discussion #13 disease

RE S E A R C H AR T I C L E

Chronic Pain in the Classroom: Teachers’ Attributions About the Causes of Chronic Pain*

DEIRDRE E. LOGAN, PhDa

SARAH P. CATANESE, PhDb

RACHAEL M. COAKLEY, PhDc

LISA SCHARFF, PhD d

ABSTRACT

BACKGROUND: School absenteeism and other impairments in school function are sig- nificant problems among children with chronic pain syndromes; yet, little is known about

how chronic pain is perceived in the school setting. The purpose of this study was to

examine teachers’ attributions about the causes of chronic pain in adolescent students.

METHODS: Classroom teachers (n = 260) read vignettes describing a hypothetical student with limb pain. They were presented with a list of possible physical and

psychological causes for the pain and asked to identify the causes to which they

attributed the pain. Vignettes varied by the presence or absence of (1) documented

medical evidence for the pain and (2) communication from the medical team.

Teachers also responded to questions assessing their responses to the student in

terms of support for academic accommodations and sympathy for the student.

RESULTS: Teachers tended to endorse a dualistic (ie, either physical or psychological) model for pain rather than a biopsychosocial model. Documented medical evidence

supporting the pain was the most influential factor affecting teachers’ attributions

about chronic pain. Teachers who attributed the pain to physical causes—either in

isolation or in combination with psychological causes—responded more positively

toward the student.

CONCLUSIONS: Many teachers lack a biopsychosocial framework through which to understand chronic pain syndromes in students. How chronic pain is described to

school personnel may affect how teachers understand the pain and respond to it.

Keywords: adolescent; attributions; chronic pain; pain; teachers.

Citation: Logan DE, Catanese SP, Coakley RM, Scharff L. Chronic pain in the

classroom: teachers’ attributions about the causes of chronic pain. J Sch Health.

2007; 77: 248-256.

a Staff psychologist at Children’s Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical School, ([email protected]), Pain Treatment Service, Children’s Hospital Boston, 333 Longwood Ave., Boston, MA 02115. b Instructor of Psychiatry and Behavioral Sciences, ([email protected]), Northwestern University, Feinberg School of Medicine, 150 E Huron St. Suite 1100, Chicago, IL 60611. c Staff psychologist, Children’s Hospital Boston, ([email protected]), Department of Psychiatry and Pain Treatment Service, Children’s Hospital Boston, 553 Longwood Ave., Boston, MA 02115. d Associate Director, Pain Treatment Service, Children’s Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical School, ([email protected]), Pain Treatment Service, Children’s Hospital Boston, 333 Longwood Ave., Boston, MA 02115.

Address correspondence to: Deirdre E. Logan, Staff psychologist at Children’s Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical School, ([email protected]), Pain Treatment Service, Children’s Hospital Boston, 333 Longwood Ave., Boston, MA 02115.

The authors express sincere thanks to Kate Nugent, Neil Taylor, and Molly Waring for research assistance; Henry Feldman, PhD, for statistical consultation; Ariel Botta, LCSW; Rebecca Brody, PhD; Dave DeMaso, MD; and Nadja Reilly, PhD, for facilitating recruitment; the Psychiatry Department of Children’s Hospital Boston for providing research funding support; and the teachers who participated in the study.

*Indicates CHES continuing education hours are available. Also available at: www.ashaweb.org/continuing_education.html

248 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association

C hronic and recurrent pain is a common experi-

ence among school-age children. Rates of pain

problems lasting 3 months or longer range from

15% to over 30% among school-age youth in epide-

miologic studies. 1-3

The understanding of chronic

pain has evolved from a traditional medical model—

in which pain was viewed as either an ‘‘organic’’ or

‘‘psychosomatic’’ phenomenon—to a biopsychosocial

model 4,5

incorporating biological, psychological, and

social factors that jointly shape the pain experience.

However, individuals experiencing chronic pain syn-

dromes and laypersons who encounter such individ-

uals vary in their understanding and acceptance of

this multifactorial model of pain.

According to attribution theory, one’s explana-

tions for causes or events predict behavior and emo-

tions in response to stressful events. 6

The attribution

of illness to physical or psychological causes appears

to have particularly marked ramifications for percep-

tions of symptomatic individuals and expectations

for their role fulfillment and standards of perfor-

mance. 7-9

Previous research indicates that when ill-

ness is attributed to psychological causes, the ill

individual evokes less pity, less liking, more anger,

and fewer resources than when the illness is attrib-

uted to physiological causes. 10

Chronic pain com-

plaints have been judged ‘‘more legitimate’’ when

attributed to physical versus psychological causes. 11

Influences on individuals’ physical or psychological

attributions for symptoms are not fully understood.

Evidence of organic pathology for the symptoms

appears to be 1 important factor; 12,13

when such evi-

dence is absent, symptoms are more likely to be dis-

credited and attributed to emotional distress or

attempts to elicit secondary gain. 14

Communication

from healthcare professionals may also serve to vali-

date symptoms in others’ eyes.

Attributions are particularly relevant to pediatric

chronic pain syndromes, which can occur with or

without an organic basis. The origins of pain are

often unclear, and the cause of injury or disability is

often not directly observable. Thus, situational fac-

tors can influence individuals’ pain attributions. A

few studies have examined attributions about child-

ren’s pain. Claar and Walker 15

explored mothers’

attributions for their children’s recurrent abdominal

pain and found that about half of mothers in their

sample endorsed a biopsychosocial model (ie, they

identified both psychological and physical factors as

causes of their child’s pain). This was true regardless

of whether their child had a specific medical diagno-

sis related to the pain. However, another study

found that when symptoms of pain occurred in the

absence of organic pathology, parents inferred more

psychological causes for a child’s misbehavior and

responded more negatively than when symptoms

occurred in the presence of organic pathology. 16

The

presence of organic disease in children with abdomi-

nal pain predicted peers’ ratings of relief from

responsibility, with children indicating that a hypo-

thetical peer should be relieved from responsibility

more often when organic disease was present. 17

Research into the influence of others’ attributions

for pain has examined parents’ and peers’ under-

standing of chronic pain but has not yet investigated

teachers’ understanding of chronic pain. This is

a notable gap in the literature given the importance

of school function in the lives of children and adoles-

cents. Youth with chronic pain disorders experience

numerous difficulties in school, including frequent

absences, decreased academic performance, comprom-

ised social functioning, and impaired ability to cope

with the demands of the classroom. 18-20

Left unad-

dressed, school functioning difficulties typically worsen,

often to the point where these youth request and

receive full-time homebound instruction. This cycle

results in adolescents missing out on developmentally

normative academic and social experiences that can be

crucial to long-term healthy adjustment. 20,21

Schools

are responsible for meeting the educational needs of

these students, who are frequently determined to be

eligible for special services under Section 504 of the

Rehabilitation Act (1973). 22

Despite clear evidence that chronic pain adversely

affects school function, 3

little is known about the

mechanisms through which this occurs. How teach-

ers understand and respond to chronic pain likely

influences academic- and pain-related outcomes. Just

as parents’ perceptions of causes of their children’s

pain appear to influence decisions they make about

their child’s treatment, 15

teachers’ perceptions about

causes of students’ pain are potentially important in

determining whether their responses to pain encour-

age or discourage adaptive functioning in school. If

children or parents feel that teachers fail to compre-

hend the nature of their pain, they may be less will-

ing to work toward improved school attendance and

other school-based functional goals. If schools apply

the biopsychosocial framework when formulating

responses to students with pain, they are more likely

to work collaboratively with students, parents, and

the healthcare team and to respond to the pain in

ways that help the student remain engaged in the

school setting. Currently, the extent to which school

personnel know about or endorse the biopsychoso-

cial model of chronic pain is unknown.

The aim of this study was to explore teachers’

attributions about chronic pain in students. Specifi-

cally, we investigated (1) the frequency of physical

and psychological attributions for chronic pain

among a group of middle- and high school teachers,

(2) whether teachers endorse a dualistic or biopsycho-

social model of pain, (3) the effects of documented

medical evidence supporting the pain complaints and

Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 249

communication from the medical team on teachers’

pain attributions, and (4) the influence of teachers’

pain attributions on their responses to the student

with pain. Specific hypotheses were as follows:

d Teachers will be more likely to endorse a dualis-

tic model in which they attribute the pain to either

physical or psychological causes than a biopsychoso-

cial model. d Teachers will be more likely to endorse physi-

cal attributions for pain in the presence of (1)

documented medical evidence indicating a biological

basis for chronic pain symptoms and (2) direct

communication from the medical team to the

school. d Teachers’ pain attributions will influence re-

sponses to the student with pain, such that teachers

who endorse physical attributions will support more

extensive classroom accommodations and will report

greater sympathy for the student.

METHODS

Participants Participants were 263 middle- and high school

classroom teachers from 6 public schools in the

greater Boston area. Schools from which participants

were recruited were selected by convenience and

included 1 urban combined (7th-12th grade) school,

2 suburban middle schools, and 3 suburban high

schools. All permanent regular classroom teachers

of academic and special subjects were eligible for

participation.

Procedures This study was part of a larger project investigating

teachers’ responses to chronic pain. 23

Data were col-

lected between March 2004 and May 2005. The study

was approved by the hospital institutional review

board and the research review committees of

participating schools. An informational consent form

was distributed with the study materials stating

that completion of materials indicated consent to

participate.

A designated liaison at each school (principal or

guidance counselor) worked with the study team to

facilitate participation. The principal or another

school administrator endorsed the study to the entire

faculty, typically by e-mail. Study personnel pre-

sented the project at school faculty meetings or dis-

tributed a written explanation by e-mail and in

teacher mailboxes. Vignettes and questionnaires

were distributed at school staff meetings and/or via

mailboxes. Reminders were sent by e-mail to

increase participation, and additional study materials

were available at the school for several weeks after

initial recruitment. Participation rates varied widely

by school, due in part to differential attendance rates

at the meetings where the study was presented.

Respondents received $10 gift certificates for class-

room supplies for their participation.

Teachers were presented with a written hypothet-

ical scenario describing an adolescent girl who devel-

ops a chronic pain syndrome affecting school

attendance and performance. Three factors were

manipulated. Two of these factors, the presence or

absence of medical evidence supporting a biological

basis for the pain and presence or absence of com-

munication from the medical team, were relevant to

the hypotheses of this study. The third factor, coop-

erative or confrontational parent-teacher interac-

tions, was not hypothesized to relate to teachers’

pain attributions and is not discussed here. (Note:

data analyses confirm that parent-teacher interac-

tions did not relate to teachers’ pain attributions.)

The full factorial approach resulted in 8 vignette ver-

sions (Figure 1).

Aside from the 3 manipulations, the rest of the

vignette was held constant across conditions. The

description of the student with pain was based on

characteristics commonly observed in youth present-

ing to tertiary care pediatric pain clinics. The student

is described as female, a good student academically,

involved in athletics, with some possible mild anxi-

ety traits. The injury involves her hand and occurs

in a situation that may or may not contain psycho-

social aspects. The description of the initial medical

workup is consistent across vignettes, as is the

degree of functional impairment in school. Across

vignettes, the student is eventually given a diagnosis

of Complex Regional Pain Syndrome, a diagnosis

based on medical history and pain symptoms, 24

thus

allowing for varied presence or absence of docu-

mented medical evidence.

Vignettes were pilot tested on 16 teachers (2 per

condition) to ensure that they were comprehensible

and that manipulations functioned as expected. Pilot

participants gave feedback on the vignette and follow-

up questions. Pilot testing indicated that the materials

were appropriate for the intended population.

Vignette conditions were equally distributed at

each school. Cell sizes represented by completed

questionnaires ranged from 24 to 39 participants.

Chi-square analyses indicate that completed forms

were equally distributed by school, teacher gender,

teaching experience, personal experience with pain,

and number of students with pain encountered in

one’s career.

Measures Demographic Information. Teachers completed a

demographic form reporting gender, years’ teaching

250 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association

experience, grade level currently taught, and esti-

mated number of students with chronic pain en-

countered in their careers.

Manipulation Check. To determine whether the

manipulated variables had the intended effects, par-

ticipants responded to true-false questions regarding

the existence of medical evidence supporting the

pain complaints and whether the healthcare team

communicated with the school. In order to ensure

that attributions were based on accurate perceptions

of the information presented in the vignette, partici-

pants who responded incorrectly were deleted from

the relevant data analyses. 11,17

Causal Attributions for Pain. Teachers reported

their beliefs about whether various physical and psy-

chological factors were involved as causes of the

adolescent’s pain on an adapted version of the

Inventory of Causes for Abdominal Pain (ICAP). 15

A

3-point response scale (‘‘probably no,’’ ‘‘maybe,’’

and ‘‘probably yes’’) was used with the stem,

‘‘Please rate whether you think the following are

among the causes of Samantha’s pain.’’ Five physical

causes (eg, muscle spasms or knotted muscles,

repeated injury to the area) and 5 psychological

causes (eg, psychological stress, social/peer problems)

were presented. Participants could endorse as many

causes as they wished. Authors of the original ICAP

report that items were generated in consultation

with a team of physician and mental health profes-

sionals with expertise in pediatric chronic pain and

intended to reflect factors linked with pediatric pain

in the research literature. 12

Responses to Pain.

1. Accommodations: Teachers were asked, ‘‘If it

were completely up to you, what is the extent

of accommodations in the school setting to

which this child should be entitled?’’ Five

choices ranging from ‘‘no accommodations’’ to

‘‘full homebound instruction’’ were offered as

responses. Responses were treated as an ordi-

nal scale.

2. Sympathy: This item read, ‘‘Please rate the level

of sympathy you currently feel for Samantha.’’

A 5-point Likert-type scale was used with

responses ranging from ‘‘no sympathy’’ to ‘‘very

strong sympathy.’’

RESULTS

Overall Findings Three participants were excluded from analyses

due to missing data, resulting in a final sample of 260.

Across schools, overall response rate was 40.9% of

total teaching staff, with rates ranging from 20.6% to

84.7% by school. The sample was 68.1% female. Par-

ticipants had a mean of 16 years’ teaching experience

(range = 1-40, SD = 11.6). Median number of students with chronic pain encountered in participants’ careers

was 3 (range = 0-100). Seventy-three percent of the sample reported some personal experience with

chronic pain in either themselves or a close friend or

family member (Table 1).

Causal Attributions for Pain Responses to the adapted ICAP attribution items

were dichotomized into ‘‘probable’’ versus uncertain

or not probable causes, following the original

authors’ approach. 15

A factor analysis of the 10

items suggests 3 factors that jointly account for

Figure 1. Text of Sample Vignette Version, With Manipulated Portions Italicized

Version: Medical evidence present; Communication from medical team present Samantha Green is a student in your class. She gets good grades but has to work hard to do so. She is a dedicated player on the girls’ soccer team. You notice that she sometimes struggles socially and seems a bit anxious, but she has never been difficult to manage in the classroom.

One day Samantha’s hand is injured when another student slams her locker door against it. Samantha is extremely distressed by the injury. Her parents take her to her pediatrician who finds no major damage, just some bruising and swelling. A week later, Samantha starts to complain of intense pain in her hand. She begins making frequent visits to the nurse’s office and fails to complete her work because the pain prevents her from writing and in- terferes with her concentration. Eventually, as the pain persists, she begins to miss school altogether. Samantha’s parents take her to an orthopedic specialist, who orders x-rays and bone scans. Mr and Mrs Green inform you that these tests showed evidence that the nerves in Samantha’s hand were functioning abnormally, and the doctor prescribed a pain medication for her.

The Greens insist that Samantha be excused from all written assignments and that her academic workload be adjusted significantly because of her injury. After consulting with school administration and the Guidance office, you attempt to meet the parents halfway in terms of adjustments to Samantha’s workload (eg, suggesting that Samantha receive Incompletes on her grades for the term, be permitted additional time to make up the work, and consider transferring out of some of her very demanding honors-level classes into less stressful ones). Mr and Mrs Green agree to give this a try because they recognize the importance of Samantha staying in school.

After 2 months—during which time Samantha has continued to miss several days of school a week and been able to do little work when she does at tend—the Greens inform you that they took Samantha to a pain management clinic at a local children’s hospital, where she was diagnosed with ‘‘Complex Regional Pain Syndrome.’’ You receive a letter from the pain management team describing Samantha’s symptoms and explaining what Complex Regional Pain Syndrome is and how it might affect an adolescent in school. The healthcare team also includes their treatment plan and offers specific re- commendations for ways to accommodate Samantha’s pain problems in the school setting.

Samantha’s guidance counselor has requested a team meeting to discuss how to respond to Samantha’s pain problem. The following questions seek your individual input and should be based on your own opinions/suggestions (even if you feel that you would not be expected to make individual decisions about some of these issues).

Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 251

60.9% of the variance. The 5 psychological attribu-

tions accounted for a single unified factor and had

a Cronbach’s alpha = .80. ‘‘Physical disease’’ and ‘‘repeated injury’’ form a second factor, with the

remaining 3 physical attributions (‘‘nerve damage,’’

‘‘muscle spasms or knots,’’ and ‘‘swelling, inflamma-

tion’’) representing a separate third factor. The phys-

ical items did not hang together as a scale

(Cronbach’s alpha = .53); rather, respondents mak- ing physical attributions for the pain tended to iden-

tify a single physical cause.

Across the sample, 58.5% of teachers endorsed at

least 1 physical attribution as a cause for the stu-

dent’s pain, and 67.2% endorsed at least 1 psycho-

logical attribution. Only 38.1% endorsed both

physical and psychological attributions for the stu-

dent’s pain. In other words, almost two thirds of

respondents held a dualistic view of the pain rather

than endorsing the biopsychosocial model. The like-

lihood of endorsing a biopsychosocial view of pain

did not differ by school. The likelihood of making

physical attributions for the pain did differ signifi-

cantly across schools (v2 = 13.53, p , .05), with the percent of participants within individual schools

endorsing physical attributions for the pain ranging

from 23.1% to 75%. Frequencies for the individual

attributions are reported in Table 2.

Bivariate correlations reveal no significant associa-

tions between the dichotomized pain attribution var-

iables and background variables including teacher

gender, teaching experience, grade level taught,

experience with students with pain, or personal pain

experience. Because the psychological attributions

demonstrated scale properties, the total number of

psychological attributions endorsed was examined.

Respondents who reported more contact with stu-

dents with chronic pain in their careers made more

psychological pain attributions (r = .14, p , .05).

Influence of Medical Evidence and Communication From the Medical Team on Pain Attributions

Manipulation Check Results. Patterns of responses

to the manipulation checks indicate that most partic-

ipants correctly perceived the presence or absence of

communication from the medical team, with 85.8%

of respondents passing this manipulation check.

Teachers had more difficulty recognizing whether

documented medical evidence supporting the pain

complaints was present in the vignettes they read.

Only 66.2% of respondents passed this manipulation

check. There was a greater tendency to interpret that

medical evidence was present when it was absent

than to interpret that medical evidence was absent

when it was present (v2 = 55.7, p , .001). Demo- graphic characteristics were examined in relation to

patterns of responses on the manipulation checks,

but no significant associations emerged. T tests

reveal no differences between participants who

passed the manipulation checks and those who

failed with respect to gender, grade taught, years’ of

teaching experience, or past experience with chronic

pain. Data analyses related to hypothesis 2 include

only those participants who passed both manipula-

tion checks, n = 145. Logistic Regression Analyses. Multivariate logistic

regression analyses examined the effects of medical evi-

dence for the pain and communication from the med-

ical team on pain attributions. To control for school

Table 2. Frequencies of Teachers’ Endorsements of Probable Causes of Student’s Pain (n = 260)

Attribution

Endorsing as Probable Cause,

n (%)

Physical Nerve damage 96 (37.2) Muscle spasms or knots 39 (15.2) Swelling, inflammation 78 (30.5) Physical disease 13 (5.1) Repeated injury to the area 15 (5.9)

Psychological Psychological stress 150 (57.9) Being overly sensitive 55 (21.3) Personal or emotional problems 88 (34.1) Social/peer problems 62 (24.2) Problems in the family 26 (10.2)

Table 1. Descriptive Data on Study Respondents by School*

School Type of School Rate of

Participation †

Teaching Experience, Mean (SD)

Female Respondents (%)

Females on Faculty (%)

A Combined (7th-12th grade) 94/111 19.2 (12.6) 57.0 63 B High school 106/294 14.2 (10.5) 69.5 57 C Middle school 12/53 15.0 (9.6) 91.7 74 D High school 19/82 17.0 (12.4) 61.1 56 E Middle school 16/40 11.4 (9.5) 100 75 F High school 13/63 12.7 (11.2) 84.6 61

*Table is modified from Table 1 in Logan et al. 23

† This column reflects the number of teachers who returned questionnaires out of the total number of classroom teachers on faculty.

252 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association

effects, dummy variables representing the schools

from which participants were drawn were entered on

the first step of the regressions. The second step of

the equation represents the addition of the indepen-

dent variables: presence of medical evidence and pres-

ence of communication.

Physical Attributions for the Pain. As expected,

presence of medical evidence significantly predicted

endorsement of physical attributions for pain (b = 1.86, SE = .43, Wald statistic = 19.2, p , .001). Con- trary to our hypotheses, presence of communication

from the medical team to the school did not predict

endorsement of physical attributions.

Endorsement of the Biopsychosocial Model. We

also assessed the effects of medical evidence and

direct communication from the medical team on the

likelihood of endorsing both physical and psychologi-

cal causes for the pain. The presence of medical evi-

dence significantly predicted endorsement of

a biopsychosocial model (b = 2.07, SE = .49, Wald statistic = 17.6, p , .001). The effect of communica- tion was not significant.

No relations were hypothesized between the

manipulations and psychological attributions for

pain. Regression analyses showed no significant

associations.

Effects of Pain Attributions on Responses to Pain

in the Classroom. The final hypothesis focused on

whether teachers’ pain attributions influenced

responses to the student with pain, in terms of instru-

mental support (extent of academic accommodations

supported) and emotional support (level of sympathy

for the student). The majority (57.8%) of teachers sup-

ported minor or no accommodations for the student,

39.3% supported moderate accommodations, 3.2%

supported major accommodations, and .8% supported

full homebound instruction. Mean level of sympathy

for the student was 3.4 (SD = .78) on a 1-5 scale. Linear regression techniques examined the effects

of attributions on responses to pain, with dummy

variables again entered on the first step to control

for school effects, and pain attributions entered on

the second step of each equation. Regarding support

for academic accommodations, there was a trend

toward significance for teachers who made physical

attributions for the pain to support more extensive

academic accommodations compared to teachers who

made no physical attributions (b = .12, p = .08). There were no differences between teachers who

did and did not endorse the biopsychosocial model

of pain in terms of support for accommodations.

Regarding sympathy, teachers who made physical

attributions for the pain expressed more sympathy

for the student compared to teachers who made no

physical attributions (b = .18, p , .01). Similar results obtained in comparing teachers who

endorsed a biopsychosocial model of pain to those

who held a dualistic view; support for the biopsy-

chosocial model predicted sympathy for the student

(b = .16, p , .01). Endorsement of psychological attributions for pain did not relate to support either

for accommodations or for sympathy. No significant

school effects emerged in any of these analyses

(Table 3).

DISCUSSION

Previous research suggests that laypeople tend to

take a dualistic view of others’ illness symptoms,

regarding causes of symptoms as either physical or

psychological. 25

Mothers of children with chronic pain

may be the exception, as past research reveals that

mothers are more likely to integrate physical and psy-

chological attributions for children’s pain. 15

The cur-

rent study suggests that teachers—frequently a child’s

next most significant caregiver after parents—do not

as commonly apply this integrated framework in

understanding pediatric chronic pain problems.

The multifactorial nature of the pain problem pre-

sented in the vignette reflects the complex presenta-

tions frequently seen in tertiary care pediatric

chronic pain clinics. Past research suggests that

when psychosocial stressors exist, individuals often

give less credibility to physical symptoms and are

more likely to perceive a psychological etiology for

illness. 14

Because chronic pain typically has few out-

wardly observable symptoms and often is comorbid

with psychological distress (whether causal or not),

teachers confronted with students with chronic pain

Table 3. Summary of Regression Results for Teacher Responses to Pain Regressed on Pain Attributions‡

Predictor: Pain Attributions

Outcomes: Teacher Responses to Student With Pain

Academic Accommodations Sympathy for Student

Physical attributions R2 = .033, b = .12† R2 = .032, b = .18* Psychological attributions R2 = .029, b = .03 R2 = .007, b = �.07 Both physical and psychological attributions (ie, biopsychosocial model) R

2 = .033, b = .10 R2 = .033, b = .16*

† p , .10. *p , .01.

b, standardized coefficient beta. ‡ Dummy variables representing schools were included in each regression equation. No significant school effects arose.

Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 253

may be inclined to interpret these problems as more

psychological than physical in nature. In clinical set-

tings, young patients with chronic pain accounting

for their poor attendance or performance in school

often state that school personnel failed to under-

stand their pain or did not believe it was ‘‘real.’’

Thus, teachers’ ability to convey sincere beliefs about

the student’s complaints of pain and express a shared

perspective of the problem may help to reduce

school avoidance and improve school functioning in

students experiencing chronic pain. The current

study underscores the need to educate classroom

teachers about the complex, multifaceted nature of

pain to help them understand and respond to it

appropriately.

One aim of the study was to assess the effects of

medical evidence on teachers’ judgments about

causes of pain. Results indicate that medical evi-

dence does appear to influence teachers’ attribu-

tions, such that when this evidence is available,

teachers are more likely to make physical attribu-

tions for pain. Previous research documents similar

effects of medical evidence for pain on individual’s

judgments of adults with chronic pain. 11-14

Pediatric

pain specialists should recognize the weight that this

information carries in school and its potential to

influence teachers’ perceptions of pain away from

a dualistic conceptualization toward a more accurate,

and potentially more salutary, biopsychosocial

framework. Contrary to expectations, direct commu-

nication from the medical team to the school did not

influence teachers’ pain attributions. Past research 26

indicates that teachers perceive communication from

the medical team to increase their competence in

managing chronic pain in school. Perhaps, communi-

cation affects teachers’ responses to pain but does not

influence causal attributions. Alternatively, the impor-

tance of effective communication between the medical

team and the school may not have been conveyed ade-

quately through the vignette methods. The quality or

effectiveness of such communication may matter more

than its simple presence or absence.

The manipulation checks revealed that many

teachers believed they were presented with medical

evidence supporting the pain problem when in fact

such evidence was absent. Perhaps, some respondents

interpreted the use of a specific diagnostic label for

the pain condition as medical evidence. The confusion

also may reflect true confusion that teachers ex-

perience when trying to understand chronic pain

conditions.

Regarding the influence of causal attributions on

responses to pain, teachers who perceived a physical

component to the pain—whether in conjunction

with psychological causes or in isolation—reported

more sympathy for the student. This finding parallels

those of Guite et al, 17

who found that peers rated

youth with chronic pain as more likable when they

perceived the pain as more physiologic in origin. It is

interesting to note that the positive effects of physi-

cal attributions for the pain on teachers’ sympathy

for the student were maintained among teachers

who made concurrent psychological attributions for

the pain. In other words, the legitimacy that physical

attributions appear to lend to chronic pain is not

mitigated by the inclusion of psychological causes in

a biopsychosocial interpretation of the pain.

Although the effect was not as strong as expected,

teachers in the sample who made physical attribu-

tions for the pain were somewhat more inclined to

grant academic accommodations. As with sympathy

for the student, the effects of physical attributions

were not attenuated by being incorporated within

the biopsychosocial model. It is not possible to deter-

mine the ‘‘appropriate’’ level of academic accommo-

dations in the hypothetical situation described in the

vignettes. For some youth with pain, providing exten-

sive academic accommodations might inadvertently re-

inforce the pain syndrome by providing an escape from

anxiety-provoking academic demands. Conversely,

providing too few accommodations might make it

difficult or impossible for some students with pain to

function adaptively in the school setting. More re-

search is needed to understand the relation between

specific responses to pain in school and functional

outcomes.

This study has practical implications for both

healthcare providers working with youth with

chronic pain and teachers who encounter them in

school. Particularly, when medical evidence is absent

and psychosocial stressors are present, the healthcare

team should work closely with schools to help them

foster adaptive functioning. Using a biopsychosocial

framework for chronic pain will allow teachers to

form more appropriate explanations for pain and

may help youth with pain to feel better understood,

thus increasing their ability to remain engaged in

the school setting. Medical and behavioral professio-

nals treating youth with chronic pain should be

aware that teachers, who must balance the needs of

a student with pain with those of numerous other

students, require information about chronic pain

and assistance in developing appropriate responses

to these conditions. Although there is little empirical

research in this area to date, 1 recent randomized

controlled trial showed that educating teachers about

disease-related pain through written materials and

teacher in-service meetings with a member of the

healthcare team led to fewer absences among youth

with sickle cell anemia. 27

Similar interventions for

chronic pain conditions of unclear etiology should

be developed and tested.

Several limitations to this research exist. Teachers’

responses to a hypothetical scenario may not precisely

254 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association

reflect reactions to actual situations. Furthermore, it

is unknown whether teachers’ responses to the con-

dition described in the vignette would generalize to

other chronic pain conditions, such as headaches or

abdominal pain, which are typically less visible.

Future research should explore these possible differ-

ences. Schools included in the study were selected

by convenience and cannot be presumed representa-

tive of all schools. Low response rates and small

sample sizes from some schools suggest that sam-

pling bias may limit generalizability; participating

teachers might have had stronger views about

chronic pain or relevant experiences (positive or

negative) that motivated participation. Female fac-

ulty were overrepresented from some of the partici-

pating schools, further limiting generalizability.

Additionally, recruitment procedures varied slightly

across schools, in accordance with school policies

and administrators’ views on how best to involve

their faculty. This inconsistency may have influ-

enced results.

Our measure of pain attributions was adapted spe-

cifically for this study and therefore not fully vali-

dated. It is worth noting that the physical attribution

items on this measure did not perform as a scale.

This is not necessarily a flaw with the measure, but

rather could reflect a tendency for individuals to

identify 1 dominant cause when making physical

attributions for pain, as opposed to viewing these

causes additively as they appear to do with psycho-

logical causes. Finally, although pilot testing sug-

gested that variable manipulations were clear, the

larger sample struggled to determine presence or

absence of medical evidence in the vignettes, requir-

ing a significant number of respondents to be

excluded from some data analyses.

In conclusion, the study reveals that teachers who

encounter youth with chronic pain in school often

lack an integrated biopsychosocial framework to help

them understand and respond to such conditions

appropriately. Future investigations are needed to

enhance our knowledge of what aspects of the

school setting, the pain condition, and the individual

teachers, adolescents, and families are important

determinants of teachers’ causal attributions for pain

and to expand our understanding of how these attri-

butions relate to youths’ ability to function with

chronic pain in the school context.

REFERENCES

1. Goodman J, McGrath P. The epidemiology of pain in children

and adolescents: a review. Pain. 1991;46:247-264.

2. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, et al.

Pain in children and adolescents: a common experience. Pain.

2000;87:51-58.

3. Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J,

Schmucker P. Pain among children and adolescents: restric-

tions in daily living and triggering factors. Pediatrics. 2005;

115(2):e152-e162.

4. Engel G. The need for a new medical model: a challenge for

biomedicine. Science. 1977;196:129-136.

5. Varni JW. An empirical model for the biobehavioral investiga-

tion of pediatric pain. Invited plenary address at the annual

meeting of the American Pain Society, October 26-29, 1989;

Phoenix, Ariz.

6. Kelley HH. Attribution in social interaction. In: Jones EE,

Kanouse DE, Kelley HH, Nisbett RS, Valins S, Weiner B, eds.

Attribution: Perceiving the Causes of Behavior. Morristown, NJ:

General Learning Press; 1972:1-26.

7. Snyder CR, Smith TW. Symptoms as self-handicapping strate-

gies: the virtues of old wine in a new bottle. In: Weary G,

Mirels H, eds. Integrations of Clinical and Social Psychology. New

York, NY: Oxford University Press; 1982:104-127.

8. Handelsman MM, Fox JT. Perceptions of asthma as a self-handi-

capping strategy. Presented at the annual meeting of the Rocky

Mountain Psychological Association, April 23, 1988; Snowbird,

Utah.

9. Walker LS, Garber J, Greene J. Psychosocial correlates of

recurrent childhood pain: a comparison of pediatric patients

with recurrent abdominal pain, organic illness, and psychiatric

disorders. J Abnorm Psychol. 1993;102:248-258.

10. Weiner B, Perry RP, Magnusson J. An attributional analysis of

reactions to stigmas. J Pers Soc Psychol. 1988;55:738-748.

11. Chibnall JT, Tait RC. Social and medical influences on attribu-

tions and evaluations of chronic pain. Psychol Health. 1999;14:

719-729.

12. Chibnall JT, Tait RC, Ross LR. The effects of medical evidence

and pain intensity on medical students’ judgments of chronic

pain patients. J Behav Med. 1997;20(3):257-271.

13. Tait RC, Chibnall JT. Observer perceptions of chronic low

back pain. J Appl Soc Psychol 1994;24(5):415-431.

14. Skelton JA. Laypersons’ judgments of patient credibility and

the study of illness representations. In: Skelton JA, Croyle RT,

eds. Mental Representation in Health and Illness. New York, NY:

Springer Verlag; 1991:1-9.

15. Claar RL, Walker LS. Maternal attributions for the causes and

remedies of their children’s abdominal pain. J Pediatr Psychol.

1999;24(4):345-354.

16. Walker LS, Garber J, Van Slyke DA. Do parents excuse the

misbehavior of children with physical or emotional symp-

toms? An investigation of the pediatric sick role. J Pediatr Psy-

chol. 1995;20(3):329-345.

17. Guite JW, Walker LS, Smith CA, Garber J. Children’s percep-

tions of peers with somatic symptoms: the impact of gender,

stress and illness. J Pediatr Psychol. 2000;25(3):125-135.

18. Chan EC, Piira T, Betts G. The school functioning of children

with chronic and recurrent pain. Pediatric Pain Letter. 2005;

7(2-3):11-16.

19. Palermo TM. Impact of recurrent and chronic pain on child

and family daily functioning: a critical review of the literature.

J Dev Behav Pediatr. 2000;21:58-69.

20. Walker LS, Johnson WS. Recurrent abdominal pain and func-

tional gastrointestinal disorders in the school setting. In:

Brown RT, ed. Handbook of Pediatric Psychology in School Settings.

Mahwah, NJ: Lawrence Erlbaum Associates; 2004:299-312.

21. Eccleston C, Crombez G, Scotford A, Clinch J, Connell HA.

Adolescent chronic pain: patterns and predictors of emotional

distress in adolescents with chronic pain and their parents.

Pain. 2004;108:221-229.

22. Rehabilitation Act, 29 U.S.C. x504. (1973). 23. Logan DE, Coakley RM, Scharff L. Teachers’ perceptions of

and responses to adolescents with chronic pain syndromes. J

Pediatr Psychol. 2007;32:139-149.

Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 255

24. Merskey H, Bogduk N., eds. Classification of chronic pain.

2nd ed. In: IASP Task Force on Taxonomy. Seattle, Wash: IASP

Press; 1994:209-214.

25. Swartzman LC, Lees MC. Causal dimensions of college stu-

dents’ perceptions of physical symptoms. J Behav Med. 1996;

19:95-110.

26. Logan DE, Curran JA. Adolescent chronic pain problems in

the school setting: exploring the experiences and beliefs of

selected school personnel through focus group methodology.

J Adolesc Health. 2005;37(4):281-288.

27. Koontz K, Short AD, Kalinyak K, Noll RB. A randomized,

controlled pilot trial of a school intervention for children with

sickle cell anemia. J Pediatr Psychol. 2004;29:7-17.

256 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association