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How do I love thee? One size does not fit all



The 2024 Global Year will examine what is known about sex and gender differences in pain perception and modulation and address sex-and gender-related disparities in both the research and treatment of pain.

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Pain is often considered a personal experience, but is in fact rarely private. Pain occurs in and is shaped by an interpersonal context. Specifically, pain grabs the attention of the person in pain and also – through expressive behaviours – the attention of others in their environment. In turn, how the observer responds impacts upon the sufferer’s pain. Findings suggest that emotional responses to another in pain are key factors in understanding caregiving behaviour. Specifically, data suggest that anticipating or observing another person’s pain elicits emotional distress and prioritizes behaviour to control the sufferer’s pain. For example, parental distress when anticipating/observing their child’s pain motivates behaviours that restrict the child’s pain exposure (Caes et al., 2012) and potentially pain-inducing activities. While such restriction (e.g., of child leisure activities) can protect the child from further pain or harm, such efforts may become maladaptive in the context of long term or inescapable pain conditions. That is, ongoing restrictions that diminish the child’s engagement in valued daily activities and thus hamper the attainment of other meaningful goals, may foster disability and contribute to maintaining or even exacerbating pain problems.

We hypothesize that optimal parental response to child pain likely reflects an ability to regulate emotional responses to best facilitate the child’s pursuit of a variety of meaningful goals – that is, goals that are not only related to pain control. A number of strategies facilitate the regulation of emotional responses In particular, attentional deployment (i.e., attentional engagement or avoidance) is empirically supported as a central strategy for the regulation of emotion. To date, a limited body of pain research has examined the role of attention in the regulation of emotional responses (e.g., Schoth, Georgallis, & Liossi, 2013), but no studies have examined the role of emotion regulation (using attention deployment in particular) in affective-motivational and behavioral outcomes in the context of child pain.

In our recently published paper in Pain (Vervoort, Trost, Sütterlin, Caes, & Moors, 2014; which attracted a lovely commentary (McMurthry, 2014), we examined whether parental attentional deployment to a child’s pain can down-regulate parental emotional distress and pain control behavior. Parental attention towards or away from child pain was manipulated during a visual task. Specifically, parents were instructed to attend to, or avoid pain faces during a visual task that paired images of an unfamiliar child’s neutral face with the same unfamiliar child’s pain expression. Prior to and following the visual task, parental distress regulation was assessed by heart rate (HR) and heart rate variability (HRV). Eye-tracking during the visual task and self-reported attentional focus towards their own child’s pain prior to their child’s subsequent participation in a cold pressor task (CPT) indexed whether the attention manipulation was successful and generalized to their own child’s pain. To enhance parental involvement during the visual task, parents were told that the visual task pictures represented children undergoing the pain procedure that their own child would undergo. In the second part of the study, parents observed their child’s CPT performance and we assessed parental pain control behaviour (indexed by latency to stop their child taking part in the CPT) and parental distress (indexed by self-report) both prior to and following CPT observation. We expected that compared to parents in the ‘Attend to Pain’ condition, parents in the ‘Avoid Pain’ condition would show (1) greater emotion regulation and (2) less pain control behaviour. Further, since both the nature and consequences of attentional processing may be modulated by individual differences, particularly level of anxiety, we examined the moderating role of parental anxiety on attentional control (eye-tracking/self-report), emotion regulation, and pain control behavior.

Eye tracking and self-report confirmed that the attention manipulation was successful and generalized to parents’ attentional focus regarding their own child’s impending pain. That is, parents who were instructed to attend to pain looked more at pain faces and reported more ruminative thinking about their own child’s pain experience. The reverse was true for parents instructed to avoid pain. Centrally (and interestingly), our findings suggested that a similar regulatory strategy has differential effects dependent upon individual differences such as the parent’s current level of anxiety. Specifically, we found that low anxious parents reported more distress (indexed by self-report and physiological measures), and demonstrated more pain control behaviour in the ‘Attend to Pain’ condition than high anxious parents and high anxious parents showed this pattern of responses when assigned to the ‘Avoid Pain’ condition. In other words, our findings suggest that attention away from pain appears more beneficial for distress outcomes among low anxious parents, and attention towards pain may be more beneficial for high anxious parents.

To our knowledge, this study represents the first piece of evidence pointing to the key role of parent emotion regulation and attentional deployment when faced with a child in pain and also the importance of individual differences. Specifically, the current findings suggest that the function of attention in the regulation of emotion is not uniformly fixed. Attentional avoidance does not invariably down-regulate emotional distress and associated protective behaviours, nor does attention to pain invariably facilitate the opposite pattern. Accordingly, the current findings suggest that interventions focused upon modulating parental attention to child pain should not proceed in a one-size-fits-all manner. Thus, the appropriate question is not which emotion regulation strategies are most effective but rather when they are effective and for whom. Assessing individual differences appears to be a key factor in this regard.

As always, future research can improve on our study. Our study only compared two attentional strategies and thus did not reflect the breadth and complexity of the emotion regulation repertoire, including the key ability to flexibly switch between different (attentional) strategies. Indeed, we expect that optimal emotional outcomes reflect a balance of pursuing pain control goals and goals not related to pain. In responding to the pain of another, one wants both to ease their pain and motivate them to pursue valued non-pain-related activities. When pain control exists as a goal in a multiple-goal context, it follows that a strategy of flexible switching between pain control and non-pain goals is necessary to facilitate optimal function. For instance, while attentional avoidance of pain may (for some individuals) be necessary to accomplish valued tasks (e.g., meeting with friends), continued avoidance may contribute to task persistence at the expense of appropriate pain control, thus exacerbating the pain problem and interfering with further task engagement. Accordingly, the ability to flexibly switch attention between multiple demands and called-for strategies is likely to play a key role in both successful emotion regulation and other goal-directed behaviour. Research examining this proposition is currently under way.

For more information on this study go here to download the complete paper.

About Tine Vervoort

Tine VervoortTine Vervoort is a Senior Research Fellow of the Flemish Research Foundation at Ghent University, Belgium. Dr Vervoort came to her career as a research psychologist in pediatric pain with a background in pediatric/psychiatric nursing (BSc, 1998) and clinical psychology (MSc, 2003). Having completed her PhD on social determinants of child pain expression (2008), she has developed a theoretically integrative and clinically informative research program examining family socialization and social context as determinants of child pain experience. Dr Vervoort has an extensive network of national and international collaborations and her work has been featured at numerous conferences and within internationally peer-reviewed journals. Most recently, Dr Vervoort is the recipient of the prestigious IASP Ulf Lindblom Young Investigator Award for Clinical Science (2014) which honors researchers who have achieved a high level of excellence as independent scholars in the field, with outstanding contributions to clinical pain research. She is the proud (and busy) mother of 3 young boys.


Caes L, Vervoort T, Eccleston C, & Goubert L (2012). Parents who catastrophize about their child’s pain prioritize attempts to control pain. Pain, 153 (8), 1695-701 PMID: 22657401

McMurtry CM (2014). How do I love thee? Let me count the ways of responding and regulating. Pain, 155 (8), 1421-2 PMID: 24837845

Schoth DE, Georgallis T, & Liossi C (2013). Attentional bias modification in people with chronic pain: a proof of concept study. Cognitive behaviour therapy, 42 (3), 233-43 PMID: 23731349

Vervoort T, Trost Z, Sütterlin S, Caes L, & Moors A (2014). Emotion regulatory function of parent attention to child pain and associated implications for parental pain control behaviour. Pain, 155 (8), 1453-63 PMID: 24769189


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