Behavioural assessmentCognitive-behavioural predictors of children's tolerance of laboratory-induced pain: implications for clinical assessment and future directions
Introduction
The cognitive-behavioural approach has come a long way since its inception as a treatment purely for emotional disorders (see Beck, Rush, Shaw, & Emery, 1979). There is a growing body of research highlighting the role of individuals' beliefs, expectations, and coping strategies on the outcome and management of a range of physical/medical stressors and symptoms, such as tinnitus (Wilson, Henry & Nicholas, 1993), epilepsy (Gillham, 1990, Goldstein, 1990), diabetes (Henry, Wilson, Bruce, Chisholm, & Rawling, 1997), cardiovascular disease (Johnston, 1997), and pain management (Turk & Rudy, 1986). Although more extensively investigated within adult samples, coping style and beliefs in one's ability to deal with physical or medical stressors are also important areas of study among children.
Children's responses to painful medical procedures and, more specifically, their ability to tolerate pain, vary considerably. Although every effort is made within clinical settings to minimise the amount of pain experienced, it is nevertheless a reality that some medical procedures result in some degree of pain. Therefore, improved knowledge of the correlates of children's pain tolerance has potentially important clinical implications for the management of children undergoing painful medical procedures. The need for more systematic study of the determinants of children's pain outcome has been highlighted by recent attempts to model paediatric pain (McGrath, 1993; Rudolph, Dennig, & Weisz, 1995; Varni, Blount, Waldron, & Smith, 1995). In particular, Rudolph and her colleagues have provided the infrastructure for further research through a conceptual model identifying a range of person-specific, contextual, and cognitive factors that may influence children's pain outcome. In light of the burgeoning literature focusing on cognitive factors in adults adjusting to physical/medical stressors (Hevey, Smith, & McGee, 1998), the present study investigated the role of such factors in children coping with acute pain. More specifically, the present study examined the role of pain self-efficacy (i.e. the belief in one's ability to cope with or master a painful experience) and pain coping strategies on children's pain tolerance, whilst bearing in mind possible developmental and sex differences.
Self-efficacy has been found, in adults, to be associated with higher levels of pain tolerance (Bandura, O'Leary, Taylor, Gauthier, & Gossard, 1987; Dolce et al., 1986; Jensen & Karoly, 1991; Litt, 1988; Vallis & Bucher, 1986), and more adaptive pain coping behaviour (Schermellehengel, Eifert, Moosbrugger, & Frank, 1997). The role of self-efficacy in relation to coping with pain during childhood has received less attention. Conceptually, researchers have acknowledged the importance of a child's beliefs about pain and their ability to cope (Peterson, 1989; Siegel & Smith, 1989), but there has been a dearth of empirical investigation. Perhaps the exception is a study by Bennett-Branson and Craig (1993), who investigated children coping with post-operative pain, and found that coping self-efficacy whilst experiencing pain was inversely related to reported distress and pain intensity levels.
Available evidence suggests that there are substantial differences in the types of coping strategies spontaneously used by children when confronted with painful or stressful events (see Siegel & Smith, 1989). Type of coping strategy may serve either as a risk factor for, or as a protective factor against, a poor pain outcome (Varni, 1989 cited by Varni et al., 1995). Coping responses have been classified along several different dimensions. One influential dichotomy distinguishes between problem-focused and emotion-focused coping (Lazarus & Folkman, 1984). Problem-focused coping strategies focus on altering or eliminating the distressing situation, such as through cognitive distraction or use of positive self-statements, while emotion-focused coping strategies are directed at regulating the emotional consequences of an event, such as through externalising or internalising/catastrophising. While this dichotomy has been applied to paediatric pain (Reid et al., 1998, Rudolph et al., 1995), more empirical work is needed to better understand the relationships between children's spontaneous use of coping strategies and their pain tolerance.
Studies of sex differences in children's use of coping strategies have yielded mixed results. Brown, O'Keeffe, Sanders, and Baker (1986) found no difference in the proportion of catastrophisers in a sample of boys as compared to a sample of girls. Another study found girls to make greater use of emotion-management strategies when dealing with cancer-related stressors, whereas boys engaged in more problem-solving (Bull & Drotar, 1991).
Developmental differences in children's use of pain coping strategies have been widely reported (Altashuler & Ruble, 1989; Bennett-Branson & Craig, 1993; Chaves & Brown, 1987). However, these findings have been brought into question by Reid, Gilbert and McGrath (1994), who suggested that earlier results may have been an artifact of the response formats used. Notably, previous studies had generally required the child to spontaneously report which coping strategies they had used, rather than utilising a checklist style of format, which is cognitively simpler. Reid et al. (1994) found no age differences in children's reported use of coping strategies when using a checklist style of response format.
There is reason, however, to expect age differences in children's ability to tolerate pain, especially a child's ability to understand the necessity of pain in some treatments. For example, Siegel and Smith (1989) noted that preschool-aged children typically rely on global, undifferentiated conceptualisations of illness, involving magical thinking and circular logic. Hence, they are less likely than older children to understand that a painful experience is usually temporary. According to Piagetian theory, the capacity for the reversibility of operations (i.e. the belief that the original situation, in this case the absence of pain, can be recreated with time and/or some intervention) is typically developed by primary school-age. Thus, the older child is able to recognise that a painful procedure may be a prerequisite for feeling better at a later stage (Bush, 1987).
The relationship between sex and children's self-reported pain intensity ratings is less clear. Some studies have found girls to report greater levels of pain intensity than boys (Carr, Lemanek, & Armstrong, 1998). However, it has been suggested that such findings may be reflective of cultural and societal expectations on children's reporting behaviour, rather than sex differences in sensitivity to pain per se (McGrath, 1993). Other studies have not found any sex differences in pain intensity ratings but, rather, on other dimensions such as unpleasantness (e.g. Goodenough et al., 1999).
Although discussions of pain assessment generally focus on the measurement of pain intensity, the present study sought to investigate factors associated with pain tolerance rather than intensity. Arguably, it is a child's level of pain tolerance, or the level of pain that he or she feels able to tolerate, which may influence the type of pain management and intervention needed to a greater degree than their reported level of pain intensity per se. Pain tolerance was studied as a function of self-efficacy and coping styles. In order to reduce the impact of confounding factors, such as pain history and medical factors, the cold-pressor pain paradigm was employed in an non-clinical sample of children. This is a widely accepted experimental method for inducing acute pain in children (Fanurik, Zeltzer, Roberts and Blount, 1993; Zeltzer, Fanurik and LeBaron, 1989; LeBaron, Zeltzer, & Fanurik, 1989; Miller, Barr, & Young, 1994). Although care needs to be taken when generalising to other pain contexts, the cold-pressor pain paradigm has permitted an ethical and more direct measurement of pain tolerance than is afforded in clinical contexts.
It was hypothesised that pain tolerance would be positively correlated with self-efficacy (both specific to cold-pressor and more general pain-related self-efficacy). With respect to coping strategies, it was expected that pain tolerance would be positively associated with use of problem-focused coping strategies (problem-solving, cognitive distraction, and positive self-statements), and negatively associated with use of emotion-focused coping strategies (internalising/catastrophising and externalising). Effects of age and sex were examined in post hoc analyses.
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Participants
A convenience sample of 53 healthy children (22 males, 31 females) between the ages of 7 and 14 years participated in the study. The mean age of the male participants was 8 years and 9 months (SD=1.88) and of the female participants 9 years and 4 months (SD=1.79). Thirty-three children were recruited from three urban Australian before-and-after school care centres and 20 children were recruited through personal contacts. Participation in the study was dependent on the return of signed
Descriptive information
Descriptive information for age, measured variables of interest, and response to the cold-pressor task is presented in Table 1. As evident in Table 1, the Cronbach's alpha reliability coefficients for the PCQ subscales were modest. Although the externalising subscale was administered as part of the modified PCQ, all children reported that they made no use of four out of the five coping strategies contributing to scores on this subscale. Given this low variability in scores, the externalising
Discussion
The results provide some support for views derived from cognitive-behavioural theory concerning the determinants of coping with acute pain (Bandura, 1986; Lazarus & Folkman, 1984; Rudolph et al., 1995). Moreover, the current study highlights the importance of considering children's pain tolerance as an important outcome measure, rather than focusing purely on a child's reported levels of pain intensity. The results suggest that pain intensity and tolerance are not necessarily closely related,
Acknowledgements
We are grateful to the children who participated in this study and to the staff at Lindfield Activity Centre, Roseville Kids' Care Out of School Hours Centre and Northbridge Before and After School Care Centre, in Sydney, Australia. Support for this research was provided in part by a National Health and Medical Research Council grant (project number 970858) awarded to J.E.T. and B.G. jointly with David Champion and John Ziegler. Some of the results of this study were presented at the 19th
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