Research and Strategies for understanding and responding to children and

families experiencing pain and stress

PROCEDURAL SUPPORT: PAIN,

TRIGGERS & STRESS POINT POTENTIAL

Strategies & Background Knowledge: To Communicate with a child in pain

Step 1 = Affirm the child's experience and acknowledge their pain

Effective responses to a child in pain:

 Respond promptly to the child’s pain in an empathic, professional, practical

manner.
 Explain in child-oriented language what is happening in his or her body.
 Make physical contact with the child in the way that feels best for you both.
 Acknowledge the pain, as you examine, palpate, observe, and/or attempt to gain
some measure of the child’s pain.
 Encourage the parent to remain with the child or teenager until the pain is under
control.
 Tell the child calmly and slowly what positive steps are being taken or will be taken
to reduce the pain and provide comfort.
 Provide hope, wherever possible, as it is sustaining.
 Instruct the child on using pain management strategies (see Chapter 5).
 Be an attentive coach and track what would therapeutically support the child’s
coping.
 Keep yourself calm, as this will help allay the child’s anxiety.

Gender Bias and Pain

 The unfamiliar usage or complexity of some common medical words or

expressions can be confusing and frightening.

 Among young children found that girls receive physical com- fort twice as often as
boys (Fearon, McGrath, & Achat, 1996).

 Downplaying a child’s pain tends unfortunately be a gender- biased phenomenon.

Researchers in a study of everyday pain among young children found that girls
receive physical com- fort twice as often as boys (Fearon, McGrath, & Achat,
1996).
The Role of Crying
 Tears release the physiological tension produced by trauma and pain" 89

Cultural attitudes toward crying

 self is formative in developing identity. A young child’s emotions and internal

sensations form the nucleus of the emerging sense of self.

 It’s unhelpful to tell a child that “it’s OK to cry” when the child is facing a painful
procedure.

 However, telling a child who is about to have a painful procedure that it is OK to

cry, conveys doom: “What I’m about to do will hurt so much that I expect you to
cry, so if you do it’s OK!” This is likely to pro- voke tension and tears because there
clearly is no other way out. A child who does not cry is likely to remember the
situa- tion as less frightening and distressing than one who does cry.

Responding to an angry child

 Don’t take it personally
 Instead explain
 What is happening with the child’s body right now.
 What needs to occur for the pain to reduce and the child to get well.
 What the plan of treatment is.
 If a procedure will occur, what it is called, what will happen, how it could feel.
 What the child can do to help him or herself get through it.
 What or who will be there to support and what they could do too.
 Invite the child into the planning team, gives them a sense of power over
their situation and takes them out of the victim role
 Questions like “That wasn’t so bad right?”
 Projects what a child believes they ‘should’ be feeling, leading to feelings
that they did something wrong or they are bad if their experience dose
not a line with what you suggested. Particularly true for rule-following,
school aged children)

Useful Responses to a Child in Pain

 Don’t ignore the child’s pain.
 Don’t rob a child of hope.
 Don’t be inconsistent with preparation or follow-through.
 Don’t use reassurance and sympathy with the child.
 Don’t say "it will be ok" or "it will be over soon!" - this increases children's
reports of pain.
 Don’t engage in the myth of two pains.
Choosing your words carefully
  Children and teens are very sensitive to the judgment or diagnoses made about
their pain experiences. Fifteen-year-old

Keeping in mind developmentally appropriate language: Guiding childhood

aptitudes towards pain
 Toddlers are at a particular high risk for developing fears 99
 ‘ouch’ and ‘hurt’= children in their toddler and preschool years
 ‘pain’ or ‘sore’ = rarely before the age of 6 years

Parent's central role in health care

 Parents empowered in this way will be an ally for pediatric health professionals.
 Parents are:
 Experts on their child: health, history, temperament, and needs.
 Key resources in caring and managing their child’s health.
 Partners in decision making and future planning. 95

 Parents, however, should never be required to coerce or restrain their child. This is
not their role in medical care.

 Parental anxiety in medical situations has been found to predict their children’s
anxiety (Jay, Ozolins, Elliott, & Caldwell)

 If we want the child to do well, we must ensure that the parent is doing well too –
they affect each other. The parent is a key to the child, and a key to the success of
the treatment plan and its follow-up.

Parents teach children the meaning of pain

 Children experience and observe how their parents deal with pain, talk about pain,
and cope with pain.

 By helping the child make sense of pain, giving it a name, and putting it in its place,
the parent may influence the formation of the early circuitry of the child’s
neuromatrix

 Trust, reliance, and understanding

 The early years are a time of particular rapid learning to establish pain attitudes
and potentially develop the brain’s neural patterns for pain processing, modulation,
and inhibition. When alerted by a child’

 Parents explain and interpret con- fusing and alarming pain signals. Whatever
their temperament,

The process of coping

 Coping responses: 3 dimensions:
  Active efforts to regulate emotion and act on the source of the environmental
stress. These include problem solving, decision making, modulating emotion
and its expression, as well as obtaining social support that is focused on the
problem, or focused on emotion.
 Accommodating efforts aimed at achieving some adjustment to the stress.
These include distraction, acceptance, cognitive reframing, self-
encouragement, minimizing or positive thinking.
 Disengaging efforts to orient attention away from the source of the stress as
well as any emotional responses. This is considered to be passive or avoidant
coping. These efforts include withdrawal or isolating oneself, wishful thinking,
denial, and avoiding thoughts or action associated with this stressor.

Coping and attention under stress

 "A child's attention is a mental filter”
 "The child then selects among various competing sources of information to process
what may be relevant”
 Younger & older children have different needs
 Over focusing on pain => more reported pain felt, potential long-term
consequences
Catastrophizing
 Catastrophizing = the manifestation of unwanted persisting negative thoughts and
distressing feelings, reacting the high threat of anticipated or experiencing pain.
 Causes greater suffering and distress
 Related to higher anxiety and depression, lower pain tolerance
 Has a negative spillover effect on other children, staff and children's parents

Giving parents support to cope

 The worst part of seeing their child in pain for some parents is their own sense of
helplessness.
 A child's pain is a parents pain.
 Gathering support and information from health care staff, friends, and other
parents is a natural way to cope. The simple act of expressing their distress away
from their ill child, conveying it to someone who hears empathically and can
appraise the situation, eases parents’ feelings of anger or helplessness. Parents in
similar situations quickly become allies for each other.

These Parental coping techniques include:

 Taking breaks to listen to a relaxation, imagery, or favorite music CD or iPod, to

return refreshed with a clearer vision of the situation and its possibilities.

 Breathing deeply to help when energy is fading or strained.

 Exercising regularly, such as walking, practicing yoga, swimming, or cycling, to

rebalance emotional and physical energies.
  Having a massage or a refreshing warm bath or shower.

 Using meditation or prayer as natural ways to draw on extra strength.

 Reading books or materials on pain management or the child’s particular condition

or disease.

 Writing to family and friends by email, blogging, or keeping a journal.

 What time of day or night does the pain occur?
 What else coincides with the pain or has preceded the onset of the pain within
the last hour?
 How long does the pain last?
 What worsens it?
 What helps the pain to settle?
 How long is your child pain-free?

Pain in particular developmental stages:

Infants: 0-12 mo

How they understand pain

 Infants are able to experience pain and discomfort before birth
 6 mo babies who have previously had needle procedures as part of a medical
treatment will become fearful and actively avoid the anticipated pain.

What to look for

 Observe the infant
 Ask the parents

Toddlers: 1-2 yr

How they understand pain

 16-24 mo very common for a child to regard their skin as defining 'self'
 Blood = the end!
 Toddlers cant articulate fear
 Experiences are still strongly based on their senses: seeing is believing

What to look for

 1 yr = can point to body part to identify pain
 Cannot always identify how they are feeling, but can identify where & how much
they are hurting by using familiar language
 "owie", "booboo"

Pre-schoolers: 3-5 yr
 How they understand pain
 Understand that pain is "something that hurts"
 Use simple words to describe their experiences
 Cause and effect concepts are not like adults
 Magical thinking
 Concrete in perceptions of life
 Time - Today is the center of the world
 Physical proof that pain will end => holding a Band-aid while having blood drawn

What to look for

 Ask about nature, location and intensity of their pain
 Observe: movements and behavior
 Changes in behaviors, sleeping, eating etc.
 A vital part of this stage is gaining increased mastery and understanding of events

School-aged: 6-12 yr

How they understand pain

 Can draw on internal cues
 Are often still naïve about external causes, like infection
 Cause & effect understanding is still concrete
 Computer = good analogy for how the brain functions

What to look for

 Ask a child directly and talk together about what you have observed
 Boys - tend to be more stoic at this age (be aware)

Adolescents: 13-18 yr

How they understand pain

 Teenagers are capable of thinking abstractly
 Often show how insight into the psychological factors or consequences of their
pain
 May ignore or amplify pain signals

What to look for

 Teens are reliable witnesses of their pain
 Private discussions - will help to avoid peer pressure of meeting others
expectations about their pain
Trigger Points& Stress Point Potential: Making Assessments

Waiting room: Quickly observe behaviors of child and family

 Introductions (how members are introduced, order of speaking, cueing etc.)
 Body language (physical orientation of family members, individual’s
positioning, closed off, arms crossed or playing)
 Stress level
Chart review: Make note of addition stressors
 Past hospitalization
 Psychological issues
 Developmental delays
 Sensory impairments
 Primary language spoken
 Where family is from (developing country? War zone?)
 Parent & Family DCF History

What a child finds stressful will depend on their:

 Developmental level
 Past experiences
 Cultural background
 Perception of the event
 Supports or resources
 Resiliency

Theory
Family systems theory
 Sees a child as a part of a larger family system within the environment
 They are impacted and affected me that system
 Stressors of the family may impact the stress and perspective of events by a
child
Bronfenbrenner’s Ecological Systems Model
 Human development is influenced by the different types of environmental
systems.
 Society
 Culture
 Norms
 Values
 Mass media
 Social policy
 Neighborhood
School
Peers
Social, health and legal services
Friends of family
Parent/ Family
Child
Bandura’s Social Learning theory
 Human behavior is learned through observationally through modeling
 We are surrounded by different models in our lives (parents, peers, tv
characters etc.)
 Children may copy these behaviors (more likely to copy behaviors of people
who they identify with)
 These behaviors will either be rewarded (strengthened/ reinforced) or
punished by those around them
 Observe and learn consequences (positive & negative) = vicarious
reinforcement
Lazarus & Folkman (1984) on Stress & Coping

 2 different types of stressors:

 Normative transitions
 Anticipated, short-term events such as managing daily life with a busy
schedule, apply to colleges, problemed relationships etc.
 Socially undesirable or negative events
 Major stressful life events – the death of a family member, loss of a job,
unexpected hospitalization or a child or parent

Stress Theory
 This model explains why people react differently when faced with the same
challenges
 Stress has less with a person's actual situation and more with how the
person perceives the strengths of her own resources.
 3 perspectives on stress as:
 An event (stimulus-oriented)
 A reaction (response-oriented)
 A transaction (relational)
Cognitive appraisal:
 Appraisals= evaluations related to how you see a situation and how it could affect
you
 Stress and coping
 Coping - The process of managing stressful situations
 Coping strategies- Refer to the specific efforts both behavioral and
psychological that people employ to master, tolerate, reduce or minimize
stressful events
 Primary appraisal
 Involves estimating the severity of a stressor and classifying it as either as..
 Is it a threat?
 Is it a challenge?
 Is it irrelevant?
 Secondary appraisal
 Involves estimating the resources available to the person for coping with the
stressor
 Can I do this?
 Resources include: physical health, family/ friend support,
financial support
Involves coping processes:
 People use both types of coping strategies to combat most stressful events //
 Problem focused coping = focused is external; attempt to solve a problem or
minimize stress by actively changing something in their environment
 Attempts to deal with the cause of the problem
 Learn new skills to manage a problem

 Emotion focused coping = the focus is internal; behavior is directed toward

dealing with distressing through and feelings that may accompany a stressful
situation
 EX) A person begins releasing pent-up emotions or Managing feelings of
anger
 External and internal factors must be considered

In order to care for one’s stress point potential, various factors should be
considered.
 How a child experiences and perceives pain (a child in pain model)
  Outside influences which impact an child’s stress (ecological model, and family
systems theory)
 How the role of the CCLS can impact patients’ pain and stress levels

Stress point care

 A term used to describe the process of identifying and planning for
situations with the greatest potential to overwhelm a child's or parents
coping resources

Additional Academic Journals relevant to the research done above:

 - https://www.woundsresearch.com/article/impact-stress-dressing-change-
patients-burns-review-literature-pain-and-itching

- https://www.sciencedirect.com/science/article/abs/pii/S030541791630496X

- https://academic.oup.com/jpepsy/article/31/4/343/925275

- https://journals.sagepub.com/doi/abs/10.1177/107484070100700202

References

Kuttner, L. (2010). A child in pain: What health professionals can do to help. Wales:
Crown House.

Rollins, J. H., Bolig, R., & Mahan, C. C. (2017). Meeting childrens psychosocial needs
across the health-care continuum. Austin, TX: PRO-ED.