Children are often required to repeatedly undergo painful medical procedures (e.g. immunizations) and their memories for pain are predictive of their health behaviours across the lifespan. Although trait anxiety has been shown to influence pain memories, little is known about the impact of state anxiety, and the influence of stable anxiety-related variables (e.g., anxiety sensitivity), on children’s memories for pain. Furthermore, although memory is often implicated in children’s reactions to future pain, there is a dearth of research directly examining the relationship between the two. The current dissertation project involved two studies. The first study investigated the impact of experimentally manipulated state anxiety, and the influence of anxiety-related variables, on children’s memories for a novel pain experience. The second study examined the influence of children’s pain memories on a subsequent pain experience. In Study 1, one hundred ten children (60 boys; 50 girls) between the ages of 8 and 12 years (Mage = 9.45 years, SD = 1.35) were randomly assigned to complete either a state anxiety induction task or a control task. Then, children completed a laboratory pain task (the cold pressor task) and provided pain ratings. Children also completed measures of state anxiety and stable anxiety-related variables. Two weeks following the laboratory visit, children were contacted by telephone and provided pain ratings based on their memories of the initial pain experience, as well as their expectancies about future pain. Results showed that children in the state anxiety induction group did not have more negative pain memories (i.e., they did not recall higher levels of pain) than children in the control group. However, irrespective of group assignment, children who had higher levels of state anxiety had more negative memories of pain intensity and pain-related fear than children with lower levels of state anxiety. Furthermore, state anxiety was a unique predictor of children’s pain memories over and above the influences of sex, stable anxiety-related variables, and experienced pain intensity and pain-related fear. Stable anxiety-related variables (anxiety sensitivity and trait anxiety) were also significant predictors of recalled pain-related fear. In Study 2, the same children once again completed the pain task and provided pain ratings one month following the initial laboratory visit. Results revealed that children’s memory of pain intensity was a better predictor of subsequent pain reporting than their actual initial experience of pain intensity; in fact, children’s pain memories mediated the relationship between reporting of pain intensity at Lab Session 1 and Lab Session 2. Children who had negatively estimated pain memories developed expectations of greater pain prior to a subsequent pain experience and showed greater increases in pain ratings over time than children who had accurate and positively estimated pain memories. Overall, these data highlight the importance of anxiety in the development of children’s memories for pain and present a model of acute pain memories that add to the growing literature on pain memories across development. Results also highlight the powerful influence of pain memories on healthy children’s pain expectancies and subsequent pain experiences, and extend predictive models of subsequent pain reporting to childhood.

Children undergoing surgical procedures often experience pain in the recovery room where parents are typically responsible for managing children’s distress. Research suggests that parents’ behavior influences children’s distress; however, no study has used time-window sequential analysis to examine the likelihood of parents’ reassurance and children’s distress interactions. The purpose of this study was to utilize time-window sequential analysis to examine the likelihood of parents’ distress preceding and following the start of children’s distress. Participants included 148 families with children 2-11 years old undergoing outpatient surgery. Reassurance was positively associated with children’s distress, but sequential analyses revealed that children’s nonverbal distress was significantly less likely to start and stop following parents’ reassurance and children’s verbal distress was significantly less likely to occur after fathers’ reassurance. These data suggest that reassurance does not prompt distress to start; however, it may maintain children’s distress.

Vaccinations provide protection against deadly diseases and children are scheduled to receive many immunization injections before the age of six. However, painful procedures, such as immunizations cause negative short- and long-term consequences for children. The Gate Control Theory of Pain suggests that physical interventions may be helpful, but they have not yet been validated as an effective intervention to manage children’s acute pain. This randomized trial examined the effectiveness of the ShotBlocker®, a physical intervention designed to decrease children’s injection pain, in a sample of 89 4- to 12- year-old children receiving immunizations at a pediatric practice. An ANOVA revealed no significant effect of treatment group (Typical Care Control, Placebo, and ShotBlocker®) on any measure of child distress. Clinical and theoretical implications are discussed.

Distraction is an effective pain management intervention and children’s coping styles are important to consider when designing interventions. The purpose of this study was to examine two movie distractions in children 3 to 11 years old receiving venipunctures and to evaluate the relations between the effectiveness of the interventions and coping styles. Results revealed no interaction and no main effects of condition or coping style. However, coping on caregiver-report of child pain approached significance. T-tests revealed significant differences between approach and avoidance coping styles, with children with an approach coping style experiencing significantly less pain compared to children with an avoidance coping style. Descriptive statistics revealed the presence of a mixed coping style, suggesting that children’s coping styles may be continuous. This study highlights the importance of examining coping styles in the context of pediatric painful medical procedures and the need to further examine the effectiveness of distraction interventions.

Children undergoing surgical procedures often experience pain in the recovery room where parents are typically responsible for managing children’s distress. Research suggests that parents’ behavior influences children’s distress; however, no study has used time-window sequential analysis to examine the likelihood of parents’ reassurance and children’s distress interactions. The purpose of this study was to utilize time-window sequential analysis to examine the likelihood of parents’ distress preceding and following the start of children’s distress. Participants included 148 families with children 2-11 years old undergoing outpatient surgery. Reassurance was positively associated with children’s distress, but sequential analyses revealed that children’s nonverbal distress was significantly less likely to start and stop following parents’ reassurance and children’s verbal distress was significantly less likely to occur after fathers’ reassurance. These data suggest that reassurance does not prompt distress to start; however, it may maintain children’s distress.

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Thesis advisor: Callista Roy / Assessing pain in nonverbal children with intellectual disability (ID) is challenging. These children are at risk for having pain from complex medical conditions and treatments for these conditions (Breau, Camfield, McGrath, Finley, 2004). Compounding this, their pain cues are often misunderstood, given that they are nonverbal and limited by their physical abilities. Although, pain assessment tools for this population exist, there is a need for tools appropriate for a range of exhibited pain expressions. The general purpose of this study was to examine the words that parents of children with ID use to describe their child's pain responses in order to improve pain recognition and management. Specifically, the aims were to: 1) Identify common pain responses; 2) Examine the relationship between type of pain response and demographic characteristics; 3) Compare common pain responses to cues in the literature. A non-directed summative content analysis identified patterns in 335 parent described pain responses of 50 nonverbal children with ID ages 6-18 years. The relationships between type of pain response and selected demographic factors were examined. Then pain responses were compared to items of pain tools for this population. Seven distinct categories of pain expression were identified in the content analysis. The greatest percentage of pain cues were within the categories of vocalization (39.4%), social behavior (21.8%) and facial expressions (16%). Four categories: vocalization, social behavior, muscle tone and activity level included opposite responses to pain. Significant relationships between type of parent described pain expression and 1) pain severity; 2) causes of ID and; 3) the gender of the child found that type of pain expression changes with severity; that patients with seizure disorders expressed pain with vocal pain expression; and that females expressed pain with more social pain expression while males expressed with more vocalizations. The results support published evidence that parents can articulate their child's pain responses. The study also provides evidence of: 1) opposite pain responses within general categories of pain; 2) a significant relationship between type of pain responses and severity of pain, cause of ID and child gender and; 3) the comprehensiveness of pain assessment tools vary greatly. / Thesis (PhD) — Boston College, 2010. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Immunizations are an essential part of children’s healthcare; however, the associated distress can have short- and long-term negative ramifications for children. Parents’ procedural behavior is one of the strongest predictors of children’s distress. The current study evaluated whether an interactive computer training program influenced parents’ knowledge of the impact that their behavior has on their children or their actual procedural behavior during children’s immunizations. 90 parents and their 4- to 6-year-old children receiving immunizations participated. Overall, findings suggest that using a computerized training module to enhance parent knowledge and behavior is helpful but requires improvements in some areas to optimize training.

The purpose of this mixed methods study was to describe the cognitive processes/knowledge sources used by Emergency Department (ED) nurses in decision-making activities regarding triage and pediatric pain assessment and management. Deficiencies persist in ED pediatric pain assessment, and management methods or approaches that might help resolve these deficiencies have not been identified previously. Methodology triangulation with sequential use of qualitative- quantitative methods provided a rich description of knowledge sources and cognitive processes used by ED nurses relative to pediatric pain assessment decisions. Based on qualitative results, a set of vignettes was developed to assess ED nurses. Data analysis using ordinal logistic regression with a cumulative logit model identified patient and nurse variables which influence triage acuity decisions. Five common themes emerged from the qualitative data; 1) Age of the child is important, 2) Behavior can tell a lot, 3) Really looking at the patient, 4) Things that help make decisions, and 5) Things that hinder decisions. Ordinal logistic regression analysis of the quantitative data identified predictor variables of infants compared to school-age children, Hispanic ethnicity, moderate number of years of ED experience (11 -20 years) and years of education that were associated with higher triage levels .The implications of this new knowledge include changes in ED triage nurse practice towards pain assessment, and increased awareness of the need for education in use of pain assessment tools. Additional implications include education related to pain management practices by ED physicians and pain medication protocols at triage. This information may enhance triage and care of the pediatric patient experiencing pain, expand the knowledge base of emergency nursing, identify areas in which to implement changes, assist in improving care provided to children experiencing pain, and provide direction for future education, training, and research.

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