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SUMMARY Over the past several decades, the eld of pediatric pain has made
impressive advances in our understanding of the pain experience of the developing child,
as well as the devastating impact of inadequately managed pain early in life. It is now well
recognized that, from infancy, children are capable of developing implicit memories of
pain that can inuence their subsequent reactions to pain. The present review provides
a synthesis of selected studies that made a signicant impact on this eld of inquiry,
with particular emphasis on recent clinical and laboratory-based experimental research
1Department o f Psychology, Dalhousie Universi ty, Life Sciences Centre, PO Box15000, Halifax, Nova Scotia, B3H 4R2, C anada
2Centre for Pediatric Pain Research, IWK Health Centre, 5850/5980, University Avenu e, Halifax, N ova Scotia, B3K 6R8, Canada
3Department of Pediatrics, Dalhousie Univer sity and the IWK Health Centre, 5850 Univer sity Avenue, PO Box9700, B3K 6R8, Canada
4Department of Psychiatr y, Dalhousie Universi ty, 5909 Veterans’ Memor ial Lane, 8th oor, Abbie J Lane Memorial Buildin g QEII Health
Sciences Centre, Halifax, Nova Scot ia, B3H 2E2, Canada
5Research, IWK Heal th Centre, 5850/5980 Universit y Avenue, PO Box 9700, Halifa x, NS B3K 6R8, Canada
6Department of Communit y Health & Epidemiology, Centre for Clinic al Research, 5790 University Avenue, Hali fax, NS B3H 1V7, Canada
*Author for correspond ence: melanieenoel@gma il.com
The eld of pediatric pain has come to appreciate the importance of children’s early pain memories in
inuencing their subsequent pain experiences.
This review synthesizes selected studies that made a signicant impact on this eld of inquiry,
with particular emphasis on recent clinical and experimental research examining children’s explicit
autobiographical memories for acute pain.
Research is beginning to enhance the precision with which children at risk for developing negatively
estimated pain memories can be identied, in light of the adverse inuence that these memories can
have on children’s subsequent pain experience.
Although there is a dearth of research examining the eectiveness of memory reframing interventions,
these treatments hold promise for reducing the adverse impact of inadequately managed pain.
With the development of new assessment tools and the pediatric fear-avoidance model of chronic
pain, future research should examine the inuence of child and parent fear-avoidance variables in the
development of children’s memories for pain.
A preliminary empirically and theoretically derived model of children’s acute-pain memory development
is proposed, which outlines the factors and relationships implicated in the process by which children’s
pain memories develop, are reframed and inuence the pain experience over time.
Practice Points
Pain is not over when the needle ends:
a review and preliminary model of acute
pain memory development in
childhood
REVIEW
Melanie Noel*1,2, Christine T Chambers1–4, Mark Petter1,2, Patrick J
McGrath1–5, Raymond M Klein1 & Sherry H Stewart1,4,6
487
ISSN 1758-1869
10.2217/PMT.12.41 © 2012 Future Medicine Ltd Pain Mana ge. (2012) 2(5), 487–497
For reprint orders, please contact: reprints@futuremedicine.com
40 years ago, it was widely believed that infants
could not feel pain [1] , which led to inadequate
treatment and needless suffering [2] . Prior to
the 1980s, infants were also believed to be
incapable of encoding, storing and retrieving
memories of past autobiographical events [3].
Recognition of the importance of children’s
memories for pain was largely inspired by land-
mark studies that were published prior to the
turn of the millennium. The seminal research
by Taddio and colleagues provided evidence of
the adverse impact of poorly managed pain in
the first days of life on subsequent pain experi-
enced at 4 and 6 months [4] . Infants who were
circumcised without the use of topical local
anesthetic, as compared with infants who
were uncircumcised, displayed a greater pain
response and cried longer at a subsequent rou-
tine immunization. Furthermore, the infants
circumcised with placebo were observed to
experience a greater increase in pain during
the subsequent immun ization than infants cir-
cumcised with topical local anesthetic. These
researchers subsequently demonstrated that
infants of diabetic mothers who were exposed
to repeated heel lances in the first 2–3 days of
life, as compared with infants who were not
exposed to repeated painful procedures, exhib-
ited a greater pain response prior to (i.e., dur-
ing skin preparation and cleansing) and during
a subsequent venipuncture [5] . These studies
dramatically demonstrated how inadequately
managed pain in the first days of life could
lead to sensitization to later pain experiences.
This research also raised the possibility that
these infants learned to anticipate pain during
a subsequent procedure and developed some
form of implicit pain memory that influenced
their distress during subsequent pain [6]. This
early work provided critical evidence for the
powerful role of children’s early memories for
pain in their subsequent pain experience and
established the importance of this area in the
field of pediatric pain.
Indeed, children’s memories for pain have
important implications for pain assessment,
treatment and health across the lifespan [6 ,7].
Many of the tools used to assess pain rely on the
child’s retrospective account of their psycholog-
ical and physical experience of pain (e.g., com-
parison between current and remembered pain
experience) and memory for pain is often used
to infer the effectiveness of current interven-
tions. Additionally, memories for pain may
play an important role in the transition of pain
from an acute to chronic state [8,101], through
operant and respondent learning processes as
well as altered processing within the CNS [8] .
Moreover, early memories for pain can have
important long-term consequences for subse-
quent health behaviors and pain perception.
Retrospective research suggests that early pain
memories influence fear and avoidance of medi-
cal care in adulthood [9]. Furthermore, among
both clinica l and healthy samples, children
who develop pain memories that are negatively
estimated (i.e., recalled pain is higher than
initial pain report) are at risk for experiencing
increases in distress and pain over time [10,11].
As such, children’s memories for pain are as
important to their subsequent health behaviors
as their actual experience of pain itself.
The purpose of this review is to offer a con-
temporary perspective on recent issues in the
field by providing a synthesis of selected studies
that have made significant contributions to our
understanding of children’s explicit memories
for acute pain, with particular emphasis on
recent clinical and laborator y-based experi-
mental research. In addition, a novel prelimi-
nary theoretical model of children’s acute pain
memory development, inspired by this research,
is presented to stimulate future research in this
area. Finally, avenues for clinical intervention
are highlighted throughout. Given that this
review paper is not intended to be a systematic
review or meta-ana lysis, a formal search strategy
was not applied.
examining children’s explicit autobiographical memories for acute pain. Research has
begun to move towards improving the precision with which children at risk for developing
negatively estimated pain memories can be identied, given the adverse inuence
these memories can have on subsequent pain experiences. As such, several fear- and
anxiety-related child and parent variables implicated in this process are discussed, and
avenues for future research and clinical intervention are identied throughout. Finally, a
preliminary empirically and theoretically derived model of acute pain memory development
in childhood is presented to parsimoniously summarize the evidence accumulated to date
and guide future i nvestigation in this area.
Pain Manage . (2012) 2(5) future science group
488
REVIEW Noel, Chambers, Petter, McGrath, Klein & Stewart
Children’s pain memories:
the state-of-the-science
Pain memories are – not unlike the pain experi-
ence [12] – subjective and multidimensional, con-
sisting of sensory (e.g., pain intensity), affective
(e.g., fear) and contextual (e.g., people, place
and time) aspects [7]. Children’s memories for
pain are constructive and reconstructive, which
makes them susceptible to distortion over time.
The manner in which memories are framed is
influenced by a host of factors including: age
[13]; distress [10]; pain intensity [14]; trait anxi-
ety [15]; negative affectivity [16]; parent–child
discourse about the event following exposure
[17] ; duration of the interim between pain expe-
rience and memory assessment [18,19]; and state
anxiety at the time of memory elicitation [20].
As a result, empirical investigation in this area is
methodologically complex. Nevertheless, given
the importance of children’s pain memories in
shaping their subsequent pain experiences, gar-
nering understanding of the processes involved
in children’s pain memory development is of
critical importance.
Previous reviews on children’s memories
for pain
There is a substantial body of literature on the
development of children’s autobiographic al
memories for stressful and traumatic events (for
reviews, see [21, 22]); however, specific research
on children’s memories for pain is relatively
limited. To date, two reviews on the topic have
been conducted. The first, by Ornstein and col-
leagues, provided an overview of research that
was primarily conducted with children in medi-
cal procedure contexts [7]. The authors provided
an information-processing framework outlining
the various stages of memory (encoding, storage
and retrieval), informed by literature on chil-
dren’s autobiographical memory development
within which the acquisition, retention and dis-
tortion of information about pain experiences
can be organized and understood. Despite the
importance of this initial review, the majority of
studies reviewed assessed children’s memory for
contextual details as opposed to aspects of the
pain itself. As such, it was unclear whether the
same principles underlying children’s contextual
memory also applied to memory for somatosen-
sory and affective aspects of pain. The second
review, by von Baeyer and colleagues, provided
an overview of developments in the field since
the time of the original review, emphasized the
consequences of children’s pain memories for
subsequent pain and healthcare behaviors, and
discussed individual differences as well as situ-
ational and methodological influences in chil-
dren’s recall [6]. Importantly, this review high-
lighted the individual variability in children’s
pain memories and resulting health behaviors
as well as potential intervention targets that
could prevent the deleterious consequences of
n egatively estimated pain memories.
Fragility of pain memories
Children’s autobiographical memory – the type
of explicit memory of an event from one’s life
that is tied to a particular place and time (e.g., a
painful medical procedure) – has been described
as remarkably robust yet significantly fragile
[23,24 ]. Similar to memory for stressful events,
children have generally been found capable of
accurately recalling previous painful experi-
ences; indeed, children as young as 3 years of age
are fairly accurate at recalling contextual aspects
of painful medical procedures, especially in the
absence of specific or leading questions [25, 26].
Similarly, among both healthy and clinical sam-
ples of children undergoing experimental and
medically induced pain, children’s pain memo-
ries have been found to be accurate after short
(e.g., 1 week) and long (e.g., 1 year) delays [27–29] .
Nevertheless, the fragility of pain memories
is rooted in the fact that memory can become
distorted over time [10,14,15, 30]. Bruck and col-
leagues conducted an investigation that pro-
vided the first and perhaps most compelling
demonstration of the reconstructive nature of
children’s pain memories [31]. They examined
children’s memories for contextual details of,
and pain experienced during, an immunization
as well as the effect of providing children with
dif ferent types of information following the
procedure on their subsequent recall. Following
immunization, children were randomly assigned
to receive either pain-affirming (e.g., ‘the shot
hurt’), pain-denying (e.g., ‘the shot did not
hurt’), or neutral (e.g., ‘the shot is over’) feed-
back. Children’s recalled pain and observer-
reported distress ratings (i.e., based on facial
features, verbalizations and degree of crying)
did not differ 1 week later; however, approxi-
mately 1 year later (range: 4–18 months) the
researchers conducted follow-up home visits on
three separate occasions to provide additional
pain-denying or neutral feedback and mis-
leading or non misleading (e.g., falsely stating
Review & preliminary model of acute pain memory development in childhood REVIEW
future science group www.futuremedicine.com 489
that the pediatrician read a story to the child)
information about the individuals involved in
the children’s care. At a fourth and final visit,
children who received pain-denying feedback
remembered crying less and experiencing less
pain than children who received neutral feed-
back. Furthermore, children who received
misleading information made more false alle-
gations regarding the individuals involved in
their care (e.g., reported that the research assis-
tant gave them the vaccination) than children
who did not receive this misleading informa-
tion. Interestingly, those children who exhibited
greater distress during the immunization were
found to be more susceptible to suggestibil-
ity 4–18 months later. Together, the findings
demonstrated the malleability of children’s pain
memories and the impact that discourse sur-
rounding the experience following the event can
have on subsequent recall.
Memory distortion & subsequent pain
experience
Once children’s pain memories become dis-
torted, they can have important implications
for distress experienced during subsequent pain
experiences. Chen and colleagues examined this
possibility among children diagnosed with leu-
kemia who were required to repeatedly undergo
lumbar punctures spaced 1 week apart as part
of their treatment protocol [10]. Although chil-
dren’s pain memories were generally accurate, a
subset of children later developed exaggerated
memories of the negative details of the lum-
bar puncture (described in more detail below).
Furthermore, children who developed more
negatively estimated, versus accurate or posi-
tively estimated, memories of pain and anxiety
exhibited greater increases in behavioral distress
(i.e., observer-rated behaviors that are indicative
of anxiety and/or pain such as crying, scream-
ing and verbalizations of anxiety), and reported
more pain over time. This was a robust find-
ing that persisted even after controlling for age,
initial distress and number of previous lumbar
punctures. This research highlighted the impor-
tance of memory distortion for subsequent dis-
tress and identified children who are most at risk
for developing maladaptive responses to pain
versus those who may be buffered from such
outcomes.
A recent investigation by Noel and colleagues
extended this research among healthy children
undergoing a novel experimental pain task [11] .
Children completed the cold pressor task on
two laboratory visits spaced 1 month apart. At
2 weeks following the initial exposure, chil-
dren’s memories for the pain task and expec-
tancies about future pain were elicited. Similar
to healthy adults [16] , children’s memories of
pain intensity were a better predictor of subse-
quent reporting of pain intensity than was their
actual initial experience of pain; in fact, chil-
dren’s memories fully mediated the relationship
between pain reporting at the initial and the
subsequent pain experience. Similar to children
with chronic illness [10] , differences in children’s
memory style also influenced subsequent pain
reporting. Children who developed negatively
estimated, versus accurate or positively esti-
mated, memories of pain intensity and pain-
related fear developed more negative expecta-
tions of future pain and showed greater increases
in pain ratings over time.
Individual vulnerability & protective
factors
Given the potential malleability of children’s
pain memories and the importance of nega-
tive distortion for subsequent pain and distress,
research has moved towards identifying children
who are most at risk for developing negatively
estimated pain memories. Although the rela-
tionship between stress and children’s memories
for autobiographical events is controversial and
marked by inconsistencies across studies [13], in
the context of pain there is a clear link between
children’s level of pain and distress experienced
during a painful event, and the subsequent fram-
ing of their memories. Across a range of medical
procedures and among both clinical and healthy
samples, it has been demonstrated that children
who exhibit greater behaviora l distress and
report higher levels of pain, tend to develop neg-
atively estimated pain memories [10,14] . Chen and
colleagues examined pain memories of children
between the ages of 3 and 18 years who were
diagnosed with cancer and who were required
to repeatedly undergo lumbar punctures as part
of their treatment protocol [10]. Higher distress
at the initial lumbar punctures was associated
with more negatively estimated pain memories,
even when controlling for number of previous
lumbar punctures.
To ensure the generalizability of these find-
ings, Noel and colleagues examined the relation-
ship between venipuncture pain experienced
during routine blood draws and memories for
Pain Manage . (2012) 2(5) future science group
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REVIEW Noel, Chambers, Petter, McGrath, Klein & Stewart
the somatosensory and affective aspects of the
pain experience [14]. Consistent with previous
research [10], children who reported higher lev-
els of pain intensity during venipuncture later
developed negatively estimated memories of
anxiety. Similarly, children undergoing hepatitis
vaccinations who received standard care (i.e., no
pain management) developed more negatively
estimated memories of pain intensity compared
with children who received pharmacological
(e.g., topical anesthetic) and nonpharmacologi-
cal (e.g., distraction) interventions. These chil-
dren also developed less accurate memories of
anxiety than children who received pharmaco-
logical intervention [30]. Furthermore, children
undergoing dental procedures who had higher
levels of trait anxiety tended to recall more pain
after a delay, suggesting that highly trait anx-
ious children may have developed n egatively
estimated pain memories [15].
Anxiety & children’s pain memories
In light of theoretical [32] and empirical [15] sup-
port for the role of anxiety in the development
of memory biases for threat and pain, Noel and
colleagues recently examined the causal impact
of state anxiety, and the influence of anxiety-
related variables, on the development of healthy
children’s memories for a novel pain experience
[33]. Children were randomly assigned to com-
plete either a laboratory state anxiety induction
task (i.e., anticipation of giving a speech in front
of judges and completing a difficult math task)
or a control task (i.e., anticipation of watching
a nature video) before completing the cold pres-
sor task. Children also completed measures of
anxiety-related variables (state/trait anxiety and
anxiety sensitivity) and provided pain ratings
immediately following the pain task and again
2 weeks later based on their memories. Results
did not reveal memory differences between chil-
dren in the state anxiety induction group and
those in the control group; however, irrespec-
tive of group assignment, state anxiety emerged
as a unique predictor of children’s memories of
pain intensity and pain-related fear, over and
above sex, stable anxiety-related variables, and
initial pain reporting. Moreover, anxiety sensi-
tivity and trait anxiety significantly predicted
children’s memories of the fearful aspect of the
pain experience. These predictive models had
substantial explanatory power accounting for
52 and 35% of the variance in recalled pain
intensit y and pain-related fear, respectively.
This research extends findings yielded among
healthy adults to earlier developmental peri-
ods [34] and further illustrates the importance
of both state anxiet y and trait-level anxiety
variables in influencing the development of
c hildren’s pain memories.
Memory reframing interventions
Given the powerful influence of pain memories
on subsequent pain experience, intervention
efforts should extend beyond the immediate
pain context; however, very few studies have
examined the effectiveness of memory refram-
ing interventions to date. Chen and colleagues
examined the influence of a brief memory
reframing intervention on subsequent distress
during repeated lumbar punctures among chil-
dren diagnosed with leukemia [35] . Children
in the treatment group’s memories were elic-
ited through a memor y inter view designed to
assess biases in children’s recall of threatening
aspects of the lumbar puncture. Subsequently,
a therapist who observed the procedure used
cognitive-behavioral strategies to reframe the
memory based on objective information yielded
during the procedure. Specifically, therapists
assisted children in re-evaluating their reac-
tions by reinforcing their beliefs about their
abilities to use coping strategies (e.g., increasing
their perceived self-efficacy), appraising their
responses to the procedure in a more realistic
manner and increasing the accuracy of their
recall. In this way, the intervention directly tar-
geted and aimed to reduce the catastrophic and
negatively estimated aspects of children’s recall,
and aimed to increase children’s perceptions
of the effectiveness of their coping abilities.
Compared with children in the control group,
those receiving the memory reframing inter-
vention showed significant reductions in dis-
tress at a subsequent lumbar puncture 1 week
later. Similarly, Pickrell and colleagues exam-Similarly, Pickrell and colleagues exam-
ined the effectiveness of a memory reframing
intervention among children (aged 6 –9 years)
undergoing repeated restorative dental treat-
ments involving local anesthesia injections [36].
At 2 weeks following the initial dental treat-
ment, children were randomized to receive
either a memory reframing intervention, which
was designed to positively reframe their memo-
ries of the previous procedure, or an interactive
neutral discussion (i.e., control condition) led
by an inter ventionist. Immediately following
the intervention or control procedure, children
Review & preliminary model of acute pain memory development in childhood REVIEW
future science group www.futuremedicine.com 491
once again underwent a similar dental treat-
ment. Findings revealed that children receiv-
ing the memory reframing intervention, as
compared with children in the control group,
remembered experiencing less pain and fear
than they actually reported at the initial pro-
cedure, reported less fear following injections
over time, and showed improvements in their
behavior (i.e., degree of cooperativeness) from
the first to the second dental treatment.
Given these findings, it is surprising that more
research has not examined the effectiveness of
similar memory reframing interventions for use
with other pediatric populations (e.g., healthy
children and children with anxiety disorders).
Given the powerful role of parents in shaping
children’s pain experience/expression [37–39], as
well as their autobiographical memories [3,40] ,
parent-led memory reframing interventions
may be particularly promising and cost effec-
tive. Moreover, given the frequency with which
parent–child interactions take place in children’s
naturalistic environments, there would be a
wealth of opportunities for verbal interactions
between parents and children aimed at positively
reconstructing pain memories.
In addition to the influence of postevent
information on the reconstruction of children’s
pain memories and subsequent pain experience,
there is a small body of experimental research
suggesting that provision of information prior
to a novel event (e.g., visiting a pretend zoo or
a pirate) can have a significant impact on the
accuracy and completeness of children’s auto-
biographical memories [41–43] . Moreover, there
is theoretical support for the role of informa-
tion provision prior to medical procedures in
promoting more accurate expectations and
schemas – based on children’s previous experi-
ences and memories – as well as optimal emo-
tion regulation and coping [44]. Given that more
accurate pain memories are linked to less pain
and anxiety during subsequent painful experi-
ences [10,11], future research should examine the
influence of pre-event information provision
and children’s pain memories and experiences
over time.
A preliminary model of acute pain
memory development in childhood
The results of the extant research on children’s
memories for pain have important theoreti-
cal and clinical implications and enhance our
understanding of the factors that influence
the development of children’s pain memories
from their inception, their reconstruction over
time, and the manner in which these memo-
ries shape subsequent pain experience. A pre-
liminary empirically and theoretically derived
model of how these factors are hypothesized to
influence pain memories, and how pain memo-
ries influence subsequent pain experiences, is
presented in Figure 1. Consistent with predic-
tions of theories of anxiety and memory biases
[32,45] , children with higher levels of anxiety
and danger-related schemata pertaining to their
general environments and somatic sensations
tend to develop pain memories that are char-
acterized by amplified estimations of sensory
and affective threat over time. Several theories
also predict that these memories develop as a
result of highly anxious children’s attentional
biases toward threatening aspects of the pain-
ful experience [32,46]; however, it is also pos-
sible that there are subtypes of highly anxious
children who differ in their individual atten-
tion style (e.g., hypervigilant versus avoidant
of threat cues) and who may also differ in the
degree to which their memories become nega-
tively estimated over time [47]. It is likely that
in addition to general anxiety-related constructs
(e.g., state/trait anxiety and anxiety sensitiv-
ity), the presence of fear and anxiety that is
specific to pain itself (e.g., fear of pain, pain
anxiety and pain catastrophizing) is strongly
related to memory biases. Furthermore, these
general anxiety-related variables are thought to
be predisposing factors that predict the devel-
opment and exacerbation of pain-specific fear
and anxiety (e.g., fear of pain and pain cata-
strophizing) [48–51] . Highly anxious children are
also likely to be characterized by a perceived
inabilit y to cope with pain [45] , which could
influence the construction and reconstruction
of pain memories at encoding and retrieval, as
well as the development of negative expectancies
of future pain. Indeed, negative memory biases,
such as the anxiety constructs described herein,
are characterized by amplified estimations of
threat; that is, highly anxious children recall
their experience as more painful and fear-induc-
ing than they initially report it to be. Once these
negative memory biases develop, they become
powerful predictors of children’s subsequent
pain experience. It has been suggested that
negative memory biases and pain expectancies
seen among highly anxious and fearful children
may become activated upon re-entry into the
Pain Manage . (2012) 2(5) future science group
492
REVIEW Noel, Chambers, Petter, McGrath, Klein & Stewart
pain context and then further exaggerated as
a result of increased arousal [10]. As a result,
negatively estimated memories and expectan-
cies likely become the experientia l context
through which subsequent pain is experienced.
Not surprisingly then, these children’s reactions
to pain, like their pain memories themselves,
come to involve even more distress over time.
Furthermore, this process likely exacerbates
and perpetuates the vicious cycle of increased
pain-specific anxiety and fear, distress, pain
during painful experiences, additional recon-
struction of negatively estimated pain memo-
ries and expectancies, and heightened subjective
r eactivity to pain over time.
To date, research on children’s memories
for pain has seldom examined the role of par-
ents. Nevertheless, children do not live and
experience pain in isolation; indeed, parents
exert a powerful influence on the socializa-
tion of children’s fear, anxiety, memory and
pain behaviors [3,3 7–4 0,52] . Children’s beliefs
and cognitions about the inherent threat value
of pain develop within the familial context.
Throu gh early vica rious and instrumental
learning about somatic symptoms (including
pain), individuals develop beliefs and cogni-
tions about the dangerousness of pain and the
appropriateness of associated behaviors [53–57] .
Similarly, children’s autobiographical memo-
ries develop within this familial context and
are highly influenced by the quality and content
of their verbal interactions with individuals in
their social environments, particularly parents
[3,40] . Cognitive affective parent factors shown
to increase child pain behaviors and anxiety,
such as parental catastrophizing about child
pain [5 8,59] and parenta l anxiety sensitivit y
[60], likely fuel the complex inter-relationships
between parent and child factors in influencing
the development of pain memories and subse-
quent response to pain. Moreover, the relation-
ships between the psychological characteristics
and behaviors of the parent and those of the
Pain experience
Pain memories
and expectations
Future pain
experience
Pain-specific child
characteristics:
– Fear of pain
– Pain anxiety
– Pain catastrophizing
– Accurate
– Exaggerated
– Minimized
Pain report
Distress
Pain report
Distress
General child
characteristics:
– Anxiety and danger
schemata: anxiety
sensitivity and
trait/state anxiety
– Attentional biases/style
Parent psychological characteristics
and behaviors:
– Parent catastrophizing about child pain
– Parent anxiety sensitivity
– Information provision: pain affirming
and pain denying
Encoding/
reframing
Figure1. A preliminary model of acute pain memory development in childhood outlining the
theoretically and empirically derived relationships between child and parent factors that are
hypothesized to inuence the development of children’s pain memories, expectations and pain
experiences over time.
Review & preliminary model of acute pain memory development in childhood REVIEW
future science group www.futuremedicine.com 493
child are likely reciprocal [61,62]; as such, par-
ents can exert influence at every stage in the
cycle. Accordingly, they have the potential to be
critical agents in intervention efforts aimed at
reducing children’s anxiety before, and fear and
pain during, painful experiences. Furthermore,
they have the potential to influence the refram-
ing of children’s pain memories and modifi-
cation of expectancies through parent–child
discourse following painful experiences.
Conclusion & future perspective
Researching children’s memories is not without
its methodological challenges (e.g., difficulty
disentangling memory of pain experience from
memory of pain reporting, necessity of reliance
on self-report and lack of control over factors
influencing memory reconstruction over time);
however, the importance of understanding the
development of pain memories and their influ-
ence on children’s experience of pain over time
cannot be overstated. The recent development
of child and parent report measures of pain-
related fear and anxiet y [48,63 ,6 4] will enable
more refined examinations of the role of anxiety
and fear in the development of children’s pain
memories. The development of the pediatric
fear-avoidance model of chronic pain [62] – an
adaptation of Vlaeyen and Linton’s model to
explain the processes by which pain transitions
from an acute to a chronic state [65] – provides
intriguing opportunities to examine the role
of cognitive and affective fear-avoidance fac-
tors in both the child’s pain experience and the
development of their pain memories over time.
Furthermore, given that the mediating role of
attention is at the core of theories put forth to
account for the relationship between anxiety
and memory biases [32], inclusion of measures
of attention in future investigations is war-
ranted. Finally, multi method investigations of
the reciprocal influences of parent and child
psychological factors in the development of
pain memories and coping over time will offer
valuable insights that will facilitate the ultimate
goal of improved pain management for chil-
dren. A lthough intriguing questions about the
nature of children’s pain memory development
exist, and research is needed to disentangle its
inherent complexity, such future research offers
promise for improved identification, assessment
and treatment of children at risk of develop-
ing pain memories that can have important
i mplications for their health across the lifespan.
Acknowledgements
Parts of this review paper are derived from unpublished
portions of the first author’s doctoral dissertation entitled,
‘Children’s memory for pain : experimental investigations
of the role of anxiety in children’s pain memories and the
influence of pain memories on subsequent pain experience’.
The authors greatly appreciate the generosity of the anony-
mous reviewer who made important contributions to the
development of the preliminary model. The authors would
also like to thank K Birnie and K Boerner for their valu-
able insights into the model. Finally, the authors would
like to sincerely thank the children and families who took
part in this dissertation research and inspired these ideas
and writing.
Financial & competing interests disclosure
M Noel and M Petter are Killam Scholars and are sup-
ported by Frederick Banting and Charles Best Canada
Gradua te S ch ol arships Doctoral Awards f rom the
Canadian Institutes of Health Research (CIHR ). At the
time that this work was completed, M Noel was also sup-
ported by a CIHR Team in Children’s Pain Fellowship. M
Noel’s dissertation research was supported by a Marion and
Donald Routh Student Research Grant f rom the Society
of Pedia tric Psyc holog y (D ivision 54, Ame rican
Psychological Association), a Canadian Pain Society
Trainee Research Award from the Canadian Pain Society,
and a Category A Research Grant from the I WK Health
Centre awarded to M Noel. Funding for this research was
also provided by an operating grant from the CIHR and
infrastructure funding from the Canada Foundation for
Innovation awarded to CT Chambers. M Noel and M
Petter are trainee members of Pain in Child Health, a
Strategic Training Initiative in Health Research of CIHR.
CT Chambers and PJ McGrath are supported by Canada
Research Chairs. SH Stewart was supported through a
Killam Research P ro fessorship from the D alhousie
University Faculty of Science at the time this research was
conducted. The authors have no other relevant affiliations
or financial involvement with any organization or entity
with a financial interest in or financial conflict with the
subject matter or materials discussed in the manuscript
apart f rom those disclosed.
No writing assistance was utilized in the production of
this manuscript.
Ethical conduct of research
The authors state that they have obtained appropriate insti-
tutional review board approval or have followed the princi-
ples outlined in the Declaration of Helsinki for all human
or animal experimental investigations that they conducted
themselves. In addition, for investi gations involving human
subjects that they themselves conducted, informed consent
has been obtained from the participants involved.
Pain Manage . (2012) 2(5) future science group
494
REVIEW Noel, Chambers, Petter, McGrath, Klein & Stewart
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