The role of narrative in the development of children's pain memories: influences of father- and mother-child reminiscing on children's recall of pain

The effect of retrieval-induced forgetting for pain-related memories on child pain-related outcomes: A randomized experimental study

BACKGROUND

Children's inability to forget the negative aspects of a painful event is associated with more anticipatory anxiety at an upcoming pain task and lower pain thresholds; however, the impact of forgetting on children's pain outcomes has not been examined. Retrieval-Induced Forgetting (RIF) was experimentally induced to investigate whether children would (1) forget more negative details of a previous painful autobiographic event and; (2) report better pain-related outcomes for an unrelated pain task (i.e., cold pressor task; CPT). Additionally, it was investigated whether the success of RIF was dependent on child characteristics known to influence children's memories for pain (i.e., attention bias to pain, attention switching ability and pain catastrophizing).

METHODS

Healthy school children (N = 128; 9-16 years old) recalled and rehearsed memory details of two painful autobiographical events, while only children in the randomized RIF group rehearsed positive details. All children underwent two CPTs (before and after RIF) and reported pain-related outcomes. Two weeks later, children recalled CPT pain and reported on future pain expectancies.

RESULTS

Children in the RIF group remembered less negative details of their past autobiographical pain events, but also reported a greater reduction in pain-related fear from the CPT 2 compared to their ratings for CPT 1, than children in the control group. They furthermore expected less pain-related fear 2 weeks later for a future pain task.

DISCUSSION

Findings suggest that RIF is a promising avenue in pediatric pain management that could be harnessed to foster more positive memories and better future pain experiences.

SIGNIFICANCE STATEMENT

Retrieval-induced forgetting (RIF) makes children forget negative details of a past autobiographical pain experience, decreases experienced pain-related fear for experimental pain and lowers future pain-related fear expectancies. Results show a promising role for RIF- based memory interventions in the context of paediatric pain care.

Health Benefits in a Cohort of Children 6 Months After Tonsil Surgery in Relation to the Perioperative Period: An Observational Prospective Cohort Study

Background and Aim

Tonsil-surgery is a common treatment for tonsillitis and upper-airway obstruction. Health benefits are a key point of clinical concern. Aim: To evaluate health benefits 6-months after pediatric tonsil-surgery and to examine the influence of the perioperative period on health-related quality of life (HRQoL).

Method

Participants, 198 children (4-17 years) who underwent tonsillectomy ± adenoidectomy on infection-related indications (TE ± A infec , n = 46), tonsillectomy ± adenoidectomy due to upper-airway-obstruction (TE ± A obstr , n = 44), or tonsillotomy ± adenoidectomy due to upper-airway-obstruction (TT ± A obstr , n = 108). Data were collected via a postoperative pain-diary, and 6-month-questionnaires. The Glasgow Children's Benefit Inventory (GCBI) evaluated HRQoL. An additional questionnaire assessed disease-specific benefits, including open-ended-questions to capture what the children wanted to convey to other children scheduled for surgery.

Results

QoL-score after surgery was positive in all indication/surgical-method groups. The highest GCBI-scores were seen in the subscale-scores for physical health and vitality. Comparing TE ± A obstr and TT ± A obstr , no significant differences were noted in the total-score or in the subscores. No differences in GCBI-scores were seen between subgroups of patients divided by postoperative pain intensity and duration. No differences in frequency or loudness of snoring or ENT-infections were seen between the groups, and satisfaction rates were high. The information that the children considered essential to share with others covered details of the day of surgery, including the anesthesia, nutrition, pain and pain relief, and well-being after surgery.

Conclusions

All indication/surgical-method groups reported improvements regarding the health benefits of surgery, with the most pronounced effect being seen for physical health and vitality. TE ± A and TT ± A showed similar benefits in cases of obstructive and infection problems. Postoperative pain had no impact on QoL at the 6-month follow-up. Children's memories of the surgery can provide direction for management and improvements in children's care. Pain management needs to be optimized to improve recovery.

Parental narrative style moderates the relation between pain-related attention and memory biases in youth with chronic pain

ABSTRACT

Negatively biased pain memories robustly predict maladaptive pain outcomes in children. Both attention bias to pain and parental narrative style have been linked with the development of these negative biases, with previous studies indicating that how parents talk to their child about the pain might buffer the influence of children's attention bias to pain on the development of such negatively biased pain memories. This study investigated the moderating role of parental narrative style in the relation between pain-related attention and memory biases in a pediatric chronic pain sample who underwent a cold pressor task. Participants were 85 youth-parent dyads who reminisced about youth's painful event. Eye-tracking technology was used to assess youth's attention bias to pain information, whereas youth's pain-related memories were elicited 1 month later through telephone interview. Results indicated that a parental narrative style using less repetitive yes-no questions, more emotion words, and less fear words buffered the influence of high levels of youth's attention bias to pain in the development of negatively biased pain memories. Opposite effects were observed for youth with low levels of attention bias to pain. Current findings corroborate earlier results on parental reminiscing in the context of pain (memories) but stress the importance of matching narrative style with child characteristics, such as child attention bias to pain, in the development of negatively biased pain memories. Future avenues for parent-child reminiscing and clinical implications for pediatric chronic pain are discussed.

Narrative Accounts of Youth and Their Mothers With Chronic Headache: Application of a Socio-narratology Framework to Pain Narratives

OBJECTIVES

This study was the first to apply a socio-narratology framework to the narratives about child pain as told by youth with chronic pain and their parents, all of whom experience chronic headaches.

BACKGROUND

Storytelling is a powerful social transaction that occurs within systems (eg, families, clinical encounters) and is both shaped by, and can shape, the pain experience. Narrative can be harnessed as a clinical tool to aid in the ability to listen, understand, and improve clinical encounters.

METHODS

Twenty-six youth (aged 11 to 18 y) and their mothers, both with chronic headaches, recruited from a tertiary level pediatric pain clinic separately completed in-depth interviews about children's pain journey narratives. Data were analyzed using narrative analysis, which incorporated elements of socio-narratology to compare similarities and differences between and within dyads' narratives.

RESULTS

Five narrative types were generated: (1) The trauma origin story-parents, but not youth, positing traumatic events as the causal link to children's pain; (2) mistreated by the medical system-neglect, harm, and broken promises resulting in learned hopelessness or relying on the family system; (3) the invalidated-invalidation of pain permeated youth's lives, with mothers as empathic buffers; (4) washed away by the pain-challenges perceived as insurmountable and letting the pain take over; and (5) taking power back from pain-youth's ability to live life and accomplish goals despite the pain.

CONCLUSION

Findings support the clinical utility of narrative in pediatric pain, including both parents' and youths' narrative accounts to improve clinical encounters and cocreate more youth-centred, empowering narratives.

The Effectiveness of Pain Science Education on Caregiver and Children's Knowledge, Beliefs, Attitudes, and Behaviors-A Systematic Review and Meta-Analysis

Pain science education (PSE) can be used as part of treatment and prevention for chronic pain in children. We assessed the effectiveness of PSE on knowledge, beliefs, attitudes, and behaviors in children and the people that care for children. We set a minimum criterion for education to address pain biology knowledge. We included studies aimed at both treatment and prevention of chronic pain. We conducted searches using 5 databases. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool. Data were pooled using a random-effects meta-analysis or assessed using a narrative synthesis. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. We screened 14,505 records and included 7 studies involving 351 caregivers and 1,285 children. Four studies were included in meta-analyses. We found low-certainty evidence that PSE has a large beneficial effect on caregiver knowledge and beliefs compared with alternative education (standardized mean difference = 1.14 [95% confidence interval: .88-1.42]; I2 = 0%). We found no difference in functional disability in children with chronic pain after PSE (Functional Disability Inventory score mean difference = .73 [95% confidence interval: -.81 to 2.27; I = 0%]). Narrative syntheses showed low-certainty evidence for improved knowledge and beliefs in children with preventative and treatment effects. Overall, we found few studies, and along with high risk of bias, this significantly contributed to the low certainty of findings. The effect of learning pain science for both preventative and treatment effects in children, carers, and the child/carer dyad remains mostly unknown. This review was prospectively registered with The international Prospective register of systematic reviews (CRD42022344382) on July 22, 2022. PERSPECTIVE: This review examines the effect of PSE on pain-related knowledge, beliefs, attitudes, and behaviors in children and the people that care for children (0-18). The findings contribute to knowledge about pain treatments and health promotion for caregivers and their children with and without chronic pain.

Photos Sculpt the Stories of Youth: Using Photovoice to Holistically Capture the Lived Experiences and Pain of Youth Who Underwent Spinal Fusion Surgery

Spinal fusion surgery is one of the most common major surgical procedures in youth. Adolescent idiopathic scoliosis (AIS) is the most frequent reason for corrective spinal fusion. AIS (∼25%-47% of cases) and spinal fusion surgeries are associated with pain, including the development of new onset chronic pain for up to 15% of youth. This research used photovoice approaches to explore the journeys of youth from before, during, and after spinal fusion surgery, to demonstrate their experiences both of and beyond pain. Twenty participants were recruited from a previous study conducted by the senior author's lab. Participants captured photos/videos in their daily life (Phase 1); collected previously taken photos/videos from before/during/after their surgery (Phase 2); and participated in individual interviews to reflexively discuss the meaning behind photos/videos (Phase 3). Before interviews, a questionnaire was administered to assess pain characteristics. Nineteen girls/women with scoliosis and one boy/man with kyphosis (12-19 years old, Mage = 16 years) participated; they identified as white (80%), other (15%), and Southeast Asian (5%). The researchers used a reflexive thematic analysis approach, which generated five themes: (1) body aesthetic versus machine; (2) expectations and anticipation of surgery/outcomes; (3) desire of normalcy and freedom; (4) navigating a hoped-for positive surgery experience; and (5) the journey sculpts identity formation and sense of self. Findings support youth advocacy, underscoring the need to validate youth concerns and inform healthcare professionals of the importance of individualized care. Youth perspectives highlighted opportunities for optimizing surgery/healthcare experiences and the psychosocial impacts of scoliosis on body image and appearance.

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

Parent-Child Communication Incongruence in Pediatric Healthcare

Parents play a key role in providing children with health-related information and emotional support. This communication occurs both in their homes and in pediatric healthcare environments, such as hospitals, outpatient clinics, and primary care offices. Often, this occurs within situations entailing heightened stress for both the parent and the child. There is considerable research within the communication literature regarding the nature of both verbal and nonverbal communication, along with the way in which these communication modalities are either similar (i.e., congruent) or dissimilar (i.e., incongruent) to one another. However, less is known about communication congruency/incongruency, specifically in parent-child relationships, or within healthcare environments. In this narrative review, we explore the concept of verbal and nonverbal communication incongruence, specifically within the context of parent-child communication in a pediatric healthcare setting. We present an overview of verbal and nonverbal communication and propose the Communication Incongruence Model to encapsulate how verbal and nonverbal communication streams are used and synthesized by parents and children. We discuss the nature and possible reasons for parental communication incongruence within pediatric settings, along with the consequences of incongruent communication. Finally, we suggest a number of hypotheses derived from the model that can be tested empirically and used to guide future research directions and influence potential clinical applications.

The Influence of Children's Pain-Related Attention Shifting Ability and Pain Catastrophizing Upon Negatively Biased Pain Memories in Healthy School Children

The current study investigated the influence of children's ability to flexibly shift attention toward and away from pain information on the development of negatively biased pain memories, thereby employing a direct measure of attention control reliant on behavioral responses in the context of pain (ie, an attention switching task). The direct influence of children's attention-shifting ability and pain catastrophizing as well as the moderating role of this shifting ability in the relationship between pain catastrophizing and the development of negatively biased pain memories was examined. Healthy school children (N = 41; 9-15 years old) received painful heat stimuli and completed measures of state and trait pain catastrophizing. They then performed an attention-switching task wherein they had to shift attention between personally relevant pain-related and neutral cues. Two weeks after the painful task, children's pain-related memories were elicited via telephone. Findings indicated that children's reduced ability to disengage attention away from pain information predicted more fear memory bias 2 weeks later. Children's pain-related attention-shifting ability did not moderate the relationship between children's pain catastrophizing and negatively biased pain memories. Findings highlight the contribution of children's attention control skills in the development of negatively biased pain memories. PERSPECTIVE: Results of the current study indicate that children with a reduced ability to shift attention away from pain information are at risk for developing negatively biased pain memories. Findings can inform interventions to minimize the development of these maladaptive negatively biased pain memories by targeting pain-relevant attention control skills in children.

Distress and Resilience Narratives within Pain Memories of Adolescents and Young Adults with Complex Regional Pain Syndrome: A Multi-Method Study

A comprehensive understanding of pain memories requires consideration of risk and resilience factors across biopsychosocial domains. Previous research has typically focused on pain-related outcomes, largely ignoring the nature and context of pain memories. Using a multiple-method approach, this study explores the content and context of pain memories in adolescents and young adults with complex regional pain syndrome (CRPS). Recruited via social media and pain-related organizations, participants completed an autobiographical pain memory task. Two-step cluster analysis was conducted on the pain memory narratives of adolescents and young adults with CRPS (n=50) using a modified version of the Pain Narrative Coding Scheme. Narrative profiles generated from the cluster analysis subsequently guided a deductive thematic analysis. Cluster analysis identified two narrative profiles of Distress and Resilience, with the role of coping and positive affect emerging as important profile predictors across pain memories. Subsequent deductive thematic analysis, utilizing Distress and Resilience codes, demonstrated the complex interplay between affect, social, and coping domains. Findings highlight the importance of applying a biopsychosocial framework to pain memory research, accounting for both risk and resilience perspectives and encourage the use of multiple method approaches to improve understanding of autobiographic pain memories. Clinical implications of reframing and recontextualizing pain memories and narratives are discussed, and the importance of exploring the origins of pain and possible application to developing resilience-based, preventative interventions is highlighted. PERSPECTIVE: Using multiple methods, this paper presents a comprehensive account of pain memories in adolescents and young adults with CRPS. Study findings promote the importance of adopting a biopsychosocial approach to examining both risk and resilience factors in understanding autobiographical pain memories in the context of pediatric pain.

A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention to Reduce Distress and Pain Associated with Vaccine Injections in Young Children

Children remember their memories of pain long after the painful experience is over. Those memories predict higher levels of future pain intensity. Young children's memories can be reframed to be less distressing. Parents and the way they reminisce about past events with their children play a key role in the formation of pain memories. A novel parent-led memory-reframing intervention changed children's memories of post-surgical pain to be less distressing. The intervention efficacy in the context of vaccine injections is unclear. This registered randomized controlled trial (NCT05217563) aimed to fill this gap. Seventy-four children aged 4.49 years (SD = 1.05) and scheduled to obtain two COVID-19 vaccine injections and one of their parents were randomized to receive: (1) standard care; (2) standard care and memory-reframing information; and (3) standard care and memory-reframing information with verbal instructions. Children reported their pain after vaccine injections. One week after the first vaccination, children reported memory of pain. Parents reported their use of memory-reframing strategies and intervention feasibility and acceptability. The intervention did not result in significant differences in children's recalled or future pain. Parents rated the intervention as acceptable and feasible.

The relation between children's attention bias to pain and children's pain-related memory biases is moderated by parental narrative style

Children's heightened attention to pain and parental narrative style have been linked to the development of negatively-biased pain memories in children (i.e., recalling higher levels of pain and fear than initially reported, which robustly predicts maladaptive pain outcomes). However, the interplay between child attention bias and parental narrative style remains to be assessed. This study aims to fill this gap using enhanced paradigms assessing children's cognitive biases for cues signaling actual pain. Healthy school children (N = 63; 9-15 years old) received painful heat stimuli while performing a spatial cueing task measuring attention bias to cues signaling actual pain. Parent-child interaction upon completion of the painful task, was coded for parental narrative style (i.e., elaboration, repetition and evaluation). Children's pain-related memories were elicited two weeks later. Findings indicated that children showed an attention bias to cues signaling pain. Furthermore, children who were hypervigilant to pain cues benefitted from parents elaborating more about the pain experience, while children who avoided pain cues developed more negatively-biased pain memories if parents had a more elaborative style compared to a more evaluative parental style. In conclusion, this study suggests that optimal ways to talk about children's pain depend upon child characteristics (i.e., children's attention bias to pain).

The Effect of Robot-Led Distraction during Needle Procedures on Pain-Related Memory Bias in Children with Chronic Diseases: A Pilot and Feasibility Study

The current study evaluated the feasibility and preliminary clinical impact of robot-led distraction during needle procedures in children with chronic diseases on pain-related memories. Participants were 22 children (8−12 years old) diagnosed with a chronic disease (e.g., chronic immune deficiency) and undergoing a needle procedure as part of their routine treatment. Children were randomized to the experimental group (i.e., robot-led distraction) or control group (i.e., usual care). For feasibility, we evaluated study- and needle-procedure-related characteristics, intervention fidelity and acceptability, and nurse perceptions of the intervention. Primary clinical outcomes included children’s memory bias for pain intensity and pain-related fear (1 week later). Results indicated that intervention components were >90% successful. Overall, the robot-led distraction intervention was perceived highly acceptable by the children, while nurse perceptions were mixed, indicating several challenges regarding the intervention. Preliminary between-group analyses indicated a medium effect size on memory bias for pain intensity (Hedges’ g = 0.70), but only a very small effect size on memory bias for pain-related fear (Hedges’ g = 0.09), in favor of the robot-led distraction intervention. To summarize, while feasible, certain challenges remain to clinically implement robot-led distraction during needle procedures. Further development of the intervention while accounting for individual child preferences is recommended.

Bibliometric and Visual Analysis of the Current Status and Trends of Postoperative Pain in Children from 1950-2021

Background

Postoperative pain in children has been overlooked for a long time. The knowledge structure, research hotspots and trends related to postoperative pain in children are unclear and have not been systematically summarized.

Purpose

We aimed to analyze the current state of research on postoperative pain in children and to conduct in-depth mining of the knowledge structure.

Methods

The PubMed database for publications on postoperative pain in children between 1950 and 2021 was searched. Bibliographic Item Co-Occurrence Matrix Builder (BICOMB) was performed to obtain the co-word matrix and co-occurrence matrix. The H-index method was used to extract high-frequency main Medical Subject Headings (MeSH) terms/subheadings.

Results

The high-frequency MeSH terms were analyzed by biclustering, strategic diagram and social network analyses. Totally, 4022 publications were retrieved. The analysis showed that 60 countries or regions published relevant documents, with the United States publishing the most significant number of papers. Totally, 811 journals published relevant papers, with Pediatric Anesthesia ranking first. Moreover, we extracted 43 high-frequency main MeSH terms/subheadings and clustered them into five categories: overview, aetiology and epidemiology, pharmacotherapy, opioid administration and dosing, and prevention and control of postoperative pain in children.

Conclusion

Pharmacological treatments, pain prevention and control are the focus of research and are becoming increasingly mature. Opioid stewardship and regional anesthesia is the trend and focus of future research. Our study offers a better understanding of the current status and knowledge structure of postoperative pain in children and provides a reference for improving postoperative pain management in children in the future.

Reframe the pain: Divided attention and positive memory reframing to reduce needle pain and distress in children-A feasibility randomized controlled trial

BACKGROUND

Negative experiences of needle procedures in childhood can lead to medical avoidance and vaccine hesitancy into adulthood. We evaluated the feasibility of two new interventions provided by clinical nurses to reduce the negative impact of vaccinations: divided attention (DA) and positive memory reframing (PMR).

METHODS

Children (8-12 years) were randomized into four groups: usual care (UC), DA, PMR or combined (DA + PMR). To evaluate feasibility, we undertook in-depth analysis of video-recorded interventions, nurse experiences (phone interviews) and child/parent memory recall of interventions (phone interviews at 2 weeks post-vaccination). Key clinical outcomes included child and parent ratings of needle-related pain intensity and fear assessed at baseline, immediately post-vaccination and 2 weeks post-vaccination (recalled).

RESULTS

A total of 54 child-parent dyads were screened, with 41 included (10/group, except PMR [n = 11]). The interventions were not always completed as intended: 10%-22% of participants received complete interventions and two had adverse events related to protocol breach. Preliminary within-group analyses showed no effects on child/parent pain ratings. However, children in DA + PMR had reduced recalled fear (p = 0.008), and PMR (p = 0.025) and DA + PMR (p = 0.003) had reduced fear of future needles. Parent ratings of child fear were also reduced immediately post-vaccination for UC (p = 0.035) and PMR (p = 0.035).

CONCLUSIONS

The interventions were feasible, although enhanced nurse training is required to improve fidelity. Preliminary clinical results appear promising, particularly for reducing needle-related fear.

PROTOCOL REGISTRATION

Protocol number ACTRN12618000687291 at ANZCTR.org.au SIGNIFICANCE: Two new nurse-led interventions to reduce negative impacts of vaccinations in children, divided attention and positive memory reframing, were feasible and may reduce needle-related fear. Nurses were able to deliver the interventions in various environments including non-clinical settings (schools). These interventions have potential to facilitate broader dissemination of vaccinations for children in a manner that minimizes distress.

The sands of time: Adolescents' temporal perceptions of peer relationships and autonomy in the context of living with chronic pain

The incidence of chronic and recurrent pain increases in adolescence. Prevalence of adolescent chronic pain is estimated to be 11%-44%, with approximately 5% adolescents experiencing moderate-to-severe chronic pain. Adolescents with chronic pain also report unwanted changes in emotional, social, and developmental functioning. Very little is known about how adolescents with chronic pain make sense of their development, the role of pain in that development, and how such developmental trajectories progress over time. A multi-methods qualitative study was designed to explore how adolescents make sense of their experience of chronic pain in the context of development. Nine adolescents (8 girls) aged 12-22 years old (Mean = 15.7, SD = 2.8) were recruited from a UK national pain service. Adolescents completed an interview on entering the service, and a follow-up interview 12 months later. They also completed monthly diaries in this 12-month period. Data comprised 18 interviews and 60 diary entries, which were analyzed using inductive reflexive thematic analysis. Analyses generated one overarching theme entitled "tug of war: push and pull," demonstrating developmental tension related to pain, and the cumulative impact these had over time. This overarching theme comprised two subthemes which capture these tensions across the developmental domains of peer relationships and autonomy. The first subtheme, "the shifting sands of peer relationships," explores the ever-changing closeness between self and peers. The second subtheme referred to "restricted choices" and how pain limited the participants' autonomy but that this, over time could push development forward. These results extend previous cross-sectional research on the developmental consequences of chronic pain, showing the dynamic fluctuations and alterations to developmental trajectories over time.

Painful reminders: Involvement of the autobiographical memory system in pediatric postsurgical pain and the transition to chronicity

Memory biases for previous pain experiences are known to be strong predictors of postsurgical pain outcomes in children. Until recently, much research on the subject in youth has assessed the sensory and affective components of recall using single-item self-report pain ratings. However, a newly emerging focus in the field has been on the episodic specificity of autobiographical pain memories. Still in its infancy, cross-sectional work has identified the presence of various memory biases in adults living with chronic pain, one of which concerns the lack of spatiotemporal specificity. Moreover, a recent prospective longitudinal study found that adults scheduled for major surgery who produced fewer specific pain memories before surgery were at greater risk of developing chronic postsurgical pain up to 12 months later. The present review draws on this research to highlight the timely need for a similar line of investigation into autobiographical pain memories in pediatric surgical populations. We (1) provide an overview of the literature on children's pain memories and underscore the need for further research pertaining to memory specificity and related neurobiological factors in chronic pain and an overview of the (2) important role of parent (and sibling) psychosocial characteristics in influencing children's pain development, (3) cognitive mechanisms underlying overgeneral memory, and (4) interplay between memory and other psychological factors in its contributions to chronic pain and (5) conclude with a discussion of the implications this research has for novel interventions that target memory biases to attenuate, and possibly eliminate, the risk that acute pain after pediatric surgery becomes chronic.

The Effect of a Pain Educational Video Upon Child Pain-Related Memory and the Moderating Role of Parental Pain- and Non-Pain-Attending Verbalizations: An Experimental Lab-Based Study

OBJECTIVES

Early memories of pain contribute to fear and may underlie the maintenance and development of chronic pain into adulthood. Accordingly, understanding determinants that may impact children's pain memory development is key. This study examined (a) the effect of a brief engaging pain educational video in healthy children before undergoing an experimental pain task upon children's recalled pain intensity and pain-related fear and (b) the moderating role of parental pain- and non-pain-attending verbalizations before and after the pain task.

METHODS

Seventy-seven children (8-15 years old) participated in an experimental heat pain task, including actual heat pain stimuli delivered through a thermode on their forearm. Children were randomized to the experimental group (i.e., watching a pain educational video) or the control group (i.e., no video). Children's recalled pain intensity and pain-related fear were elicited 2 weeks later.

RESULTS

Findings showed that recalled pain intensity (but not recalled pain-related fear) of children who watched the pain educational video was significantly lower compared to the control group (p = .028). Further, parental pain-attending verbalizations before the pain task moderated the impact of the video upon children's recalled pain intensity (p = .038). Specifically, children in the control group, but not the experimental group, whose parents used less pain-attending verbalizations recalled higher pain intensity, whereas children whose parents used more pain-attending verbalizations recalled lower pain intensity.

CONCLUSIONS

As children's pain memories have important implications for pain assessment, treatment, and health across the lifespan, these findings might have important implications for the prevention of development or maintenance of maladaptive pain-related outcomes.

Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective

A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child's quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.

Let's (Not) Talk About Pain: Mothers' and Fathers' Beliefs Regarding Reminiscing About Past Pain

Children's memories for past pain set the stage for their future pain experiences. Parent-child reminiscing about pain plays a key role in shaping children's pain memories. Parental beliefs about the functions of reminiscing are associated with parental reminiscing behaviors. To date, no studies have investigated parental beliefs regarding the functions of reminiscing about past pain or the associations between parental beliefs and reminiscing about past pain. This study aimed to fill these gaps. One-hundred and seven parents (52% fathers) of young children were asked about their beliefs regarding reminiscing about past pain. Interview data were first analyzed using inductive reflexive thematic analysis. A coding scheme was created based on the generated themes to quantitatively characterize parental beliefs. Parents also reminisced with their children about unique past events involving pain. Parent-child reminiscing narratives were coded to capture parent reminiscing behaviors. Inductive reflexive thematic analysis generated three major themes representing parental beliefs regarding reminiscing about past pain: “reminiscing to process past pain,” “reminiscing as a learning tool,” and “avoiding reminiscing about past pain.” Parents who endorsed avoiding reminiscing used fewer optimal reminiscing elements (i.e., open-ended questions) when reminiscing about past painful experiences with children. Parents who endorsed reminiscing to process past pain used more emotion-laden language when reminiscing about past pain. Mothers and fathers of boys and girls endorsed the reminiscing functions to a similar degree. Parents of older, vs. younger, children endorsed reminiscing to process past pain to a greater degree. Developmental considerations and clinical implications of the findings are discussed.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

Mother– and Father–Child Reminiscing About Past Events Involving Pain, Fear, and Sadness: Observational Cohort Study

Objective

Pain in childhood is prevalent and is associated with fear, particularly in the context of injuries or procedural pain, and negative emotions (e.g., sadness). Pain and fear share a bidirectional relationship, wherein fear exacerbates the experience of pain and pain increases subsequent anticipatory fear. The existing research has focused primarily on children’s immediate experience of pain and fear. Research on how children remember or talk about past painful, fearful, or sad events is lacking. Parent–child reminiscing about past pain has been demonstrated to differ from reminiscing about other past negative emotional events (i.e., those involving sadness, but not fear). The present study aimed to examine differences in how parent–child dyads reminisce about past pain, fear, and sadness.

Methods

One hundred and three 4-year-old children (55% girls) and their parents (52% fathers) engaged in a narrative elicitation task in which they reminisced about unique past events involving pain, fear, and sadness. Parent–child narratives were coded using established coding schemes based on the developmental psychology literature.

Results

Parent–child narratives about pain were characterized by fewer emotion-laden words and explanations, as well as more pain-related words compared to sadness or fearful narratives. Mothers and fathers reminisced with sons and daughters in a similar way across all types of events.

Conclusions

Parent–children reminiscing about past painful events differs from reminiscing about other types of distressing events (e.g., involving sadness or fear). This highlights a possibility of differential socialization of pain versus fear. Potential clinical implications of the findings are discussed.

The Moderating Role of Attention Control in the Relationship Between Pain Catastrophizing and Negatively-Biased Pain Memories in Youth With Chronic Pain

The present study examined the role of attention control in understanding the development of negatively-biased pain memories as well as its moderating role in the relationship between pain catastrophizing and negatively-biased pain memories. Youth with chronic pain (N = 105) performed a cold pressor task (CPT) and completed self-report measures of state/trait pain catastrophizing and attention control, with the latter comprising both attention focusing and attention shifting. Two weeks after the CPT, youth's pain-related memories were elicited via telephone allowing to compute pain and anxiety memory bias indices (ie, recalling pain intensity or pain-related anxiety, respectively, as higher than initially reported). Results indicated no main effects of attention control and pain catastrophizing on pain memories. However, both components of attention control (ie, attention focusing and attention shifting) moderated the impact of pain catastrophizing on youth's memory bias, with opposite interaction effects. Specifically, whereas high levels of attention shifting buffered the influence of high pain catastrophizing on the development of pain memory bias, high levels of attention focusing strengthened the influence of high pain catastrophizing on the development of anxiety memory bias. Interaction effects were confined to trait catastrophizing (ie, not state catastrophizing). Theoretical and clinical implications are discussed. PERSPECTIVE: This article investigates the role of attention control in the development of negatively-biased pain memories in children with chronic pain. Findings underscore the importance of targeting differential components of attention control and can inform intervention efforts to minimize the development of negatively biased pain memories in youth with chronic pain.

What is pain: Are cognitive and social features core components?

Pain is a universal experience, but it has been challenging to adequately define. The revised definition of pain recently published by the International Association for the Study of Pain addressed important shortcomings of the previous version; however, it remains narrow in its focus on sensory and emotional features of pain, failing to capture the substantial roles of cognitive and social core components of the experience and their importance to advances in pain management. This paper reviews evidence and theoretical models for the significant role social and cognitive factors play in pain experience and we argue that without explicit recognition of these core components in the definition, significant nuances are lost at a cost to understanding and clinical management of pain. A focus on sensory and emotional features perpetuates biomedical interventions and research, whereas recognition of cognitive and social features supports a multidimensional model of pain, advances in interdisciplinary care, and the benefits of cognitive behavioral therapy and self‐management interventions. We also explore the six Key Notes that accompany the new definition of pain, discuss their application to the understanding of pain in childhood, and, in doing so, further explore social and cognitive implications. Considerations are also described for assessment and treatment of pain in pediatric populations.

Targeting the stress response in pediatric pain: current evidence for psychosocial intervention and avenues for future investigation

Nonpharmacological treatments for chronic pain in youth have been identified as first-line treatments over and above medication. Therapies such as cognitive-behavioral therapy and mindfulness-based stress reduction have shown good efficacy in reducing the psychological correlates (eg, anxiety, depression, and stress) and social or behavioral sequelae (eg, limited physical activity and lack of school engagement) associated with pediatric chronic pain. However, minimal research has examined the physiological mechanism(s) of action for these interventions. A recent review (Cunningham, et al., 2019) emphasized the need for objective (ie, physiological) assessment of treatment response in pediatric pain populations. The current review adds to this literature by identifying the physiological stress response as a particular target of interest in interventions for pediatric pain. Research indicates that youth with chronic pain report high rates of psychological stress, posttraumatic stress symptoms, and exposure to adverse childhood experiences (abuse/neglect, etc). In addition, a host of research has shown strong parallels between the neurobiology of pain processing and the neurobiology of stress exposure in both youth and adults. Interventions such as narrative or exposure therapy (eg, trauma-focused cognitive-behavioral therapy) and mindfulness-based or meditation-based therapies have shown particular promise in alleviating the neurobiological impact that stress and pain can have on the body, including reduction in allostatic load and altered connectivity in multiple brain regions. However, no study to date has specifically looked at these factors in the context of pediatric pain treatment. Future research should further explore these constructs to optimize prevention in and treatment of these vulnerable populations.

Reframe the Pain: A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention

Negatively-biased pain memories (ie, recalling more pain as compared to earlier reports) are a robust predictor of future pain experiences. This randomized controlled trial examined the efficacy of a memory-reframing intervention to reframe children's pain memories. Sixty-five children (54% girls, M_age=5.35 years) underwent a tonsillectomy and reported their levels of post-surgical pain intensity and pain-related fear. 2 weeks post-surgery, children and 1 of their parents were randomized to the memory-reframing intervention or control group. Following control/intervention instructions, parents and children reminisced about the past surgery as they normally would (control) or using the memory-reframing strategies (intervention). Children recalled their post-surgical pain intensity and pain-related fear one week later. Parents reported the intervention's acceptability. Recruitment statistics were used to assess feasibility. Controlling for initial pain intensity ratings and using the Faces Pain Scale Revised, children in the intervention group reported more accurate/positively-biased memories for day 1 post-surgery pain intensity (M = 2.60/10; 95% CI, 1.62 to 3.68), compared to children in the control group (M = 4.11/10; 95% CI, 3.12 to 5.03), η_p² = .07, p = .040. The intervention was acceptable and feasible. Optimal parent-child reminiscing about a past pain experience resulted in children remembering their pain more accurately/positively. Clinicaltrials.gov:NCT03538730. PERSPECTIVE: This article presents results of the first randomized controlled trial examining the efficacy of parent-led memory-reframing intervention to change children's memories for pain. Children of parents who were taught and engaged in optimal reminiscing about a past surgery experience remembered their pain intensity more accurately/positively.

Multidimensional Self-report Assessment of Children's Acute Pain in an Inpatient Setting

OBJECTIVE

This study assessed the feasibility of administering a multidimensional, self-report pain assessment protocol to children in an inpatient, acute pain context, and sought insight into the interrelationships between sensory, affective, and evaluative pain dimensions.

METHODS

A total of 132 children (5 to 16 y) experiencing acute pain were recruited from acute pain ward rounds or the short-stay surgical unit. A multidimensional self-report assessment protocol was administered, assessing pain intensity, pain-related affect, bother, perceived unfairness, and pain expectations (for tomorrow and in 1 wk). Duration of protocol administration was assessed and ease of administration was rated. Pain-related behaviors were rated using the Face, Legs, Activity, Cry, and Consolability (FLACC) Scale.

RESULTS

The duration of protocol administration was <2.5 minutes, on average, for all age groups. Median ease of protocol administration was 7/10 for 5- to 7-year-olds and 8/10 for older age groups. Pain-related bother was higher for 14- to 16-year-olds, relative to younger age groups, and significantly correlated with perceived unfairness (r=0.59, P<0.01), intensity (r=0.76, P<0.01), and affect (r=0.33, P<0.05). For younger age groups, bother was significantly positively correlated only with pain intensity (rs=0.59 to 0.79, Ps<0.01) and affect (rs=0.4 to 0.71, Ps <0.05). A stepwise multiple regression analysis found multidimensional self-reported information (especially pain intensity and perceived unfairness), accounted for significant additional amount of variance, beyond that explained by age, pain duration, and observed pain behavior.

DISCUSSION

Sensory, affective, and evaluative aspects of children's clinical, acute pain experience may be assessed using self-report tools, which provide unique and valuable information about their pain experience.

Father- and Mother-Child Reminiscing About Past Pain and Young Children's Cognitive Skills

Objective Painful experiences are common, distressing, and salient in childhood. Parent-child reminiscing about past painful experiences is an untapped opportunity to process pain-related distress and, similar to reminiscing about other distressing experiences, promotes children's broader development. Previous research has documented the role of parent-child reminiscing about past pain in children's pain-related cognitions (i.e., memories for pain), but no study to date has examined the association between parent-child reminiscing about past painful experiences and children's broader cognitive skills. Design and Methods One hundred and ten typically developing four-year-old children and one of their parents reminisced about a past painful autobiographical event. Children then completed two tasks from the NIH Toolbox Cognitive Battery, the Flanker Inhibitory Control & Attention Test and the Picture Sequence Memory Test, to measure their executive function and episodic memory, respectively. Results Results indicated that the relation between parental reminiscing style and children's executive function was moderated by child sex, such that less frequent parental use of yes-no repetition questions was associated with boys' but not girls', greater performance on the executive function task. Children displayed greater episodic memory performance when their parents reminisced using more explanations. Conclusions The current study demonstrates the key role of parent-child reminiscing about pain in children's broader development and supports the merging of developmental and pediatric psychology fields. Future longitudinal research should examine the directionality of the relation between parent-child reminiscing about past pain and children's developmental outcomes.

The Socialization of Young Children's Empathy for Pain: The Role of Mother- and Father-Child Reminiscing

OBJECTIVE

Empathy for pain allows one to recognize, understand, and respond to another person's pain in a prosocial manner. Young children develop empathy for pain later than empathy for other negative emotions (e.g., sadness), which may be due to social learning. How parents reminisce with children about past painful events has been linked to children's pain cognitions (e.g., memory) and broader socioemotional development. The present study examined how parent-child reminiscing about pain may be linked to children's empathic behaviors toward another person's pain.

METHODS

One hundred and fourteen 4-year-old children (55% girls) and for each, one parent (51% fathers) completed a structured narrative elicitation task wherein they reminisced about a past painful autobiographical event for the child. Children were then observed responding in a lab-based empathy task wherein they witnessed a confederate pretending to hurt themselves. Children's empathic behaviors and parent-child narratives about past painful events were coded using established coding schemes.

RESULTS

Findings revealed that parents who used more neutral emotion language (e.g., How did you feel?) when discussing past painful events had children who exhibited more empathic concern in response to another's pain. Similarly, children who used more explanations when reminiscing about past painful events displayed more empathic concern about another's pain.

CONCLUSIONS

Findings highlight a key role of parent-child reminiscing about the past pain in the behavioral expression of empathy for pain in young children.

Decreasing Pain and Fear in Medical Procedures with a Pediatric Population (DREAM): A Pilot Randomized Within-Subject Trial

BACKGROUND

Many children with injuries, including burns and fractures, experience moderate to severe pain during medical procedures. Recent studies claim that nonpharmacologic pain management using virtual reality (VR) could distract children from procedural pain by engaging multiple senses.

AIMS

The aims of this pilot randomized clinical trial were to assess the acceptability and feasibility of VR distraction in children with burns or fractures undergoing painful medical procedures, as well as the staff nurses, and assess the preliminary efficacy of VR distraction on pain intensity, pain-related fear, and subsequent recall of both.

MATERIALS AND METHOD

A within-subject study design, in which participants served as their own control, was used. A total of 20 children from 7 to 17 years old with an injury were recruited at the surgical-trauma outpatient clinics of the Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine). Each participant received both standard and experimental treatments through randomized order. Pain (numerical rating scale) and pain-related fear (Children's Fear Scale) measures were taken before the procedure and after each sequence, followed by a measure of children's (graphic rating scale) and nurses' acceptability of the intervention through their satisfaction level. Recall of pain intensity and pain-related fear were assessed 24 hours after the procedure. Wilcoxon signed-rank tests were used, with a significance level at 0.05.

RESULTS

Results showed that VR distraction was an acceptable and feasible intervention for children and nurses of these outpatient clinics. Preliminary effects showed that, compared to standard of care, children participants reported a significant decrease in pain intensity (p = .023) and pain-related fear (p = .011) during VR as well as less recalled pain-related fear (p = .012) at 24 hours after the procedure. No side effects were reported.

CONCLUSION

VR is a promising intervention with children undergoing painful procedures because it is immersive and engages multiple senses. It is a low-cost intervention well accepted by children and nursing staff at this clinical site and is easy to implement in daily practice for procedural pain management.

Gender and parental involvement in parent-child reminiscing in a Scandinavian sample

Despite the extensive bulk of literature on maternal reminiscing style, only a handful of reminiscing studies have investigated gender differences in parental reminiscing style, with none of these studies having explored the possible relationship between parental involvement level and parental reminiscing style. The current study investigated gender differences in parental reminiscing style across positive and negative event types in an egalitarian Scandinavian context while exploring the potential relationship between parental reminiscing style and parental involvement level. Mothers and fathers from N = 88 families reminisced about shared happy and sad events, respectively, with their 4-year-old children. Overall, parental involvement level was not related to parental reminiscing style. However, mothers' elaborations and positive evaluations were associated with their level of involvement level in the sad event conversations. Although mothers and fathers did not differ in their reminiscing style overall, gender differences appeared in the consistency of parental reminiscing style across event types.

Communication between parents and well-siblings in the context of living with a child with a life-threatening or life-limiting condition

Effective parent-child communication may serve to buffer the potential negative impacts of stressful situations on a child. Children who have a brother or sister with a life-threatening or life-limiting medical condition may turn to their parents for help with comprehending the situation, to help maintain their own ability to function across various life areas or to receive emotional support. There is a need for more investigation into the nature and importance of parent-child communication in the context of living with a seriously ill brother or sister. The current paper presents a framework of parent-sibling communication in the context of living with a seriously unwell child, distinguishing the focus of communication (illness-related vs. non-illness-related) and the purpose of communication (information-provision vs. emotional support). Such a framework offers a holistic approach to exploring some of the challenges of communication between parents and well-siblings. The state of current knowledge regarding the focus and purpose of communication between parents and well-siblings is reviewed, and implications for research and possible clinical applications discussed.

Parent-Child Reminiscing about Past Pain as a Preparatory Technique in the Context of Children's Pain: A Narrative Review and Call for Future Research

Pain permeates childhood and remains inadequately and/or inconsistently managed. Existing research and clinical practice guidelines have largely focused on factors influencing the immediate experience of pain. The need for and benefits of preparing children for future pain (e.g., painful procedures) has been well established. Despite being a robust predictor of future pain and distress, memories of past painful experiences remain overlooked in pediatric pain management. Just as autobiographical memories prepare us for the future, children’s memories for past pain can be harnessed to prepare children for future painful experiences. Children’s pain memories are malleable and can be reframed to be less distressing, thus reducing anticipatory distress and promoting self-efficacy. Parents are powerful agents of change in the context of pediatric pain and valuable historians of children’s past painful experiences. They can alter children’s pain memories to be less distressing simply by talking, or reminiscing, about past pain. This narrative review summarizes existing research on parent–child reminiscing in the context of acute and chronic pediatric pain and argues for incorporation of parent–child reminiscing elements into preparatory interventions for painful procedures.

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.