Perspectives on emotional memory images and the persistence of pain

Multiple influences prevent recovery from pain. Our viewpoint is that non-conscious emotional memory images (EMIs) triggers outdated stress responses contributing to the intractability of pain. In this perspectives article we explore the concept that EMIs contribute to the persistence of pain. We contend that psychophysiological "stress" responses, resulting from first-time, novel and unprecedented pernicious or adverse events form EMIs within very short time frames (split-second learning). Subsequently, these EMIs are re-triggered in daily living, "re-playing" stress responses. We postulate that EMIs continually "raise the alarm" to socio-ecological stimuli by re-triggering the HPA-axis and amplifying neural input associated with threat, fear, anxiety, and pain, creating a debilitating state of psychophysiological dis-ease. We position the EMI within a philosophical debate on the nature and locus of memory and explain how the EMI, irrespective of whether it is a "thing" or a metaphor, can create a basis of understanding for the client to grasp. We describe a therapeutic approach (Split-Second Unlearning) to "clear" EMIs and the "stickiness" of pain and help people embark on a healing journey. This involves surveillance of clients for micro-expression(s) signifying an in-the-moment stress response, representative of the presence of an EMI, and encouraging the client to become a curious observer within/of their own experience. This helps the client detach their EMI from its stress response. We contend that this occurs rapidly without the need to get bogged down in a whole-life narrative. We advocate further exploration of our EMI model of dis-ease in the context of intractable pain.

Assessing Pain Research: A Narrative Review of Emerging Pain Methods, Their Technosocial Implications, and Opportunities for Multidisciplinary Approaches

Pain research traverses many disciplines and methodologies. Yet, despite our understanding and field-wide acceptance of the multifactorial essence of pain as a sensory perception, emotional experience, and biopsychosocial condition, pain scientists and practitioners often remain siloed within their domain expertise and associated techniques. The context in which the field finds itself today-with increasing reliance on digital technologies, an on-going pandemic, and continued disparities in pain care-requires new collaborations and different approaches to measuring pain. Here, we review the state-of-the-art in human pain research, summarizing emerging practices and cutting-edge techniques across multiple methods and technologies. For each, we outline foreseeable technosocial considerations, reflecting on implications for standards of care, pain management, research, and societal impact. Through overviewing alternative data sources and varied ways of measuring pain and by reflecting on the concerns, limitations, and challenges facing the field, we hope to create critical dialogues, inspire more collaborations, and foster new ideas for future pain research methods.

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.

Communicating with Youth about Pain: Developmental Considerations

BACKGROUND

Pain experiences can negatively impact children and adolescents, leading to trauma symptoms and nonadherence to important health behaviors. Developmentally-tailored communication strategies may mitigate this risk.

METHODS

This article reviews cognitive and linguistic developmental factors, within the familial and cultural context, that are important to consider when communicating with youth about acute, procedural, and/or chronic pain.

RESULTS

Youth undergoing acute or procedural pain benefit from pain education, truthful information about the procedure, and advance preparation. The use of analogies may be particularly helpful for patient understanding of chronic pain development, maintenance, and treatment. Youth with developmental disabilities may express pain differently than their normative peers, requiring adaptation of communication strategies.

CONCLUSION

Developmentally-tailored pain communication is an important tool for caregivers and healthcare providers that may foster adaptive functioning in youth who experience pain.

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.

A child in pain: A psychologist’s perspective on changing priorities in scientific understanding and clinical care

My research and clinical career followed a trajectory of increasing appreciation for the importance of social factors as determinants of pain experience and expression. The social contexts of children’s lives determine whether infants and children are exposed to pain, how socialization in family and ethnocultural contexts lead to pain as a social experience, comprised of thoughts and feelings as well as sensory input, how others shape pain experience and expression, less so for automatic/reflexive features than purposeful representations, and how other's appraisals of children’s pain reflect the observer's unique background and capacities for intervening in the child’s interests. A greater understanding of the social dimensions of pain, as reflected in the social communication model of pain, would support innovation of psychological and social interventions.

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

Negatively biased memories for pain (ie, recalled pain is higher than initial report) robustly predict future pain experiences. During early childhood, parent-child reminiscing has been posited as playing a critical role in how children's memories are constructed and reconstructed; however, this has not been empirically demonstrated. This study examined the role of parent-child reminiscing about a recent painful surgery in young children's pain memory development. Participants included 112 children (Mage = 5.3 years; 60% boys) who underwent a tonsillectomy and one of their parents (34% fathers). Pain was assessed in hospital and during the recovery phase at home. Two weeks after surgery, parents and children attended a laboratory visit to participate in a structured narrative elicitation task wherein they reminisced about the surgery. Four weeks after surgery, children completed an established pain memory interview using the same previously administered scales through telephone. Narratives were coded for style (elaboration) and content (pain and emotion) based on coding schemes drawn from the developmental psychology literature. Findings revealed that a more elaborative parental reminiscing style in addition to greater use of emotional words predicted more accurate/positively biased pain memories. Greater parental use of pain words predicted more negatively biased pain memories. Although there were no sex and parent-role differences in pain memory biases, mothers and fathers differed in how they reminisced with their boys vs girls. This research underscores the importance of parent-child reminiscing in children's pain memory development and may be used to inform the development of a parent-led memory reframing intervention to improve pediatric pain management.

Does the IASP definition of pain need updating?

The current IASP definition of pain has come under renewed criticisms recently. There is a new momentum for its revision as reflected by the fact that IASP has now a Presidential Task Force dedicated to look into whether there is enough warrant to update the definition. I critically review all the major criticisms of the current definition in detail, and raise new difficulties rarely discussed before. I show that none of the major criticisms has enough warrant to force us to substantially revise the current definition. Combined with the discussion of the new difficulties, there is nonetheless a need to restate the definition using slightly different terminology that will make the original intent of the current definition clearer and more precise. A restatement of the definition is proposed and its potential is discussed in light of some empirical questions that remain.

Perceived language proficiency and pain assessment by registered and student nurses in native English-speaking and EAL children aged 4-7 years

AIMS AND OBJECTIVES

To identify the factors that influence decisions made by health professionals when assessing the pain of native English speaking and children whose English is an additional language.

BACKGROUND

Pain assessment in children is often poorly executed following acute injury. Whilst a range of pain assessment tools have been developed, little guidance is provided for assessing pain in children with English as an additional language.

DESIGN

Factorial survey design.

METHODS

Twenty minor injuries unit nurses and 20 children's nursing students participated in an electronic survey to make judgements on 12 scenarios describing a child attending a minor injuries unit following an incident, accompanied by a parent. Respondents had to decide the most important form of pain assessment, and whether they would ask a parent or an interpreter to assess the pain of the child. An open-ended question asked about the difficulties found in making a judgement.

RESULTS

Observation of the child's behaviour was the most common pain assessment reported. The visual analogue scale was significantly associated with children with proficient English. Respondents were significantly more likely to involve parents in the assessment if they could speak English well compared to parents with poor English skills. Moreover, nursing students were significantly more likely than registered nurses to call for support from an interpreter. Thematic analysis identified three themes related to difficulties with pain assessment: contrasting approaches, differing perceptions of pain and overcoming challenges.

CONCLUSIONS

The reduced ability to communicate between child, parent and healthcare professional highlights the need to identify forms of assessment based on individual cases.

RELEVANCE TO CLINICAL PRACTICE

The number of children with English as an additional language has seen a marked rise over the last decade. In situations where communication ability is reduced, assessment of pain should be tailored to meet the needs of the child. This may require timely access to interpreter services.

How parents make sense of their young children's expressions of everyday pain: a qualitative analysis

BACKGROUND

Little is known about the communication of everyday pain between young children and their parents, i.e. when children experience pain resulting from minor injury or illness that occur in everyday life. This study aimed to gain an in-depth understanding of how parents make sense of their young children's expression of everyday pains and how they respond.

METHODS

Parents (n = 48) of children (1-5 years inclusive) participated in focus group discussions at seven children's centres across England where they were asked to describe their children's communication of everyday pain. Thematic analysis was used to analyse the data.

RESULTS

Six main themes were identified in the parents' discourse. Parents described children's pain communication as (1) sharing common elements, but unique to each child; (2) having multifaceted pain and non-pain-related purposes; (3) challenging to interpret; (4) influenced by their own pain-related communication; (5) requiring a variety of pharmacological, psychological and physical strategies to manage. The sixth theme that emerged from the data related to parents' dissatisfaction with health care providers, particularly general practitioners' sometimes quick dismissal of parental concerns about their children's pain and illness complaints.

CONCLUSIONS

These findings suggest that parents have well developed, although personal, ways of recognizing and responding to their children's communication of pain, but also experience uncertainty in their judgments. Parents would benefit from information about the developmental aspects of pain and should be included as active partners in their children's pain assessment and management.

Translating the tears: parents' use of behavioural cues to detect pain in normally developing young children with everyday minor illnesses or injuries

OBJECTIVES

The objectives of this paper were to (i) identify the behavioural cues used by parents to detect young children's transient pain from minor illnesses or injuries ('everyday pain'); and (ii) perform an initial psychometric evaluation of the Parents' Post-operative Pain Measure (PPPM) in the context of children's everyday pain.

METHOD

Cross-sectional Internet survey.

RESULTS

One thousand seven hundred sixteen parents of children (1-6 years) completed the survey. The parents reported more behaviours when children had pain from minor illnesses than from minor injuries (9.6 ± 3.9 vs. 2.5 ± 2.3, P < 0.001). Principal component analysis of the PPPM revealed a two-factor solution for illness-related pain and a three-factor solution for injury-related pain. Behavioural cues varied with characteristics of children (age, gender and prior hospital experience) and parents (gender, age and parenting experience).

CONCLUSIONS

The PPPM is a promising tool for parental assessment of children's pain in everyday situations. Further research is needed to determine its utility in facilitating communication between parents and healthcare professionals, and in improving the management of young children's pain.

From tears to words: the development of language to express pain in young children with everyday minor illnesses and injuries

BACKGROUND

Little is known about the development of language to express pain in the young or how children and parents verbally communicate when young children have everyday minor illnesses and injuries.

METHODS

UK parents of children between the ages of 1 and 6 were invited to complete an Internet survey on children's pain language during everyday situations of minor illness or injury.

RESULTS

Of the 1716 parents completing the survey, 45% reported their child had at least one word to express pain by 17 months of age, increasing to 81% by 23 months of age. Children used different words based on their age and in the contexts of minor illnesses and injuries, with words for expressing pain related to illness emerging slightly later. Children's language was purposeful in describing causes of pain and requesting specific forms of assistance from parents even in the very youngest age groups. Parents' communicated with their children primarily to gain further information about the source and nature of pain and to direct children's behaviour.

CONCLUSIONS

Children rapidly develop an extensive vocabulary to describe pain between 12 and 30 months of age, with words for pain from injury emerging first and reflecting the development of normal speech acquisition. The differences in verbal expressions in the context of minor illnesses and injuries suggest that children make a cognitive distinction between the origins and sensory aspects of pain. These findings can help parents, childcare and healthcare professionals to appreciate the early communication capabilities of young children and to engage in more effective pain assessment and management for young children.

Perceiving pain in others: automatic and controlled mechanisms

Recent developments in clinical, cognitive, and behavioral sciences as well as in social neuroscience can provide new perspectives on our understanding of different forms of pain expression and the social reactions of observers to various types of pain expression. Studies indicate that pain expression is governed by both automatic (unintentional, reflexive) and controlled (intentional, purposive) neuroregulatory systems. Reciprocal mechanisms in observers responsible for automatic (unintentional, reflexive) and controlled (intentional, reflective) reactions also are important. Observers appear more likely to display immediate "visceral" emotional reactions to unintentional, reflexive expression, whereas controlled expression characterized by purposive behavior appears more likely to elicit reflection on the nature and origins of the person's pain. This review summarizes research within the context of a theoretical model for understanding how pain is perceived in others.

PERSPECTIVE

People attempting to understand another person's pain may have access to the person's spontaneous behavioral reaction as well as verbal report and other purposive communications. The former instigates reflexive and emotional reactions, whereas the latter tends to be perceived as confounding expression of experience with response to situational demands.

The communication of pain in paediatric dentistry

AIM

In this paper the communication model of pain is reviewed and the information then applied to understanding the acute pain experience of children in dentistry, with attention directed to improving the process of pain assessment.

BACKGROUND

Expression of pain in children is of great importance as it enables them to engage others who may provide care. The experience of pain, however, is inherently private and not directly accessible to others. Therefore, it requires judgment and skill on the part of observers if pain is to be assessed accurately. In addition, there are striking individual differences in how people react to pain, which makes the assessment of pain in others an even greater challenge. Craig and colleagues [2008] have proposed the use of the social communication model of pain that gives priority to understanding the numerous social factors that affect whether children are successful in communicating painful distress.

CONCLUSION

When children's pain is underestimated or a child's self-report is not seen as credible, there is a considerable risk of failure to deliver needed dental care.

The effects of parental presence upon the facial expression of pain: the moderating role of child pain catastrophizing

This experiment investigated the effects of child catastrophic thinking and parental presence on the facial expressions of children when experiencing pain. School children experienced pressure pain in either one of two conditions: (1) when observed by a parent (n=53 children and their parent), or (2) when observed by an adult stranger (n=31 children). Analyses revealed that children showed more facial pain expression in the presence of their parent than in the presence of the stranger. This effect was, however, only found for children with infrequent catastrophic thoughts about pain. Children who have frequent catastrophic thoughts expressed high pain regardless of who they believed was observing them. Results are discussed in terms of the social consequences of pain catastrophizing, and the variables contributing to the expression or suppression of pain display in children and its impact upon others.