Abstract
Background and aims
To better understand the associations between pain beliefs and pain coping strategies in a sample of community adolescents.
Methods
Four hundred and thirty-four adolescents were asked to complete measures of physical function, pain-related beliefs and use of pain coping strategies. A series of three hierarchical regression analyses were performed.
Results
Approach coping strategies demonstrated significant and positive associations with beliefs about the importance of solicitousness responding and control over pain. Problem-focused avoidance coping strategies evidenced a negative association with the belief of being disabled by pain, and a positive association with the importance of exercise. Emotion-focused avoidance coping strategies showed significant and positive associations with beliefs about being disabled by pain and that emotions affect pain, and negative associations with beliefs about control over pain and the appropriateness of pain medications.
Conclusions
The findings provide important new information regarding the potential role that beliefs could play as predictors of pain coping in adolescents living in the community. Prospective studies are needed to evaluate the possible causal role that beliefs play in decisions to use what pain coping strategy and under what circumstances.
Implications
The role that pain beliefs and coping strategies play in the adjustment to pain in adolescents in the community has both similarities to and differences with the role that these factors play in adolescent clinical populations. This information can guide the development of community-based treatment programs for adolescents with pain.
1 Introduction
The cognitive-behavioral model hypothesizes that psychological factors play a key role in explaining a youth’s adjustment to chronic pain [1], [2], [3], [4], [5], [6], and the way that they respond to pain treatment [2], [3], [7], [8], [9]. Nevertheless, negative responses (e.g. catastrophic thinking) appear to be more salient predictors than more positive responses (e.g. coping self-statements) [7], [10], [11], [12].
Pain-specific beliefs include thoughts held by individuals reflecting meaning of pain and its consequences, one’s control over pain, and expectancies about pain treatment and recovery. Pain coping responses refer to the behavioral and cognitive efforts to manage the pain problem. In general, coping strategies associated with an active approach to the problem and problem-focused avoidance strategies have been viewed as adaptive. Emotion-focused avoidance strategies have been generally viewed as maladaptive. Approach strategies attempt to deal with pain and the emotional-related distress in an active way. Problem-focused avoidance strategies attempt to disengage from pain while regulating emotional reactions. Emotion-focused avoidance strategies attempt to disengage from pain without attempting to regulate the negative emotions provoked by it. Although beliefs and coping are conceptually distinct, they are hypothesized to influence each other [13], [14], [15], [16].
Most of the data supporting the importance of pain beliefs and coping responses to pain adjustment in youths with pain has been gathered in clinical samples. Currently we know very little about the importance of pain coping and beliefs in non-clinical populations. Given the possibility that responses found to be important to adjustment in clinical populations may or may not play a role in adjustment to chronic pain in community populations, research in this area should also study individuals with pain in the community.
To our knowledge, there is only one study that has examined the associations between pain-related beliefs and coping in a community sample of children with pain. In this study, Huguet and colleagues [13] found that beliefs about the controllability of pain were positive and significantly associated with adaptive coping strategies. Such beliefs were negatively associated with maladaptive coping responses. These preliminary findings support the association between pain beliefs and pain coping responses in a community sample. However, additional work is needed to replicate and extend them. Such research could help identify the beliefs that might have the greatest influence on coping as well as adjustment and function in both clinical and community youth samples with pain. This would allow us to compare which of these beliefs could then be targeted early in treatment in clinical samples and in secondary prevention programs. This work is also critical because it would influence how youth in the community might be educated about pain (e.g. in the school by their teachers, or by a primary care doctor in the community).
Given these considerations, the aim of this work was to better understand the associations between pain beliefs and pain coping strategies in a community-based sample of youths. Based on existing research, we hypothesized that beliefs that have been shown to be associated with poorer function in clinical samples will be negatively associated with approach and problem-focused avoidance coping strategies, and positively associated with emotion-focused avoidance coping. On the other hand, beliefs that have been shown to be associated with better function in clinical samples will show the opposite pattern.
2 Materials and methods
2.1 Participants
Schoolchildren enrolled in grades 7–12 in several schools of the province of Tarragona (Catalonia, Spain) were invited to participate in the study. Inclusion criteria were: [1] being able to read and write Catalan; [2] being between 12 and 18 years old and; [3] providing complete responses to the questionnaires used in this study. Exclusion criteria were: [1] having any cognitive impairment that would limit the ability to participate; [2] not returning the informed consent signed by their parents or guardians.
2.2 Measures
2.2.1 Sociodemographic and pain history variables
All participants were asked to provide information about their age, sex, presence or absence of pain in the last 3 months, pain location, maximum pain intensity of the most frequent pain in the past week, and whether their pain had been present for more than 3 months.
2.2.2 Pain beliefs
Pain beliefs were assessed by a Catalan version of the 35-item Pediatric version of the Survey of Pain Attitudes-Revised (Peds-SOPA-R [8], [17], [18]). The Peds-SOPA-R items are scored into seven scales assessing different pain belief domains. Medical Cure (the extent to which the respondent believes in a medical cure for the pain problem), Medication (the extent to which the respondent believes that medication is an appropriate treatment for his or her pain), Disability (the extent to which the respondent believes that one is unable to function because of pain), Emotion (the extent to which the respondent believes that his or her emotions impact his or her pain), Solicitousness (the extent to which the respondent believes that others should be solicitous in response to his or her experience of pain), Control (the extent to which the respondent believes he or she can control the pain), and Exercise (the extent to which the respondent believes that exercise is beneficial for pain management). Respondents are asked to report the level of agreement with each item/belief statement on a 3-point Likert scale where 0 means “I do not agree with this”, 1 “I am not sure” and 2 “I agree with this”. The Peds-SOPA-R scales have shown to provide reliable and valid scores in clinical and community samples of adolescents [8], [17], [18]. Cronbach’s alpha of the Peds-SOPA-R scales in our sample ranged from 0.67 to 0.85, indicating adequate to good internal consistency.
2.2.3 Pain coping
Pain coping responses were assessed using a Catalan version of the Pain Coping Questionnaire (PCQ [16]). The Catalan version of the PCQ is a 36-item questionnaire that assesses seven different pain coping strategies: Information Seeking and Problem Solving, Seeking Social Support, Positive Self-Statements, Behavioral Distraction, Cognitive Distraction, Externalizing and Internalizing/Catastrophizing. The measure can also be used to create scores representing three higher-order factors, two viewed as adaptive (approach coping strategies, Problem-Focused Avoidance strategies) and one viewed as maladaptive (Emotion-Focused Avoidance strategies). We used the three higher-order factor scale scores in the current analyses. With the PCQ, respondents are asked to rate the frequency with which they use each coping response on a 5-point Likert-type scale (from 1=“Never” to 5=“Very often”) when they have pain. The PCQ has been shown to provide valid and reliable scores in clinical and community samples of children and adolescents [13], [16]. Cronbach’s alpha of the PCQ scales in our sample ranged 0.77–0.91 for the lower–order factors and from 0.82 to 0.89 for the higher-order factors, indicating good to excellent internal consistency.
2.2.4 Physical function
We assessed physical function using the Catalan version of the 15-item Functional Disability Inventory (FDI [19]). The FDI assesses perceived limitations in activity caused by pain. With the FDI, respondents are asked to rate the extent to which they had any problem or difficulty in performing each of the activities listed in the last few days on a 5-point Likert-type scale (0=“No trouble” to 4=“Impossible to do”). The FDI has shown good to provide reliable and valid data [19], [20]. In this study we used a Catalan version of the questionnaire that has showed to provide reliable and valid scores [21]. In our sample, Cronbach’s alpha of the FDI was 0.89, indicating good internal consistency.
2.3 Procedures
Twelve schools from the province of Tarragona (Catalonia, Spain) were chosen by proximity, contacted and invited to enroll in the present study. In case they agreed to participate a letter explaining the study was sent to the parents of all the students enrolled in grades 7–12. If parents agreed that their children could participate in the study, they were asked to return a signed informed consent form. After that, researchers went to the schools and administered the questionnaires to the participants during school hours. First, participants were asked to indicate if they had experienced pain in any area of their body in the last 3 months. If so, they were then asked to indicate the location of their pain (or pains) and to report the maximum pain intensity of the most frequent pain. Next, they were asked whether this pain had been present for more than 3 months. In this study, for a pain problem to be considered as chronic, it had to be present for at least 3 months. After that, participants were asked to complete paper-and-pencil versions of the questionnaires thinking of their most frequent pain. The study was approved by the Department of Education of the Catalan Government and by the participating schools.
2.4 Data analysis
We first computed means and standard deviations (for continuous variables), numbers and percentages (for dichotomous variables) to describe the sample. We also performed t-tests in order to determine if there were differences between the scales scores of those participants who had chronic, acute or no pain. We then examined the distribution of the study variables in order to ensure that they met the assumption of normality (for use in the planned analyses). In order to test the study hypothesis, we performed a series of three hierarchical regression analyses. Approach coping strategies (i.e. PCQ scales measuring “Information Seeking & Problem Solving”, “Seeking Social Support”, and “Positive Self-Statements”), Problem-Focused Avoidance coping strategies (i.e. PCQ scales measuring “Behavioral Distraction”, and “Cognitive Distraction”) and Emotion-Focused Avoidance coping strategies (i.e. PCQ scales measuring “Externalizing” and “Internalizing/Catastrophizing”) were the criterion variables. We entered sex and age in step 1 and pain intensity, physical disability and chronicity in step 2 as control variables. In step 3, we entered all the scales of the Peds-SOPA-R measuring “Medical Cure”, “Medication”, “Disability”, “Emotion”, “Solicitousness”, “Control” and “Exercise”.
3 Results
3.1 Description of the study sample
A total of 850 adolescents, from 9 of the 12 invited schools, were contacted and invited to participate. Of these, 579 (68%) returned the informed consent signed and participated in the study. One hundred and forty five participants (25%) did not complete all the measures, and were excluded from final analysis. Thus, the final sample of participants was made up of the 434 adolescents (51% of the initially invited) of whom 373 (86%) reported that they had experienced pain in the 3 months preceding this survey. The average age was 14.01 years old (SD=1.99; range=12–18 years), and 255 (59%) were girls/women. See Table 1 for additional descriptive information about the study sample.
Descriptive data for the study sample (n=434).
| n | % | |
|---|---|---|
| Participants’ age | ||
| 12 | 96 | 22 |
| 13 | 81 | 19 |
| 14 | 79 | 18 |
| 15 | 79 | 18 |
| 16 | 61 | 14 |
| 17 | 26 | 6 |
| 18 | 12 | 3 |
| Pain Chronicity | ||
| Acute | 263 | 61 |
| Chronica | 110 | 25 |
| No pain | 61 | 14 |
| Pain location of the most frequent pain | ||
| Head, face and mouth | 82 | 22 |
| Cervical region | 12 | 3 |
| Upper shoulder and upper limbs | 51 | 13 |
| Thoracic region | 6 | 2 |
| Abdominal region | 53 | 14 |
| Lower back, lumbar spine, sacrum an coccyx | 32 | 9 |
| Lower limbs | 84 | 22 |
| Pelvic region | 7 | 2 |
| Anal, perineal and genital region | 2 | 1 |
| Missing data | 44 | 12 |
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aPain lasting more than 3 months.
3.2 Assumptions testing
Skewness and kurtosis of all the variables were evaluated, as well as the histograms and p-p plots in order to ensure that all the variables were normally distributed. Results showed that all the scales scores have normal distributions (skewness=−0.56 to 1.10, kurtosis=−1.26 to 0.72).
3.3 Descriptive data of the study variables
Table 2 shows descriptive data about all the variables/questionnaires used in the study for each subgroup (i.e. no pain, acute pain and chronic pain). Significant differences were found between participants with acute pain and without pain in the following variables: SOPA medical cure (t=−3.67, p<0.001), PCQ externalizing (t=3.07, p=0.002) and disability (FDI) (t=3.76, p<0.001). Significant differences were also found between participants with chronic pain and without pain in the following variables: SOPA medical cure (t=−2.71, p=0.007), SOPA medication (t=−2.61, p=0.010), PCQ externalizing (t=4.70, p<0.001), PCQ internalizing/catastrophizing (t=3.33, p=0.001) and disability (FDI) (t=4.43, p<0.001). Finally, significant differences were found between participants with acute and chronic pain in the following variables: SOPA medication (t=2.06, p=0.041), SOPA emotion (t=2.50, p=0.013), PCQ emotion (t=−2.50, p=0.014), PCQ internalizing/catastrophizing (t=−2.58, p=0.010), pain intensity (t=−4.97, p<0.001).
Descriptive data for the study measures.
| Mean (SD) | Mean (SD) | Mean (SD) | |
|---|---|---|---|
| No pain group | Acute pain group | Chronic pain group | |
| Peds-SOPA-R scales | |||
| Medical cure | 1.53 (0.48) | 1.29 (0.47) | 1.32 (0.51) |
| Medication | 1.35 (0.53) | 1.26 (0.55) | 1.11 (0.64) |
| Disability | 0.72 (0.55) | 0.72 (0.53) | 0.71 (0.59) |
| Emotion | 1.02 (0.63) | 1.18 (0.65) | 0.99 (0.71) |
| Solicitousness | 1.38 (0.62) | 1.39 (0.56) | 1.25 (0.65) |
| Control | 1.20 (0.54) | 1.13 (0.55) | 1.09 (0.56) |
| Exercise | 0.87 (0.58) | 1.00 (0.57) | 0.93 (0.67) |
| PCQ scales | |||
| Information Seeking and Problem Solving | 2.63 (0.88) | 2.76 (0.75) | 2.83 (0.87) |
| Seeking Social Support | 3.02 (1.09) | 3.17 (0.99) | 3.01 (1.12) |
| Positive Self-statement | 3.21 (1.07) | 3.20 (0.91) | 3.35 (1.09) |
| Behavioral Distraction | 3.36 (1.22) | 3.41 (1.12) | 3.32 (1.28) |
| Cognitive Distraction | 3.32 (1.12) | 3.03 (0.94) | 3.00 (1.07) |
| Externalizing | 1.50 (0.67) | 1.84 (0.80) | 2.12 (1.05) |
| Internalizing/catastrophizing | 2.08 (0.81) | 2.30 (0.86) | 2.57 (0.97) |
| Pain intensity | – | 7.53 (1.71) | 8.50 (1.75) |
| FDI | 5.54 (9.12) | 10.60 (9.99) | 12.60 (9.90) |
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Peds-SOPA-R=Pediatric version of the Survey of Pain Attitudes – revised version; PCQ=Pain Coping Questionnaire; FDI=Functional Disability Inventory.
The ratings of the current sample in the PCQ scales and SOPA scales are very similar to those reported in the development studies of the original questionnaires [16], [17]. They are also similar to those reported in the validation studies of the versions of the questionnaires that we used [8], [13], [18]. The ratings on the FDI are lower than those informed in the development study of the original questionnaire (mean=11.25 and SD=9.84) [19] and similar to those found in the validation study of the version of the questionnaire that we used (mean=10.81 and SD=10.44) [21].
3.4 Regression analyses
3.4.1 Pain beliefs that predict Approach coping strategies
In the regression analyses predicting Approach coping strategies, the demographic variables explained a statistically significant 2% of variance; this effect was due primarily to the effects of sex (β=0.12, p=0.030). The pain-related variables did not contribute significantly to the model. After controlling for these variables, beliefs about pain explained an additional 10% of the variance. The Peds-SOPA-R scale scores that demonstrated significant and positive associations with the use of approach coping strategies were Solicitousness (β=0.15, p=0.012), and Control (β=0.15, p=0.013) (see Table 3).
Multiple regression analyses predicting Approach coping strategies.
| Step | Predictor | R 2 | R 2 change | F | β | t | p-Value | Tolerance | VIF |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Demographic data | 0.02 | 0.02 | 4.3 | 0.030 | ||||
| Age | 0.08 | 1.42 | 0.155 | 0.905 | 1.11 | ||||
| Sex | 0.12 | 2.26 | 0.030 | 0.873 | 1.15 | ||||
| 2 | Pain variables | 0.022 | 0.002 | 0.189 | 0.904 | ||||
| Pain chronicity | 0.01 | 0.22 | 0.824 | 0.806 | 1.24 | ||||
| Physical disability | 0.09 | 1.52 | 0.130 | 0.835 | 1.20 | ||||
| Pain intensity | 0.02 | 0.33 | 0.745 | 0.812 | 1.23 | ||||
| 3 | Peds-SOPA-R beliefs | 0.12 | 0.11 | 7.5 | <0.001 | ||||
| Solicitousness | 0.15 | 2.52 | 0.012 | 0.737 | 1.36 | ||||
| Control | 0.15 | 2.49 | 0.013 | 0.752 | 1.33 | ||||
| Medication | 0.10 | 1.71 | 0.088 | 0.796 | 1.26 | ||||
| Emotion | 0.11 | 1.94 | 0.053 | 0.816 | 1.23 | ||||
| Medical cure | 0.05 | 0.84 | 0.399 | 0.683 | 1.47 | ||||
| Disability | −0.10 | −1.54 | 0.125 | 0.656 | 1.52 | ||||
| Exercise | 0.07 | 1.24 | 0.216 | 0.788 | 1.27 |
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Highlighted p were significant at 0.05, 0.01 or 0.001.
3.4.2 Pain beliefs that predict Problem-Focused Avoidance coping strategies
In the regression analyses predicting Problem-Focused Avoidance strategies, demographics explained a significant 8% of the variance; this effect was due primarily to the effects of sex (β=−0.21, p=0.001) and pain-related variables which explained an additional 4% of the variance, an effect that was due primarily to the effects of pain intensity (β=0.13, p=0.014). After controlling for these variables, pain-related beliefs explained an additional 16% of the variance. Beliefs that exercise is beneficial for pain management demonstrated significant and positive associations with the use of Problem-Focused Avoidance coping strategies (β=0.11, p=0.035), and the belief that one is disabled by pain evidenced a significant and negative association with the use of Problem-Focused Avoidance strategies (β=−0.34, p<0.001, see Table 4).
Multiple regression analyses predicting Problem-Focused Avoidance coping strategies.
| Step | Predictor | R 2 | R 2 change | F change | β | t | p-Value |
|---|---|---|---|---|---|---|---|
| 1 | Demographic data | 0.08 | 0.08 | 14.73 | <0.001 | ||
| Age | −0.01 | −0.26 | 0.798 | ||||
| Sex | −0.21 | −4.10 | <0.001 | ||||
| 2 | Pain variables | 0.12 | 0.04 | 5.51 | 0.001 | ||
| Pain chronicity | −0.02 | −0.38 | 0.708 | ||||
| Physical disability | −0.02 | −0.30 | 0.763 | ||||
| Pain intensity | 0.13 | 2.47 | 0.014 | ||||
| 3 | Peds-SOPA-R beliefs | 0.28 | 0.16 | 10.05 | <0.001 | ||
| Solicitousness | −0.03 | −0.46 | 0.643 | ||||
| Control | 0.08 | 1.43 | 0.153 | ||||
| Medication | −0.04 | −0.697 | 0.487 | ||||
| Emotion | 0.03 | 0.50 | 0.618 | ||||
| Medical cure | 0.10 | 1.80 | 0.073 | ||||
| Disability | −0.34 | −5.87 | <0.001 | ||||
| Exercise | 0.11 | 2.12 | 0.035 |
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Peds-SOPA-R=Pediatric version of the Survey of Pain Attitudes – revised version.
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Highlighted p were significant at 0.05, 0.01 or 0.001.
3.4.3 Pain beliefs that predict Emotion-Focused Avoidance coping strategies
In the regression analyses predicting Emotion-Focused Avoidance strategies, age and sex showed to be non-significant (R2=0.01, p=0.095), whereas pain-related variables explained a significant 15% of the variance; this effect was due to the effects of disability (β=0.27, p<0.001), pain intensity (β=−0.13, p=0.011) and pain chronicity (β=0.12, p=<0.021). After controlling these variables, pain-related beliefs explained an additional 12% of the variance. The beliefs that one is disabled by pain and that emotion can impact pain evidenced significant and positive associations with the use of Emotion-Focused Avoidance coping strategies (β=0.15, p=0.013 and β=0.14, p=0.007, respectively), whereas the beliefs that pain is controllable and that medications are appropriate for pain management evidenced negative associations with the use of those strategies (β=−0.16, p=0.004 and β=−0.21, p<0.001) (see Table 5).
Multiple regression analyses predicting Emotion-Focused Avoidance coping strategies.
| Step | Predictor | R 2 | R 2 change | F change | β | t | p-Value |
|---|---|---|---|---|---|---|---|
| 1 | Demographic data | 0.01 | 0.01 | 2.37 | 0.095 | ||
| Age | 0.04 | 0.71 | 0.477 | ||||
| Sex | 0.02 | 0.44 | 0.658 | ||||
| 2 | Pain variables | 0.16 | 0.15 | 20.20 | <0.001 | ||
| Pain chronicity | 0.12 | 2.31 | 0.021 | ||||
| Physical disability | 0.27 | 5.31 | <0.001 | ||||
| Pain intensity | −0.13 | −2.57 | 0.011 | ||||
| 2 | Peds-SOPA-R beliefs | 0.28 | 0.12 | 7.42 | <0.001 | ||
| Solicitousness | 0.09 | 1.61 | 0.108 | ||||
| Control | −0.16 | −2.89 | 0.004 | ||||
| Medication | −0.21 | −3.94 | <0.001 | ||||
| Emotion | 0.14 | 2.73 | 0.007 | ||||
| Medical cure | −0.03 | −0.53 | 0.599 | ||||
| Disability | 0.15 | 2.51 | 0.013 | ||||
| Exercise | −0.02 | −0.45 | 0.653 |
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Peds-SOPA-R=Pediatric version of the Survey of Pain Attitudes – revised version.
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Highlighted p were significant at 0.05, 0.01 or 0.001.
4 Discussion
The overall aim of this work was to better understand the associations between pain beliefs and pain coping strategies in a community adolescent sample. The findings indicate the possibility that the role that pain beliefs and pain coping strategies play in the adjustment to pain in adolescents in the community has both similarities to and differences with the role that these factors play in adolescent clinical populations.
Consistent with previous research performed in clinical samples, control and exercise beliefs evidenced significant and positive associations with the use of approach and problem-focused avoidance coping strategies. Similarly, beliefs about pain control evidenced significant and negative associations with the use of emotion-focused avoidance coping strategies. Moreover, beliefs in oneself as disabled were significantly and negatively associated with the use of problem-focused avoidance coping strategies and significantly and positively associated with the use of emotion-focused avoidance coping strategies. Furthermore, beliefs that emotion can impact pain were significantly and positively associated with emotion-focused avoidance coping strategies. However, inconsistent with previous research in clinical samples, solicitousness beliefs were found to be significantly and positively associated with the use of approach coping strategies.
As a group, these findings suggest that many, but not all, of the pain beliefs found to be associated with better function in clinical samples – including a sense of control over pain, an understanding that regular exercise and activity are helpful for chronic pain, and the lack of a belief in oneself as disabled by pain – would be potential targets for pain treatments or secondary prevention programs for adolescents with pain in the community. There is an increasing focus on the development of interventions that can impact large groups of individuals in the community, including web-based treatments [22], [23] and smartphone applications [24], which have been developed for children and adolescents. The current findings suggest the possibility (but do not prove, see limitations, below) that these treatments may be most effective if they target the beliefs found to be most closely associated with approach or problem-focused avoidance coping.
On the other hand, one belief found to be associated with impaired function in clinical samples – the belief that others should be solicitous when one (the adolescent) experiences pain – was in fact associated with more approach coping in our community sample which has been consistently found to be related to better function and treatment outcomes (e.g. [13]). This finding might be explained in part because of potential conceptual and item overlap in the measures. Specifically, one of the subscales of the coping measure used in the study classifies Seeking Social Support as an approach coping response. It would make sense for children who believe that others should be solicitous to be more likely to seek social support as a coping strategy. Thus, social support seeking (and related solicitude beliefs) might be considered a “double-edged sword” that has the potential to be both helpful and unhelpful [25], [26].
Similarly, and also inconsistent with previous research in clinical samples of youths with pain, beliefs in the appropriateness of medications for pain management showed a significant and negative association with the use of emotion-focused avoidance coping strategies. Such beliefs have been found related to impaired function (e.g. [16]). It is possible that, for youths in the community, occasional use of medications for their pain is more often helpful than harmful. However, as this was an unexpected finding. Also, given that the cross-sectional design used here does not permit conclusions regarding causal relationships, we would not interpret this finding to suggest that adolescents should be encouraged to “believe in analgesic medications” as an appropriate pain coping strategy based on the current findings alone. Instead, this finding suggests the need to examine more closely the role that medications play in the adjustment to pain in community samples of youths with pain, and to determine the helpfulness or unhelpfulness of beliefs related to medication use in this population.
There are a number of limitations of this study that should be kept in mind when interpreting the results. First, participants were requested to recall a past painful experience and maybe this procedure introduced a recall bias that could influence the results of the study. Nevertheless, this procedure has been successfully used in previous studies using these questionnaires [8], [13], [18]. Second, all measures were based on self-report. Despite the fact that self-reports are considered to be the best way to assess subjective information when the person is capable of responding, it could add method bias. It would be interesting to add observational or parent/teacher-proxy reports measuring coping or physical disability in future studies. Third, although all the measures used have been validated in community samples, they have been developed to be used with children and adolescents with chronic pain. Finally, and perhaps most importantly, this study used a cross-sectional design, from which it is not possible to draw causal conclusions. Thus, future prospective studies such as clinical trials designed to modify pain beliefs using, for example, cognitive restructuring are needed to determine if the beliefs found to be most closely associated with coping responses, actually have a causal impact on coping and disability.
5 Conclusion
Despite the study’s limitations, the findings provide important new information regarding the potential roles that beliefs could play as predictors of coping in adolescents living in the community. These findings have important implications for understanding the generalizability of previous findings among adolescent clinical populations, as well as for identifying the beliefs and coping responses that have the most likelihood of being important in the adjustment to the kinds of pain problems that adolescents in the community face. Such information can guide the development of community-based treatment programs, the evaluations of which could be used to help determine the causal role of pain-related beliefs and coping in the adjustment of chronic pain in these populations.
Funding source: Spanish Ministry of Economy and Competitiveness
Award Identifier / Grant number: PSI2012-32471
Award Identifier / Grant number: PSI2015-70966-P
Funding statement: This work was supported by Obra Social de La Caixa; the Spanish Ministry of Economy and Competitiveness (grants PSI2012-32471, PSI2015-70966-P); the European Regional Development Fund (ERDF) and Vicerectorat de Recerca of Universitat Rovira i Virgili (PFR program). MR salary and travel support was funded by a bequest from the estate of Mrs. Beryl Ivey to Dr. Warren R. Nielson and by the Earl Russell Chair in Pain Medicine, Western University, London, Ontario. SG is supported by a predoctoral grant from MINECO. JM’s work is supported by the Institució Catalana de Recerca i Estudis Avançats (ICREA-Acadèmia) and Fundación Grünenthal.
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Authors’ statements
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Conflict of interest: Authors state no conflict of interest.
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Informed consent: Informed consent has been obtained from all individuals included in this study.
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Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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