Special Interest Group on Pain in Childhood
Pediatric Pain Letter

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Editor:
Deirdre E. Logan, PhD
Children's Hospital Boston
Boston, USA

Associate Editor:
Abbie L. Jordan, PhD
University of Bath
Bath, UK






Copyright © 2020,
Special Interest Group on
Pain in Childhood,
International Association
for the Study of Pain®,
www.childpain.org

ISSN 1715-3956

Disclaimer:
Information appearing in Pediatric Pain Letter is not reviewed by, and is not necessarily endorsed by, the Special Interest Group on Pain in Childhood, nor by IASP ®.

Vol. 22 No. 3

October 2020

Commentary

“It all seems so unfair: Pain-related injustice appraisals in youth with chronic pain and their caregivers

Megan M. Miller, Mary K. Lynch, Adam T. Hirsh, and Amy E. Williams

printable version (PDF)

Appraisals of injustice can arise from a variety of circumstances including violations of basic human rights, challenges to equity norms and just world beliefs (Mohiyeddini & Schmitt, 1997; Fetchenhauer & Huang, 2004; Hafer & Begue, 2005), or experiences of suffering or irreparable loss (Miller, 2001). Of particular relevance to the lattermost, chronic pain is often appraised as unfair or unjust. As defined by the Injustice Experiences Questionnaire (IEQ; Sullivan et al., 2008), pain-related injustice is a cognitive-emotional factor comprised of appraisals of blame (e.g. I feel as if I have been robbed of something very precious”), unfairness (e.g. It all seems so unfair”), severity (e.g. No one should have to live this way”), and irreparable loss (e.g. My life will never be the same”). Although the IEQ was initially developed for accidental injury-related pain, injustice appraisals have been linked to poor functional and psychological outcomes in adults with a variety of chronic pain conditions including fibromyalgia (Rodero et al., 2012; Ferrari & Russell, 2014), arthritis (Yakobov et al., 2014a; Ferrari & Russell, 2014; Ferrari, 2015), post-surgical pain (Yakobov et al., 2014b; Yakobov et al., 2018), genito-pelvic pain (Pâquet et al., 2016), HIV-related pain (Penn et al., 2019), traumatic brain injury (Iverson et al., 2018), and mixed chronic pain conditions (Carriere et al., 2017; Carriere et al., 2018; Sturgeon et al., 2017).

Initial findings also suggest that pain-related injustice is an important and distinct cognitive-emotional factor in the chronic pain experience for youth. Cross-sectionally, higher levels of pain-related injustice are associated with higher levels of pain intensity, pain catastrophizing, and functional disability, and with poorer emotional, social, and school functioning (Miller et al., 2016a). Importantly, pain-related injustice accounted for significant variance in pain intensity, functional disability, and emotional, social, and school functioning even after accounting for pain catastrophizing (Miller et al., 2016a). These findings also highlight that pain-related injustice is distinct from other well-established constructs such as catastrophizing. Initial longitudinal findings are especially compelling, suggesting that baseline pain-related injustice appraisals predict future levels of emotional (3- and 12-month), social (3- and 12-month), and school (3-month) functioning, above and beyond that of baseline pain intensity and catastrophizing (Miller et al., 2016b; Miller et al., 2018a). It is important to note that perceptions of pain-related injustice are not necessarily cognitive distortions; rather they often develop in response to very real differential or otherwise unfair treatment that individuals experience related to their chronic pain.

The social aspect of pain is especially important for youth, as caregivers play a salient role in youth’s pain experience. To date, two studies have examined injustice appraisals among caregivers of youth with chronic pain. Higher levels of caregiver injustice appraisals about their child’s pain are associated with worse child-reported physical, emotional, social, and academic functioning (Baert et al., 2020). Interestingly, caregivers have been found to endorse higher levels of injustice about their child’s pain than does their child (Miller et al., 2018b), which inspired an examination of the interaction between caregiver and child appraisals of injustice. In a sample of 253 child-caregiver dyads from a university-affiliated pain clinic, the majority of dyads (78%) endorsed concordant (i.e. child and caregiver reported similar levels) appraisals. Dyads where the child endorsed significantly higher injustice appraisals than the caregiver reported the most severe pain and functional disability and the worst quality of life compared to dyads with concordant appraisals and to dyads where the child endorsed significantly lower appraisals than the caregiver (Miller et al., 2018b). Taken together, these findings suggest that child and caregiver pain-related injustice appraisals play a unique and interactive role in the child’s pain experience. Although much remains to be known, at this point we contend that routine assessment of pain-related injustice appraisals should be integrated into pediatric clinical practice.

As a distinct construct, pain-related injustice should be assessed separately from other constructs relevant to the pediatric pain experience. The child and parent forms of the IEQ (12 items that are summed for a total score) provide a brief but thorough assessment of pain-related injustice. In adults with chronic pain a score of 19 or above is considered clinically significant (Scott et al., 2013a), however a parallel score has yet to be established for youth with chronic pain. We recommend clinicians assess from all aspects of the construct including blame (e.g. “I feel as if I have been robbed of something very precious”), unfairness (e.g. “It all seems so unfair”), severity (e.g. “Most people don’t understand how severe my condition is”), and irreparable loss (e.g. “My life will never be the same”) appraisals. Clinicians could further leverage these measures by querying about highly endorsed items during the assessment interview and periodically throughout treatment. Alternatively, clinicians might include select questions that seem particularly relevant to a given patient and/or family with chronic pain. This may include ascertaining if the patient feels others (i.e. family, friends, and medical professionals) believe and understand the severity of their pain. Identifying the source of the perceived injustice is important, as it may impair the child’s medical care or social interactions (Mohammadi et al., 2017; Monden et al., 2020. Additionally, caregivers may believe that their child has lost the ability to achieve their goals or live a normal life (i.e. irreparability of loss), which may inadvertently hinder child development. Finally, some patients and families may express thoughts of blame toward someone or something that is seen as having caused or perpetuated their chronic pain. Given the connections between pain-related injustice and negative emotions for the patient (Scott et al., 2013b), as well as those between caregiver behaviors and the child’s pain experience (Mohammadi et al., 2017; Palermo & Chambers, 2005; Palermo et al., 2014), injustice appraisals may be a novel intervention target to enhance patient and family functioning.

While specific interventions for pain-related injustice have yet to be identified, treatment techniques from Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT) may be tailored for this purpose. Given the importance of parental injustice appraisals in this context, the techniques discussed below may also be adjusted for work with caregivers of youth with chronic pain. Prior to beginning any of this work, it is vital to validate the patient and family in their pain journey, as many have likely experienced negative or unfair pain-related situations (e.g. pain-related dismissal/invalidation by providers/family/peers, misdiagnoses, lack of financial support for treatments) prior to arriving in your office. Dismissal or invalidation of one’s pain by healthcare providers is a common experience for youth with chronic pain (Igler et al., 2017; Defenderfer et al., 2018) particularly for those with diagnostic uncertainty (Neville et al., 2019). Validation of these experiences can allay patient/family concerns that you are telling them to “get over it”. Research has indicated that individuals high in pain-related injustice often display cognitive inflexibility (i.e. strongly connected to/fused with their thoughts of blame and unfairness; Scott et al., 2014). In turn, this limits their use of active coping strategies and engagement in activities they deem important or valuable. This suggests that using ACT principles to identify value-based activities while supporting a growth mindset and flexible thinking may reduce the functional repercussions of injustice appraisals. Cognitive coping strategies that facilitate acceptance of one’s current experience, such as cognitive diffusion or cognitive reframing, may further reduce pain-related injustice appraisals and improve functioning (Rodero et al., 2012). When active coping strategies and pain acceptance are used, treatment suggestions such as physical activity, adherence to medications, and use of relaxation and distraction can be incorporated as enjoyment and values based living.

As noted above, negative emotions often accompany injustice appraisals. In particular, appraisals of blame/unfairness are associated with increased anger (Scott et al., 2013b). Forgiveness based techniques have been suggested to build empathy and compassion for those believed to have wronged them or caused their pain (Monden et al., 2016). Additionally, appraisals of irreparable loss and pain severity have been associated with increased depressive symptoms (Scott et al., 2013b). Standard techniques from CBT for chronic pain, including behavioral activation and cognitive reframing (Palermo, 2012), may be particularly useful in managing these symptoms. Strategies to improve emotion regulation, while not directly targeting pain-related injustice, may serve to generally decrease the internalization of or fusion with the injustice appraisals (Williams, 2016).

Social connection and engagement, a common challenge among youth with chronic pain, may be a mechanism by which pain-related injustice impacts outcomes and, thus, a possible area for intervention. Preliminary findings suggest that the deterioration of social connections mediates the relationship between pain-related injustice and poor outcomes in adults (Sturgeon et al., 2016). Fostering peer relationships and community engagement in youth would likely enhance their social support and increase their positive interactions, both in general and in relation to pain.

In addition to intervening at the patient/family level, efforts to address common situations that may drive appraisals of injustice are necessary. Developing educational modules surrounding common situations or patient-provider interactions that result in patient appraisals of injustice would enable healthcare trainees and providers to gain insight into how their actions may drive injustice appraisals and give them guidance on how to appropriately validate a patient’s pain.

While no single strategy will fit for all patients or caregivers with high pain-related injustice, identifying the specific underlying thoughts, as well as their emotional and social correlates, will provide specific targets for treatment. We recommend that clinicians (1) strongly consider evaluating and addressing pain-related injustice when working with youth with chronic pain and their families and (2) actively work to improve awareness and training for healthcare providers regarding pain-related injustice.

Megan M. Miller, PhD
Department of Psychology, Indiana University-Purdue University Indianapolis & Department of Psychiatry, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
email: mmm24[at]iupui.edu

Mary K. Lynch, PhD
Department of Psychology, Indiana University-Purdue University Indianapolis & Department of Psychiatry, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA

Adam T. Hirsh, PhD
Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA

Amy E. Williams, PhD
Department of Psychiatry, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA

Cite as: Miller MM, Lynch MK, Hirsh AT, Williams AE. It all seems so unfair”: Pain-related injustice appraisals in youth with chronic pain and their caregivers. Pediatric Pain Letter 2020;22(3):28-32. ppl.childpain.org

References

Baert F, Miller MM, Trost Z, Hirsh AT, McParland J, De Schryver M, et al. Parental injustice appraisals in the context of child pain: examining the construct and criterion validity of the IEQ-Pc and IEQ-Ps. J Pain 2020;21:195-211. PubMed Abstract

Carriere JS, Martel MO, Kao MC, Sullivan MJI, Darnall BD. Pain behavior mediates the relationship between perceived injustice and opioid prescription for chronic pain: a collaborative health outcomes information registry study. J Pain Res 2017;10:557-566. PubMed Abstract

Carriere JS, Sturgeon JA, Yakobov E, Kao MC, Mackey SC, Darnall BD. The impact of perceived injustice onpain-related outcomes: a combined model examining the mediating roles of pain acceptance and anger in a chronic pain sample. Clin J Pain 2018;34:739-747. PubMed Abstract

Defenderfer EK, Bauer K, Igler E, Uihlein JA, Davies WH. The experience of pain dismissal in adolescence. Clin J Pain 2018;34:162-167. PubMed Abstract

Ferrari R. A cross-sectional study of perceived injustice and disability in hip osteoarthritis. Eur J Rheumatol 2015;2:47-51. PubMed Abstract

Ferrari R, Russell AS. Perceived injustice in fibromyalgia and rheumatoid arthritis. Clin Rheumatol 2014;33:1501-1507. PubMed Abstract

Fetchenhauer D, Huang X. Justice sensitivity and distributive decisions in experimental games. Pers Individ Diff 2004;36:1015-1029.

Hafer CL, Bègue L. Experimental research on just-world theory: problems, developments and future challenges. Psychol Bull 2005;131:128-167. PubMed Abstract

Igler EC, Defenderfer EK, Lang AC, Bauer K, Uihlein J, Davies WH. Gender differences in the experience of pain dismissal in adolescence. J Child Health Care 2017;21:381-391. PubMed Abstract

Iverson GL, Terry DP, Karr JE, Panenka WJ, Silverberg ND. Perceived injustice and its correlates after mild traumatic brain injury. J Neurotrauma 2018;35:1156-1166. PubMed Abstract

Miller DT. Disrespect and the experience of injustice. Annu Rev Psychol 2001;52:527-553. PubMed Abstract

Miller MM, Scott EL, Trost Z, Hirsh AT. Perceived injustice is associated with pain and functional outcomes in children and adolescents with chronic pain: a preliminary examination. J Pain 2016a;17:1217-1226. PubMed Abstract

Miller M, Scott E, Trost Z, Hirsh A. (500) Injustice perceptions predict future functioning in children with chronic pain. J Pain 2016b;17:S99-S100.

Miller MM, Williams AE, Scott EL, Trost Z, Hirsh AT. Injustice perceptions predict future functioning in children with chronic pain: A 12-month follow-up. Ann Behav Med 2018a;52:S336.

Miller MM, Wuest D, Williams AE, Scott EL, Trost Z, Hirsh AT. Injustice perceptions about pain: parent–child discordance is associated with worse functional outcomes. Pain 2018b;159:1083-1089. PubMed Abstract

Mohammadi S, de Boer MJ, Sanderman R, Hagedoorn M. Caregiving demands and caregivers’ psychological outcomes: the mediating role of perceived injustice. Clin Rehabil 2017;31:403-413. PubMed Abstract

Mohiyeddini C, Schmitt MJ. Sensitivity to befallen injustice and reactions to unfair treatment in a laboratory situation. Soc Justice Res 1997;10:333-353.

Monden KR, Philippus A, Draganich C, MacIntyre B, Charlifue S. A qualitative exploration of perceived injustice among individuals living with spinal cord injury. Rehabil Psychol 2020;65:54-62. PubMed Abstract

Monden KR, Trost Z, Scott W, Bogart KR, Driver S. The unfairness of it all: exploring the role of injustice appraisals in rehabilitation outcomes. Rehabil Psychol 2016;61:44-53. PubMed Abstract

Neville A, Jordan A, Beveridge JK, Pincus T, Noel M. Diagnostic uncertainty in youth with chronic pain and their parents. J Pain 2019;20:1080-1090. PubMed Abstract

Palermo TM. Cognitive-behavioral therapy for chronic pain in children and adolescents. New York: Oxford University Press, 2012. Link

Palermo TM, Chambers CT. Parent and family factors in pediatric chronic pain and disability: an integrative approach. Pain 2005;119:1-4.

Palermo TM, Valrie CR, Karlson CW. Family and parent influences on pediatric chronic pain: a developmental perspective. Am Psychol 2014;69:142-152. PubMed Abstract

Pâquet M, Bois K, Rosen NO, Mayrand MH, Charbonneau-Lefebvre V, Bergeron S. Why us? Perceived injustice is associated with more sexual and psychological distress in couples coping with genito-pelvic pain. J Sex Med 2016;13:79-87. PubMed Abstract

Penn TM, Trost Z, Parker R, Wagner WP, Owens MA, Gonzalez CE, et al. Social support buffers the negative influence of perceived injustice on pain interference in people living with HIV and chronic pain. Pain Rep 2019;4:e710. PubMed Abstract

Rodero B, Luciano JV, Montero-Marín J, Casanueva B, Palacin JC, Gili M, et al. Perceived injustice in fibromyalgia: psychometric characteristics of the Injustice Experience Questionnaire and relationship with pain catastrophising and pain acceptance. J Psychosom Res 2012;73:86-91. PubMed Abstract

Scott W, McCracken LM, Trost Z. A psychological flexibility conceptualisation of the experience of injustice among individuals with chronic pain. Br J Pain 2014;8:62-71. PubMed Abstract

Scott W, Trost Z, Bernier E, Sullivan MJL. Anger differentially mediates the relationship between perceived injustice and chronic pain outcomes. Pain 2013b;154:1691-1698. PubMed Abstract

Scott W, Trost Z, Milioto M, Sullivan MJL. Further validation of a measure of injury-related injustice perceptions to identify risk for occupational disability: a prospective study of individuals with whiplash injury. J Occup Rehabil 2013a;23:557-565. PubMed Abstract

Sturgeon JA, Carriere JS, Kao MJ, Rico T, Darnall BD, Mackey SC. Social disruption mediates the relationship between perceived injustice and anger in chronic pain: a collaborative health outcomes information registry study. Ann Behav Med 2016;50:802-812. PubMed Abstract

Sturgeon JA, Ziadni MS, Trost Z, Darnall BD, Mackey SC. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption. Scand J Pain 2017;17:390-396. PubMed Abstract

Sullivan MJL, Adams H, Horan S, Maher D, Boland D, Gross R. The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. J Occup Rehabil 2008;18:249-261. PubMed Abstract

Williams AC. Defeating the stigma of chronic pain. Pain 2016;157:1581-1582.
Yakobov E, Scott W, Stanish W, Dunbar M, Richardson G, Sullivan M. The role of perceived injustice in the prediction of pain and function after total knee arthroplasty. Pain 2014b;155:2040-2046. PubMed Abstract

Yakobov E, Scott W, Stanish WD, Tanzer M, Dunbar M, Richardson G, et al. Reductions in perceived injustice are associated with reductions in disability and depressive symptoms after total knee arthroplasty. Clin J Pain 2018;34:415-420. PubMed Abstract

Yakobov E, Scott W, Tanzer M, Stanish W, Dunbar M, Richardson G, et al. Validation of the Injustice Experiences Questionnaire adapted for use with patients with severe osteoarthritis of the knee. J Arthritis 2014b;3:130