Journal of Pediatric Psychology, Vol. 27, No. 8, 2002, pp. 689-698
© 2002 Society of Pediatric Psychology
Social Consequences of Children's Pain: When Do They Encourage Symptom Maintenance?
1 Vanderbilt University School of Medicine, 2 Vanderbilt University
All correspondence should be sent to Lynn S. Walker, Division of Adolescent Medicine and Behavioral Science, 436 Medical Center South, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-3571. E-mail: Lynn.Walker{at}mcmail.vanderbilt.edu.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionReferences |
|---|
Objective: To examine the influence of social factors (e.g., attention, relief from responsibility) and children's perceived competence on pediatric symptom maintenance.
Methods: Participants were 151 pediatric patients (ages 8-18) with recurrent abdominal pain. They were interviewed at a clinic visit and again 2 weeks later. The Social Consequences of Pain questionnaire assessed four types of social consequences: positive attention, negative attention, activity restriction, and privileges.
Results: Two types of social consequences (positive attention and activity restriction) predicted greater symptom maintenance, but this effect was moderated by children's perceived self-worth and academic competence. To the extent that children rated their self-worth and academic competence as low, the impact of social factors on symptom maintenance was stronger.
Conclusions: Children's success in their normal social roles may affect the extent to which they identify with the sick role and find it a rewarding alternative to other social roles.
Key words: recurrent abdominal pain; social learning; secondary gain; perceived competence.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Diverse theoretical traditions propose that symptom maintenance may be influenced by social consequences of illness. Freud (1959
) introduced the
psychodynamic concept of secondary gain, defined as interpersonal or social
advantage attained by the patient as a consequence of illness. Behavior theory
offers an alternative conceptual framework in which symptoms and disability
are regarded as responses influenced by their consequences. Applying this
operant conditioning model to chronic pain, Fordyce
(1989) suggested that
consequences such as positive attention from others may serve as rewards that
reinforce symptoms. The constructs of secondary gain and reinforcers are
similar in that both are social consequences hypothesized to maintain symptoms
(Fishbain, 1994). These
constructs have been applied in efforts to understand maintenance of symptom
complaints and disability in both adults and children
(Craig, 1978;
McGrath, 1990).
It has been proposed that the impact of social consequences on illness
behavior in children may vary as a function of children's psychosocial
development (Walker, 1999).
For example, a critical task of middle childhood is the development of a sense
of mastery or competence (Erikson,
1964). Relief from responsibility as a consequence of illness may
be more rewarding for children who have not developed a sense of competence
than for children who perceive themselves as competent. Specifically, children
who perceive themselves as inadequate may welcome being excused from the
challenge of school and social activities; for them, relief from
responsibility may serve as a reward that reinforces illness-related
disability. In contrast, children who perceive themselves as competent may
regard being excused from activities as a lost opportunity for further
success; for them, relief from responsibility may be aversive and is unlikely
to reinforce symptoms and disability.
In addition to relief from responsibility, children may receive solicitous
attention from others as a consequence of illness. Theoretical and empirical
literature suggests that such interpersonal attention may reinforce symptom
complaints (e.g., Blount et al.,
1989; Fordyce,
1989). For example, solicitous attention from parents predicted
slower recovery from oral surgery in adolescent patients
(Gidron, McGrath, & Goodday,
1995). The impact of solicitous attention on children's illness
behavior may also vary as a function of children's competence. For example,
children who have not mastered school activities and peer relationships may
welcome attention for symptoms as an alternative source of self-validation. In
contrast, children who perceive themselves as competent in routine daily
activities may place less value on attention for symptoms.
This study tested the hypothesis that the impact of social consequences on
symptom maintenance is moderated by children's perceived success at normative
tasks of psychosocial development. We conceptualized this success in terms of
perceived global self-worth as well as perceived competence specific to
academic and social roles (cf. Harter,
1985). The study sample consisted of children with recurrent
abdominal pain (RAP), a common pediatric condition typically not associated
with significant organic disease (Apley,
1975). Children with RAP experience frequent debilitating episodes
of abdominal pain and complain of a variety of other nonspecific somatic
symptoms as well (Walker, Garber, &
Greene, 1991). An advantage of studying symptom maintenance in a
functional condition such as RAP was that the course of organic disease was
not a confound in predicting changes in children's symptoms. We expected that
positive attention and relief from responsibility would predict symptom
maintenance 2 weeks following a medical evaluation, but this effect would be
moderated by children's perceived competence. Specifically, the impact of
positive attention and relief from responsibility on symptom maintenance was
expected to be greater at lower levels of perceived competence.
Social consequences of illness may be negative as well as positive.
According to behavioral theory, negative attention from others (e.g.,
irritation) should punish and therefore decrease symptoms. However, the
empirical literature is mixed regarding the impact of negative attention on
symptom maintenance. For example, in a study of adult pain patients, negative
attention from others was associated with increased pain behavior,
perhaps because negative attention created affective distress that contributed
to somatic symptoms (Kerns et al.,
1991). Therefore, we did not make specific hypotheses regarding
the impact of negative social consequences on children's symptom
maintenance.
Instruments designed to assess social consequences of illness in children
have focused exclusively on positive responses by parents toward their
children (cf. Walker & Zeman, 1992; Whitehead et al.,
1982;
1986). Thus, a secondary goal
of this study was to develop a new instrument, the Social Consequences of Pain
Questionnaire (SCP), which assesses both positive and negative social
consequences of children's illness behavior. Factor analysis was conducted to
identify dimensions of social consequences assessed by the new instrument.
Preliminary validity data also were obtained.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Participants
Study participants included 151 children referred to a pediatric gastroenterology clinic for evaluation of recurrent episodes of abdominal pain of at least 3 months' duration (cf. von Baeyer & Walker, 1999
). New patients without identified
organic disease or mental retardation were eligible. Participants ranged in
age from 8 to 18 years (M = 12.01, SD = 2.5). Most were
female (57%) and Caucasian (96%). Family socioeconomic status (SES) ranged
from the lowest (8) to highest level (66) on the Hollingshead Two-Factor Index
of Social Status (Hollingshead,
1975) (M = 41.91, SD = 11.70).
Procedure
Parents of patients referred for evaluation of abdominal pain were
contacted by telephone several days prior to the scheduled clinic appointment.
The study was described and those who expressed interest were screened for
eligibility criteria and asked to arrive early at the clinic. Informed consent
procedures, approved by the institutional review board, were conducted prior
to administering the study protocol. Parents completed questionnaires in the
waiting room while children were interviewed in a private room nearby. A
second interview with the children was conducted by telephone two weeks
following the initial interview.
Development of a Measure of Social Consequences of Pain
The Illness Behavior Encouragement Scales (IBES; Walker & Zeman, 1992)
provided the format and initial content for development of the SCP. The IBES
refers exclusively to positive consequences delivered by parents. The SCP
includes consequences delivered by parents, teachers, and peers. Moreover, the
SCP assesses both positive consequences (e.g., attention, relief from
responsibility, and privileges associated with illness) and negative
consequences (e.g., being ignored or criticized for symptom complaints). The
stem for SCP items is "When you have a bad stomach ache, how
often..." Like the IBES, the 5-point response format includes
"Never" (coded 0), "Hardly Ever" (coded 1),
"Sometimes" (coded 2), "Often" (coded 3), and
"Always" (coded 4). The SCP was administered at the initial
evaluation.
The SCP was factor analyzed using a principal-components factor analysis with varimax rotation. Inspection of the scree plot of eigenvalues suggested a four-factor solution. Items with the highest factor loadings were used to define each of the four factors. The initial factor accounted for 23.1% of the variance and was characterized by positive attention from others. It was labeled "positive attention." Factor 2 (10.5% of the variance) included items assessing relief from responsibilities and restriction of activities. It was labeled "activity restriction" (rather than "relief from responsibility") to avoid the implication that not doing one's chores was necessarily a "relief." Factor 3 (6.4% of the variance) included items assessing criticism and failure of others to validate the child's symptoms. It was labeled "negative attention." Factor 4 (5.5% of the variance) included items reflecting special privileges and was labeled "privileges." Table I lists the items, factor loadings, and eigenvalues for each factor. Subscale scores were computed as the average item rating for each factor.
|
Other Measures
Children's Somatization Inventory. The Children's Somatization
Inventory (CSI; Garber, Walker, &
Zeman, 1991; Walker, Garber,
& Greene, 1991) assesses the severity of nonspecific somatic
symptoms commonly reported by children with RAP. It was completed by children
at the initial visit and again 2 weeks later. The CSI includes symptoms from
the revised third edition of the Diagnostic and Statistical Manual of
Mental Disorders criteria for somatization disorder (DSM-III-R:
American Psychiatric Association,
1987) and from the somatization factor of the Hopkins Symptom
Checklist (Derogatis, Lipman, Rickels,
Uhlenhuth, & Covi, 1974). Examples of items include
"headaches," "feeling low in energy," and
"faintness or dizziness." Respondents rate the extent to which
they have experienced each of the 35 symptoms during the last 2 weeks using a
5-point scale ranging from "not at all" (0) to "a whole
lot" (4). Total scores, obtained by summing all item ratings, can range
from 0 to 140. Three-month test-retest Pearson reliability for the CSI is .50
for well patients and .66 for patients with a chronic pain syndrome
(Walker et al., 1991). In this
study, alpha reliability was .89 at the initial administration and .91 at the
follow-up administration.
Perceived Competence. Children's perceived competence was assessed
at the initial evaluation with three subscales of the Self-Perception Profile
for Children (SPPC; Harter,
1985). The SPPC assesses children's global and domain-specific
perceptions of self-worth. Subscales included in this study were Global
Self-Worth, Academic Competence, and Social Competence. The SPPC has a 4-point
response format and six items on each subscale. Harter
(1985) reported adequate
internal consistency and convergent validity. Total scores on each subscale
were computed by summing responses to items on that subscale. Alpha
reliability was .83 for Global Self-Worth, .77 for Academic Competence, and
.59 for Social Competence.
Multidimensional Scale of Perceived Social Support (MSPSS;
Zimet, Powell, Farley, Werkman, &
Berkoff, 1990). The MSPSS is a brief, self-report measure of
perceived social support. It was administered to children at the initial
evaluation. Subscales assessing Family Support and Peer Support were
administered in order to examine their relation to SCP positive attention and
negative attention. Each MSPSS subscale has four items rated on a 7-point
Likert-type scale ranging from "very strongly disagree" (coded 1)
to "very strongly agree" (coded 7). The MSPSS has good internal
reliability and strong factorial validity
(Zimet et al., 1990). In this
study, alpha reliability was .74 for Family Support and .71 for Peer
Support.
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Psychometric Properties and Descriptive Data on the SCP Scales
Alpha Reliability and Intercorrelation of SCP Scales. Alpha reliability for the SCP subscales was .73 for negative attention, .84 for positive attention, .83 for activity restriction, and .67 for privileges. The intercorrelation among the subscales is presented in Table II. The Pearson correlation coefficients between SCP subscales ranged from .02 (between privileges and negative attention) to .50 (between positive attention and activity restriction), indicating that the subscales assess relatively independent constructs.
|
Relation of Pain Consequences to Other Constructs. Construct validity of the SCP was assessed by examining the Pearson correlations of the SCP subscales with other variables and constructs including age and social support (Table II). Age had a significant negative correlation with positive attention, probably reflecting decreased parental oversight as children enter adolescence. Positive attention had significant positive correlations with MSPSS family and peer support, whereas negative attention had significant negative correlations with measures of support, providing evidence for the construct validity of these SCP subscales.
Frequency of Social Consequences by Child Gender and Type of Consequence. Analysis of variance with child gender as a factor and type of consequence as a repeated measure indicated a significant difference in the frequency of the different types of consequences (Wilks Lambda [3, 145] = 88.11, p < .0001). Positive Attention was endorsed significantly more frequently than activity restriction (t[151] = 3.26, p < .0001), which in turn was endorsed significantly more frequently than privileges (t[150] = 8.73, p < .0001). Finally, privileges was endorsed significantly more frequently than negative attention (t[150] = 2.38, p < .02). The mean item rating and standard deviation for each subscale was as follows: positive attention, M = 1.97, SD = .81; activity restriction, M = 1.76, SD = .76; privileges, M = 1.11, SD = .84; and negative attention, M = .89, SD = .74. Child gender did not have a significant effect on the frequency of any type of pain consequence.
Pain Consequences as Predictors of Symptom Maintenance
Hierarchical multiple regression analyses were conducted to assess (1)
whether pain consequences predicted symptom maintenance 2 weeks following the
initial evaluation and (2) whether children's perceived self-worth, academic
competence, and social competence moderated the effect of pain consequences on
symptom maintenance. All analyses controlled for initial CSI symptom scores
and predicted CSI symptom scores at the 2-week follow-up.
Activity Restriction. The first series of analyses examined the influence of SCP activity restriction on symptom maintenance. Results yielded a significant interaction between activity restriction and global self-worth, shown in Table III. A graph of the interaction between activity restriction and global self-worth indicated that, for children with lower global self-worth, higher levels of activity restriction were associated with higher levels of symptoms at follow-up, controlling for initial symptom levels (Figure 1). Children with higher global self-worth, in contrast, tended to exhibit low symptom levels at follow-up regardless of level of activity restriction. In another analysis, the interaction between activity restriction and academic competence approached significance (p < .06) and was similar to the interaction between activity restriction and global self-worth; activity restriction predicted symptom maintenance in children with low academic competence but not in those with high academic competence. Social competence did not moderate the effect of activity restriction on symptom maintenance.
|
|
Positive Attention. The second series of analyses yielded significant effects for the interaction between positive attention and global self-worth and for the interaction between positive attention and academic competence. Results of these analyses are shown in Tables IV and V. Graphs of the interaction effects indicated that, for children with lower global self-worth or academic competence, higher levels of positive attention were associated with higher levels of symptoms at follow-up, controlling for initial symptom levels. Children with higher global self-worth or academic competence, in contrast, tended to exhibit low symptom levels at follow-up regardless of the amount of positive attention that they received for symptoms. The interaction between positive attention and global self-worth is depicted in Figure 2. Social competence did not moderate the effect of positive attention on symptom maintenance.
|
|
|
Negative Attention. A third series of analyses indicated a significant interaction effect between negative attention and global self-worth in predicting symptom maintenance. Results of the analysis are presented in Table VI and the interaction effect is illustrated in Figure 3. Higher levels of negative attention were associated with higher symptom levels at follow-up, but only for children with lower global self-worth. Neither perceived academic competence nor social competence moderated the impact of negative attention on symptom maintenance.
|
|
Privileges. The Privileges scale of the SCP had no significant direct or interaction effect on symptom maintenance.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Study results suggest that social factors influence symptom maintenance in pediatric pain patients, but the impact of these factors varies as a function of children's perceived self-worth and academic competence. Among children who rated their self-worth or academic competence as low, restriction of routine daily activities and responsibilities predicted greater symptom maintenance 2 weeks following a medical evaluation. It is possible that activity restriction reinforced symptoms in these children by allowing them to avoid activities at which they expected to perform poorly (cf. Letham, Slade, Troup, & Bentley, 1983). In that sense, activity restriction was indeed a "relief" from responsibility. It also is possible that lower perceived self-worth reflected factors such as depressed mood that contributed to symptom maintenance in these children. Among children with higher perceived self-worth and academic competence, activity restriction did not influence symptoms following the medical evaluation. These children tended to have low symptomatology at follow-up, regardless of the amount of activity restriction at the time of initial evaluation.
Positive attention also influenced symptom maintenance. Similar to the findings for activity restriction, the impact of positive attention varied as a function of children's perceived self-worth and academic competence. Among children with lower self-worth or lower perceived academic competence, positive attention for symptoms predicted greater symptom maintenance following the clinic visit. This association may reflect social reinforcement of symptoms. Children who perceive themselves as lacking competence in normal daily roles may be especially vulnerable to the reinforcing impact of attention for their somatic symptoms. We expected that such attention would have little impact on symptom maintenance in children with greater perceived competence. Unexpectedly, however, attention for symptoms actually predicted a decrease in symptoms for children with higher self-worth or higher perceived academic competence. It may be that even during times of illness, these very capable children also receive attention for competent behavior not associated with the sick role. To the extent that alternative behaviors are reinforced and are incompatible with sick role behavior, the impact of positive attention on symptoms would be reduced.
Negative attention did not predict symptom decreases and therefore could
not be regarded as "punishing" symptoms. Indeed, to the extent
that children perceived others as ignoring or criticizing their symptoms, they
exhibited greater symptom maintenance. This impact of negative attention was
significantly greater for children with lower levels of perceived self-worth.
Others have suggested that negative attention may predict symptoms
indirectly—that is, by creating emotional distress, which, in turn,
contributes to somatic symptoms (cf. Kerns
et al., 1991). Children with lower self-worth may be particularly
vulnerable to the impact of negative attention if they have difficulty
generating alternative behavior that is rewarded with positive attention.
Children with higher levels of self-worth, in contrast, may engage in
alternative behavior when their symptom complaints are ignored or criticized
by others.
As discussed, the data indicated that perceived academic competence played
a role similar to that of global self-worth. In contrast, perceived social
competence did not moderate the impact of social consequences on symptom
maintenance, perhaps because Harter's
(1985) Social Competence scale
focuses on peer relationships, whereas the SCP emphasized family more than
peer attention to symptom complaints. Prior work has shown that children's
symptom complaints influence peer responses to them
(Guite, Walker, Smith, & Garber,
2000). Future work might focus on the effects of positive and
negative peer attention on children's symptom maintenance.
A particular strength of the study was the use of a longitudinal design with statistical control for initial symptom levels in predicting symptoms at follow-up. Most previous research on the relation of social consequences to illness behavior has used cross-sectional data. Because RAP is an episodic condition, future research should include multiple data points over time in order to assess the duration of symptom maintenance.
This study focused on Caucasian children referred to a tertiary care
setting for evaluation of recurrent abdominal pain. Additional work is needed
to determine whether the findings generalize to children in primary care
settings and to children of other ethnic groups. It is possible that gender
differences, not observed in this sample, would be evident in those
populations. The study is further limited by use of self-report measures.
Although subjective perceptions of the consequences of illness are relevant in
predicting future pain behavior, inclusion of objective measures of the social
consequences of pain would help tease out the relative contribution of each to
the development of chronic pain syndromes. Indeed, others have shown that the
predictive effect of solicitous behavior on patients' treadmill performance is
greater when solicitous behavior is reported by the caregiver than by the
patient (Lousberg, Schmidt, &
Groenman, 1992). Finally, inclusion of objective measures of
children's competencies would help to determine whether perceived versus
actual competence moderates the effect of social consequences on symptom
maintenance.
A second aim of this study was to describe the development and initial validation of the SCP, a measure that assesses children's perceptions of the frequency of various social consequences associated with their pain episodes. Factor analysis identified four distinct types of consequence that we labeled positive attention, activity restriction, negative attention, and privileges. The only other child-report measure of social consequences of pain, the IBES (Walker & Zeman, 1982) did not assess negative consequences and treated positive consequences as a single dimension. However, a recent study using a Dutch translation of the IBES (Bijttebier & Vertommen, 1999) found that positive responses assessed by the IBES reflected two distinct types of response—"Attention Consequences" (e.g., extra time with parents) and "Escape Consequences" (e.g., being relieved from activities and granted special privileges). Thus, three of the factors on the SCP—positive attention, activity restriction, and privileges—appear to reflect constructs imbedded in the IBES. Additional research is needed to replicate the factor structure of the SCP, examine its test-retest reliability, and further explore its construct validity, particularly the relation of the SCP to observer ratings of social consequences associated with children's pain episodes.
Results of this study have implications for the evaluation and treatment of
children with RAP and other chronic or recurrent pain conditions. In
evaluating the role of social consequences in reinforcing children's symptoms,
one must consider the context of children's progress in normative
developmental tasks. Children's satisfaction with their performance on these
tasks may influence the attractiveness or reinforcement value of the sick
role. Thus, social consequences associated with sick role behavior, such as
staying home from school, may reinforce symptoms in some children but may in
fact be aversive for others. In related work, Radley and Greene
(1987) postulated that
secondary gain occurs when individuals both define themselves in terms of
illness and withdraw from participation in normal roles. Children who view
themselves as inadequate in normal childhood roles may be most likely to
define themselves in terms of their illness. The sick role offers them a
legitimate alternative to roles at which they perceive themselves as failing.
When attention and relief from responsibility accompany their sick role
behavior, symptoms and disability are likely to be reinforced and maintained
long after any organic disease processes have resolved. In these cases, it is
important that treatment include efforts to develop children's competencies
and to reward their participation in more appropriate roles.
In treating children with chronic or recurrent pain conditions, the
clinician must broaden the family's focus beyond concern for the child's
physical health to consideration of the whole child, including positive health
associated with various competencies (cf.
Seeman, 1989). Even very
protective parents who are reluctant to limit attention to their children's
symptoms may agree to reward their children's success in activities not
associated with the sick role. Thus, the family may be enlisted in promoting
children's competencies so that the relative attractiveness of the sick role
is gradually reduced.
|
Acknowledgments |
|---|
This study was supported by a grant to the investigators from the National Institute for Child Health and Development (HD23264) and by a core grant (HD15052) to the John F. Kennedy Center, Vanderbilt University.
Received June 8, 2002; revision received December 27, 2001; revision received May 13, 2002; accepted May 13, 2002
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.
Apley, J. (1975). The child with abdominal pains. London: Blackwell.
Bijttbier, P., & Vertommen, H. (1999). Antecedents, concomitants and consequences of pediatric headache: Confirmatory construct validation of two parent-report scales. Journal of Behavioral Medicine, 22, 437-456.[Web of Science][Medline]
Blount, R. L., Corbin, S. M., Sturges, J. W., Wolfe, V. V., Prater, J. M., & James, L. D. (1989). The relationship between adults' behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behavior Therapy, 20, 585-601.[Web of Science]
Craig, K. D. (1978). Modeling and social learning factors in chronic pain. In J. Bonica (Ed.), Advances in pain research (Vol. 5, pp. 813-827). New York: Raven Press.
Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist. Behavioral Science, 19, 1-15.[Web of Science][Medline]
Erikson E. (1964). Childhood and society (2nd ed.). New York: Norton.
Fishbain, D. A. (1994). Secondary gain concept: Definition problems and its abuse in medical practice. American Pain Society Journal, 3, 264-273.
Fishbain, D. A., Rosomoff, H. L., Cutler, R. B., & Rosomoff, R. S. (1995). Secondary gain concept: A review of the scientific evidence. Clinical Journal of Pain, 11, 6-21.
Fordyce, W. E. (1989). The cognitive/behavioral perspective on clinical pain. In J. D. Loeser & K. J. Egan (Eds.), Managing the chronic pain patient (pp. 51-64). New York: Raven Press.
Freud, S. (1959). Introductory lectures on psychoanalysis (1917) (Vol. 16). London: Hogarth Press.
Garber, J., Walker, L. S., & Zeman, J. (1991). Somatization symptoms in a community sample of children and adolescents: Further validation of the Children's Somatization Inventory. Psychological Assessment, 3, 588-595.
Gidron, Y., McGrath, P. J., & Goodday, R. (1995). The physical and psychosocial predictors of adolescents' recovery from oral surgery. Journal of Behavioral Medicine, 18, 385-399.[Web of Science][Medline]
Guite, J. W., Walker, L. S., Smith, C. A., & Garber, J.
(2000). Children's perceptions of peers with somatic symptoms:
The impact of gender, stress, and illness. Journal of Pediatric
Psychology, 25,
125-135.
Harter, S. (1985). Manual for the Self-Perception Profile for Children. Denver, CO: University of Denver.
Hollingshead, A. B. (1975). Four-factor index of social status. Working paper, Department of Sociology, Yale University.
Kerns, R. D., Southwick, S., Giller, E. L., Haythornthwaite, J. A., Jacob, M. C., & Rosenberg, R. (1991). The relationship between reports of pain-related social interactions and expressions of pain and affective distress. Behavior Therapy, 22, 101-111.
Lethem, J., Slade, P. D., Troup, J. D. G., & Bentley, G. (1983). Outline of a fear-avoidance model of exaggerated pain perception—I. Behaviour Research and Therapy, 21, 401-418.[Web of Science][Medline]
Lousberg, R., Schmidt, A. J., & Groenman, N.H. (1992). The relationship between spouse solicitousness and pain behavior: Searching for more experimental evidence. Pain, 51, 75-79.[Web of Science][Medline]
McGrath, P. A. (1990). Pain in children: Nature, assessment, and treatment. New York: Guilford Press.
Radley, A., & Greene, R. (1987). Illness as adjustment: A methodology and conceptual framework. Sociology of Health and Illness, 9, 179-207.
Seeman, J. (1989). Toward a model of positive health. American Psychologist, 44, 1099-1109.[Medline]
von Baeyer, C. L., & Walker, L. S. (1999). Children with recurrent abdominal pain: Issues in the selection and description of research participants. Journal of Developmental and Behavioral Pediatrics, 20, 307-313.[Web of Science][Medline]
Walker, L. S. (1999). The evolution of research on recurrent abdominal pain: History, assumptions, and new directions. In P. J. McGrath & G. A. Finley (Eds.), Chronic and recurrent pain in children and adolescents (pp. 141-172). Seattle, WA: International Association for the Study of Pain.
Walker, L. S., Garber, J., & Greene, J. W. (1991). Somatization symptoms in pediatric abdominal pain patients: Relation to chronicity of abdominal pain and parent somatization. Journal of Abnormal Child Psychology, 19, 379-394.[Web of Science][Medline]
Walker, L. S., Garber, J., & Greene, J. W. (1993). Psychosocial characteristics of recurrent childhood pain: A comparison of children with recurrent abdominal pain, organic illness, and psychiatric disorders. Journal of Abnormal Psychology, 102, 248-258.[Web of Science][Medline]
Walker, L. S, Garber, J., & Van Slyke, D. A.
(1995). Do parents excuse the misbehavior of children with
physical or emotional symptoms? An investigation of the pediatric sick role.
Journal of Pediatric Psychology,
20, 329-345.
Walker, L. S., & Zeman, J. L. (1993). Parental
response to child illness behavior. Journal of Pediatric
Psychology, 17,
49-71.
Whitehead, W. E., Busch, C. M., Heller, B. R., & Costa, P. T. (1986). Social learning influences on menstrual symptoms and illness behavior. Health Psychology, 5, 13-23.
Whitehead, W. E., Winget, C., Fedoravicius, A. S., Wooley, S., & Blackwell, B. (1982). Learned illness behavior in patients with irritable bowel syndrome and peptic ulcer. Digestive Diseases and Sciences, 27, 202-208.[Web of Science][Medline]
Zimet, G. D., Powell, S. S., Farley, G. K., Werkman, S., & Berkoff, K. A. (1990). Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 55, 610-617.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  L. L Cohen, K. E Vowles, and C. Eccleston Parenting an Adolescent with Chronic Pain: An Investigation of How a Taxonomy of Adolescent Functioning Relates to Parent Distress J. Pediatr. Psychol., November 13, 2009; (2009) jsp103v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. E. Mano, K. A. Khan, R. J Ladwig, and S. J Weisman The Impact of Pediatric Chronic Pain on Parents' Health-Related Quality of Life and Family Functioning: Reliability and Validity of the PedsQL 4.0 Family Impact Module J. Pediatr. Psychol., November 10, 2009; (2009) jsp099v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. E. Simons, R. L. Claar, and D. L. Logan Chronic Pain in Adolescence: Parental Responses, Adolescent Coping, and their Impact on Adolescent's Pain Behaviors J. Pediatr. Psychol., September 1, 2008; 33(8): 894 - 904. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. E. Beck A Developmental Perspective on Functional Somatic Symptoms J. Pediatr. Psychol., June 1, 2008; 33(5): 547 - 562. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. C. Peterson and T. M. Palermo Parental Reinforcement of Recurrent Pain: The Moderating Impact of Child Depression and Anxiety on Functional Disability J. Pediatr. Psychol., July 1, 2004; 29(5): 331 - 341. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||