UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

An analysis of the pain experience and spontaneous coping abilities of children and adolescents with… Bennett-Branson, Susan Marie 1987

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1987_A8 B72.pdf [ 7.2MB ]
Metadata
JSON: 831-1.0097252.json
JSON-LD: 831-1.0097252-ld.json
RDF/XML (Pretty): 831-1.0097252-rdf.xml
RDF/JSON: 831-1.0097252-rdf.json
Turtle: 831-1.0097252-turtle.txt
N-Triples: 831-1.0097252-rdf-ntriples.txt
Original Record: 831-1.0097252-source.json
Full Text
831-1.0097252-fulltext.txt
Citation
831-1.0097252.ris

Full Text

AN ANALYSIS OF THE PAIN EXPERIENCE AND SPONTANEOUS COPING ABILITIES OF CHILDREN AND ADOLESCENTS WITH ARTHRITIS by SUSAN MARIE BRANSON B.A., The U n i v e r s i t y o f ' B r i t i s h Columbia, 1983 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER.OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July ; 1987 © Susan Branson, 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Psychology The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date A-vAcjaaT / H 8 ? DE-6(3/81) - i i . -ABSTRACT Very few good e m p i r i c a l i n v e s t i g a t i o n s of pain and coping i n c h i l d r e n and adolescents c u r r e n t l y appear i n the published l i t e r a t u r e . In c o n t r a s t to the a d u l t l i t e r a t u r e , f o r e t h i c a l reasons, a foundation of b a s i c research using experimentally-induced pain does not e x i s t i n the p e d i a t r i c l i t e r a t u r e -(McGrath, i n p r e s s ) . This remaining d e f i c i e n c y i n knowledge about c h i l d r e n ' s spontaneous a b i l i t i e s to cope with pain i s p a r t i c u l a r l y harmful because i t means that c l i n i c i a n s must base t h e i r assessment and treatment of pain i n c h i l d r e n on t h e i r knowledge of a d u l t s (Jeans, 1983). The need to consider cognitive-developmental i s s u e s has been emphasized i n s e v e r a l recent papers (Lavigne, S c h u l e i n , & Hahn, 1986; Maddux, Roberts, Sledden, & Wright, 1986; Thompson & V a r n i , 1986). The present i n v e s t i g a t i o n evaluated the pain experienced and spontaneous coping s t r a t e g i e s used by 39 c h i l d r e n and adolescents w i t h various forms of a r t h r i t i s , during a p a i n f u l joint-measuring task which i s t y p i c a l l y part of physiotherapy treatments f o r t h i s i l l n e s s . The two purposes of the study were: 1) to assess age/cognitive-developmental d i f f e r e n c e s and 2) to compare " e f f e c t i v e copers" versus c h i l d r e n who were having some d i f f i c u l t i e s coping with pain ( i e . pain was i n t e r f e r i n g w i t h t h e i r a c t i v i t i e s of d a i l y l i v i n g ) . Three age groups (5-7 years, 8-10 years, and 11-18 y e a r s ) , corresponding to the P i a g e t i a n stages of p r e o p e r a t i o n a l , concrete o p e r a t i o n a l and formal o p e r a t i o n a l thought, were compared. Subjects were videotaped while the range of motion i n t h e i r j o i n t s was measured by the p h y s i o t h e r a p i s t . Videotapes were subsequently coded f o r b e h a v i o r a l coping s t r a t e g y use. Immediately f o l l o w i n g the j o i n t measurement task, s u b j e c t s were interviewed regarding thoughts they r e c a l l e d e x p e r i encing. Transcribed i n t e r v i e w s were subsequently coded f o r c o g n i t i v e coping strategies reportedly used and catastrophizing cognitions reportedly experienced. In addition, parents completed two questionnaires rating the degree to which pain interferes with their child's ac t i v i t i e s of daily l i v i n g , and the physiotherapist made a global rating of each child's functional capacity. The overall MANOVA using age group as a between groups factor, with self-reported pain variables entered as dependent measures was nonsignificant. A significant multivariate effect did emerge, however, when the coping variables were entered as dependent measures in a second overall MANOVA. Followup univariate analyses revealed an age/cognitive-developmental trend in behavioral and cognitive coping strategy use. Children in the youngest group (preoperational) used primarily behavioral strategies to cope with pain elici t e d by the physiotherapy joint-measuring task, whereas slightly older children (concrete operational) began to supplement their repertoire of behavioral coping strategies with some cognitive coping strategies. A significant rise in reported cognitive coping strategy use was observed in the oldest group (formal operational). In addition, a discriminant function revealed that the two most important discriminators between "effective copers" versus children having some d i f f i c u l t i e s coping with pain were the amount of pain expression (vocal or nonvocal) coded and the amount of catastrophizing thoughts reportedly experienced during the physiotherapy task. Implications of these results for the treatment of children having d i f f i c u l t i e s coping with art h r i t i c pain are discussed. - i v -CONTENTS PAGE TITLE PAGE ABSTRACT i i TABLE'JOF CONTENTS i v LIST OF TABLES v i LIST OF FIGURES v i i i ACKNOWLEDGEMENTS i x INTRODUCTION 1 Overview 1 Juvenile Rheumatoid A r t h r i t i s and Related Rheumatic Diseases i n Children 3 The Role of Pain i n Rheumatic Diseases 3 Treatment 9 D e f i n i t i o n and C l a s s i f i c a t i o n 10 Coping with Pain 15 D e f i n i t i o n of Coping 15 C l a s s i f i c a t i o n of Coping Strategies 17 Adults' Strategies f o r Coping with Pain: Assessment and Evaluation 18 Children's Strategies for Coping with Pain: Assessment and Evaluation 24 Cognitive Development and Reported Coping Strategy Use 32 Effectiveness of Coping Strategies Used by Children 39 Coping with" A r t h r i t i c Pain 41 Adults' Strategies for Coping with A r t h r i t i c Pain 42 Children's Strategies f o r Coping with A r t h r i t i c Pain... 44 The Relationship Between Functional D i s a b i l i t y and Coping with A r t h r i t i c Pain 45 - V -PAGE Purpose and Hypotheses 48 METHOD 51 Subject C h a r a c t e r i s t i c s 51 Equipment 54 Procedure 54 Measures . 59 Parent Ratings 59 HAQ D i s a b i l i t y Scale 59 Interference with A c t i v i t i e s Questionnaire 59 Self-Report Measures - Interview 60 P e d i a t r i c Pain Interview 60 Cognitive Coping Interview 62 Cognitive Coping Categories - Coding Manual 62 Catastrophizing Cognitions - Coding Manual 64 Observational Measures 67 Behavioral Coping Strategies - Coding Manual 67 Behavioral Coping Strategies - Coding Procedure 68 Physiotherapist Ratings 70 Pain Intensity Rating - Physiotherapist 70 Functional Assessment 70 Physician Ratings 70 Disease-Related Data Form 70 C l a s s i f i c a t i o n of Subjects' Effectiveness of Coping with Pain... 73 S t a t i s t i c a l Analyses 73 RESULTS 75 DISCUSSION 107 REFERENCES 121 APPENDICES 138 - v i -LIST OF TABLES Page Table 1. Classification of Rheumatic Diseases Represented in Subject Sample 11 Table 2. Distribution of Sex in the Age Groups 53 Table 3. Types of Arthritis Represented in the Subject Sample 55 Table 4. Joint used in Standardized Range of Motion Task 58 Table 5. Interrater Reliability for Cognitive Coping Categorization 65 Table 6. Interrater Reliability for Catastrophizing Cognitions Categorization 66 Table 7. Interrater Reliability for Behavioral Coping Strategies 71 Table 8. Summary of Mean Scores on Pain Variables by Age Group 76 Table 9. Number of Subjects Marking Above the Midpoint on the VAS Ratings 77 Table 10. Sensory Pain Descriptors Endorsed by more than 30% of the Sample 79 Table 11. Affective or Evaluative Descriptors Endorsed by more than 30% of the Subjects 80 Table 12. Relationship Between Pain Variables 82 Table 13. Summary of Age Group Means and Univariate ANOVA'S: Coping and Catastrophizing Variables 85 Table 14. Summary of Age Group Means and Univariate ANOVA'S: Proportion of Total Coping Accounted for by Behavioral Coping 88 Table 15. Number of Subjects Using Behavioral Coping Subtypes at Least Once 89 Table 16. Number of Subjects Reportedly Using Cognitive Coping Coping Subtypes at Least Once 90 Table 17. Number of Subjects Reportedly Experiencing Catastrophizing Subtypes at Least Once 91 Table 18. Miscellaneous other Coping Strategies Observed and/or Reported 93 Table 19. Mean Scores on Functional Disability Measures 95 - v i i -Table 20. A c t i v i t i e s w i t h which Pain Reportedly I n t e r f e r e s 96 Table 21. Medications P r e s c r i b e d to Subjects i n Sample 98 Table 22. P r i n c i p l e Component A n a l y s i s of the Subjects' Z scores on the F u n c t i o n a l D i s a b i l i t y Measures 100 Table 23. P r i n c i p l e Component A n a l y s i s of a l l Seven Disease-Related V a r i a b l e s 102 Table 24. P r i n c i p l e Component A n a l y s i s of the Four Chosen Disease-Related V a r i a b l e s 103 Table 25. Disc r i m i n a n t Function A n a l y s i s Results 105 Table 26. C o r r e l a t i o n of V a r i a b l e s w i t h the F i r s t D i s c r i m i n a n t Function 106 - v i i i -LIST OF FIGURES Page Figure 1. Mean Frequency of C o g n i t i v e Coping Strategy Use by Age Group 86 - i x -Acknowledgement I would l i k e to thank Dr. K. C r a i g f o r h i s h e l p f u l comments and encouragement with t h i s research p r o j e c t . In a d d i t i o n , I would l i k e to thank the s t a f f at the A r t h r i t i s Centre i n Vancouver f o r use of t h e i r f a c i l i t y and access to t h e i r p a t i e n t s . In p a r t i c u l a r , Dr. M a l l i s o n , Dr. P e t t y , and Jacquie M a r t i n have c o n t r i b u t e d g r e a t l y to t h i s p r o j e c t . - 1 -INTRODUCTION Overview The primary purpose of the present i n v e s t i g a t i o n was to assess and evaluate the spontaneous s t r a t e g i e s used by c h i l d r e n and adolescents w i t h J u v e n i l e Rheumatoid A r t h r i t i s (JRA) and r e l a t e d rheumatic diseases to cope w i t h p a i n . As i s t y p i c a l of the p e d i a t r i c pain l i t e r a t u r e i n general (Beyer & Byers, 1985; Jeans, 1983), very few good e m p i r i c a l i n v e s t i g a t i o n s of pain and coping i n c h i l d r e n and adolescents w i t h a r t h r i t i s c u r r e n t l y appear i n the published l i t e r a t u r e . S e v e r a l f a c t o r s may be r e s p o n s i b l e f o r the current p a u c i t y of research. These f a c t o r s i n c l u d e : (.1) the myth accepted by e a r l y researchers t h a t c h i l d r e n do not experience pain as a d u l t s do (Eland & Anderson, 1977); (2) the myth that c h i l d r e n cannot provide accurate i n f o r m a t i o n about t h e i r own pain experience and coping a b i l i t i e s (Ross & Ross, 1984b); and/or (3) the trend towards assessing only c h i l d r e n ' s " d i s t r e s s " r e a c t i o n s to pa i n , r a t h e r than t h e i r coping a b i l i t i e s (e.g., Gross, S t e r n , L e v i n , Dale, & Wojnilower, 1983; Winer, 1982). The remaining d e f i c i e n c y i n knowledge about c h i l d r e n ' s spontaneous a b i l i t i e s to cope w i t h pain i s p a r t i c u l a r l y harmful because i t means th a t c l i n i c i a n s must base t h e i r assessment and treatment of pain i n c h i l d r e n on t h e i r knowledge of a d u l t s (Jeans, 1983). C h i l d r e n of d i f f e r e n t ages may i n f a c t use very d i f f e r e n t coping s t r a t e g i e s , and s t r a t e g i e s that are e f f e c t i v e f o r c h i l d r e n may be very d i f f e r e n t from those that are e f f e c t i v e f o r a d u l t s . F u r t h e r , i n v e s t i g a t i o n of spontaneous.strategies f o r coping w i t h pain may have important i m p l i c a t i o n s f o r the i d e n t i f i c a t i o n and treatment of " i n e f f e c t i v e copers" ( i . e . , c h i l d r e n who are having d i f f i c u l t i e s coping w i t h p a i n ) . Because of the r e l a t i v e l a c k of prec e d e n t - s e t t i n g research, i n v e s t i g a t o r s - 2 -of pain and coping i n c h i l d r e n are forced to look f i r s t to the a d u l t l i t e r a t u r e f o r an i n d i c a t i o n of p o t e n t i a l l y key f a c t o r s to assess, and then to e m p i r i c a l l y demonstrate the a p p l i c a b i l i t y of those f a c t o r s to c h i l d r e n of d i f f e r e n t ages. Research w i t h a d u l t s regarding key f a c t o r s i n pain assessment and coping w i t h pain has only r e c e n t l y begun to be extended to c h i l d r e n . Regarding pain assessment, the a d u l t l i t e r a t u r e p o i n t s to the need f o r a multidimensional approach, tapping not only sensory f a c t o r s (e.g., pain i n t e n s i t y ) , but a l s o c o g n i t i v e and emotional f a c t o r s ( C r a i g , 1984a, 1984b; Melzack & Casey, 1968). Research has r e c e n t l y begun to demonstrate the a p p l i c a b i l i t y of a multidimensional model of pain to c h i l d r e n of v a r y i n g ages (Grunau & C r a i g , 1987; C r a i g , McMahon, Morison, & Zaskow, 1984). Regarding coping w i t h p a i n , the a d u l t l i t e r a t u r e p o i n t s not only to the key r o l e of b e h a v i o r a l and c o g n i t i v e s t r a t e g i e s employed by pain s u f f e r e r s (e.g., Turk, Meichenbaum, & Genest, 1983), but a l s o to the r o l e of another c o g n i t i v e f a c t o r l a b e l e d " c a s t r a s t r o p h i z i n g " . " C a t a s t r o p h i z i n g " c o g n i t i o n s , defined as maladaptive, d y s f u n c t i o n a l , and a n x i e t y - l a d e n c o g n i t i o n s concerning pain (Reesor & C r a i g , i n p r e s s ) , have r e c e n t l y been l i n k e d w i t h coping e f f e c t i v e n e s s i n a d u l t p a t i e n t s w i t h v a r i o u s c h r o n i c pain c o n d i t i o n s (Keefe et a l . , 1987; Reesor & C r a i g , i n press; Turner & Clancy, 1987). I n i t i a l research w i t h c h i l d r e n a l s o lends support to the important r o l e of c a t a s t r o p h i z i n g c o g n i t i o n s i n coping w i t h pain (Brown, 0'Keefe, Sanders, & Baker, 1986; H u n t - F i t z g e r a l d & L i d d e l l , 1985). Once key f a c t o r s f o r i n v e s t i g a t i o n have been s p e c i f i e d , researchers studying p e d i a t r i c populations are then faced w i t h the d i f f i c u l t task of choosing measures which can be understood by c h i l d r e n of v a r y i n g ages and cognitive/developmental l e v e l s . The Varni/Thompson P e d i a t r i c Pain Questionnaire i s a r e c e n t l y introduced, multidimensional measure of pain designed to be developmentally appropriate (PPQ; V a r n i & Thompson, 1985). I t - 3 -has r e c e n t l y been a p p l i e d to the study of a r t h r i t i c pain i n c h i l d r e n w i t h JRA ( V a r n i , Thompson, & Hanson, 1987). In a d d i t i o n , s t r u c t u r e d i n t e r v i e w s and o b s e r v a t i o n a l systems have r e c e n t l y been developed and a p p l i e d to the study of c h i l d r e n ' s spontaneous b e h a v i o r a l and c o g n i t i v e s t r a t e g i e s f o r coping w i t h pain (Brown et a l . , 1986; Curry & Russ, 1985). What remains i n the p e d i a t r i c l i t e r a t u r e i s the need to s y s t e m a t i c a l l y assess and evaluate the pain experienced and coping s t r a t e g i e s used by c h i l d r e n of d i f f e r e n t ages (at d i f f e r e n t l e v e l s of c o g n i t i v e complexity) w i t h chronic pain c o n d i t i o n s . The present i n v e s t i g a t i o n addresses t h i s need, i n v e s t i g a t i n g pain experience and coping s t r a t e g y use i n c h i l d r e n w i t h JRA and r e l a t e d rheumatic diseases. J u v e n i l e Rheumatoid A r t h r i t i s and Related Rheumatic Diseases i n C h i l d r e n The Role of P a i n i n Rheumatic Diseases The term " a r t h r i t i s " r e f e r s to inflammation of the j o i n t s , and i s c h a r a c t e r i z e d by s w e l l i n g or l i m i t a t i o n of movement w i t h heat, p a i n , or tenderness. Despite the i n c o r p o r a t i o n of pain i n the c l i n i c a l d e f i n i t i o n of " a r t h r i t i s " , the r o l e and s i g n i f i c a n c e of pain experienced by c h i l d r e n w i t h J u v e n i l e Rheumatoid A r t h r i t i s (JRA) and other rheumatic diseases remains under debate i n the l i t e r a t u r e . In a d u l t p a t i e n t s w i t h Rheumatoid A r t h r i t i s (RA), c h r o n i c pain and acute pain exacerbations of v a r i a b l e i n t e n s i t y are g e n e r a l l y considered to be a major consequence of the disease, and are of primary concern to both p a t i e n t s and p r o f e s s i o n a l s (Bradley, 1985; Hart, 1974; Hart & Huskisson, 1972). In i t s c l a s s i f i c a t i o n of ch r o n i c pain syndromes, the I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study of Pain (IASP) describes pain a s s o c i a t e d w i t h RA i n a d u l t s as: " d i f f u s e aching, burning pain i n j o i n t s , u s u a l l y moderately severe; u s u a l l y i n t e r m i t t e n t w i t h exacerbations and rem i s s i o n s " (IASP, 1986, p. 536). - 4 -Most s t u d i e s w i t h a d u l t RA p a t i e n t s i n v o l v i n g pain v a r i a b l e s have tended to focus on q u a n t i t a t i v e aspects of p a i n , r e l y i n g mostly on v i s u a l analogue s c a l e (VAS) r a t i n g s of pain i n t e n s i t y (Skevington, 1986). Only w i t h i n the past few years has the M c G i l l Pain Questionnaire (MPQ), developed by Melzack (1975) been used to assess pain i n a d u l t s w i t h a r t h r i t i s (Burckhardt, 1984). In a d d i t i o n , McDaniel et a l . (1986) have r e c e n t l y developed and v a l i d a t e d a method f o r measuring pain behaviors i n a d u l t RA p a t i e n t s . P a t i e n t s ' performance of a standardized 10 minute sequence of s i t t i n g , walking, r e c l i n i n g and standing i s videotaped and l a t e r coded f o r pain behaviors such as guarding, grimacing, and rubbing a f f e c t e d j o i n t s . In c o n t r a s t to a d u l t p a t i e n t s w i t h RA, p h y s i c i a n s r e p o r t that many c h i l d r e n w i t h JRA and r e l a t e d rheumatic diseases complain l i t t l e of j o i n t pain ( A n s e l l , 1984; Cassidy, 1982; Rodnan, Schumacher, & Z v a i f l e r , 1983). Some researchers as w e l l as p r o f e s s i o n a l s , mistakenly, take t h i s r e l a t i v e l a c k of pain complaint i n c h i l d r e n as an i n d i c a t i o n that c h i l d r e n a c t u a l l y experience l i t t l e or no a r t h r i t i c p a in a s s o c i a t e d w i t h t h e i r d isease. Downplaying the r o l e of pain i n JRA i s , however, u n j u s t i f i e d given the extremely l i m i t e d e m p i r i c a l research t h a t e x i s t s i n t h i s area (only 5 c u r r e n t l y published e m p i r i c a l s t u d i e s ) . The f i r s t two s t u d i e s to emerge i n the l i t e r a t u r e concluded t h a t c h i l d r e n w i t h JRA, i n c o n t r a s t to a d u l t s w i t h RA, experience r e l a t i v e l y minimal pain (Laaksonen & Laine, 1961; S c o t t , A n s e l l , & Huskisson, 1977). These conclusions may, however, be overstated given the research methods used, and are challenged by more recent f i n d i n g s . Laaksonen and Laine (1961), i n the f i r s t published i n v e s t i g a t i o n , compared pain r a t i n g s of 24 c h i l d r e n w i t h JRA, aged 4-14 years, to a c o n t r o l group of 30 RA p a t i e n t s , aged 18-51 years, who had s i m i l a r durations of the rheumatoid process. Degree of pain during three p h y s i c a l tasks [(1) movement i n extreme p o s i t i o n s of j o i n t , (2) p a l p i t a t i o n of j o i n t , and (3) use of j o i n t i n weight - 5 -bearing] was estimated using a f o u r - p o i n t d e s c r i p t i v e s c a l e [(1) "no p a i n " , (2) " u n c e r t a i n or s l i g h t p a i n " , (3) " d e f i n i t e p a i n " , and (4) "very severe p a i n " ] . I t i s not s p e c i f i c a l l y s t a t e d i n the o r i g i n a l r e p o r t whether esti m a t i o n s of pain were made by p a t i e n t s themselves, although l a t e r c i t a t i o n s presume t h i s to be so. D e s c r i p t i v e r e s u l t s , based on the o r i g i n a l i n v e s t i g a t o r s ' v i s u a l i n s p e c t i o n of the data, i n d i c a t e d that more of the j o i n t s t e s t e d were given "no p a i n " r a t i n g s by c h i l d r e n than a d u l t s and, s i m i l a r l y , more a d u l t s gave r a t i n g s of " u n c e r t a i n or s l i g h t " and " d e f i n i t e p a i n " , but that there d i d not seem to be much of a d i f f e r e n c e between a d u l t s and c h i l d r e n on the number of "very severe p a i n " r a t i n g s (a maximum of four p a t i e n t s gave r a t i n g s t h i s high on any one t a s k ) . I t should be noted that r a t i n g s given by c h i l d r e n when c u r r e n t l y inflamed j o i n t s ( e s p e c i a l l y w r i s t s , ankles and elbows) were moved i n extreme p o s i t i o n s were j u s t as high as those given by a d u l t s . In the two tasks i n v o l v i n g " l o a d i n g " ( p a l p i t a t i o n of j o i n t , and use of j o i n t i n weight b e a r i n g ) , however, c h i l d r e n tended to give lower pain r a t i n g s than a d u l t s even when c u r r e n t l y inflamed j o i n t s were s e l e c t i v e l y assessed. In d e s c r i b i n g f i n d i n g s on the two " l o a d i n g " t a s k s , on which c h i l d r e n gave lower pain r a t i n g s than a d u l t s (even f o r c u r r e n t l y inflamed j o i n t s ) , the authors i n t i m a t e t h a t these tasks leave more room f o r "imagined" pain than the task i n v o l v i n g movement i n extreme p o s i t i o n s . Thus, they seem to h i n t at a greater degree of p s y c h o l o g i c a l involvement i n the pain experience of a d u l t s , or perhaps a greater degree of exaggerated pain complaints i n a d u l t s . Yet, when d i s c u s s i n g r e s u l t s of the study as a whole, the authors g l o b a l l y conclude that "the r e s u l t s tend to support the observation t h a t c h i l d r e n s u f f e r i n g from rheumatoid a r t h r i t i s s u f f e r l e s s discomfort i n the a f f e c t e d j o i n t s than a d u l t s " (Laaksonen & Laine, 1961). Thus, i n t h e i r c o n c l u s i o n s , these authors seem to suggest that c h i l d r e n experience l e s s j o i n t p a i n , i n - 6 -general, than a d u l t s . A second study comparing reported pain i n c h i l d r e n versus a d u l t s was conducted by S c o t t , A n s e l l , and Huskisson (1977). Pain i n t e n s i t y r a t i n g s of 100 c h i l d r e n w i t h p o l y a r t i c u l a r onset JRA, using a v i s u a l analogue s c a l e (VAS) and a four point d e s c r i p t i v e s c a l e , were compared to those of 100 a d u l t s w i t h RA. Eleven c h i l d r e n were r e p o r t e d l y unable to understand how to give pain r a t i n g s on the v i s u a l analogue s c a l e . VAS pain i n t e n s i t y r a t i n g s given by the c h i l d r e n predominantly c l u s t e r e d below the midpoint, whereas r a t i n g s i n the a d u l t sample were d i s t r i b u t e d approximately evenly above and below the midpoint. I n t e n s i t y r a t i n g s given on the d e s c r i p t i v e s c a l e c o r r e l a t e d s i g n i f i c a n t l y w i t h r a t i n g s on the VAS. Scores on the VAS were not s i g n i f i c a n t l y c o r r e l a t e d w i t h disease a c t i v i t y or disease s e v e r i t y . The authors argue that t h e i r f i n d i n g s f i t w i t h the c o n c l u s i o n that "pain i s not a prominent fea t u r e of the symptomatology" of JRA ( S c o t t et a l . , 1977, p. 187), and speculate that t h i s may be because c h i l d r e n l a c k the experience or maturational requirements f o r pain s e n s a t i o n . S e v e r a l c r i t i c i s m s can be made of the measures, methods of data a n a l y s i s and conclusions drawn i n these two e a r l y s t u d i e s . F i r s t , i t must be recognized t h a t the measures used, tap only one aspect of the pain experience ( i n t e n s i t y ) , i g n o r i n g other key components, such as c o g n i t i v e and emotional f a c t o r s , i n v o l v e d i n a multidimensional c o n c e p t u a l i z a t o n of pain ( C r a i g , 1984a, 1984b). As V a r n i and Jay (1984) note, a major methodological problem i n both s t u d i e s i s t h e i r l a c k of c o n s i d e r a t i o n of c h i l d r e n ' s c o g n i t i v e developmental stage and c o n c e p t u a l i z a t i o n of p a i n . Because c h i l d r e n i n these s t u d i e s were as young as 4 years, they may not have known the meaning of the term "pain " ( V a r n i , 1983), and t h e i r r a t i n g s t h e r e f o r e may be i n v a l i d . I f more developmentally appropriate measures had been used, c h i l d r e n i n these s t u d i e s may w e l l have described pain experiences s i m i l a r to that of a d u l t s . - 7 -Secondly, i t must be noted that d i f f e r e n c e s between c h i l d r e n and a d u l t s were analyzed d e s c r i p t i v e l y r a t h e r than s t a t i s t i c a l l y , l e a v i n g more room f o r i n t e r p r e t e r b i a s . In making g l o b a l d e s c r i p t i v e summaries of the data, both sets of authors f a i l to acknowledge the existence of some i n d i v i d u a l cases, and some s i t u a t i o n s (e.g., movement of inflamed j o i n t s i n extreme p o s i t i o n s ) where c h i l d r e n d i d give moderate to high r a t i n g s of p a i n . Given these methodological and i n t e r p r e t i v e l i m i t a t i o n s then, the g l o b a l conclusions made by Laaksonen and Laine (1961) and Scott et a l . (1977) that c h i l d r e n w i t h JRA " s u f f e r " or "sense" r e l a t i v e l y l i t t l e pain seem to be an u n j u s t i f i e d extension of t h e i r data. Rather, i t seems more l i k e l y t hat the way c h i l d r e n d escribe or evaluate p a i n f u l sensations d i f f e r s from a d u l t s . The t h i r d published study which addresses some of the methodological c r i t i c i s m s aimed at the e a r l i e r two s t u d i e s , was conducted by Beales, Keen, and Lennox Holt (1983a). Beales et a l . (1983a) used an i n t e r v i e w format to assess the pain experience of 39 6-17 year-old JRA o u t p a t i e n t s . V a r i a b l e s assessed were: (1) j o i n t sensations (endorsement of eleven p o s s i b l e sensation word d e s c r i p t o r s p r e v i o u s l y obtained from i n t e r v i e w s w i t h JRA's); (2) i n t e r p r e t a t i o n of sensations (responses to the open ended question, "What do the sensations represent to you?"); (3) unpleasantness of sensations ( p o s i t i o n on a VAS w i t h anchors "not at a l l nasty or unpleasant" versus " n a s t i e s t and most unpleasant you can imagine"), and (A) s e v e r i t y of j o i n t pain ( p o s i t i o n on a VAS w i t h anchors "no pain at a l l " versus "worst pain you can imagine"). R e s u l t s of the Beales et a l . (1983a) study showed f i r s t l y t hat a l l c h i l d r e n reported some uncomfortable j o i n t sensations. The sensation d e s c r i p t o r "aching" was endorsed by 100% of the c h i l d r e n . F i f t y - t h r e e percent of 12-17 year-olds and 50% of the 6-11's endorsed some form of "sharp" sensation (e.g., " c u t " , " p r i c k e d " , "smacked", or "pinched"). Secondly, i n t e r p r e t a t i o n s and r a t i n g s of unpleasantness of symptoms were - 8 -more n e g a t i v e l y e v a l u a t i v e i n the older group of c h i l d r e n . S i x to 11 year-olds d i d not r e p o r t j o i n t sensations as the r e p r e s e n t a t i o n of i n t e r n a l pathology, however, 12-17 year-olds unanimously reported t h a t j o i n t sensations t r i g g e r e d thoughts about the unpleasant i m p l i c a t i o n s of a r t h r i t i s (e.g., d i s a b i l i t y ) (Beales et a l . , 1983a, p. 63). A s i m i l a r r i s e i n n e g a t i v i t y was r e f l e c t e d i n the VAS r a t i n g s of unpleasantness, w i t h 83% of 6-11 year-olds marking below the midpoint on the VAS compared to 80% of 12-17 year-olds above the midpoint. T h i r d l y , i n c o n t r a s t to previous f i n d i n g s , 56% of a l l c h i l d r e n i n the Beales et a l . (1983a) study (age groups combined) gave s e v e r i t y of j o i n t pain r a t i n g s above the midpoint on the VAS. When the data from the two age groups are described s e p a r a t e l y , i t i s noted that 58% of 6-11 year-olds gave pain r a t i n g s below the midpoint, compared to only 20% of 12-17 year - o l d s . The authors conclude that o l d e r JRA's more n e g a t i v e l y evaluate t h e i r sensations and that these e v a l u a t i o n s i n t u r n , i n f l u e n c e the extent to which j o i n t sensations are i n t e r p r e t e d as pain. The i n t e r v i e w method used i n the Beales et a l . (1983a) study gave c h i l d r e n more of an opportunity to describe t h e i r s ensations, as opposed to o b t a i n i n g one or two non-verbal r a t i n g s (Laaksonen & Laine, 1961; Scott et a l . , 1977). In a d d i t i o n , Beales et a l . (1983a) improved upon previous research by acknowledging and measuring v a r i a b i l i t y i n pain r a t i n g s among c h i l d r e n , and by tapping a dimension other than i n t e n s i t y b e l i e v e d to be a s s o c i a t e d w i t h the pain experience (the c o g n i t i v e / e v a l u a t i v e dimension). Two more recent s t u d i e s (Thompson, V a r n i , & Hanson, 1987; V a r n i , Thompson, & Hanson, 1987) represent f i r s t steps towards an even broader-based assessment of pain a s s o c i a t e d w i t h JRA. V a r n i et a l . (1987) administered the Varni/Thompson P e d i a t r i c P a i n Questionnaire (PPQ; Va r n i & Thompson, 1985) to 25 c h i l d r e n w i t h JRA, aged 5-15. As part of the PPQ, r a t i n g s of pain - 9 -i n t e n s i t y were made, using a developmentally appropriate VAS. R e s u l t s i n d i c a t e d a h i g h l y s i g n i f i c a n t c o r r e l a t i o n between VAS pain i n t e n s i t y r a t i n g s given by mothers, c h i l d r e n and p h y s i c i a n s . This s i g n i f i c a n t c o r r e l a t i o n can be i n t e r p r e t e d as supportive data r e l e v a n t to the v a l i d i t y of c h i l d r e n ' s s e l f - r e p o r t e d r a t i n g s of current p a i n . In a d d i t i o n , VAS i n t e n s i t y r a t i n g s given by mothers and c h i l d r e n regarding worst pain over the past week were a l s o h i g h l y s i g n i f i c a n t l y c o r r e l a t e d . Worst pain r a t i n g s were n o t i c e a b l y higher than present pain r a t i n g s (Thompson et a l . , 1987; V a r n i et a l . , 1987). This f i n d i n g p o i n t s out a p o s s i b l e b i a s which may occur when pain assessments are only made i n the c l i n i c ( i . e . , the pain experience of JRA's may be underestimated). Words most commonly endorsed by t h i s sample of c h i l d r e n w i t h JRA to describe t h e i r a r t h r i t i c pain i n c l u d e d : sore (70%), aching (65%), uncomfortable (6 5 % ) , miserable (52%) ( V a r n i et a l . , 1987). In summary, much remains to be i n v e s t i g a t e d regarding the experience and s i g n i f i c a n c e of pain a s s o c i a t e d w i t h JRA. S i n g l e a d m i n i s t r a t i o n s of i n t e n s i t y r a t i n g s c a l e s do not adequately tap the pain experience of c h i l d r e n w i t h JRA. In order to tap p o t e n t i a l f l u c t u a t i o n s i n pain experience, not only should current pain r a t i n g s be given, but r a t i n g s of pain experienced during the past week a l s o should be i n c l u d e d (Thompson et a l . , 1987). Interviews and q u e s t i o n n a i r e s (e.g., PPQ) seem to provide a r i c h and v a l i d source of i n f o r m a t i o n from parents, and c h i l d r e n as young as 5, regarding pain experiences a s s o c i a t e d w i t h JRA (Beales et a l . , 1983a; V a r n i et a l . , 1987). Treatment The major goals i n the treatment of JRA and r e l a t e d rheumatic diseases are r e l i e f of symptoms (e.g., inflammation and/or p a i n ) , maintenance or r e s t o r a t i o n of j o i n t f u n c t i o n and muscle s t r e n g t h , and prevention of secondary d e f o r m i t i e s (Cassidy, 1982; Rodnan et a l . , 1983). T y p i c a l l y , a m u l t i d i s c i p l i n a r y approach to treatment i s taken, i n v o l v i n g medication, - 10 -p h y s i c a l and occupational therapy, and p s y c h o s o c i a l s e r v i c e s (Cassidy, 1982; P e t t y , 1982a). The anti-inflammatory and a n a l g e s i c medication of choice i n most cases i s A s p i r i n ( P e t t y , 1982a). Treatment w i t h a s p i r i n i s s a t i s f a c t o r y i n 70% of JRA cases (Cassidy, 1982). "Gold therapy" (intramuscular gold s a l t i n j e c t i o n s ) may be implemented i n some p a t i e n t s w i t h chronic a r t h r i t i s who have been u n s a t i s f a c t o r i l y responsive to a s p i r i n (Brewer, G i a n n i n i , & B a r k l e y , 1980), and c o r t i c o s t e r o i d therapy may be used i n cases of severe, u n c o n t r o l l e d systemic JRA ( S c h a l l e r , 1976). P h y s i c a l e x e r c i s e s to maintain or r e s t o r e muscle s t r e n g t h and m o b i l i t y are a l s o e s s e n t i a l f e a t u r e s of therapy i n most cases (Donovan, 1976). M o b i l i t y i s maintained by e x e r c i s e s which put j o i n t s through a f u l l range of motion. P a t i e n t s must a c t i v e l y move j o i n t s i n the d i r e c t i o n of l i m i t a t i o n , and pressure or r e s i s t a n c e may be a p p l i e d , i n c r e a s i n g the e f f o r t r e q u i r e d to make that motion (Jacobs, 1982). U n f o r t u n a t e l y , these p h y s i c a l e x e r c i s e s , which are a part of r e h a b i l i t a t i v e treatment, can themselves be p a i n - e l i c i t i n g s t i m u l i (Laaksonen & Laine, 1961). In a d d i t i o n to e x e r c i s e s , other p h y s i c a l techniques such as s p l i n t i n g , massage, ul t r a s o u n d , or the a p p l i c a t i o n of hot or c o l d packs are a l s o used to r e s t o r e j o i n t f u n c t i o n i n g or c o r r e c t deformity i n some p a t i e n t s (Donovan, 1976). D e f i n i t i o n and C l a s s i f i c a t i o n (Table 1 provides a summary of rheumatic disease types represented i n the subject sample) J u v e n i l e Rheumatoid A r t h r i t i s J u v e n i l e Rheumatoid A r t h r i t i s (JRA) i s the most common connective t i s s u e disease i n c h i l d r e n (Cassidy, 1982b), w i t h an estimated prevalence of approximately 65 per 100,000 c h i l d r e n under age 16 ( P e t t y , 1982a). One general i n c l u s i o n a r y c r i t e r i o n f o r the d i a g n o s i s of JRA i s p e r s i s t e n t " a r t h r i t i s " i n one or more j o i n t s f o r at l e a s t s i x months (Brewer et a l . , 1977). Diagnosis of JRA i s much more complex than t h i s one c r i t e r i o n , Table 1. C l a s s i f i c a t i o n of Rheumatic Diseases Represented i n the Subject Sample A. Connective Tissue Diseases 1. J u v e n i l e Rheumatoid A r t h r i t i s (JRA) a. P a u c i a r t i c u l a r Onset JRA b. P o l y a r t i c u l a r Onset JRA c. Systemic Onset JRA 2. Systemic Lupus Erythematosus (SLE) 3. Miscellaneous a. Mixed Connective Tissue Disease (MCTD) B. Seronegative Spondyloarthropathies 1., J u v e n i l e Ankylosing S p o n d y l i t i s (JAS) 2. A Syndrome of S e r o n e g a t i v i t y , Enthesopathy and Arthropathy (SEA Syndrome) 3. P s o r i a t i c S p o n d y l o a r t h r i t i s (adapted from Cassidy, 1982a) - 12 -however. As r e f l e c t e d i n the American Rheumatism A s s o c i a t i o n c r i t e r i a , JRA i s not considered to be a s i n g l e disease e n t i t y , but r a t h e r i s c l a s s i f i e d i n t o three d i s t i n c t c a t e g o r i e s according to onset subtype as manifested during the f i r s t s i x months of the disease: (1) p a u c i a r t i c u l a r , (2) p o l y a r t i c u l a r , and (3) systemic onset. In a d d i t i o n , there are a number of other c o n d i t i o n s w i t h some s i m i l a r c h a r a c t e r i s t i c s to JRA (e.g., rheumatic f e v e r , systemic lupus erthyematosus, a n k y l o s i n g s p o n d y l i t i s ) , and t h e r e f o r e d i f f e r e n t i a l diagnoses or e x c l u s i o n a r y c r i t e r i a are a l s o e s s e n t i a l (Brewer et a l . , 1977; Rodnan et a l . , 1983). P a u c i a r t i c u l a r onset JRA i s the most commonly o c c u r r i n g subtype, accounting f o r 40% or more JRA p a t i e n t s (Rodnan et a l . , 1983), and i s a l s o the m i l d e s t form of the disease. In t h i s subtype, a r t h r i t i s i s l i m i t e d t o four or fewer j o i n t s (Brewer et a l . , 1977). Knees and ankles are most commonly i n v o l v e d (Cassidy, 1982), w i t h a f f e c t e d j o i n t s t y p i c a l l y f o l l o w i n g an asymmetrical p a t t e r n (Rodnan et a l . , 1983). Chronic i r i d o c y c l i t i s (inflamed i r i s and c i l i a r y body) occurs i n 20-40% of p a t i e n t s w i t h t h i s subtype, p l a c i n g them at r i s k of developing v i s u a l impairment (Calabro, Holgerson, Sonpal, & Khoury, 1976; Cassidy, S u l l i v a n , & P e t t y , 1976). The peak age of onset of p a u c i a r t i c u l a r JRA i s between 1-3 years and g i r l s are up to f i v e times more l i k e l y to develop t h i s subtype of JRA than boys ( P e t t y , 1982b). P o l y a r t i c u l a r onset JRA, the next most f r e q u e n t l y o c c u r r i n g subtype, accounts f o r 30-40% of p a t i e n t s and i s c h a r a c t e r i z e d by a r t h r i t i s i n f i v e or more j o i n t s (Brewer et a l . , 1977). Knees, w r i s t s and ankles are most commonly i n v o l v e d , w i t h a f f e c t e d j o i n t s o f t e n f o l l o w i n g a symmetrical p a t t e r n ( A n s e l l , 1977; Rodnan et a l . , 1983). S i g n i f i c a n t f u n c t i o n a l impairment and j o i n t deformity i s most commonly a s s o c i a t e d w i t h p o l y a r t i c u l a r onset, o c c u r r i n g i n over h a l f of the p a t i e n t s w i t h t h i s subtype ( P e t t y , 1982a). Peaks i n age of onset occur between 1-3 and at 9 years, and g i r l s are approximately three - 13 -times more l i k e l y to develop t h i s subtype of JRA than boys ( P e t t y , 1982b). Systemic onset JRA, the t h i r d and most severe form of the disease, occurs i n approximately 10% of JRA p a t i e n t s (Cassidy, 1982). C l i n i c a l c h a r a c t e r i s t i c s of t h i s group i n c l u d e a r t h r i t i s i n one or more j o i n t s accompanied by "systemic f e a t u r e s " i n c l u d i n g d a i l y high s p i k i n g f e v e r s w i t h or without rheumatoid rash or other organ involvement, such as p e r i c a r d i t i s , i . e . , inflammation of the membrane surrounding the heart (Brewer et a l . , 1977; Cassidy, 1982; Rodnan et a l . , 1983). Spleen, l i v e r and lymph nodes may a l s o be i n v o l v e d ( P e t t y , 1982a). Systemic onset JRA can begin at any age i n childhood and a f f e c t s approximately an equal r a t i o of g i r l s to boys ( P e t t y , 1982b; Rodnan et a l . , 1983). JRA t y p i c a l l y f o l l o w s an unpredictable course; onset may be sudden or i n s i d i o u s and periods of p a r t i a l r e mission are l i k e l y to occur (Coley, 1972). Although JRA i s considered a chronic i l l n e s s , i t i s estimated t h a t at l e a s t 75% of JRA p a t i e n t s e v e n t u a l l y enter long remissions w i t h l i t t l e or no r e s i d u a l d i s a b i l i t y (Hanson, K o r n r e i c h , B e r n s t e i n , King, & Singsen, 1977). Systemic Lupus Erythematosus (SLE) Systematic Lupus Erythematosus (SLE), a l s o a connective t i s s u e disease, occurs much l e s s f r e q u e n t l y i n c h i l d r e n than does JRA. No accurate prevalence data are a v a i l a b l e ( P e t t y , 1982b), however the estimated incidence of SLE i n c h i l d r e n under 15 years i s 0.6 per 100,000 ( S i e g e l & Lee, 1973). SLE has m u l t i p l e m a n i f e s t a t i o n s , one of which i s a r t h r i t i s . Other m a n i f e s t a t i o n s i n c l u d e r e n a l disease and s k i n disease. Age of onset f o r SLE i s o f t e n i n the teenage years, w i t h g i r l s being a f f e c t e d 4.5 times more f r e q u e n t l y than boys ( P e t t y , 1982b). Mixed Connective Tissue Disease (MCTD) Mixed Connective Tissue Disease (MCTD) i s a connective t i s s u e disease which i s uncommon i n childhood ( P e t t y , 1982b). I t i s c h a r a c t e r i z e d by - 14 -overlapping f e a t u r e s of SLE, scleroderma and m y o s i t i s ( P e t t y , 1982b). P a t i e n t s w i t h t h i s disease g e n e r a l l y have an e x c e l l e n t response to c o r t i c o s t e r o i d therapy, and have a favourable prognosis (Dabich, 1982). J u v e n i l e Ankylosing S p o n d y l i t i s (JAS) J u v e n i l e Ankylosing S p o n d y l i t i s (JAS) i s diagnosed 7.5 to 15 times l e s s f r e q u e n t l y i n c h i l d r e n than JRA. Since no p r e c i s e c r i t i e r i a f o r the d i a g n o s i s of JAS e x i s t at present, t r u e prevalence r a t e s are as yet u n a v a i l a b l e ( P e t t y , 1982b). JAS i s a s u b c l a s s i f i c a t i o n of seronegative spondyloarthropathy (Cassidy, 1982). The spondyloarthropathy c l a s s i f i c a t i o n c o n s i s t s of subtypes of a r t h r i t i s which a f f e c t not only p e r i p h e r a l j o i n t s , but a l s o the a x i a l s k eleton ( P e t t y , 1982c). Inflammation i n s e v e r a l s p i n a l j o i n t s , i n a d d i t i o n to the absence of rheumatoid f a c t o r s and a n t i n u c l e a r a n t i b o d i e s (hence the term "seronegative") are two of the main fea t u r e s which set spondyloarthropathies apart from JRA ( P e t t y , 1982c). A l s o , i n c o n t r a s t to JRA, some evidence suggests a p o t e n t i a l genetic p r e d i s p o s i t i o n t o spondyloarthropathies ( C a l i n & F r i e s , 1975). Generally i n JAS p a t i e n t s few p e r i p h e r a l j o i n t s are a f f e c t e d , mostly i n the lower e x t r e m i t i e s . A r t h r i t i s i n the a x i a l s k e l e t o n o f t e n appears l a t e i n the c l i n i c a l p i c t u r e . In i t s e a r l y stages, t h e r e f o r e , the c l i n i c a l f e a t u r e s of JAS are o f t e n d i f f i c u l t to d i f f e r e n t i a t e from JRA ( P e t t y , 1982b). JAS i s o f t e n accompanied by e n t h e s i t i s (tenderness at s i t e s of i n s e r t i o n of tendons and ligaments to bone). I t occurs s i x times more f r e q u e n t l y i n boys (the reverse sex d i f f e r e n c e from JRA), and the peak age of onset i s l a t e c h i l d h o o d / e a r l y adolescence ( l a t e r than f o r most cases of JRA) ( P e t t y , 1982c). A Syndrome of S e r o n e g a t i v i t y , Enthesopathy and Arthropathy (SEA syndrome) The c l a s s i f i c a t i o n c r i t e r i a f o r SEA syndrome i n c l u d e : onset of musculoskeletal symptoms before age 17, absence of d e t e c t a b l e rheumatoid f a c t o r s and a n t i n u c l e a r a n t i b o d i e s , presence of e n t h e s i t i s and a r t h r i t i s - 15 -(Rosenburg & P e t t y , 1982). C h i l d r e n w i t h t h i s syndrome may have an e a r l y or v a r i a n t form of JAS. SEA syndrome occurs nine times more f r e q u e n t l y i n boys, and the mean age of onset i s 10 years ( P e t t y , 1982c). P s o r i a t i c S p o n d y l o a r t h r i t i s P s o r i a t i c s p o n d y l o a r t h r i t i s i s g e n e r a l l y c l a s s i f i e d as a seronegative spondyloarthropathy. I t i s a form of a r t h r i t i s which occurs i n a s s o c i a t i o n w i t h p s o r i a s i s . Prevalence of t h i s syndrome i s unknown, but may be more common than p r e v i o u s l y suspected ( M a l l i s o n , 1987, personal communication). Coping w i t h Pain D e f i n i t i o n of Coping Coping. Coping i s defined by Lazarus and h i s colleagues as " . . . c o n s t a n t l y changing c o g n i t i v e and behavioural e f f o r t s to manage s p e c i f i c e x t e r n a l and/or i n t e r n a l demands th a t are appraised as t a x i n g or exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 5 ) . Included i n t h i s d e f i n i t i o n are s e v e r a l key concepts. F i r s t , t h i s d e f i n i t i o n i m p l i e s that coping i s not s t a t i c , but r a t h e r that i t i s a changing process wherein i n d i v i d u a l s c o n t i n o u s l y a p p r a i s e , a c t , then reappraise the environment and themselves (Lazarus, A v e r i l l , & Opton, 1974). Also key to the d e f i n i t i o n of coping proposed by Lazarus and h i s colleagues i s the involvement of e f f o r t , i m p l y i n g , as Turk (1979) notes, that coping i s under the i n d i v i d u a l ' s c o n t r o l , and t h a t c o g n i t i v e and behavioural s t r a t e g i e s are employed s p e c i f i c a l l y to a l t e r the a v e r s i v e s i t u a t i o n . C o u n t e r i n t u i t i v e l y , however, the i n d i v i d u a l may not be c o n s c i o u s l y aware of these coping " e f f o r t s " (Turk, 1979). A f i n a l aspect of t h i s coping d e f i n i t i o n to be emphasized i s that coping, i s seen as i n v o l v i n g e f f o r t s to manage, but not n e c e s s a r i l y master, s t r e s s o r s . I t i s recognized that " . . . e f f e c t i v e coping under (some) c o n d i t i o n s i s t h a t which a l l o w s the person to t o l e r a t e , minimize, accept or ignore what cannot be mastered" - 16 -(Lazarus & Folkman, 1984, p. 140). Coping s t y l e s . One approach to studying coping emphasizes c o n s i s t e n t patterns or s t y l e s . An example of a coping s t y l e considered by some to be s t a b l e i n a d u l t s i s the repressor versus s e n s i t i z e r s t y l e (Byrne, 1961). Cohen and Lazarus (1973) define r e p r e s s i o n (or avoidance) as the tendency to avoid or deny emotional or t h r e a t e n i n g aspects of the s i t u a t i o n , whereas s e n s i t i z a t i o n (or v i g i l a n c e ) i s defined as the tendency to be o v e r l y a l e r t to the t h r e a t e n i n g aspects of the s i t u a t i o n . C l a s s i f i c a t i o n of i n d i v i d u a l s according to these coping d i s p o s i t i o n s does not, however, r e l i a b l y p r e d i c t adjustment or coping behaviours e x h i b i t e d (Andrew, 1970; Cohen & Lazarus, 1973). Lazarus and Folkman (1984) argue against a d i s p o s i t i o n a l approach to coping, such as the c l a s s i f i c a t i o n of i n d i v i d u a l s as repressors or s e n s i t i z e r s , because i t underestimates the complexity and v a r i a b i l i t y i n v o l v e d i n the ongoing coping process. I n d i v i d u a l s use a wide v a r i e t y of coping s t r a t e g i e s and the type of s t r a t e g i e s employed depends on f a c t o r s such as s i t u a t i o n a l demands as appraised by the i n d i v i d u a l (Folkman & Lazarus, 1980; 1986) or c u l t u r a l background (Abu-Saad, 1984; Murphy, 1974). Coping s t r a t e g i e s . Rather than i n v e s t i g a t i n g coping s t y l e s , Lazarus and h i s colleagues advocate the i n v e s t i g a t i o n of coping s t r a t e g i e s . Turk (1979) de f i n e s coping s t r a t e g i e s as "...those s e t s of overt and covert behaviours \ that i n d i v i d u a l s engage that are under t h e i r c o n t r o l , and th a t are performed s p e c i f i c a l l y to modulate an a v e r s i v e s i t u a t i o n " (p. 301). Two key f u n c t i o n s of coping s t r a t e g i e s are: (1) to change the problem s i t u a t i o n i t s e l f or (2) to c o n t r o l the meaning of the problem s i t u a t i o n ( P e a r l i n & Schooler, 1978), although these goals are not always achieved. Some coping s t r a t e g i e s can be i n e f f e c t i v e or even maladaptive. The coping outcome r e s u l t i n g from the employment of s p e c i f i c coping s t r a t e g i e s needs to be e m p i r i c a l l y demonstrated - 17 -s i n c e no one s t r a t e g y i s i n h e r e n t l y adaptive, or g l o b a l l y s u p e r i o r to other s t r a t e g i e s (Lazarus & Folkman, 1986; Tan, 1982; Turk, Meichenbaum, & Genest, 1983). Lazarus and Folkman (1986) argue that the adaptiveness of a given s t r a t e g y v a r i e s , depending on the s t r e s s o r faced and the phase w i t h i n the coping process i n which i t i s employed. For example, a woman's d e n i a l of the p o s s i b i l i t y that a breast lump may be cancerous would be considered maladaptive i f i t precluded v i s i t i n g the doctor f o r medical t e s t s , whereas i t may be an adaptive coping s t r a t e g y f o r t h a t same i n d i v i d u a l while w a i t i n g f o r the t e s t r e s u l t s . C l a s s i f i c a t i o n of coping s t r a t e g i e s . The research l i t e r a t u r e on s t r a t e g i e s used to cope with p a i n , u n f o r t u n a t e l y , i s not uniformly guided by any one c l a s s i f i c a t i o n scheme, but r a t h e r , i s a conglomeration of t h e o r e t i c a l and p r a c t i c a l s u b d i v i s i o n s . Folkman and Lazarus (1980), f o r example, d i v i d e coping s t r a t e g i e s , on a t h e o r e t i c a l b a s i s , i n t o two main modes or c a t e g o r i e s : (1) problem-focused coping, which i n v o l v e s e f f o r t s to a l t e r the person-environment r e l a t i o n s h i p (e.g., i n f o r m a t i o n s e e k i n g ) , and (2) emotion-focused coping, which r e f e r s to thoughts or a c t i o n s aimed at reducing the emotional impact of the s t r e s s o r (e.g., r e l a x a t i o n ) . These two c a t e g o r i e s of coping are not considered to be mutually e x c l u s i v e , but r a t h e r , i n d i v i d u a l s use a complex combination of s t r a t e g y types (Monat & Lazarus, 1985). Fu r t h e r , s e v e r a l c l a s s i f i c a t i o n schemes s p e c i f i c to c o g n i t i v e coping s t r a t e g i e s incorporated i n c o g n i t i v e - b e h a v i o r a l i n t e r v e n t i o n s t u d i e s have been developed. For example, Turk et a l . (1983) c l a s s i f y c o g n i t i v e coping s t r a t e g i e s i n t o : (1) imaginative i n a t t e n t i o n , (2) imaginative transformation of the p a i n , (3) imaginative transformation of the context, (4) a t t e n t i o n d i v e r s i o n - e x t e r n a l , (5) a t t e n t i o n d i v e r s i o n - i n t e r n a l , and (6) s o m a t i z a t i o n / d i s s o c i a t i o n . A more recent c l a s s i f i c a t i o n scheme proposed by Fernandez (1986) recommends grouping a l l c o g n i t i v e coping s t r a t e g i e s i n t o - 18 -three broad c a t e g o r i e s : (1) imagery, (2) s e l f - s t a t e m e n t s , and (3) a t t e n t i o n - d i v e r s i o n . An e m p i r i c a l l y r a t h e r than t h e o r e t i c a l l y - d e r i v e d d i v i s i o n of b e h a v i o r a l and c o g n i t i v e coping s t r a t e g i e s i s provided by Wack and Turk (1984). Using a multidimensional s c a l i n g s t a t i s t i c a l technique, these authors i d e n t i f i e d e i g h t c a t e g o r i e s of coping s t r a t e g i e s : (1) pleasant imaginings, (2) rhythmic c o g n i t i v e a c t i v i t y , (3) e x t e r n a l focus of a t t e n t i o n , (4) pain acknowledging, (5) dramatized coping, (6) n e u t r a l imaginings, (7) breathing a c t i v i t y , and (8) behavioural a c t i v i t y . A l a c k of u n i f o r m i t y i n the c l a s s i f i c a t i o n of coping s t r a t e g i e s a l s o e x i s t s i n the coping l i t e r a t u r e reviews. For example, Tan (1982), and Turk et a l . (1983) review c o g n i t i v e coping s t r a t e g i e s , whereas McCaul and Malot t (1984) separate out d i s t r a c t i o n techniques. This tendency to s o r t the l i t e r a t u r e i n t o uniquely defined c a t e g o r i e s l i k e l y p a r t i a l l y accounts f o r the remaining l a c k of cohesiveness w i t h i n the a d u l t coping l i t e r a t u r e . A d u l t s ' S t r a t e g i e s f o r Coping with P a i n : Assessment and E v a l u a t i o n Much of our e a r l y knowledge regarding s t r a t e g i e s used by a d u l t s to cope w i t h pain has come from b a s i c research w i t h experimentally induced p a i n , e.g., c o l d pressor pain (Kanfer & Goldfoot, 1966), or pressure-induced pain (Barber & Cooper, 1972), i n volunteer s u b j e c t s . Development of the a d u l t coping l i t e r a t u r e began w i t h the e v a l u a t i o n of coping s t r a t e g i e s taught t o these volunteer s u b j e c t s . Taught s t r a t e g i e s have t y p i c a l l y been evaluated i n terms of t h e i r a b i l i t y to s i g n i f i c a n t l y a l t e r l e v e l s of pain i n t e n s i t y reported or experimental s u b j e c t s ' t o l e r a n c e f o r induced p a i n , i n comparison to no treatment c o n t r o l s or placebo c o n t r o l s (e.g., Beers & K a r o l y , 1979; B l i t z & D i n n e r s t e i n , 1971). Once some degree of success had been demonstrated with volunteer s u b j e c t s , s e v e r a l c o g n i t i v e and c o g n i t i v e - b e h a v i o u r a l s k i l l treatments began to be - 19 -evaluated w i t h acute and chronic pain c o n d i t i o n s i n c l i n i c a l s e t t i n g s . For example, Tan and Poser (1982) a p p l i e d a c o g n i t i v e - b e h a v i o u r a l s k i l l package treatment to help a d u l t p a t i e n t s experience l e s s acute pain during a noxious X-ray procedure (a knee arthrogram). A p p l i c a t i o n of c o g n i t i v e coping s t r a t e g i e s to some chronic pain c o n d i t i o n s has a l s o been evaluated. For example, R y b s t e i n - B l i n c h i k (1979) found three r e i n t e r p r e t i v e c o g n i t i v e s t r a t e g i e s to be e f f e c t i v e i n reducing the pain r a t i n g s and pain behaviours of a sample of a d u l t s w i t h a v a r i e t y of chronic pain c o n d i t i o n s . S i m i l a r l y , Brown (1984) noted that migraineurs taught to use c o g n i t i v e s t r a t e g i e s reported reduced headache a c t i v i t y compared to placebo c o n t r o l s . Three key reviews of p a i n - r e l a t e d coping s t r a t e g y i n v e s t i g a t i o n s c u r r e n t l y appear i n the l i t e r a t u r e . Tan (1982) reviewed i n v e s t i g a t i o n s of c o g n i t i v e and c o g n i t i v e - b e h a v i o u r a l coping s k i l l treatments, McCaul and M a l o t t (1984) evaluated d i s t r a c t i o n methods and Turk, Meichenbaum and Genest (1983) reviewed s t u d i e s of c o g n i t i v e coping s k i l l s . In summary, the conclusions drawn from these reviews i n d i c a t e t h a t t r a i n e d coping s k i l l s of v a r i o u s types have s u c c e s s f u l l y increased v o l u n t e e r s ' t o l e r a n c e f o r experimentally induced pain ( i n some but not a l l c a s e s ) , but that many more s t u d i e s using c l i n i c a l pain populations are necessary before conclusions can be made regarding the c l i n i c a l success of these treatments. F u r t h e r , Turk et a l . (1983) note that no one c o g n i t i v e coping s t r a t e g y has c l e a r l y been shown to be s u p e r i o r . In the process of e v a l u a t i n g coping s t r a t e g i e s taught to volunteer subjects to increase t o l e r a n c e f o r experimentally induced p a i n , i t was noted t h a t , i n some cases, s u b j e c t s spontaneously used t h e i r own s t r a t e g i e s to cope w i t h pain (Barber & Cooper, 1972; Kanfer & Goldfoot, 1966; S c o t t , 1978). This f i n d i n g opened up new areas of i n v e s t i g a t i o n . In order to i n v e s t i g a t e the e f f e c t i v e n e s s of spontaneous s t r a t e g i e s , however, the question of how to assess them needed to be addressed. - 20 -Even today, there i s no s i n g l e agreed-upon method f o r assessing spontaneous coping s t r a t e g i e s . I n t e r v i e w s , i n which volunteer subjects are asked what they d i d or thought about to cope with induced p a i n , have been used (e.g., Alder & Lomazzi, 1972). Spanos, Radtke-Bodorick, Ferguson, and Jones (1979) note the importance of asking general questions about thoughts during pain i n d u c t i o n i n a d d i t i o n to s p e c i f i c questions about coping s t r a t e g i e s used. An i n c i d e n t a l f i n d i n g i n t h e i r i n v e s t i g a t i o n i n d i c a t e d that subjects may i n f a c t spontaneously use a number of c o g n i t i v e s t r a t e g i e s but may not l a b e l them as such, and t h e r e f o r e may underreport coping e f f o r t s i f only s p e c i f i c , d i r e c t e d questions are asked of them. I n v e s t i g a t o r s of spontaneous coping s t r a t e g i e s , and i n p a r t i c u l a r c o g n i t i v e s t r a t e g i e s , must be aware of the i s s u e s of a c c e s s i b i l i t y and b i a s i n r e c a l l . I f subjects do not report using spontaneous c o g n i t i v e s t r a t e g i e s , t h i s may r e f l e c t p o s s i b l e confounding f a c t o r s such as: (1) an i n a b i l i t y to v e r b a l l y describe c o g n i t i v e or s u b j e c t i v e experiences, or (2) a l a c k of metacognitive a b i l i t y ( s p e c i f i c a l l y , the awareness of one's own p s y c h o l o g i c a l processes (Selman, 1980) or (3) a l a c k of conscious awareness of the use of s p e c i f i c coping s t r a t e g i e s ( N i s b e t t & Wilson, 1977; Turk, 1979). Whereas, i f subjects do r e p o r t c o g n i t i v e s t r a t e g i e s , the i s s u e of whether these s t r a t e g i e s were a c t u a l l y employed during the task, as opposed to simply r e f l e c t i n g post-hoc r a t i o n a l i z a t i o n s remains (Turk et a l . , 1983). Because c o g n i t i o n s are p r i v a t e l y experienced, i n v e s t i g a t o r s must accept the s e l f - r e p o r t of s u b j e c t s . However, N i s b e t t and Wilson (1977) s t r e s s the need f o r c a u t i o n i n i n t e r p r e t i n g post-hoc accounts of c o g n i t i v e processes. Even i f s e l f - r e p o r t s of c o g n i t i o n s are based on i n f e r e n c e though they should s t i l l be viewed as data which i s of i n t e r e s t to i n v e s t i g a t o r s (Genest & Turk, 1982). In order to improve a c c e s s i b i l i t y and reduce biases p o t e n t i a l l y i n v o l v e d i n r e t r o s p e c t i v e r e c a l l , Genest and Turk (1982) suggest p l a y i n g back to - 21 -s u b j e c t s a videotape of the p a i n - e l i c i t i n g s i t u a t i o n . T his assessment method provides s e l f - g e n e r a t e d cues or prompts which are l e s s l i k e l y to i n v o l v e experimenter bias (Meichenbaum, Burland, & Gruson, 1979), and which are b e l i e v e d to minimize r e f l e c t i o n (Genest & Turk, 1982). In a d d i t i o n , Genest and Turk (1982) s t r e s s the importance of a semi-structured i n t e r v i e w format, using open-ended questions. The use of open-ended questions makes data harder to q u a n t i f y , but i s a format which i s l e s s l i k e l y to be biased by demand c h a r a c t e r i s t i c s , and which provides a r i c h e r source of i n f o r m a t i o n (Genest & Turk, 1982; Spanos et a l . , 1979). P o t e n t i a l i n v e s t i g a t o r s of spontaneous coping s t r a t e g i e s must not be discouraged by these d i f f i c u l t assessment i s s u e s . I n v e s t i g a t i o n of spontaneous coping s t r a t e g i e s promises to provide extremely v a l u a b l e i n f o r m a t i o n about e f f e c t i v e and i n e f f e c t i v e coping w i t h p a i n . I t must be noted that pain p a t i e n t s i n coping s k i l l treatment s t u d i e s are t y p i c a l l y those p a t i e n t s r e f e r r e d f o r p s y c h o l o g i c a l treatment because they are evaluated ( e i t h e r by themselves or t h e i r p h y s i c i a n s ) to be not coping w e l l w i t h t h e i r p a i n . Therefore, much of the a d u l t l i t e r a t u r e regarding taught s t r a t e g i e s f o r coping w i t h c l i n i c a l pain focuses s e l e c t i v e l y on " i n e f f e c t i v e copers". Penneybaker's (1982) work provides an important caveat against unquestioning extensions of f i n d i n g s w i t h " i n e f f e c t i v e copers" to a l l pain p a t i e n t s . I t may be that symptom r e p o r t i n g pain p a t i e n t s have a d i s t i n c t coping a p p r a i s a l process; the way they i n t e r p r e t , monitor and emotionally r e a c t to symptoms may be q u i t e d i f f e r e n t from p a t i e n t s who are coping w e l l w i t h t h e i r p a i n , and t h e r e f o r e are not r e f e r r e d f o r p s y c h o l o g i c a l treatment. Thus, there i s a need to study and compare " e f f e c t i v e copers" and " i n e f f e c t i v e copers", and to e m p i r i c a l l y evaluate the e f f i c a c y of spontaneous coping s t r a t e g i e s used by these two groups of pain p a t i e n t s at p a r t i c u l a r phases w i t h i n the coping process. Research such as t h i s i s needed to i d e n t i f y the - 22 -range of f a c t o r s that i n f l u e n c e the adaptive process (Turk, 1979). Spanos, Brown, Jones, and Homer (1981) provide a comparison of spontaneous thought processes i n volunteer s u b j e c t s who could be conceptualized as " e f f e c t i v e copers" versus " i n e f f e c t i v e copers". Subjects wrote down a l l thoughts experienced during a c o l d pressor task. Analyses revealed t h a t subjects who reported l e s s pain and had a greater t o l e r a n c e f o r pain were a l s o those whose thoughts were c l a s s i f i e d predominantly as "coping thoughts" (e.g., imagined events i n c o n s i s t e n t w i t h p a i n , or engaged i n p o s i t i v e s e l f - s t a t e m e n t s ) . On the other hand, s u b j e c t s whose thoughts were c l a s s i f i e d predominantly as "exaggerated" (e.g., r e f l e c t i n g worry about or exaggeration of the pain) were l e s s able to t o l e r a t e p a i n , and gave higher i n t e n s i t y r a t i n g s . This study, and others done w i t h volunteer s u b j e c t s , i n d i c a t e t h a t some su b j e c t s can use spontaneous c o g n i t i v e coping s t r a t e g i e s to cope e f f e c t i v e l y w i t h pain (Turk et a l . , 1983). In f a c t , Turk et a l . (1983) note that i n 36% of i n v e s t i g a t i o n s reviewed, c o g n i t i v e coping s k i l l treatments were no b e t t e r than s u b j e c t s ' use of spontaneous coping s t r a t e g i e s . F u r t h e r , they describe a case example i n which taught coping s t r a t e g i e s a c t u a l l y i n t e r f e r e d w i t h a volunteer s u b j e c t ' s own coping s t y l e and thus r e s u l t e d i n a decrement of a b i l i t y to t o l e r a t e p a i n . This example may have important i m p l i c a t i o n s f o r the t r a i n i n g of coping s k i l l s i n c l i n i c a l pain p a t i e n t s . I t i s l i k e l y t h a t p a t i e n t s ' spontaneous coping s t r a t e g i e s would need to be assessed i n i t i a l l y , and s t r a t e g i e s taught should b u i l d upon, r a t h e r than r e p l a c e , those e f f e c t i v e spontaneous s t r a t e g i e s . U n f o r t u n a t e l y , the use of spontaneous s t r a t e g i e s i n c l i n i c a l populations has not yet r e c e i v e d much systematic measurement. Copp (1974) noted t h a t most a d u l t s i n chr o n i c pain r e p o r t using some s o r t of c o g n i t i v e s t r a t e g y as w e l l behavioural pain management s t r a t e g y . More r e c e n t l y , R o s e n s t i e l and Keefe - 23 -(1983) have begun to s y s t e m a t i c a l l y assess the spontaneous c o g n i t i v e and behavioural pain coping s t r a t e g i e s used by a d u l t p a t i e n t s w i t h chronic low back pain (CLBP). These i n v e s t i g a t o r s used a s u p p l i e d response questionnaire format ( C o g n i t i v e Coping Questionnaire) to assess s t r a t e g i e s . They found that scores on t h i s questionnaire s i g n i f i c a n t l y p r e d i c t e d measures of behavioural and emotional adjustment to c h r o n i c pain ( i e . d i s a b i l i t y s t a t u s ) . Reesor and C r a i g ( i n p r e s s ) , i n an i n v e s t i g a t i o n of spontaneous c o g n i t i v e coping s t r a t e g i e s employed by CLBP p a t i e n t s , used the Coping S t r a t e g i e s Questionnaire developed by R o s e n s t i e l and Keefe (1983) as w e l l as a s t r u c t u r e d i n t e r v i e w format adapted from Genest (1978). The sample of CLBP p a t i e n t s s t u d i e d was d i v i d e d i n t o c o n t r o l CLBP versus "medically incongruent" CLBP p a t i e n t s . " M e d i c a l l y incongruent" CLBP p a t i e n t s were those who met s p e c i f i c q u a n t i f i a b l e c r i t e r i a r e f l e c t i n g pain r e p o r t i n g that was deemed exaggerated, d i s p r o p o r t i o n a t e , and/or anatomically deviant r e l a t i v e to known organic impairment (Reesor & C r a i g , i n p r e s s ) . Poorer success i n medical treatments has been documented f o r CLBP p a t i e n t s who d i s p l a y m u l t i p l e m e d i c a l l y incongruent pain s i g n s (Dzioba & Doxey, 1984). An assessment of the spontaneous c o g n i t i v e coping s t r a t e g i e s used by "medically incongruent" pain p a t i e n t s and c o n t r o l s , conducted by Reesor and C r a i g ( i n p r e s s ) , revealed that those s t r a t e g i e s tapped by the s t r u c t u r e d i n t e r v i e w d i s c r i m i n a t e d between groups b e t t e r than s t r a t e g i e s endorsed on the Coping Strategy Questionnaire. " M e d i c a l l y incongruent" pain p a t i e n t s reported s i g n i f i c a n t l y more c a t a s t r o p h i z i n g thoughts than c o n t r o l s , but, s u r p r i s i n g l y , no s i g n i f i c a n t group d i f f e r e n c e s emerged i n terms of number of s p e c i f i c types of s t r a t e g i e s reported. Although the research design used by Reesor and C r a i g ( i n press) does not permit cau s a l e x p l a n a t i o n s , i t seems that c a t a s t r o p h i z i n g thoughts are a s s o c i a t e d w i t h " i n e f f e c t i v e coping" w i t h CLBP , a r e s u l t s i m i l a r to the f i n d i n g s of Spanos et a l . (1981) w i t h experimentally induced pain i n - 24 -volunteer s u b j e c t s . I n summary, the e f f e c t i v e n e s s of s t r a t e g i e s used by a d u l t s to cope w i t h pain depends on the type of s t r a t e g y (spontaneous or taught) and the population s t u d i e d (volunteer or c l i n i c a l pain p a t i e n t s ) . Several c o g n i t i v e and c o g n i t i v e - b e h a v i o u r a l s k i l l treatments have been demonstrated to be e f f e c t i v e w i t h volunteer s u b j e c t s , but extension to c l i n i c a l populations has s t i l l not unequivocally been demonstrated (McCaul & M a l o t t , 1984; Tan, 1982). In some cases, spontaneous coping s t r a t e g i e s are j u s t as e f f e c t i v e as taught s t r a t e g i e s (Turk et a l . , 1983). No one s t r a t e g y has been proven most e f f e c t i v e (Turk et a l . , 1983), and i n f a c t some types of thoughts, such as c a t a s t r o p h i z i n g , tend to be a s s o c i a t e d w i t h i n e f f e c t i v e coping outcome (Reesor & C r a i g , i n press; Spanos et a l . , 1981). C h i l d r e n ' s S t r a t e g i e s f o r Coping w i t h P a i n : Assessment and E v a l u a t i o n Knowledge regarding c h i l d r e n ' s coping a b i l i t i e s has only r e c e n t l y s t a r t e d to develop. Coping research i n c h i l d r e n i s , f o r e t h i c a l reasons, not b u i l t upon a foundation of b a s i c research using experimentally-induced pain i n volunteers (McGrath, P.A., i n p r e s s ) . Rather, the knowledge base regarding e f f e c t i v n e s s of v a r i o u s coping s t r a t e g i e s i n c h i l d r e n has s t a r t e d to develop from the a p p l i c a t i o n of coping s k i l l treatments adapted from the a d u l t l i t e r a t u r e . C o g n i t i v e and c o g n i t i v e - b e h a v i o u r a l coping s k i l l treatments, such as s e l f - h y p n o s i s , d i s t r a c t i o n , and thought-stopping have been designed to help c h i l d r e n cope w i t h acute pain experienced during p a i n f u l procedures such as the bone marrow a s p i r a t i o n s , lumbar punctures or endless venipuncture procedures c h i l d r e n w i t h cancer have to undergo ( H i l g a r d & LeBaron, 1982; Kellerman, 1980; Kuttner, 1985; Ross, 1984; Ross & Ross, 1984a). R e l a x a t i o n and c o g n i t i v e coping s t r a t e g i e s have a l s o been taught to h o s p i t a l i z e d c h i l d r e n w i t h acute i l l n e s s e s (Howard, 1981; LaGreca, & O t t i n g e r , 1979; Peterson & - 25 -Shigetomi, 1981), to c h i l d r e n undergoing d e n t a l procedures ( N o c e l l a & Kaplan, 1982; S i e g e l & Peterson, 1980), and p r e v e n t i v e l y , to a general population of t h i r d and f o u r t h grade school c h i l d r e n (Ross & Ross, 1985). Researchers have begun to develop and evaluate coping s k i l l treatments f o r p e d i a t r i c chronic pain c o n d i t i o n s such as migraines ( R i c h t e r , McGrath, Humphreys, Goodman, F i r e s t o n e , & Keene, 1986), r e c u r r e n t abdominal pain (McGrath & Feldman, i n press) and burn pain (McGrath & V a i r , 1984). McGrath, Dunn-Geier, Cunningham, Brunette, D'Astraus, Humphreys, L a t t e r , Keene, and Goodman (1985) i n c l u d e coping s k i l l i n s t r u c t i o n as one of nine p s y c h o l o g i c a l g u i d e l i n e s f o r h e l p i n g c h i l d r e n to cope with chronic p a i n . As i s the case w i t h the a d u l t coping l i t e r a t u r e , packages of coping s k i l l s are u s u a l l y taught and t h e r e f o r e the e f f i c a c y of s p e c i f i c s t r a t e g i e s has not been s i f t e d out. In a d d i t i o n , the po p u l a t i o n of p a t i e n t s r e c e i v i n g these treatments tend to be " i n e f f e c t i v e copers" and, t h e r e f o r e , may not be t y p i c a l of a l l p e d i a t r i c pain p a t i e n t s (Penneybaker, 1982). Only w i t h i n the past few years have researchers begun to assess spontaneous coping s t r a t e g i e s used by c h i l d r e n . The o r i g i n a l emphasis i n p e d i a t r i c pain research was on spontaneous " d i s t r e s s " or "negative" behaviours e x h i b i t e d by c h i l d r e n undergoing p a i n f u l procedures such as immunizations (e.g., Gross et a l . , 1983; Winer, 1984). These behaviours have t y p i c a l l y been seen as responses to the pain experience, and an emphasis on e f f o r t f u l spontaneous coping s t r a t e g i e s has been l a c k i n g u n t i l r e c e n t l y . G r a d u a l l y , methods of assessing c h i l d r e n ' s spontaneous coping s t r a t e g i e s have become more s o p h i s t i c a t e d , progressing from: (1) questions about coping in c l u d e d i n more general p e d i a t r i c pain i n t e r v i e w s and q u e s t i o n n a i r e s (Abu-Saad, 1984; Jeans & Gordon, 1981, as c i t e d i n Jeans, 1983; J e r r e t t , 1985; R e i s s l a n d , 1983; Ross & Ross, 1984b; Savedra, Gibbons, T e s l e r , Ward, & Wegner, 1982; Savedra, T e s l e r , & Ward, 1981; T e s l e r , Wegner, Savedra, Gibbons, & Ward, - 26 -1981); (2) to i m a g i n a l l y reconstructed pain s i t u a t i o n s and s e l f - r e p o r t e d s t r a t e g i e s (Brown, O'Keefe, Sanders, & Baker, 1986; H u n t - F i t z g e r a l d & L i d d e l l , 1985); and f i n a l l y to (3) i n v i v o assesments i n which c h i l d r e n ' s behavioural s t r a t e g i e s used to cope w i t h pain are observed and coded, and c o g n i t i v e s t r a t e g i e s are tapped using a semi-structured i n t e r v i e w a f t e r the pain s i t u a t i o n (Curry & Russ, 1985). The d e s c r i p t i v e i n f o r m a t i o n from i n t e r v i e w s t u d i e s provides a b a s i c s t a r t i n g point f o r knowledge regarding c h i l d r e n ' s awareness of s t r a t e g i e s f o r coping w i t h p a i n . For example, as part of an i n t e r v i e w study a s s e s s i n g p e d i a t r i c p a i n , conducted by Savedra and her colleagues (Savedra et a l . , 1981; Savedra et a l . , 1982; T e s l e r et a l . , 1981), 214 9-12 y e a r - o l d c h i l d r e n were asked "What helps you f e e l b e t t e r when you are i n p a i n ? " Approximately h a l f of the s u b j e c t s were drawn f o r a h o s p i t a l population " w i t h a v a r i e t y of medical and s u r g i c a l c o n d i t i o n s " , and h a l f were inte r v i e w e d i n a school s e t t i n g . The authors provide a d e s c r i p t i v e r a t h e r than a s t a t i s t i c a l a n a l y s i s of the r e s u l t s . E i g h t - f i v e percent of the c h i l d r e n i n t h e i r sample i d e n t i f i e d a t l e a s t one s t r a t e g y to cope w i t h p a i n . C h i l d r e n most f r e q u e n t l y (n = 56) reported that t a k i n g medicine makes them f e e l b e t t e r and others reported s t r a t e g i e s such as r e s t or r e l a x a t i o n (n_ = 49), presence of others (n = 39), food or d r i n k (n = 21), or a t t e n t i o n , e.g., a hug (n = 50). Abu-Saad (1984) a l s o asked a sample of 13 Asian-American g i r l s and 11 boys aged 9-12 years the same question regarding coping. C h i l d r e n ' s responses are l i s t e d i n order of frequency of occurrence, but the number of responses given by i n d i v i d u a l c h i l d r e n i s not i n d i c a t e d . The most frequent response was the use of Chinese medicine and household remedies, followed by being t a l k e d to or cheered up by others. R e l a t i v e l y few c h i l d r e n i n t h i s study reported coping e f f o r t s they themselves use, although responses l i k e r e s t i n g , rubbing the area, screaming or h i t t i n g were mentioned by some. In d i s c u s s i n g these - 27 -r e s u l t s , Abu-Saad (1984) argues t h a t c h i l d r e n ' s coping s t r a t e g i e s are c o n s i s t e n t w i t h c u l t u r a l a t t i t u d e s towards i l l n e s s . D e s c r i p t i o n s of responses i n these two i n t e r v i e w s t u d i e s seem to i n d i c a t e that the m a j o r i t y of s t r a t e g i e s reported by c h i l d r e n 9-12 ye a r s - o l d to cope w i t h pain are s u p p l i e d or " e x t e r n a l " r a t h e r than " s e l f - i n i t i a t e d " s t r a t e g i e s (e.g., t a k i n g medication, r e c e i v i n g hugs). These f i n d i n g s may, however, underestimate the c h i l d r e n ' s c a p a c i t y to engage i n self-management. The wording of i n t e r v i e w questions may have created a demand t o answer w i t h " e x t e r n a l " s t r a t e g i e s . Some i n t e r v i e w e r s have asked c h i l d r e n "What do you do or t h i n k about when you are i n pain?", r a t h e r than (as i n the two s t u d i e s c i t e d above) asking "What makes you f e e l b e t t e r ? " , and thus have addressed the question of demand c h a r a c t e r i s t i c s . This a l t e r n a t e question was asked i n a l a r g e - s c a l e i n t e r v i e w study conducted by Ross and Ross (1984b), and i n s i m i l a r s t u d i e s conducted by Jeans and Gordon (1981; as c i t e d i n Jeans, 1983), R e i s s l a n d (1983), and J e r r e t t (1985). Ross and Ross (1984b) inte r v i e w e d a t o t a l of 994 c h i l d r e n aged 5-12 years. They were disappointed to f i n d that i n answer t o the question "What do you do or t h i n k about when you are i n pain?", only 21% of sub j e c t s reported using s e l f - i n i t i a t e d coping s t r a t e g i e s . Those reported i n c l u d e d : d i s t r a c t i o n methods (n = 93), p h y s i c a l procedures such as c l e n c h i n g a f i s t (n_ = 91) and thought-stopping, r e l a x a t i o n / i m a g e r y , or fantasy (n_ = 29). F u r t h e r , they warn tha t 13 of the subgroup of c h i l d r e n r e p o r t i n g s e l f - i n i t i a t e d coping s t r a t e g i e s were c h i l d r e n w i t h leukemia who were c u r r e n t l y working w i t h a p e d i a t r i c i a n , and t h e r e f o r e these s t r a t e g i e s may not have been "spontaneous" coping s t r a t e g i e s . Ross and Ross (1984b) reported no c l e a r l y defined age trends i n c h i l d r e n ' s responses, which stands i n c o n t r a s t to e a r l i e r observations made by Jeans and Gordon (1981; as c i t e d i n Jeans, 1983), and R e i s s l a n d (1983). C h i l d r e n i n the - 28 -5, 7, and 9-year-old age groups of the Jeans and Gordon (1981; as c i t e d i n Jeans, 1983) sample, tended to r e p o r t d i r e c t a c t i o n , p h y s i c a l - b e h a v i o u r a l s t r a t e g i e s to cope w i t h pain whereas c h i l d r e n 11 and 13 years of age reported a number of p s y c h o l o g i c a l s t r a t e g i e s . S i m i l a r l y , R e i s s l a n d (1983) found t h a t c h i l d r e n l e s s than 7 years 4 months only reported behavioural s t r a t e g i e s (e.g., " c a l l Mummy"), but older c h i l d r e n reported more c o g n i t i v e and more autonomous coping s t r a t e g i e s . A recent i n t e r v i e w study by J e r r e t t (1985) takes a more o p t i m i s t i c p e r s p e c t i v e than Ross and Ross (1984b) regarding c h i l d r e n ' s knowledge of s e l f - i n i t i a t e d coping s t r a t e g i e s . J e r r e t t (1985) c l a s s i f i e d the 145 coping responses generated by her sample of 40, 5-9 y e a r - o l d c h i l d r e n i n t o three of Lazarus' (1980) coping subtypes: (1) d i r e c t a c t i o n p h y s i c a l a c t i v i t i e s , (2) avoidance a c t i v i t i e s , and (3) help-seeking a c t i v i t i e s . According to t h i s c l a s s i f i c a t i o n approach, responses such as " t a k i n g medicine", or "holding mummy's hand" were seen as help-seeking a c t i v i t i e s (and thus, e f f o r t f u l coping s t r a t e g i e s ) r a t h e r than as s t r a t e g i e s r e f l e c t i n g perceived e x t e r n a l c o n t r o l over the pain s i t u a t i o n . A lso supplementing t h i s optimism about c h i l d r e n ' s awareness of s e l f - i n i t i a t e d coping s t a t e g i e s , are the i n c i d e n t a l f i n d i n g s and c l i n i c a l impressions of Unruh, McGrath, Cunningham, and Humphreys (1983). In a study of p i c t u r e s drawn by p e d i a t r i c migraine p a t i e n t s of themselves i n p a i n , Unruh et a l . (1983) found that p a t i e n t s most f r e q u e n t l y portrayed themselves a c t i v e l y doing something to cope w i t h t h e i r p a i n . Only 1/109 drawings showed a c h i l d t a k i n g medication. This f i n d i n g was i n t e r p r e t e d to be congruent w i t h Unruh et a l . ' s (1983) c l i n i c a l experience t h a t although t a k i n g medication i s a commonly mentioned coping s t r a t e g y , c h i l d r e n seldom perceive medications as the s o l u t i o n to t h e i r pain problems. In a d d i t i o n to the research methods of w r i t t e n q u e s t i o n n a i r e s , open-ended - 29 -i n t e r v i e w s and pain drawings discussed above, imaginal r e c o n s t r u c t i o n has a l s o been used to tap c h i l d r e n ' s spontaneous c o g n i t i v e coping s t r a t e g i e s . Brown et a l . (1986) asked 1,116 8-18 year-olds about c o g n i t i o n s r e l a t e d to an imagined dent a l v i s i t and c l a s s r e p o r t s i t u a t i o n (making a p r e s e n t a t i o n i n f r o n t of the c l a s s ) and one personal s i t u a t i o n (a recent, s e l f - g e n e r a t e d s t r e s s o r ) . Each response given by c h i l d r e n was c l a s s i f i e d as e i t h e r a Coping or C a t a s t r o p h i z i n g c o g n i t i o n . For the d e n t a l s i t u a t i o n , s u b c l a s s i f i c a t i o n s w i t h i n the Coping c o g n i t i o n s were: (1) P o s i t i v e S e l f - t a l k ; (2) A t t e n t i o n D i v e r s i o n ; (3) R e l a x a t i o n ; and (4) Thought-stopping. The C a t a s t r o p h i z i n g category was subdivided i n t o : (1) Focusing on Negative A f f e c t or P a i n ; (2) Thoughts of Escape or Avoidance; (3) Concern about an U n l i k e l y Consequence; and (4) Concern about the D e n t i s t . (NOTE: Some c a t e g o r i e s of coping and c a t a s t r o p h i z i n g c o g n i t i o n s developed from the c l a s s r e p o r t s i t u a t i o n and personal s i t u a t i o n data d i f f e r e d from these c a t e g o r i e s a p p l i c a b l e to the d e n t a l v i s i t data, however only the r e s u l t s from the d e n t a l s i t u a t i o n are reported here. The d e n t a l s i t u a t i o n i s the most r e l e v a n t of the three s i t u a t i o n s , s i n c e i t i s not only a s t r e s s - p r o d u c i n g s i t u a t i o n but a l s o may be pain-producing.) Analyses revealed t h a t reported use of P o s i t i v e S e l f - t a l k and A t t e n t i o n D i v e r s i o n , the two most f r e q u e n t l y reported subcategories of coping c o g n i t i o n s , increased s i g n i f i c a n t l y w i t h age. In a d d i t i o n to c l a s s i f y i n g i n d i v i d u a l reported c o g n i t i o n s , Brown et a l . (1986) a l s o c l a s s i f i e d s u bjects g l o b a l l y , according to the type of c o g n i t i o n s t h a t dominated c h i l d r e n ' s responses. Those c h i l d r e n who reported predominantly coping c o g n i t i o n s were c l a s s i f i e d as "Copers" and those who reported predominantly c a t a s t r o p h i z i n g c o g n i t i o n s were c l a s s i f i e d as " C a t a s t r o p h i z e r s " . Analyses revealed a greater number of Copers w i t h i n c r e a s i n g age. No sex d i f f e r e n c e i n the prevalence of Copers was found. Despite the noted increase i n Coping c o g n i t i o n s w i t h age, C a t a s t r o p h i z i n g - 30 -c o g n i t i o n s remained p r e v a l e n t . A l s o , Brown et a l . (1986) found t h a t c h i l d r e n c l a s s i f i e d as Copers reported lower l e v e l s of t r a i t a n x i e t y than C a t a s t r o p h i z e r s . However, because the a n x i e t y and coping measures were both s e l f - r e p o r t measures, and because they covered s i m i l a r content area, t h i s c o r r e l a t i o n may be confounded by s i m i l a r i t i e s i n assessment method (e.g., some items on the an x i e t y inventory may be the same as c a t a s t r o p h i z i n g responses reported by c h i l d r e n ) . In a s i m i l a r study of coping s e l f - s t a t e m e n t s , H u n t - F i t z g e r a l d and L i d d e l l (1985) asked over 1,500 9-12 yea r - o l d school c h i l d r e n to imagine what they would say to themselves i f they were i n s e v e r a l d i f f e r e n t d e n t a l s i t u a t i o n s (e.g., appointment and w a i t i n g room s i t u a t i o n s ) taken from the Dental Anxiety s c a l e . C h i l d r e n were t o l d to "Think as hard as you can about i t and when I say stop, w r i t e as q u i c k l y as you can what you were saying to y o u r s e l f " . Independent clauses of reported s e l f - s t a t e m e n t s were c l a s s i f i e d as e i t h e r " p o s i t i v e " or "negative", and as r e l a t i n g t o behaviour, c o g n i t i o n , or f e e l i n g . Self-statements were assigned a " p o s i t i v e " valence i f they r e f l e c t e d " p o s i t i v e coping w i t h the s i t u a t i o n " , whereas they were assigned a negative valence i f i t was deemed that they would "make the de n t a l v i s i t i n t o an unpleasant experience" ( H u n t - F i t z g e r a l d , 1984). In an e f f o r t to evaluate the e f f e c t i v e n e s s of coping or adaptation i n c h i l d r e n r e p o r t i n g d i f f e r e n t types of s e l f - s t a t e m e n t s , H u n t - F i t z g e r a l d and L i d d e l l (1985) analyzed which self-statement c a t e g o r i e s were s i g n i f i c a n t l y r e l a t e d to s e l f - r e p o r t e d d e n t a l a n x i e t y scores. They found t h a t higher d e n t a l a n x i e t y scores, i n boys, were s i g n i f i c a n t l y r e l a t e d to the presence of "negative c o g n i t i o n " and "negative f e e l i n g " s e l f - s t a t e m e n t s . In g i r l s , higher d e n t a l a n x i e t y scores were s i g n i f i c a n t l y r e l a t e d to the presence of "negative c o g n i t i o n " , "negative f e e l i n g " , and "negative behaviour" s e l f - s t a t e m e n t s . Also i n g i r l s , the presence of " p o s i t i v e f e e l i n g " s e l f - s t a t e m e n t s was - 31 -s i g n i f i c a n t l y r e l a t e d to lower d e n t a l a n x i e t y scores. These c o r r e l a t i o n s p o t e n t i a l l y i n d i c a t e t h a t some spontaneously reported s e l f - s t a t e m e n t s may i n f a c t be r e l a t e d to an i n e f f e c t i v e coping outcome. However, as w i t h the Brown et a l . (1986) f i n d i n g s , these c o r r e l a t i o n s may simply r e f l e c t s i m i l a r i t i e s i n the methodology used to assess both a n x i e t y and negative s e l f - s t a t e m e n t s . Findings from the s t u d i e s c i t e d above e f f e c t i v e l y counter the commonly held assumption t h a t c h i l d r e n are not able to communicate u s e f u l i n f o r m a t i o n regarding coping w i t h p a i n . The v a l i d i t y of responses given by c h i l d r e n may s t i l l need to be s c r u t i n i z e d , however, p a r t i c u l a r l y i f a s u p p l i e d response format (e.g., i n v e n t o r i e s or c h e c k l i s t s of s t r a t e g i e s t o be endorsed by s u b j e c t s ) i s used. In studying the impact of v a r i o u s i n t e r v i e w parameters, Ross and Ross (1984c) noted t h a t when an example of a coping s t r a t e g y was s u p p l i e d , over 80% of c h i l d r e n s a i d they used t h a t s t r a t e g y and r a t e d i t the most e f f e c t i v e s t r a t e g y d e s p i t e the f a c t that very few had spontaneously reported using that s t r a t e g y . Thus the choice of a generated response format ( i . e . , spontaneous coping s t r a t e g i e s s u p p l i e d by the c h i l d r e n themselves) made by the authors c i t e d above, incr e a s e s the l i k e l i h o o d of response v a l i d i t y . Although the coping s t r a t e g i e s reported above are more l i k e l y to be s t r a t e g i e s that c h i l d r e n a c t u a l l y use than i f they were e l i c i t e d v i a a s u p p l i e d response format, i t must be noted t h a t they are r e c a l l e d or h y p o t h e t i c a l s t r a t e g i e s . I t i s s t i l l p o s s i b l e t h a t i n v i v o s t r a t e g i e s employed by c h i l d r e n to cope w i t h pain s i t u a t i o n s may d i f f e r . There i s c u r r e n t l y only one published study i n the l i t e r a t u r e a s s e s s i n g c h i l d r e n ' s i n v i v o use of coping s t r a t e g i e s . Curry and Russ (1985) assessed both behavioural and c o g n i t i v e coping s t r a t e g i e s employed by 30 8-10 y e a r - o l d c h i l d r e n during a d e n t a l v i s i t . These i n v e s t i g a t o r s i d e n t i f i e d 3 behavioural and 6 c o g n i t i v e coping s t r a t e g i e s from a review of the a d u l t coping l i t e r a t u r e . C h i l d r e n ' s behaviour during the - 32 -d e n t a l v i s i t was observed and coded, and c o g n i t i v e s t r a t e g i e s were coded from responses to post-procedure i n t e r v i e w questions. Curry and Russ (1985) found t h a t every c h i l d used at l e a s t 2 c o g n i t i v e coping and 1 behavioural coping category, and t h a t o l d e r c h i l d r e n tended to use a greater number and v a r i e t y of c o g n i t i v e coping s t r a t e g i e s . Older c h i l d r e n were s i g n i f i c a n t l y more l i k e l y to focus on p o s i t i v e aspects a s s o c i a t e d w i t h a s t r e s s o r and l e s s l i k e l y to seek i n f o r m a t i o n than younger c h i l d r e n . This i n c r e a s e i n the frequency of c o g n i t i v e s t r a t e g i e s reported w i t h i n c r e a s i n g age i s i n keeping w i t h the i n t e r v i e w data of Jeans and Gordon (1981) and R e i s s l a n d (1983), and imaginal r e c o n s t r u c t i o n data of Brown et a l . ( i n p r e s s ) , but stands i n c o n t r a s t to the Ross and Ross (1984b) i n t e r v i e w data which y i e l d e d no c l e a r l y d efined age trends. C o g n i t i v e Development and Reported Coping Strategy Use. As noted above, there i s i n c o n s i s t e n c y i n the l i t e r a t u r e regarding the e x i s t e n c e of c l e a r - c u t d i f f e r e n c e s i n the number and types of s t r a t e g i e s f o r coping w i t h pain reported by c h i l d r e n of d i f f e r e n t ages. The p a t t e r n emerging from those s t u d i e s t h a t do f i n d age d i f f e r e n c e s i s , however, c o n s i s t e n t . In g e n e r a l , " o l d e r " c h i l d r e n i n c r e a s i n g l y r e p o r t the use of c o g n i t i v e coping s t r a t e g i e s (Brown et a l . , 1986; Curry & Russ, 1985; Jeans & Gordon, 1981; as c i t e d i n Jeans, 1983; R e i s s l a n d , 1983). Age groups r e f e r r e d to as " o l d e r " vary among s t u d i e s . In d i s c u s s i n g age trends i n the data, both R e i s s l a n d (1983) and Curry and Russ (1985) make only general reference to the p o t e n t i a l r o l e of c o g n i t i v e developmental d i f f e r e n c e s . Although s e v e r a l authors emphasize the need f o r a cognitive-developmental p e r s p e c t i v e (e.g., Lavigne, S c h u l e i n , & Hahn, 1986; Thompson & V a r n i , 1986), the s p e c i f i c r o l e of c o g n i t i v e development i n the development of c h i l d r e n ' s s t r a t e g i e s f o r coping w i t h pain has yet to be e m p i r i c a l l y s p e c i f i e d . Developmental f i n d i n g s from l i t e r a t u r e regarding c h i l d r e n ' s understanding of - 33 -i l l n e s s , h e a l i n g , p a i n , and medical procedures provide the groundwork f o r s p e c u l a t i o n s as to the r o l e of c o g n i t i v e development. Maddux, Roberts, Sledden, and Wright (1986) propose two ways i n which c h i l d r e n ' s l e v e l of c o g n i t i v e development can impact g e n e r a l l y on h e a l t h behavior. F i r s t , i n c r e a s e s i n c o g n i t i v e complexity have been shown to correspond w i t h a more s o p h i s t i c a t e d c o n c e p t u a l i z a t i o n of i l l n e s s or pain t h a t a l l o w s f o r greater personal c o n t r o l . Secondly, i n c r e a s e s i n c o g n i t i v e complexity have been shown to correspond w i t h a b i l i t y to understand the purpose of p a i n f u l medical treatments, and thus the reason f o r cooperation. Several s t u d i e s have demonstrated progressive changes i n c h i l d r e n ' s understanding of i l l n e s s , corresponding w i t h the P i a g e t i a n stages of p r e o p e r a t i o n a l , concrete o p e r a t i o n a l , and formal o p e r a t i o n a l thought (Piaget & Inhelder, 1969). Bibace and Walsh (1979), f o r example, have i d e n t i f i e d s i x successive stages i n c h i l d r e n ' s causal explanations of i l l n e s s . At what these authors l a b e l the "phenomenistic" and "contagion" stages, corresponding w i t h p r e o p e r a t i o n a l thought, c h i l d r e n tended to give magical c a u s a l explanations of i l l n e s s , or c a u s a l explanations based on p h y s i c a l p r o x i m i t y . At the "contamination" stage, corresponding to concrete o p e r a t i o n a l thought, m u l t i p l e concrete, e x t e r n a l causes were mentioned. At the " i n t e r n a l i z a t i o n " stage, corresponding to more advanced concrete o p e r a t i o n a l thought, c a u s a l explanations of i l l n e s s became l o c a t e d i n s i d e the body. F i n a l l y , a t the " p h y s i o l o g i c a l " and " p s y c h o p h y s i o l o g i c a l " stages, corresponding to the attainment of formal o p e r a t i o n s , c h i l d r e n gave m u l t i p l e c a u s a l explanations of i l l n e s s , both concrete and a b s t r a c t , and i n c l u d e d the r o l e of the i n d i v i d u a l ' s behavior, thoughts, and f e e l i n g s i n c o n t r i b u t i n g to h e a l t h . In other words, w i t h i n c r e a s i n g c o g n i t i v e complexity, c h i l d r e n ' s understanding progressed from a view that i l l n e s s i s caused by e x t e r n a l , magical f a c t o r s , to a view that i n c o r p o r a t e s not only e x t e r n a l f a c t o r s but a l s o personal c o n t r o l i n - 34 -determining h e a l t h s t a t u s . S e v e r a l other i n v e s t i g a t i o n s , a l s o using a P i a g e t i a n model, have found s i m i l a r stages i n the development of c h i l d r e n ' s conceptions of i l l n e s s c a u s a l i t y (Brewster, 1982; P e r r i n & G e r r i t y , 1981; Simeonsson et a l . , 1979; Whitt, Dykstra, & T a y l o r , 1979). Taken together, these s t u d i e s provide strong evidence f o r the r o l e of c o g n i t i v e development i n c h i l d r e n ' s understanding of i l l n e s s c a u s a l i t y . A l s o , a developmental trend p a r a l l e l i n g c o g n i t i v e developmental changes has been documented regarding c h i l d r e n ' s concepts of h e a l i n g . Neuhauser, Amsterdarm, Hines, and Steward (1978) found t h a t personal c o n t r o l was i n c r e a s i n g l y mentioned i n c a u s a l explanations of h e a l i n g reported by more c o g n i t i v e l y complex s u b j e c t s . This f i n d i n g was r e p l i c a t e d by Caradang, F o l k i n s , Hines, and Stewart (1979). As w i t h the development of c h i l d r e n ' s understanding of i l l n e s s and h e a l i n g , developmental trends i n c h i l d r e n ' s understanding of pain have been t h e o r e t i c a l l y proposed. W i l l i s , E l l i o t t , and Jay (1982), perhaps s t a t i n g the obvious, suggest t h a t the m o t i v a t i o n a l - a f f e c t i v e , c o g n i t i v e - e v a l u a t i v e , and even s e n s o r y - d i s c r i m i n a t i v e components of pain discussed by Melzack (1973) must undergo maturational changes. D e s c r i p t i v e data r e l e v a n t to developmental d i f f e r e n c e s on the c o g n i t i v e - e v a l u a t i v e dimension of pain are provided by Beales et a l . (1983a). As p r e v i o u s l y noted, Beales et a l . observed t h a t t h e i r sample of 12 to 17 y e a r - o l d c h i l d r e n / a d o l e s c e n t s w i t h a r t h r i t i s not only reported sensory d e s c r i p t o r s of j o i n t s ensations, as d i d t h e i r sample of 6 to 11 y e a r - o l d s , but a d d i t i o n a l l y unanimously reported n e g a t i v e l y e v a l u a t i v e i n t e r p r e t a t i o n s of j o i n t s e nsations; a l l 12 to 17 year-olds reported t h a t the sensations reminded them of t h e i r d i s a b i l i t y c o n d i t i o n (Beales et a l . , 1983, p. 68). Developmental trends i n c h i l d r e n ' s concepts of p a i n , p a r a l l e l i n g changes i n c o g n i t i v e development have r e c e n t l y been documented by Gaffney and Dunne - 35 -(1986). These authors d i v i d e d t h e i r sample of 680 I r i s h school c h i l d r e n , aged 5 to 14 years, i n t o three age groups corresponding to the P i a g e t i a n stages of p r e - o p e r a t i o n a l , concrete o p e r a t i o n a l , and formal o p e r a t i o n a l t h i n k i n g . D e f i n i t i o n s of pain given by c h i l d r e n i n the age group corresponding t o p r e o p e r a t i o n a l t h i n k i n g tended to centre on p e r c e p t u a l l y dominant, p h y s i c a l f a c t o r s . C h i l d r e n i n the age group corresponding to concrete operations began to use analogies i n t h e i r d e s c r i p t i o n s of p a i n , and r e p o r t e d l y demonstrated a developing awareness of the p s y c h o l o g i c a l concomitants of pain (e.g., i t s a b i l i t y to a f f e c t the mood of the s u f f e r e r ) . F i n a l l y , c h i l d r e n i n the age group corresponding to formal o p e r a t i o n a l thought gave d e f i n i t i o n s of pain which i n c l u d e d both a p h y s i c a l and a p s y c h o l o g i c a l component. C h i l d r e n i n t h i s l a t t e r group r e p o r t e d l y viewed pain more a c t i v e l y ; they tended to define pain as something which has to be coped w i t h , d e a l t w i t h , or borne (Gaffney & Dunne, 1986). These f i n d i n g s of developmental d i f f e r e n c e s corresponding to P i a g e t i a n stages of c o g n i t i v e development stand i n c o n t r a s t to the e a r l i e r negative f i n d i n g s of Ross and Ross (1984). In t h e i r l a r g e s c a l e i n t e r v i e w study w i t h 994 c h i l d r e n aged 5 to 12 years, Ross and Ross (1984) found no s i g n i f i c a n t age trends i n c h i l d r e n ' s d e f i n i t i o n s of p a i n . Apart from p l a y i n g a r o l e i n c h i l d r e n ' s c o n c e p t u a l i z a t i o n s of i l l n e s s , h e a l i n g , and p a i n , l e v e l of c o g n i t i v e development may a l s o l i m i t c h i l d r e n ' s understanding of the i n t e n t of medical procedures. Brewster (1982) found three stages i n the development of c h r o n i c a l l y i l l c h i l d r e n ' s understanding of the i n t e n t of medical procedures. In the f i r s t stage, c h i l d r e n tended to view procedures as punishment, i n the second, procedures were c o r r e c t l y perceived, but c h i l d r e n expressed a b e l i e f t h a t the s t a f f ' s empathy depended on the p a t i e n t s ' expression of p a i n . In the t h i r d stage, c h i l d r e n c o r r e c t l y i n f e r r e d both i n t e n t of the medical procedure and u n c o n d i t i o n a l empathy of the medical s t a f f (Brewster, 1982). - 36 -Beales, Lennox H o l t , Keen, and M a l l o r (1983b), i n t h e i r i n t e r v i e w study of 75 c h i l d r e n w i t h JRA, found a s i m i l a r i n c r e a s e i n c h i l d r e n ' s understanding of the purpose of physiotherapy treatments, w i t h i n c r e a s i n g age. Few of the younger c h i l d r e n i n t h e i r sample (7-11 years) demonstrated a p p r e c i a t i o n t h a t treatments which caused unpleasant sensations could have long term b e n e f i t s . In f a c t , 38% of the 7-11 year o l d s b e l i e v e d physiotherapy made t h e i r a r t h r i t i s worse, s i n c e moving inflamed j o i n t s c r e a tes discomfort. Older c h i l d r e n (12-17), on the other hand, were g e n e r a l l y able to appreciate the b e n e f i t of physiotherapy treatments upon i n t e r n a l pathology, and tended to t h i n k t h a t to be e f f e c t i v e , treatment needs to be unpleasant (Beales e t a l . , 1983b). Jay, D z o l i n s , E l l i o t t , and C a l d w e l l (1983) present data i n d i c a t i n g t h a t developmental changes i n c h i l d r e n ' s understanding of the i n t e n t of medical procedures, such as those c i t e d above, i n t u r n , can impact on c h i l d r e n ' s b e h a v i o r a l responses to procedures ( s p e c i f i c a l l y " d i s t r e s s " b e h a v i o r s ) . In t h e i r study of c h i l d r e n w i t h cancer, Jay et a l . (1983) found t h a t c h i l d r e n over 7 years of age demonstrated f i v e times l e s s " d i s t r e s s " behaviors than younger c h i l d r e n . As noted by the authors, such a dramatic drop i n the r a t e of " d i s t r e s s " behaviors at approximately age 7 suggests the involvement of a cognitive-developmental f a c t o r . (Note: Most c h i l d r e n above age 7 would have a t t a i n e d at l e a s t concrete o p e r a t i o n a l t h i n k i n g . ) In summary then, changes i n c h i l d r e n ' s understanding of i l l n e s s , h e a l i n g , p a i n , and medical procedures correspond w i t h changes i n c o g n i t i v e development. With i n c r e a s i n g c o g n i t i v e complexity, beginning a t the P i a g e t i a n stage of concrete operations, c h i l d r e n become i n c r e a s i n g l y aware of the p s y c h o l o g i c a l f a c t o r s a s s o c i a t e d w i t h i l l n e s s (e.g., Bibace & Walsh, 1979) and pain (Gaffney & Dunne, 1986), and are able to understand the i n t e n t of medical procedures (Beales et a l . , 1983; Brewster, 1982). As w e l l , c h i l d r e n become i n c r e a s i n g l y aware of personal c o n t r o l c a p a c i t i e s a s s o c i a t e d w i t h h e a l i n g - 37 -(Neuhauser et a l . , 1978), and coping w i t h pain (Gaffney & Dunn, 1986). An i n c r e a s i n g l y s o p h i s t i c a t e d awareness of i l l n e s s , p a i n , and the i n t e n t of p a i n f u l medical procedures, i n combination w i t h the c a p a c i t y to understand the r o l e of one's own i n f l u e n c e on h e a l i n g or coping w i t h pain seems to l e a d to i n c r e a s i n g l y adaptive s t y l e s of coping i n c h i l d r e n (Jay et a l . , 1983). Since the data, reviewed above, regarding c h i l d r e n ' s l e v e l of c o g n i t i v e development and understanding of i l l n e s s and p a i n , and how to cope w i t h them are c o r r e l a t i o n a l i n nature, a c a u s a l connection or an e x p l a n a t i o n of s p e c i f i c c a u s a l mechanisms that may account f o r t h a t r e l a t i o n remain s p e c u l a t i v e . Most authors f i n d i n g age d i f f e r e n c e s have used a P i a g t i a n model i n d i s c u s s i n g t h e i r r e s u l t s . According to P i a g e t i a n theory, i n the p r e o p e r a t i o n a l period ( g e n e r a l l y 2-7 years of age), c h i l d r e n tend to focus on only those f e a t u r e s of a s i t u a t i o n t h a t are p e r c e p t u a l l y dominant, and t h e i r concepts of c a u s a l i t y are phenomenistic (based on c o n t i g u i t y i n time or space). In c o n t r a s t , concrete o p e r a t i o n a l c h i l d r e n ( g e n e r a l l y 8-10 years of age) can focus on, and i n t e r r e l a t e s e v e r a l aspects of a s i t u a t i o n simultaneously, and have some a b i l i t y to understand c a u s a l r e l a t i o n s i n a more r e a l i s t i c way. At t h i s stage of c o g n i t i v e development, egocentrism i n thought d e c l i n e s , and a t r a n s i t i o n toward a b s t r a c t t h i n k i n g a b i l i t y i s b e l i e v e d to occur. I t i s not u n t i l the attainment of formal operations ( g e n e r a l l y at about age 12) t h a t c h i l d r e n become capable of understanding purely a b s t r a c t concepts and are able to make r e a l i s t i c c a u s a l connections. Causal reasoning a b i l i t y i s one s p e c i f i c aspect of c o g n i t i v e development which has been demonstrated to account f o r q u a l i t a t i v e and q u a n t i t a t i v e d i f f e r e n c e s seen i n c h i l d r e n ' s understanding of i l l n e s s (Bibace & Walsh, 1980; Simeonsson et a l . , 1979). A second s p e c i f i c aspect of c o g n i t i v e development which may be key i n e x p l a i n i n g the l i n k between c o g n i t i v e development and concepts of i l l n e s s , pain and coping, i s the development of metacognition. - 38 -Metacognition i s defined by F l a v e l l (1981) as "knowledge or c o g n i t i o n t h a t takes as i t s object or r e g u l a t e s any aspect of any c o g n i t i v e endeavor", o r , more simply " c o g n i t i o n about c o g n i t i o n " (p. 37). As pointed out by Reeve and Brown (1985), "metacognition" i s a metaconstruct which has been defined too many ways i n the c l i n i c a l l i t e r a t u r e . As used i n the c l i n i c a l l i t e r a t u r e , metacognition g l o b a l l y r e f e r s to the a b i l i t y of the c o g n i t i v e system to s e l f - m o n i t o r and s e l f - r e g u l a t e c o g n i t i v e a c t i v i t y (Reeve & Brown, 1985). There i s a need, then, to f u r t h e r s p e c i f y the p a r t i c u l a r type of metacognition which seems r e l e v a n t to the development of c h i l d r e n ' s understanding of i l l n e s s , pain and coping. Selman's (1980) d e s c r i p t i o n of c h i l d r e n ' s developing c a p a c i t y f o r awareness of t h e i r own p s y c h o l o g i c a l processes seems a p p l i c a b l e . According to Selman (1980), the c a p a c i t y f o r self-awareness progresses from an i n i t i a l l e v e l at which awareness of the d i f f e r e n c e between the "inner s e l f " or p s y c h o l o g i c a l processes and "outer experience" i s very l i m i t e d , to a second l e v e l at which i n t r o s p e c t i o n or awareness of t h e i r own p s y c h o l o g i c a l processes i s p o s s i b l e . Selman (1980) emphasizes the r o l e of c h i l d r e n ' s s o c i a l p e r s p e c t i v e t a k i n g a b i l i t y i n h i s e x p l a n a t i o n of developing awareness of p s y c h o l o g i c a l processes. He r e f e r s to the p r e r e q u i s i t e a b i l i t y to put oneself i n the place of a second person and look back on one's own p s y c h o l o g i c a l s t a t e s (p. 98). Preadolescent c h i l d r e n have been shown to have t h i s " l e v e l 2" a b i l i t y to be aware of t h e i r own p s y c h o l o g i c a l processes', but more complex, s o p h i s t i c a t e d awareness ( l e v e l s 3 and A) develop i n adolescence (Selman, 1980). These f i n d i n g s are c o n s i s t e n t w i t h F l a v e l l ' s (1979) f i n d i n g s t h a t other r e l a t e d types of metacognitive a b i l i t y ( i n p a r t i c u l a r "metamemory") begin to emerge i n middle childhood. In summary, the connection between c o g n i t i v e development and c h i l d r e n ' s a b i l i t y to understand and cope w i t h i l l n e s s and pain remains s p e c u l a t i v e . The - 39 -P i a g e t i a n model, which i n c o r p o r a t e s an e x p l a n a t i o n of the development of c a u s a l understanding and the a b i l i t y to t h i n k a b s t r a c t l y , seems a p p l i c a b l e , but more research s p e c i f i c a l l y e x p l o r i n g the connection i s needed. F u r t h e r , the development of metacognitive a b i l i t y may w e l l prove to be a key c o g n i t i v e developmental v a r i a b l e i n e x p l a i n i n g d i f f e r e n c e s i n the coping a b i l i t i e s of c h i l d r e n . E f f e c t i v e n e s s of coping s t r a t e g i e s used by c h i l d r e n . Perhaps even more important than r e s o l v i n g the debate regarding developmental trends i n c h i l d r e n ' s spontaneous coping s t r a t e g i e s i s the need to e m p i r i c a l l y evaluate the e f f e c t i v e n e s s of s p e c i f i c s t r a t e g i e s . The f i n d i n g t h a t c h i l d r e n of a c e r t a i n age are capable of using c e r t a i n s t r a t e g i e s does not n e c e s s a r i l y i n d i c a t e age d i f f e r e n c e s i n coping outcome ( i . e . , the a b i l i t y to cope w e l l w i t h p a i n ) . As p r e v i o u s l y noted, no s i n g l e coping s t r a t e g y has been i d e n t i f i e d as i n h e r e n t l y e f f e c t i v e w i t h a d u l t s (Turk et a l . , 1983). The c u r r e n t l i t e r a t u r e provides very l i t t l e i n f o r m a t i o n regarding the e f f e c t i v e n e s s of c h i l d r e n ' s coping s t r a t e g i e s . Both Brown et a l . (1986) and H u n t - F i t z g e r a l d and L i d d e l l (1985) incorp o r a t e d s e l f - r e p o r t measures of a n x i e t y to provide an i n i t i a l e v a l u a t i o n of the e f f e c t i v e n e s s of s p e c i f i c types of c o g n i t i v e coping s t r a t e g i e s . Their r e s u l t s i n d i c a t e a s i g n i f i c a n t negative c o r r e l a t i o n between "coping" or " p o s i t i v e " c o g n i t i o n s and a n x i e t y , and a p o s i t i v e c o r r e l a t i o n between " c a t a s t r o p h i z i n g " or "negative" c o g n i t i o n s and a n x i e t y . These r e s u l t s are c o n s i s t e n t w i t h i n d i c a t i o n s from the a d u l t l i t e r a t u r e of a l i n k between c a t a s t r o p h i z i n g thoughts and maladaptive or l e s s e f f e c t i v e coping w i t h pain (Reesor & C r a i g , 1987). As p r e v i o u s l y mentioned, however, shared method variance may have s p u r i o u s l y i n f l a t e d the c o r r e l a t i o n a l f i n d i n g s of Brown et a l . (1986) and H u n t - F i t z g e r a l d and L i d d e l l (1985). In order to evaluate the e f f e c t i v e n e s s of c h i l d r e n ' s coping s t r a t e g i e s , a c l e a r d e f i n i t i o n of e f f e c t i v e coping must f i r s t be made. Neither Brown et a l . - 40 -(1986) nor H u n t - F i t z g e r a l d and L i d d e l l (1985) e x p l a i n t h e i r assumed l i n k between low a n x i e t y r a t i n g s and e f f e c t i v e coping. McGrath et a l . (1985) t h e o r e t i c a l l y d e fine e f f e c t i v e coping w i t h pain as l i m i t i n g a c t i v i t i e s somewhat during severe bouts of pain but c o n t i n u i n g w i t h normal a c t i v i t i e s when only experiencing moderate p a i n . An example of "noncoping", given by these authors, i s avoidance of a c t i v i t i e s because of the p r e d i c t e d p o s s i b i l i t y t h a t they may cause pain. Dunn-Geier, McGrath, Rourke, L a t t e r , and D'Astous (1986) used a s i m i l a r d e f i n i t i o n of e f f e c t i v e coping i n t h e i r a n a l y s i s of adolescents' a b i l i t y to cope w i t h c h r o n i c p a i n . They d i v i d e d a sample of adolescents s u f f e r i n g from three types of c h r o n i c pain i n t o "copers" and "noncopers". Subjects were c l a s s i f i e d as "noncopers" i f they had missed three or more days of school each month f o r the past two months because of p a i n , and were c o n t i n u i n g to miss sc h o o l . They were matched on age, sex and l o c a t i o n of pain (knee, stomache, or headache). Subjects p a r t i c i p a t e d i n a 15 minute e x e r c i s e task chosen t o simulate d a i l y a c t i v i t i e s which normally t r i g g e r p a i n , and the i n t e r a c t i o n between mothers and adolescents during t h i s task was coded. Results i n d i c a t e d that adolescents c l a s s i f i e d as "noncopers" engaged i n s i g n i f i c a n t l y more "negative behaviour", "pain e x p r e s s i o n " and " o f f - t a s k behaviour"; they were much more l i k e l y than "copers" to express anger, r e f u s a l or discouragement, to complain of p a i n , or to noncomply w i t h the p a i n - e l i c i t i n g t a s k . Since these are a l l behaviours which could be used to change the p a i n - e l i c i t i n g s i t u a t i o n ( i e . mothers tended to discourage the p e r s i s t e n c e of "noncopers" w i t h e x e r c i s e s , perhaps out of sympathy), i t can be argued that these behaviours are a c t u a l l y coping s t r a t e g i e s . "Negative behaviour", "pain e x p r e s s i o n " and " o f f - t a s k behaviour", based on Dunn-Geier et a l . ' s (1986) r e s u l t s , seem to be i n e f f e c t i v e coping s t r a t e g i e s , - A l -sinc e they are a s s o c i a t e d w i t h "noncoping" (defined as excessive school absence because of p a i n ) . Further research i s needed to evaluate the e f f e c t i v e n e s s of these behavioural coping s t r a t e g i e s i n other s i t u a t i o n s . In a d d i t i o n , many other behavioural s t r a t e g i e s and c o g n i t i v e s t r a t e g i e s used by c h i l d r e n remain i n need of e v a l u a t i o n . In summarizing the c h i l d coping l i t e r a t u r e , data from s t u d i e s employing q u e s t i o n n a i r e s , i n t e r v i e w s , drawings, i m a g i n a l r e c o n s t r u c t i o n and i n v i v o observations i n d i c a t e the f o l l o w i n g : (1) C h i l d r e n as young as 5 years are aware of spontaneous s t r a t e g i e s to cope w i t h pain (Jeans & Gordon, 1981, as c i t e d i n Jeans, 1983; J e r r e t t , 1985; R e i s s l a n d , 1983; Ross & Ross, 198Ab); (2) Reports of s p e c i f i c types of c o g n i t i v e coping s t r a t e g i e s have been documented i n c h i l d r e n as young as 8 years (Brown, i n press; Curry & Russ, 1985); and (3) Beh a v i o r a l coping s t r a t e g i e s have been observed i n c h i l d r e n as young as 8 years (Curry & Russ, 1985). Some, but not a l l (Ross & Ross, 198Ab), s t u d i e s r e p o r t a developmental trend i n c h i l d r e n ' s spontaneous coping s t r a t e g i e s (Curry & Russ, 1985; Jeans & Gordon, 1981; R e i s s l a n d , 1983). E m p i r i c a l e v a l u a t i o n of the r e l a t i o n s h i p between c h i l d r e n ' s use of s p e c i f i c coping s t r a t e g i e s and t h e i r a b i l i t y to cope e f f e c t i v e l y w i t h pain i s c u r r e n t l y l i m i t e d . Coping w i t h A r t h r i t i c P a i n As i s the general trend i n the c h i l d coping l i t e r a t u r e as a whole, very l i t t l e sound e m p i r i c a l data c u r r e n t l y e x i s t regarding s t r a t e g i e s used by c h i l d r e n and adolescents to cope w i t h a r t h r i t i c p a i n . The published l i t e r a t u r e contains only one case example of a coping s k i l l treatment w i t h a hemophilic c h i l d e xperiencing a r t h r i t i c pain ( V a r n i , G i l b e r t , & D i e t r i c h , 1981), as w e l l as the d e s c r i p t i v e data provided by Beales e t a l . (1983a,b) and - 42 -i n d i r e c t l y r e l e v a n t comments provided by Ross and Ross (1984b) i n t h e i r i n v e s t i g a t i o n of pain i n c h i l d r e n . The r e l e v a n t a d u l t l i t e r a t u r e i s somewhat more developed. A d u l t s ' S t r a t e g i e s f o r Coping with A r t h r i t i c P a i n . Treatment s t u d i e s done w i t h a d u l t RA p a t i e n t s i n d i c a t e the e f f e c t i v e n e s s of taught c o g n i t i v e - b e h a v i o r a l s k i l l s f o r coping w i t h p a i n . At present, i s o l a t e d e v a l u a t i o n of s p e c i f i c coping s t r a t e g i e s i s not p o s s i b l e , however, si n c e treatments have t y p i c a l l y i n v o l v e d m u l t i p l e components, such as education, coping s k i l l s t r a i n i n g , reinforcement of appropriate coping behavior and methods to boost s e l f - e f f i c a c y (Bradley, 1985). For example, a recent thorough and w e l l - c o n t r o l l e d study by O'Leary (1986) i n d i c a t e s t h a t a combination of taught c o g n i t i v e and b e h a v i o r a l coping s t r a t e g i e s i n c l u d i n g r e l a x a t i o n , guided imagery, a t t e n t i o n r e f o c u s i n g , d i s s o c i a t i o n , r e l a b e l i n g , and self-encouragement was s i g n i f i c a n t l y r e l a t e d to enhanced s e l f - e f f i c a c y , reduced pain and j o i n t inflammation and improved p s y c h o s o c i a l f u n c t i o n i n g i n a d u l t RA p a t i e n t s . S i m i l a r l y , Bradley et a l . (1985) have demonstrated c o g n i t i v e behavior therapy to be more e f f e c t i v e than s o c i a l support or a no treatment c o n t r o l c o n d i t i o n , having an impact not only on s e l f - r e p o r t e d pain i n t e n s i t y , but a l s o on pain behavior and disease a c t i v i t y l e v e l . Case study f i n d i n g s w i t h two a d u l t p a t i e n t s e x p e r i e n c i n g a r t h r i t i c p a in a s s o c i a t e d w i t h hemophilia ( V a r n i , 1981a) a l s o i n d i c a t e that " s e l f - r e g u l a t i o n t r a i n i n g " , i n v o l v i n g r e l a x a t i o n , meditative b r e a t h i n g , and pain reducing imagery r e s u l t e d i n " c l i n i c a l l y s i g n i f i c a n t " decrements i n the s k i n temperature at a r t h r i t i c j o i n t s . A more methodologically sound follow-up case study of three a d u l t p a t i e n t s w i t h hemophilia ( V a r n i , 1981b) i n d i c a t e d a decrease i n weekly average pain i n t e n s i t y r a t i n g s (0-10 s c a l e ) from 5.1 during b a s e l i n e monitoring to 2.2 at follow-up. Only one r e c e n t l y published study i n v e s t i g a t i n g a d u l t s ' spontaneous - 43 -s t r a t e g i e s f o r coping w i t h a r t h r i t i c pain appears i n the l i t e r a t u r e a t present. This study by Keefe et a l . (1987) i n v e s t i g a t e d the spontaneous coping s t r a t e g i e s used by a sample of 51 a d u l t s to cope w i t h o s t e o a r t h r i t i s p a i n . The Coping Strategy Questionnaire (CSQ) developed by R o s e n s t e i l and Keefe (1983) was used as a measure of s e l f - r e p o r t e d coping s t r a t e g y use. I t was revealed t h a t one of the two f a c t o r s e x t r a c t e d from the CSQ data y i e l d e d i n t h i s sample ( r e f e r r e d to by the authors as " P a i n - C o n t r o l and R a t i o n a l Thinking") s i g n i f i c a n t l y d i s c r i m i n a t e d between a subgroup of o s t e o a r t h r i t i s p a t i e n t s w i t h what Reesor and C r a i g (1967) have termed m e d i c a l l y incongruent symptoms (pain r e p o r t s i n c o n s i s t e n t w i t h disease s t a t u s measures) versus a subgroup not demonstrating such symptoms. A n a l y s i s of the separate coping subtypes from the CSQ i n c o r p o r a t e d i n the " P a i n - C o n t r o l and R a t i o n a l T h i n k i n g " f a c t o r revealed t h a t the c a t a s t r o p h i z i n g subscale was loaded n e g a t i v e l y and s e l f - r a t e d a b i l i t y to c o n t r o l decrease pain loaded p o s i t i v e l y . Keefe et a l . ' s (1987) f i n d i n g s are t h e r e f o r e c o n s i s t e n t w i t h previous r e s u l t s i n the general a d u l t pain/coping l i t e r a t u r e p o i n t i n g to not only the r o l e of coping a b i l i t y , but a l s o l a c k of c a t a s t r o p h i z i n g c o g n i t i o n s i n e f f e c t i v e coping (Reesor & C r a i g , 1987; Spanos et a l . , 1979; Turner & Clancy, 1987). In a d d i t i o n to d i s c r i m i n a t i n g between a d u l t o s t e o a r t h r i t i s p a t i e n t s whose pain r e p o r t s are m e d i c a l l y congruent versus m e d i c a l l y incongruent, the " P a i n - C o n t r o l and R a t i o n a l T h i n k i n g " f a c t o r e x t r a c t e d from the CSQ data i n Keefe et a l . ' s (1987) sample a l s o explained s i g n i f i c a n t p r o p o r t i o n s of the variance i n the two pain r e p o r t measures used: i n c l u d e d : (1) a t o t a l score c a l c u l a t e d by summing the number of pain d e s c r i p t o r s endorsed from the MPQ, and (2) the pain s c a l e from the A r t h r i t i s Impact Measurement Scale (AIMS). The " P a i n - C o n t r o l and R a t i o n a l T h i n k i n g " f a c t o r emerged as a s i g n i f i c a n t p r e d i c t o r of pain measured these two ways, even a f t e r f i r s t e n t e r i n g demographic v a r i a b l e s (age and sex) and medical s t a t u s v a r i a b l e s (disease - 44 -s e v e r i t y , o b e s i t y s t a t u s , d i s a b i l i t y payments r e c e i v e d , and c h r o n i c i t y of pain) i n the h i e r a r c h i c a l r e g r e s s i o n a n a l y s i s . This f i n d i n g i s c o n s i s t e n t w i t h the l i n k between coping s t r a t e g y use and decreased pain r a t i n g s documented i n the general a d u l t pain/coping l i t e r a t u r e (e.g., Turk et a l . , 1983). C h i l d r e n ' s S t r a t e g i e s f o r Coping w i t h A r t h r i t i c P a i n . Only one case study e v a l u a t i n g the e f f e c t i v e n e s s of taught c o g n i t i v e - b e h a v i o u r a l s k i l l s f o r coping w i t h a r t h r i t i s pain i n c h i l d r e n has been published to date. V a r n i et a l . (1981) re p o r t a case example of a 9-year-old hemophilic boy who was e x p e r i e n c i n g bleeding and a r t h r i t i c pain i n h i s lower e x t r e m i t i e s . At b a s e l i n e , t h i s boy gave an average pain i n t e n s i t y r a t i n g of 7 on a s c a l e of 0 to 10, and he was wheelchair bound 50% of the time. Once he learned to use the same coping s t r a t e g i e s taught to a d u l t hemophilic p a t i e n t s ( V a r n i , 1981a; V a r n i , 1981b), he reported increased m o b i l i t y , school attendance incre a s e d , number of h o s p i t a l i z a t i o n s decreased, and at a follow-up assessment one year l a t e r , he gave average pain i n t e n s i t y r a t i n g s of 2. No systematic data regarding spontaneous s t r a t e g i e s used by c h i l d r e n w i t h a r t h r i t i s to cope w i t h pain appear i n the l i t e r a t u r e a t present. Informal observations r e l e v a n t to coping are, however, made i n s e v e r a l i n v e s t i g a t i o n s of a r t h r i t i c pain i n c h i l d r e n : F i r s t , Ross and Ross (1984b), as part of t h e i r l a r g e i n t e r v i e w study a s s e s s i n g pain and coping i n c h i l d r e n , note t h a t the coping s t r a t e g i e s described by t h e i r subsample of nine c h i l d r e n w i t h v a r i o u s forms of a r t h r i t i s c o n s i s t e d of "knowing the p h y s i c a l p a i n - f r e e l i m i t s , keeping w i t h i n them, and r e f u s i n g to a l l o w oneself to become depressed about the l i m i t a t i o n s of a c t i v i t y " (Ross & Ross, 1984b, p. 187). Secondly, Beales et a l . (1983a) found t h a t t h e i r sample of o l d e r c h i l d r e n w i t h JRA (12-17 years) unanimously reported that j o i n t sensations t r i g g e r e d thoughts about the unpleasant i m p l i c a t i o n s of a r t h r i t i s (e.g., d i s a b i l i t y ) . - 45 -The authors i n c l u d e d i r e c t quotes from a few sub j e c t s which are r e l e v a n t to coping. For example, they i n c l u d e the f o l l o w i n g quote by a 15-year-old g i r l whose response was r e p o r t e d l y t y p i c a l of many 12-17 year-olds i n t h e i r sample: " I hate i t when i t hurts l i k e t h a t , because i t reminds me of a l l the t h i n g s I can't do." (Beales et a l . , 1983a, p. 63). Beales et a l . (1983a) argue that s i n c e older c h i l d r e n are able to understand the i n t e r n a l pathology and the p o s s i b l e long term i m p l i c a t i o n s of a r t h r i t i s , they are more capable of experiencing i l l n e s s - r e l a t e d p e s s i m i s t i c thoughts ( c a t a s t r o p h i z i n g ) . Together w i t h the f i n d i n g s of Ross and Ross (1984b), the Beales et a l . (1983) f i n d i n g s provide a h i n t as to the coping s t r a t e g i e s used by some c h i l d r e n w i t h a r t h r i t i c p a i n . At l e a s t some of these c h i l d r e n apparently cope by l i m i t i n g a c t i v i t i e s t h a t cause p a i n , and many c h i l d r e n o l d e r than 12, w i t h JRA, rep o r t experiencing c a t a s t r o p h i z i n g thoughts a s s o c i a t e d w i t h p a i n . The R e l a t i o n s h i p between f u n c t i o n a l d i s a b i l i t y and coping w i t h a r t h r i t i c  p a i n . F u n c t i o n a l d i s a b i l i t y , defined as impairment i n a c t i v i t i e s of d a i l y l i v i n g (ADL), i s a frequent consequence of a r t h r i t i s i n a d u l t s (Bradley, 1985). I t i s the most f r e q u e n t l y used outcome c r i t e r i a to evaluate the e f f e c t i v e n e s s o f , or need f o r some form of s e r v i c e or therapy. F r i e s , S p i t z , K r a i n e s , and Holman (1980) emphasize the need to d i s t i n g u i s h "outcome" measures, such as f u n c t i o n a l d i s a b i l i t y from d i s e a s e - r e l a t e d "process" measures (e.g., degree of a c t i v e inflammation). Although disease a c t i v i t y i s r e l a t e d to f u n c t i o n a l d i s a b i l i t y , changes can p o t e n t i a l l y occur i n one without corresponding, or proportionate changes i n the other. For example, changes i n f u n c t i o n a l d i s a b i l i t y can be r e l a t e d to p s y c h o l o g i c a l f a c t o r s (e.g., coping s t r a t e g y use) or other p h y s i c a l f a c t o r s not d i r e c t l y r e l a t e d t o disease a c t i v i t y (e.g., e x e r c i s e or physiotherapy) (Liang & J e t t e , 1981; Steinb r o c k e r , Traeger, & Batterman, 1949). Measures of f u n c t i o n a l d i s a b i l i t y most f r e q u e n t l y used i n the a d u l t - 46 -rheumatology l i t e r a t u r e are the d i s a b i l i t y s c a l e s i n c l u d e d i n the d i s a b i l i t y s c a l e s i n c l u d e d i n the Health Assessment Questionnaire (HAQ; F r i e s , S p i t z , & Young, 1982), A r t h r i t i s Impact Measurement Scale (AIMS; Meenan, Gertman, & Mason, 1980), and Sickness Impact P r o f i l e (SIP; Bergner, B o b b i t t , C a r t e r , & G i l s o n , 1981). A g l o b a l c l i n i c a l judgment of f u n c t i o n a l d i s a b i l i t y i s made i n some cases using the American Rheumatism A s s o c i a t i o n f u n c t i o n a l c l a s s i f i c a t i o n ( S teinbrocker et a l . , 1949). Sev e r a l i n v e s t i g a t o r s have noted the i n t e r r e l a t i o n between s e l f - r e p o r t e d p a i n , d i s e a s e - r e l a t e d v a r i a b l e s (e.g., medication use) and f u n c t i o n a l d i s a b i l i t y . Roberts, Bennett, and Smith (1986), f o r example, found s e l f - r e p o r t e d f u n c t i o n a l d i s a b i l i t y to be s i g n i f i c a n t l y c o r r e l a t e d w i t h pain r e p o r t i n a d u l t s w i t h a r t h r i t i s . S i m i l a r l y , K a z i s , Meenan, and Anderson (1983) recorded s e l f - r e p o r t e d f u n c t i o n a l d i s a b i l i t y , pain and medication use i n a d u l t p a t i e n t s w i t h RA over a six-month p e r i o d . R e s u l t s revealed t h a t pain reported at the s t a r t of the study was a more s t a t i s t i c a l l y s i g n i f i c a n t p r e d i c t o r of f u n c t i o n a l d i s a b i l i t y and l e v e l of pain s i x months l a t e r , than was medication use. F u r t h e r , N i c a s s i o et a l . (1985) have found f u n c t i o n a l d i s a b i l i t y i n a d u l t a r t h r i t i s p a t i e n t s to be r e l a t e d to f e e l i n g s of personal h e l p l e s s n e s s . M i l l e r , S p i t z , Simpson, and W i l l i a m s (1982) r e p o r t d e s c r i p t i v e data using the f u n c t i o n a l d i s a b i l i t y index s c a l e from the Health Assessment Questionnaire i n a follow-up study of a d u l t s who had a r t h r i t i s ( e i t h e r JRA or JAS) as c h i l d r e n . A d u l t s i n t h i s sample were found to be f u n c t i o n i n g w e l l on average; only 13 of 82 had d i s a b i l i t y index scores greater than 1 on a 0 to 3 s c a l e . Subjects' age, type of a r t h r i t i s , and d u r a t i o n of disease were not s i g n i f i c a n t l y r e l a t e d to present f u n c t i o n a l d i s a b i l i t y index scores, although continued j o i n t pain and r e c u r r e n t j o i n t s w e l l i n g i n t o adulthood were s t a t i s t i c a l l y s i g n i f i c a n t l y r e l a t e d to present f u c n t i o n a l d i s a b i l i t y . - 47 -To date, none of the f u n c t i o n a l d i s a b i l i t y measures developed f o r use w i t h a d u l t a r t h r i t i s p a t i e n t s have been adapted f o r use w i t h c h i l d r e n / a d o l e s c e n t s below the age of 18 years. V a r n i et a l . (1986), i n t h e i r study of pain i n c h i l d r e n and adolescents (4-16 years) w i t h JRA, i n c o r p o r a t e d a question from the PPQ asking mothers to r a t e the degree t o which pain i n t e r f e r e d w i t h a number of s p e c i f i e d a c t i v i t i e s (e.g., school attendance, s l e e p i n g , a p p e t i t e ) . Although the a c t i v i t i e s l i s t e d were not the same as a c t i v i t i e s of d a i l y l i v i n g g e n e r a l l y i n c l u d e d i n f u n c t i o n a l d i s a b i l i t y s c a l e s used w i t h a d u l t s (e.g., grooming, walking, r e c l i n i n g ) , t h i s question could be viewed as a type of f u n c t i o n a l d i s a b i l i t y measure. For d e s c r i p t i v e purposes, response options were coded i n t o the f o l l o w i n g three c a t e g o r i e s : Yes, No, or Sometimes. Re s u l t s i n d i c a t e d t h a t 65% of mothers s a i d t h a t t h e i r c h i l d ' s pain i n t e r f e r e d w i t h " s p o r t s " . For the item " a p p e t i t e " , 44% s a i d i t i n t e r f e r e d , f o r " s l e e p " -43%, " f a v o u r i t e a c t i v i t i e s " - 31%, "school attendance - 22%, and " u n l i k e d a c t i v i t i e s " - 17% of mothers s a i d t h e i r c h i l d ' s pain i n t e r f e r e d . Therefore, pain experienced by some, but not a l l JRA's (according to maternal estimates) i n t e r f e r e s w i t h a number of normal a c t i v i t i e s . I n d i v i d u a l v a r i a b i l i t y e x i s t s i n the degree of l i m i t a t i o n of a c t i v i t i e s caused by p a i n . A recent i n v e s t i g a t i o n conducted by McCormick, Stemmler and Athreya (1986) provides evidence supporting the use of reported i n t e r f e r e n c e w i t h a c t i v i t i e s of d a i l y l i v i n g as an outcome measure f o r c h i l d r e n w i t h a r t h r i t i s . These i n v e s t i g a t o r s conducted a telephone survey w i t h the parents of 138 p e d i a t r i c p a t i e n t s at the P e d i a t r i c Rheumatology Centre of the C h i l d r e n ' s H o s p i t a l of P h i l a d e l p h i a . C h i l d r e n were r e c e i v i n g ongoing followup due to a c t i v e a r t h r i t i s . R e s u l t s revealed that the number of the c h i l d ' s a c t i v i t i e s of d a i l y l i v i n g l i m i t e d by i l l n e s s was the most s t a t i s t i c a l l y s i g n i f i c a n t p r e d i c t o r of high f a m i l y impact of the disease (more s i g n i f i c a n t than the c h i l d ' s s p e c i f i c d i a g n o s i s ) . I n t e r f e r e n c e w i t h a c t i v i t i e s of d a i l y l i v i n g was - 48 -measured i n t h i s study by mothers' responses to questions taken from the Rand Health Insurance Study C h i l d Health Questionnaire ( E i s e n , Donald, Ware, & Brook, 1980). Family impact was measured usi n g a parent-report s c a l e developed by S t e i n and Reissman (1980). Purpose and Hypotheses The present i n v e s t i g a t i o n had three main purposes: I . Age/Cognitive Developmental D i f f e r e n c e s i n Self-Reported P a i n . The f i r s t purpose was to assess age group/cognitive developmental d i f f e r e n c e s i n VAS pain i n t e n s i t y r a t i n g s made, and pain d e s c r i p t o r s endorsed by c h i l d r e n and adolescents w i t h a r t h r i t i s . The f o l l o w i n g s p e c i f i c hypotheses regarding s e l f - r e p o r t e d pain were made, a p r i o r i , on the b a s i s of previous research: (1) I t was p r e d i c t e d that the age groups would not d i f f e r s i g n i f i c a n t l y on present pain i n t e n s i t y r a t i n g s because the p a i n - e l i c i t i n g s t i mulus used (standardized range of motion task) i s one which previous research has shown to be uniformly p a i n f u l f o r s u b j e c t s of d i f f e r e n t ages (Laaksonen & Laine, 1961). (%: M± = M 2 = M 3) (2) A successive s i g n i f i c a n t i n c r e a s e i n number of a f f e c t i v e and e v a l u a t i v e pain d e s c r i p t o r s endorsed was expected between age groups (H2: < M2 < M3). This p r e d i c t i o n i s c o n s i s t e n t w i t h Gaffney and Dunne's (1986) f i n d i n g s of successive increases i n c h i l d r e n ' s awareness of the p s y c h o l o g i c a l concomitants of pa i n , corresponding w i t h P i a g e t i a n c o g n i t i v e developmental stages. P r e d i c t e d age d i f f e r e n c e s i n the use of a f f e c t i v e or e v a l u a t i v e terms to describe pain a l s o f o l l o w from the Beales et a l . (1983a) f i n d i n g t h a t older c h i l d r e n w i t h JRA perceive j o i n t sensations as more unpleasant, and provide more n e g a t i v e l y e v a l u a t i v e d e s c r i p t i o n s of sensations. - 49 -I I • Age/Cognitive Developmental D i f f e r e n c e s i n Coping S t r a t e g i e s and  C a t a s t r o p h i z i n g Cognitions The second purpose was to assess age group/cognitive developmental d i f f e r e n c e s i n the frequency of various types of spontaneous b e h a v i o r a l and c o g n i t i v e s t r a t e g i e s f o r coping w i t h pain used by c h i l d r e n and adolescents w i t h a r t h r i t i s . The f o l l o w i n g age-related s p e c i f i c hypotheses were made: (1) A successive s i g n i f i c a n t increase i n frequency of reported c o g n i t i v e coping s t r a t e g y use was expected between age groups ((H3: M-^  < M2 < M3). This p r e d i c t i o n i s i n keeping w i t h previous l i t e r a t u r e demonstrating an increase i n the number of c o g n i t i v e coping s t r a t e g i e s reported by older c h i l d r e n (Brown et a l . , 1986; Curry & Russ, 1985; Jeans & Gordon, 1981; as c i t e d i n Jeans, 1983; R e i s s l a n d , 1983). Successive i n c r e a s e s i n the use of c o g n i t i v e coping s t r a t e g i e s f o l l o w s from previous l i t e r a t u r e demonstrating an increase i n the c a p a c i t y to understand the r o l e of personal c o n t r o l i n h e a l i n g (Neuhauser et a l . , 1978) or pain (Gaffney & Dunne, 1986), corresponding w i t h successive l e v e l s of c o g n i t i v e development. A l s o , awareness of p s y c h o l o g i c a l processes (metacognition) i s proposed as a p r e r e q u i s i t e s k i l l , necessary f o r awareness of c o g n i t i v e coping s t r a t e g i e s . ( I n order f o r c h i l d r e n to describe t h e i r thoughts and c o g n i t i v e coping s t r a t e g i e s , they must f i r s t be aware of them.) Selman's (1980) work on the development of c h i l d r e n ' s awareness of t h e i r own p s y c h o l o g i c a l processes a l s o leads to the p r e d i c t i o n of i n c r e a s i n g reported c o g n i t i v e coping s t r a t e g y use w i t h age. (2) Subjects i n the youngest age group were expected to use s i g n i f i c a n t l y more be h a v i o r a l coping s t r a t e g i e s than subjects i n the o l d e s t age group (H4: Mi > M3). This p r e d i c t i o n f o l l o w s from the conclusions of Curry and Russ (1985) that w i t h i n c r e a s i n g age, c h i l d r e n tend to r e l y l e s s on b e h a v i o r a l s t r a t e g i e s , and more on c o g n i t i v e s t r a t e g i e s f o r coping w i t h p a i n . I t should be noted, however, that t h i s c o n c l u s i o n drawn by Curry and Russ (1985) was - 50 -based on t h e i r f i n d i n g of a s i g n i f i c a n t c o r r e l a t i o n between age and the frequency of coded use of "information seeking", which was only one of the b e h a v i o r a l coping s t r a t e g i e s coded. A successive decrease between age groups i n b e h a v i o r a l coping s t r a t e g y use was not p r e d i c t e d s i n c e such a p r e d i c t i o n does not f o l l o w from c o g n i t i v e developmental theory. (3) A successive s i g n i f i c a n t increase i n frequency of c a t a s t r o p h i z i n g c o g n i t i o n s experienced was expected between age groups (H5: Mi < M 2 < M3). This p r e d i c t i o n was based on the Beales et a l . (1983a) f i n d i n g that c a t a s t r o p h i z i n g c o g n i t i o n s were unanimously included i n j o i n t sensation d e s c r i p t i o n s given by older c h i l d r e n (12-17 years) with JRA. Beales et a l . (1983) i m p l i c a t e c o g n i t i v e development i n e x p l a i n i n g these r e s u l t s . I t must be noted, however, that t h i s p r e d i c t i o n of increased c a t a s t r o p h i z i n g w i t h age/cognitive developmental l e v e l was not found by Brown et a l . (1986) when p h y s i c a l l y healthy c h i l d r e n aged 8 to 18 years were asked to r e p o r t t h e i r c o g n i t i o n s about imagined d e n t a l s i t u a t i o n s . NOTE: For these f i r s t two research purposes, the subject sample was d i v i d e d , on an a p r i o r i b a s i s , i n t o the f o l l o w i n g three age groups: 1) 5 to 7 years, 2) 8 to 10 years, and 3) 11 to 18 years, each c o n t a i n i n g t h i r t e e n s u b j e c t s . These d i v i s i o n s were intended to approximate grouping by P i a g e t i a n stages of c o g n i t i v e development ( p r e o p e r a t i o n a l , concrete o p e r a t i o n a l , and formal o p e r a t i o n a l stages s u c c e s s i v e l y ) (Piaget & Inhelder, 1969). Of course i n d i r e c t i n f e r e n c e of c o g n i t i v e stage based on age groupings i s l e s s p r e c i s e than a c t u a l measurement of s u b j e c t s ' c o g n i t i v e stage, and any conclusions i m p l i c a t i n g c o g n i t i v e d i f f e r e n c e s between groups must be tempered by t h i s r e l a t i v e i m p r e c i s i o n . Measurements of c o g n i t i v e stage were not included i n t h i s study because the time r e q u i r e d may have r e s u l t e d i n a smaller sample of w i l l i n g v o l u n t e e r s , s i n c e f a m i l i e s w i t h a c h r o n i c a l l y i l l c h i l d are t y p i c a l l y kept busy w i t h medical appointments. - 51 -I I I . Coping E f f e c t i v e n e s s E v a l u a t i o n The t h i r d purpose was to s t a t i s t i c a l l y analyze the p a i n , coping and c a t a s t r o p h i z i n g v a r i a b l e s which best d i s c r i m i n a t e between subjects c l a s s i f i e d as " e f f e c t i v e copers" versus " l e s s e f f e c t i v e copers" ( s u b j e c t s f o r whom pain i s r a t e d by a parent and the p h y s i o t h e r a p i s t as i n t e r f e r i n g somewhat with t h e i r a c t i v i t i e s of d a i l y l i v i n g ) . I t was hypothesized that frequency of c a t a s t r o p h i z i n g c o g n i t i o n s experienced would emerge as a s i g n i f i c a n t v a r i a b l e i n the d i s c r i m i n a t i o n between " e f f e c t i v e copers" and " l e s s e f f e c t i v e copers". This hypothesis was based on the l i n k i n d i c a t e d by both the c h i l d and a d u l t coping l i t e r a t u r e between " i n e f f e c t i v e coping" and "negative" or c a t a s t r o p h i z i n g thoughts (Brown et a l . , 1986; H u n t - F i t z g e r a l d , & L i d d e l l , 1985; Keefe et a l . , 1987; Reesor & C r a i g , i n press; Spanos et a l . , 1981; Turner & Clancy, 1987). METHOD Subject C h a r a c t e r i s t i c s C h i l d r e n and adolescents w i t h JRA and r e l a t e d rheumatic diseases were r e c r u i t e d through the A r t h r i t i s Centre i n Vancouver, which has contact w i t h a l l p e d i a t r i c a r t h r i t i c p a t i e n t s i n B r i t i s h Columbia. I n i t i a l l y , the s o c i a l worker i n the treatment programme contacted f a m i l i e s whose c h i l d r e n f i t the research c r i t e r i a . She b r i e f l y explained the research p r o j e c t to them and asked i f the experimenter could phone the f a m i l y to provide more informa t i o n and ask them to p a r t i c i p a t e i n the study. The research c r i t e r i a f o r s e l e c t i o n of subjects were as f o l l o w s : (1) diagnosed as having JRA, or a r e l a t e d rheumatic disease according to the American Rheumatism A s s o c i a t i o n c r i t e r i a ; (2) between the ages of 5 and 18 years; (3) p r e f e r a b l y c u r r e n t l y i n an a c t i v e phase of the i l l n e s s ( a c t i v e j o i n t inflammation); (4) whose parents provide w r i t t e n consent to p a r t i c i p a t e ; and (5) who, themselves, provide v e r b a l consent to p a r t i c i p a t e . - 52 -In t o t a l , data was c o l l e c t e d on 46 s u b j e c t s , however data from only 39 subj e c t s were used. Two sub j e c t s were not included i n the analyses because they were found to have disease c h a r a c t e r i s t i c s making them i n a p p r o p r i a t e f o r i n c l u s i o n . Data from two other s u b j e c t s were l o s t due to t e c h n i c a l d i f f i c u l t i e s w i t h the audio and video equipment. A l s o , i n order to ensure equal c e l l s i z e s , three subjects from the older age group who d i d not have a c t i v e inflammation, and who p a r t i c i p a t e d i n the standardized task only, were excluded when i t was recognized that comparable numbers of sub j e c t s i n the two youngest age groups were not a v a i l a b l e . I t should be noted that a l l , p a t i e n t s , excepting two, who f i t the research c r i t e r i a and were contacted agreed to p a r t i c i p a t e . Subjects were d i v i d e d i n t o three age groups, each c o n t a i n i n g 13 su b j e c t s . The youngest group ranged i n age from 5 years-2 months to 7 years-9 months, with a mean age of 6 years. Subjects i n the middle age group ranged from 8 years-7 months to 10 years-11 months, with a mean age of 8 years. Older subjects ranged from 11 years-10 months to 17 years-3 months, w i t h a mean age of 14 years. The sample c o n s i s t e d of 24 females and 15 males. See Table 2 f o r the d i s t r i b u t i o n of sex i n the age groups. Socioeconomic s t a t u s was c l a s s i f i e d using the B l i s h e n Index of Canadian occupations ( B l i s h e n & McRoberts, 1976). Subjects were assigned scores p l a c i n g them w i t h i n one of s i x SES ranges. Scores were based on parents' education, income, and occupational s t a t u s . The higher SES score of the two parents was used. A l l s i x SES ranges were represented i n the subject sample, with most subjects f a l l i n g w i t h i n the middle or upper ranges. The m a j o r i t y of sub j e c t s were Caucasian (n = 29). Two s u b j e c t s had one Black American parent, one was n a t i v e I n d i a n , three were East I n d i a n , one had one Portuguese parent, one was P h i l l i p i n o , and two were of Chinese descent. As s p e c i f i e d i n the s e l e c t i o n c r i t e r i a , the m a j o r i t y of subjects were diagnosed as having JRA, although other r e l a t e d rheumatic diseases represented - 53 -Table 2. D i s t r i b u t i o n of Sex i n the Age Groups Age Group Females Males 5-7 years 7 6 8-10 years 10 3 11-18 years 7 6 - 54 -i n the sample in c l u d e d : lupus, MCTD, JAS, SEA syndrome, and p s o r i a t i c a r t h r i t i s . See Table 3 f o r the number of subjects w i t h each type of a r t h r i t i s . I t was o r i g i n a l l y a c r i t e r i a f o r p a r t i c i p a t i o n that subjects have a c t i v e inflammation, but i n order to obtain a l a r g e r sample s i z e , the data from e i g h t subjects without current i d e n t i f i a b l e a c t i v e inflammation were r e t a i n e d . One of these subjects was i n the youngest age group, four were i n the middle group, and three were i n the o l d e s t age group. Physiotherapy sessions were video-taped w i t h an RCA C o l o r v i s i o n Camera Model No. 0516V M039, with a b u i l t - i n microphone and a Panosonic VHS video c a s s e t t e recorder. Subjects' v e r b a l responses to the pain and c o g n i t i v e coping i n t e r v i e w s were audio-taped w i t h a Sanyo c a s s e t t e tape recorder, Model No. TC-71. Procedure An i n i t i a l phone c a l l was made to those f a m i l i e s who had i n d i c a t e d an i n t e r e s t i n p a r t i c i p a t i n g . The purpose of t h i s c a l l was to b r i e f l y e x p l a i n the study and to set up an appointment time to meet w i t h the parent and c h i l d to e x p l a i n the study i n more d e t a i l . [NOTE: Only one parent, t y p i c a l l y the mother, gave consent f o r t h e i r c h i l d to p a r t i c i p a t e and completed qu e s t i o n n a i r e s . ] For 25 of the s u b j e c t s , t h i s i n i t i a l meeting w i t h the parent took place at the p a r t i c i p a n t ' s home, i n advance of a r e g u l a r l y scheduled physiotherapy appointment. In the other 14 cases, the i n i t i a l e x p l a n a tion meeting took place i n the c h i l d r e n ' s w a i t i n g area at the A r t h r i t i s Centre 1/2 to 1 hour before the c h i l d was scheduled f o r a medical check-up. During t h i s meeting, the purpose of the study and the procedures i n v o l v e d were explained i n f u l l . Once d e t a i l s of the study had been explained to t h e i r s a t i s f a c t i o n , and i f the parent and c h i l d / a d o l e s c e n t i n d i c a t e d a w i l l i n g n e s s to p a r t i c i p a t e , the parent was then asked to read and s i g n a p a r t i c i p a t i o n consent form (see - 55 -Table 3. Types of A r t h r i t i s Represented i n the Subject Sample Type of a r t h r i t i s 11 JRA - p a u c i a r t i c u l a r onset JRA 15 - p o l y a r t i c u l a r onset JRA 7 - systemic onset JRA 1 Lupus 1 MCTD 1 JAS 2 SEA Syndrome 4 P s o r i a t i c a r t h r i t i s 7 - 56 -Appendix A), and a permission f o r r e l e a s e of s p e c i f i c medical i n f o r m a t i o n r e q u i r e d f o r the present study (see Appendix B). Also at t h i s time, the parent was asked to f i l l out two questionnaires intended to evaluate the e f f e c t i v e n e s s of t h e i r c h i l d ' s coping w i t h pain (see Appendices C and D). For 25 of the 39 s u b j e c t s , assessment of the subject's pain experience and coping s t r a t e g i e s took place during and immediately f o l l o w i n g a r e g u l a r l y scheduled physiotherapy session at the A r t h r i t i s Centre. A l l physiotherapy e x e r c i s e s during that session were videotaped. (The videotape was necessary f o r coding behavioural coping s t r a t e g i e s employed during physiotherapy, and a l s o was used to cue r e c a l l of c o g n i t i v e coping s t r a t e g i e s employed.) The m a j o r i t y of the physiotherapy session was not standardized, but r a t h e r was the r e g u l a r r o u t i n e which had been i n d i v i d u a l i z e d f o r each p a t i e n t . The l a s t few minutes, however, c o n s i s t e d of a standardized t e s t of range of motion (ROM). Range of motion (ROM) i s defined as the degrees of motion a v a i l a b l e i n a j o i n t as measured from a pre-defined zero s t a r t i n g p o s i t i o n . Motion away from the zero point i s r e f e r r e d to as " f l e x i o n " . The term "extension" r e f e r s to the r e t u r n motion to the zero s t a r t i n g p o s i t i o n . G e n e r a l l y , a measuring instrument c a l l e d a goniometer, resembling a p r o t r a c t o r w i t h moveable arms, i s used f o r measuring ROM (American Academy of Orthopaedic Surgeons, 1965). In the present study, the amount of a v a i l a b l e extension or f l e x i o n (whichever d i r e c t i o n of movement was l i m i t e d f o r that c h i l d ) was measured by the p h y s i o t h e r a p i s t i n one j o i n t , three times c o n s e c u t i v e l y . Movement of the j o i n t to the point of maximum extension or f l e x i o n was a s s i s t e d by the p h y s i o t h e r a p i s t . The p h y s i o t h e r a p i s t , paced by the c h i l d , continued pushing the j o i n t u n t i l she judged the end of a v a i l a b l e range had been reached. Judgment of t h i s end point of motion was made s u b j e c t i v e l y by the p h y s i o t h e r a p i s t , based on an "end f e e l " which, depending on the j o i n t measured, r e p o r t e d l y f e e l s l i k e bone on bone, or l i k e a muscle spasm or can - 57 -f e e l spongy. The j o i n t used i n t h i s standardized ROM task was one which the p h y s i o t h e r a p i s t judged to be p a r t i c u l a r l y sore f o r that c h i l d at the present time. For subjects who were p a r t i c i p a t i n g i n r e g u l a r l y scheduled physiotherapy s e s s i o n s , the j o i n t used was t y p i c a l l y one on which motion-improving e x e r c i s e s were performed throughout the s e s s i o n . For those few subjects without a c t i v e inflammation, the j o i n t most r e c e n t l y sore or inflamed was measured. Whenever p o s s i b l e , f o r increased consistency, the knee was chosen f o r measurement. See Table 4 f o r a summary of j o i n t s used i n the ROM task. For the 14 subjects who were not p r e s e n t l y scheduled f o r r e g u l a r physiotherapy treatment at the A r t h r i t i s Centre i n Vancouver, assessment of pain experience and coping s t r a t e g i e s took place e i t h e r immediately before or a f t e r t h e i r medical examination. These subjects performed only the standardized t e s t of range of motion (ROM). A second p h y s i o t h e r a p i s t conducted the standardized ROM measurements on these 14 su b j e c t s s i n c e the p h y s i o t h e r a p i s t who had conducted treatment sessions and measured ROM f o r the other 25 su b j e c t s was away on maternity leave at that time. These d i f f e r e n c e s i n procedure and p h y s i o t h e r a p i s t were not expected to act as confounds i n the present study however, si n c e the 14 su b j e c t s p a r t i c i p a t i n g only i n the standarized ROM task were approximately evenly d i s t r i b u t e d across the three age groups. A l s o , pain experienced and coping s t r a t e g i e s demonstrated during the standardized ROM ta s k , were the s p e c i f i c t a r g e t s of i n v e s t i g a t i o n . P a i n and coping data obtained during the r e s t of the physiotherapy session ( f o r those 25 subjects r e g u l a r l y r e c e i v i n g physiotherapy at the A r t h r i t i s Centre) were used only f o r a d d i t i o n a l d e s c r i p t i v e i n f o r m a t i o n . Immediately f o l l o w i n g completion of t h i s standardized ROM task, subjects - 58 -Table A. J o i n t Used i n Standardized Range of Motion Task J o i n t i i knee 18 ankle 8 w r i s t 7 hip 1 shoulder 2 elbow 2 toe 1 - 59 -were interviewed regarding t h e i r pain experience and thoughts r e l a t e d to coping w i t h pain e l i c i t e d by the j o i n t measurements. Also immediately f o l l o w i n g the physiotherapy s e s s i o n , the p h y s i o t h e r a p i s t r a t e d the su b j e c t ' s current f u n c t i o n a l s t a t u s , and i n t e n s i t y of pain experienced during the standardized ROM task. P a r t i c i p a n t s were t o l d that upon completion of data analyses, they would be mailed a summary of group f i n d i n g s and c o n c l u s i o n s . ( A l l parents and many of the subjects were e s p e c i a l l y i n t e r e s t e d i n the outcome.) Measures  Parent Ratings HAQ D i s a b i l i t y s c a l e . A modified v e r s i o n of the D i s a b i l i t y s c a l e developed by F r i e s et a l . (1980) f o r use w i t h a d u l t RA p a t i e n t s was used (see Appendix C). The o r i g i n a l questionnaire was designed to measure s e l f - r e p o r t e d a b i l i t y i n the f o l l o w i n g nine general c a t e g o r i e s of a c t i v i t i e s of d a i l y l i v i n g (ADL): (1) dre s s i n g and grooming; (2) a r i s i n g ; (3) e a t i n g ; (4) walking, (5) hygiene; (6) reach; (7) g r i p ; (8) outside a c t i v i t i e s ; and (9) sexual a c t i v i t y . The three questions grouped under the l a t t e r two c a t e g o r i e s were excluded from the v e r s i o n used i n the present study because they were seen as i n a p p r o p r i a t e f o r c h i l d r e n / a d o l e s c e n t s . Scoring of the o r i g i n a l v e r s i o n of the D i s a b i l i t y s c a l e designed f o r use w i t h a d u l t s y i e l d s a D i s a b i l i t y Index score. The highest score on any question w i t h i n a general category i s taken as the score f o r t h a t category. The D i s a b i l i t y Index score i s then c a l c u l a t e d by adding these category scores and d i v i d i n g by the t o t a l number of c a t e g o r i e s completed. Highly acceptable l e v e l s of r e l i a b i l i t y and v a l i d i t y have been demonstrated f o r the o r i g i n a l v e r s i o n of t h i s s c a l e designed f o r a d u l t s ( F r i e s et a l . , 1980). In t h i s i n v e s t i g a t i o n , s u b j e c t s ' D i s a b i l i t y Index scores were c a l c u l a t e d and reported f o r d e s c r i p t i v e purposes, but f o r s t a t i s t i c a l analyses, a t o t a l d i s a b i l i t y - 60 -score was c a l c u l a t e d . Scores on a l l items w i t h i n c a t e g o r i e s were t o t a l e d . Use of t h i s t o t a l d i s a b i l i t y score, r a t h e r than' the averaged D i s a b i l i t y Index score allowed f o r greater v a r i a b i l i t y between su b j e c t s on an otherwise r e s t r i c t e d range of scores. F u n c t i o n a l d i s a b i l i t y , defined as the degree to which a r t h r i t i s i n t e r f e r e s w i t h the i n d i v i d u a l ' s l e v e l of performance i n a c t i v i t i e s of d a i l y l i v i n g , was used as the f i r s t of three measures of e f f e c t i v e n e s s of coping w i t h pain. I n t e r f e r e n c e w i t h A c t i v i t i e s Questionnaire. This questionnaire was derived from a question i n c l u d e d i n the Varni/Thompson P e d i a t r i c P a i n Questionnaire Form P (Parent) and Form A (Adolescent) (PPQ; V a r n i & Thompson, 1985). The respondent r a t e s the degree to which pain i n t e r f e r e s w i t h a l i s t of 12 a c t i v i t i e s (e.g., s p o r t s , school attendance). The f o l l o w i n g 5 r a t i n g s of degree of i n t e r f e r e n c e are provided as response options: 0 = "never", 1 = " r a r e l y " , 2 = "sometimes", 3 = " o f t e n " , and 4 = "always" (see Appendix D). This questionnaire was a l s o i n c l u d e d as the second of three measures of e f f e c t i v e n e s s of coping w i t h p a i n . V a r n i et a l . ( i n press) found that mothers of some, but not a l l JRA c h i l d r e n i n t h e i r sample, r a t e d pain as i n t e r f e r i n g w i t h the r e c r e a t i o n a l and academic a c t i v i t i e s l i s t e d . I f , as Ross and Ross (1984b) suggest, l i m i t a t i o n of a c t i v i t y w i t h i n p a i n - f r e e l i m i t s i s , i n f a c t , a s t r a t e g y used by c h i l d r e n w i t h JRA to cope w i t h t h e i r p a i n , i t i s p o s s i b l e that i t may be over-used by some c h i l d r e n . I f many a c t i v i t i e s are l i m i t e d , i n a n t i c i p a t i o n of p a i n , then the s t r a t e g y may become maladaptive (McGrath et a l . , 1985). Self-Report Measures-Interview P e d i a t r i c Pain Interview. This measure i s a modified and shortened v e r s i o n of the Varni/Thompson P e d i a t r i c Pain Questionnaire - Form C ( C h i l d ) (PPQ; V a r n i & Thompson, 1985). Questions were asked v e r b a l l y as part of a semi-structured i n t e r v i e w (see Appendix E ) . Ross and Ross (1984b) have found - 61 -the semi-structured i n t e r v i e w to be a p a r t i c u l a r l y f r u i t f u l source of info r m a t i o n about c h i l d r e n ' s pain experience. The PPQ i s a r e l a t i v e l y new measure modeled a f t e r the M c G i l l Pain Questionnnaire (MPQ; Melzack, 1975) but designed to be s e n s i t i v e to c o g n i t i v e developmental c o n c e p t u a l i z a t i o n s of c h i l d r e n . The modified v e r s i o n of the PPQ-Form C ( C h i l d ) used i n t h i s study i n c l u d e d : (1) a developmentally appropriate v i s u a l analogue s c a l e (VAS) f o r r a t i n g s of present pain i n t e n s i t y and worst pain i n t e n s i t y over the past week; and (2) both an open-ended question and a c h e c k l i s t to e l i c i t c h i l d r e n ' s sensory, a f f e c t i v e and e v a l u a t i v e pain d e s c r i p t o r s . An adolescent form of the PPQ i s a l s o a v a i l a b l e . For the present study, however, adolescents f i l l e d out the c h i l d form of the PPQ. This choice was made because the a d d i t i o n a l i n f o r m a t i o n provided by the adolescent form was not r e q u i r e d and a l s o because comparisons by age groups, which were part of the analyses, might p o t e n t i a l l y have been confounded by d i f f e r e n c e s i n wording or response format of questions. This choice does not r e f l e c t an a t t i t u d e that adolescents are not capable of p r o v i d i n g the more d e t a i l e d i n f o r m a t i o n included i n the PPQ-Form A (Adolescent). The PPQ has r e c e n t l y been used s u c c e s s f u l l y w i t h a sample of JRA's between the ages of A and 16 years ( V a r n i et a l . , 1987). Some v a l i d i t y i n f o r m a t i o n i s provided by the r e s u l t s of t h i s i n v e s t i g a t i o n . I n t e n s i t y r a t i n g s f o r both present pain and worst pain over the past week made by c h i l d r e n , mothers and the p h y s i c i a n i n the Varni et a l . (1987) sample were not s i g n i f i c a n t l y d i f f e r e n t . In a d d i t i o n , r a t i n g s of pain i n t e n s i t y tended to increase as g l o b a l r a t i n g s of disease a c t i v i t y i n c r e a s e d , p r o v i d i n g some con s t r u c t v a l i d i t y f o r the VAS r a t i n g s . In the present study, the s i m i l a r i t y between present pain i n t e n s i t y r a t i n g s made by the c h i l d / a d o l e s c e n t and the p h y s i o t h e r a p i s t (see Appendix J ) - 62 -was s t a t i s t i c a l l y analyzed. C o g n i t i v e Coping Interview. The i n t e r v i e w format used i n t h i s study to tap c h i l d r e n ' s / a d o l e s c e n t s ' c o g n i t i v e coping s t r a t e g i e s (see Appendix F) was derived from a combination of the C o g n i t i v e Coping Interview (CCI) format developed by Curry and Russ (1985) and the Str u c t u r e d Interview Schedule f o r Pain (SISP) format developed by Genest (1978) and modified by Reesor and C r a i g ( i n p r e s s ) . The CCI i s a s t r u c t u r e d i n t e r v i e w that was designed to e l i c i t i n f o r m a t i o n about c h i l d r e n ' s c o g n i t i v e processes during d e n t a l treatment. Open-ended questions are asked about c h i l d r e n ' s thoughts and s e l f - s t a t e m e n t s , and follow-up probes are s p e c i f i e d depending upon the type of response given by the c h i l d The CCI has been used s u c c e s s f u l l y w i t h a sample of c h i l d r e n aged 8-10 who underwent d e n t a l treatment; a l l c h i l d r e n gave scoreable responses using t h i s format (Curry & Russ, 1985). Because the CCI i n t e r v i e w format has been used s u c c e s s f u l l y w i t h c h i l d r e n , the wording of most questions and probes followed t h i s format. D i r e c t i o n s from the CCI that are s p e c i f i c to the de n t a l s i t u a t i o n were replaced by d i r e c t i o n s s p e c i f i c to the physiotherapy ROM task. In order to tap not only e f f e c t i v e c o g n i t i v e coping s t r a t e g i e s , but a l s o c a t a s t r o p h i z i n g thoughts, the wording of one question was a l t e r e d , f i t t i n g more c l o s e l y w i t h the SISP format (Genest, 1978). A l s o , a f o l l o w up probe absent from the CCI but included i n the SISP was i n c l u d e d i n the i n t e r v i e w format used. C o g n i t i v e Coping Categories - Coding Manual. Categories of coping s t r a t e g i e s to be coded from the t r a n s c r i b e d c o g n i t i v e coping i n t e r v i e w s were developed by the p r i n c i p a l i n v e s t i g a t o r a p r i o r i . Categories and d e f i n i t i o n s used (see Appendix G) were adapted from those used by Brown et a l . (1986), and Curry and Russ (1985). Coding systems developed by these authors were used to c l a s s i f y c o g n i t i v e s t r a t e g i e s used by c h i l d r e n i n a de n t a l s i t u a t i o n . They - 63 -have demonstrated a p p l i c a b i l i t y to c h i l d r e n . The f o l l o w i n g f i v e c a t e g o r i e s of c o g n i t i v e coping used by Curry and Russ (1985) were in c l u d e d i n the present i n v e s t i g a t i o n : (1) "emotion-regulating s e l f - t a l k , (2) " b e h a v i o r - r e g u l a t i n g s e l f - t a l k , (3) " d i v e r s i o n a r y t h i n k i n g " , (4) " r e a l i t y - o r i e n t e d working through", and (5) " c o g n i t i v e r e a p p r a i s a l " . In the present c l a s s i f i c a t i o n system, however, " d i v e r s i o n a r y t h i n k i n g " was c l a s s i f i e d as " i n t e r n a l a t t e n t i o n d i v e r s i o n " , and a s i x t h category of " e x t e r n a l a t t e n t i o n d i v e r s i o n " was added. F i n a l l y , "thought stopping", as defined by Brown et a l . (1987), was added i n the present c l a s s i f i c a t i o n system as a seventh category of c o g n i t i v e coping. The frequency of occurrence f o r each c o g n i t i v e coping subtype was coded from the w r i t t e n p r o t o c o l s by a t r a i n e d coder who remained b l i n d to the s p e c i f i c hypotheses of the experiment was w e l l as to s u b j e c t s ' group assignment. Each clause/phrase that i n c l u d e d enough d e t a i l to be scoreable under one of the c a t e g o r i e s was scored as an occurrence. The coder was t r a i n e d using sample p r o t o c o l s from subjects not used i n the data analyses. A randomly s e l e c t e d 25% of the p r o t o c o l s were a l s o scored by the primary i n v e s t i g a t o r i n order to c a l c u l a t e r e l i a b i l i t y , although i n a l l cases, data recorded by the coder was used i n the analyses. Since the data were analyzed i n the form of t o t a l frequencies ( " q u a n t i t a t i v e " r a t h e r than " c a t e g o r i c a l " d a t a ) , " s e s s i o n r e l i a b i l i t y " was c a l c u l a t e d , using Pearson product-moment c o r r e l a t i o n s (Hartmann, 1982). I t must be recognized that the c o r r e l a t i o n s t a t i s t i c provides a measure of the c o m p a r a b i l i t y of the r e l a t i v e p o s i t i o n of p a i r s of scores recorded by the observer and the primary i n v e s t i g a t o r ( r e l i a b i l i t y check), and as such i s not s t r i c t l y a measure of agreement. As noted by Foster and Cone (1986), a systematic tendency f o r one observer to record higher frequencies of behavior than another can be masked by c o r r e l a t i o n a l s t a t i s t i c s . In order to r u l e out operation of such b i a s e s , - 64 -t - t e s t s were performed on the d i f f e r e n c e between mean frequencies recorded by the observer and the r e l i a b i l i t y checker. C o r r e l a t i o n s based on the p a i r e d scores of observers across s u b j e c t s are reported i n Table 5. C o r r e l a t i o n s f o r groupings of c o g n i t i v e coping subtypes and f o r t o t a l c o g n i t i v e coping are reported, s i n c e these were the v a r i a b l e s entered i n t o s t a t i s t i c a l analyses. Values ranged from .61 to .98. None of the t - t e s t s reached s i g n i f i c a n c e . [NOTE: For explanation of regroupings of subtypes see R e s u l t s s e c t i o n . ] C a t a s t r o p h i z i n g Cognitions-Coding Manual. Categories of c a t a s t r o p h i z i n g c o g n i t i o n s to be coded from the t r a n s c r i b e d c o g n i t i v e coping i n t e r v i e w s were developed by the p r i n c i p l e i n v e s t i g a t o r a p r i o r i . Three c a t e g o r i e s were adapted from Brown et a l . (1987): (1) "thoughts of p a i n , f e a r or a n x i e t y " , (2) "thoughts of escape", and (3) "concern about u n l i k e l y responses". As p r e v i o u s l y noted, the Brown et a l . (1987) system has demonstrated a p p l i c a b i l i t y to c h i l d r e n . A f o u r t h category of c a t a s t r o p h i z i n g , l a b e l e d " l a c k of c o n t r o l " , which was i n c l u d e d i n the present i n v e s t i g a t i o n , was adapted from Genest's (1978) system. Genest's (1978) coding system has r e c e n t l y been used to c l a s s i f y the c a t a s t r o p h i z i n g c o g n i t i o n s of a d u l t s experiencing chronic low back pain. D i f f e r e n c e s i n reported use of c a t e g o r i e s s p e c i f i e d by Genest (1978) was found to be a s i g n i f i c a n t d i s c r i m i n a t i n g f a c t o r between " e f f e c t i v e copers" and " i n e f f e c t i v e copers" (Reesor & C r a i g , i n p r e s s ) . As w i t h the c o g n i t i v e coping s t r a t e g i e s , c a t a s t r o p h i z i n g c o g n i t i o n s reported by each subject were coded from the w r i t t e n p r o t o c o l by a t r a i n e d coder. I n t e r r a t e r r e l i a b i l i t y f o r c a t a s t r o p h i z i n g c o g n i t i o n subcategories and summary scores used i n the analyses, expressed as Pearson c o r r e l a t i o n s , ranged from .91 to .96. None of the t - t e s t s performed on d i f f e r e n c e s between mean frequency r a t i n g s made by the coder and r e l i a b i l i t y checker reached s i g n i f i c a n c e (see Table 6). - 65 -Table 5. I n t e r r a t e r R e l i a b i l i t y f o r C o g n i t i v e Coping C a t e g o r i z a t i o n Category of C o g n i t i v e Coping r_ t (df=9) emotion-regulating s e l f - t a l k * a t t e n t i o n d i v e r s i o n ( i n t e r n a l + e x t e r n a l ) ' .98 1.94 thought stopping 1.0 .00 r e a l i t y - o r i e n t e d working through .61 .51 c o g n i t i v e r e a p p r a i s a l .87 .00 t o t a l frequency of c o g n i t i v e s t r a t e g y use .98 2.06 *Because of low base r a t e , t h i s category d i d not occur w i t h i n the subsample of cases randomly s e l e c t e d f o r c a l c u l a t i o n of i n t e r r a t e r r e l i a b i l i t y . To report i n t e r r a t e r r e l i a b i l i t y as 1.0 f o r t h i s subcategory would t h e r e f o r e be misleading. - 66 -Table 6. I n t e r r a t e r R e l i a b i l i t y f o r C a t a s t r o p h i z i n g Cognitions C a t e g o r i z a t i o n Category T_ t (df=9) thoughts of p a i n , f e a r or an x i e t y .91 .00 other c a t a s t r o p h i z i n g (thoughts of escape + concern about u n l i k e l y consequences + l a c k of c o n t r o l ) .97 -1.00 t o t a l frequency of c a t a s t r o p h i z i n g .96 -.80 - 67 -Observational Measures Beh a v i o r a l Coping S t r a t e g i e s - Coding Manual. Categories of be h a v i o r a l coping s t r a t e g i e s to be coded from the videotaped physiotherapy sessions were developed by the p r i n c i p l e i n v e s t i g a t o r a p r i o r i . F i v e of the seven c a t e g o r i e s i n c l u d e d were adapted from the Behavioral Coping Observation Scale developed by Curry and Russ (1985): (1) "inf o r m a t i o n seeking", (2) " v e r b a l c o n t a c t " , (3) " p h y s i c a l c o n t a c t " , (4) " v e r b a l r e f u s a l " , and (5) "nonverbal r e f u s a l (the l a t t e r two were r e f e r r e d to c o l l e c t i v e l y by Curry and Russ (1985) as " l i m i t s e t t i n g " ) . Two f u r t h e r c a t e g o r i e s , l a b e l e d (1) "vocal pain expression", and (2) "nonvocal pain expression", were a l s o included as b e h a v i o r a l coping s t r a t e g i e s . Dunn-Geier et a l . (1986) found that when adolescents having d i f f i c u l t i e s coping w i t h chronic pain ( l a b e l e d "noncopers" by the authors) complained v o c a l l y of p a i n , t h e i r mothers allowed them to perform l e s s of the p a i n - e l i c i t i n g e x e r c i s e s r e q u i r e d as part of p a r t i c i p a t i o n i n the study. Reasoning r e t r o s p e c t i v e l y from these f i n d i n g s then, v o c a l pain expression was seen as a b e h a v i o r a l coping s t r a t e g y . Extending beyond Dunn-Geier et a l . ' s (1986) f i n d i n g s , i t was be l i e v e d that not only v o c a l , but a l s o nonvocal pain can serve as a b e h a v i o r a l coping s t r a t e g y . In the present i n v e s t i g a t i o n , " s i g h i n g " , "grimacing", and "rubbing" were grouped together w i t h i n a be h a v i o r a l coping category l a b e l e d "nonvocal p a i n " expression. D e f i n i t i o n s of these examples of nonvocal pain were taken from the Keefe and Block (1982) o b s e r v a t i o n a l measure of pain behavior, as adapted by McDaniel et a l . (1986) f o r a p p l i c a t i o n to a d u l t s w i t h rheumatoid a r t h r i t i s . In viewing the sample s u b j e c t s ' videotapes (those used to t r a i n the coder), i t was apparent that i n some cases s u b j e c t s expressed pain or t o l d the p h y s i o t h e r a p i s t when to stop pushing on t h e i r j o i n t , s o l e l y because she asked - 68 -them to do so. Since pain expression or v e r b a l r e f u s a l i n these cases was not seen as r e f l e c t i v e of the c h i l d ' s spontaneous b e h a v i o r a l coping r e p e r t o i r e , e x p l i c i t e x l u s i o n a r y c r i t e r i a f o r v o c a l pain and v e r b a l r e f u s a l c a t e g o r i e s were in c l u d e d i n the beh a v i o r a l coping coding system. Behavioral Coping S t r a t e g i e s - Coding Procedure. Coding procedures were s p e c i f i e d i n the A d d i t i o n a l Coding Information Sheet (see Appendix 1-2). Because of low base r a t e s of b e h a v i o r a l coping s t r a t e g y use, occurrence of s t r a t e g i e s were coded continuously to maximize data y i e l d e d . Designated r e s t breaks were not necessary because f o r most subjects there were i n t e r m i t t e n t time periods during which the p h y s i o t h e r a p i s t was not i n the room and the c h i l d was not performing p a i n - e l i c i t i n g a c t i v i t i e s . Every 30 seconds, the coder was cued by an audiotaped r e c o r d i n g to move on to the next i n t e r v a l on the coding sheet. Time i n t e r v a l r e c o r d i n g was used i n order to s p e c i f y time periods when the ph y s i o t h e r a p i s t was i n the room w i t h the c h i l d , s i n c e physiotherapy sessions i n v o l v e d v arying amounts of p o t e n t i a l l y p a i n f u l j o i n t movement and s t r e t c h i n g , supervised or performed by the p h y s i o t h e r a p i s t . Although the data were recorded i n t h i s format, the research questions posed by the present i n v e s t i g a t i o n were based on se s s i o n t o t a l s r ather than on i n t e r v a l data. The observer recorded the presence of each occurrence of a given b e h a v i o r a l s t r a t e g y used during the physiotherapy session by p l a c i n g t i c k marks i n the appropriate box of the coding sheet, f o r each time i n t e r v a l (see Appendix 1-3). The only exception to t h i s procedure was the category " v e r b a l contact". For t h i s category, a maximum of one t i c k mark was placed i n the box f o r " v e r b a l c o n t a c t " w i t h i n any given 30 second time i n t e r v a l . T his coding d e c i s i o n was made due to d i f f i c u l t i e s o p e r a t i o n a l i z i n g d i s c r e t e u n i t s w i t h i n continuous c h a t t i n g . Some preparation of the coding sheets was done i n advance by the p r i n c i p l e - 69 -i n v e s t i g a t o r . The coder received coding sheets with pre-numbered time i n t e r v a l s , and with a t i c k i n the c i r c l e at the side for i n t e r v a l s during which the physiotherapist was present. In add i t i o n , time i n t e r v a l s during which the standardized task occurred were copied on coloured paper. This advance preparation was done i n order to allow the coder to attend s e l e c t i v e l y to coding the behavioral coping subtypes. Coding sheets were purposely made large (Note: example i n Appendix 1-3 i s reduced i n si z e ) i n order that the coder needed only to glance down quickly i n order to place a t i c k i n the appropriate box, and could then re-focus on the T.V. screen. A f i n a l coding procedure to note i s that videotapes were watched through (completely) twice per subject. This coding decision was made because one of the sources of u n r e l i a b i l i t y which emerged i n t r a i n i n g appeared to be poor audio c l a r i t y on the video recording. The physiotherapy "rooms" at the A r t h r i t i s Centre are beds with a cu r t a i n pulled round, and when other patients were i n other beds, t h e i r voices were at times also picked up by the microphone, as well as other extraneous noise i n the physiotherapy treatment room (noisy icebox!). The frequency of behavioral coping s t r a t e g i e s used by each subject was coded by a trained coder who remained b l i n d to the hypotheses of the experiment as well as to subjects' group assignment. Videotapes of subjects not used i n the data analyses were used to t r a i n the coder. Videotaped mock vignettes focusing s p e c i f i c a l l y on d i f f i c u l t examples or d i s t i n c t i o n s i n the coding system were also used. Training sessions were held weekly or biweekly over a period of several months u n t i l an acceptable l e v e l of r e l i a b i l i t y was obtained between the coder and the p r i n c i p l e i n v e s t i g a t o r . Following t h i s , coding meetings were held every other week to continue t r a i n i n g and discuss d i f f i c u l t to code examples that had arisen i n coding completed over the past weeks. The Additional Coding Information Sheet (Appendix 1-2), specifying - 70 -coding procedures, was a l s o used i n t r a i n i n g . A randomly s e l e c t e d 25% of videotapes were a l s o coded by the p r i n c i p a l i n v e s t i g a t o r i n order to c a l c u l a t e i n t e r r a t e r r e l i a b i l i t y . I n t e r r a t e r r e l i a b i l i t y f o r beh a v i o r a l coping subcategories and summary scores used i n the analyses, expressed as Pearson c o r r e l a t i o n s , ranged from .90 to .98. None of the t - t e s t s performed on d i f f e r e n c e s between mean frequency r a t i n g s made by the coder and r e l i a b i l i t y checker revealed a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e . Although the t-value f o r " t o t a l b e h a v i o r a l coping" was s i g n i f i c a n t at the j> < .05 l e v e l , a f t e r a p p l i c a t i o n of the Bo n f e r r o n i c o r r e c t i o n , which l i m i t s the experiment-wise e r r o r r a t e s , t h i s d i f f e r e n c e f a i l e d to reach s i g n i f i c a n c e (see Table 7). P h y s i o t h e r a p i s t Ratings Pain I n t e n s i t y Ratings - P h y s i o t h e r a p i s t . Immediately f o l l o w i n g the physiotherapy s e s s i o n , the p h y s i o t h e r a p i s t r a t e d perceived i n t e n s i t y of pain experienced by the c h i l d during the standardized task, using the same VAS employed by c h i l d r e n (see Appendix J ) . F u n c t i o n a l Assessment. A g l o b a l r a t i n g of the c h i l d ' s current f u n c t i o n a l c a p a c i t y , using the American Rheumatism A s s o c i a t i o n f u n c t i o n a l c l a s s i f i c a t i o n (Steinbrocker et a l . , 1949), was made by the p h y s i o t h e r a p i s t (see Appendix J ) . This r a t i n g was in c l u d e d as the t h i r d of the three measures of coping e f f e c t i v e n e s s . P h y s i c i a n Ratings D i s e a s e - r e l a t e d Data Form (see Appendix K). The p e d i a t r i c rheumatologist provided the f o l l o w i n g d i s e a s e - r e l a t e d data f o r each c h i l d : (1) type of a r t h r i t i s , (2) dur a t i o n of i l l n e s s ( i e . present age minus age of on s e t / d i a g n o s i s ) , (3) medications p r e s c r i b e d , (4) number of j o i n t s a f f e c t e d ( i e . number of j o i n t s i n which there has at some point been inflammation). In a d d i t i o n , (5) an a c t i v e j o i n t count ( i e . number of j o i n t s w i t h a c t i v e - 71 -Table 7. I n t e r r a t e r R e l i a b i l i t y f o r B e h a v i o r a l Coping S t r a t e g i e s B e h a v i o r a l Coping Strategy r t(df=9) Verbal contact ( i n f o r m a t i o n seeking + v e r b a l contact) .92 ,42 Pain expression ( v o c a l + nonvocal pain) .96 2, .22 Verbal r e f u s a l .90 2, .08 T o t a l b e h a v i o r a l coping s t r a t e g i e s .98 2, .62* *jo < .05 - 72 -inflammation at present) and (6) erythrocyte sedimentation r a t e (ESR) were in c l u d e d as measures of present degree of a c t i v i t y of a r t h r i t i s . The a c t i v e j o i n t count was c a l c u l a t e d by noting a c t i v i t y as an a l l or none phenomena i n each of the j o i n t s or j o i n t groups. This a c t i v e j o i n t count was based on r a t i n g s of f l u i d , warmth and tenderness i n the j o i n t s (American Rheumatism A s s o c i a t i o n , 1982). Subjects' most r e c e n t l y measured er y t h r o c y t e sedimentation r a t e (ESR) was recorded from the medical c h a r t s . The ESR i s used to evaluate the a c t i v i t y of v a r i o u s rheumatic diseases. For rheumatoid a r t h r i t i s , i t i s considered to be only a crude index of degree of acute inflammation, as r e f l e c t e d by changes i n the c o n s t i t u t i o n of blood plasma p r o t e i n s . Rapidly sedimenting blood plasma c e l l s has been w e l l documented to be a s s o c i a t e d w i t h degree of inflammation ( F i s c h e l , 1967). The Westergren method of c a l c u l a t i n g ESR was used (Westergren, 1926). This method i n v o l v e s drawing a shaken sample of blood i n t o a Westergren tube, up to the 200 mm mark, and then p l a c i n g i t i n a rack v e r t i c a l l y . At the end of one hour, the distance between the top of the plasma column and the top of the sedimented red blood c e l l column i s measured ( i n mm). The r e s u l t i s reported as mm f a l l i n one hour ( F i s c h e l , 1967). F i n a l l y , a seventh d i s e a s e - r e l a t e d v a r i a b l e recorded was a g l o b a l r a t i n g of disease s e v e r i t y . A g l o b a l r a t i n g of disease s e v e r i t y , as e i t h e r "none", " m i l d " , "moderate", "severe" or "very severe" was made by the p e d i a t r i c rheumatologist. This more g l o b a l , s u b j e c t i v e r a t i n g was i n c l u d e d because the other d i s e a s e - r e l a t e d v a r i a b l e s , taken s e p a r a t e l y , may not capture the s e v e r i t y of a given c h i l d ' s disease (e.g., a c h i l d may have only one j o i n t a f f e c t e d yet t h e i r disease s t a t u s may be r a t e d as more severe than another c h i l d w i t h s e v e r a l a f f e c t e d j o i n t s ) . These d i s e a s e - r e l a t e d v a r i a b l e s were in c l u d e d not only f o r d e s c r i p t i v e purposes, but a l s o because i t was p r e d i c t e d that they would covary w i t h the - 73 -ps y c h o l o g i c a l v a r i a b l e s of i n t e r e s t . C l a s s i f i c a t i o n of Subjects' E f f e c t i v e n e s s of Coping with P a i n . F u n c t i o n a l d i s a b i l i t y (the degree to which pain i n t e r f e r e s w i t h a number of a c t i v i t i e s of d a i l y l i v i n g ) was used to c l a s s i f y s u b j e c t s as " e f f e c t i v e copers" or " l e s s e f f e c t i v e copers". I t seems from the a v a i l a b l e research, that one of the ways c h i l d r e n w i t h a r t h r i t i s cope w i t h pain i s by l i m i t i n g a c t i v i t i e s t h a t cause pain (Ross & Ross, 1984b). Overuse of such a strat e g y would mean a greater degree of f u n c t i o n a l d i s a b i l i t y . I n t e r f e r e n c e w i t h school attendance caused by pain has been used p r e v i o u s l y to c l a s s i f y c h i l d r e n w i t h chronic pain i n t o " e f f e c t i v e copers" and " l e s s e f f e c t i v e copers" (Dunn-Geier et a l . , 1986; McGrath et a l . , 1985). F u n c t i o n a l d i s a b i l i t y f o r each subject was ra t e d by a parent usin g : (1) the HAQ D i s a b i l i t y s c a l e , and (2) I n t e r f e r e n c e w i t h A c t i v i t i e s Questionnaire, as w e l l as by the p h y s i o t h e r a p i s t , using (3) the American Rheumatism A s s o c i a t i o n F u n c t i o n a l C l a s s i f i c a t i o n . S t a t i s t i c a l Analyses I . Age/Cognitive Developmental D i f f e r e n c e s i n Self-Reported Pain A MANOVA, using age group as the between groups f a c t o r , was performed i n order to determine whether s i g n i f i c a n t d i f f e r e n c e s between age groups due to the m u l t i v a r i a t e combination of pain v a r i a b l e s e x i s t e d . U n i v a r i a t e one-way ANOVA's were planned, as a follow-up to the MANOVA, as w e l l as t o t e s t s p e c i f i c u n i v a r i a t e d i r e c t i o n a l hypotheses, made a p r i o r i . I I . Age/Cognitive Developmental D i f f e r e n c e s i n Coping S t r a t e g i e s and C a t a s t r o p h i z i n g Cognitions A second MANOVA, using age group as the between groups f a c t o r was performed i n order to determine whether s i g n i f i c a n t d i f f e r e n c e s between age groups due to the m u l t i v a r i a t e combination of coping and c a t a s t r o p h i z i n g v a r i a b l e s e x i s t e d . U n i v a r i a t e one-way ANOVA's were performed as a follow-up -Ik -to an o v e r a l l s i g n i f i c a n t MANOVA. S p e c i f i c u n i v a r i a t e d i r e c t i o n a l hypotheses made a p r i o r i were followed up using t - t e s t s . A Bo n f e r r o n i stepped-down alpha l e v e l ( H a r r i s , 1975) ( i . e . , alpha l e v e l of .05 d i v i d e d by the number of coping and c a t a s t r o p h i z i n g v a r i a b l e s = .0125) was a p p l i e d to the u n i v a r i a t e analyses to f u r t h e r guard against i n f l a t i o n of the experiment-wise Type 1 e r r o r r a t e . I I I . Coping E f f e c t i v e n e s s E v a l u a t i o n The three f u n c t i o n a l d i s a b i l i t y measures were used to c l a s s i f y s u b j e c t s i n t o two "coping e f f e c t i v e n e s s " groups. For t h i s purpose, s u b j e c t s ' scores (expressed as z scores) on the three f u n c t i o n a l d i s a b i l i t y measures were subjected to a p r i n c i p l e component a n a l y s i s . A median s p l i t on the r e s u l t i n g f u n c t i o n a l d i s a b i l i t y f a c t o r scores was then used to a s s i g n subjects as e i t h e r " e f f e c t i v e copers" or " l e s s e f f e c t i v e copers". In order to assess the r e l a t i v e c o n t r i b u t i o n of the pain v a r i a b l e s , b e h a v i o r a l coping subtypes, c o g n i t i v e coping subtypes and c a t a s t r o p h i z i n g subtypes i n d i s c r i m i n a t i n g " e f f e c t i v e copers" from " l e s s e f f e c t i v e copers", these se t s of dependent v a r i a b l e s were then entered i n t o a step-wise d i s c r i m i n a n t f u n c t i o n a n a l y s i s . Since f u n c t i o n a l d i s a b i l i t y i s t y p i c a l l y c o r r e l a t e d w i t h disease s t a t u s , i t was expected that subjects c l a s s i f i e d as " e f f e c t i v e copers" ( i e . lower f u n c t i o n a l d i s a b i l i t y f a c t o r score) would a l s o tend to have a l e s s severe disease s t a t u s , whereas su b j e c t s c l a s s i f i e d as " l e s s e f f e c t i v e copers" ( i e . higher f u n c t i o n a l d i s a b i l i t y f a c t o r scores) would a l s o tend to have a more severe disease s t a t u s . Therefore, i n an attempt to s i f t disease s t a t u s f a c t o r s out of the c l a s s i f i c a t i o n of coping e f f e c t i v e n e s s groups, and thus gain i n t e r p r e t i v e c l a r i t y , s u b j e c t s were c l a s s i f i e d a second way, removing the c o n t r i b u t i o n of the d i s e a s e - r e l a t e d v a r i a b l e s measured. For t h i s purpose, a r e g r e s s i o n a n a l y s i s , using disease s t a t u s f a c t o r scores ( s u b j e c t s ' scores on the f i r s t p r i n c i p l e component derived from the d i s e a s e - r e l a t e d v a r i a b l e s ) to p r e d i c t f u n c t i o n a l d i s a b i l i t y f a c t o r scores was c a l c u l a t e d . Subjects' - 75 -r e s i d u a l i z e d scores ( r e s i d u a l i z e d about the r e g r e s s i o n l i n e ) were then computed by s u b t r a c t i n g s u b j e c t s ' p r e d i c t e d f u n c t i o n a l d i s a b i l i t y scores ( c a l c u l a t e d using the beta weights y i e l d e d i n the r e g r e s s i o n a n a l y s i s ) from s u b j e c t s ' a c t u a l f u n c t i o n a l d i s a b i l i t y scores ( i e . r e s i d u a l i z e d score = y-y, where y = b^(x) + bg, s e t t i n g x = disease s t a t u s f a c t o r score and y = f u n c t i o n a l d i s a b i l i t y f a c t o r s c o r e ) . A median s p l i t on the r e s u l t i n g r e s i d u a l i z e d scores was then used to ass i g n s u b j e c t s as e i t h e r " e f f e c t i v e copers", or " l e s s e f f e c t i v e copers" ( r e f e r r i n g i n t h i s case to p s y c h o l o g i c a l coping e f f e c t i v e n e s s , w i t h the c o n t r i b u t i o n of disease s t a t u s v a r i a b l e s s t a t i s t i c a l l y removed). A second step-wise d i s c r i m i n a n t f u n c t i o n , a n a l y s i s based on t h i s r e c l a s s i f i c a t i o n of "coping e f f e c t i v e n e s s " groups was then performed, e n t e r i n g the same s e t s of dependent v a r i a b l e s as were entered i n the f i r s t a n a l y s i s . RESULTS I . Age/Cognitive Developmental D i f f e r e n c e s i n Self-Reported Pain A t o t a l of four pain v a r i a b l e s (present pain i n t e n s i t y VAS, worst pain i n t e n s i t y VAS, number of sensory pain d e s c r i p t o r s endorsed, and number of a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s endorsed) were analyzed i n a one-way MANOVA. The o v e r a l l MANOVA was n o n s i g n i f i c a n t (Wilks Lambda = .77, F(6, 64) = 1.46, 2. > -05), t h e r e f o r e followup u n i v a r i a t e analyses are not v a l i d to re p o r t . D e s c r i p t i v e data on these v a r i a b l e s i s i n t e r e s t i n g to note, however. See Table 8 f o r a summary of mean scores on the pain v a r i a b l e s by age group. (1) Present pain i n t e n s i t y VAS r a t i n g . When q u a n t i f y i n g the amount of pain f e l t during the range of motion t a s k , subjects used almost the f u l l range of the VAS (0-98 mm). Twenty-two s u b j e c t s chose p o i n t s below 50 mm (the mi d p o i n t ) , and 17 chose p o i n t s above 50 mm (see Table 9 ) . The mean i n t e n s i t y r a t i n g s by age group, from youngest to o l d e s t were: 46 mm, 47 mm, and 47 mm. The . o v e r a l l n o n s i g n i f i c a n c e of the MANOVA i n d i c a t e s t h a t these means were not 76 -Table 8. Summary of Mean Scores on Pain V a r i a b l e s by Age Group Number of Sensory Number of A f f e c t i v e Present Pain Worst Pain D e s c r i p t o r s or E v a l u a t i v e VAS* VAS* Endorsed D e s c r i p t o r s Endorsed 5-7 y r s . 46 (34) 28 (35) 6.9 (8.2) 3.4 (4.4) 8-10 y r s . 47 (27) 27 (30) 8.8 (6.8) 3.6 (2.2) 11-18 y r s . 47 (31) 64 (39) 10.0 (3.8) 3.2 (2.7) n = 13 per group *expressed i n mm - 77 -Table 9. Number of Subjects Marking Above the Midpoint on the VAS Ratings Age group Present Pain Worst Pain Over Past Week 5-7 y r s . 5 3 8-10 y r s . 5 3 11-18 y r s . 7 9 n = 13 i n each group - 78 -s i g n i f i c a n t l y d i f f e r e n t from one another, as was p r e d i c t e d . (2) Worst pain i n t e n s i t y over the past week VAS r a t i n g . S i m i l a r to the present pain VAS r a t i n g s , s u b j e c t s used the f u l l range of the VAS (0-100 mm) when r a t i n g the worst pain they had experienced i n t h e i r j o i n t s over'the past week. Twenty-four subjects chose p o i n t s below 50 mm, and 15 chose p o i n t s above 50 mm. The m a j o r i t y of subjects s c o r i n g above the midpoint were i n the o l d e s t age group (see Table 9 ) . The mean r a t i n g s by age group, from youngest to o l d e s t groups were: 28 mm, 27 mm and 64 mm. V i s u a l i n s p e c t i o n of these means i n d i c a t e s a p o s s i b l e trend toward higher worst pain VAS r a t i n g s , on average, i n the older group. Consistent w i t h t h i s i n t e r p r e t a t i o n i s the f i n d i n g t h a t the ma j o r i t y of sub j e c t s who scored above the midpoint on the VAS were i n the older age group. Because of the n o n s i g n i f i c a n t o v e r a l l MANOVA, a true u n i v a r i a t e e f f e c t f o r t h i s v a r i a b l e cannot be confirmed, however. (3) Number of sensory pain d e s c r i p t o r s endorsed. On average, subjects i n the sample as a whole endorsed 9 (SD = 6) sensory pain d e s c r i p t o r s . The range of scores v a r i e d from 0 to 29 (the maximum number of sensory d e s c r i p t o r s was 30). The mean number of sensory d e s c r i p t o r s endorsed by age group from youngest to o l d e s t s u c c e s s i v e l y was: 6.9, 8.8, and 10.0. These age group d i f f e r e n c e s were not s t a t i s t i c a l l y s i g n i f i c a n t . T h i r t e e n of the sensory pain d e s c r i p t o r s were endorsed by 30% or more of the su b j e c t s (see Table 10). (4) Number of a f f e c t i v e or e v a l u a t i v e pain d e s c r i p t o r s endorsed. On average, subjects i n the sample as a whole endorsed 3 (SD = 3) a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s . The range of scores was 0-15 (the maximum number of a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s was 15). The mean number of a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s endorsed by age group from youngest to o l d e s t , s u c c e s s i v e l y was: 3.4, 3.6, 3.2 F i v e of the a f f e c t i v e or e v a l u a t i v e word d e s c r i p t o r s were endorsed by 30% or more of the sub j e c t s (see Table 11). The t o t a l number of pain d e s c r i p t o r s (sensory, a f f e c t i v e or e v a l u a t i v e ) - 79 -Table 10. Sensory Pain D e s c r i p t o r s Endorsed by More than 30% of the Sample De s c r i p t o r % of su b j e c t s endorsing sore 73 p u l l i n g 70 s t r e t c h i n g 57 squeezing 54 t i g h t 49 warm 43 pres s i n g 40 tugging 40 aching 40 pinching 38 hot 38 spreading 30 t i n g l i n g 30 n = 37 - 80 -Table 11. A f f e c t i v e or E v a l u a t i v e D e s c r i p t o r s Endorsed by more than 30% of Subjects D e s c r i p t o r % of Subjects Endorsing uncomfortable 76 t i r i n g 46 h o r r i b l e 35 t e r r i b l e 32 bad 32 n = 37 - 81 -endorsed was h i g h l y s i g n i f i c a n t l y c o r r e l a t e d (p_ < .001) w i t h s u b j e c t s ' present pain VAS r a t i n g s , but was not s i g n i f i c a n t l y c o r r e l a t e d w i t h t h e i r VAS r a t i n g s of worst j o i n t pain over the past week (see Table 12). Two a d d i t i o n a l r e s u l t s not i n v o l v i n g age group comparisons of pain v a r i a b l e s are i n t e r e s t i n g to note. F i r s t , VAS r a t i n g s of present pain i n t e n s i t y made by the subject and the p h y s i o t h e r a p i s t were s i g n i f i c a n t l y c o r r e l a t e d ( r = .46, JD = .001), however, a t - t e s t a n a l y s i s on the means revealed a s i g n i f i c a n t d i f f e r e n c e ( t = 5.46, _p_ < .01). i n d i c a t i n g a systematic b i a s , w i t h s u b j e c t s tending to rep o r t higher l e v e l s of pain than the two p h y s i o t h e r a p i s t s ' r a t i n g s . The mean VAS r a t i n g given by sub j e c t s was 47 mm (SD = 30), whereas the mean VAS r a t i n g given by the p h y s i o t h e r a p i s t s was 22 mm (SD = 24). Secondly, i t i s i n t e r e s t i n g to note t h a t mean present pain i n t e n s i t y VAS r a t i n g s c a l c u l a t e d f o r the sample as a whole (X = 47, SD = 30) was s l i g h t l y higher than mean VAS r a t i n g s of worst j o i n t pain experienced over the past week (X = 39, SD = 30). I I . Age/Cognitive Developmental D i f f e r e n c e s i n Coping S t r a t e g i e s  and C a t a s t r o p h i z i n g Cognitions Analyses used f o r t h i s research purpose were based on t o t a l frequency scores, s i n c e t h i s was the l e v e l of s p e c i f i c i t y of hypotheses to be t e s t e d . For d e s c r i p t i v e purposes, however, the number of sub j e c t s using the various b e h a v i o r a l and c o g n i t i v e coping s t r a t e g y subtypes, and experiencing c a t a s t r o p h i z i n g c o g n i t i o n subtypes were a l s o reported. Several of the o r i g i n a l l y proposed b e h a v i o r a l coping subtypes (see Appendix 1-1) were e i t h e r dropped from data analyses or were recombined. "Nonverbal c o n t a c t " was dropped because i t occurred i n only one s u b j e c t . "Nonverbal r e f u s a l " was dropped because of poor i n t e r r a t e r agreement. This category of b e h a v i o r a l coping was not scored by the coder i n any of the cases on which r e l i a b i l i t y was c a l c u l a t e d , whereas i t was scored i n three cases by the p r i n c i p l e - 82 -Table 12. R e l a t i o n s h i p Between Pain V a r i a b l e s Present Pain Worst Pain T o t a l Pain D e s c r i p t o r s Present Pain VAS Worst Pain .0712 VAS T o t a l P a i n D e s c r i p t o r .5919* .1564 n = 39 *p_ < .001 - 83 -i n v e s t i g a t o r . I t was b e l i e v e d , t h e r e f o r e , that the a c t u a l frequency of "nonverbal r e f u s a l " i n the present study may have been higher than the frequency recorded by the coder. Rather than combining "nonverbal r e f u s a l " w i t h the " v e r b a l r e f u s a l " category, because of low recorded frequency of occurrence, t h i s category was dropped from the analyses. "Information seeking" was combined w i t h " v e r b a l c o n t a c t " because of inf r e q u e n t occurrences of these two c a t e g o r i e s ; the combination subtype i s h e r e a f t e r r e f e r r e d to as "v e r b a l c o n t a c t " . F i n a l l y , " v o c a l pain e x p r e s s i o n " was combined w i t h "nonvocal pain e x p r e s s i o n " because of the inf r e q u e n t recordings of "nonvocal pain expression"; the combination subtype i s h e r e a f t e r r e f e r r e d to as "pain ex p r e s s i o n " [NOTE: I t must be cautioned that i n f r e q u e n t recordings of the "nonvocal pain e x p r e s s i o n " coping subtype may w e l l be due to the i m p r e c i s i o n of videorecordings used. Because of r e s t r i c t e d space i n the physiotherapy "room" (draped-off bed), the f u l l length of the c h i l d was not v i s i b l e a t one time, p r e c i p i t a t i n g the need to pan the camera at some p o i n t s i n order f o r the coder to see when j o i n t s were being worked on by the p h y s i o t h e r a p i s t . In a d d i t i o n , some e x e r c i s e s r e q u i r e d t h a t s u b j e c t s face away from the camera, making f a c i a l grimaces impossible to observe.] Secondly, as w i t h the b e h a v i o r a l coping coding, some of the o r i g i n a l l y proposed subtypes of c o g n i t i v e coping (see Appendix G) were e i t h e r dropped from analyses or combined. " B e h a v i o r - r e g u l a t i n g s e l f t a l k " was dropped because i t occurred i n only one sub j e c t . " E x t e r n a l a t t e n t i o n d i v e r s i o n " , because of i t s infrequent occurrence, was combined w i t h " i n t e r n a l a t t e n t i o n d i v e r s i o n " , c r e a t i n g a new category named " a t t e n t i o n d i v e r s i o n " . T h i r d l y , again because of infrequent occurrence, c a t a s t r o p h i z i n g c o g n i t i o n subtypes "concern about u n l i k e l y consequences", " l a c k of c o n t r o l " , and "thoughts of escape", o r i g i n a l l y proposed as separate c a t e g o r i e s (see Appendix H), were combined and renamed "other c a t a s t r o p h i z i n g " . - 84 -Age group d i f f e r e n c e s i n the t o t a l frequency of b e h a v i o r a l coping, c o g n i t i v e coping and c a t a s t r o p h i z i n g c o g n i t i o n s were f i r s t analyzed i n a one-way MANOVA, usin g age group as the between groups f a c t o r . An o v e r a l l s i g n i f i c a n t m u l t i v a r i a t e e f f e c t emerged (Wilk's lambda = .69, F(6, 68) = 2.27, £ <..05). Follow-up one-way ANOVAs using t o t a l frequency of b e h a v i o r a l coping and t o t a l frequency of c a t a s t r o p h i z i n g c o g n i t i o n s were n o n s i g n i f i c a n t (p. > .05), however the one-way ANOVA performed us i n g t o t a l frequency of c o g n i t i v e coping s t r a t e g i e s was s i g n i f i c a n t at the JD < .01 l e v e l (£(2, 36) = 5.38). For a summary of age group means and ANOVA r e s u l t s , see Table 13. A B o n f e r r o n i stepped down alpha l e v e l of .017 was a p p l i e d to the u n i v a r i a t e analyses to provide f u r t h e r c o n t r o l over Type 1 e r r o r . A p p l i c a t i o n of the B o n f e r r o n i c o r r e c t i o n d i d not remove the s i g n i f i c a n t e f f e c t f o r c o g n i t i v e coping s t r a t e g i e s . T - t e s t s were, i n t u r n performed to t e s t the s p e c i f i c a p r i o r i hypotheses of age group d i f f e r e n c e s i n the frequency of c o g n i t i v e coping s t r a t e g y use. The mean f o r the o l d e s t age group was revealed to be s i g n i f i c a n t l y d i f f e r e n t from that of the youngest group (_t = 3.25, _p_ < .02), however the o l d e s t group was not s i g n i f i c a n t l y d i f f e r e n t from the middle group and the middle group was not s i g n i f i c a n t l y d i f f e r e n t from the youngest group. See Figure 1 f o r a graph of mean frequency of c o g n i t i v e coping s t r a t e g y use by age group. In a d d i t i o n to the t o t a l frequency of b e h a v i o r a l coping, c o g n i t i v e coping and c a t a s t r o p h i z i n g c o g n i t i o n s , the proportions of t o t a l coping s t r a t e g y use accounted f o r by b e h a v i o r a l coping s t r a t e g y use was examined as a f o u r t h coping v a r i a b l e . Since t h i s v a r i a b l e i s derived from a recombination of two v a r i a b l e s entered i n t o the MANOVA, i t was not i n c l u d e d as one of the dependent v a r i a b l e s i n the MANOVA. A separate ANOVA performed to t e s t f o r age/cognitive developmental d i f f e r e n c e s i n the p r o p o r t i o n s of t o t a l coping s t r a t e g y use accounted f o r by b e h a v i o r a l coping s t r a t e g y use was h i g h l y s i g n i f i c a n t ( F ( 2 , - 85 -Table 13. Summary of Age group Means and U n i v a r i a t e ANOVA'S: Coping and C a t a s t r o p h i z i n g V a r i a b l e s Dependent V a r i a b l e 5-7 y r s 8-10 y r s 11-18 y r s F(2,36) _p_ T o t a l Frequency of Be h a v i o r a l Coping 4.1(3.5) 2.1(2.6) 2.5(3.3) 1.59 .2183 T o t a l Frequency of C o g n i t i v e Coping .31(.48) 2.7(2.3) 4.3(4.9) 5.38 .0090 T o t a l Frequency of C a t a s t r o p h i z i n g C o g n i t i o n s 2.1(3.2) 1.5(1.8) 2.9(1.9) 1.09 .3469 - 86 -Figure 1. Mean Frequency of C o g n i t i v e Coping Strategy Use by Age Group Mean Frequency (.31) K 2.7) 5-7 years 8-10 years i i - : (A.3) 8 years - 87 -20) = 9.46, 2 . < .001). See Table 14 f o r a summary of the age group means and ANOVA r e s u l t s f o r t h i s v a r i a b l e . Since no a p r i o r i hypotheses were made regarding t h i s v a r i a b l e , a Newman-Keuls post hoc m u l t i p l e comparisons t e s t was used to compare group means. Re s u l t s of t h i s a n a l y s i s revealed the o l d e s t group to be s i g n i f i c a n t l y d i f f e r e n t from the youngest group (p_ < .01) but not s i g n i f i c a n t l y d i f f e r e n t from the middle group (JD > .05). The middle group was a l s o shown to be s i g n i f i c a n t l y d i f f e r e n t from the youngest group (JD < .01). For d e s c r i p t i v e purposes, the number of sub j e c t s demonstrating the various b e h a v i o r a l coping s t r a t e g y subtypes and r e p o r t i n g c o g n i t i v e coping, and c a t a s t r o p h i z i n g subtypes are summarized i n Tables 15-17. V i s u a l i n s p e c t i o n of Table 15 i n d i c a t e s a decrease by age group i n the number of sub j e c t s using " v e r b a l c o n t a c t " as a b e h a v i o r a l coping s t r a t e g y , but not i n the number using "pain e x p r e s s i o n " or " v e r b a l r e f u s a l " . Secondly, a general p a t t e r n of successive i n c r e a s e s by age group i n the number of sub j e c t s r e p o r t e d l y using each of the c o g n i t i v e coping s t r a t e g y subtypes i s revealed (see Table 16). T h i r d l y , v i s u a l i n s p e c t i o n s of Table 16 i n d i c a t e s a jump i n the number of subjects i n the older group r e p o r t e d l y experiencing "other c a t a s t r o p h i z i n g " c o g n i t i o n s . I t was the i n v e s t i g a t o r ' s impression, based on t h i s v i s u a l i n s p e c t i o n of the data that perhaps some, but not a l l , subtypes of b e h a v i o r a l coping decreased i n frequency w i t h age, and some, but not a l l , c a t a s t r o p h i z i n g subtypes increased w i t h age. I n i t i a l ANOVA's performed on combined frequency of b e h a v i o r a l coping s t r a t e g i e s used and combined frequency of c a t a s t r o p h i z i n g c o g n i t i o n s r e p o r t e d l y experienced, would l i k e l y have masked such an e f f e c t i f i t d i d i n f a c t e x i s t . Therefore e x p l o r a t o r y f o l l o w up ANOVA's were performed on the frequency data f o r the three b e h a v i o r a l coping subtypes and the two c a t a s t r o p h i z i n g subtypes. A B o n f e r r o n i stepped down alpha l e v e l of .01 (ie.o< = .05 f 5) was a p p l i e d to the u n i v a r i a t e analyses to provide c o n t r o l over Type - 88 -Table 14. Summary of Age Group Means and U n i v a r i a t e ANOVAS: Pro p o r t i o n of T o t a l Coping Accounted f o r by B e h a v i o r a l Coping X Dependent V a r i a b l e 5-7 y r s 8-10 y r s 11-18 y r s F(2,30) £ P r o p o r t i o n .95(.07) .41(.39) .38(.41) 9.46 .0007 N = 33 (NOTE: 6 s u b j e c t s were excluded from t h i s a n a l y s i s because no coping s t r a t e g i e s were recorded). - 89 -Table 15. Number of Subjects Using B e h a v i o r a l Coping Subtypes at Least Once Age Group Beha v i o r a l Coping Subtype 5-7 y r s 8-10 y r s 11-18 y r s Verbal contact 7 1 1 pain expression 9 7 7 v e r b a l r e f u s a l 2 3 3 n = 13 i n each group - 90 -Table 16. Number of Subjects Reportedly Using C o g n i t i v e Coping Subtypes at Least Once Age Group C o g n i t i v e Coping Subtype 5-7 y r s . 8-10 y r s . 11-18 y r s . emotion-regulating s e l f t a l k 0 2 3 a t t e n t i o n d i v e r s i o n 1 5 7 thoughtstopping 1 1 4 r e a l i t y - o r i e n t e d working through 1 4 8 c o g n i t i v e r e s t r u c t u r i n g 1 4 6 n = 13 i n each group Table 17. Number of Subjects Reportedly Experiencing C a t a s t r o p h i z i n g Subtypes at Least Once Age Group C a t a s t r o p h i z i n g Subtypes 5-7 y r s . 8-10 y r s . 11-18 Thought of pain or f e a r / a n x i e t y 8 10 11 Other c a t a s t r o p h i z i n g 3 2 6 n = 13 i n each group - 92 -I e r r o r . A s i g n i f i c a n t age group e f f e c t emerged f o r the " v e r b a l c o n t a c t " be h a v i o r a l coping subtype (F(2, 36) = 5.94, £ < .01), but not f o r the other two b e h a v i o r a l coping subtypes, nor f o r the two c a t a s t r o p h i z i n g subtypes (j>. > .05). A Newman-Keuls post hoc m u l t i p l e comparisons t e s t was used to compare group means f o r the v e r b a l contact v a r i a b l e . R e sults of t h i s a n a l y s i s revealed the o l d e s t group to be s i g n i f i c a n t l y d i f f e r e n t from the youngest group (j> < .01), but not s i g n i f i c a n t l y d i f f e r e n t from the middle group (_p_ > .05). The middle group was a l s o shown to be h i g h l y s i g n i f i c a n t l y d i f f e r e n t from the youngest group (£ < .01). Also of i n t e r e s t to note are the "miscellaneous other" types of coping and c a t a s t r o p h i z i n g noted by the coders and the p r i n c i p l e i n v e s t i g a t o r when viewing videotapes of e n t i r e physiotherapy sessions and s c o r i n g w r i t t e n p r o t o c o l s . The c h i l d r e n demonstrated and reported using a wide v a r i e t y of coping s t r a t e g i e s . To l i m i t a d e s c r i p t i o n of t h e i r coping s t r a t e g i e s to the c a t e g o r i e s f o r m a l l y coded, or to i n f e r that subjects f o r whom few or no s t r a t e g i e s were coded lacked s t r a t e g i e s of any kind would do them a d i s s e r v i c e . Therefore, a l i s t of "miscellaneous other" s t r a t e g i e s was compiled (see Table 18). In a d d i t i o n , v a r i a t i o n between c h i l d r e n using the same s t r a t e g i e s (and thus coded the same) was a l s o noted. For example, some c h i l d r e n v o c a l l y expressed pain by u t t e r i n g a s e r i e s of s o f t "ow's", others by exclaiming louder "that h u r t s ! " and sounding ind i g n a n t , and others expressed pain nonvocally by grimacing. I n d i v i d u a l d i f f e r e n c e s i n the types of i n f o r m a t i o n sought from the p h y s i o t h e r a p i s t a l s o were noted. I t was the impression of the primary i n v e s t i g a t o r that older c h i l d r e n tended to ask more s o p h i s t i c a t e d questions about disease process or d a i l y l i v i n g i m p l i c a t i o n s (eg. why hasn't my disease r e m i t t e d ? , or w i l l i t be OK f o r me to do a l l the karate e x e r c i s e s ? ) , whereas younger c h i l d r e n tended to ask questions r e l a t i n g to present physiotherapy a c t i v i t i e s or o b j e c t s used i n physiotherapy (eg. what - 93 -Table 18: Miscellaneous Other Coping S t r a t e g i e s Observed and/or Reported 1. s t o i c i s m / a v o i d i n g pain expression (eg. l y i n g p e r f e c t l y q u i e t and s t i l l , perhaps with eyes closed) 2. imaginary play w i t h the goniometer (eg. using i t as a pretend gun or measuring a d o l l ' s j o i n t ) 3. avo i d i n g a l l p o s s i b l e v e r b a l and nonverbal contact w i t h the p h y s i o t h e r a p i s t / d i s c o u r a g i n g development of a f r i e n d l y r e l a t i o n s h i p w i t h the p h y s i o t h e r a p i s t (eg. covering ears, l o o k i n g away, c l o s i n g eyes) 4. f i d g e t t i n g , w r i g g l i n g , bouncing on the bed 5. being mischievous (eg. h i d i n g the p h y s i o t h e r a p i s t ' s pen or goniometer) 6. performing e x e r c i s e s i n a way t h a t ' s not p a i n f u l (eg. remove e x t r a weight from weight bag, a f t e r the angle j o i n t i s moved a t ) 7. nonverbal i n f o r m a t i o n seeking (eg. c l o s e l y watch the p h y s i o t h e r a p i s t ' s a c t i o n s , or l o o k i n g on the goniometer to see how f a r t h e i r j o i n t moved) 8. being e x t r a cooperative (eg. doing more e x e r c i s e s than t o l d to do, or t e l l i n g the p h y s i o t h e r a p i s t to push f a r t h e r on t h e i r j o i n t ) 9. asking f o r a break mid-treatment session 10. having a c o l d pepsi ready to dr i n k when the treatment s e s s i o n i s over 11. c r e a t i n g minor pain by pinching the nose i n order to d e t r a c t a t t e n t i o n from j o i n t pain 12. planning to v i s i t a f a i t h healer 13. asking f o r an e x t r a strength T y l e n o l 14. r o l l e r s k a t i n g (the v i b r a t i o n r e p o r t e d l y helps) 15. t a k i n g a bath or t h i n k i n g about being i n a bath 16. hot water b o t t l e 17. reading 18. t e l l your parents i t ' s h u r t i n g so they can take you to the doctor and get i t ( a r t h r i t i s ) under c o n t r o l - 94 -are these hot packs made o f ? , or how f a r d i d I g e t ? ) . I I I . Coping E f f e c t i v e n e s s E v a l u a t i o n F u n c t i o n a l d i s a b i l i t y measures: D e s c r i p t i v e data. As i n d i c a t e d i n Table 19, the mean scores on the three f u n c t i o n a l d i s a b i l i t y measures were qu i t e low. Subjects, on average, were reported by parents and r a t e d by the p h y s i o t h e r a p i s t as coping w e l l w i t h t h e i r pain ( i . e . , not a l l o w i n g i t to i n t e r f e r e w i t h t h e i r a c t i v i t i e s of d a i l y l i v i n g ) . (1) Subjects' scores on the I n t e r f e r e n c e w i t h A c t i v i t i e s Questionnaire completed by parents showed the most v a r i a b i l i t y of the three f u n c t i o n a l d i s a b i l i t y measures, ranging from 0 to 30 (maximum p o s s i b l e = 48). The a c t i v i t i e s most o f t e n rated as i n t e r f e r e d w i t h by pain were s p o r t s , f a v o u r i t e a c t i v i t i e s , enjoying the f a m i l y , a p p e t i t e , and attending school. See Table 20 f o r a summary of a c t i v i t i e s which are r e p o r t e d l y l i m i t e d ( a t l e a s t "sometimes") by p a i n . (2) For the d i s a b i l i t y s c a l e from the HAQ, t o t a l scores, r a t h e r than D i s a b i l i t y Index scores, were used i n the s t a t i s t i c a l analyses. T o t a l Scores ranged from 0 to 30 (maximum p o s s i b l e = 39), w i t h the m a j o r i t y of s u b j e c t s s c o r i n g at or c l o s e to 0. [NOTE: The mean D i s a b i l i t y Index Score, c a l c u l a t e d as s p e c i f i e d by F r i e s et a l . (1980) was .5, on a s c a l e where 0 = "no problems" and 1 = "some problems".] (3) The m a j o r i t y of subjects (n = 23) r e c e i v e d a f u n c t i o n a l c a p a c i t y r a t i n g from the p h y s i o t h e r a p i s t of 1 (1 = "complete a b i l i t y to c a r r y on a l l usual d u t i e s without handicap"). T h i r t e e n subjects were c l a s s i f i e d as 2 (2 = "adequate f o r normal a c t i v i t i e s d e s p i t e handicap of discomfort or l i m i t e d motion i n one or more j o i n t s " ) . Only three subjects were c l a s s i f i e d as 3 (3 = " l a r g e l y or wholly bedridden or confined to a wheelchair; l i t t l e or no s e l f - c a r e " ) . The three f u n c t i o n a l d i s a b i l i t y measures (2 parent questionnaires and 1 Table 19. Mean Scores on F u n c t i o n a l D i s a b i l i t y Measures I n t e r f e r e n c e w i t h A c t i v i t i e s Questionnaire 11.66 (8.OA) (parent r e p o r t ) HAQ D i s a b i l i t y s c a l e 5.92 (8.25) (parent r e p o r t ) Steinbrocker F u n c t i o n a l A b i l i t y Rating 1.49 ( .64) ( p h y s i o t h e r a p i s t r a t i n g ) n = 38 - 96 -Table 20. A c t i v i t i e s w i t h which Pain Reportedly I n t e r f e r e s Number of parents r e p o r t i n g that pain i n t e r f e r e s , at l e a s t "sometimes" w i t h A c t i v i t y that a c t i v i t y s p o rts 28 f a v o r i t e a c t i v i t i e s 20 enjoying f a m i l y 16 e a t i n g / a p p e t i t e 16 attending school 16 s l e e p i n g 1A schoolwork 13 u n l i k e d a c t i v i t i e s 13 seeing f r i e n d s 10 T.V./reading/movie-going 3 n = 38 NOTE: The response options f o r frequency of i n t e r f e r e n c e "sometimes", " o f t e n " , or "always" were c o l l a p s e d f o r t h i s t a b l e . - 97 -physiotherapist rating) were a l l highly s i g n i f i c a n t l y i n t e r c o r r e l a t e d (£ < .001), lending support for the construct v a l i d i t y of the r a t i n g s . Disease r e l a t e d v a r i a b l e s : d e s c r i p t i v e data. As noted i n the methods section, the seven disease-related variables were included for d e s c r i p t i v e purposes as well as to s t a t i s t i c a l l y evaluate and remove the contribution of disease status from the c l a s s i f i c a t i o n of subjects i n t o coping effectiveness groups. F i r s t , d e s c r i p t i v e data are presented. (1) Type of a r t h r i t i s . As noted i n the des c r i p t i o n of subjects, the majority of subjects (n=23) were diagnosed as having JRA. Other types of a r t h r i t i s represented i n the subject sample included: Lupus, MCTD, JAS, SEA syndrome and p s o r i a t i c a r t h r i t i s . Type of a r t h r i t i s was quantified for the purposes of s t a t i s t i c a l analyses by assigning each type of code number. (2) Duration of i l l n e s s . The average number of months with the disease was 56. (3) Medications prescribed. The majority of subjects were prescribed one nonsteroidal anti-inflammatory-analgesic medication (most commonly T o l e c t i n , Enterophen, or Naproxen). Nine subjects were re c e i v i n g c o r t i c o s e r o i d therapy (Prednisone). Three of these nine subjects and f i v e a d d i t i o n a l subjects were also r e c e i v i n g disease-remitting agents (gold s a l t i n j e c t i o n s , hydroxychloroquine, or Salazopyrine). See Table 21 for a more s p e c i f i c summary of medications prescribed. Medication type was quantified f o r the purposes of s t a t i s t i c a l analyses by assigning each combination of medication types a code number. (A) Number of j o i n t s a f f e c t e d . The number of j o i n t s i n which there has, at some point, been inflammation ranged from 0 to 60. The majority of subjects (n = 28) had nine or les s affected j o i n t s . I t must be cautioned, that for some ch i l d r e n with multiple j o i n t s involved, number of j o i n t s used for s t a t i s t i c a l purposes should not be interpreted as exact, since precise - 98 -Table 21. Medications P r e s c r i b e d to Subjects i n Sample Medication Type n not p r e s e n t l y on medication 4 1 n o n s t e r o i d a l anti-inflammatory-analgesic 20 disease r e m i t t i n g agent alone 1 disease r e m i t t i n g agent + 1 n o n s t e r o i d a l a n t i - i n f l a m m a t o r y - a n a l g e s i c 4 1 s t e r o i d a l + 1 n o n s t e r o i d a l a n t i - i n f l a m m a t o r y - a n a l g e s i c s 5 1 s t e r o i d a l + 2 n o n s t e r o i d a l anti-inflammatory-analgesic 1 1 s t e r o i d a l + 1 n o n s t e r o i d a l anti-inflammatory-analgesic + disease r e m i t t i n g agent 3 - 99 -es t i m a t i o n of number of j o i n t s a f f e c t e d i n these cases was not p o s s i b l e . (5) Number of j o i n t s w i t h a c t i v e inflammation. A c t i v e j o i n t counts ranged from 0 to A3 w i t h a mean of 7. (6) Erythrocyte Sedimentation Rate (ESR). ESR data were missing f o r 12 s u b j e c t s . For the remaining 27 s u b j e c t s , ESR values ranged from 7 to 80 mm wi t h a mean of 30 mm f a l l i n one hour. [NOTE: With a moderate degree of inflammation, the ESR (Westergren) g e n e r a l l y f a l l s between 15-A0 mm i n one hour ( F i s c h e l , 1967).] (7) Gl o b a l Rating of Disease S e v e r i t y . The m a j o r i t y of su b j e c t s (n=25) were assigned a g l o b a l disease s e v e r i t y r a t i n g of " m i l d " or "moderate". Seven sub j e c t s were assigned a r a t i n g of "none", s i x were assigned a r a t i n g of "severe" and only one subject was assigned a g l o b a l r a t i n g of "very severe". Coping e f f e c t i v e n e s s c l a s s i f i c a t i o n . For some s u b j e c t s , parents and the p h y s i o t h e r a p i s t d i d re p o r t that pain at times, i n t e r f e r e d w i t h a c t i v i t i e s of d a i l y l i v i n g (ADL). I t i s these subjects who were c l a s s i f i e d as " l e s s e f f e c t i v e copers". I t must be recognized, however, t h a t although these c h i l d r e n had higher' f u n c t i o n a l d i s a b i l i t y scores than subjects c l a s s i f i e d as " e f f e c t i v e copers", they should not be considered "noncopers". P r i o r to c l a s s i f y i n g s u bjects as " e f f e c t i v e copers" or " l e s s e f f e c t i v e copers", s u b j e c t s ' scores on the three f u n c t i o n a l d i s a b i l i t y measures were converted i n t o Z scores i n order to standardize t h e i r m e t r i c . These f u n c t i o n a l d i s a b i l i t y Z scores were then subjected to a p r i n c i p l e component a n a l y s i s . One f a c t o r emerged with an eigenvalue greater than 1. This f u n c t i o n a l d i s a b i l i t y f a c t o r accounted f o r 68.6% of the variance (see Table 22). Since only one f a c t o r was e x t r a c t e d , the s o l u t i o n could not be r o t a t e d . Subjects were c l a s s i f i e d as " e f f e c t i v e copers" or " l e s s e f f e c t i v e copers", using a median s p l i t on t h e i r f u n c t i o n a l d i s a b i l i t y f a c t o r scores. C l a s s i f i c a t i o n of s u b j e c t s i n t o "coping e f f e c t i v e n e s s " groups was a l s o - 1 0 0 -Table 22. P r i n c i p l e Component A n a l y s i s of Subjects' Z Scores on the F u n c t i o n a l D i s a b i l i t y Measures Factor Measure 1 In t e r f e r e n c e w i t h A c t i v i t i e s Questionnaire .37 HAQ D i s a b i l i t y Scale .42 Steinbrocker F u n c t i o n a l A b i l i t y Rating .41 n = 38 - 101-performed a second way, using a median s p l i t on s u b j e c t s ' r e s i d u a l i z e d f u n c t i o n a l d i s a b i l i t y f a c t o r scores (see s t a t i s t i c a l analyses s e c t i o n f o r e x p l a n a t i o n ) . This a d d i t i o n a l method of c l a s s i f i c a t i o n was included i n an attempt to s i f t out disease s t a t u s from coping e f f e c t i v e n e s s , as c l a s s i f i e d these two ways. The seven d i s e a s e - r e l a t e d v a r i a b l e s were f i r s t subjected to a p r i n c i p l e component a n a l y s i s and r o t a t e d orthogonally w i t h varimax r o t a t i o n . Two f a c t o r s emerged with eigenvalues greater than 1. These f a c t o r s accounted f o r 64.7% of the variance (see Table 23). Type of a r t h r i t i s and du r a t i o n of i l l n e s s , i t can be seen, load much more h e a v i l y on a separate f a c t o r from the other medical v a r i a b l e s . Since n e i t h e r type of a r t h r i t i s nor duration of i l l n e s s c o r r e l a t e d s i g n i f i c a n t l y w i t h any of the three f u n c t i o n a l d i s a b i l i t y measures, whereas a l l other medical v a r i a b l e s d i d c o r r e l a t e s i g n i f i c a n t l y w i t h f u n c t i o n a l d i s a b i l i t y , and si n c e type of a r t h r i t i s and du r a t i o n of i l l n e s s load onto a separate f a c t o r from the other medical v a r i a b l e s , i t was decided that a second p r i n c i p l e component would be run, excluding these two v a r i a b l e s from the analyses. F u r t h e r , s i n c e ESR data was e i t h e r missing or a number of months out of date f o r s e v e r a l s u b j e c t s , and thus was reducing the sample s i z e a v a i l a b l e f o r the p r i n c i p l e component a n a l y s i s , t h i s v a r i a b l e was a l s o dropped. The remaining four d i s e a s e - r e l a t e d v a r i a b l e s (number of j o i n t s a f f e c t e d , medication, current inflammation r a t i n g , and g l o b a l s e v e r i t y r a t i n g ) were then subjected to a second p r i n c i p l e component a n a l y s i s . One f a c t o r emerged with an eigenvalue greater than 1. This f a c t o r accounted f o r 66.6% of the variance (see Table 24). I t was t h i s f a c t o r which was used as the "disease s t a t u s f a c t o r " . To summarize, subjects were c l a s s i f i e d i n t o " e f f e c t i v e copers" and " l e s s e f f e c t i v e copers" two ways ( f i r s t , u sing a median s p l i t on t h e i r f u n c t i o n a l - 102-Table 23. P r i n c i p l e Component A n a l y s i s of a l l Seven Disease-Related V a r i a b l e s Measure Factor 1 2 Type of A r t h r i t i s -.02296 -.54646 Duration of I l l n e s s -.04791 .58206 Number of J o i n t s A f f e c t e d .28220 -.14506 Medication .22249 .12052 Current Inflammation Rating .27561 -.14044 ESR .21227 .23084 Glo b a l S e v e r i t y Rating .24670 .03214 n = 38 - 103-Table 24. P r i n c i p l e Component A n a l y s i s of the Four Chosen Disease-Related V a r i a b l e s Factor Measure 1 Number of j o i n t s a f f e c t e d .34457 Medication .22556 Current inflammation r a t i n g .34587 Global s e v e r i t y r a t i n g .29336 n = 38 - 104-d i s a b i l i t y f a c t o r scores, and secondly, using a median s p l i t on t h e i r r e s i d u a l i z e d f u n c t i o n a l d i s a b i l i t y s c o r e s ) . Two step-wise d i s c r i m i n a n t f u n c t i o n analyses were then performed to determine which dependent v a r i a b l e s o p t i m a l l y d i s c r i m i n a t e d " e f f e c t i v e copers" from " l e s s e f f e c t i v e copers". Three pain v a r i a b l e s (present pain VAS, worst pain VAS, and t o t a l number of pain d e s c r i p t o r s endorsed) a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s ) were entered as dependent v a r i a b l e s . In a d d i t i o n , the f o l l o w i n g ten coping and c a t a s t r o p h i z i n g subtypes were entered: 1. v e r b a l contact, 2. pain expression, 3. v e r b a l r e f u s a l , 4. emotion-regulating s e l f - t a l k , 5. a t t e n t i o n d i v e r s i o n , 6. thought stopping, 7. r e a l i t y - o r i e n t e d working through, 8. c o g n i t i v e r e a p p r a i s a l , 9. thoughts of pain or f e a r / a n x i e t y and 10. other c a t a s t r o p h i z i n g . R e s u l t s of the d i s c r i m i n a n t f u n c t i o n analyses revealed that one beh a v i o r a l coping v a r i a b l e ( p a i n e x p r e s s i o n ) , three c o g n i t i v e coping v a r i a b l e s (emotion-regulating s e l f - t a l k , c o g n i t i v e r e a p p r a i s a l and thoughtstopping), and one c a t a s t r o p h i z i n g v a r i a b l e (other c a t a s t r o p h i z i n g ) emerged as s i g n i f i c a n t (jp_ < .01) i n making the d i s c r i m i n a t i o n between su b j e c t s c l a s s i f i e d as " e f f e c t i v e copers" and " l e s s e f f e c t i v e copers" (see Table 25). The d i s c r i m i n a n t f u n c t i o n based on these v a r i a b l e s c o r r e c t l y c l a s s i f i e d 78.95% of s u b j e c t s . Three " e f f e c t i v e copers" were m i s c l a s s i f i d as " l e s s e f f e c t i v e copers", while f i v e " l e s s e f f e c t i v e copers" were m i s c l a s s i f i e d as " e f f e c t i v e copers". Emotion-regulating s e l f - t a l k and thoughtstopping were n e g a t i v e l y weighted i n the d i s c r i m i n a t i o n between " e f f e c t i v e copers" versus " l e s s e f f e c t i v e copers", whereas pain expression, c o g n i t i v e r e a p p r a i s a l and other c a t a s t r o p h i z i n g were p o s i t i v e l y weighted (see Table 26). In the second step-wise d i s c r i m i n a n t f u n c t i o n a n a l y s i s , grouping subjects i n t o " e f f e c t i v e copers" and " l e s s e f f e c t i v e copers" on the b a s i s of r e s i d u a l i z e d scores, none of the p a i n , coping or c a t a s t r o p h i z i n g v a r i a b l e s emerged as s i g n i f i c a n t d i s c r i m i n a t o r s . Since s u b j e c t s ' scores on the - 105-Table 25. D i s c r i m i n a n t Function A n a l y s i s R e s u l t s V a r i a b l e Step Entered Wilk's Lambda pain expression 1 .78* other c a t a s t r o p h i z i n g 2 .73* emotion-regulating s e l f - t a l k 3 .67* c o g n i t i v e r e a p p r a i s a l 4 .63* thoughtstopping 5 .61* n = 38 *p_ < .01 - 106-Table 26. C o r r e l a t i o n of V a r i a b l e s w i t h the F i r s t D i s c r i m i n a n t Function V a r i a b l e Canonical C o r r e l a t i o n C o e f f i c i e n t pain expression .67 other c a t a s t r o p h i z i n g .40 emotion-regulating s e l f - t a l k -.35 c o g n i t i v e r e a p p r a i s a l .13 thoughtstopping -.11 - 107-f u n c t i o n a l d i s a b i l i t y f a c t o r and disease s t a t u s f a c t o r were so h i g h l y c o r r e l a t e d (r_ = .78), removing the variance a t t r i b u t a b l e to the disease s t a t u s f a c t o r r e s u l t e d i n coping e f f e c t i v e n e s s groups nondiscriminable using p a i n , coping or c a t a s t r o p h i z i n g v a r i a b l e s . Therefore, the f i r s t d i s c r i m i n a n t f u n c t i o n a n a l y s i s performed, using only f u n c t i o n a l d i s a b i l i t y f a c t o r scores to group s u b j e c t s was used i n l a t e r i n t e r p r e t a t i o n s . I t must be s t r e s s e d , however, that coping e f f e c t i v e n e s s c l a s s i f i e d i n t h i s manner does not j u s t r e f l e c t p s y c h o l o g i c a l coping, but that disease s t a t u s i s i n e x o r a b l y intermixed i n the c l a s s i f i c a t i o n . DISCUSSION I . Age/Cognitive Developmental D i f f e r e n c e s i n Self-Reported Pain (1) Present pain VAS. As hypothesized [H]_: M^ = M 2 = M3], on average, age groups d i d not d i f f e r s i g n i f i c a n t l y i n i n t e n s i t y of pain r e p o r t e d l y experienced during the range of motion task. This f i n d i n g i s c o n s i s t e n t w i t h Laaksonen and Laine (1961), who reported no d i f f e r e n c e s between the pain r a t i n g s given by c h i l d r e n w i t h JRA versus r a t i n g s given by a d u l t s w i t h RA, when inflamed j o i n t s were moved i n extreme p o s i t i o n s . I n d i v i d u a l v a r i a b i l i t y i n i n t e n s i t y r a t i n g s was demonstrated, with s u b j e c t s using almost the f u l l a v a i l a b l e range of the VAS. The f i n d i n g that 43% of s u b j e c t s gave r a t i n g s above the midpoint of the VAS s c a l e i s i n c o n s i s t e n t w i t h Scott et a l . (1977), who found that pain i n t e n s i t y r a t i n g s given by c h i l d r e n w i t h JRA predominently c l u s t e r e d below the midpoint on a VAS s c a l e . Methodological d i f f e r e n c e s between the Scott et a l . (1977) study and the present i n v e s t i g a t i o n may e x p l a i n t h i s discrepancy. In the present i n v e s t i g a t i o n , standardized v e r b a l i n s t r u c t i o n s on how to use the VAS included not only a d e f i n i t i o n of the end p o i n t s but a l s o i n c l u d e d an explanation of which part of the VAS should be marked f o r "no h u r t " , "some h u r t " , or a "whole - 1 0 8 -l o t " of h u r t " . This v e r b a l explanation was f u r t h e r c l a r i f i e d by p o i n t i n g to the p o r t i o n of the VAS r e f e r r e d to i n the v e r b a l e x p l a n a t i o n . Scott et a l . (1977), who used a VAS designed f o r a d u l t s , note that some of the c h i l d r e n i n t h e i r sample were unable to understand how to give pain r a t i n g s on the VAS used. In c o n t r a s t , most c h i l d r e n i n the present i n v e s t i g a t i o n gave the impression of immediately understanding the VAS ( c o n f i d e n t l y p l a c i n g a mark on the l i n e a f t e r having the VAS explained to them, and not w a i t i n g to hear the f u l l r e - e x p l a n a t i o n of the VAS before using the s c a l e the second time f o r the worst pain r a t i n g ) . A few of the younger c h i l d r e n looked confused when the VAS was f i r s t explained to them, but appeared to have understood the s c a l e once i t was r e - e x p l a i n e d . (2) Worst pain i n t e n s i t y over the past week VAS r a t i n g . No s p e c i f i c a p r i o r i hypotheses were made regarding worst pain r a t i n g s . A trend i n the data i n d i c a t e s a jump i n r a t i n g s given by the o l d e s t group. Because of n o n s i g n i f i c a n c e of the o v e r a l l MANOVA, t h i s trend must be i n t e r p r e t e d c a u t i o u s l y , however. I t may seem l o g i c a l to argue that s i n c e no s i g n i f i c a n t age d i f f e r e n c e s i n present pain VAS r a t i n g s emerged, no s i g n i f i c a n t age d i f f e r e n c e s should be expected on worst pain VAS r a t i n g s , and t h e r e f o r e the noted age trend i s l i k e l y not a t r u e e f f e c t . However, there are s e v e r a l p o t e n t i a l reasons to expect age d i f f e r e n c e s to emerge on worst pain r a t i n g s , and not present pain r a t i n g s . For example, Laaksonen and Laine's (1961) r e s u l t s lead to the p r e d i c t i o n t h a t at more intense l e v e l s of pain (such as that e l i c i t e d by movement of inflamed j o i n t s i n extreme p o s i t i o n s ) consistency i n pain r e p o r t across d i f f e r e n c e ages occurs, whereas age d i f f e r e n c e s i n pain r e p o r t emerge at lower l e v e l s of pain (such as those e l i c i t e d by normal j o i n t use and weight b e a r i n g ) . The content of the question asked about pain may a l s o produce v a r i a b i l i t y i n the responses given by c h i l d r e n of d i f f e r e n t ages. S. Ross has r e c e n t l y - 109-observed that questions about s p e c i f i c instances of pain don't tend to e l i c i t age d i f f e r e n c e s i n c h i l d r e n ' s responses, whereas questions about pain i n general do tend to e l i c i t age d i f f e r e n c e s (S. Ross, personal communication, 1987). I f t h i s i s the case, the f i n d i n g of age d i f f e r e n c e s i n worst pain r a t i n g s , but not i n r a t i n g s of pain experienced during the ROM task may be r e l a t e d to d i f f e r e n c e s i n the degree of s p e c i f i c i t y i n the questions. Consistent w i t h t h i s o b s e r v a t i o n , i s the Beales et a l . (1983a) f i n d i n g that when asked to give a general r a t i n g of t h e i r p a i n , age d i f f e r e n c e s emerged; a greater percentage of older c h i l d r e n than younger c h i l d r e n marked above the midpoint on the VAS. A t h i r d , r e l a t e d reason why age trends may be expected i n worst pain r a t i n g s , but not i n r a t i n g s of present pain experienced during the physiotherapy ROM task i s l i n k e d to d i f f e r e n c e s i n the degree to which r e t r o s p e c t i v e r e c a l l i s r e q u i r e d . Present pain r a t i n g s r e f e r r e d to pain experienced a few minutes p r i o r , whereas r a t i n g s of worst pain over the past week r e q u i r e that c h i l d r e n remember pain instances over the past week. Findings from the a d u l t l i t e r a t u r e i n d i c a t e that r a t i n g s of pain experienced f i v e days p r i o r were c o n s i s t e n t w i t h r a t i n g s made at the time ( i e . r e c a l l was accurate) but that d i s t o r t i o n s occur when r a t i n g s of pain r e q u i r e longer periods of r e c a l l ( E i c h , Reeves, Jaeger, & Graff-Radford, 1985; Hunter, P h i l i p s , & Rachman, 1979). Perhaps, then, i f c h i l d r e n are r e q u i r e d to r e c o n s t r u c t , r a t h e r than r e c a l l pain experienced, age trends are e l i c i t e d . (3) Number of sensory pain d e s c r i p t o r s endorsed. No s p e c i f i c a p r i o r i hypotheses were made regarding the number of sensory pain d e s c r i p t o r s endorsed. In ge n e r a l , there d i d appear to be consistency among sub j e c t s i n the sensory words chosen to describe sensations experienced during the physiotherapy ROM task. The l i s t of d e s c r i p t o r s endorsed by 30% or more of the subject sample has face v a l i d i t y ( i e . they are sensations which could - 1 1 0 -r a t i o n a l l y be expected, given the nature of the ROM t a s k ) . Out of keeping w i t h r e s u l t s from previous s t u d i e s i n v o l v i n g general r a t i n g s of pain i n c h i l d r e n w i t h JRA (Beales et a l . , 1983a; V a r n i et a l . , 1986), and a d u l t s w i t h RA (Burckhardt, 1984), the d e s c r i p t o r "aching" was not the most f r e q u e n t l y endorsed. I t seems th a t s u b j e c t s i n the present i n v e s t i g a t i o n were making a d i s t i n c t i o n between acute pain experienced during the physiotherapy ROM task, versus ongoing chronic pain experienced when performing a c t i v i t i e s of d a i l y l i v i n g . Backing up t h i s impression i s the f i n d i n g t h a t the m a j o r i t y of s u b j e c t s who reported they d i d experience "everyday" j o i n t p a i n , reported i t as being a d i f f e r e n t k i n d of pain from pain e l i c i t e d by physiotherapy. For example, s e v e r a l s u b j e c t s r e f e r r e d , or a l l u d e d to "everyday" j o i n t pain as being more achy, l e s s t i m e - l i m i t e d , and l e s s c o n t r o l l a b l e . Also supportive of the impression that s u b j e c t s viewed acute pain e l i c i t e d by physiotherapy as q u a l i t a t i v e l y d i f f e r e n t from "everyday" j o i n t p a i n , i s the f i n d i n g that pain i n t e n s i t y VAS r a t i n g s made f o r physiotherapy-produced pain were h i g h l y s i g n i f i c a n t l y c o r r e l a t e d w i t h the t o t a l number of pain d e s c r i p t o r s endorsed to describe pain produced by the physiotherapy ROM t a s k , but were not s i g n i f i c a n t l y c o r r e l a t e d w i t h VAS r a t i n g s of worst "everyday" j o i n t pain over the past week. (4) Number of a f f e c t i v e or e v a l u a t i v e pain d e s c r i p t o r s endorsed. No s i g n i f i c a n t d i f f e r e n c e s emerged between age groups i n the number of a f f e c t i v e or e v a l u a t i v e pain d e s c r i p t o r s endorsed, f a i l i n g to support the second a p r i o r i hypothesis [H^: M-^  < M2 < M3]. This r e s u l t would seem to be i n c o n s i s t e n t w i t h Gaffney and Dunne's (1986) f i n d i n g of successive i n c r e a s e s i n c h i l d r e n ' s awareness of the p s y c h o l o g i c a l components of p a i n , corresponding w i t h P i a g e t i a n c o g n i t i v e developmental stages. This i n c o n s i s t e n c y may be r e l a t e d to the degree of s p e c i f i c i t y of the question asked. In the present i n v e s t i g a t i o n , s u b j e c t s endorsed d e s c r i p t o r s t h a t f i t w i t h sensations - i n -experienced s p e c i f i c a l l y during the physiotherapy ROM task. When Ross and Ross (1984b) asked c h i l d r e n to f u r t h e r describe s p e c i f i c examples of p a i n , the pa t t e r n of c o n s i s t e n t age d i f f e r e n c e s noted by Gaffney and Dunne (1976) d i d not emerge. I t must be noted that the present discrepant r e s u l t s do not d i r e c t l y d ispute the Gaffney and Dunne (1986) f i n d i n g s . I t may w e l l be that older c h i l d r e n are i n c r e a s i n g l y aware th a t pain sensations can be a s s o c i a t e d w i t h negative a f f e c t (eg. sad mood) or can be n e g a t i v e l y evaluated, but d i d not n e g a t i v e l y i n t e r p r e t sensations experienced during the physiotherapy ROM task and d i d not r e a c t to them with negative a f f e c t . In a d d i t i o n to being i n c o n s i s t e n t w i t h the f i n d i n g s of Gaffney and Dunne (1986), the l a c k of age d i f f e r e n c e s i n the number of a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s endorsed, i s a l s o i n c o n s i s t e n t w i t h the Beales et a l . (1983a) f i n d i n g that older c h i l d r e n / a d o l e s c e n t s w i t h JRA r a t e j o i n t sensations as more unpleasant, and provide more n e g a t i v e l y e v a l u a t i v e d e s c r i p t i o n s of sensations. This ,discrepancy may be due to methodological d i f f e r e n c e s i n the two s t u d i e s . In the present study, word d e s c r i p t o r s were endorsed from a l i s t read aloud, and were to r e f e r s p e c i f i c a l l y to sensations experienced during the physiotherapy ROM task, whereas i n the Beales et a l . (1983a) study, c h i l d r e n gave d e s c r i p t i o n s of general "everyday" j o i n t sensations and t h e i r meaning. Age d i f f e r e n c e s i n the endorsement of a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s may have emerged i f subjects had been asked to choose d e s c r i p t o r s f i t t i n g "everyday" j o i n t sensations. The f o l l o w i n g statement made by one of the older s u b j e c t s (admittedly more i n s i g h t f u l and v e r b a l l y ept than most s u b j e c t s ) i l l u s t r a t e s the d i s t i n c t i o n between e v a l u a t i o n s of p h y s i o t h e r a p y - e l i c i t e d versus "everyday" j o i n t p a i n : "The k i n d of pain you get from a r t h r i t i s , t h a t ' s bad. That's why you're on medication, and t h a t ' s why you're coming to physio. But the k i n d of pain that you get from physio, from doing the e x e r c i s e s , i t ' s b e n e f i c i a l , because i n the long run, - 1 1 2 -l i k e , i t strengthens your muscles and gets everything working, and a c t i v e and moving. So i t ' s a good pain i n th a t e v e n t u a l l y i t w i l l h o p e f u l l y ease the bad pain as i t were, [boy, CA: 14] Sever a l s u b j e c t s mentioned (not as e l o q u e n t l y ) , or a l l u d e d to a s i m i l a r d i s t i n c t i o n between e v a l u a t i o n s of p h y s i o t h e r a p y - e l i c i t e d versus "everyday" j o i n t p a i n . F i n a l l y , the a n a l y s i s of the r e l a t i o n between VAS pain i n t e n s i t y r a t i n g s made by the c h i l d r e n and the two p h y s i o t h e r a p i s t s i s of i n t e r e s t . Although these r a t i n g s were s i g n i f i c a n t l y c o r r e l a t e d , s u b j e c t s ' pain i n t e n s i t y VAS r a t i n g s were, on average, s i g n i f i c a n t l y higher than p h y s i o t h e r a p i s t s ' . This d i f f e r e n c e may be due to a d i f f e r e n t i n t e r p r e t a t i o n or use of the VAS by sub j e c t s and p h y s i o t h e r a p i s t s . When asked at the end of the study how they had used the VAS, based on t h e i r r e c a l l of an i n i t i a l e x p l a n a t i o n of the VAS, n e i t h e r of the two p h y s i o t h e r a p i s t s i n v o l v e d i n the data c o l l e c t i o n were able to c o r r e c t l y r e c a l l the wording used w i t h the c h i l d r e n (see Appendix E ) . One p h y s i o t h e r a p i s t reported u s i n g the endpoints to mean "good" and "not so good", the other p h y s i o t h e r a p i s t reported using the endpoints to mean "no p a i n " and "the worst pain you've ever had". Neither r e c a l l e d an explanation t h a t i f the c h i l d had "some p a i n " the mark should be placed somewhere i n the middle of the VAS. This f i n d i n g may then be a t t r i b u t a b l e to a methodological flaw (inadequate i n i t i a l e x p l a n ation of how to use the VAS) and would t h e r e f o r e need to be r e p l i c a t e d i n f u t u r e research before being considered a tr u e e f f e c t . Several f a c t o r s which may c o n t r i b u t e to a t r u e d i f f e r e n c e i n pain i n t e n s i t y r a t i n g s given by c h i l d r e n / a d o l e s c e n t s versus r a t i n g s given by p h y s i o t h e r a p i s t s were, however, noted by the p r i n c i p l e i n v e s t i g a t o r . For example, some c h i l d r e n / a d o l e s c e n t s w i t h a s t o i c a l s t y l e of coping appeared to be i n very l i t t l e pain yet, when i n t e r v i e w e d , reported experiencing a l o t of pain. I t may be that a s t o i c a l s t y l e i s , i n some cases, misleading. Furthermore, i t seemed that some c h i l d r e n were anxious about p a r t i c i p a t i n g i n - 1 1 3 -the study and performing the physiotherapy ROM task, and i t i s p o s s i b l e t h a t , i n these cases, c h i l d r e n r a t e d sensations of a n x i e t y or d i s t r e s s as p a i n , whereas the p h y s i o t h e r a p i s t s ' r a t i n g s were based on p a t h o p h y s i o l o g i c a l i n d i c a t o r s t y p i c a l l y c o r r e l a t e d w i t h pain (e.g., degree of inflammation or r e s t r i c t e d motion). I I . Age/Cognitive Developmental D i f f e r e n c e s i n Coping S t r a t e g i e s and  C a t a s t r o p h i z i n g Cognitions Reported c o g n i t i v e coping s t r a t e g y use. The hypothesis of successive increases by age group i n the frequency of reported c o g n i t i v e use [H3: M^ < M 2 < M3] was p a r t i a l l y , but not completely supported. Although mean frequencies increased s u c c e s s i v e l y by age group, only the d i f f e r e n c e between the o l d e s t group (11-18 years) and youngest group (5-7 years) was s t a t i s t i c a l l y s i g n i f i c a n t . This f i n d i n g i s c o n s i s t e n t w i t h previous l i t e r a t u r e demonstrating more frequent reported c o g n i t i v e s t r a t e g y use i n " o l d e r " c h i l d r e n (Brown et a l . , 1986; Curry & Russ, 1985; Jeans & Gordon, 1981; as c i t e d i n Jeans, 1983; R e i s s l a n d , 1983). Three stages c l e a r l y p a r a l l e l i n g the P i a g e t i a n stages of p r e o p e r a t i o n a l , concrete o p e r a t i o n a l , and formal o p e r a t i o n a l thought d i d not emerge, but r a t h e r , a s i g n i f i c a n t r i s e i n reported c o g n i t i v e s t r a t e g y use occurred i n the age group corresponding w i t h formal o p e r a t i o n a l t h i n k i n g . Perhaps i t i s the case that the attainment of concrete o p e r a t i o n a l t h i n k i n g a l l o w s f o r a somewhat increased c a p a c i t y to use and/or rep o r t using c o g n i t i v e coping s t r a t e g i e s , but that the attainment of the a b i l i t y to t h i n k a b s t r a c t l y i s necessary i n order to a l l o w f o r a s i g n i f i c a n t l y increased c a p a c i t y . The r o l e of metacognitive development, i m p l i c a t e d i n the l i t e r a t u r e review, cannot be d i r e c t l y evaluated from the present data. I t can only be speculated that the demonstrated r i s e i n reported c o g n i t i v e s t r a t e g y use by older c h i l d r e n may r e f l e c t a c o r r e l a t e d increase i n c a p a c i t y f o r awareness of one's own p s y c h o l o g i c a l processes, as noted by Selman (1980). - 1 1 4 -An i s s u e to be discussed i s the v e r i d i c a l i t y of c o g n i t i v e coping s t r a t e g i e s r e p o r t e d l y used. I t may be that the playback of the videotape and cued r e c a l l of thoughts created the demand f o r c h i l d r e n to r e p o r t a l l of the c o g n i t i v e coping s t r a t e g i e s they know about. Even i f t h i s were the case, i t would not d e t r a c t from the r e s u l t s , however, but would mean that the frequency of coping s t r a t e g y use demonstrated i n the present i n v e s t i g a t i o n should be recognized as r e f l e c t i n g frequency of reported c o g n i t i v e coping s t r a t e g y use. B e h a v i o r a l coping s t r a t e g y use. The hypothesis t h a t s u b j e c t s i n the o l d e s t group (11-18 years) would use s i g n i f i c a n t l y fewer b e h a v i o r a l s t r a t e g i e s than s u b j e c t s i n the youngest group (5-7 years) [H4: > M3], made on the b a s i s of conclusions by Curry and Russ (1985) was not supported. This c o n c l u s i o n by Curry and Russ (1985) was based more s p e c i f i c a l l y on a demonstrated d e c l i n e i n " i n f o r m a t i o n seeking" w i t h age. Followup e x p l o r a t o r y analyses, breaking down b e h a v i o r a l s t r a t e g y use i n t o i t s subtypes i n d i c a t e t h a t " v e r b a l c o n t a c t " (a b e h a v i o r a l coping s t r a t e g y subtype which i n c o r p o r a t e s " i n f o r m a t i o n seeking") was, on average, used l e s s f r e q u e n t l y i n the o l d e r group than i n the younger group but t h a t age d i f f e r e n c e s i n the frequency of "pain e x p r e s s i o n " and " v e r b a l r e f u s a l " ( t e l l i n g the p h y s i o t h e r a p i s t to stop) were n o n s i g n i f i c a n t . Since "pain e x p r e s s i o n " was the most f r e q u e n t l y used be h a v i o r a l s t r a t e g y , the t o t a l frequency of b e h a v i o r a l coping s t r a t e g y use was predominated by scores on t h i s subtype. Therefore, analyses using the t o t a l score may have masked more f i n e - g r a i n e d d i f f e r e n c e s between age groups i n s p e c i f i c subtypes of b e h a v i o r a l coping such as " i n f o r m a t i o n seeking" or " v e r b a l c o n t a c t " w i t h the p h y s i o t h e r a p i s t . A s l i g h t l y d i f f e r e n t i n t e r p r e t a t i o n i s provided by r e s u l t s of the ANOVA performed on p r o p o r t i o n scores. This a n a l y s i s i n d i c a t e s t h a t r a t h e r than using s i g n i f i c a n t l y fewer b e h a v i o r a l coping s t r a t e g i e s o v e r a l l , w i t h i n c r e a s i n g age/cognitive development, i t seems that c h i l d r e n add c o g n i t i v e - 115-coping s t r a t e g i e s to t h e i r coping r e p e r t o i r e . The percentage of t o t a l coping accounted f o r by b e h a v i o r a l coping was found to be s i g n i f i c a n t l y smaller i n the two age groups corresponding w i t h concrete operations (8-10 years) and formal operations (11-18 years) than f o r the age group corresponding w i t h p r e o p e r a t i o n a l t h i n k i n g (5-7 y e a r s ) . Taken together w i t h the analyses performed on frequency of t o t a l b e h a v i o r a l coping s t r a t e g y use, and frequency of reported c o g n i t i v e coping corresponding to p r e o p e r a t i o n a l t h i n k i n g use predominantly b e h a v i o r a l s t r a t e g i e s f o r coping w i t h p a i n , then at an age corresponding to concrete o p e r a t i o n a l t h i n k i n g , they begin to r e p o r t using c o g n i t i v e s t r a t e g i e s , and f i n a l l y at an age corresponding to the attainment of formal o p e r a t i o n a l t h i n k i n g , a s i g n i f i c a n t i n c r e a s e i n the reported use of c o g n i t i v e coping occurs. This i n t e r p r e t a t i o n i s c o n s i s t e n t w i t h Jay et a l . ' s (1983) data and i n t e r p r e t a t i o n that a t r a n s i t i o n point i n coping s t r a t e g y use occurs at an age corresponding to concrete o p e r a t i o n s . The i n d i r e c t "assessment" of c o g n i t i v e l e v e l used i n the present study (grouping by age), coupled w i t h the c o r r e l a t i o n a l nature of the data preclude c a u s a l statements regarding the connection between c o g n i t i v e developmnent and the types of s t r a t e g i e s used by c h i l d r e n to cope wth p a i n , n e v e r t h e l e s s , the c o r r e l a t i o n a l l i n k i s important to note. C a t a s t r o p h i z i n g Cognitions Reportedly Experienced The hypothesized successive increase i n c a t a s t r o p h i z i n g c o g n i t i o n s reported by the three age groups [H5: Ml < M2 < M3] was not supported. This negative f i n d i n g i s i n c o n s i s t e n t w i t h the r e s u l t s of Beales et a l . (1983a). As p r e v i o u s l y discussed w i t h regard to the number of a f f e c t i v e or e v a l u a t i v e d e s c r i p t o r s endorsed, t h i s discrepancy may be due to a general l a c k of negative e v a l u a t i o n of sensations experienced during physiotherapy. I f s u b j e c t s were asked, more g l o b a l l y , to r e p o r t thoughts they r e c a l l when - 1 1 6 -experiencing "everyday" j o i n t p a i n , s i g n i f i c a n t age group d i f f e r e n c e s may have emerged. Followup e x p l o r a t o r y analyses f a i l e d to confirm the impression t h a t o l d e r c h i l d r e n reported experiencing more c a t a s t r o p h i z i n g c o g n i t i o n s when "other c a t a s t r o p h i z i n g " was assessed s e p a r a t e l y from "thoughts of p a i n " . I t was noted by the p r i n c i p l e i n v e s t i g a t o r that the few s t r i k i n g l y negative examples of s t r a t e g y use, t h i s r e s u l t seems to i n d i c a t e that c h i l d r e n at an age c a t a s t r o p h i z i n g i n the present sample were reported by adolescents. I t i s these i n d i v i d u a l examples of c a t a s t r o p h i z i n g t h a t are most e a s i l y r e c a l l e d . Data from the present study demonstrate, however, that g e n e r a l i z a t i o n from these few extreme cases to adolescents as a whole i s not warranted. Although, as argued by Beales et a l . (1983a), i n c r e a s i n g c o g n i t i v e complexity may i ncrease the p o t e n t i a l f o r o l d e r c h i l d r e n to experience c a t a s t r o p h i z i n g c o g n i t i o n s a s s o c i a t e d w i t h j o i n t p a i n , t h i s p o t e n t i a l i s not i n a l l cases t r a n s l a t e d i n t o a c t u a l experience. F u r t h e r , i n c r e a s i n g c o g n i t i v e complexity i n o l d e r c h i l d r e n a l l o w s f o r increased use of c o g n i t i v e coping s t r a t e g i e s which may counterbalance an increa se i n c a t a s t r o p h i z i n g should i t occur. I I I . Coping E f f e c t i v e n e s s E v a l u a t i o n O v e r a l l , the c h i l d r e n and adolescents w i t h JRA and r e l a t e d rheumatic diseases i n the present sample were shown to be coping w e l l w i t h t h e i r p a i n . The average D i s a b i l i t y Index Score c a l c u l a t e d from the shortened v e r s i o n of the d i s a b i l i t y s c a l e of the HAQ was .5 f o r the present sample, which i s lower than the average D i s a b i l i t y index score of 1.1 reported i n a sample of a d u l t s w i t h a r t h r i t i s ( F r i e s , 1983). On average, the c h i l d r e n w i t h a r t h r i t i s sampled i n the present study don't demonstrate the p a t t e r n of behaviors r e f e r r e d to by Parson's (1971) as the " s i c k r o l e " ( i e . being i l l does not n e c e s s a r i l y mean an a l t e r e d r o l e or l i m i t a t i o n i n r e g u l a r a c t i v i t i e s ) . Disease s t a t u s v a r i a b l e s were shown to be i n e x o r a b l y mixed i n wi t h the 117-c l a s s i f i c a t i o n of sub j e c t s as " e f f e c t i v e copers" or " l e s s e f f e c t i v e copers" ( i e . more severe disease s t a t u s tended to c o r r e l a t e w i t h increased d i f f i c u l t i e s coping w i t h p a i n ) . Removing the variance a t t r i b u t a b l e to disease s t a t u s v a r i a b l e s , removed meaningful d i f f e r e n c e s between the two coping e f f e c t i v e n e s s groups. Other s t u d i e s i n the a d u l t l i t e r a t u r e which have i n v e s t i g a t e d coping e f f e c t i v e n e s s , have s i m i l a r l y reported the need to recognize the overlap between e f f e c t i v e n e s s of coping w i t h p a i n , and disease s t a t u s v a r i a b l e s (Keefe et a l . , 1987; Reesor & C r a i g , i n p r e s s ) . R e s u l t s of the d i s c r i m i n a n t f u n c t i o n a n a l y s i s p o i n t to the r o l e of be h a v i o r a l and c o g n i t i v e coping s t r a t e g y use as w e l l as c a t a s t r o p h i z i n g c o g n i t i o n s experienced, i n i d e n t i f y i n g coping e f f e c t i v e n e s s s t a t u s . Subjects c l a s s i f i e d as " l e s s e f f e c t i v e copers" tended to express more pain ( v o c a l l y and nonvocally) during the physiotherapy ROM t a s k , more o f t e n r e p o r t e d experiencing c a t a s t r o p h i z i n g thoughts (thoughts of escape, concern about u n l i k e l y adverse consequences, or l a c k of c o n t r o l ) , and were l e s s l i k e l y to re p o r t using emotion-regulating s e l f t a l k , thoughtstopping or c o g n i t i v e r e a p p r a i s a l to cope w i t h pain experienced during the ROM task. I n t e r e s t i n g l y , none of the s e l f - r e p o r t pain v a r i a b l e s emerged as s t a t i s t i c a l l y s i g n i f i c a n t i n making the d i s c r i m i n a t i o n . When asked to r a t e and describe t h e i r pain experience, s u b j e c t s c l a s s i f i e d as " l e s s e f f e c t i v e copers" d i d not n e c e s s a r i l y give higher VAS r a t i n g s or endorse more pain d e s c r i p t o r s . This i s c o n s i s t e n t w i t h comments repeatedly made by parents that episodes of increased pain i n these c h i l d r e n are o f t e n not accompanied by increased pain complaint, n e c e s s i t a t i n g the need f o r parents to i n f e r i n d i r e c t l y (e.g., by no t i n g i n t e r f e r e n c e w i t h a c t i v i t i e s of d a i l y l i v i n g ; ADL) when c h i l d r e n are having some d i f f i c u l t i e s coping w i t h pain. A second i m p l i c a t i o n of the d i s c r i m i n a n t f u n c t i o n a n a l y s i s r e s u l t s i s that not a l l subtypes of b e h a v i o r a l and c o g n i t i v e coping s t r a t e g i e s are a s s o c i a t e d - 1 1 8 -w i t h e f f e c t i v e coping w i t h p a i n . Because pain expression during the ROM task has the p o t e n t i a l to r e s u l t i n the p h y s i o t h e r a p i s t pushing l e s s on a sore j o i n t , i t may be shaped, becoming a coping s t r a t e g y because of operant processes. Increased frequency of pain expression during the ROM task i s shown to be r e l a t e d to " l e s s e f f e c t i v e coping" w i t h pain (greater l i m i t a t i o n of ADL r a t e d by parents and the p h y s i o t h e r a p i s t ) , although a c a u s a l l i n k cannot be concluded given the c o r r e l a t i o n a l nature of the data. This noted l i n k between frequency of pain expression during e x e r c i s e s and " l e s s e f f e c t i v e coping" i s c o n s i s t e n t w i t h Dunn Geier et a l . ' s (1986) f i n d i n g s w i t h c h i l d r e n experiencing c h r o n i c headache p a i n . Loadings on the f i r s t d i s c r i m i n a n t f u n c t i o n of the three c o g n i t i v e coping v a r i a b l e s which emerge as s i g n i f i c a n t , seem to i n d i c a t e t h a t reported use of emotion-regulating s e l f - t a l k (e.g., t e l l i n g y o u r s e l f to stay calm) and thoughtstopping ( g e t t i n g r i d of thoughts about pain) are a s s o c i a t e d w i t h " e f f e c t i v e coping", whereas reported use of c o g n i t i v e r e a p p r a i s a l ( r a t i o n a l i z a t i o n s or d e n i a l ) i s a s s o c i a t e d w i t h " l e s s e f f e c t i v e coping". I n t e r p r e t a t i o n of these c o g n i t i v e coping f i n d i n g s must be made c a u t i o u s l y , however, since these v a r i a b l e s are shown to be l e s s s t a t i s t i c a l l y important i n the s e p a r a t i o n between coping e f f e c t i v e n e s s groups. F u r t h e r , i t must be noted that emotion-regulating s e l f t a l k i s the category of c o g n i t i v e coping f o r which no r e l i a b i l i t y c o e f f i c i e n t was c a l c u l a t e d because of nonoccurrence i n the s u b j e c t s randomly s e l e c t e d f o r the r e l i a b i l i t y check. A t h i r d i m p l i c a t i o n of the d i s c r i m i n a n t f u n c t i o n r e s u l t s i s t h a t the frequency of c a t a s t r o p h i z i n g thoughts experienced i s r e l a t e d to coping e f f e c t i v e n e s s . Those c h i l d r e n who experienced thoughts such as wanting the physiotherapy to end, not being able to c o n t r o l the p a i n , or being concerned about u n l i k e l y events, tended to be c l a s s i f i e d as " l e s s e f f e c t i v e copers". This l i n k between c a t a s t r o p h i z i n g thoughts and coping outcome i s c o n s i s t e n t - 1 1 9 -w i t h s i m i l a r recent f i n d i n g s i n a d u l t p a t i e n t s w i t h o s t e o a r t h r i t i s (Keefe et a l . , 1987), or other forms of chr o n i c p a i n , such as chr o n i c low back pain (Reesor & C r a i g , i n press; Turner & Clancy, 1987). Although the present data only i n d i c a t e a c o r r e l a t i o n a l l i n k , i t may be that the experience of maladaptive thoughts during p a i n - e l i c i t i n g physiotherapy e x e r c i s e s i n t e r f e r e s w i t h the i n i t a t i o n o f , or p e r s i s t e n c e i n the use of adaptive s t r a t e g i e s f o r coping w i t h p a i n . N i c a s s i o et a l . (1985) have noted t h a t a d u l t s w i t h RA can get caught i n a v i s c i o u s c y c l e , i n which f u n c t i o n a l impairment i s l i n k e d w i t h f e e l i n g s of personal h e l p l e s s n e s s . An experienced l a c k of c o n t r o l or hel p l e s s n e s s may, i n t u r n , r e s u l t i n decreased a b i l i t y to p s y c h o l o g i c a l l y cope w i t h pain experienced. Several i m p l i c a t i o n s f o l l o w from the d i s c r i m i n a n t f u n c t i o n a n a l y s i s r e s u l t s . Frequent pain expression ( v o c a l or nonvocal) during physiotherapy e x e r c i s e s , and reported experiencing of c a t a s t r o p h i z i n g c o g n i t i o n s may prove to be more va l u a b l e i n the i d e n t i f i c a t i o n of c h i l d r e n / a d o l e s c e n t s who are having some d i f f i c u l t i e s coping w i t h a r t h r i t i s p a i n , than a c t u a l s e l f - r e p o r t e d pain r a t i n g s or d e s c r i p t i o n s . Treatment i m p l i c a t i o n s which f o l l o w from t h i s data i n d i c a t e t h a t operant procedures r e s u l t i n g i n decrease of pain expression i n " l e s s e f f e c t i v e copers" (e.g., Fordyce, 1978) would not be adequate, but rath e r a c o g n i t i v e approach aimed at modifying maladaptive thoughts experienced during physiotherapy e x e r c i s e s may be c a l l e d f o r . In a d d i t i o n , i t would seem that c h i l d r e n i d e n t i f i e d as having problems coping w i t h pain could b e n e f i t from t r a i n i n g i n the use of adaptive coping s t r a t e g i e s . Data from the s e l f - r e p o r t e d pain v a r i a b l e s p o i n t to the p o t e n t i a l l y c r u c i a l r o l e of an accurate understanding of the purpose of p a i n f u l physiotherapy treatments i n minimizing c a t a s t r o p h i z i n g thoughts and negative e v a l u a t i o n s a s s o c i a t e d w i t h j o i n t sensations experienced during physiotherapy e x e r c i s e s . Explanations of the purpose of physiotherapy treatments and the - 1 2 0 -reasons f o r experienced j o i n t sensations which are explained to c h i l d r e n using terms c o n s i s t e n t w i t h t h e i r l e v e l of c o g n i t i v e complexity (Whitt et a l . , 1979) may play an e s s e n t i a l r o l e i n c h i l d r e n ' s a b i l i t y to cope e f f e c t i v e l y w i t h pain experienced during treatments. A f u r t h e r treatment i m p l i c a t i o n which f o l l o w s from the data on b e h a v i o r a l and c o g n i t i v e coping s t r a t e g y use, i s the need to consider the c h i l d ' s age, and c o g n i t i v e developmental l e v e l when designing coping s t r a t e g y treatments. Present data would i n d i c a t e that behaviorally-mediated coping s t r a t e g i e s may be more e a s i l y implemented by younger/less c o g n i t i v e l y complex c h i l d r e n (5-7 y e a r s ) , than c o g n i t i v e l y - m e d i a t e d coping s t r a t e g i e s . C o g n i t i v e coping s t r a t e g y treatment packages, such as those reported i n the a d u l t coping l i t e r a t u r e , are l i k e l y to be most e f f e c t i v e w i t h older/more c o g n i t i v e l y complex c h i l d r e n and adolescents. Future research i s needed to evaluate the d i f f e r e n c e between acute j o i n t p a i n , as experienced during physiotherapy e x e r c i s e s , versus c h r o n i c j o i n t pain experienced when performing r e g u l a r a c t i v i t i e s of d a i l y l i v i n g . Further i n v e s t i g a t i o n of d i f f e r e n c e s i n c h i l d r e n ' s r a t i n g s and d e s c r i p t i o n s of these two types of a r t h r i t i c p a i n , and the s t r a t e g i e s used to cope w i t h them i s needed. In a d d i t i o n , f u r t h e r i n v e s t i g a t i o n of the r o l e of c a t a s t r o p h i z i n g c o g n i t i o n s and " h e l p l e s s n e s s " i n coping e f f e c t i v e n e s s are l i k e l y to y i e l d u s e f u l data regarding the i d e n t i f i c a t i o n and treatment of c h i l d r e n / a d o l e s c e n t s w i t h JRA and r e l a t e d rheumatic diseases who are having some d i f f i c u l t i e s coping w i t h a r t h r i t i c p a i n . - 121 -References Abu-Saad,, H. (1984). C u l t u r a l components of pai n : The Asian-American c h i l d . C h i l d r e n ' s Health Care, 13, 11-14. A l d e r , R., & Lomazzi, F. (1973). Perceptual s t y l e and pain t o l e r a n c e . I . The i n f l u e n c e of c e r t a i n p s y c h o l o g i c a l f a c t o r s . J o u r n a l of Psychosomatic Research, 17, 369-379. American Academy of Orthopaedic Surgeons. Committee f o r the Study of J o i n t Motion. (1965). J o i n t motion: Method of measuring and r e c o r d i n g . Great B r i t a i n : American Academy of Orthopaedic Surgeons. American Rheumatism A s s o c i a t i o n . (1982). D i c t i o n a r y of the Rheumatic Diseases. V o l . 1: Signs and symptoms. NY: Contact A s s o c i a t e s I n t e r n a t i o n a l L t d . Andrew, J . H. (1970). Recovery from surgery, w i t h and without prepartory i n s t r u c t i o n , f o r three coping s t y l e s . J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology, 15, 223-226. A n s e l l , B. M. (1977a). J o i n t m a n i f e s t a t i o n s i n c h i l d r e n w i t h j u v e n i l e c h r o n i c p o l y a r t h r i t i s . A r t h r i t i s and Rheumatism, 20, 204-206. A n s e l l , B. M. (1984). Problems of assessing pain i n j u v e n i l e a r t h r i t i s . In R. R i z z i & M. V i s e n t i n (Eds.), P a i n : Proceedings of the J o i n t Meeting of the European Chapters of the I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study of P a i n . Abano, Terme, May, 1983. P i c c i n / B u t t e r w o r t h s . Barber, T. X., & Cooper, B. J . (1972). E f f e c t s of pain experimentally induced and spontaneous d i s t r a c t i o n . P s y c h o l o g i c a l Reports, 31, 647-651. Beales, J . G., Keen, J . H., & Lennox H o l t , P. J . (1983a). The c h i l d ' s perception of the disease and the experience of pain i n j u v e n i l e chronic a r t h r i t i s . The J o u r n a l of Rheumatology, 10, 61-65. - 122 -Beales, J . G., Lennox H o l t , P. J . , Keen, J . H., & M e l l o r , V. P. (1983b). C h i l d r e n w i t h j u v e n i l e c hronic a r t h r i t i s : Their b e l i e f s about t h e i r i l l n e s s and therapy. Annals of the Rheumatic Diseases, 42, 481-486. Beers, T. M., & K a r o l y , P. (1979). C o g n i t i v e s t r a t e g i e s , expectancy, and coping s t y l e i n the c o n t r o l of p a i n . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 47, 179-180. Bergner, M., B o b b i t t , R. A., C a r t e r , W. B., & G i l s o n , B. S. (1981). The sickness impact p r o f i l e : Development and f i n a l r e v i s i o n s of a h e a l t h s t a t u s measure. Medical Care, XIX, 787-805. Beyer, J . E., & Byers, H. L. (1985). Knowledge of p e d i a t r i c p a i n : The s t a t e of the a r t . C h i l d r e n ' s Health Care, 13, 150-159. Bibace, R., & Walsh, M. E. (1979). Developmental stages i n c h i l d r e n ' s conceptions of i l l n e s s . In G. C. Stone, F. Cohen, & N. E. Adler (Eds.), Health psychology (pp. 285-301). San F r a n c i s c o : Jossey-Bass. B l i s h e n , B. R., & McRoberts, H. A. (1976). A r e v i s e d socioeconomic index f o r occupations i n Canada. Canadian Review of Sociology and Anthropology, 13, 71-79. B l i t z , B., & Dinn, A. J . (1971). Role of a t t e n t i o n a l focus i n pain p e r c e p t i o n : Manipulation of response to noxious s t i m u l a t i o n by i n s t r u c t i o n s . J o u r n a l of Abnormal Psychology, 77, 42-45. Bradley, L. A. (1985). P s y c h o l o g i c a l aspects of a r t h r i t i s . B u l l e t i n on the  rheumatic d i s e a s e s , 35, 1-12. Bradley, L. A., Turner, R. A., Young, L. D., Agudelo, C. A., Anderson, K. 0., & McDaniel L. K. (1985). E f f e c t s of c o g n i t i v e - b e h a v i o r a l therapy on pain behavior of rheumatoid a r t h r i t i s (RA) p a t i e n t s : P r e l i m i n a r y outcomes. Scandinavian J o u r n a l of Behavior Therapy, 14, 51-64. - 123 -Brewer, E. J . , Bass, J . , Baum, J . , Cassidy, J . T., F i n k , C , Jacobs, J . , Hanson, V., Levinson, J . E., S c h a l l e r , J . , & S t i l l m a n , J . S. (1977). Current proposed r e v i s o n of JRA c r i t e r i a . A r t h r i t i s and Rheumatism, 20(2-March Suppl.), 195-199. Brewer, E. J . , J r . , G i a n n i n i , E. H., & Ba r k l e y , E. (1980). Gold therapy i n the management of j u v e n i l e rheumatoid a r t h r i t i s . A r t h r i t i s and Rheumatism, 23, 404-411. Brewster, A. B. (1982). C h r o n i c a l l y i l l h o s p i t a l i z e d c h i l d r e n ' s concepts of t h e i r i l l n e s s . P e d i a t r i c s , 69, 355-362. Brown, J . M. (1984). Imagery coping s t r a t e g i e s i n the treatment of migraine. P a i n , 18, 157-167. Brown, J . M., 0'Keefe, J . , Sanders, S. H., & Baker, B. (1986). Developmental changes i n c h i l d r e n ' s c o g n i t i o n to s t r e s s f u l and p a i n f u l s i t u a t i o n s . J o u r n a l of P e d i a t r i c Psychology, 11, 343-357. Burckhardt, C. S. (1984). The use of the M c G i l l P a i n Questinnnaire i n assessing a r t h r i t i s p a i n . P a i n , 19, 305-314. Byrne, D. (1961). The r e p r e s s i o n - s e n s i t i z a t i o n s c a l e : R a t i o n a l e , r e l i a b i l i t y and v a l i d i t y . J o u r n a l of P e r s o n a l i t y , 29, 334-349. Calabro, J . J . , Holgerson, W. B., Sonpal, G. M., & Khourny, M. I . (1976). J u n v e n i l e rheumatoid a r t h r i t i s : A general review and r e p o r t of 100 p a t i e n t s observed f o r 15 years. Seminars i n A r t h r i t i s and Rheumatism, _5, 257-298. C a l i n , A., & F r i e s , J . F. (1975). The s t r i k i n g prevalence of a n k y l o s i n g s p o n d y l i t i s i n "healthy" W27 p o s i t i v e males and females. A c o n t r o l l e d study. New England J o u r n a l of Medicine, 293, 835. - 124 -Caradang, M. S. A., F o l k i n s , C. H., Hines, P. A., & Steward, M. S. (1979). The r o l e of c o g n i t i v e l e v e l and s i b l i n g i l l n e s s i n c h i l d r e n ' s c o n c e p t u a l i z a t i o n s of i l l n e s s . American J o u r n a l of Orthopsychiatry, 49, 474-481. Cassidy, J . T. (1982a). D e f i n i t i o n and c l a s s i f i c a t i o n of rheumatic diseases i n c h i l d r e n . In J . T. Cassidy (Ed.), Textbook of p e d i a t r i c rheumatology (pp. 1-13). New York: Wiley. Cassidy, J . T. (1982b). J u v e n i l e rheumatoid a r t h r i t i s . In J . T. Cassidy (Ed.), Textbook of p e d i a t r i c rheumatology (pp. 169-282). New York: Wiley. Cassidy, J . T., S u l l i v a n , D. B., & P e t t y , R. E. (1976). C l i n i c a l p atterns of c h r o n i c i r i d o c y c l i t i s i n c h i l d r e n w i t h j u v e n i l e rheumatoid a r t h r i t i s . A r t h r i t i s and Rheumatism, 20(Suppl.), 224-227. Cohen, F., & Lazarus, R. S. (1973). A c t i v e coping processes, coping d i s p o s i t i o n s , and recovery from surgery. Psychosomatic Medicine, 35, 375-389. Coley, J . L. (1972). The c h i l d w i t h j u v e n i l e rheumatoid a r t h r i t i s . The American J o u r n a l of Occupational Therapy, 26, 325-329. Copp, L. A. (1974). The spectrum of s u f f e r i n g . American J o u r n a l of Nursing, 74, 491-495. C r a i g , K. D. (1984a). Psychology of p a i n . Postgraduate Medical J o u r n a l , 60, 835-840. C r a i g , K. D. (1984b). Emotional aspects of p a i n . In P. D. Wall & R. Melzack ( E d s . ) , Textbook of pa i n . Edinburgh: C h u r c h i l l / L i v i n g s t o n e . C r a i g , K. D., McMahon, R. J . , Morison, J . D., & Zaskow, C. (1984). Developmental changes i n i n f a n t pain expression during immunization i n j e c t i o n s . S o c i a l Science and Medicine, 19, 1331-1337. Curry, S. L., & Russ, S. W. (1985). I d e n t i f y i n g coping s t r a t e g i e s i n c h i l d r e n . J o u r n a l of C l i n i c a l C h i l d Psychology, 14, 61-69. - 125 -Dabich, L. (1982). Scleroderma. In J . T. Cassidy (Ed.), Textbook of p e d i a t r i c rheumatology. New York: Wiley. Donovan, W. H. (1976). P h y s i c a l measures i n the treatment of j u v e n i l e rheumatoid a r t h r i t i s . A r t h r i t i s and Rheumatism, 20(Suppl.), 553-557. Dunn-Geier, B. J . , McGrath, P. J . , Rourke, B. P., L a t t e r , J . , & D'Astous, J . (1986). Adolescent chronic p a i n : The a b i l i t y to cope. P a i n , 26, 23-32. Dzioba, R. B., & Doxey, N. C. (1984). A prospective i n v e s t i g a t i o n i n t o the orthopaedic and psychologic p r e d i c t o r s of outcome of f i r s t lumbar surgery f o l l o w i n g i n d u s t r i a l i n j u r y . Spine, 9_, 614-623. E i s e n , M., Donald, C. A., Ware, J . E., & Brook, R. H. (1980). C o n c e p t u a l i z a - t i o n and measurement of h e a l t h f o r c h i l d r e n i n the h e a l t h insurance study. Santa Monica, CA: The Rand Corp. Eland, J . M., & Anderson, J . E. (1977). The experience of pain i n c h i l d r e n . In A. Jacox (Ed.), P a i n : A sourcebook f o r nurses and other p r o f e s s i o n a l s . Boston: L i t t l e , Brown. F i s h e l , E. E. (1967). The e r i t h r o c y t e sedimentation r a t e . In A. S. Cohen (Ed.), Laboratory d i a g n o s t i c procedures i n the rheumatic d i s e a s e s . Boston: L i t t l e , Brown, and Company. F l a v e l l , J . H. (1981). C o g n i t i v e monitoring. In W. P. Dickson (Ed.), C h i l d r e n ' s o r a l communication s k i l l s . New York: Academic Press. Folkman, S., & Lazarus, R. S. (1986). I f i t changes, i t must be a process: A study of emotion and coping during three stages of a c o l l e g e examination. J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology, 50, 992-1003. Folkman, S., & Lazarus, R. S. (1980). An a n a l y s i s of coping i n a middle-aged community sample. J o u r n a l of Health and S o c i a l Behavior, 21, 219-239. Fordyce, w. E. (1978). Learning processes i n p a i n . In R. A. Sternbach (Ed.), The psychology of p a i n . NY: Raven Press. - 126 -F o s t e r , S. L., & Cone, J . D. (1986). Design and use of d i r e c t observation procedures. In A. R. Ciminero, K. S. Calhoun, & H. E. Adams (Eds.), Handbook of behavior assessment (2nd ed.). NY: Wiley. F r i e s , J . F., S p i t z , P., K r a i n e s , R. G., & Holman, H. R. (1980). Measurement of p a t i e n t outcome i n a r t h r i t i s . A r t h r i t i s and Rheumatism, 23, 137-145. F r i e s , J . F., S p i t z , P. W., & Young, D. Y. (1982). The dimensions of h e a l t h outcomes: The Health Assessment Questionnaire, d i s a b i l i t y and pain s c a l e s . J o u r n a l of Rheumatology, j ) , 789-793. Gaffney, A., & Dunne, E. A. (1986). Developmental aspects of c h i l d r e n ' s d e f i n i t i o n s of pain. P a i n , 26, 105-117. Genest, M. (1978). S t r u c t u r e d i n t e r v i e w schedule f o r pain (SISP). Unpublished manuscript. Genest, M., & Turk, D. C. (1982). Think-aloud approaches t o c o g n i t i v e assessment. In T. V. M e r l u z z i , C. R. G l a s s , & M. Genest (Eds.), C o g n i t i v e assessment. New York: G u i l f o r d P r e s s . Gross, A. M., S t e r n , R. M., L e v i n , R. B., Dale, J . , & Wojnilower, D. A. (1983). The e f f e c t of mother-child s e p a r a t i o n on the behavior of c h i l d r e n experiencing a d i a g n o s t i c medical procedure. J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 51. 783-785. Grunau, R. V. E., & C r a i g , K. D. (1987). Pain expression i n neonates: F a c i a l a c t i o n and c r y . P a i n , 28, 295-410. Hanson, V., K o r n r e i c h , H., B e r n s t e i n , B., King, K., & Singsen, B. (1977). Prognosis of j u v e n i l e rheumatoid a r t h r i t i s . A r t h r i t i s and Rheumatism, 20 (Sup p l . ) , 279-284. H a r r i s , R. J . (1975). A primer of m u l t i v a r i a t e s t a t i s t i c s . NY: Academic Press. - 127 -Hart, F. D. (1974). The c o n t r o l of pain i n the rheumatic d i s o r d e r s . In F. D. Hart (Ed.), The treatment of c h r o n i c pain (pp. 63-96). P h i l a d e l p h i a , PA: Davis. Hart, F. D., & Huskisson, R. R. (1972). Pain patterns i n the rheumatic d i s o r d e r s . B r i t i s h Medical J o u r n a l , h_, 213-216. Hartmann, D. P. (1982). Using observers to study behavior. USA: Jossey-Bass. H i l g a r d , J . R., & Lebaron, S. (1982). R e l i e f of a n x i e t y and pain i n c h i l d r e n and adolescents w i t h cancer: Q u a n t i t a t i v e measures and c l i n i c a l o b servations. I n t e r n a t i o n a l J o u r n a l of C l i n i c a l and Experimental  Hypnosis, 30, 417-442. Howard, J . (1981). K i d d i e s t r e s s . Science, 2, 78-79. H u n t - F i t z g e r a l d , G. (1984). A c l a s s i f i c a t i o n system f o r c h i l d r e n ' s w r i t t e n responses while imagining s i t u a t i o n s r e l a t e d to a d e n t a l v i s i t . Unpublished- manual. H u n t - F i t z g e r a l d , G., & L i d d e l l , A. (1985, November). An a n a l y s i s of c h i l d r e n ' s s e l f - t a l k w h i l e imagining s i t u a t i o n s r e l a t e d to a d e n t a l v i s i t . Poster presented at the annual convention of the A s s o c i a t i o n of the Advancement of Behavior Therapy, Houston, TX. I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study of Pain Subcommittee on Taxonomy. (1986). C l a s s i f i c a t i o n of c h r o n i c p a i n : D e s c r i p t i o n s of c h r o n i c pain syndromes and d e f i n i t i o n s of pain terms. P a i n , 3_(Suppl.), 536-537. Jacobs, J . C. (1982). J u v e n i l e rheumatoid a r t h r i t i s . In J . A. Downey & N. L. Low (Eds.), The c h i l d w i t h d i s a b l i n g i l l n e s s : P r i n c i p l e s of r e h a b i l i t a t i o n . New York: Raven Pres s . Jay, S. M., O z o l i n s , M., E l l i o t t , C. H., & C a l d w e l l , S. (1983). Assessment of c h i l d r e n ' s d i s t r e s s during p a i n f u l medical procedures. Health Psychology, 2, 133-148. - 128 -Jeans, M. E. (1983). P a i n i n c h i l d r e n - a neglected area. In P. F i r e s t o n e , P. McGrath, & W. Feldman (Eds.), Advances i n b e h a v i o r a l medicine w i t h c h i l d r e n and youth. H i l l s d a l e , NJ: Lawrence Erlbaum. J e r r e t t , M. D. (1985). C h i l d r e n and t h e i r pain experience. C h i l d r e n ' s Health Care, 14, 83-89. Kanfer, F. H., & Goldfoot, D. A. (1966). S e l f - c o n t r o l and t o l e r a n c e of noxious s t i m u l a t i o n . P s y c h o l o g i c a l Reports, 18, 79-85. Katz, E. R., Kellerman, J . , & S i e g e l , D. E. (1981). Anxiety as an a f f e c t i v e focus i n the c l i n i c a l study of acute b e h a v i o r a l d i s t r e s s . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 49, 470-471. K a z i s , L. E., Meenan, R. F., & Anderson, J . J . (1983). Pain the rheumatic diseas e s . A r t h r i t i s and Rheumatism, 26, 1017-1022. Keefe, F. J . , & Block, A. R. (1982). Development of an observation method f o r assessing pain behavior i n chronic low back pain p a t i e n t s . Behavior Therapy, 13, 363-375. Keefe, F. J . , C a l d w e l l , D. S., Queen, K. T., G i l , K. M., Martinez, S., C r i s s o n , J . E., Ogden, W., & Nunley, J . (1987). Pain coping s t r a t e g i e s i n o s t e o a r t h r i t i s p a t i e n t s . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 55, 208-212. Kellerman, J . (1980). P s y c h o l o g i c a l i n t e r v e n t i o n s i n p e d i a t r i c oncology. In M. Jospe, J . Nieberding, S B . D. Cohen (Eds.), P s y c h o l o g i c a l f a c t o r s i n h e a l t h care (pp. 113-128). Lexington, MA: Heath. Kuttner, L. T. (1985). P s y c h o l o g i c a l treatment of d i s t r e s s , pain and a n x i e t y f o r young c h i l d r e n w i t h cancer. Laaksonen, A. L., & Laine, V. (1961). A comparative study of j o i n t pain i n a d u l t and j u v e n i l e rheumatoid a r t h r i t i s . Annals of the Rheumatic Diseases, 20, 386-387. - 129 -La Greca, A. M., & O t t i n g e r , D. R. (1979). S e l f - m o n i t o r i n g and r e l a x a t i o n t r a i n i n g i n the treatment of m e d i c a l l y ordered e x e r c i s e s i n a 12-year-old female. J o u r n a l of P e d i a t r i c Psychology, _4, 49-54. Lavigne, J . V., S c h u l e i n , M. J . , & Hahn, Y. S. (1986). P s y c h o l o g i c a l aspects of p a i n f u l medical c o n d i t i o n s i n c h i l d r e n . I . Developmental aspects and assessment. P a i n , 27, 133-146. Lazarus, R. S., A v e r i l l , J . R., & Opton, E. M. (1974). The psychology of coping: Issues i n research and assessment. In G. V. Coelho, D. A. Hamburg, & J . E. Adams (Eds.), Coping and a d a p t a t i o n . New York: B a s i c Books. Lazarus, R. S., & Folkman, S. (1986, May). Age d i f f e r e n c e s i n s t r e s s processes. Paper presented at the 66th annual convention of the Western P s y c h o l o g i c a l A s s o c i a t i o n , S e a t t l e , WA. Lazarus, R. S., & Folkman, S. (1984). The concept of coping. In R. S. Lazarus & S. Folkman (Eds.), S t r e s s , a p p r a i s a l , and coping. New York: Springer. L i a n g , M. H., & J e t t e , A. M. (1981). Measuring f u n c t i o n a l a b i l i t y i n c h r o n i c a r t h r i t i s . A r t h r i t i s and Rheumatism, 24, 80-86. Maddux, J . E., Roberts, M. C , Sledden, E. A., & Wright, L. (1986). Developmental i s s u e s i n c h i l d h e a l t h psychology. American P s y c h o l o g i s t , 41, 25-34. McCaul, K. D., & M a l o t t , J . M. (1984). D i s t r a c t i o n and coping w i t h p a i n . P s y c h o l o g i c a l B u l l e t i n , 95, 516-533. McCormick, M. C , Stemmler, M., M., & Athreya, B. H. (1986). The impact of childhood rheumatic diseases on the f a m i l y . A r t h r i t i s and Rheumatism, 29, 872-879. - 130 -McDaniel, L. K., Anderson, K. 0., Bradley, L. A., Young, L. D., Turner, R. A., Agudelo, C. A., & Keefe, F. J . (1986). Development of an observation method f o r as s e s s i n g pain behavior i n rheumatoid a r t h r i t i s p a t i e n t s . P a i n , 24, 165-184. McGrath, P. A. ( i n p r e s s ) . The management of chr o n i c pain i n c h i l d r e n . In The handbook of chronic p a i n . Amsterdam: E l s e v i e r P r e s s . McGrath, P., Dunn-Geier, J . , Cunningham, J . , Brunette, R., D'Astous, J . , Humphreys, P., L a t t e r , J . , Keene, D., & Goodman, J . T. (1985). P s y c h o l o g i c a l g u i d e l i n e s f o r h e l p i n g c h i l d r e n cope w i t h c h r o n i c benign i n t r a c t i b l e p a i n . The C l i n i c a l J o u r n a l of P a i n , 1, 1-5. McGrath, P., & Feldman, W. ( i n p r e s s ) . C l i n i c a l approach to r e c u r r e n t abdominal pain i n c h i l d r e n . Developmental B e h a v i o r a l P e d i a t r i c s . McGrath, P., & V a i r , C. A. (1984). P s y c h o l o g i c a l aspects of pain management of the burned c h i l d . C h i l d r e n ' s Health Care, 13, 15-19. Meenan, R. F., Gertman, P. M., & Mason, J . H. (1980). Measuring h e a l t h s t a t u s i n a r t h r i t i s : The A r t h r i t i s Impact Measurement Sc a l e s . A r t h r i t i s and Rheumatism, 23, 146-152. Meichenbaum, D., Burland, S., & Gruson, L. (1979, October). Metacognitive assessment. Paper presented a t the Conference on the Growth of I n s i g h t , Wisconsin Research and Development Center. Melzack, R. (1975). The M c G i l l Pain Questionnaire: Major p r p e r t i e s and s c o r i n g methods. P a i n , 1_, 277-299. Melzack, R., & Casey, K. L. (1968). Sensory, m o t i v a t i o n a l , and c e n t r a l c o n t r o l determinants of pain: A new conceptual model. In D. Kenshalo (Ed.), The s k i n senses (pp. 423-443). S p r i n g f i e l d , I L : Thomas. M i l l e r , J . J . , S p i t z , P. W., Simpson, U., & W i l l i a m s , G. F. (1982). The s o c i a l f u n c t i o n of young a d u l t s who had a r t h r i t i s i n childhood. J o u r n a l of P e d i a t r i c s , 100, 378-382. - 131 -Monat, A., & Lazarus, R. S. (Eds.). (1985). S t r e s s and coping: An anthology, 2nd ed. New York: Columbia U n i v e r s i t y Press. Murphy, L. B. (1974). Coping, v u l n e r a b i l i t y and r e s i l i e n c e i n childhood. In G. V. Coelho, D. A. Hamburg, & J . E. Adams (Eds.), Coping and a d a p t a t i o n . New York: Basic Books. Neuhauser, C , Amsterdam, B., Hines, P., & Steward, M. (1978). C h i l d r e n ' s conceptions of h e a l i n g : C o g n i t i v e development and l o c u s of c o n t r o l f a c t o r s . American J o u r n a l of Orthopsychiatry, 48, 334-341. N i c a s s i o , P. M., W a l l s t o n , K. A., C a l l a h a n , L. F., Herbert, M., & P i n c u s , T. (1985). The measurement of h e l p l e s s n e s s i n rheumatoid a r t h r i t i s : The development of the a r t h r i t i s h e l p l e s s n e s s index. J o u r n a l of Rheumatology, 12, 462-467. N i s b e t t , R. E., & Wilson, T. D. (1977). T e l l i n g more than we know: Verbal r e p o r t s on mental processes. P s y c h o l o g i c a l Review, 84, 231-259. N o c e l l a , J . , & Kaplan, R. M. (1982). T r a i n i n g c h i l d r e n to cope w i t h d e n t a l treatment. J o u r n a l of P e d i a t r i c Psychology, 1_, 175-178. O'Dell, A. J . (1977). Pain a s s o c i a t e d w i t h a r t h r i t i s and other rheumatic d i s o r d e r s . In A. Jacox (Ed.), P a i n : A sourcebook f o r nurses and other p r o f e s s i o n a l s . Boston: L i t t l e , Brown. O'Leary, A. (1985). P s y c h o l o g i c a l f a c t o r s i n rheumatoid a r t h r i t i s p a in and immune f u n c t i o n : A s e l f - e f f i c a c y approach. Manuscript submitted f o r p u b l i c a t i o n . Parsons, T. (1971). I l l n e s s and the r o l e of the p h y s i c i a n : A s o c i o l o g i c a l p e r s p e c t i v e . In C. Kluckhohn, H. A. Murray, & D. M. Schneider (Eds.), P e r s o n a l i t y i n nature, s o c i e t y and c u l t u r e . NY: A l f r e d A. Kropf. P e a r l i n , L. I . , & Schooler, C. (1978). The s t r u c t u r e of coping. J o u r n a l of  Health and S o c i a l Behavior, 19, 2-21. - 132 -Pennebaker, J . W. (1982). The psychology of p h y s i c a l symptoms. New York: Sp r i n g e r - V e r l a g . P e r r i n , E. C , & G e r r i t y , P. S. (1981). There's a demon i n your b e l l y : C h i l d r e n ' s understanding of i l l n e s s . P e d i a t r i c s , 67, 841-849. Peterson, L., & Shigetomi, C. (1981). The use of coping techniques to minimize a n x i e t y i n h o s p i t a l i z e d c h i l d r e n . Behavior Therapy, 12, 1-14. P e t t y , R. E. (1982a). J u v e n i l e rheumatoid a r t h r i t i s . Annals RCPSC, 15, 475-481. P e t t y , R. E. (1982b). Epidemiology and genetics of the rheumatic diseases of childhood. In J . T. Cassidy (Ed.), Textbook of p e d i a t r i c rheumatology. New York: John Wiley & Sons. P e t t y , R. E. (1982c). Spondyloarthropathies. In J . T. Cassidy (Ed.), Textbook of p e d i a t r i c rheumatology. NY: Wiley. P i a g e t , J . , & I n h e l d e r , B. (1969). The psychology of the c h i l d . London: Routledge and Kegan P a u l . Reeve, R. A., & Brown, A. L. (1985). Metacognition reconsidered: I m p l i c a t i o n s f o r i n t e r v e n t i o n s research. J o u r n a l of Abnormal C h i l d Psychology, 13, 343-356. Reesor, K. A., & C r a i g , K. D. ( i n p r e s s ) . M e d i c a l l y incongruent c h r o n i c back pa i n : P h y s i c a l l i m i t a t i o n s , s u f f e r i n g , and i n e f f e c t i v e coping. P a i n . R e i s s l a n d , N. (1983). C o g n i t i v e maturity and the experience of f e a r and pain i n h o s p i t a l . S o c i a l Science and Medicine, 17, 1389-1345. R i c h t e r , I . L., McGrath, P. J . , Humphreys, P. J . , Goodman, J . T., F i r e s t o n e , P., & Keene, D. (1986). C o g n i t i v e and r e l a x a t i o n treatment of p e d i a t r i c migraine. P a i n , 25, 195-204. Roberts, N., Bennett, S., & Smith, R. (1986). P s y c h o l o g i c a l f a c t o r s a s s o c i a t e d w i t h d i s a b i l i t y i n a r t h r i t i s . J o u r n a l of Psychosomatic Research, 30, 223-231. - 133 -Rodnan, G. P., & Schumacher, H. R. (Eds.). (1983). Primer on the rheumatic diseases (8th Ed.). A t l a n t a , GA: A r t h r i t i s Foundation. Rosenberg, A. M., & P e t t y , R. E. (1982). A syndrome of seronegative enthesopathy and arthropathy i n c h i l d r e n . A r t h r i t i s and Rheumatism, 25, 1041-1047. R o s e n s t i e l , A. K., & Keefe, F. J . (1983). The use of coping s t r a t e g i e s i n chronic low back pain p a t i e n t s : R e l a t i o n s h i p to p a t i e n t c h a r a c t e r i s t i c s and current adjustment. P a i n , 17, 33-44. Ross, D. M. (1984). Thought-stopping: A coping s t r a t e g y f o r impending f u t u r e events. Issues i n Comprehensive P e d i a t r i c Nursing, _7, 83-89. Ross, D. M., & Ross, S. A. (1985). Pain i n s t r u c t i o n w i t h t h i r d - and f o u r t h -grade c h i l d r e n : A p i l o t study. J o u r n a l of P e d i a t r i c Psychology, 10, 55-63. Ross, D. M., & Ross, S. A. (1984a). S t r e s s r e d u c t i o n procedures f o r the school-age h o s p i t a l i z e d leukemic c h i l d . P e d i a t r i c Nursing, 10, 393-395. Ross, D. M., & Ross, S. A. (1984b). Childhood p a i n : The school-aged c h i l d ' s viewpoint. P a i n , 20, 179-191. Ross, D. M., & Ross, S. A. (1984c). The importance of type of q u e s t i o n , p s y c h o l o g i c a l c l i m a t e and subject set i n i n t e r v i e w i n g c h i l d r e n about p a i n . P a i n , 19, 71-79. Ryb s t e i n - B l i n c h e k , E. (1979). E f f e c t s of d i f f e r e n t c o g n i t i v e s t r a t e g i e s on chronic pain experience. J o u r n a l of B e h a v i o r a l Medicine, 2_, 93-101. Savedra, M., Gibbons, P., T e s l e r , M., Ward, J . , & Wegner, C. (1982). How do c h i l d r e n d e scribe pain? A t e n t a t i v e assessment. P a i n , 14, 95-104. Savedra, M., T e s l e r , M. D., Ward, J . A., & Wegner, C , & Gibbons, P. T. (1981). D e s c r i p t i o n of the pain experience: A study of school-age c h i l d r e n . Issues i n Comprehensive P e d i a t r i c Nursing, _5, 373-380. S c h a l l e r , J . G. (1976). C o r t i c o s t e r o i d s i n j u v e n i l e rheumatoid a r t h r i t i s . A r t h r i t i s and Rheumatism, 20(Suppl.), 537-543. - 134 -S c h m i r l e r , D. M. H. (1983). J u v e n i l e rheumatoid a r t h r i t i c (JRA) c h i l d r e n and t h e i r mothers; A multimethod comparison w i t h a healthy p o p u l a t i o n . Manuscript submitted f o r p u b l i c a t i o n . S c o t t , D. S. (1978). Experimenter-suggested c o n d i t i o n s and pain c o n t r o l : Problem of spontaneous s t r a t e g i e s . P s y c h o l o g i c a l Reports, 43, 156-158. S c o t t , P. J . , A n s e l l , B. M., & Huskisson, E. C. (1977). Measurement of pain i n j u v e n i l e c h r o n i c p o l y a r t h r i t i s . Annals of the Rheumatic Diseases, 36, 186-187. Selman, R. L. (1980). The growth of i n t e r p e r s o n a l understanding:  Developmental and c l i n i c a l analyses. NY: Academic P r e s s . Shaw, E. G., & Routh, D. K. (1982). E f f e c t of mother presence on c h i l d r e n ' s r e a c t i o n to a v e r s i v e procedures. J o u r n a l of P e d i a t r i c Psychology, 7_, 33-42. S i e g a l , L. J . , & Peterson, L. (1980). S t r e s s r e d u c t i o n i n young d e n t a l p a t i e n t s through coping s k i l l s and sensory i n f o r m a t i o n . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 48, 785-787. S i e g e l , M., & Lee, M. L. (1973). The epidemiology of systemic lupus erythematosus. Seminars i n A r t h r i t i s and Rheumatism, 3_, 1-54. Simeonsson, R. J . , Buckley, L., & Monson, L. (1979). Conceptions of i l l n e s s c a u s a l i t y i n h o s p i t a l i z e d c h i l d r e n . J o u r n a l of P e d i a t r i c Psychology, 4^ , 77-84. Skevington, S. M. (1986). P s y c h o l o g i c a l aspects of pain i n rheumatoid a r t h r i t i s : A review. S o c i a l Science and Medicine, 6.» 567-575. Spanos, N. P., Brown, J . M., Jones, B., & Horner, D. (1981). C o g n i t i v e a c t i v i t y and suggestion f o r a n a l g e s i a i n r e d u c t i o n of reported p a i n . J o u r n a l of Abnormal Psychology, 90, 554-561. - 135 -Spanos, N. P., Radtke-Bodorick, H. L., Ferguson, J . D., & Jones, B. (1979). The e f f e c t s of hypnotic s u s c e p t i b i l i t y , suggestions f o r a n a l g e s i a , and the u t i l i z a t i o n of c o g n i t i v e s t r a t e g i e s on the r e d u c t i o n of p a i n . J o u r n a l of Abnormal Psychology, 88, 282-292. S t e i n , R. E. K., & Riessman, C. K. (1980). The development of an impact on f a m i l y s c a l e : P r e l i m i n a r y f i n d i n g s . Medical Care, 18, 485-472. St e i n b r o c k e r , 0., Traeger, C. H., & Batterman, R. C. (1949). Therapeutic c r i t e r i a i n rheumatoid a r t h r i t i s . The Jo u r n a l of the American Medical A s s o c i a t i o n , 140, 659-662. Tan, S. (1982). C o g n i t i v e and c o g n i t i v e - b e h a v i o r a l methods f o r pain c o n t r o l : A s e l e c t i v e review. P a i n , 12, 201-228. Tan, S., & Poser, E. G. (1982). Acute pain i n a c l i n i c a l s e t t i n g : E f f e c t s of c o g n i t i v e - b e h a v i o r a l s k i l l s t r a i n i n g . Behaviour Research and Therapy, 20, 535-545. T e s l e r , M. D., Wegner, C , Savedra, M., Gibbons, P. T., & Ward, J . A. (1981). Coping s t r a t e g i e s of c h i l d r e n i n p a i n . Issues i n Comprehensive P e d i a t r i c Nursing, .5, 351-359. Thompson, K. L., & V a r n i , J . W. (1986). A developmental c o g n i t i v e -b i o b e h a v i o r a l approach to p e d i a t r i c pain assessment. P a i n , 25, 283-296. Thompson, K. L., V a r n i , J . W., & Hanson, V. (1987). Comprehensive assessment of c h r o n i c m u s c u l o s k e l e t a l pain i n c h i l d r e n w i t h j u v e n i l e rheumatoid a r t h r i t i s : An e m p i r i c a l model. J o u r n a l of P e d i a t r i c Psychology, 12, 241-255. Turk, D. C. (1979). Factors i n f l u e n c i n g the adaptive process with c h r o n i c i l l n e s s : I m p l i c a t i o n s f o r i n t e r v e n t i o n . In I . Sarason & C. Sp i e l b e r g e r (Eds.), S t r e s s and a n x i e t y , V o l . 6. Toronto: Wiley. - 136 -Turk, D. C , Meichenbaum, D., & Genest, M. (1983). Pain and b e h a v i o r a l  medicine: A c o g n i t i v e b e h a v i o r a l p e r s p e c t i v e . New York: The G u i l f o r d Press. Turner, J . A., & Clancy, S. (1986). S t r a t e g i e s f o r coping w i t h chronic low back pain: R e l a t i o n s h i p to pain and d i s a b i l i t y . P a i n , 24, 355-364. V a r n i , J . W. (1981a). B e h a v i o r a l medicine i n hemophilia a r t h r i t i c pain management: Two case s t u d i e s . Archives of P h y s i c a l Medicine and R e h a b i l i t a t i o n , 62, 183-187. V a r n i , J . W. (1981b). S e l f - r e g u l a t i o n techniques i n the management of chronic a r t h r i t i c pain i n hemophilia. Behavior Therapy, 12, 185-194. V a r n i , J . W. (1983). C l i n i c a l b e h a v i o r a l p e d i a t r i c s : An i n t e r d i s c i p l i n a r y b i o b e h a v i o r a l approach. New York: Pergamon Press. V a r n i , J . W., G i l b e r t , A., & D i e t r i c h , S. L. (1981). B e h a v i o r a l medicine i n pain and a n a l g e s i a management f o r the hemophilic c h i l d w i t h Factor V I I I I n h i b i t o r . P a i n , 11, 121-126. V a r n i , J . W., & Jay, S. M. (1984). B i o b e h a v i o r a l f a c t o r s i n j u v e n i l e rheumatoid a r t h r i t i s : I m p l i c a t i o n s f o r research and p r a c t i c e . C l i n i c a l Psychology Review, h_, 543-560. V a r n i , J . W., & Thompson, K. L. (1985). The Varni/Thompson P e d i a t r i c P a i n Questionnaire. Unpublished manuscript. V a r n i , J . W., Thompson, K. L., & Hanson, V. (1987). The Varni/Thompson P e d i a t r i c P a i n Questionnaire: I . Chronic m u s c u l o s k e l e t a l pain i n j u v e n i l e rheumatoid a r t h r i t i s . P a i n , 28, 27-38. Wack, J . T., & Turk, D. C. (1984). Latent s t r u c t u r e of s t r a t e g i e s used to cope with n o c i c e p t i v e s t i m u l a t i o n . Health Psychology, _3, 27-43. Westergren, A. (1926). The technique of the red c e l l sedimentation r e a c t i o n . American Review of T u b e r c u l o s i s , 14, 94. - 137 -Whitt, S. K., Dykstra, W., & T a y l o r , C. A. (1979). C h i l d r e n ' s conceptions of i l l n e s s and c o g n i t i v e development. C l i n i c a l P e d i a t r i c s , 18, 327-339. W i l l i s , D. J . , E l l i o t t , C. H., & Jay, S. (1982). P s y c h o l o g i c a l e f f e c t s of p h y s i c a l i l l n e s s and i t s concomitants. In J . M. Tuma (Ed.), Handbook f o r  the p r a c t i c e of p e d i a t r i c psychology (pp. 28-66). New York: W i l e y - I n t e r s c i e n c e . Winer, G. A. (1982). A review and a n a l y s i s of c h i l d r e n ' s f e a r f u l behavior i n d e n t a l s e t t i n g s . C h i l d Development, 53, 1111-1133. 138 -Appendix A P a r t i c i p a t i o n Consent Form DATE: I , , v o l u n t a r i l y give my consent f o r myself and my daughter/son to be p a r t i c i p a n t s i n a research p r o j e c t i n v o l v i n g an assessment of c h i l d r e n ' s / a d o l e s c e n t s ' a b i l i t i e s f o r coping w i t h a r t h r i t i c discomfort. This study w i l l be conducted by Susan Branson _ i n a s s o c i a t i o n w i t h Dr. K.D. C r a i g from The U n i v e r s i t y of B r i t i s h Columbia. The procedures to be followed and t h e i r purpose have been explained to me, and I understand them. They are as f o l l o w s : 1. I w i l l complete two w r i t t e n questionnaires designed to measure my c h i l d ' s a b i l i t y to perform a c t i v i t i e s of d a i l y l i v i n g . 2. During and immediately f o l l o w i n g one r e g u l a r l y scheduled physiotherapy s e s s i o n , my c h i l d w i l l provide i n f o r m a t i o n about a r t h r i t i c discomfort, and the t h i n g s she/he does or t h i n k s about to reduce that discomfort. (a) In order to assess my c h i l d ' s f e e l i n g s of discomfort, she/he w i l l be asked to describe sensations experienced during the physiotherapy s e s s i o n . Her/his d e s c r i p t i o n w i l l be audio-recorded and l a t e r t r a n s c r i b e d . (b) In order to assess behaviours used by my c h i l d to cope w i t h a r t h r i t i c d iscomfort, h e r / h i s behaviour during the physiotherapy s e s s i o n w i l l be video-recorded. (c) In order to help my c h i l d remember h e r / h i s thoughts used to cope with discomfort, the videotape of the l a s t few minutes of the physiotherapy session w i l l be played back to her/him. While watching the videotape, my c h i l d w i l l r eport any thoughts she/he can remember going through h e r / h i s mind during that l a t t e r part of the physiotherapy s e s s i o n . Thoughts reported w i l l be audiorecorded and l a t e r t r a n s c r i b e d . I understand that my p a r t i c i p a t i o n i n t h i s study w i l l i n v o l v e a t o t a l of approximately 1/2 hour of my time, and that my c h i l d ' s p a r t i c i p a t i o n w i l l i n v o l v e a t o t a l of approximately 1/2 -3/4 hour of h e r / h i s time, i n a d d i t i o n to the time r e q u i r e d f o r the r e g u l a r l y scheduled physiotherapy s e s s i o n . I f I wish, I may r e c e i v e feedback upon completion of the study about the f i n d i n g s . A l l i nformation c o l l e c t e d about my c h i l d s h a l l be kept s t r i c t l y c o n f i d e n t i a l and published r e s u l t s of the study w i l l r eport group f i n d i n g s only. Audio- as w e l l as video-tapes of my c h i l d w i l l be used only f o r the purposes of t h i s study and w i l l then be erased. I understand that t h i s consent may be withdrawn at any time, and that r e f u s a l to p a r t i c i p a t e or withdrawal from the study w i l l i n no way jeopardize treatment of my c h i l d . My questions concerning t h i s p r o j e c t have been answered to my s a t i s f a c t i o n . I have read and understood the f o r e g o i n g , and have been given a copy of t h i s consent form f o r my own records. Parent's Signature - 139 -Appendix B Permission for Release of Information DATE: I , , permit Susan Branson access to the following i l lness-related information about my daughter/son '  1. age of onset of i l lness 2. medical diagnosis (subtype of ar thr i t i s ) 3. medication type/dose 4 . current physician's rating of disease status and severity I understand that this information w i l l be used only for the purposes of the study and w i l l be kept s t r i c t l y confidential . I also acknowledge that I have been given a copy of this consent form for my records. Parent's Signature - 140 -Appendix C Disabi l i ty Index Questionnaire No Some Needs Problems Problems Help Can't Do 1. DRESSING AND GROOMING Is your child able to: a. get her/his clothes out of the closet and drawers b. dress on her/his own, including handling of closures (buttons, zippers, snaps) c. shampoo her/his hair 2. ARISING Is your chi ld able to: a. stand up from a straight chair without using her/his arms for support 3. EATING Is your chi ld able to: a. cut her/his meat b. l i f t a f u l l cup or glass to her/his mouth 4. WALKING Is your chi ld able to: a. walk outdoors on f lat ground 5. HYGIENE Is your chi ld able to: a. wash and dry her/his entire body b. use the bathtub c. turn taps on and off d. get on and off the to i le t 6. REACH Is your chi ld able to: a. comb her/his hair b. reach and get down a 5 lb bag of sugar which i s above her/his head 7. GRIP Is your chi ld able to: a. open push-button car doors b. open jars which have been previously opened c. use a pen or pencil - U 1 -Appendix D I n t e r f e r e n c e w i t h A c t i v i t i e s Questionnaire Does your daughter's/son's a r t h r i t i c discomfort/pain get i n the way o f , or stop her/him from doing any of the f o l l o w i n g ? Please t i c k the most c o r r e c t o p t i o n f o r your daughter/son. Never Rarely Sometimes Often Always Enjoying the f a m i l y E a t i n g / a p p e t i t e Seeing f r i e n d s Sports Sleeping Watching T.V. Reading Schoolwork Attending school Going to the movies F a v o r i t e a c t i v i t i e s U n l i k e d a c t i v i t i e s Comments? - U2 -Appendix E Pediatric Pain Interview - Modified PPQ-C (Child) I'm really interested in what you feel and what you think about when you do physiotherapy exercises. You're the expert on what i t ' s like for you. I have a tape recorder here. I ' l l just turn i t on and we'll make this like a real interview. You're the expert that I'm interviewing. Warm-Up Question (for children 10 years and under who seemed shy or uncomfortable) Fi r s t , I'm going to ask you a different question though. I bet you can answer this really well. , what do you think i t would feel (child's name) like to hold an ice cube in you hand? How would you explain to me what i t would feel like? (verbally reward answers and prompt i f necessary, e.g., Would i t be hot? Would i t be dry?) You're t e r r i f i c at explaining what things feel l i k e . 1. , I don't know what i t feels like when you do physiotherapy child's name exercises so I need you to t e l l me in your own words what i t f e l t like when you did that exercise where I r i s moved your . specific joint used Alternative Follow-Up Questions la (ask i f the child mentions pain/hurt) You've used the words , , etc. to t e l l me what i t feels l i k e . What other words can you think of to describe the hurt you felt? lb (ask i f the child doesn't mention i t hurts). Did i t hurt at all? lc (ask i f the child says i t doesn't hurt). Now I know that i t didn't hurt, what would you say i t did feel like? What words can you think of to t e l l me how i t felt? (then use these words generated by the child in place of the word "hurt" in later questioning). - U 3 -2. I have a l i s t of words that some other children/teens say describe the way i t feels when they hurt. Some of these words may f i t for you. I ' l l say each word and you t e l l me yes or no i f that word i s the way i t feels for  you. Say yes only i f the word I say real ly explains what you f e l t during that last physiotherapy exercise. (Read the words one by one and record "Y" or "N" beside each) Did i t feel ? cutting pounding t ingl ing tiring, deep beating squeezing throbbing horrible stabbing; burning pull ing sickening biting, screaming, scraping aching uncomfortable cold tugging pricking cruel warm miserable Stretching Pinching unbearable sad itching terr ib le stinging cool sore flashing pressing fearful pins & needles sharp jumping; tight hot spreading punishing scared lonely bad - 144 -3. So you told me that during that last exercise you did, where you had to move around your , i t hurt. (specific joint used) (Show the child the visual analogue scale). What I'd like you to do now then, i s to mark a place along the line that best shows how much i t hurt during that last exercise. If you had no pain or hurt, you would put a mark at this end of the line by the happy face (point to happy face). If you had some pain or hurt, you would put a mark near the middle of the line (point to middle). If you had a whole lot of pain or hurt, you would put a mark by the sad face (point to sad face). 4. Do you ever hurt in your joints during the week when you're not at physiotherapy, when you're just doing everyday things? Would you use the same words you told me before or different words for how the hurt feels during the week? Is i t the same feeling as during the exercises or i s i t different? 5. What did the worst hurt/pain that you f e l t in your joints last week feel like? (Show the child the visual analogue scale.) I'd like you to mark a place along this line that best shows how much i t hurt for the worst hurt/pain you had last week. Remember, IF (same explaination of the visual analogue scale as before). What was happening when i t hurt that much. Where was i t hurting? © Not H u r t i n g No D i s c o m f o r t No P a i n H u r t i n g a Whole L o t V e r y U n c o m f o r t a b l e S e v e r e P a i n - 145 -Appendix F C o g n i t i v e Coping Interview Some c h i l d r e n / t e e n s have c e r t a i n thoughts and say t h i n g s to themselves when they are doing t h e i r physiotherapy e x e r c i s e s and they're h u r t i n g . I'm i n t e r e s t e d i n f i n d i n g out about what s o r t s of t h i n g s you thought about during that very l a s t e x e r c i s e when you had to move your as f a r as p o s s i b l e . ( s p e c i f i c j o i n t used) I'd l i k e you to t h i n k r e a l l y hard and t r y to remember a l l the t h i n g s that went through your mind when you were doing that l a s t e x e r c i s e ... even i f they were j u s t s i l l y t h i n g s you thought to y o u r s e l f . What were the thi n g s you s a i d to y o u r s e l f ? (Pause) Do you remember any? To help you remember b e t t e r , I ' l l play back the movie/video of you doing that l a s t e x e r c i s e . I f you remember something you were saying to y o u r s e l f , l e t me know, and I ' l l stop the tape so you can t e l l me what i t was you were t h i n k i n g about. Do you understand? ( r e - e x p l a i n i f necessary) ( s t a r t the videotape at the p o i n t where the standardized physiotherapy task begins. Press the pause button when the c h i l d spontaneously provides a thought and use the appropriate follow-up probe from the l i s t below). Follow-Up Probes (a) i f c h i l d r e p o r t s a thought paraphrase i t b r i e f l y when the c h i l d pauses, and then ask "Was there anything e l s e you were t h i n k i n g ? " (b) i f c h i l d r e p o r t s a n x i e t y - r e l a t e d thoughts or thoughts regarding maladaptive behaviours or r e a c t i o n s , ask i f there was anything he thought about, s a i d to h i m s e l f , or d i d to help him curb these r e a c t i o n s . For example; ^ C h i l d : " I kept t h i n k i n g I would c r y " I n t e r v i e w e r : "Did you t h i n k anything to y o u r s e l f that helped you not to cry? or C h i l d : " I kept t h i n k i n g about how much i t h u r t " I n t e r v i e w e r : "Did you t h i n k about anything or say anything to y o u r s e l f that helped you not to t h i n k about how much i t h u r t ? " - 146 -(c) i f c h i l d responds that he t r i e d not to t h i n k about what the p h y s i o t h e r a p i s t was doing or t r i e d to t h i n k about other t h i n g s ask: "What d i d you t h i n k about that helped you not to t h i n k about the p h y s i o t h e r a p i s t , " or 'What were the t h i n g s you were t h i n k i n g ? " (d) i f c h i l d r e p o r t s having done something non-cognitive (eg. "looked a t the camera", "looked away"), ask "What were you t h i n k i n g w h i l e you... ("looked a t the camera", e t c . ) I f the c h i l d hasn't spontaneously provided any thoughts a f t e r watching 30 seconds of the videotape, p i c k a point on the video a t which an e x p l i c i t behaviour ( v e r b a l or nonverbal) i s e x h i b i t e d by the c h i l d , press the pause button and use that behaviour as a cue to prompt r e c a l l . For example, "Oh, you s a i d ouch there, what were you t h i n k i n g or saying to y o u r s e l f r i g h t then? or "Gee you r e a l l y sighed there, what were you t h i n k i n g r i g h t then?" Then use the appropriate follow-up probe to get the c h i l d to expand or s p e c i f y . A f t e r asking follow-up questions, r e l e a s e the pause button and continue the video. Repeat the above procedure ( e i t h e r f o l l o w i n g up spontaneously reported thoughts or cueing and then f o l l o w i n g up thoughts). For c h i l d r e n who do not spontaneously r e p o r t thoughts, stop the tape and cue them four times. Once the e n t i r e videotape of the l a s t physiotherapy task has been run through, ask "Have I got a l l of the th i n g s you thought about now? Any other t h i n g s you s a i d to y o u r s e l f ? I s there anything e l s e you t h i n k to y o u r s e l f or you d£ e s p e c i a l l y to make i t hurt l e s s ? " For c h i l d r e n who provided at l e a s t one thought, say " T e r r i f i c . You t o l d me t h i n g s you thought about. Thank you". For c h i l d r e n number who were not able to provide any thoughts reassure them by saying "That's j u s t f i n e . Remember, l i k e I s a i d , not a l l c h i l d r e n t h i n k about things during those e x e r c i s e s " , - U 7 -Appendix G Cog n i t i v e Coping S t r a t e g i e s CALMING SELF-TALK (A) Emotion-Regulating S e l f - T a l k - Self-statements d e a l i n g w i t h the c h i l d s f e a r s , a n x i e t i e s or p a i n , e.g., " I t o l d myself to stay c a l m / i t ' s not so bad"; "be brave"; " I t ' l l a l l be over i n a few minutes"; " I t o l d myself don't worry/everything w i l l be OK". (NB: responses may have a calming q u a l i t y , as i f a parent was saying something to the c h i l d to soothe her/him). (B) Behaviour-Regulating S e l f - t a l k - Self-statements that help the c h i l d to c o n t r o l d i s r u p t i v e behaviours such as c r y i n g or f i d g e t t i n g , e.g., " I t o l d myself be s t i l l / d o n ' t cry/be good". ATTENTION DIVERSION (A) E x t e r n a l A t t e n t i o n D i v e r s i o n Responses i n d i c a t i n g that the c h i l d was t r y i n g to focus h e r / h i s a t t e n t i o n away from the e x e r c i s e / p a i n and onto something e l s e , e.g., " I looked at "; " I was l i s t e n i n g to what the other k i d s were saying"; " I (ob j e c t i n room) (B) I n t e r n a l A t t e n t i o n D i v e r s i o n " I was t h i n k i n g about i n s t e a d " ; " I t h i n k about other t h i n g s " ; (some other t o p i c or image " I t r y to t h i n k good thoughts". that does not i n v o l v e pain) THOUGHT STOPPING C h i l d r e p o r t s t h a t she/he t r i e d not to t h i n k about the p a i n , or t r i e d to block i t out but does not re p o r t s p e c i f i c replacement thoughts (as w i t h a t t e n t i o n d i v e r s i o n ) when l a t e r prompted, e.g., " I t r i e d to get my mind o f f the h u r t i n g " ; " I j u s t t r i e d not to t h i n k about i t " . (Before s c o r i n g a response as thought stopping, r u l e out a t t e n t i o n d i v e r s i o n . ) REALITY-ORIENTED WORKING THROUGH Responses i n d i c a t i n g that the c h i l d has thought through or imagined aspects of the treatment process with some degree of accuracy. Thoughts can r e f e r to what the procedures w i l l be l i k e , how they w i l l f e e l , or the purpose of the procedure, e.g., " I was t r y i n g to f i g u r e out what the p h y s i o t h e r a p i s t was doing"; " I thought about what i t was l i k e l a s t time I came to physiotherapy and f i g u r e d t h i s time would probably be j u s t l i k e t h a t " ; "Oh, t h i s i s the s t r e t c h i n g p a r t " ; " I f i g u r e d she was t r y i n g to get my f i n g e r s to bend back f u r t h e r " ; " t h a t ' s the l a s t one"; " i t ' s over now". COGNITIVE REAPPRAISAL ( P o s i t i v e T h i n k i n g / R a t i o n a l i z a t i o n s ) Responses r e f l e c t i n g a r e a p p r a i s a l of the s i t u a t i o n which makes i t seem more benign; or p o s i t i v e , e.g., " I was t h i n k i n g about the things I l i k e about going to the p h y s i o t h e r a p i s t (such as missing s c h o o l , glad to see h e r ) ; " I t ' s good to go to physiotherapy"; I ' l l be able to move around b e t t e r afterwards". - 148 -Appendix H C a t a s t r o p h i z i n g Cognitions THOUGHTS OF PAIN OR FEAR/ANXIETY (A) C h i l d focuses a t t e n t i o n on the pain/makes reference to pain or discomfort, e.g., " I was t h i n k i n g about how much i t h u r t " ; "This h u r t s " ; " I wonder i f t h i s w i l l h u r t " . OR (B) C h i l d expresses nervousness, a n x i e t y - r e l a t e d symptoms, worrying, e.g., "I'm scared"; " I f e e l shaky". THOUGTHS OF ESCAPE C h i l d mentions a thought about t e r m i n a t i n g the e x e r c i s e , e.g., "When i s she going to stop?"; " I wish she'd stop"; " I hope t h i s i s the l a s t one". CONCERN ABOUT UNLIKELY RESPONSES C h i l d r e p o r t s u n r e a l i s t i c concerns about the p h y s i o t h e r a p i s t ' s b e h a v i o u r / i n t e n t i o n s or about h e r / h i s own b e h a v i o u r s / i n t e n t i o n s , e.g., " I s the p h y s i o t h e r a p i s t t r y i n g to k i l l me?" " I could k i l l her"; " W i l l she be mean to me?" LACK OF CONTROL C h i l d i n d i c a t e s a l a c k of personal c o n t r o l over the pain experienced or he r / h i s own r e a c t i o n to the pa i n , e.g., " I t (the c h i l d ' s attempt to d i s t r a c t h e r s e l f / h i m s e l f ) didn't work"; " I can't take i t (the p a i n ) " . - 149 -Appendix 1-1 Behavioural Coping S t r a t e g i e s INFORMATION SEEKING C h i l d asks the p h y s i o t h e r a p i s t a question ( i ) i n order to ob t a i n i n f o r m a t i o n regarding the procedures the ph y s i o t h e r a p i s t w i l l use and/or why those procedures are being used, eg. " W i l l you be p u t t i n g weights on my ankles today?" ( i i ) i n order to ob t a i n feedback regarding how w e l l they d i d on procedures/ e x e r c i s e s performed. OR OR ( i i i ) i n order to ob t a i n i n f o r m a t i o n about t h e i r a r t h r i t i s ( i e . questions about the disease process or about t h e i r present symptoms) SUPPORT-SEEKING/RELATIONSHIP BUILDING (A) Verbal Contact: ( i ) C h i l d i n i t i a t e s conversation ( i e . chats or jokes) w i t h p h y s i o t h e r a p i s t regarding non-physiotherapy r e l a t e d  t o p i c s OR ( i i ) C h i l d continues conversation i n i t i a t e d by t h e r a p i s t . [NOTE: Exclude from s c o r i n g d i r e c t responses to questions posed by the p h y s i o t h e r a p i s t . Any response to questions that adds more d e t a i l than a yes/no/ or cursory r e p l y or changes the t o p i c i s s c o r a b l e . ] (B) P h y s i c a l Contact: C h i l d seeks p h y s i c a l contact w i t h the p h y s i o t h e r a p i s t (or parent, i f pr e s e n t ) . eg. c h i l d asks to hold the p h y s i o t h e r a p i s t ' s hand or hugs her. EFFORTS TO MAINTAIN CONTROL (A) Vocal P a i n Expression: C h i l d v o c a l l y expresses p a i n . eg. any voc a l expressions such as "ouch", "ah", "oo", " t h a t h u r t s " ; groans; a u d i b l e c r y i n g . [NOTE: Exclude v e r b a l expression of pain made i n i n response to d i r e c t questions by the ph y s i o t h e r a p i s t . eg. (physio) "How does t h a t f e e l ? " ( c h i l d ) " I t hurts a b i t . " , not scored.] [NOTE: Independently record each d i s c r e t e v e r b a l expression that occurs, eg. 0w.0w.0w. scored as three instances of v e r b a l pain expression] - 150 -Nonvocal Pain Expression: ( i ) C h i l d grimaces (defined as an obvious f a c i a l expression of pain which may i n c l u d e a furrowed brow, narrowed eyes, tightened l i p s , corners of mouth p u l l e d back, and clenched t e e t h . I t may resemble w i n c i n g ) . Record second occurrence of grimace i f f a c i a l muscles are tightened again a f t e r having smoothed out completedly. OR ( i i ) C h i l d sighs (defined as an obvious and exaggerated e x h a l a t i o n of a i r . Must be accompanied by a v i s i b l e r i s e and f a l l of the shoulders or the cheeks must be expanded to be s c o r e a b l e ) . OR ( i i i ) C h i l d rubs j o i n t s ( d e fined as massaging an a f f e c t e d j o i n t or body part f o r at l e a s t 3 consecutive seconds). Verbal R e f u s a l : ( i ) C h i l d v e r b a l l y asks the p h y s i o t h e r a p i s t to d i s c o n t i n u e pressure a p p l i e d to the j o i n t s , eg. C h i l d says "Be c a r e f u l " ; "Wait a minute"; "That's enough"; "Stop"; "No"; "That's a l l " . [NOTE: Exclude v e r b a l requests to d i s c o n t i n u e pressure made i n response to a d i r e c t question asked by the p h y s i o t h e r a p i s t , eg. (physio) "Can I go f u r t h e r ? " ( c h i l d ) "No. Stop", not scored.] OR ( i i ) C h i l d v e r b a l l y refuses to do e x e r c i s e s d i c t a t e d by the p h y s i o t h e r a p i s t . [Include complaining or grumbling about e x e r c i s e s , eg. i n whiney tone c h i l d says "Oh, do I have t o ? " ; "No, not those again"; or " I hate those".] Nonverbal R e f u s a l : ( i ) C h i l d nonverbally asks the p h y s i o t h e r a p i s t to d i s c o n t i n u e pressure a p p l i e d to the j o i n t s , eg. C h i l d puts up a hand or v i s i b l y t r i e s to withdraw j o i n t being e x e r c i s e d . OR ( i i ) C h i l d nonverbally refuses to do e x e r c i s e s d i c t a t e d by the p h y s i o t h e r a p i s t . eg. refuses to t u r n onto stomach when physio-t h e r a p i s t asks or shakes head to nonverbally i n d i c a t e "No". - 151 -APPENDIX 1-2 Additional Behavioral Coping Coding Information 1. When to start coding ( i ) Play interval tape up to the point where you've heard "Begin recording when you hear the 1 . . . . 1", then press stop on the audiotape machine. ( i i ) Then insert videotape, turn up volume and press play. ( i i i ) When you hear "Start now" on the videotape, press play on the audiotape machine and begin coding. 2. Changing intervals As you hear the number cuing you to move to the next interval , move your left hand down to the next interval , keeping your eyes on the TV as much as possible, so that you don't miss any nonverbal behaviours. 3. When to t ick a strategy as having occurred ( i ) Place a t ick within the appropriate box in the interval that coping strategy was in i t ia ted i n . ( i i ) Record each occurrence of strategies within that interval . EXCEPTION: Verbal Contact i s ticked only once per interval (indicating i t occurred at least once in that interval ) . 4. Exclusion of physiotherapist-elicited strategies ( i ) Verbal coping strategies ( ie . Verbal Contact, Pain Verbalization, Verbal Refusal) are scored only when they are in i t ia ted by the ch i ld , or go  beyond mere replies to questions/prompts made by the physiotherapist. ( i i ) To help you decide i f a given verbalization i s scoreable, keep in your mind what the physiotherapist has just asked. ( i i i ) If i t ' s helpful , you could record an X for examples of verbal strategies not scoreable because they are in reply to the physiotherapist. ( iv) PAIN-VERBAL (a) WHEN NOT TO SCORE: - in response to physio's question eg. P: C: OR P: C: - When physio says "Tell me when i t hurts", f i r s t pain verbalization i s not scored. "How does that feel?" "It hurts a bit". "Does i t hurt there?" "Ow, yes". - 152 -(b) WHEN TO SCORE; - Do score any f u r t h e r pain v e r b a l i z a t i o n s o c c u r r i n g a f t e r the f i r s t one made i n response to the p h y s i o t h e r a p i s t . eg. P: " T e l l me i f i t h u r t s " . C: "Ow. Ow. i t hurts a l o t the r e " . ( F i r s t "Ow" not scored but second "Ow" and " i t hurts a l o t t h e r e " both scored.) REFUSAL-VERBAL (a) WHEN NOT TO SCORE - i n response to physio's question, eg. P: "Do you want to stop?" C: "Yes, stop". - When physio says " T e l l me when to stop". F i r s t "stop" not scored. (b) WHEN TO SCORE - Do score any f u r t h e r r e f u s a l s that occur a f t e r the f i r s t one made i n response to the p h y s i o t h e r a p i s t . eg. P: " T e l l me when to stop". C: "Stop. That's enough". ( F i r s t "stop" not scored, but "That's enough" i s scoreable.) - 153 -Appendix 1-3 Behavioral Coping Coding Sheet - 154 -Appendix J Pain Intensity Rating - Physiotherapist Please place a mark along this l ine at the point which best indicates how much pain you think experienced during the chi ld's name standardized movement in extreme positions task. © Not H u r t i n g No D i s c o m f o r t No P a i n H u r t i n g a Whole L o t V e r y U n c o m f o r t a b l e S e v e r e P a i n Steinbrocker Functional Abi l i ty Rating - Physiotherapist Please c i rc le the functional rating currently most appropriate for (child's name) 1 = COMPLETE a b i l i t y to carry on a l l usual duties without handicaps 2 = ADEQUATE for normal act iv i t ies despite handicap of discomfort or limited motion in one or more joints 3 = LIMITED only to l i t t l e or none of duties of usual occupation or self-care 4 = INCAPACITATED = largely or wholly bedridden or confined to a wheelchair, l i t t l e or no self care - 155 -Appendix K Disease-Related Data Form - Physician Date of research participation Date on which disease-related data were collected chi ld's name 1. age of onset was yrs months 2. The particular type of ar thr i t i s this chi ld has been diagnosed as having is 3. number of joints involved i s 4. medication type dose prescribed frequency 5. The total amount of current inflammatory act iv i ty (active joint count) i s 6. The most recent erythrocyte sedimentation rate from the charts is date 7. The global rating of disease severity most appropriate i s : none mild moderate severe very severe 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0097252/manifest

Comment

Related Items