CHILD HEALTH PSYCHOLOGY, Schemes and Mind Maps of Psychology

Download CHILD HEALTH PSYCHOLOGY and more Schemes and Mind Maps Psychology in PDF only on Docsity! CHILD HEALTH PSYCHOLOGY A BIOPSYCHOSOCIAL PERSPECTIVE JULIE M. TURNER-COBB SAGE has been part of the global academic community since 1965, supporting high quality research and learning that transforms society and our understanding of individuals, groups, and cultures. SAGE is the independent, innovative, natural home for authors, editors and societies who share our commitment and passion for the social sciences. Find out more at: www.sagepublications.com 00-Turner-Cobb_Prelims.indd 3 11/15/2013 5:35:36 PM Covered in this chapter • The biopsychosocial approach to the experience of pain • The pain experience in children and analgesic management of pain • The prevalence of pain and disability in children • Cognitive, behavioural and emotional factors in coping with pain • The role of early life pain experience on subsequent pain • Psychosocial interventions in acute and chronic pain In this chapter, I explore the biopsychosocial experience of pain and how children cope with pain, from neonates and infants through to the experience of pain in adoles- cence. To begin with, I consider the prevalence of pain in children and the context of pain relief through pharmacological intervention. I then compare the characteristics of the experience of acute pain (e.g., dental pain or pain from an acute traumatic injury such as a car accident) with the characteristics of chronic pain experienced in chronic conditions (e.g., juvenile arthritis or sickle cell disease). In particular, I focus on how children cope with acute and chronic pain and how this may change over time, with age and experience, and consider both adaptive coping and maladaptive coping responses such as catastrophizing. Also considered are the assessment of pain, differ- ences between children and adolescents in the expression of pain, and the role of sex differences in pain. I then draw on this knowledge to examine psychosocial interven- tions to reduce the experience of acute and chronic pain in children. Whilst reading this chapter, keep in mind the concepts of stress, coping, acute and chronic definitions and lifespan issues already covered in previous chapters. For those who like more of a 9THE EXPERIENCE OF PAIN IN CHILDHOOD 09-Turner-Cobb_CH-09.indd 234 11/15/2013 5:37:04 PM PAIN IN CHILDHOOD 237 L T B C S SG T GATE CONTROL SYSTEM SG T INPUT L S − −− + + + − − + − + + T A PsychologicalVariables ACTION SYSTEM CENTRAL CONTROL FIGURE 9.1 Evolution of the ‘gate control theory’ Source: Melzack (1999a). 09-Turner-Cobb_CH-09.indd 237 11/15/2013 5:37:04 PM 238 ACUTE AND CHRONIC ILLNESS DURING CHILDHOOD the original 1965 schematic diagram of ‘gate control theory’ (pictured along the bot- tom of the diagram) as well as the earlier and more basic diagram of Noordenbos’s (A), and Melzack’s (B) and Wall’s (C) later sketches, which progressively inspired it (Melzack, 2001). In terms of metaphors, then, it took 300 years to move from the metaphor of the belfry to one of a gate (albeit, an electrical circuitry ‘gate’ rather than the more colourful metaphor this perhaps conjures up today). So what does this now well-accepted ‘gate control theory’ of pain tell us? At the core of this theory is the idea that the experience of pain is more than merely sensory perception. It simultaneously involves both a biological feedforward action and a psychophysiological feedback action, the product of which determines the degree that the ‘gate’ is open and hence the amount of pain perceived. The first of these, the feedfor- ward action, operates from the pain receptors located in the skin and bodily organs linking to a series of ‘gates’ in the substantia gelatinosa (SG) which lies within the dorsal horn throughout the spinal column. The SG initiates the production of substance P which acti- vates the T fibres, thus ‘opening’ the ‘gate’; the degree to which the gates are open depend- ing on the combined amount of excitatory and inhibitory information being transmitted across three types of nerve fibres: (i) the A delta fibres (associated with sharp pain); (ii) the C fibres (associated with dull, throbbing pain); and (iii) the A beta fibres which respond to touch and gentle pressure. These impulses are then transmitted to the pain centres of the brain. The A delta fibres and C fibres (both ‘S’ in Melzack and Wall’s original 1965 diagram) relay pain information on this feedforward part of the system, opening the gate, whilst acti- vation of the A beta fibres (‘L’ in Melzack and Wall’s original 1965 diagram) has the opposite effect of closing the gate via a feedback mechanism which loops from the brain directly back to the gate mechanism. This explains why gently rubbing the site of injury reduces the expe- rience of pain, since the A beta fibres transmit information more quickly than the C fibres (Morrison and Bennett, 2012). Simultaneously, our cognitive and emotional response sys- tems are activated in the brain (central control box), and these activate nerves that relay information down through the spinal column to the gates receiving feedforward impulses. The thalamus and cortex of the brain detect A fibre nociception and are associated with planning and action (e.g., motivating an individual to get away from the pain), whereas the limbic system, hypothalamus and autonomic nervous system detect C fibre activation and enable an emotional response to the pain. Operating via the release of hormones such as endorphins (naturally occurring pain relievers), this psychophysiological feedback can open the gates further or close the gates depending on the characteristics of the emotions and cognitions; for example, anxiety may add to the degree that the gate is open, whereas relax- ation may contribute to closing the gate (Morrison and Bennett, 2012). Endorphins (natural pain relievers) act to reduce the effectiveness of substance P (neurotransmitter which enables pain to be transmitted across nerves; Kalat, 2001) at the level of the brain and SG in the spinal cord (Morrison and Bennett, 2012). Pharmacological pain medication can act to close the gate by interrupting both feedback and feedforward mechanisms. A modern representa- tion of this feedforward and feedback system is shown in Figure 9.2 which illustrates the ascending and descending pain pathways from the spinal cord to the brain. It is in these descending pain pathways that the psychological factors of affect, motivation and cognition 09-Turner-Cobb_CH-09.indd 238 11/15/2013 5:37:04 PM PAIN IN CHILDHOOD 239 are able to act to moderate the sensory perception of pain or, in Melzack’s own words, the ‘brain processes can select, filter and modulate pain signals’ (Melzack, 1999a: S122). Melzack considered the gate control theory as revolutionary in prioritizing the central nerv- ous system (CNS) as ‘an essential component’ in the experience of pain. Melzack (1999a) added to this ‘gate control theory’ of pain in order to explain more complex pain experiences which the original theory was unable to accommodate, such as cases of phantom limb pain in which patients who had had a limb amputated still experi- enced significant chronic pain in the non-existent limb. Of course, the limb was no longer able to transmit the sensory information generating the pain, so what Melzack cleverly deduced was that the neural networks responsible for the pain experience were still in existence in the brain, acting as stimuli to produce the pain, even though the route for the sensory stimuli to produce the patterns no longer existed. Effectively, the brain processes are acting ‘in the absence of any inputs’ (Melzack, 1999a: S123). Melzack referred to the ‘body-self ’ as an individual’s distinct awareness of themselves in relation to their environ- ment, and this body-self involves numerous dimensions (e.g., sensory, affective, evaluative, and postural) with underlying brain processes that are genetically ‘built-in’ but capable of FIGURE 9.2 Ascending and descending pain pathways Source: Rozenzweig et al. (2002: 240). 09-Turner-Cobb_CH-09.indd 239 11/15/2013 5:37:04 PM 242 ACUTE AND CHRONIC ILLNESS DURING CHILDHOOD chronic pain syndromes characterized by hypocortisolaemic states, such as rheumatoid arthritis, and have also been observed in musculoskeletal conditions (Turner-Cobb et al., 2010). Melzack (1999a) also links sex differences in pain to increases in cortisol via oestro- gen, which induces cytokine release, and an increase in chronic pain conditions with age, due to the over-production of cortisol damaging the hippocampus and setting off a vicious spiral which further reduces the ability of the brain to control cortisol release. Receiving increasing attention in pain research is the focus of the social context of pain and the interaction of this context with individual factors and what these bring to the pain experience. The social context can include relationships, social support, family environment, and previous experience with pain, and individual factors include demographic variables such as age and sex (for an excellent review, see Gatchel et al., 2007). In modern conceptual- izations and application of the biopsychosocial perspective to pain, the focus is shifting to consider these factors not only as integral to the model but as being involved as precursors of the pain experience. In other words, it is not just that psychosocial factors are involved in the feedback from the brain to pain perception, but that they are already in place, ready and waiting, as the individual brings these to the situation before the pain experience hits, thus having a huge influence on the outcome. When considering pain in children, we are consider- ing a neural network under development, the early social context beginning to play out on the experience of pain and the experience of pain shaping future responses. That the social context is so influential in the pain experience means that there is enormous potential for psychosocial intervention to influence the psychobiological experience of pain. Hence, it is essential to consider a life-course perspective when attempting to understand the biopsychosocial model of pain, as well as the effect of stress across the life course. Early trauma may influence the subsequent experience of pain, and the way that a child responds to chronic stress may, in part, determine future pain experience through the early setting or programming of hormonal, neural and behavioural stress response systems which may trig- ger and determine subsequent psychological and physical responses to pain. In other words, the body-self neuromatrix, which is a product of both sensory and psychological activation and determines an individual’s experience of pain, operates in a co-dependent manner with the psychobiological stress response systems of the body. If this sounds familiar, and the theory of allostasis and notion of allostatic load come to mind as useful concepts in explain- ing the parallel ideas and interacting relationships between pain and stress, then you have been paying attention (if not, go back and read Chapter 2 before proceeding). THE PAIN EXPERIENCE IN CHILDREN AND ANALGESIC MANAGEMENT OF PAIN PAIN IN CHILDREN The theories and models outlined above were developed based on pain in adults rather than pain experienced by children. But what is known specifically about the pain experience of 09-Turner-Cobb_CH-09.indd 242 11/15/2013 5:37:05 PM PAIN IN CHILDHOOD 243 children and how do these theories hold up when examining paediatric pain? A number of different versions of the biopsychosocial model of pain have been applied in order to under- stand the experience of acute and chronic pain across the different ages of childhood and into adolescence. A number of different methodologies have been used to assess the experi- ence of pain in children and how children cope with pain. Methods of assessment of pain from illness, injury, or surgery include interviews (e.g., the Pain Experience Interview; McGrath et al., 2000); observation (direct or indirect via video, e.g., Vervoort et al., 2009); and questionnaires and pain-rating charts/visual analogue scales – for example, the Pain Experience Questionnaire (PEQ; Hermann et al., 2008); the Bath Adolescent Pain Ques- tionnaire (BAPQ; Eccleston et al., 2005), the Chronic Pain Acceptance Questionnaire for Adolescents (CPAQ-A; McCracken et al., 2010), and the Fear of Pain Questionnaire for Children (FOPQ-C; Simons et al., 2011) – with children, their parents, and/or medical staff. Various methods of induction of pain in the laboratory have used heat stimulation or cold-pressor tasks to assess responses to pain, tolerance and coping responses in healthy and clinical populations. In the studies referred to throughout this chapter, you will see a range of assessment methods included. Questionnaire assessment is the most frequently used, particularly for older children and adolescents, but, of course, for younger children, particularly preverbal, if assessment is direct rather than via parents and medical staff, then observation and interview are necessary. Excellent reviews of pain assessment and coping in children can be found in Gaffney et al. (2003), Eccleston et al. (2006), Hermann et al. (2007) and Huguet et al. (2010). For a more general discussion of biopsychosocial methodologies in child health research, refer back to Chapter 3. An excellent example that articulates the pain experience of younger children is pro- vided in an innovative qualitative study by Woodgate and Kristjanson (1996), who assessed the experience of acute pain in 11 children aged 2.5–6.5 years, hospitalized for abdomi- nal, chest, plastic or reconstructive surgery. They used a variety of assessment methods, including extensive observation and interview (with children, parents and staff), to under- stand the pain experience in children. Whilst the language the children used to describe their pain reflected differences in age (e.g., older children using terms such as ‘stabbing, jumping in and out’, compared to simpler words such as ‘owie’ in the younger children), they note that there was a commonality to their pain experience, and it was the experi- ence of pain itself which was the overriding factor in shaping their experience of hospi- talization (Woodgate and Kristjanson, 1996). On the basis of these findings, Woodgate and Kristjanson put forward a model of acute pain experience in young children known as ‘Getting better from my hurts’, which identifies influences on their pain experience and the consequences of this experience, as shown in Figure 9.4. Pain described by the chil- dren was categorized as either pain that the children were experiencing at the time or potential pain which had the ‘threat of hurting’ (1996: 238). The pain experience was influenced by aspects of the child themselves, how others take care of them (including parents and nurses), and aspects of the non-social environment termed ‘things out there’ which included both pleasant and unpleasant symbols. Three types of coping strategy were used to deal with the pain experience: (i) ‘hiding away’; (ii) ‘fighting it’; and (iii) ‘making it good’, descriptions and examples of which are given in Figure 9.4. 09-Turner-Cobb_CH-09.indd 243 11/15/2013 5:37:05 PM 244 ACUTE AND CHRONIC ILLNESS DURING CHILDHOOD I am not feeling better I am a little better I can’t take it anymore I am better Who I am How others take care Nurses Parents Good care ‘Getting better’ strategies My hurts Things out there ‘Things out there’ = pleasant or unpleasant symbols in the child’s non-social environment that directly or indirectly influence their pain experience • Examples of pleasant/good symbols: sight of favourite soft toy, feel of comforting blanket • Examples of unpleasant symbols: sight of needles/surgical gloves, sound of removal of surgical drain ‘My hurts’ = Central problem identified by the children Process of getting better involves three conditions: (i) ‘Who I am’ (ii) ‘How others take care’ (iii) ‘Things out there’ ‘Getting better’ Description and examples strategies 1. ‘Hiding away’ Withdrawing and distancing: not answering questions, avoiding eye contact, being quiet 2. ‘Fighting it’ Resistance to or attack on pain: tensing, pull- ing away, hitting, slapping or grabbing pain source, grimacing, crying, being angry 3. ‘Making it good’ Protection and comfort: guarded body move- ments, rubbing, patting, asking for help, dis- traction, fixed or serious facial expressions FIGURE 9.4 ‘Getting better from my hurts’: the young child’s pain experience Source: Woodgate and Kristjanson (1996: 238). These authors emphasize the importance of the ‘subtleness’ (p. 240) of the pain responses observed in young children. The strategies of ‘hiding away’ (p. 238) and ‘mak- ing it good’ (p. 238), observed after a painful treatment, were expressed in quiet or seri- ous behaviours, in contrast to the more noisy and overt pain responses associated with ‘fighting it’ (p. 239) in anticipation of, or during, a procedure. The emotions of ‘fear, anxiety, anger, and sadness’ (p. 240) were all observed as part of the pain experience and 09-Turner-Cobb_CH-09.indd 244 11/15/2013 5:37:05 PM PAIN IN CHILDHOOD 247 in children with life-limiting conditions. They point out that, despite concern and a desire to relieve suffering, an aggressive approach to treating pain is often met with ‘reluctance’ by parents and medical staff. Friedrichsdorf and Kang (2007) summarize the ‘myths and obstacles’ reported in the literature regarding the use of opioids for managing pain in chil- dren as shown in Table 9.1. These myths and obstacles particularly highlight parental fear and practitioner education as important targets for addressing this issue. So we know that the pain experience is a complex interaction between biological and psychosocial factors. We also know that, from a sensory perspective, children are just as capable of feeling pain as adults. I have outlined the importance of managing pain in chil- dren and the significance of treating pain in children on a number of levels. These levels include a minimizing of pain for purposes of reducing suffering in the short term, but also in order to reduce any future impact that the early pain experience may have. In terms of establishing the self-neuromatrix pattern, inadequate treatment of pain in early childhood may increase the experience of pain in later childhood or adolescence and lay the early foundations for chronic pain in adulthood. As Schechter et al. (2003) point out, although chronic and recurrent pain in children does not carry with it the economic burden of work absenteeism that is seen in adult pain conditions, pain and disability in children results in school absenteeism which may lead to social problems and future economic limitations, as well as the likelihood of adult pain, disability and dysfunction. THE PREVALENCE OF PAIN AND DISABILITY IN CHILDREN So how much of a problem are pain and pain-related disability in childhood? The preva- lence of pain in children is difficult to assess, and pain of all types is often under-reported or under-recorded. Van Dijk and colleagues (2006) point to the fact that, whilst chronic pain prevalence is well documented in adults, we know a lot less about the incidence, Parental concerns Health-care practitioner concerns • Fear of giving up • Misconceptions of opioids as ‘too strong for children’ • Fear of side-effects • Worry that their child will become ‘addicted’ to pain medications • Cultural or religious beliefs • Lack of sufficient education regarding managing pain • Misconceptions about frequency and severity of side- effects, such as respiratory depression • Worries that opioids will shorten life expectancy • Concerns that escalating opioid doses will increase the likelihood of tolerance, and thus make pain control more difficult as the disease progresses Source: Friedrichsdorf and Kang (2007). TABLE 9.1 Myths and obstacles associated with reluctance to use opioids for paediatric pain control 09-Turner-Cobb_CH-09.indd 247 11/15/2013 5:37:05 PM 248 ACUTE AND CHRONIC ILLNESS DURING CHILDHOOD prevalence and pain experiences across various types of pain in children (for descriptions of prevalence and incidence, see Chapter 7). A large epidemiological study in The Nether- lands of over 5,000 children aged 0–18 years reported pain in the past 3 months in over half the sample (54 per cent) and chronic or recurrent pain (most commonly limb pain, headache, abdominal pain or back pain) in over 25 per cent of participants (Perquin et al., 2000). As shown in Figure 9.5, prevalence was influenced by age and sex: for both girls and boys, the prevalence of chronic and recurrent pain increased with age; for girls, there was a leap in chronic/recurrent pain between the ages of 12 and 14 years, attributed to the onset of puberty and menstruation; and chronic/recurrent pain was significantly higher overall in girls than in boys (Perquin et al., 2000). 60 50 40 30 20 10 P er ce nt ag e R ep or tin g P ai n 0 0 2 Age (years) 4 6 8 10 12 14 16 18 > 3 months 4 weeks to 3 months < 4 weeks FIGURE 9.5 Age-specific prevalence rates of pain in (a) boys and (b) girls (0–18 years) shown separately. Lines represent pain of different duration. Data were based on one pain report per child Source: Perquin et al. (2000: 55, fig. 1). 60 50 40 30 20 10 P er ce nt ag e R ep or tin g P ai n 0 0 2 Age (years) 4 6 8 10 12 14 16 18 > 3 months 4 weeks to 3 months < 4 weeks (a) (b) 09-Turner-Cobb_CH-09.indd 248 11/15/2013 5:37:06 PM PAIN IN CHILDHOOD 249 Data from another European study, this time using a sample of over 700 German chil- dren who were aged 10–18 years, show a similar increase in pain with age and similar pain locations (Roth-Isigkeit et al., 2004). In this study, pain in the past 3 months was reported by 85.3 per cent of the sample, chronic pain lasting more than 3 months was reported by almost half (45.5 per cent) of the sample, and recurrent pain in one-third of the sample (33.7 per cent). There were no sex differences found for pain duration or fre- quency in this study (Roth-Isigkeit et al., 2004). These pain figures are higher than for the Dutch sample, but bear in mind that the German sample consisted of older children and both found an increase of pain prevalence with age. Similar results have been found for acute pain in a Canadian study of the prevalence of acute, recurrent and chronic pain in a sample of 495 school children aged 9–13 years (van Dijk et al., 2006). These researchers report 96 per cent of children as having experienced acute pain in the past month, 57 per cent reporting recurrent pain and only 6 per cent reporting either currently having or hav- ing previously had a chronic illness. The most frequent acute pain was from headache (reported by 78 per cent of the sample). In addition to this period prevalence, a sex difference was found with significantly higher lifetime prevalence for acute pain (from accident/ injury, stitches and bee stings) in boys compared to girls (van Dijk et al., 2006). Finally, a recent German study looked specifically at children (n = 2,249) who fell into the category of severe impairment from chronic pain due to tension headache, migraine, functional abdominal pain or musculoskeletal pain and often with more than one type of pain (Zernikow et al., 2012). Almost a quarter of the German sample also had a diagnosis of clinical depression and almost one-fifth a diagnosis of clinical anxiety. Sex differences PRECIPITANTS Disease Injury Stress Procedures INTERVENING VARIABLES Biological predispositions Family environment School environment Cognitive appraisal Coping strategies Perceived social support PAIN Perception Behaviour FUNCTIONAL STATUS Activities of daily living School attendance Depressive symptoms Anxious symptoms Behaviour problems Interpersonal relations FIGURE 9.6 A hypothesized multidimensional biobehavioural model of paediatric pain Source: Vetter (2012: 148, fig. 11.1); adapted from Varni et al. (1996); originally published in Varni et al. (1989). Reproduced with the kind permission of Springer Science+Business Media B.V. 09-Turner-Cobb_CH-09.indd 249 11/15/2013 5:37:06 PM 252 ACUTE AND CHRONIC ILLNESS DURING CHILDHOOD sex differences in how adolescents (aged 12–15 years) express pain to their peers and peer attitudes were found to influence the perception of ease of access to, and use of, OTC medications. In using the biopsychosocial model to identify the factors that con- tribute to pain and disability, and hence which factors may be most effective targets for psychosocial interventions to reduce pain in children, McGrath and Hillier (2003) very usefully conceptualize situational (cognitive, behavioural and emotional) factors and child factors as illustrated in Figure 9.7. Taken as a whole, these are the contextual fac- tors that influence the pain experience. COGNITIVE, BEHAVIOURAL AND EMOTIONAL FACTORS IN COPING WITH PAIN In order to explore the vast literature that has developed in support of the biopsychosocial approach to managing pain, I now consider some of these contextual, situational and child factors, using the pain classifications of acute, chronic and recurrent pain given at the beginning of the chapter. EXPERIMENTAL PAIN IN HEALTHY CHILDREN A prequel, if you like, to considering pain states is the application of pain in the experimen- tal setting with healthy individuals. A significant amount of pain research is conducted in this way in adults, although for obvious ethical and moral reasons less so with children. Work that has been done, particularly in the US and Canada, gives a useful baseline under- standing of pain in the otherwise healthy context. For example, Lu and colleagues (2007) used a series of tasks to induce pressure, thermal heat, and cold (using the cold pressor test) in a sample of children and adolescents aged 8–18 years and assessed how they coped with the pain. The cold pressor test is a standard laboratory pain endurance (tolerance) and intensity test which involves participants submerging their forearm in a bucket of icy water for as many seconds or minutes as possible. Based on the pain intensity that the participants were able to endure, Lu et al. (2007) found the coping strategies of positive self-statements and behavioural distraction to be associated with ‘pain resistance’ as lower pain intensity was reported when using these techniques. Strategies of seeking emotional support and internalizing/catastrophizing were labelled as ‘pain-prone’ since the use of these was associ- ated with a lower pain tolerance and greater reporting of pain intensity (Lu et al., 2007). In a similar study using just the cold pressor test, in a slightly younger sample of 7–14-year- olds, Piira and colleagues (2006) used visual images described in word form as attentional strategies. These strategies composed either external distraction (e.g., scene of playing ball in a park) or internal sensory-focusing (e.g., relating to water temperature or feeling cold). The control group received no visual images at all. Whilst pain tolerance was greatest for both intervention groups compared to the control group, an age difference emerged in 09-Turner-Cobb_CH-09.indd 252 11/15/2013 5:37:07 PM PAIN IN CHILDHOOD 253 which the youngest children (7–9 years) performed best in the external distraction condi- tion, whereas the older children (10–14 years) performed just as well using either interven- tion (Piira et al., 2006). This demonstrates the importance of age in selecting the most effective type of distraction intervention. ACUTE PAIN IN CHILDREN Research examining acute pain in children has focused on three main areas: (i) routine medical vaccinations, injury and unplanned procedures, including emergency depart- ment admissions; (ii) dental anxiety and orthodontic pain; and (iii) the largest of these areas, postoperative pain. The use of secondary control coping has been found to be particularly beneficial in this context, with children using these coping strategies report- ing less pain compared to those who used primary control coping strategies or relin- quished control coping (Langer et al., 2005). An interesting study by Crandall and colleagues (2007) of adolescents aged 11–17 years, who had received an acute blunt traumatic injury (associated in the majority with injury following accidents), describes the ‘struggle for internal control’ that these adolescents experienced in dealing with their pain, reported in interview 1–11 days after the accident. Internal control is defined by the authors as ‘behavioural and cognitive actions used to control and endure their pain’ (2007: 229) and characterized by a passive, inward focus (e.g., staying still, not crying or screaming) which contrasts with ‘loss of control’ (p. 229) in which their distress was out- ward and overt (e.g., distress, resisting medical intervention, crying, screaming). They found that adolescents used internal control in order to ‘maintain independence and self- control over their pain’ (p. 233) and point out that the use of such behaviours is consist- ent with the autonomy of adolescence, but may mask the pain being experienced by these patients. They also point to the vital importance of the presence of both family and peers for support in managing their pain. Crandall et al.’s (2007) conceptual model of internal control is shown in Figure 9.8. Studies of acute pain from dental and orthodontic treatment have also reported the common use of cognitive coping strategies, both internal coping strategies (e.g., ‘I tell myself it will be over soon’) and external coping strategies (e.g., ‘I like it when the nurse holds my hand’), with internal strategies being the most frequently used in pre-adolescent children (Versloot et al., 2004; Van Meurs et al., 2005). It is the younger adolescent children (11–13 years) compared to older adolescents (age 14–17 years) who appear to experience more pain during orthodontic treatment (Brown and Moerenhout, 1991). In postopera- tive pain, Crandall and colleagues (2009) point to the importance of ameliorating anxiety preoperatively to reduce pain after surgery. They report evidence of significant relation- ships between prior anxiety and postoperative pain in their sample of children aged 7–13 years undergoing tonsillectomy. Amongst other factors, they stress the importance of pre- vious surgical experience as an influencing factor in postoperative pain. In adolescents, evidence for links between preoperative expectations of pain and anxiety and postopera- tive pain experienced has also been found (Logan and Rose, 2005). 09-Turner-Cobb_CH-09.indd 253 11/15/2013 5:37:07 PM M ov em en t C om m un ic at io n N ov el o r un ex pe ct ed hi gh ly in te ns e pa in A ct ua l o r po te nt ia l l os se s C lin ic ia ns : N on su pp or tiv e U na va ila bl e In ad eq ua te k no w le dg e E xp er ie nc e w ith p ai n D ec re as in g pa in in te ns ity R ec ov er y of s el f a nd ot he rs C lin ic ia ns : S up po rt iv e K no w le dg ea bl e T ho ug ht s to pp in g D is tr ac tio n P os iti ve th in ki ng S le ep S ta yi ng c al m P ai n pe rc ep tio ns P hy si ca l l os se s C lin ic ia ns ’ a ct io ns In te rn al c o n tr o l B eh av io u ra l ac ti o n s C o g n it iv e ac ti o n s L o ss o f se lf -c o n tr o l S el f- co n tr o l Th re at s P ro m o te FI G U R E 9. 8 C on ce pt ua l m od el o f ‘ in te rn al c on tro l’ of p ai n ex pe rie nc es in a do le sc en ts fo llo w in g ac ut e bl un t t ra um at ic in ju ry So ur ce : C ra nd al l e t a l. (2 00 7) . 09-Turner-Cobb_CH-09.indd 254 11/15/2013 5:37:07 PM PAIN IN CHILDHOOD 257 children with chronic abdominal, headache, neuropathic or musculoskeletal pain who had higher levels of anxiety sensitivity (fear of anxiety-related sensations such as increased heart rate) were also more afraid of pain and, consequently, this linked to a higher level of pain disability. Both age and sex differences in coping responses in chronic pain appear to emerge in children, with 8–12-year-olds showing differences in preference for the use of social sup- port (girls’ preference) over behavioural distraction (boys’ preference), and adolescents (aged 13–18 years) showing greater use of positive self-talk than children (Lynch et al., 2007). Sex differences have also been found in how adolescents remember their experi- ence of pain. An innovative study by Hechler et al. (2009) asked adolescents (aged 12–18 years) to report not just their current level of pain during an interview, but also to recall their memory of pain intensity in the previous time periods of 24 hours, 7 days, and 4 weeks. Adolescent girls were found to report higher pain intensity than boys within the time frame of 7 days and also 4 weeks, despite having similar medical diagnoses and being similar on other diagnostic criteria. The authors suggest that this may be due to expecta- tions in gender role and point to the importance of pain memory in designing intervention programmes as remembered pain may influence future pain (Hechler et al., 2009). RECURRENT PAIN The most common form of recurrent pain in children is that of abdominal pain with preva- lence as high as 25 per cent in 9–12-year-olds (see Dufton et al., 2011), representing a sig- nificant childhood problem with the potential for setting patterns of chronic pain in later life. These children have high rates of functional disability and a significantly reduced social life (Dufton et al., 2011), putting them at a disadvantage in the transition to adolescence. Using an experimental paradigm which combined elements of stress testing and the cold pressor task for pain tolerance and intensity, Dufton et al. (2011) compared the performance of chil- dren with recurrent abdominal pain or clinical anxiety and healthy control children without pain. They report greater reactivity as measured by increases in heart rate to the stress and pain testing in the sample with abdominal pain or anxiety (Dufton et al., 2011). In relation to coping, secondary control coping (in the form of acceptance, distraction, or positive think- ing) has also been shown to reduce pain more effectively than involuntary actions or disen- gagement coping (such as avoidance in the form of escape or denial in the form of inaction) in children with recurrent abdominal pain (Thomsen et al., 2002) and this benefit of second- ary control coping was also confirmed in the Dufton et al. (2011) study. THE ROLE OF PARENTS IN THE PAIN EXPERIENCE The dual effect between pain experience in a child and the impact on the parent(s) is important both for the health of the parent and for the reciprocal impact that the paren- tal response has on the child’s pain experience and level of disability. I have already hinted at this in considering various types of pain conditions above, but there is a surpris- ingly small amount of literature reported in this area, particularly for the parental effect 09-Turner-Cobb_CH-09.indd 257 11/15/2013 5:37:07 PM 258 ACUTE AND CHRONIC ILLNESS DURING CHILDHOOD on the child, compared to other aspects of the biopsychosocial pain experience and also compared to the amount of research on the parental effects and influence in chronic conditions more generally. Yet there is an emerging interest in this area. For an excellent brief review, see Palermo and Eccleston (2009) who highlight the importance of consid- ering the parent in child and adolescent chronic pain. The way in which these intercon- nected relationships between parent and adolescent functioning operate is generating increasing interest. One model proposed by Vowles and colleagues (2010) includes both adolescent and caregiver psychosocial responses and pain management behaviours of the caregiver in relation to adolescent pain functioning, and on catastrophizing responses in both the adolescent and their parents. The important influence of parental catastrophizing about their child’s pain experi- ence has also been demonstrated in healthy children and adolescents in a laboratory setting (Caes et al., 2011). Both maternal and paternal catastrophizing have been found to influence how the parent interacts with the child and also the level of pain reported, although sex differences between parents have also been noted. In particular, mothers appear to exhibit a greater degree of catastrophizing compared to fathers, and this dif- ference was reflected in greater rumination rather than any differences in the compo- nents of magnification (exaggeration of the pain experience) and helplessness (Hechler et al., 2011). THE ROLE OF EARLY LIFE PAIN EXPERIENCE ON SUBSEQUENT PAIN Some of the most striking research to emerge in the area of pain in children, certainly for the lifespan perspective taken in this book, is that of the effect of early exposure to painful stimuli on subsequent pain experiences. To use the word ‘striking’ is perhaps an underes- timation of the interest and excitement that this research topic ignites: this is a flag-waving, stand-on-your-chair level of interest; this really is important work, as not only does it relate to pain but it links to other key areas of interest in child health psychology, such as early life stress and adaptation. Whilst significant research has previously examined this phenomenon in animals, the application to human pain research is only just emerging. Recent work includes children who experienced pain early in life, either as hospitalized newborns (Hermann et al., 2006) or from burn injuries incurred between 6 and 24 months of age (Wollgarten-Hadamek et al., 2009). In these two studies, children were followed up at ages 9–14 years and 9–16 years respectively, and participated in standard experimental laboratory pain tasks, including thermal and mechanical stimulation techniques (Hermann et al., 2006; Wollgarten-Hadamek, et al., 2009). In both studies, these school-age children, several years after the experience of early pain, showed elevated heat-pain thresholds and greater perceptual sensitization to ther- mal stimulation compared to controls. Hermann et al. (2006) report this as evidence of 09-Turner-Cobb_CH-09.indd 258 11/15/2013 5:37:07 PM PAIN IN CHILDHOOD 259 ‘altered responsivity’ to pain stimulation, with enhanced sensitization involving central pain pathways and elevation of pain thresholds associated with activation of the limbic system in pain feedback pathways. They theorize that this increased threshold ‘masks’ underlying sensitivity until sufficient pain input occurs, which explains why the children showed a higher pain threshold under low levels of stimulation, but when this became more intense the enhanced sensitization became evident (Hermann et al., 2006). A later study by Hermann’s group examined the psychosocial context of this increased thresh- old/sensitivity in the 9–14-year-old children with neonatal intensive care unit (NICU) experience and found more catastrophizing in this group compared to controls. The mothers of the NICU children with more severe experiences exhibited more solicitous caretaking behaviour (i.e., showing special care and interest) in relation to their child’s pain (Hohmeister et al., 2009). The mere presence of the mother was linked to an increase in heat-pain threshold in the child and less habituation to tonic heat. The authors highlight the dyadic result of neonatal pain experience on child cognition and the reinforcing effect of maternal behaviour. This simultaneous sensitization and inhibition is reminis- cent of the PTSD models of stress associated with the third type of allostatic load discussed in Chapter 5. PSYCHOSOCIAL INTERVENTIONS IN ACUTE AND CHRONIC PAIN To summarize the evidence presented so far in this chapter, we know from at least as early as Melzack and Wall’s (1965) proposed ‘gate control theory’ that psychosocial factors can influence an individual’s experience of pain. This is just as true in children, for whom the situational context of the family and school has a key role within the biopsychosocial model. From pain in neonates through to adolescents, situational cognitive, behavioural and emotional factors, as well as child factors including demographics of age, sex, and previous pain experience, all make up the context of pain, which together with the sen- sory input determine the pain experience. The group of coping responses that outperform all other coping responses are those of secondary control coping, and the type of coping associated with the most harmful or pain-perpetuating scenarios is that of catastrophizing, whether in the child or parent. Child factors relating to developmental stage of understanding and characteristic differ- ences across age groups in dealing with pain, in particular the characteristic features of autonomy and control in adolescence, all have a major influence on the pain experience. Consequently, these biopsychosocial factors offer the potential for psychosocial interven- tion in the management of pain, alongside pharmacological treatment. We complete this chapter with a brief coverage of psychosocial interventions. Psychosocial interventions to relieve pain, or alter the pain experience in children, have focused on acute pain (associated with medical procedures, vaccination and treatment in 09-Turner-Cobb_CH-09.indd 259 11/15/2013 5:37:07 PM A g e P ai n b eh av io ur s C o g ni tiv e- b eh av io ur al a p p ro ac h es C o m p le m en ta ry t h er ap ie s In fa nt s A vo id in g ey e co nt ac t G rim ac in g D iff ic ul ty s uc ki ng H ig h- pi tc he d cr yi ng Q ui ve rin g ch in D iff ic ul ty c al m in g W an tin g to b e st ill H ic cu pp in g C ha ng es in b re at hi ng p at te rn U se p ac ifi er (‘ du m m y’ ) S w ad dl in g To uc h D is tra ct io n M us ic M as sa ge S uc ro se s ol ut io n A ro m at he ra py To dd le rs D iff ic ul ty s le ep in g Lo ss o f i nt er es t i n pl ay In cr ea se in c ry in g, ir rit ab ili ty o r r es tle ss ne ss R ed uc tio n in e at in g or d rin ki ng S to ry -te lli ng B lo w in g bu bb le s To ys D is tra ct io n A rt an d m us ic th er ap y M as sa ge W ar m /c oo l c om pr es s A ro m at he ra py P re sc ho ol D iff ic ul ty s le ep in g Lo ss o f i nt er es t i n pl ay Q ui et o r c ur le d N ee d to b e he ld S ay s so m et hi ng h ur ts R ed uc tio n in e at in g or d rin ki ng D is tra ct io n (c ar to on s) O ffe r f av ou rit e to y/ ob je ct to h ol d A rt an d m us ic th er ap y M as sa ge R ei ki E m ot iv e im ag er y W ar m /c oo l c om pr es s A ro m at he ra py S ch oo l-a ge D iff ic ul ty s le ep in g M oa ni ng /c ry in g H ol di ng o r p ro te ct in g ar ea o f d is co m fo rt Lo ss o f i nt er es t i n pl ay D ec re as e in a ct iv ity le ve l C om pl ai ni ng o f p ai n R ed uc tio n in e at in g or d rin ki ng C re at e a sa fe e nv iro nm en t D im li gh ts , d ec re as e no is e, c al m m an ne r Po w er o f s ug ge st io n C ou nt in g A rt an d m us ic th er ap y B re at hi ng te ch ni qu es Vi su al iz at io n/ gu id ed im ag er y M as sa ge R ei ki P ro gr es si ve m us cl e re la xa tio n W ar m /c oo l c om pr es s H yp no si s (> 1 0 yr s) A cu pu nc tu re (> 10 y rs ) A ro m at he ra py Yo ga /m ed ita tio n/ re fle xo lo gy A do le sc en t In cr ea si ng ly q ui et Lo ss o f i nt er es t i n fri en ds a nd fa m ily D ec re as e in a ct iv ity le ve l In cr ea se in a ng er o r i rr ita bi lit y C ha ng es in e at in g ha bi ts C re at e a sa fe e nv iro nm en t D im li gh ts , d ec re as e no is e, c al m m an ne r D is tra ct io n TV , v id eo g am e, re ad a b oo k, m us ic A rt an d m us ic th er ap y B re at hi ng te ch ni qu es Vi su al iz at io n/ gu id ed im ag er y M as sa ge R ei ki W ar m /c oo l c om pr es s H yp no si s A cu pu nc tu re A ro m at he ra py Yo ga /m ed ita tio n/ re fle xo lo gy TA B LE 9 .2 N on -p ha rm ac ol og ic al a pp ro ac he s to p ae di at ric p ai n m an ag em en t So ur ce : A da pt ed fr om F rie dr ic hs do rf an d K an g (2 00 7) . 09-Turner-Cobb_CH-09.indd 262 11/15/2013 5:37:07 PM PAIN IN CHILDHOOD 263 CHAPTER SUMMARY In this chapter, we have examined the theories of pain experience, how children of dif- ferent ages cope with pain, and the importance of the social context and role of the fam- ily in coping with pain. The experience of pain in neonates through to adolescents has emphasized the need for treating pain through a combination of pharmacological and psychosocial intervention. A range of acute, chronic, and recurrent pain experiences has been addressed, including surgical or postoperative pain, dental/orthodontic pain, pain following acute accidents, and pain associated with chronic illness, highlighting juvenile chronic arthritis and sickle cell disease. Changes in coping responses over time, with age and experience, have been addressed, and the response of catastrophizing has been con- trasted with the more adaptive strategy of secondary control coping. I have also high- lighted sex differences in pain and the impact of pain responses on level of disability. This chapter links particularly well with the previous three chapters on acute and chronic illness and palliative care. As with these previous topics, the topic of pain experience and intervention underscores the life-course theme which runs throughout this book. Not only is the treatment of pain important for the child and their family during the pain experience, whether acute or chronic in nature, but how pain is dealt with in childhood has implications for lifelong psychophysiological responses to painful stimuli. This is another beautiful exam- ple not only of the biopsychosocial model in action, but also of its implications for the life- course trajectory in health and illness. In Chapter 10, I move on to consider the experience of illness not in the child themselves, but their experience of illness in a parent. KEY CONCEPTS AND ISSUES • Pain prevalence and intensity • Acute, chronic, and recurrent pain • The context of pain • Catastrophizing versus secondary control coping • Gate control theory, the body-self neuromatrix, and the neurosignature • Pain stress • The social context of pain • Pain assessment • Cold pressor test • The under-treatment of pain in children • Disability • Pain resistance • Internal control • Anxiety sensitivity • Role of parents, family, and school • Cognitive behavioural therapy techniques and interventions in pain 09-Turner-Cobb_CH-09.indd 263 11/15/2013 5:37:07 PM 264 ACUTE AND CHRONIC ILLNESS DURING CHILDHOOD USEFUL WEBSITES The British Pain Society: www.britishpainsociety.org The International Association for the Study of Pain: www.iasp-pain.org FURTHER READING For a very readable version of the original ‘gate control theory’ of pain and associated concepts (first published in 1982, following the advent of Melzack and Wall’s (1965) revolutionary theory): Melzack, R. and Wall, P.D. (2008) The Challenge of Pain (updated 2nd edn). London: Penguin Books. One of the original papers on the neuro- matrix: Melzack, R. (1999) Pain: an overview. Acta Anaesthe- siologica Scandinavica, 43(9): 880–4. For one of the clearest accounts of the ‘gate control theory’ of pain with a modern-day clinical application, see: Morrison, V. and Bennett, P. (2012) An Introduction to Health Psychology, 3rd edn. Harlow, Essex: Pearson Education. One of the absolute best texts on child pain, including separate chapters on specific pain problems (sickle cell disease, cancer pain, headaches in children and adolescents, and pain and stress in the NICU), this is a must read, although be aware that the cost of the hardcover version would empty most stu- dent loan budgets (electronic library copies are available): Schechter, N.L., Berde, C.B. and Yaster, M. (eds) (2003) Pain in Infants, Children and Adolescents. Philadelphia: Lippincott Williams & Wilkins. An excellent text for everything you could want to know about pain, including in- depth coverage of pain pathways, mecha- nisms and processes with a lifespan per- spective: Holdcroft, A. and Jaggar, S. (eds) (2005) Core Topics in Pain. Cambridge: Cambridge University Press. Practical, usable clinical guidelines from the British Psychological Society for age- relevant psychosocial interventions during acute medical procedures in children and adolescents: Gaskell, S. (2010) Evidence-based guidelines for the management of invasive and/or distressing proce- dures with children. Position paper. Leicester: British Psychological Society (BPS). 09-Turner-Cobb_CH-09.indd 264 11/15/2013 5:37:07 PM