to parenting a younger child (Jordan et al., 2007) and is consistent with the lower levels of age- appropr iate autonomy reported by adolescents with chronic head- ache (Lewandowski and Palermo, 200 9). Parental pain catastrophizing strongly infl uences children \200\231s func- tioning. Mother s reported higher rates of pain catastrophizing than fathers, specifi cally a greater tende ncy to ruminate about their child \200\231s pain (Hechler et al., 2011). Negative consequen ces have been associated with parental catastrophic thinking about their child \200\231s pa in, including increased parenting stress and parent psychologi- cal distress, as well as wo rsened child pain-related disability and school attendance (Goubert et al., 2006). As in ac ute pain, parent pain catastrophizing contributes signifi cantly to parental responses to c hildren \200\231s chronic pain (Hechler et al., 2011). Parental pain cata- strophizing and protective responses to children \200\231s pain were unique predictors of school attendance and overall school impairment in adolescents with chronic pain, above the eff ects of adol escent pain intensity and depressive symptoms (Logan et al., 2012). Parental protectiveness mediated the relationship between parent pain catastrophizing and adolescent school functi oning and attendance (Logan et al., 2012). Caes and colleagues (2011) demonstrated that par ent distress mediated the relationship between parental cata- strophic thinking and parents \200\231 tendency to restrict pain-inducing activity in children with chronic pain. In \202 uence of family functioning A recent systematic review revealed signifi cant diff erences in fam- ily functioning between families of children with chronic pain and healthy controls (Lewandowski et al., 2010). Families of children with chronic pain generally repor ted poorer family functioning as exemplifi ed through less family cohesion, less organizati on, greater confl ict, and greater psychological distress. Poorer family function- ing was also associated with increased child disability; however the relationship between family fu nctioning and child pain was less consistent, possibly due to diff erences in how family fu nctioning was measured across reviewed studies (Lewandowski et al., 2010). However, poor fa mily functioning is not universal, as it appears to characterize a particular subgroup of c hildren with chronic pain (Scharff et al., 2005) and is related to parental beliefs that th e cause of the child \200\231s pain is \200\230medical only \200\231 (Guite et al., 2009). Altogether, these studies support the critical role of family factors in paediat- ric chro nic pain and should be included as an important target for intervention. Children \200\231s psychological functioning and pain-related beliefs have repeatedly moder ated the relationship between parent behav- iours and child pain outcomes. Th e negative im pact of maladaptive parent behaviors (i.e. solicitousness, protectiveness, minimization of the child \200\231s pain) on child \200\231s functional disability and somatic com- plaints were strongest for children with greater psychological dis- tress (Claar et al., 2008; Pet erson and Palermo, 2004). Furthermore, child pain catastrophizing moderated the relationshi p between parent symptom-related talk during a painful task and child symp- tom complaints; while the relationship between non-symptom talk and child symptom complaints was moderated by child perceived pain-related threat (Williams et al., 2010). Future research should con tinue integrating fi ndings from experimental and clinic-based studies, and incorporate mor e complex multivariate analyzes to allow stronger claims about the causal relationships bet ween paren- tal beliefs, functioning and behaviors, and child pain outcomes. Role of family in interventions for pediatric chronic pain Research supports the eff ective ness of parental involvement in treat- ment of chronic pain. Of 25 randomized controlled tr ials included in a recent meta-analytic review, seven described involvement of parents in p sychological therapies for pediatric chronic pain (Palermo 2009); however, the infl uence o f parent/family involve- ment on trial outcomes was not explored. Cognitive-behavior therapy (CBT) has received attention as an eff ective intervention for p ediatric chronic pain, oft en with family involvement as an important component for achievi ng and maintaining treatment gains (Robins et al., 2005). Parent involve- ment in CBT is ba sed on principles of operant conditioning and modeling, such that child pain and level of f unctioning by parent reinforcement of independent adaptive coping by the child and limiting parents \200\231 attention to child pain behaviors (Palermo and Eccleston, 2009; Noel et a l., 2012b). Box 12.2 provides a summary Role of the parent \200\223child relationship Despite its theorized relevance (Palermo and Chambers, 2005), lim- ited research has expressly examined the parent \200\223child relatio nship SECTION 3 social and psychological basis of pediatric pain 116 Conclusion A large body of research showcases the relevance of the family, par- ticularly p arents, in pediatric pain. Findings support the infl uence of parent behaviors, psychologic al functioning, and beliefs about pain (e.g. pain catastrophizing) on children \200\231s ac ute and chronic pain outcomes. Several studies have innovatively integrated clini- cal and experimental methods of inquiry, representing a promis- ing trend in the fi eld bringing bo th scientifi c rigor and external validity to research fi ndings. Correspondingly, parent i nvolvement in interventions is largely based on modifying parental responses to children \200\231s pain using principles of operant conditioning. Family relationships and the famil y environment are revealed as infl uen- tial frameworks both molded by and contributing to children \200\231s pain experience. Because of the expanding literature on sex dif- ference s in parent responding to children \200\231s pain, the inclusion of fathers in future resea rch should be prioritized. Consideration of a developmental framework is oft en omitted fro m current theories of pain and the family. Diverging trends are noted in pediatric acute an d chronic pain research. Investigations of the family in paediat- ric chronic pain are expa nding in scope, exploring the infl uence of individual, dyadic and familial level factors. In contrast, stud- ies examining the family in pediatric acute pain are narrowing in scope, seeking a more detailed understanding of parent \200\223child interactions. Pain and the f amily remains a very active and inno- vative area of inquiry, off ering continued insight i nto the broader context within which children experience pain. Box 12.2 Recommendations for parents for managing chronic pain in children \227\206 Limit or remove attention from the pain. \227\206 Be sure that your child goes to school each day. \227\206 Help your child identify stress at home and at school. \227\206 Provide attention and special activities on days when your child does not have stomach aches. \227\206 Limit activities and interactions on sick days. \227\206 Avoid talking about any pains or illness you have. \227\206 Support your child in practicing their pain coping strategies (e.g. relaxation, distraction). of key messages to parents regarding behavioral pain manage- ment. Parents and children are engaged in a collaborative partner- ship where parents can both model and supportively \200\230coach \200\231 their child during treatment and for relapse prevention (Noel et al. , 2012b; Palermo et al., 2009; Robins et al., 2005). CBT treatment protocols diff er in the type and extent of parental involvement required, with some requiring joint attendance of the parent at a portion of treatment sessions (Robins et al., 2005) and others deliv- ering content separately and concurrently to parents and children (Noel et al., 2012a; Palermo e t al., 2009; for further discussion of CBT see Logan et al., Chapter 50, this volume). A ra ndomized con- trolled trial comparing CBT to standard medical care for children with recurr ent abdominal pain and their parents reported signifi - cantly reduced child pain and schoo l absences for the CBT group immediately post-treatment and at 1-year follow-up (Robins et al., 2005). Signifi cant reductions in parent pain-promoting behaviors were reported aft er a CBT intervention with parental involvement for children with recurrent abdominal pain (N oel et al., 2012a). Children with chronic pain and parents participating in an 8-week famil y CBT intervention online similarly reported signifi cant reduced pain and activity limitat ions as compared with a wait-list control immediately post-treatment and maintained at 3-mo nth follow-up (Palermo et al., 2009). Although some interventions address the importance of parents \200\231 own mental health (Noel et al., 2012a; Palermo et al., 2009), most do not assess parent psychoso- cial functioning. One study evaluating an interdisciplinary CBT pr ogram reported signifi cant improvements in parent anxi- ety, depression, and stress post-t reatment that was maintained at 3-month follow-up (Eccleston et al., 2003). Children attend ing this program also showed improvements in physical function and disability, anxiety, pai n catastrophizing, somatic awareness, and school attendance (Eccleston et al., 2003). References Bandura, A. (1977). Social learning theory. Englewood Cliff s, NJ: Prentice- Hall Inc. 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