Cognitive Biases and Young People’s Pain Experiences: What do we know and where to go next?

Many children and teenagers are affected by chronic pain, which can negatively impact their day-to-day activities, how they feel, and their likelihood of future health problems[1,2,3,4]. Psychological therapies are effective at treating pain and related disability across pain conditions in young people, but there is lots of room for improving their long-term effectiveness[5]. To do this, we need to understand the psychological factors that make chronic pain experiences more disabling.

Cognitive biases – the tendency to notice, think about, and interpret information matching your personal concerns, beliefs and interests – are likely to play an important part in the response to pain. Pain attracts attention because it is threatening[6]. Indeed, cognitive biases might create a vicious cycle in some people whom seem vulnerable to taking more notice of potentially threatening information, feel afraid, and want to avoid further pain. This may keep them watching out for signals that might be linked to pain and might also make them avoid helpful behaviours because they are afraid that they will cause pain or injury[6]. There are lots of studies linking cognitive biases and pain in adults, but much less is known about their role in the pain of children and teenagers. We conducted the first topical review[7] of research into the relationships between cognitive biases and pain in young people. We searched academic databases for relevant experimental studies, then reviewed what we currently know about this topic, why it is important, and potential directions for future research. In this post, we will go over some of the key findings and make the case for further investigation.

Overall, we found that there appear to be relationships between some cognitive biases and pain experiences in children and teenagers, but for others this evidence is not too clear. For example, studies found that children with chronic pain can have biased memories about pain experiences that differ from pain ratings during the actual experience. However, the findings are not clear-cut, with evidence of both over-reporting and under-reporting pain levels in memories[8,9,10]. There was no consistent evidence to suggest whether children with chronic pain had a greater bias of attention towards or away from pain than those without.[11,12,13,14]. The different findings across studies may be influenced by the use of different methods of assessing bias and by tasks not representing how biases emerge in day-to-day life. Further, clear associations may only be found at particular ages so studies looking at children versus young people may have different findings because of this.

An area of research that has received less attention in children and young people is interpretation bias – the tendency to interpret ambiguous information in a threatening way, particularly in body-related situations. There is robust evidence of greater threat interpretations in adults with chronic pain compared to those without[15]. Teenage chronic pain patients were less likely to endorse non-threatening explanations of body-related situations than non-patients[16]. In community teenagers, greater negative interpretation bias towards body-related and social situations was found to relate to greater pain experiences[17]. This bias was also found to interact with other pain vulnerability factors, like the tendency to view pain experiences as catastrophic, and was related to disability in chronic pain patients[16,17]. Interpretation bias might have an important role to play in young people’s pain experiences, but further investigation is needed to tease out its nature and its role.

Evidence for relationships between cognitive biases and chronic pain in children and teenagers presents several research challenges for the future. Importantly, to clarify the relationship between biases and pain experiences we need to systematically study if tasks used in adults are truly appropriate for younger age groups, especially tasks relying on reasoning ability and verbal comprehension. Additionally, we need to investigate how different biases relate to each other, and how exactly they influence pain outcomes and disability. If we can understand cognitive biases in children and teenagers, it could provide insight into who is at risk of chronic pain, who might respond to a given treatment, and specific processes that therapies could target.

In children and teenagers, it is also important to research how biases emerge across development and relate to pain outcomes over time. Certain cognitive biases may begin to affect children at different points due to developmental milestones such as the ability to think in the abstract. This research would require long-term studies with large numbers of children of wide age ranges. If we could understand when and how to target these biases before they become well-established, it may help in treating the effects of pain in children and adolescents and preventing long-term problems.

About Sarah Beale

Sarah is a research worker in the Psychology Department at King’s College London, where she completed her MSc Health Psychology. She is interested in studying evidence-based psychological interventions and their applications to people with long-term physical health conditions.

About Jennifer Lau

Jennifer LauJennifer is a Reader in the Psychology Department at King’s College London. She is interested in studying anxiety, depression and pain in young people; she hopes that a better understanding of the psychological and brain-based factors could contribute to more effective and accessible treatments in the future.


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