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PEDIATRIC ANESTHESIA

Exploring Sociodemographic and Personality Characteristic Predictors of Parental Pain Perceptions

Rachel Yaffa Zisk, PhD, RN, MPH^*, Margaret Grey, DrPH, RN, FAAN^*, Jill E. MacLaren, PhD, and Zeev N. Kain, MD, MBA

From the *Department of Anesthesiology, Yale University School of Nursing, New Haven, Connecticut; the Departments of Anesthesiology, Pediatrics, and Child Psychiatry, Center for the Advancement of Perioperative Health®, Yale University School of Medicine, New Haven, Connecticut; and Henrietta Szold School of Nursing, Hebrew University-Hadassah Medical Organization, Jerusalem, Israel.

Address correspondence to Rachel Yaffa Zisk, PhD, RN, MPH, Yale School of Nursing and the Department of Anesthesiology, Yale University School of Medicine, 100 Church St. South, New Haven, CT 06536. Address e-mail to rachelzisk{at}yahoo.com.

	Abstract

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BACKGROUND: We studied the relationship between children's and parents' sociodemographic and personality characteristics and parents' perceptions of their children's pain.

METHODS: One-hundred-ten parents of children undergoing surgery completed measures of pain perception (e.g., Medication Attitude Questionnaire; MAQ) and parent and child personality characteristics (e.g., Neuroticism, Extraversion and Openness to experience Five-Factor Inventory; NEO-FFI). Factor analysis and logistic regression models were developed.

RESULTS: In terms of pain medication perceptions (MAQ), descriptive analysis showed that more than 70% of parents feared side effects of analgesia, 43% thought analgesics were addictive, and 37% thought that the less often children receive analgesia, the better it worked. Factor analyses of the MAQ revealed a three factor solution explaining 52% of the variance in parental pain medication perceptions. Conceptually, these factors represented Appropriate Use Attitude of Analgesics, Concerns about Side Effects, and Avoidance of Analgesia. Stepwise regression models were used to identify predictors of parents' scores on each of the three factors. Results indicated that less educated parents and parents of more sociable and more reactive children were more likely to indicate that they would avoid giving analgesia (Avoidance factor; P < 0.001). Parents with higher conscientiousness scores (NEO-FFI) and those with more impulsive children were more likely to perceive that analgesia was appropriate to use for child pain (Appropriate Use Attitude factor; P < 0.001).

DISCUSSION: We conclude that many parents have misconceptions of pain and analgesics, and that child and parent personality characteristics can be used to identify parents at risk of these misconceptions.

	Introduction

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Each year, more than three million children undergo surgery in the United States and most of them experience pain and distress. Although the medical staff is responsible for administration of pain medication in the hospital, when the child recovers at home, medication is controlled by parents. Previous studies have indicated that, unfortunately, many parents do not adhere to the postoperative analgesia recommendations provided by their health care providers (1–5). For example, 50%–60% of parents provided less than the prescribed number of analgesic doses (1,2,5). Further, up to 70% of the acetaminophen doses children received at home were subtherapeutic (based on 15 mg/kg), and 58.8% of the children received less than the recommended acetaminophen daily dose (60 mg·kg^–1·day^–1). Parents were also likely to administer less potent compounds than those prescribed (acetaminophen with no codeine rather than the prescribed combination), or to increase the time interval between analgesic doses (1,2,5–7). These practices are incongruent with the recommendations of the American Academy of Pediatrics indicating that early, effective management of pain is more successful than delayed management (8).

The reasons behind parental undermedication of postoperative pain are not clear. Previous studies conducted with children undergoing elective surgery found that parents feared side effects of analgesics, were worried about future drug use or addiction, and believed that analgesia should be used only as a last resort (1,3,6,7,9). Further, parents thought that acetaminophen worked best if provided only when the pain was severe (9) and would not give analgesics before the onset of pain (6). Given that these misconceptions have been found to affect administration of pain medications (3), there is a clear need for educational efforts to address these beliefs. To better focus these effects, research should be conducted to identify parents most likely to have these misconceptions.

Pain is a noxious stimulus that evokes responses that are influenced by multiple personality characteristics (10–12). A child's temperament has been repeatedly shown to influence pain expressions in a variety of clinical settings (12–18). For example, children who were rated as more active displayed more preoperative distress after blood sampling (15) and during immunizations (16), and children who were rated as more active demonstrated higher pain scores in the hospital after tonsillectomies (6). Therefore, it is not surprising that parents expect children with different behavioral styles or temperaments to express pain differently. Interestingly, there is little data regarding the effects of a child's temperament on parental pain perceptions and parental pain management and, thus, there is a need for such research.

The purpose of this study is to examine parental perceptions about children's pain expression, pain management, and the consequences of untreated pain in children. This study further examines the relations among children's and parents' personality and sociodemographic characteristics and parental pain perceptions. The long-term goal of this research is to identify factors associated with misconceptions about pain, and to develop an intervention to address these misconceptions in parents.

	METHODS

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The participants were a convenience sample of parents of healthy children aged 3–14 yr undergoing elective surgical procedures at a university hospital in the United States. Parents were approached and recruited on the day of surgery. After giving informed consent, parents completed the questionnaires listed below while in the preoperative waiting area. To ensure a full distribution of children's ages, a stratified approach was used and 35–40 parents for each age group: 3–6.9 yr, 7–9.9 yr, and 10–14 yr were recruited. The study was approved by the IRB and parents provided written informed consent.

Demographic/background information questionnaire.
This questionnaire was designed to gather sociodemographic information about the family and past surgical and nonsurgical hospital experiences of the child.

Parental Pain Perceptions
Parental Perception and Untreated Pain in Children
To examine parental perception of the consequences of untreated pain in children, parents were asked to respond "yes" or "no" to the following two questions "Do you think that untreated pain can cause physical damage?" and "Do you think that untreated pain can cause psychological damage?"

Medication Attitude Questionnaire
This questionnaire was developed to examine attitudes about using pain medication for treating children's pain. The instrument consists of 16 items each rated on a 7-point Likert scale with handles ranging from "strongly disagree " [1] to "strongly agree " [7]. Parents were instructed to consider analgesia as any medication prescribed for a specific event or over-the-counter analgesia any time. Internal consistency (Cronbach's Alpha) for the overall scale is reported between 0.68 and 0.73 (9,19). For the four subscales the internal consistency coefficients are reported between 0.63 and 0.75 (9).

Parental Pain Expression Perceptions
To address the lack of a structured instrument that examines parental perceptions of children's pain expressions, the authors assembled a group of experts (pediatric practitioners, pediatric researchers, and parents) to address this issue. On the basis of clinical experience, previous research, and a review of the literature, the group identified nine items evaluating parental perceptions of pain expression in children.

Child Personality Characteristics
Emotionality, Activity, Sociability, and Impulsivity Scale of Child Temperament (EASI)
This instrument assesses baseline temperament of the child through parental report and is constructed of 20 items in four categories: emotionality, activity, sociability, and impulsivity, scored on a 5-point Likert scale. Instrument test-retest reliability ranged from 0.75–0.91 (mean = 0.82) across scales. Convergent validity is reported to be r = 0.77 when compared to other temperament measures (20). Internal consistency (Cronbach's Alpha) has been reported to range from 0.69 to 0.76 (21).

Parental Personality Characteristics
Although there are currently no empirical data to suggest the ideal instruments for evaluating predictors of parental pain perceptions, we considered clinical experience and the convergence of literature in the area of parental perceptions and pain in the selection of our measures. The following instruments were chosen to evaluate adult temperament (NEO-FFI), anxiety, State-Trait Anxiety Inventory (STAI), and coping styles, Miller Behavioral Style Scale (MBSS).

The Neuroticism, Extraversion and Openness to experience Five-Factor Inventory (NEO-FFI)
This measure is a shortened version of the NEO Personality Inventory (NEO-PI), a widely used measure of the "five-factor model" of personality for adults. The NEO-FFI measures the five domains of adult personality and temperament: neuroticism (N), extraversion (E), openness to experience (O), agreeableness (A), and conscientiousness (C). The instrument consists of 60 items that are rated on a 5-point scale and is for adults aged 17 yr and older. Internal consistency for the subscales is = 0.86, = 0.77, = 0.73, = 0.68 and = 0.81 for N, E, O, A, C respectively (22).

Miller Behavioral Style Scale
The MBSS is designed to differentiate coping styles of being active information seekers (monitors) or passive information avoiders or distractors (blunters). Participants are given four stress-inducing scenarios, each having eight possible responses, and are asked to choose all the statements that reflect how they would act in such a situation. Miller (23) reports that the test-retest correlation for the monitoring subscale was 0.72 (P < 0.01) and 0.75 (P < 0.01) for the blunting scale, and that the internal consistency was = 0.70.

State-Trait Anxiety Inventory
This instrument is a widely used self-report anxiety assessment instrument for adults. The questionnaire consists of two separate scales; one measures state and the other measures trait anxiety. Test-retest correlations for the STAI are high, and range from 0.73 to 0.86. Alpha coefficients are reported as 0.92 for state anxiety and 0.90 for trait anxiety (24).

Statistical Analysis
All analyses were conducted using SPSS 13.0 (SPSS®, Chicago, IL). Descriptive statistics and correlations were used to describe the sample. Data analysis was completed in three phases. First, univariate descriptive analyses were conducted to evaluate frequency of responses on the Medication Attitude Questionnaire (MAQ) and Parental Pain Expression Perceptions (PPEP). Second, two separate factor analyses with variance maximizing rotations (Varimax rotations) were used to explore the statistical and conceptual groupings of items on the MAQ and PPEP respectively. Cronbach's Alpha was used to evaluate the internal consistency of items within each factor. Finally, stepwise linear regression was used to examine the ability of socio-demographic and personality characteristics in predicting the derived factor scores of the MAQ and PPEP.

To facilitate examination of the effects of sociodemographic and personality characteristic on parental pain perceptions, factor analysis was conducted as a preliminary step to reduce the dimensions of the pain perception instruments. The result of such a factor analysis is that clusters of highly correlated (and thus, in most cases, conceptually related) items are combined to form continuous scales. The attendant subscores reliably condense the useful information from the available data. For further information on factor analysis the reader is referred to http://www.ats.ucla.edu/STAT/spss/output/factor1.htm.

Stepwise linear regressions were conducted in the following manner. Separate stepwise regression analyses were conducted for each of the following combinations of dependent items on the MAQ and PPEP respectively. The dependent variables considered were the subscores on the perception measures produced by the factor analysis. The independent sociodemographic variables included were child age, child gender, parental and child previous surgical experience, a combination of parents' educational level, mother's age, and the number of hours the mother worked outside the home. The independent personality characteristic variables were the score on the trait anxiety measure, the subscores on NEO-FFI, the total score on the Miller MBSS measure and the child's subscores on the EASI measure. The inclusion criteria for variables were P value 0.10 and the removal criteria were P value 0.15. We chose to present the coefficients, the 95% confidence intervals and the P value of all items included in the final models. Some of the independent variables did not reach statistical significance (P value 0.05) but are approaching significance and should be considered as variables to consider in future research.

To ensure that the independent variables that were significantly correlated were not entered into the same model, the following steps were taken. Demographic variables were examined and, due to the high correlation between both parents' education levels, the education variable was combined for both parents. In other cases where demographic variables were highly correlated (e.g., education and household income), only one variable was incorporated into the model. Additionally, as state and trait anxiety scores in our population were significantly correlated (0.37, P value <0.001), we included each into the model separately and found similar findings. Given that trait anxiety is theoretically considered to be more of a personality measure than state anxiety, we chose to use STAI Trait as our predictor. For further information on stepwise linear regression the reader is referred to http://www.statsoft.com/textbook/stgrm.html#stepwise.

	RESULTS

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One-hundred-ten parents of children ages 3–14 yr (8.6 ± 3.6 yr) undergoing elective surgical procedures were recruited for this study. The majority of the children (51.7%) had orthopedic and ear-nose-and throat surgeries. A total of 73% of the families were Caucasian and 79% were in married/partnered families. Demographic characteristics of the sample and surgery distributions are presented in Table 1.

Phase One: Descriptive Analyses of Parental Pain Perceptions
Medication Attitude Questionnaire
Inspection of parental responses to the MAQ items revealed that many parents had concerns regarding analgesia for their child (Table 2). Indeed, 73% of parents agreed that side effects are cause for worry when giving children analgesics. Parents also believed that children should be given analgesics as little as possible because of side effects (51%) and/or addictive potential (43%). In addition, they believed that the less often children received analgesia, the better it worked (37%).

Parental Pain Expression Perceptions
Inspection of parental responses on the PPEP measure revealed that many parents had misconceptions regarding children's pain expressions (Table 3). More than 40% of the parents agreed that children always express pain by crying or whining; 43% agreed that children exaggerate pain; 38% thought that children always tell their parents when they are in pain; and 31% thought that children complain about pain to get attention.

We also found in reviewing the answers to the freestanding questions that while most parents (89%) indicated that untreated pain can cause psychological damage, a smaller percentage of the parents (69%) thought that untreated pain can cause physical damage.

Phase Two: Factor Structure of Parental Perceptions
Medication Attitude Questionnaire
Factor analysis with Varimax rotation produced a 3-factor solution explaining 52% of the MAQ variance. The factors were Appropriate-Use-Attitude (items 8, 12, 13, 16) explained 16.5% of the variance, Fear of Side Effects (items 3, 5, 7, 9, 14) explained 22.1% of the variance and Avoidance (items 1, 2, 4, 6, 10, 11, 15) explained 13.7% of the variance. To examine the internal consistency of the items, a Cronbach's Alpha was calculated and was found to be moderate (0.58). Please refer to Table 4 for factor loading on the MAQ.

Parental Pain Expression Perceptions
A factor analysis with Varimax rotation of the PPEP suggested a 3-factor solution, explaining 69% of the variance. The factors were Active, Loud Behaviors (items 1, 2, 4, 5) explained 33.4% of the variance, Attention-Seeking (items 6, 7, 8) explained 21.6% of the variance, and Quiet, Withdrawn Behaviors (items 3, 9) explained 14.2% of the variance. The Cronbach's Alpha, calculated for the whole measure, of 0.79 suggested internal consistency among the items. Please refer to Table 5 for factor loading of the PPEP.

Phase Three: Prediction of Parental Pain Perceptions
Medication Attitude Questionnaire
Step-wise linear regressions were used to examine the impact of socio-demographic and personality characteristics on MAQ factor scores. See Table 6 for a summary of these regressions. Results indicated that less educated parents, parents of more sociable children and parents of children with higher activity on the EASI were more likely to score higher on the Avoidance factor. Parents with higher conscientiousness scores (NEO-FFI) and those with more impulsive children (EASI) were more likely to perceive analgesia as appropriate (Appropriate-Use-Attitude factor). Parents with higher extraversion scores (NEO-FFI) scored lower on the Appropriate-Use-Attitude factor. More educated parents, parents with higher agreeableness and openness scores (NEO-FFI), and parents with higher MBSS scores (Monitors) scored higher on the Side Effects factor of the MAQ.

Parental Pain Expression Perceptions
See Table 7 for summaries of the stepwise linear regressions used to evaluated prediction of sociodemographic variables and personality characteristics on PPEP scores. Results indicated that parents with higher education levels scored lower on the Active, Loud Behaviors factor of the PPEP, while parents with higher neuroticisms and conscientiousness scores (NEO-FFI) as well as parents of impulsive children (EASI) scored higher on the Active, Loud Behaviors factor on the PPEP. Parents with higher extraversion and neuroticisms scores (NEO-FFI) scored higher on the Attention-Seeking factor of the PPEP. There were no sociodemographic or personality characteristic that significantly predicted parental responses to the two questions regarding the consequences of untreated pain in children.

	DISCUSSIONS

Top Abstract Introduction METHODS RESULTS DISCUSSIONS REFERENCES

 
The purpose of this study was to evaluate parental attitudes towards their children's pain and pain management, and to explore sociodemographic and personality predictors of these attitudes. We found that many parents in this study feared the side effects of analgesia, and some were concerned and uncertain about children's addiction to analgesia. We also found that some parent and child sociodemographic variables were related to parental perceptions of the provision of analgesia to children and children's pain expression. Parental and child personality characteristics also affected parental perceptions of analgesia.

In terms of parental concerns regarding analgesia, it is possible that parents perform a skewed cost-benefit analysis. That is, parents may believe that the risks of under-treated pain do not outweigh the risks of medication side effects. Our finding that more than 30% of the parents thought that untreated pain does not cause physical damage supports this possible explanation. Surprisingly, some parents were uncertain about whether or not children feel less pain than adults. This finding reinforces the significant need to enhance parental knowledge with respect to children's pain. The findings that parents fear analgesia, and have negative perceptions regarding children's pain expressions, are reason for concern, especially in view of the recent increase of awareness of pediatric pain both in clinical settings and in the media.

In terms of predicting attitudes toward pain and analgesia, our results indicated that parents with less education feared addiction and analgesic side effects more than parents with higher education. The explanation for this relation is unclear, but it is possible that less educated parents have less exposure to literature refuting the attitudes that analgesia is unsafe and addictive, and that less educated parents may have less access to information regarding the safety of analgesics.

Parental coping scores affected the Side Effect factor of the MAQ. Parents with high monitoring scores (that is, parents who actively seek information and tend to be vigilant about their surroundings; 23) feared the side effects of analgesia less than parents who were low in monitoring. It is possible that parents who are monitors attend closely to information about analgesics and thus may be more likely to have learned that recommended analgesia is safe and that the benefits of analgesia outweigh the risks of its side effects.

In the present study, parents with higher openness scores (NEO-FFI) were less concerned about side effects of analgesia as compared to those with lower openness scores. The elements of openness include intellectual curiosity, independent of judgment, and active imagination (22); therefore, it is not surprising that parents with these traits seek information and can more accurately weigh the risks and benefits of analgesia. Parents with high conscientiousness scores thought that analgesia was appropriate for use more than parents with low conscientiousness scores. Conscientious individuals are described as determined, punctual, and reliable, and high scores on conscientiousness are associated with academic and professional achievement (22). Therefore, it is expected that parents with high conscientiousness scores will follow the recommendation to provide the recommended analgesia.

In addition to perceptions about analgesics, this study explored parents' perceptions of children's pain expression. Although child self-report is considered to be the "gold standard" of pain measurement in the literature, previous research has demonstrated that children do not always verbally express their pain to their parents (25). In line with these findings, most parents in this study agreed that children in pain may not report pain immediately and that "quiet" children can be in pain. More educated parents were less likely to think that children in pain always verbally informed their parents and that children primarily expressed pain primarily through Active, Loud Behaviors.

Parents with higher neuroticism scores on the NEO-FFI endorsed beliefs that children expressed pain primarily through Active, Loud Behaviors, and scored higher on the Attention-Seeking factor (i.e., beliefs that children complain about pain to get attention and that children exaggerate pain). The elements of neuroticism include emotional stability and adaptability. People who score lower on the neuroticism scale tend to be more relaxed when faced with stressful situations, and therefore may be more able to be aware of subtle changes in their children's behaviors (e.g., quiet withdrawn behaviors). On the other hand, parents who score higher on neuroticism may become more upset when their child is in pain and may be less likely to recognize these changes as pain cues, therefore believing that children complain about pain to get attention and exaggerate their pain.

Child temperament has been shown to affect how children express pain (6,12–17). Therefore, it is not surprising that parents expect children with different behavioral styles or temperament to express pain differently. In this study, parents of more impulsive children expected children to express pain through active and loud behaviors such as crying, and believed that children complain about pain to get attention and that children exaggerate pain.

Several limitations of this study should be noted. First, we examined a convenience sample of parents of healthy children undergoing elective surgery in one hospital, and therefore the generalizability of these findings may be limited. Additionally, we did not stratify our data based on parent and child past surgical experience or type of surgery that the child was undergoing while the parents completed the questionnaires. Prior surgical experience had no affect on parental pain perceptions. Future studies are needed to evaluate the effects of these variables on actual parental pain management practices at home. Nonetheless, this study is the first to examine the effect of both parent and child characteristics on parental perception of pain expression and pain management. We suggest that the various personality predictors for parents who are more concerned with analgesics use should be incorporated in any future educational intervention.

	ACKNOWLEDGMENTS

 
The authors thank Dr. Jane Dixon for factor analysis consultation, Dr. Kristopher Fennie and Dr. Michael F. Dowd for the statistical consultation and assistance, Mr. Tony Ma for his assistance with managing the data, the staff of the Perioperative Center at YNHH and the participants of this study for their help and support of this research project.

	Footnotes

 
Accepted for publication December 28, 2006.

Support by the Yale School of Nursing grant T32NR008346, and the National Institute of Child and Health Diseases (Bethesda, MD) grant NIH-2R01HD037007-04A1.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zisk, R. Y. Articles by Kain, Z. N. Search for Related Content PubMed PubMed Citation Articles by Zisk, R. Y. Articles by Kain, Z. N. Related Collections Pediatrics Pain