Journal of Pediatric Psychology, Vol. 27, No. 3, 2002, pp. 245-257
© 2002 Society of Pediatric Psychology
Interactive Effects of Internalizing and Externalizing Problem Behaviors on Recurrent Pain in Children
1 University of Jyväskylä, Finland, 2 Psychiatric Clinic of Kankaanpää, Hospital District of Satakunta, Finland, 3 Harvard Medical School, 4 University of Helsinki and University of Oulu, Finland, 5 Indiana University
All correspondence should be sent to Inka Vaalamo, Ämmätsäntie 18, 36840 Pohja, Finland. E-mail: ievaalam{at}hotmail.com .
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Abstract |
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Objective: To examine, in children, relationships between self-reported recurrent pain and emotion regulation indicated by rated internalizing and externalizing problem behaviors and adjustment.
Method: Finnish 11-12-year-old schoolchildren (N = 414) completed a questionnaire measuring recurrent pain. Emotion regulation was assessed by a Multidimensional Peer Nomination Inventory, Teacher Rating Form. Relationships between recurrent pain and emotion regulation were examined in logistic regression analyses, after controlling for past injuries and chronic illnesses.
Results: Independent of injuries and chronic illnesses, externalizing and internalizing problem behaviors related to recurrent pain, and more so together than separately. Gender differences were found; constructive behavior associated with recurrent pain only in girls.
Conclusions: Low self-control of emotions, indicated by internalizing and externalizing problem behaviors, was related to pain in both boys and girls; high self-control of emotions, indicated by constructive behavior, associated with pain only in girls.
Key words: recurrent pain; emotion regulation; externalizing problem behavior; internalizing problem behavior.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Recurrent pain, repeated episodes of reported pain in the absence of identifiable etiology, is common among children and adolescents. Studies indicate that 12%-24% of school-age children report frequent headache (Beiter, Ingersoll, Ganser, & Orr, 1991
; King, Wold, Tudor-Smith,
& Harel, 1996; Kolip,
1997; Tamminen et al.,
1991), 9%-19% report abdominal pain
(Alfvén, 1993;
Apley, 1975;
Beiter et al., 1991;
Ingersoll, Grizzle, Beiter, & Orr,
1993; Kolip, 1997;
Tamminen et al., 1991), 13%
report chest pain (Alfvén,
1993), and 32% report musculoskeletal pain
(Mikkelsson, Salminen, & Kautiainen,
1997a). Pain has been shown to seriously impair the daily
functioning of children (Langeveld, Koot,
& Passchier, 1999;
Martin-Herz, Smith, & McMahon,
1999). Children with recurrent pain have more school absence and
interference with social activities than children without pain
(Martin-Herz et al.,
1999).
Evidence links emotion regulation to the function of the autonomic nervous
system (Cole, Fox, Zahn-Waxler, Usher,
& Welsh, 1996; Gross,
1998; Gross & Levenson,
1993) and to many somatic disorders
(Ewart & Kolodner, 1994;
Gross & Levenson, 1997;
Keltikangas-Järvinen,
Räikkönen, Ravaja, Näätänen, & Ryynänen,
1995; Pennebaker,
1991). Emotional expression and suppression are hypothesized to
play a role in the existence of pain
(Burns, Johnson, Mahoney, Devine, &
Pawl, 1995; Gamsa &
Vikis-Freibergs, 1991; Gross
& John, 1995; King &
Emmons, 1991; Traue,
1995).
Pulkkinen (1995) posits a
model of emotional and behavioral regulation to explain recurrent pain in
childhood (Figure 1). The model
has been useful in explaining emotion regulation of people having physical
symptoms (Kokkonen, Pulkkinen, &
Kinnunen, 2001). It has been tested for over 30 years
(Pitkänen, 1969;
Pulkkinen, 1995;
Pulkkinen, Kaprio, & Rose,
1999) and has shown predictive value over 20 years
(Kokko & Pulkkinen, 2000;
Laursen, Pulkkinen, & Adams,
2000;
Hämäläinen & Pulkkinen,
1996; Pulkkinen,
1996; Pulkkinen &
Pitkänen, 1994;
Rönkä, Kinnunen, &
Pulkkinen, 2000;
Rönkä & Pulkkinen,
1995). Emotion regulation refers to the redirection, control, and
modification of emotional arousal to enable an individual to function
adaptively in emotionally arousing situations
(Cicchetti, Ganiban, & Barnett,
1991). Emotion regulation helps maintain internal arousal within a
manageable, performance-optimizing range. The model of emotional and
behavioral regulation posits two orthogonal dimensions: expression versus
inhibition of behavior, and low versus high self-control of emotions
(Pulkkinen, 1995). These
dimensions result from inhibitory and enhancing processes in the regulation of
emotion and behavior: neutralization versus intensification of emotions and
suppression versus activation of behavior. In the neutralization of emotion,
an individual focuses attention on the aspects of the situation that help to
regulate emotional arousal and its interpretation
(Pulkkinen, 1995). Although
emotion regulation often occurs once an emotion is elicited, an individual can
also regulate his or her emotion by choosing situations for optimal emotional
responding (Gross, 1999a).
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In the intensification of emotion, an individual's attention in a situation
is on cues that intensify emotion. Intensification of emotion is facilitated
by temperamental low reactivity, parental socialization, transitory state, and
anticipation of emotional confrontation
(Pulkkinen, 1995). In
behavioral suppression, an emotional state, such as anxiety, is bound to
situational cues but behavior for changing the situation is suppressed. The
activation of behavior is seen in the lower threshold and latency and in the
higher intensity of reaction. Combinations of these inhibitory and enhancing
processes define four behavioral prototypes (A to D): (1) externalizing
problem behavior, characterized by intense emotions and active behavior (Type
A); (2) internalizing problem behavior, characterized by intense emotions and
suppressed behavior (Type D), which is often referred to as emotional
suppression in the literature; (3) constructive behavior, characterized by
neutralized emotions and active behavior (Type B); and (4) compliant behavior,
characterized by neutralized emotions and suppressed behavior (Type C).
According to the model, internalizing and externalizing problem behaviors
depict low self-control of emotions, and constructive and compliant behaviors
depict high self-control of emotions. This interpretation has been confirmed
by several studies. For example, the self-control rating scale
(Kendall & Wilcox, 1979)
correlates highly positively with teacher-rated constructive and compliant
behaviors and highly negatively with hyperactivity-impulsivity, aggression,
and anxiety (Lehto, Pulkkinen, &
Juujärvi, 2000). Another study demonstrates continuity in low
self-control of emotion from childhood to adulthood
(Kokkonen & Pulkkinen,
1999). Low self-control of emotions in childhood was also related
to long-term unemployment in adulthood
(Kokko, Pulkkinen, & Puustinen,
2000) and to the lowered use of cognitive emotion-regulation
strategies in adulthood (Kokkonen &
Pulkkinen, 1999). Main components of low self-control of emotions
are inattentiveness and moodiness
(Calkins, 1994; Gross,
1998,
1999b;
Eisenberg, Fabes, Guthrie, & Reiser,
2000; Pope & Bierman,
1999; Pulkkinen, Kooistra,
Tolvanen, & Mäkiaho, 2001;
Rothbart & Putnam, in
press). Low self-control of emotions in childhood has also been
linked to self-reported physical symptoms, such as gastrointestinal problems,
in adulthood (Kokkonen et al.,
2001).
Emotional suppression, meaning inhibition of ongoing emotion-expressive
behavior (Gross, 1998;
Gross & Levenson, 1993),
has been assumed to characterize the emotion regulation of those with
recurrent pain (Alexander,
1950; Engel, 1959;
Passchier, Goudswaard, Orlebek, & Verhage, 1988;
Traue, 1995). There is
evidence that recurrent pain relates to anxiety and depression
(Ingersoll et al., 1993;
Kristjánsdõttir,
1997; Martin-Herz et al.,
1999; Mikkelsson, Sourander,
Piha, & Salminen, 1997b), which, according to Pulkkinen's
(1995) model of emotion and
behavioral regulation, indicates emotional intensification and behavioral
suppression (Type D). In addition, some experimental studies have shown that
those with recurrent pain are more likely to suppress emotional expression in
stressful situations than those without pain
(Traue, 1995;
Traue, Gottwald, Henderson, & Bakal,
1985).
However, not all studies support the notion that people with recurrent pain
would be more prone to suppress their emotions than those without pain. In
fact, some studies indicate that recurrent pain is related to emotion
expression rather than suppression (Gamsa
& Vikis-Freibergs, 1991;
Gross & John, 1995), and
research with children and adolescents has shown that recurrent pain is
associated with externalizing problem behaviors, such as aggression and
inattention (Mikkelsson et al.,
1997b). Other studies have not found this relation between pain
and externalizing problem behavior
(Cooper, Bawden, Camfield, & Camfield,
1987; McGrath, Goodman,
Firestone, Shipman, & Peters, 1983;
Walker, Garber, & Greene,
1993; Walker & Greene,
1989; Wasserman, Whitington,
& Riviara, 1988). These studies, however, were restricted to
abdominal pain or headache. Further, these samples were clinically selected
and may not be representative. Therefore, the central feature of emotion
regulation in children with pain may not be the suppression of emotions, but
rather intensified emotions or low self-control of emotions, reflected in both
internalizing and externalizing problem behaviors.
According to Malatesta and Culver
(1993), the relationship
between emotion regulation and physical symptoms depends on gender (see also
Burns et al., 1995). Ignoring
the effect of gender when examining the relationship between emotion
regulation and pain may be one factor explaining the contradictory results.
The studies that have noticed the effect of gender show that boys with
recurrent pain have more problems with emotion regulation and especially
externalizing problem behavior (Andrasik et
al., 1988; Beiter et al.,
1991; Garrick, Ostrov, &
Offer, 1988; Tamminen et al.,
1991). However, not all the studies have found differences between
boys and girls (Ingersoll et al.,
1993; Mikkelsson et al.,
1997b).
Conflicting findings concerning the association of recurrent pain with
internalizing and externalizing problem behaviors make conclusions difficult
to draw. Some of the limitations of previous research include
nonrepresentative clinical populations, heterogeneous samples, common variance
due to measuring both emotion regulation and pain with the same method, and
failure to control identifiable etiologies for recurrent pain. In addition,
there are a great number of studies examining internalizing and externalizing
problem behaviors separately in relation to pain, not allowing the study of
their common effects on the likelihood for pain compared to the effects of
each of them separately. These two problem behaviors have been shown to be
highly related (Knox, King, Hanna, Logan,
& Ghaziuddin, 2000;
Zoccolillo, 1993). According
to Pulkkinen's (1995) model of
emotional and behavioral regulation, low self-control of emotion underlies
both problems. To improve on previous studies, we have taken the following
steps: (1) studied the interacting effects of internalizing and externalizing
problem behaviors; (2) used a theoretical framework to tie the different
results together; (3) used a representative, nonclinical population; (4) taken
heterogencity of the sample into account by examining gender differences; (5)
measured emotion regulation and pain by different methods; (6) taken different
kinds of pain reports into account; and (7) controlled for chronic illnesses
and injuries in order to avoid taking into account pain with known physical
etiology.
The purpose of this study was to examine the relationship between recurrent
pain and emotion regulation. We hypothesized that low self-control of
emotions, indicated by both internalizing and externalizing problem behaviors
(Pulkkinen, 1995) would be
related to recurrent pain (Beiter et al.,
1991; Ingersoll et al.,
1993; Mikkelsson et al.,
1997b). Furthermore, we hypothesized that the relationship between
recurrent pain and externalizing problem behavior would be stronger for boys
than for girls (Andrasik et al.,
1988; Beiter et al.,
1991; Garrick et al.,
1988; Tamminen et al.,
1991).
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Method |
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Participants
The data reported here were collected from an ongoing longitudinal study of behavioral development and health habits, FinnTwin12, which will ascertain and study
2,800 twin pairs from five consecutive and complete birth cohorts
of Finnish twin children. Data for this analysis were collected through
self-report questionnaires administered at baseline to a cohort born in 1984
and then tested in 1996, at ages 11-12. Twins were identified from the
nation's Central Population Registry as part of Finnish Twin Cohort studies
(Kaprio, Koskenvuo, & Rose,
1990); 87% of the twin families contacted were willing to
participate in the study and provided a written, informed consent to
participate in the questionnaire study. Permission to contact the school
attended by the twin children, to carry out teacher ratings, was obtained from
92.7% of these families. Given the population-based assessment and very high
response rates, our sample is representative of Finnish children of this
age. Although the study population consists of twins, this analysis ignores their twin status and considers them as individuals drawn from the population. To avoid statistical issues arising from having two individuals from each family in the data set, the study sample was formed by randomly selecting one co-twin from each twin pair. The sample consisted of 414 children, 196 girls and 218 boys. Age of the children ranged from 10.9 to 12.2 years with a mean of 11.4 years (SD =.29). On average boys (M = 11.46, SD =.28) were slightly older than girls (M = 11.36, SD =.29, t[411] = 3.38, p =.001).
Measures
Emotion Regulation. A multidimensional inventory of children's
social behavior was developed for peer nomination (MPNI; the Multidimensional
Peer Nomination Inventory; see Pulkkinen,
1982; Pulkkinen et al.,
1999) within the framework of the model of emotional and
behavioral regulation. It was designed to assess the behavioral prototypes of
the model. A 37-item Teacher Rating Form (TR-MPNI), used in this study, was
developed from the MPNI (Pulkkinen et al.,
1999).
The TR-MPNI items were presented in the form of statements (e.g.,
"Cannot concentrate in anything"). The teachers were asked to rate
each twin on every item on a four-point scale where 0 = does not apply; 1 =
applies sometimes, but not consistently; 2 = certainly applies, but not in a
pronounced way; 3 = applies in a pronounced way. A factor analysis (principal
axis method and varimax rotation) of the structure of the TR-MPNI resulted in
three main factors called behavioral problems (here: externalizing problem
behavior), adjustment, and emotional problems (here: internalizing problem
behavior), as in the previous analysis by Pulkkinen et al.
(1999). The original names of
the factors refer to the framework model; the names used here are synonymous
constructs commonly used in literature. Subscales of these factors and their
coefficients alphas for girls and boys, respectively, were as follows:
Hyperactivity-Impulsivity,.91 and.95; Aggression,.84 and.91; Inattention,.80
and.85; Constructive behavior,.81 and.87; Compliant Behavior,.38 and.74;
Social Activity,.64 and.67; Depression,.73 and.75; and Social Anxiety,.75
and.69. The TR-MPNI has been shown to be reliable and has both concurrent and
discriminative validity (Pulkkinen et al.,
1999).
In the Finnish public school system, children under age 13 attend primary schools, where all classes have a classroom teacher; the classroom teacher instructs the children in most school subjects and knows the children well, usually teaching the same children for about 3 years. In some schools, children have the same classroom teacher from the beginning of primary school (at age 7) until its end (at age 13). For this study, the mean size of the classes was 25 children (SD = 7.20); the mean school size was 247 children (SD = 175).
Recurrent Pain. Items measuring recurrent pain were based on a
World Health Organization (WHO) survey on schoolchildren's health and
health-related behaviors (King et al.,
1996) and a structured pain questionnaire
(Mikkelsson, 1998; Mikkelsson
et al.,
1997a,b).
The items classify pain symptoms during the previous 3 months by body area and
frequency. The following body areas were distinguished: neck and shoulders;
low back; lower extremities; upper extremities; chest, upper back, and
buttocks; headache and abdominal pain were included also. The concerned body
area was identified in a schematic to help children distinguish each named
area. A 5-level frequency classification (almost daily, more than once a week,
once a week, once a month, seldom, or never) was used in the pain
questionnaire (Mikkelsson,
1998). A dichotomized variable was formed to reflect whether each
child did or did not report weekly pain, and test-retest reliability of this
dichotomized variable is satisfactory, over a brief time-interval, (
=
0.9) (Mikkelsson 1997a). The
concurrent validity of the questionnaire, against interview, has been studied
with an observed agreement of 86%, ( = 0.67.)
Pain Due to Injury. If the children had experienced pain due to injury, they were asked to mark the area of the injury on the pain schematic with a different color.
Long-Term Illnesses. Parents were asked if their children ever had asthma, history of febrile or other seizures (with lapses of consciousness or convulsions), or whether they have had other chronic diseases. The parents were asked also if their children took any medication for chronic disease. From these parental reports, a variable was formed to classify children into those who ever had long-term illness and those who used medications for chronic disease. A history of seizures and other chronic diseases was not included in this variable, because these diseases did not correlate with recurrent pain.
Data Analyses
Analyses were conducted in SPSS, with p value <.05 considered
statistically significant. Chi-square was used to study the differences in
pain reports among girls and boys. Mann Whitney U test was used to
study differences in frequencies of emotion regulation in girls and boys.
Spearman rank correlations were computed to examine interrelationships between
pain variables.
We analyzed the hypothesis relating recurrent pain to low self-control of emotions by multivariate logistic regression analysis. Odds ratios (ORs) with 95% confidence intervals (95% Cls) were used to measure risk for increases in recurrent pain as the variable increased one standard deviation. Continuous variables (emotion regulation) were standardized before analysis. Pain due to injuries and longterm illnesses were accounted for, by entering them first in the model. We put the interaction effects of emotion regulation variables in the models after their main effects. In detailed analyses of interaction effects, one variable was divided into three categories, and logistic regression analyses were then performed on the other unclassified variable across each of the three categories; approximately a third of the participants were included in each category, so that the first category included those with lowest scores on the variable in question; the second included those with intermediate scores, and those with the highest scores on the variable formed the third category. Finally, cross-tabulations with adjusted standardized residuals were used to reveal the proportions of children reporting recurrent pain according to these classified variables.
We analyzed the hypothesis of gender differences in the relationship of pain to emotion regulation with logistic regression. We computed interaction effects of gender and emotion regulation on pain, while controlling for long-term illnesses and pain due to injuries.
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Results |
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Descriptive Statistics
Almost half of the children (44%) reported frequent (at least weekly) pain (Table I). Pain was most frequently reported in lower extremities. Chi-square analyses revealed no significant gender differences between those with and without frequent pain episodes. With regard to single pains, however, boys reported more pain in lower extremities than girls, and girls had more chest pain than boys (Table I). Spearman correlations showed that pains in different parts of the body were related, the median correlation being.29 (p =.000). Pain due to injuries was reported by 34% of the children, and parents reported that 15% had long-term diseases (asthma, convulsions or muscular contractions, long-term medication).
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Mann-Whitney U tests were used to explore gender differences in teacher-reported emotion regulation. Boys were rated as having more externalizing problem behavior than girls (Mann-Whitney U = 12698; p =.000). Conversely, girls were rated as better adjusted than boys (Mann-Whitney U = 14462; p =.000).
Relationship Between Low Self-Control of Emotions and Pain
We performed a series of logistic regression analyses to examine the
association of emotion regulation with recurrent pain, while controlling for
pain due to injuries and long-term illnesses. Low self-control of emotions was
related to recurrent pain in the general model. Both internalizing problem
behavior and externalizing problem behavior were associated with pain,
independently of injuries and long-term illnesses (see
Table II). There was an
interaction effect of internalizing and externalizing problem behaviors on
pain. To assess the nature of the interaction effect, externalizing problem
behaviors were divided into three classes, and logistic regression analyses of
internalizing problem behaviors were then performed with each of these three
classes. Results revealed that internalizing problem behaviors related to pain
only in the context of externalizing problem behaviors. If
internalizing problem behaviors were one standard deviation above the mean,
the risk for recurrent pain nearly doubled in children rated to have the most
externalizing problem behaviors (OR = 1.89, 95% CI = 1.22, 2.84, p
=.004). Analogously, when internalizing problem behaviors were divided into
three classes, externalizing problem behaviors were associated with pain
only at the highest level of internalizing problem behaviors. In this
case, the increase was over two fold, when externalizing problem behaviors
increased one standard deviation (OR = 2.06, 95% CI = 1.29, 3.29, p
=.003). The interaction effect was further examined using cross-tabulation,
and children having both abundant externalizing and internalizing problem
behaviors were more likely to suffer from recurrent pain than children with
moderate or low degrees of either or both problems
(Table III).
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The probability of children having recurrent pain is illustrated in Figure 2. Children had a greater probability of having pain if they had both internalizing and externalizing problem behaviors one standard deviation above the average (see externalizing problem behavior line 1.0 SD above the mean and 1.0 SD point in the horizontal axis in Figure 2) compared to those with average internalizing and externalizing problem behaviors score (see mean externalizing problem behavior line and 0 SD point in the horizontal axis in Figure 2); the probabilities were about 85% and 58%, respectively.
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The associations of the subscales of internalizing and externalizing problem behaviors were examined after influences of long-term illnesses and injuries were controlled. Hyperactivity-Impulsivity (OR = 1.26, 95% CI = 1.01, 1.57, p =.040), Inattention (OR = 1.26, 95% CI = 1.01, 1.57, p =.039), and Depression (OR = 1.37, 95% CI = 1.09, 1.72, p =.007) were related to pain independently of injuries and long-term illnesses. Depression and aggression had an interaction effect on pain (p =.019): only in the most aggressive children was depression associated with pain. As depression increased one standard deviation, risk for recurrent pain doubled in the children rated most aggressive (OR = 2.14, 95% CI = 1.35, 3.40, p =.001). Correspondingly, only among the most depressed children was aggression related to pain. As aggressiveness increased one standard deviation above the mean, the risk for recurrent pain increased one and a half times in the context of elevated depressive symptoms (OR = 1.48, 95% CI = 1.01, 2.18, p =.044). There was an interaction effect for hyperactivity-impulsivity and depression on pain (p =.009), which parallelled the interaction effect of depression and aggression: Only in the most depressed children was hyperactivity-impulsivity related to pain (OR = 1.86, 95% CI = 1.21, 2.86, p =.005). Correspondingly, only among children rated most hyperactive-impulsive was depression associated with pain (OR = 2.28, 95% CI = 1.42, 3.67, p =.0007). Thus, it seems that the internalizing problem behavior of depression and the externalizing problem behaviors of aggression and impulsivity have the strongest relationship with pain.
Gender Effects
No effects were found in examining interaction effects of gender with
internalizing and externalizing problem behaviors. There was a significant
interaction effect on recurrent pain for adjustment and gender independent of
chronic illnesses and injuries (p =.043). In the interaction of the
subscales of adjustment (Constructive Behavior, Compliant Behavior, Social
Activity) and gender, constructive behavior and gender had an interaction
effect on repeated pain (p =.024). In girls, high constructive
behavior was associated with recurrent pain reports: as it increased with one
standard deviation, risk for pain increased one and a half times (OR = 1.51,
95% CI = 0.69, 1.96, p =.042). In boys, there was no association
between pain and constructive behavior.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The goal of this article was to examine relationships between children's self-reported recurrent pain and teacher-rated emotion regulation. The study has several strengths. First, the data allowed an examination of recurrent pain and emotion regulation while controlling for pain due to injuries and long-term illnesses. Second, in addition to externalizing and internalizing problem behaviors, that is, difficulties in adjustment, we also assessed socially adjusted behavior. Third, in addition to commonly reported headache and abdominal pain, various musculoskeletal pains were measured. Fourth, the sample was drawn from a representative, nonclinical population, to eliminate biases associated with seeking health care services.
As hypothesized, our data indicate that recurent pain is related to low
self-control of emotions indexed by teacher-rated internalizing and
externalizing problem behaviors. Relationships of internalizing and
externalizing problem behaviors to pain depended on each other: they were
associated with pain more strongly together than separately. These results are
consistent with previous reports indicating that children reporting recurrent
pain exhibit both internalizing (Ingersoll
et al., 1993;
Kristjánsdóttir,
1997; Martin-Herz et al.,
1999; Mikkelsson et al.,
1997b) and externalizing
(Mikkelsson et al., 1997b)
problem behaviors. The relationships were rather modest when examined
separately, but stronger in children with both externalizing and internalizing
problem behaviors. Depression, aggression, and impulsivity were the specific
emotions and behaviors that related to pain. Our data do not support the
notion that suppression of emotional expression is a prominent feature of
children with recurrent pain at ages 11 to 12. Rather, according to the model
of emotion and behavioral regulation
(Pulkkinen, 1995), low
self-control of emotions resulting from intensification of emotional
experience seems to characterize the emotion regulation of children reporting
pain. This is consistent with previous results suggesting that the strength of
the emotional response is the central feature of emotion regulation in adults
with somatic complaints (Burns et al.,
1995; Gross & John,
1995). We found that inattentiveness was related to both
depression and aggression, thus confirming that internalizing and
externalizing problem behaviors have low attentional control in common, which
is an integral part of emotion regulation
(Calkins, 1994;
Eisenberg et al., 2000; Gross,
1998,
1999b;
Pope & Bierman, 1999;
Pulkkinen et al., 2001;
Rothbart & Putnam, in
press).
The relationship between low self-control of emotions and pain may be
explained in many ways. First, internalizing problems may lead to pain through
sympathetic activity and muscle constriction
(Gross, 1998; Gross &
Levenson, 1993,
1997; Pennebaker,
1985,
1991;
Traue, 1995). Second, pain
can, itself, act as a stressor lowering life satisfaction
(Langeveld et al., 1999) and
increasing the likelihood for aggression
(Anderson, Anderson, Dill, & Deuser,
1998; Berkowitz,
1993; Gamsa &
Vikis-Freibergs, 1991). Animal studies have shown that, as a
result of painful stimulation, animals start to fight or flee
(Berkowitz, 1993).
Correspondingly, the more pain humans report, the more likely they report
feeling angry and turn to aggressive behavior
(Gamsa & Vikis-Freibergs,
1991). In experimental work, participants feel more resentment in
painful situations (Anderson et al.,
1998) and are more willing to harm others
(Berkowitz, Cochran, & Embree,
1981) than in neutral situations.
Third, pain and emotion regulation may also share a common etiology.
Serotonin metabolism could be the basis for low self-control of emotions and
pain, as it has been associated with both phenomena
(France et al., 1987;
Jensen et al., 1994;
Lund, 1994). From the
psychological perspective, negative affectivity could be associated with
reports of high levels of negative feelings, as well as physical symptoms
(Deary, Scott, & Wilson,
1997; Watson & Pennebaker,
1989). Similarly, physiological reactivity levels may predispose
to specific emotions and ways of emotion regulation (Kagan,
1992,
1998) as well as to muscle
constriction and thus to pain (Traue,
1995). Given our results, one might think that children who have
difficulties neutralizing their emotional arousal may have similar problems in
diminishing their experience of pain. They may be sensitive to both negative
feelings and painful physical experiences and may intensify the experience of
both.
These different explanations of the relationship between pain and emotion
regulation need not be mutually exclusive; the relationship may be
bidirectional. It could be, for example, that pain acts as a stressor to
increase emotional turmoil of a child, which, in turn, lowers the threshold
for pain (Kristjánsdóttir,
1997). Emotional turmoil, itself, may strain the coping capacity
of a child and thus increase the stress experienced. This may activate the
sympathetic nervous system, which may increase muscle tension and pain.
Consequently, pain and low self-control of emotions may exacerbate one another
and lead to a vicious circle. For those with biological or psychological
susceptibilities to pain and negative feelings (serotonin metabolism, negative
affectivity, physical reactivity), the vicious circle may be particularly
likely.
Contrary to previous research (Andrasik
et al., 1988; Beiter et al.,
1991; Garrick et al.,
1988; Tamminen et al.,
1991), boys with recurrent pain in this study had no more
externalizing problem behaviors than did girls, perhaps reflecting
methodological and sampling differences. Gender differences were found:
constructive behavior associated with recurrent pain only in girls. Thus, in
addition to low self-control of emotions, constructive behavior may also
increase the risk for recurrent pain in girls. The optimality of emotion
regulation seems to be central with regard to well-being
(Cole, Michel, & Teti,
1994; see also Eisenberg et
al., 1997). Research on the relationship between adjustment and
pain is limited, as adjustment has been identified mainly from a negative
perspective. Most studies have found that children with pain have more
adjustment difficulties than children without pain
(Beiter et al., 1991;
Ingersoll et al., 1993;
Mikkelsson et al., 1997b).
However, one study consistent with our results found that high sociability
among 5-year-old children predicted later headache
(Aromaa, Rautava, Helenius, &
Sillanpää, 1998). Constructive behavior, occurring as
excess caring of others and overconscientiousness, could result in neglect of
one's own needs and difficulties in self-assertiveness. In turn, this may lead
to an accumulation of stressors, which may increase muscle constriction and
pain.
We note some limitations of this study. First, its cross-sectional nature
does not allow causal inferences. In the future, research should be directed
to understanding underlying mechanisms between pain and low self-control of
emotional behavior and between pain and constructive behavior in girls.
Genetically informative research designs, including pairwise analyses of the
twin data here described, will be particularly useful to estimate genetic and
familial environmental covariance. Second, variables that mediate the
relationship between pain and emotion regulation were not included in this
study. These variables might include a parenting style that causes stress in a
child and does not support the development of emotion regulation. Third,
emotion regulation was measured solely with teacher ratings. Teachers see only
part of children's lives and may not recognize covert symptoms of anxiety and
depression. On the other hand, teacher ratings are a reliable method to
measure overt problems of emotion regulation
(Cole, Martin, Lachlan, Henderson, &
Harwell, 1998; Pulkkinen et
al., 1999). Further, teacher ratings reduce the possibility of
common variance found when subjects complete self-report questionnaires on
separate constructs (Pulkkinen et al.,
1999). Fourth, reliability of the compliance scale for girls was
rather low, which makes the results for that scale uncertain.
Fifth, pain was measured according to its location and frequency, but its
chronicity and severity were ignored. It has been shown, however, that
recurrent pain is a fairly permanent symptom in childhood and adolescence
(Choquet & Menke, 1987;
Mikkelsson et al., 1997a).
Sixth, pain measurement relied on children's retrospective observations of
pain. Consequently, memory problems or tendencies to overemphasize or minimize
symptoms may reduce the reliability of results. However, self-reports are the
only reliable method to measure pain due to its subjective nature
(McGrath, 1996;
Savedra & Tesler, 1989;
Varni, Walco, & Katz,
1989). Diary methods could have made the measurement more valid,
as they are less dependent on memory (see Hunfeld, Deuervaarder, Hazebroek,
van Suijlekom-Smit, & van der Wouden, 1997;
Metsähonkala, Sillanpää,
& Tuominen, 1997). Seventh, it is possible that pain reported
in this study had a known organic etiology, as medical examination could not
be arranged. However, the etiology of pain has not been shown to affect the
relationship of pain and internalizing and externalizing problem behaviors
(Walker et al., 1993;
Walker & Greene, 1989). In
girls, menstruation was not taken into account as a possible cause of pain.
However, pain due to menstruation would occur more rarely than once a week,
and in this study, the criterion for recurrent pain was at least weekly
occurrence. Further, only 5% of the girls in this sample had reported the
onset of menstruation.
The twin status of the participants is not likely to affect the
generalizablity of our results: A study by Gjone and Nøvik
(1995) found no differences
between twins and other children with regard to externalizing problem behavior
and only slight differences with regard to internalizing problem behavior.
With regard to other age groups, the relationship between different problems
and pain might be clearer among older children, especially boys
(Andrasik et al., 1988). In
adults, also, there is much evidence that pain relates to low self-control of
emotions (Bru, Mykletun, & Svebak,
1993; Gamsa &
Vikis-Freibergs, 1991;
Schermelleh-Engel, Eifert, Moosbrugger,
& Frank, 1996).
The results of this study suggest that both internalizing and externalizing
problem behaviors should be taken into account in clinical examinations of
recurrent pain in childhood. Problems of emotion regulation associated with
recurrent pain may indicate the need for clinical intervention, as the
co-occurrence of emotional dysregulation and pain has been shown to increase
the persistence of both problems
(Ferdinand & Verhulst,
1995). Physicians evaluating adolescents with recurrent pain
should assess internalizing and externalizing problem behaviors and refer to
mental health professional for further evaluation as needed.
|
Acknowledgments |
|---|
Data collection was supported by the National Institute on Alcohol Abuse and Alcoholism (AA-09203 and AA-00145) and by the Academy of Finland, Finnish Centre of Excellence Programme no. 40166. We thank Asko Tolvanen, Risto Hietala, and Ari Mäkiaho for their statistical and computing aid and advice. We also thank Marja Mikkelson, MD, for her contribution to the measurement of pain.
Received March 13, 2000; revision received November 20, 2000; accepted July 31, 2001
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