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Pediatric Fear-Avoidance Model of Chronic Pain

Pain: Foundation, Application and Future Directions

Here is one of her most cited papers (and it’s open access!!) exploring the fear/avoidance model relating to pain. (link below)
Not only does this paper explore the link between fear and anxiety for the child’s experience of pain. But also touches upon the role of the parent and the impact upon the parent.
“Parent catastrophizing about child pain has been linked to more childhood illness-related parenting stress, anxiety and depression, as well as greater disability and poorer school attendance among children and adolescents, over and above child pain intensity”
It reminds me of something the head of the paediatric ward used to say waaaaay back when I was working the wards: Support the parent, support the child.’ Remembering that the parent is the most influential analgesic, soother and skilled distracter, one role for clinicians may be in helping parents to develop informed and helpful reactions to their child’s’ pain experiences. But how we navigate may require developing our communication skills.

The Paper

The fear-avoidance model of chronic musculoskeletal pain has become an increasingly popular conceptualization of the processes and mechanisms through which acute pain can become chronic. Despite rapidly growing interest and research regarding the influence of fear-avoidance constructs on pain-related disability in children and adolescents, there have been no amendments to the model to account for unique aspects of pediatric chronic pain. A comprehensive understanding of the role of fear-avoidance in pediatric chronic pain necessitates understanding of both child/adolescent and parent factors implicated in its development and maintenance. The primary purpose of the present article is to propose an empirically-based pediatric fear-avoidance model of chronic pain that accounts for both child/adolescent and parent factors as well as their potential interactive effects. To accomplish this goal, the present article will define important fear-avoidance constructs, provide a summary of the general fear-avoidance model and review the growing empirical literature regarding the role of fear-avoidance constructs in pediatric chronic pain. Assessment and treatment options for children with chronic pain will also be described in the context of the proposed pediatric fear-avoidance model of chronic pain. Finally, avenues for future investigation will be proposed.

Click here to access the paper

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Relive: What can we learn from childhood experiences of pain?


What can we learn from childhood experiences of pain?

A/Professor Melanie Noel, kicked off our winter Le Pub Home Brew program by exploring the role of childhood experiences of pain in adult pain.

Melanie has contributed hugely to the scientific base on pain in children and has been recognised widely for her outstanding research, receiving early career awards from the International Association for the Study of Pain (IASP), the Canadian Pain Society, the American Pain Society, the Canadian Psychological Association, and the Society of Pediatric Psychology. 

She is particularly fascinated by the role of parents and family in children’s mental and physical health and in-particular to the development of self-regulation around the pain experience.  She is an absolutely awesome researcher and speaker, bringing her energy and passion to the subject.  

“I’m really excited to do this, I hope there are lots of questions! I’m not really bringing much powerpoint material, I just really want to share what really gets me going, why this topic is so interesting and what I’m working on right now.  I love that this is a live and open space where I can really just share my ideas with you all.”


From the first days of birth, infants can form memories of pain. Once formed, these memories play a powerful role in shaping future pain and health care experiences. As children acquire language and their explicit memory system develops, these memories become constructed and reconstructed in their interactions with others, and particularly for young children, in their interactions with parents. Memory is not like a tape recorder. You can’t play back an experience and have it recounted exactly as it happened. Rather these memories are highly susceptible to distortion. Children who develop negative biases in memory (i.e., they recall more pain than they initially experienced) are at risk for developing fears and avoidance of pain and heath care, and are also at risk for pain transitioning from an acute to chronic state. Moreover, emerging research suggests that brain regions associated with memory are implicated in the chronic pain state in youth. Once pain become chronic in adolescence, more pathological forms of remembering (e.g., in Post-Traumatic Stress Disorder) develop which further exacerbates pain and decreases quality of life. Dr. Noel will describe a program of research that is establishing factors implicated in the development of children’s memories for pain, the role of pain memories in future pain experiences, and the development of a parent-led intervention to reframe children’s pain memories to buffer against the development of memory biases and lead to better pain outcomes in the future. She will also discussed work to understand the neurobiological, cognitive-behavioural, and interpersonal factors that lead to the development and maintenance of chronic pain and PTSD in youth to improve how to tailor treatments for the most vulnerable children.

Key Points

Key messages from the Le Pub for clinicians:

  • Only 40 years ago it was widely believed that babies couldn’t feel pain. The things we experience the first few days of our life can affect how we experience pain throughout our entire life.
  • 1 in 5 kids has chronic pain. Only in the last 7 or 8 years have we learned that, if untreated, these kids become adults with chronic pain.
  • Memories matter – Pain and pain learning starts in childhood. How parents talk to their kids about painful experiences has a profound effect on pain memories and has a HUGE influence on a how a child experiences pain into adulthood
  • Pain is not just a sensation…parents can create a positive or negative ‘experience’ around it. Correct exaggeration, help a child to see they have some control over the experience and offer distraction…e.g. take a deep breath, we’ll go for pizza afterwards
  • There is hope! Even if you feel like you’ve messed up as a parent responding to your children’s pain experiences, just a couple of positive experiences can change your child’s pain trajectory

Key messages from Le Pub for Patients

  • What happens to us, what happened to our parents, even to our grandparents, can set the stage for whether we have pain as adults. Pain and pain learning starts in childhood
  • What can parents do to help raise kids with good pain coping skills? Talk about the pain experience. Highlight anything positive that happened. Remember pain is not just a sensation, but an entire experience. Help them see they have some control over the experience
  • Pain is stigmatized, it’s disbelieved, it’s repressed… and because we don’t talk about it, we learn many of the things we (think we) know about pain from popular media. Stop and pay attention to what you (and your kids) are watching and how it portrays pain.
  • Validation is fundamental. People  experiencing pain need to feel heard

Research papers

It seems outrageous that some people believed that infants didn’t experience pain.  Check out this fantastic paper to find out how early painful experiences can influence us.

If you are a parent with ongoing pain can this influence your child’s experiences of pain? And if so, in what way? Check out this fascinating (free access) paper exploring the intergenerational connections between chronic pain and PTSD.

One of Melanie’s most cited papers exploring the fear/avoidance model relating to pain. Not only does this paper explore the link between fear and anxiety for the child’s experience of pain. But also touches upon the role of the parent and the impact upon the parent.