Journal of Pediatric Psychology, Vol. 28, No. 1, 2003, pp. 47-57
© 2003 Society of Pediatric Psychology
Pain Reactivity and Somatization in Kindergarten-Age Children
University of Northern British Columbia
All correspondence should be sent to Elizabete M. Rocha, Department of Psychology, University of Saskatchewan, Saskatoon, SK Canada. E-mail: e.rocha{at}usask.ca.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionReferences |
|---|
Objective To evaluate predictors of somatization and pain reactivity in childhood. Methods Facial expressions of children undergoing inoculation were scored for pain reactivity. Measures of temperament, pain experience, pain models, parental behavior, and parental ability to decode pain were examined for their ability to predict pain reactivity and somatization in a structural modeling analysis. Results Pain reactivity was associated positively with parental reports of their child's somatization. Child temperament, previous negative experiences with medical procedures, and maternal responses to their children's pain were positively associated with pain reactivity. Conclusions Temperament and pain experience may play a role in children's pain reactivity, and reactivity may contribute to the development of somatization. Although the model that guided the analysis proved to be a reasonable description of the outcomes, several anticipated relationships were not significant. We discuss implications for a refined model of somatization and for early identification and prevention.
Key words: pain; reactivity; facial expression; temperament; somatization; structural modeling.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Somatization refers to high rates of complaint about bodily disturbances, discomfort, and dysfunction out of proportion to pathology (Garralda, 1996
). Estimates of
its prevalence are difficult to establish due to different standards for
assessment. Somatization disorder as defined in DSM-IV is rarely
diagnosed in children (Campo & Fritsch,
1994). Garber, Walker, and Zeman
(1991) provided a prevalence
estimate of 1% in a community sample of children and adolescents, whereas
Offord et al. (1987)
characterized approximately 4.5% of boys and 10.7% of girls in the 12- to
16-year-old range as displaying a somatization syndrome. Patterns of
somatization are thought to develop throughout childhood and to remain fairly
stable in adulthood (Campo & Fritsch,
1994; Garralda,
1996; Mechanic,
1980). Identifying factors that play a role in its development is
important in advancing understanding, prevention, and management of
somatization.
Pain reactivity refers to the extent of change in pain-related behaviors
following a standard noxious experience. Although pain reactivity can be
assessed by evaluating a number of behaviors, facial expressions of pain
provide considerable advantages. Experimental and clinical studies have
identified a limited set of facial actions that correlate with pain, vary in
intensity, appear to be sensitive to variations in pain experience, and can be
observed readily in the natural environment
(Craig, Prkachin, & Grunau,
2001). There is evidence of replicable individual differences in
pain reactivity as assessed by facial expression in adults
(Prkachin, 1992) and children
(Barr, Boyce, & Zeltzer,
1994).
The goal of this study was to identify predictors of pain reactivity and somatization in kindergarten-age children undergoing routine diphtheria-pertussis-tetanus-polio (DPTP) inoculations. The study of responses to inoculation at this age presents a number of advantages. In most jurisdictions, children entering kindergarten must undergo a DPTP booster; therefore, it is a convenient way of recruiting a broadly representative sample. Inoculations have a clearly defined stimulus and specific time of onset and are generally considered painful to children at this age. Moreover, this inoculation occurs just prior to beginning school. Consequently, children have been exposed largely to family influences and comparatively less to the social demands associated with school performance and peer relationships that may exacerbate or complicate somatization processes.
We used structural equation modeling to assess and refine a model of expected relationships. Structural modeling terminology distinguishes "upstream" variables, which can be thought of as predictors, from "downstream" variables, which can be thought of as outcomes. To ease exposition, the literature review will be organized from downstream (outcome) to upstream (predictor) variables. Figure 1 presents the conceptual model; the full explanation is outlined later.
|
A variety of psychosocial variables might be expected to predict
somatization. Operant conditioning approaches emphasize the importance of
contingent reinforcement in the development of styles of pain behavior and
somatization (Fordyce, 1976).
Dunn-Geier, McGrath, Rourke, Latter, and D'Astous
(1986) found that the mothers
of adolescents who were missing school because of pain were more likely to
encourage avoidance of distress and discourage coping than mothers of matched
controls, supporting the existence of familially mediated reinforcement of
somatization. A direct relationship also has been found between parents'
encouragement of illness behavior (a concept that resembles somatization
closely) and their children's somatization
(Walker & Zeman, 1992).
These findings support the expectation that children whose parents report
encouraging illness behavior should exhibit increased somatic complaints.
Modeling theory (Craig,
1986) suggests that pain behavior and somatization are influenced
by relevant behaviors displayed by family members. Several findings are
consistent with this expectation (Campo
& Fritsch, 1994; Garralda,
1996). For example, a higher incidence of abdominal pain disorders
has been reported in the families of children with recurrent abdominal pain
than of healthy children (Apley,
1975), and the number of pain models in one's home has been found
to be positively related to the frequency of pain reports
(Edwards, Zeichner, Kuczmierczyk, &
Boczkowski, 1985). Other studies suggest that the relationship
between modeling and somatization in children may not be straightforward. For
example, Walker, Garber, and Greene
(1991) found that the
somatization scores of children with recurrent abdominal pain of uncertain
origin were positively related to somatization scores of their parents.
However, the somatization scores of parents and children were unrelated among
patients with pain associated with demonstrable pathology and a healthy
control group. In a longitudinal study, Walker, Garber, and Greene
(1994) found that parental
somatization was associated prospectively with somatic complaints in their
children. Paternal somatization varied directly with child somatization,
whereas maternal somatization was associated only with child somatization
among boys from families with high levels of stressful life events. These
findings provide some support for a social learning perspective; however, they
suggest that complex social processes may differ across patient groups.
Although pain is not the same thing as somatization, a repertoire of somatic complaints may be built on a substrate of individual differences in pain reactivity. For example, children who react more vigorously than others to painful stimulation may react more vigorously to other forms of discomfort and provide greater opportunity for reinforcement of general bodily complaints. Alternatively, enhanced pain reactivity and somatization may both reflect the operation of a third variable, such as enhanced sensitivity to somatic sensations. For these reasons, pain reactivity can predict somatization.
Pain expression occurs in a social context and can be understood as serving
a communicative function (Prkachin,
1986). During inoculations, parents respond to their children's
behavior with behavior changes of their own
(Negayama, 1999). Behaviors
such as reassurance, empathy, criticizing, and bargaining with the child have
been related to increased child distress, whereas distraction and
nonprocedural talk have been related to decreased levels of distress
(Blount et al., 1989;
Cohen, Manimala, & Blount,
2000; Dahlquist, Power, &
Carlson, 1995; Frank, Blount,
Smith, Manimala, & Martin, 1995;
Gonzalez, Routh, & Armstrong,
1993; Sweet & McGrath,
1998). Presumably parents' behaviors represent attempts to
influence their children (Kopp,
1982). Although it has been suggested that some parental behaviors
may increase children's distress, parents may be reacting to early cues of
their child's distress. For example, Dahlquist et al.
(1995) found that parents'
rate of verbal interaction predicted child distress. The authors suggested
that parents may be sensitive to signs of distress in the child and therefore
more likely to interact with the child to modulate their distress.
Accordingly, in this study, maternal behavior was modeled as a downstream
variable reflecting the expectation that higher levels of behavioral response
to the vaccination among children would be associated with increased maternal
responses. We examined maternal behaviors previously identified in the
literature, including the provision of emotional support, distraction, praise,
explanation, bargaining, threatening, criticizing, pleading, expressing pain,
and anxious verbalizations.
Pain reactivity is probably influenced by several factors. In adults, pain
reactivity is associated with social modeling
(Prkachin & Craig, 1985).
In addition, children bring to the pain experience temperaments that may
influence their reactivity. Research has suggested that temperament is
associated with pain reactivity. For example, Wallace
(1989) reported that
hospitalized children rated as high on the temperament variable of intensity
were more likely to be administered analgesics postoperatively than children
who were rated as less intense. Schechter, Berstein, Beck, Hart, and Scherzer
(1991) and Young and Fu
(1988) reported that
temperament dimensions of approach, nonadaptability, and rhythmicity
correlated positively with pain behavior during injections. Grunau, Whitfield,
and Petrie (1994) reported
that, with the exception of those born at extremely low birthweight, toddlers
showing high emotional reactivity were also rated by their parents as highly
sensitive to pain. Temperament dimensions reflecting the ease with which a
child adjusts to new circumstances (adaptability) and the tendency to approach
new situations (approachability) were related to distress during a voiding
cystourethrogram (Merrit, Ornstein, & Spicker, 1994). Based on the
foregoing, we expected that children described as less adaptable, more likely
to withdraw, and more negative in mood would display increased pain
reactivity.
Prkachin and Craig (1995)
suggested that individuals differ in their sensitivity to evidence of pain in
others. Such differences in "decoding" ability may influence an
individual's response to the pain behavior of others. In this study, we
examined whether variations in parents' ability to decode facial expressions
of pain were related to their children's pain reactivity. Neither current
literature nor theory supports a directional hypothesis about the relationship
between sensitivity to facial expressions of pain among parents and their
children's pain reactivity; thus, no directional hypothesis was
formulated.
There is evidence that previous pain experience influences later pain
behavior in complex ways. If attention is restricted to the number of pain
experiences, the general results are equivocal. In infants and toddlers,
experiencing more medical interventions has been related to decreased
sensitivity (Grunau, Whitfield, &
Petrie, 1994), but some research has also demonstrated
sensitization (Taddio, Katz, Hersich,
& Koren, 1997). In older children, some research has suggested
habituation to medical procedures
(Jacobsen, Manne, Gorfinkle, & Schorr,
1990; Jay, Ozolins, Elliott,
& Caldwell, 1983), whereas others report no significant effect
of previous pain (Katz, Kellerman, &
Siegel, 1980; Wong &
Baker, 1988). When account is taken of the intensity or valence of
pain experience, the effects appear to be more consistent. Children whose
previous pain experiences have been more intense or unpleasant have been
reported to exhibit more subsequent distress than children whose experiences
have been less intense (Bijttebier &
Vertommen, 1998; Dahlquist et
al, 1986; Frank et al.,
1995). Accordingly, children who had more negative experiences
with previous medical procedures likely would display increased pain
reactivity.
In summary, theory and existing evidence suggested the formulation of a model in which parental encouragement of illness behavior and the number of pain models in the home are viewed as predictors of somatization. Pain reactivity also is seen as having a central role as a predictor of somatization and parental behavior during inoculation. Pain reactivity, in turn, is viewed as reflecting previous pain experience, temperament, parental decoding ability, and number of pain models. No existing studies have examined these influences comprehensively.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Participants and Setting
The participants were 163 mothers and their children. The mean age of the children (53% boys) was 62 months (SD = 3.5, range = 56-68 months). Eighty-four percent were from two-parent families. Mean maternal age was 32 years (SD = 5). Families' occupational status was generally middle class (mean socioeconomic index = 44.39, SD = 13.27), according to the scale developed by Blishen, Carroll, and Moore (1987
). Ninety-four percent of
the families were Caucasian; the remainder were Aboriginal and Indo-Canadian.
The study was conducted at a community health unit. Seven nurses administered
the injections. Three hundred fifty-nine parents were approached to participate. Two hundred eighty-nine (81%) agreed. Twenty-six parent-child pairs were used as a pilot sample. Due to low participation rates among pilot study fathers, only mothers were recruited for the final study. Four children were not videotaped because they had very strong emotional reactions prior to the needle and were taken to another room. One mother withdrew midway through the procedure. Of the 263 remaining participants, 186 (71%) returned completed questionnaires.
Apparatus
An 18-inch color television/VCR combination with remote control was used to
show parents video clips. A color video camera mounted on a tripod was used to
record the child's facial behavior. Tapes were later superimposed with a
digital time display so that specific time segments could be selected and
coded. An 18-inch color monitor and video-cassette recorder with remote
control, stop action, and slow motion feedback were used to code the
videotapes.
Measures
Somatization. Somatization was assessed by the parent
version of the Children's Somatization Inventory (P-CSI;
Garber et al., 1991). The
P-CSI is a widely used measure of children's somatization derived from
DSM-IV criteria. Mothers rated the extent to which their children had
experienced each of 36 somatic complaints in the last 2 weeks on four-category
scales ranging from not at all (0) to a whole lot (3). The total score,
obtained by summing the ratings, can range from 0 to 140. The P-CSI has
adequate internal consistency (Cronbach 
= .86;
Garber et al., 1991).
Encouragement of Illness Behavior. The extent to which
mothers encouraged their children's reports of somatic complaints was assessed
with the Illness Behavior Encouragement Scale (IBES;
Walker & Zeman, 1992).
This measure consisted of 10 items referring to parent responses to pain
symptoms. Adequate internal consistency (Cronbach = .83), test-retest
reliability, and construct validity have been demonstrated for the IBES
(Walker & Zeman, 1992).
Items 3 and 6 of the original scale were removed as they pertained to homework
and were not appropriate for this age group.
Number of Pain Models. Mothers completed a form on which they reported the number of people in the home, either presently or in the past, who had experienced chronic pain. The total number of people reported was used as the number of pain models in the home.
Child's Pain Reactivity. Facial responses during
inoculation were used to index the child's pain reactivity, using an
abbreviation of the Facial Action Coding System (FACS;
Ekman & Friesen, 1978).
One trained coder carried out all the coding, and a second scored 7% of the
segments (n = 12) to determine interobserver agreement. Both coders
had demonstrated proficiency on the FACS final test
(Ekman & Friesen,
1978).
The facial action units (AUs) coded were AU 4 = brow lowerer, AU 6 = cheek
raise, AU 7 = lid tightener, AU 9 = nose wrinkle, AU 10 = upper lip raise, AU
20 = lip stretch, AU 27 = jaw drop, and AU 43 = eyes closed. These actions
have been identified by a number of researchers as being correlated with pain
(e.g., Craig, Hyde, & Patrick,
1991; Prkachin,
1992; Prkachin & Mercer,
1989). An intensity score, ranging from 1 (barely evident) to 5
(maximal), was assigned to each of the actions present. Interobserver
agreement, calculated according to the formula given by Ekman and Friesen
(1978), was .87, which
compares favorably with other FACS studies.
A FACS pain index was calculated by summing the products of the intensity
(1-5) of each AU and its duration
(Prkachin, Berzins, & Mercer,
1994). The following 10-second segments were coded: (a) baseline:
10 seconds prior to the injection, (b) reaction to the injection, and (c)
recovery: 10 seconds after the injection. Actions were coded as present if the
onset occurred during the designated time or if the onset was prior to the
designated time, but evidenced an increase of two or more intensity points.
For procedural reasons, in 4% of the segments, the child's face was not
visible.
Maternal Responses. A measure of the mother's behavioral
responses to her child's inoculation was developed and applied to videotapes
of the parent-child interaction. Ten categories of behavior were derived from
the literature (e.g., Blount et al.,
1989; Jacobsen et al.,
1990; Patterson & Ware,
1988) and operationalized: emotional support, distraction, praise
or positive talk, explanation or procedural statements, bargain/reward,
yell/threaten, criticize, plead, pain expression, and anxious questions or
comments. The behaviors were coded as present or absent over an interval from
20 seconds prior to injection to withdrawal of the needle. Twelve percent of
the video-tapes were coded by two research assistants to determine
interobserver agreement. Cohen's kappa was .90.
Temperament. Mothers completed the Behavioral Styles
Questionnaire (BSQ), a 100-item temperament measure for children 3 to 7 years
old (McDevitt & Carey,
1978). The BSQ assesses nine temperament traits: activity,
rhythmicity, approach, adaptability, intensity, mood, persistence,
distractibility, and threshold. Internal consistency ranges from .47 to .84
for the nine BSQ categories. Test-retest reliability ranges from .67 to .94
(McDevitt & Carey,
1978).
Parental Decoding Ability. To measure the ability to decode
facial expressions of pain, mothers observed a video-tape containing 12
excerpts of shoulder pain patients taken from a previous study
(Prkachin & Mercer, 1989).
The excerpts depicted facial expressions as patients were exposed to
range-of-motion tests. Each of the 12 excerpts showed the patient's head and
shoulders and was approximately 2 s long followed by 5 s of black screen.
Equal numbers of men and women were represented, and patients' pain responses
varied in intensity from no pain to severe pain, as indexed by measurements of
facial expression (Prkachin,
1992; Prkachin et al.,
1994). Immediately after viewing each clip, mothers rated how much
pain they thought the person expressed, using a 10-cm visual analog scale
(VAS) with anchor points of "no pain" and "severe
pain." VAS scores for each excerpt were correlated with FACS scores
quantifying the intensity of the patients' pain. The resulting correlation
coefficient calculated for each mother was taken as a measure of her ability
to decode pain. The mean correlation between maternal ratings and patient pain
scores was .52 (SD = .15).
Child's Previous Pain. Mothers completed a form that asked
questions about their child's previous experience with medical procedures.
They rated their child's reaction to the following experiences: medical and
dental appointments, throat cultures, blood work, hospitalizations, and
surgeries. A 7-point Likert scale (negative, neutral, positive) taken from
Dalhquist et al. (1986) was
used for the ratings. An index of the amount of previous negative
experience with medical procedures was calculated by summing the number of
medical procedures to which the child had shown a negative response (i.e., a
rating of 1, 2, or 3). The mean negative experience score was 1.6 (SD
= 1.4).
Procedures
Assessment of mothers' abilities to decode pain behavior took place in a
private room. On completion of this assessment, they were given a package
containing the questionnaires and demographics. Mothers were provided with a
self-addressed, stamped envelope and asked to complete the forms at home and
return them.
All children were administered a single 5 cc DPTP inoculation in the upper arm. The immunizations were carried out in a large cubicle that had a video camera. Children were seated on their mothers' laps, while the nurse swabbed the skin with alcohol and then administered the injection.
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Data Preparation
To simplify the temperament data, BSQ variables were subjected to a factor analysis employing a principal components extraction with varimax rotation. The three factors extracted accounted for 64% of the shared variance. Loadings are shown in Table I. Variables are ordered and grouped by size of loading to facilitate interpretation. Items with loadings of .5 or greater on the factors were used to aid in interpretation of the constructs. Activity and persistence loaded on Factor 1, which was labeled accordingly. Approach/withdrawal, mood, and adaptability loaded on the second factor, called Adjustment. Intensity, distractibility, and sensory threshold loaded on Factor 3 and this construct was called Sensitivity. These findings are consistent with a factor analysis performed on the BSQ in nursery school children by Simonds and Simonds (1982
).
|
Table II presents data on the occurrence of the maternal responses to inoculation. Due to the low occurrence of several categories, only behaviors displayed by at least 10% of mothers were used for analysis. Four behaviors met this criterion: emotional support, explaining/procedural statements, praise or positive talk, and distraction. The frequencies of these behaviors were summed to yield a single score (0-4) reflecting the number of types of maternal responses during inoculation. Mean number of maternal responses was 1.8 (SD = .92).
|
Of the 186 participants who returned their questionnaires, 21 were excluded due to missing data. Two cases were identified as multivariate outliers and were deleted according to the recommendations of Tabchnick and Fidell (1996). Thus, 163 cases remained for analysis.
Analyses
Table III presents bivariate
correlations among all the variables. Several low-to-moderate but nevertheless
significant relationships (all ps < .05) were observed. In
particular, the temperament variable of adjustment showed significant
associations with previous pain, pain reactivity, and somatization. Previous
pain experience was associated with illness behavior encouragement,
somatization, maternal behavior, and particularly pain reactivity. Pain
reactivity, in turn, was significantly related to maternal behavior and
somatization.
|
The conceptual model of Figure
1 was used to guide a structural modeling analysis, using a
maximum likelihood method, in LISREL 8.30
(Joreskog & Sorbom, 1999).
Factor scores for the three temperament dimensions were entered in the place
of the temperament construct. All exogenous variables were allowed to
intercorrelate with one another. The goodness-of-fit results are presented in
Table IV. This model provided a
reasonable approximation to the empirical data, as indicated by several
standard criteria. The 
2 was not significant, even though the
sample was relatively large, and the 2/df ratio was
less than 3, which is considered satisfactory by Joreskog
(1969). Furthermore, the Root
Mean Square Residual (RMSR) was low, whereas the Goodness of Fit Index (GFI)
and the Adjusted Goodness of Fit Index (AGFI) were very close to 1. The
temperament variable of adjustment (path coefficient = .20) and previous pain
experience (path coefficient = .19) emerged as significant predictors of pain
reactivity, which, in turn, emerged as a significant predictor of somatization
(path coefficient = .22). Pain reactivity was also a significant predictor of
maternal response (path coefficient = .33). The coefficients representing the
relations between maternal decoding ability, the temperamental variables of
sensitivity and activity/persistence, and pain reactivity were not
significant, nor were the coefficients for the relations between familial
modeling and pain reactivity or somatization. Finally, the relation between
somatization and illness-behavior encouragement was not significant.
|
|
To develop a more parsimonious description of the outcome, we derived a reduced model (see Figure 2) by eliminating the variables that did not contribute significantly in any of the pathways. This model was then reevaluated in LISREL. The reduced model also provided a reasonable fit to the data, with nonsignificant
2,
low 2/df ratio and RMSR, and high GFI and AGFI. The
reduced model did not differ significantly from the original model.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
This study evaluated predictors of somatization and pain reactivity in young children. The results of the structural modeling analyses suggested that the initial conceptual model of predictors of somatization and pain reactivity was a reasonable approximation of the empirical outcome; however, some of the expected relations were not observed and a simplified model also provided a reasonable fit to the data.
Predictors of Somatization
Contrary to expectations, somatization as assessed by maternal report on
the P-CSI was unrelated either to the presence of pain models or maternal
reports of encouraging illness behavior. However, as hypothesized, pain
reactivity was a significant predictor of somatization. This finding is new to
the literature. The fact that the measures of pain reactivity and somatization
were derived from different sources (one from observations of behavior and the
other from mothers) and assessed at different times enhances our confidence
that this is a meaningful finding. Although the P-CSI contains items that
assess pain responses, it also assesses a more generic range of illness
presentation consistent with the concept of somatization (i.e., a tendency to
present a variety of somatic complaints). Because pain is the cardinal somatic
complaint, it seems reasonable to suggest that the child's response to an
acute pain stimulus may be a marker of how that child responds to physical
symptoms in general. This observation has two potentially important
implications. First, observations of children's pain reactivity may provide a
means of identifying those at risk of future somatization disorders or
increased engagement with health care. Second, increased study of parents' and
others' responses to pain expression may help identify mechanisms responsible
for the development or prevention of somatization.
The foregoing conclusions assume a degree of continuity between
somatization, as assessed by the P-CSI, and the clinical entity of
somatization. Few, if any, of the children who participated in this study
would meet diagnostic criteria for somatization. There is debate over criteria
for identifying clinically significant somatization with the P-CSI
(Campo & Fritsch, 1994;
Garralda, 1996). If a
stringent criterion of 13 or more symptoms is applied, then only 3.6% of our
sample would qualify. This figure is slightly higher than the 1.1% reported by
Garber et al. (1991), and the
mean P-CSI score in this sample (3.48) was slightly higher than that of
slightly older children (2.14) in Garber et al.
(1991). In a longitudinal
study of predictors of somatization among children 4.5 years of age, from data
at 3 years, Grunau, Whitfield, Petrie, and Fryer
(1994), using a different
instrument, reported that none of their sample of otherwise healthy
4.5-year-olds exceeded clinical cutoff scores for somatization. In the same
sample, followed up at ages 8-10, 8% exceeded clinical cutoffs
(Grunau, Whitfield, & Petrie,
1998). Thus, although caution is warranted in interpreting the
meaning of the term somatization in this study, the characteristics
of our sample do not differ markedly from others in the literature.
Predictors of Pain Reactivity
Children with temperaments characterized as low in adjustment exhibited
enhanced pain reactivity. This outcome is consistent with other studies of
children from a range of ages (Grunau et
al., 1994; Merrit et al., 1994;
Schechter et al., 1991;
Wallace, 1989;
Young & Fu, 1988).
Together with this study, these findings suggest that children whom their
parents describe as prone to negative mood, unadaptable, and withdrawn also
are given to enhanced reactions to pain. The consistency of this finding
underscores the importance of considering temperamental differences among
children in decisions about their management in medical settings.
Children who had more negative experiences with medical procedures reacted
more intensely to the pain of inoculation than those with fewer negative
experiences. These findings are consistent with previous literature that takes
into account the role of quality of previous medical experience on subsequent
pain behavior (Bittjebier & Vertommen, 1998;
Dahlquist et al., 1986;
Frank et al., 1995). Thus, it
seems that quality, rather than number, is the crucial variable mediating the
impact of previous experiences with medical procedures. Children may retain
vivid memories of negative past experiences that serve to sensitize them and
enhance their response to current pains. Indeed, research in adult populations
has demonstrated that adult pain and fear levels are associated with recalled
experiences of pain from childhood (Pate,
Blount, Cohen, & Smith, 1996). Further research into the
relationship between memory of painful procedures and subsequent distress in
children is warranted.
Mothers' abilities to decode facial expressions of pain were unrelated to their children's pain reactivity. It is possible that the test of decoding ability developed for this study was insufficiently sensitive to reveal relationships with children's pain behavior and that a different form of assessment, perhaps having parents decode the pain behavior of children, would have been more informative. Nevertheless, this study suggests that any relationship between parental decoding of pain expression and pain behavior is not straightforward. Further research is necessary to sort out alternative possibilities and clarify the ecological significance, if any, of individual differences in the ability to decode pain expression.
Maternal Responses to Children's Pain
Consistent with previous research with younger children
(Sweet & McGrath, 1998),
mothers of children who exhibited a stronger response to the inoculation were
more likely to interact with their child during the procedure, providing
emotional support, praise, distraction, and explanatory and procedural
comments during the inoculation. Although these behaviors are quite different
from one another and may represent different parental strategies or styles,
they are commonly observed in studies of inoculation. Given their knowledge of
their child's temperament and previous reactions to pain, mothers may have
been able to anticipate their child's level of distress and consequently
engage in efforts to quell it. In addition, a mother's behavior may have been
governed by her child's response during the inoculation. The correlational
analysis supports each of these possibilities, since maternal responses were
associated with temperament and previous pain, to a limited degree, and with
child reactivity to a greater degree.
Implications of the Structural Modeling Analyses
Structural modeling can help evaluate and refine models of complex
relationships among variables. Although the initial model that guided this
study was statistically consistent with the empirical outcomes, a substantial
number of the expected relationships did not emerge as significant, leading us
to propose and test the reduced model of
Figure 2. Given the a
posteriori nature of the revised model, it can be offered only as a basis for
future studies.
The reduced model may not fully capture the dynamic properties of some of
the variables it retains. For example, maternal response is conceived within
the model as a "downstream" variable. This implies that the
behaviors assessed represent the mother's responses to her child's pain
displays. However, a mother's behaviors are not simply reactions. They are
also attempts to regulate the stressful situation in which she and the child
find themselves. This interpretation supports the expectation that, over time,
maternal responses to their children should have recursive consequences on the
child, possibly affecting pain reactivity or other components of the overall
response to inoculation stress. Consistent with this suggestion, Grunau,
Whitfield, Petrie, and Fryer
(1994) have found that
mothers' sensitivity to cues from their 3-year-old children, assessed by
behavioral observation, was associated prospectively with somatization
assessed at age 4.5. Such potential effects were not modeled in this study and
represent a challenge for future research.
It is important to note some of the limitations of this study. Problems
with the measure of family health information may have obscured the
hypothesized relationships with pain reactivity and somatization. That is,
mothers' reports of pain problems within the family may have been affected by
the unspecific nature of the question ("Does anyone in your home suffer
from pain?"). Although previous research has shown that pain behavior
and pain models in the home are positively related
(Edwards et al., 1985;
Jamison & Walker, 1992),
it may be more informative to assess whether family members model adaptive or
maladaptive pain management strategies.
As fathers were not included in the sample, findings are generalizable only
to mother—child influences. Future studies should attempt to obtain data
from fathers, as they play an important role in the socialization of pain and
somatization for their children (Schechter
et al., 1991).
The results support further research into the role of temperament and previous medical experiences in the development of pain and somatization. Understanding how temperament and previous pain experiences can influence coping during painful medical procedures may help to target children at risk for extreme pain reactivity and may ultimately lead to pain interventions tailored to children's individual predispositions. Further study of the relationship between pain reactivity and somatization is also warranted.
Although the path model employed in this study implies a causal direction from pain reactivity to somatization, obviously such a conclusion is not sustainable solely on the strength of this evidence. However, the methods employed here lend themselves to incorporation into prospective studies that can help resolve causal direction. Because patterns for exhibiting somatization develop in childhood and progress into adulthood, identification of factors that may play a role in the ontogeny of somatization is an important goal for future research. The findings of this study can serve as a foundation for prospective models attempting to account for variation in pain and somatization in young children.
|
Acknowledgments |
|---|
We thank Lynn Lee-Ran, Karen Schierer, Christine Gertzen, Caron Hurt, Elizabeth Hughes, Greg Pope, and Reiko Graham for assistance with data collection and reliability coding. We also thank the staff members of the Northern Interior Health Unit and the children and their parents who participated. This study was based on Elizabete M. Rocha's master's thesis submitted to the University of Northern British Columbia. Bruno D. Zumbo is now at the Department of Educational and Counseling Psychology, and Special Education, University of British Columbia.
|
Notes |
|---|
This paper was reviewed and accepted during the term of the previous editor, Anne E. Kazak, PhD, ABPP.
Received March 12, 2001; revision received August 15, 2001; accepted March 28, 2002
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Apley, J. (1975). The child with abdominal pains. Black-well: Oxford.
Barr, R. G., Boyce, W. T., & Zeltzer, L. K. (1994). The stress-illness association in children: A perspective from the biobehavioral interface. In R. J. Haggerty, L. K. Sherrod, N. Garmezy, & M. Rutter (Eds.), Stress, risk and resilience in children and adolescents: Processes, mechanisms and interventions. Cambridge: Cambridge University Press.
Bijttebier, P., & Vertommen, H. (1998). The impact of previous experience on children's reactions to venipunctures. Journal of Health Psychology, 3, 39-46.[Abstract]
Blishen, B. R., Carroll, W. K., & Moore, C. (1987). The 1981 socioeconomic index for occupations in Canada. Canadian Review of Sociology and Anthropology, 24, 465-488.
Blount, R. L., Corbin, S., Sturges, J. W., Wolfe, V. V., Prater, J., & James, L. (1989). The relationship between adults' behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behaviour Therapy, 20, 561-585.
Campo, J. V., & Fritsch, S. L. (1994). Somatization in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 1223-1235.[Web of Science][Medline]
Cohen, L. L., Manimala, R., & Blount, R. L. (2000). Easier said than done: What parents say they do and what they do during children's immunizations. Children's Health Care, 29, 79-86.
Craig, K. D. (1986). Pain in context: Social modeling influences. In R. A. Sternbach (Ed.), The psychology of pain (pp. 67-96). New York: Raven.
Craig, K. D., Hyde, S. A., & Patrick, C. J. (1991). Genuine, suppressed and faked facial behavior during exacerbation of chronic low back pain. Pain, 46, 153-160.[CrossRef][Web of Science][Medline]
Craig, K. D., Prkachin, K. M., & Grunau, R. V. E. (2001). The facial expression of pain. In D.C. Turk & R. Melzack (Eds.), Handbook of pain assessment (2nd ed.). New York: Guilford.
Dahlquist, L. M., Gil, K. M., Armstrong, F. D., DeLawyer, D. D., Greene, P., & Wuori, D. (1986). Preparing children for medical examinations: The importance of previous medical experience. Health Psychology, 5, 249-259.[CrossRef][Web of Science][Medline]
Dahlquist, L. M., Power, T. G., & Carlson, L.
(1995). Physician and parent behavior during invasive pediatric
cancer procedures: Relationships to child behavioral distress.
Journal of Pediatric Psychology,
20, 477-490.
Dunn-Geier, B. J., McGrath, P. J., Rourke, B. P., Latter, L., & D'Astous, J. (1986). Adolescent chronic pain: The ability to cope. Pain, 26, 23-32.[CrossRef][Web of Science][Medline]
Edwards, P. W., Zeichner, A., Kuczmierczyk, A. R., & Boczkowski, J. (1985). Familial pain models: The relationship between family history of pain and current pain experience. Pain, 28, 379-384.
Ekman, P., & Friesen, W. V. (1978). Manual for the Facial Action Coding System. Palo Alto, CA: Consulting Psychologists Press.
Ekman, P., & Friesen, W. V., & Simmons, R. C. (1985). Is the startle reaction an emotion? Journal of Personality and Social Psychology, 49, 1416-1426.
Fordyce, W. E. (1976). Behavioral methods for chronic pain and illness. St. Louis, MO: Mosby.
Frank, N. C., Blount, R. L., Smith, A. J., Manimala, M. R., &
Martin, J. K. (1995). Parent and staff behavior, previous child
medical experience, and maternal anxiety as they relate to child procedural
distress and coping. Journal of Pediatric Psychology,
20, 277-289.
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: A Journal of Consulting and Clinical Psychology, 3, 588-595.
Garralda, M. E. (1996). Somatization in children. Journal of Child Psychology and Psychiatry and Allied Disciplines, 37, 13-33.[Web of Science][Medline]
Gonzalez, J. C., Routh, D. K., & Armstrong, F. D.
(1993). Effects of maternal distress versus reassurance on
children's reactions to injections. Journal of Pediatric
Psychology, 18,
593-604.
Grunau, R. E., Whitfield, M. F., & Petrie, J. H. (1994). Pain sensitivity and temperament in extremely low-birth-weight premature toddlers and preterm and full-term controls. Pain, 58, 341-346.[CrossRef][Web of Science][Medline]
Grunau, R. E., Whitfield, M. F., & Petrie, J.
(1998). Children's judgements about pain at age 8-10 years: Do
extremely low birthweight (
1000 g) children differ from full birthweight
peers? Journal of Child Psychology, Psychiatry and Allied
Disciplines, 39,
587-594.[CrossRef][Web of Science][Medline]
Grunau, R. E., Whitfield, M. F., Petrie, J. H., & Fryer, E. L. (1994). Early pain experience, child and family factors as precursors of somatization: A prospective study of extremely premature and fullterm children. Pain, 56, 353-359.[CrossRef][Web of Science][Medline]
Jacobsen, P. B., Manne, S. L., Gorfinkle, K., & Schorr, O. (1990). Analysis of child and parent behaviour during painful medical procedures. Health Psychology, 9, 559-576.[CrossRef][Web of Science][Medline]
Jamison, R. N., & Walker, L. S. (1992). Illness behavior in children of chronic pain patients. International Journal of Psychiatry in Medicine, 22, 329-342.[Web of Science][Medline]
Jay, S. M., Ozolins, M., Elliott, C. H., & Caldwell, S. (1983). Assessment of children's distress during painful medical procedures. Health Psychology, 2, 133-147.
Joreskog, K. G. (1969). A general approach to confirmatory maximum liklihod factor analysis. Psychometrika, 34, 183-202.[CrossRef][Web of Science]
Joreskog, K. G., & Sorbom, D. (1999). LISREL 8.30: A guide to the program and applications. Chicago: Scientific Software International.
Katz, E. R., Kellerman, J., & Siegel, S. E. (1980). Behavioral distress in children with cancer undergoing medical procedures: Developmental considerations. Journal of Consulting and Clinical Psychology, 48, 356-365.[CrossRef][Web of Science][Medline]
Kopp, C. (1982). Antecedents of self-regulation: A developmental perspective. Developmental Psychology, 18, 199-214.[CrossRef][Web of Science]
McDevitt, S. C., & Carey, W. B. (1978). The measurement of temperament in 3-7-year-old children. Journal of Child Psychology and Psychiatry, 19, 245-253.[Web of Science][Medline]
Mechanic, D. (1980). The experience of reporting common physical complaints. Journal of Health and Social Behaviour, 21, 146-155.[CrossRef][Web of Science][Medline]
Merritt, K. A., Ornstein, P. A., & Spicker, B.
(1994). Children's memory for a salient medical procedure:
Implications for testimony. Pediatrics,
94, 17-23.
Negayama, K. (1999). Development of reactions to pain
of inoculation in children and their mothers. International Journal
of Behavioral Development, 23,
731-746.
Offord, D. R., Boyle, M. H., Szatmari, P., Rae-Grant, N. I., Links,
P. S., Cadman, D. T., Byles, J. A., Crawford, J. W., Blum, H. M., & Byrne,
C. (1987). Ontario Child Health Study: II. Six-month prevalence
of disorder and rates of service utilization. Archives of General
Psychiatry, 44,
832-836.
Pate, J. F., Blount, R. L., Cohen, L. L., & Smith, A. J. (1996). Childhood medical experience and temperament as predictors of adult functioning in medical situations. Children's Health Care, 25, 281-198.[CrossRef]
Patterson, K. L., & Ware, L. L. (1988). Coping skills for children undergoing painful medical procedures. Issues in Comprehensive Pediatric Nursing, 11, 113-143.[Medline]
Prkachin, K. M. (1986). Pain behaviour is not unitary. Behavioral & Brain Sciences, 9, 754-755.[Web of Science]
Prkachin, K. M. (1992). The consistency of facial expressions of pain: A comparison across modalities. Pain, 51, 297-306.[CrossRef][Web of Science][Medline]
Prkachin, K. M., Berzins, S., & Mercer, S. R. (1994). Encoding and decoding of pain expressions: A judgement study. Pain, 58, 253-259.[CrossRef][Web of Science][Medline]
Prkachin, K. M., & Craig, K. D. (1985). Influencing nonverbal expressions of pain: Signal detection analyses. Pain, 21, 399-409.[CrossRef][Web of Science][Medline]
Prkachin, K. M., & Craig, K. D. (1995). Expressing pain: The communication and interpretation of facial pain signals. Journal of Nonverbal Behaviour, 19, 191-205.
Prkachin, K. M., & Mercer, S. R. (1989). Pain expression in patients with shoulder pathology: Validity, properties and relationship to sickness impact. Pain, 39, 257-265.[CrossRef][Web of Science][Medline]
Schechter, N. L., Berstein, B. A., Beck, A., Hart, L., &
Scherzer, L. (1991). Individual differences in children's
response to pain: Role of temperament and parental characteristics.
Pediatrics, 87,
171-177.
Simonds, J. F., & Simonds, M. P. (1982). Factor analysis of temperament category scores in a sample of nursery school children. Journal of Clinical Psychology, 38, 359-366.[CrossRef][Web of Science]
Sweet, S. D., & McGrath, P. J. (1998). Relative
importance of mothers' versus medical staffs' behavior in the prediction of
infant immunization pain behavior. Journal of Pediatric
Psychology, 23,
249-256.
Tabachnick, B. G., & Fidell, L. S. (1996). Using multivariate statistics (3rd ed.). New York: Harper-Collins.
Taddio, A., Katz, J., Hersich, A. L., & Koren, G (1997). Effect of neonatal circumcision on pain responses during subsequent routine vaccination. Lancet, 349, 599-603.[CrossRef][Web of Science][Medline]
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.[CrossRef][Web of Science][Medline]
Walker, L. S., Garber, J., & Greene, J. W. (1994). Somatic complaints in pediatric patients: A prospective study of the role of negative life events, child social and academic competence and parental somatic symptoms. Journal of Consulting and Clinical Psychology, 62, 1213-1221.[CrossRef][Web of Science][Medline]
Walker, L. S., & Zeman, J. L. (1992). Parental
response to child illness behavior. Journal of Pediatric
Psychology, 17,
49-71.
Wallace, M. R. (1989). Temperament: A variable in children's pain management. Pediatric Nursing, 15, 118-121.[Medline]
Wong, D. L., & Baker, C. M. (1988). Pain in children: Comparisons of assessment scales. Pediatric Nursing, 14, 9-17.[Medline]
Young, M. R., & Fu, V. R. (1988). Influence of play and temperament on the young child's response to pain. Child Health Care, 18, 209-217.[CrossRef]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  N. Wolff, A.-S. Darlington, J. Hunfeld, F. Verhulst, V. Jaddoe, A. Hofman, J. Passchier, and H. Tiemeier Determinants of Somatic Complaints in 18-month-old Children: The Generation R Study J. Pediatr. Psychol., September 8, 2009; (2009) jsp058v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. S. Walker, J. E. Beck, J. Garber, and W. Lambert Children's Somatization Inventory: Psychometric Properties of the Revised Form (CSI-24) J. Pediatr. Psychol., May 1, 2009; 34(4): 430 - 440. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. A. Walco Needle Pain in Children: Contextual Factors Pediatrics, November 1, 2008; 122(Supplement_3): S125 - S129. [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]
|
|
|
|
|
|
E. M. Rocha and K. M. Prkachin Temperament and Pain Reactivity Predict Health Behavior Seven Years Later J. Pediatr. Psychol., May 1, 2007; 32(4): 393 - 399. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||