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Chronic pain in the classroom: teachers' attributions about the causes of chronic pain *.

Chronic and recurrent pain is a common experience among school-age children. Rates of pain problems lasting 3 months or longer range from 15% to over 30% among school-age youth in epidemiologic studies. (1-3) The understanding of chronic pain has evolved from a traditional medical model--in which pain was viewed as either an "organic" or "psychosomatic" phenomenon--to a biopsychosocial model (4,5) incorporating biological, psychological, and social factors that jointly shape the pain experience. However, individuals experiencing chronic pain syndromes and laypersons who encounter such individuals vary in their understanding and acceptance of this multifactorial model of pain.

According to attribution theory, one's explanations for causes or events predict behavior and emotions in response to stressful events. (6) The attribution of illness to physical or psychological causes appears to have particularly marked ramifications for perceptions of symptomatic individuals and expectations for their role fulfillment and standards of performance. (7-9) Previous research indicates that when illness is attributed to psychological causes, the ill individual evokes less pity, less liking, more anger, and fewer resources than when the illness is attributed to physiological causes. (10) Chronic pain complaints have been judged "more legitimate" when attributed to physical versus psychological causes. (11) Influences on individuals' physical or psychological attributions for symptoms are not fully understood. Evidence of organic pathology for the symptoms appears to be 1 important factor; (12,13) when such evidence is absent, symptoms are more likely to be discredited and attributed to emotional distress or attempts to elicit secondary gain. (14) Communication from healthcare professionals may also serve to validate symptoms in others' eyes.

Attributions are particularly relevant to pediatric chronic pain syndromes, which can occur with or without an organic basis. The origins of pain are often unclear, and the cause of injury or disability is often not directly observable. Thus, situational factors can influence individuals' pain attributions. A few studies have examined attributions about children's pain. Claar and Walker (15) explored mothers' attributions for their children's recurrent abdominal pain and found that about half of mothers in their sample endorsed a biopsychosocial model (ie, they identified both psychological and physical factors as causes of their child's pain). This was true regardless of whether their child had a specific medical diagnosis related to the pain. However, another study found that when symptoms of pain occurred in the absence of organic pathology, parents inferred more psychological causes for a child's misbehavior and responded more negatively than when symptoms occurred in the presence of organic pathology. (16) The presence of organic disease in children with abdominal pain predicted peers' ratings of relief from responsibility, with children indicating that a hypothetical peer should be relieved from responsibility more often when organic disease was present. (17)

Research into the influence of others' attributions for pain has examined parents' and peers' understanding of chronic pain but has not yet investigated teachers' understanding of chronic pain. This is a notable gap in the literature given the importance of school function in the lives of children and adolescents. Youth with chronic pain disorders experience numerous difficulties in school, including frequent absences, decreased academic performance, compromised social functioning, and impaired ability to cope with the demands of the classroom. (18-20) Left unaddressed, school functioning difficulties typically worsen, often to the point where these youth request and receive full-time homebound instruction. This cycle results in adolescents missing out on developmentally normative academic and social experiences that can be crucial to long-term healthy adjustment. (20,21) Schools are responsible for meeting the educational needs of these students, who are frequently determined to be eligible for special services under Section 504 of the Rehabilitation Act (1973). (22)

Despite clear evidence that chronic pain adversely affects school function, (3) little is known about the mechanisms through which this occurs. How teachers understand and respond to chronic pain likely influences academic- and pain-related outcomes. Just as parents' perceptions of causes of their children's pain appear to influence decisions they make about their child's treatment, (15) teachers' perceptions about causes of students' pain are potentially important in determining whether their responses to pain encourage or discourage adaptive functioning in school. If children or parents feel that teachers fail to comprehend the nature of their pain, they may be less willing to work toward improved school attendance and other school-based functional goals. If schools apply the biopsychosocial framework when formulating responses to students with pain, they are more likely to work collaboratively with students, parents, and the healthcare team and to respond to the pain in ways that help the student remain engaged in the school setting. Currently, the extent to which school personnel know about or endorse the biopsychosocial model of chronic pain is unknown.

The aim of this study was to explore teachers' attributions about chronic pain in students. Specifically, we investigated (1) the frequency of physical and psychological attributions for chronic pain among a group of middle- and high school teachers, (2) whether teachers endorse a dualistic or biopsychosocial model of pain, (3) the effects of documented medical evidence supporting the pain complaints and communication from the medical team on teachers' pain attributions, and (4) the influence of teachers' pain attributions on their responses to the student with pain. Specific hypotheses were as follows:

* Teachers will be more likely to endorse a dualistic model in which they attribute the pain to either physical or psychological causes than a biopsychosocial model.

* Teachers will be more likely to endorse physical attributions for pain in the presence of (1) documented medical evidence indicating a biological basis for chronic pain symptoms and (2) direct communication from the medical team to the school.

* Teachers' pain attributions will influence responses to the student with pain, such that teachers who endorse physical attributions will support more extensive classroom accommodations and will report greater sympathy for the student.



Participants were 263 middle- and high school classroom teachers from 6 public schools in the greater Boston area. Schools from which participants were recruited were selected by convenience and included 1 urban combined (7th-12th grade) school, 2 suburban middle schools, and 3 suburban high schools. All permanent regular classroom teachers of academic and special subjects were eligible for participation.


This study was part of a larger project investigating teachers' responses to chronic pain. (23) Data were collected between March 2004 and May 2005. The study was approved by the hospital institutional review board and the research review committees of participating schools. An informational consent form was distributed with the study materials stating that completion of materials indicated consent to participate.

A designated liaison at each school (principal or guidance counselor) worked with the study team to facilitate participation. The principal or another school administrator endorsed the study to the entire faculty, typically by e-mail. Study personnel presented the project at school faculty meetings or distributed a written explanation by e-mail and in teacher mailboxes. Vignettes and questionnaires were distributed at school staff meetings and/or via mailboxes. Reminders were sent by e-mail to increase participation, and additional study materials were available at the school for several weeks after initial recruitment. Participation rates varied widely by school, due in part to differential attendance rates at the meetings where the study was presented. Respondents received $10 gift certificates for classroom supplies for their participation.

Teachers were presented with a written hypothetical scenario describing an adolescent girl who develops a chronic pain syndrome affecting school attendance and performance. Three factors were manipulated. Two of these factors, the presence or absence of medical evidence supporting a biological basis for the pain and presence or absence of communication from the medical team, were relevant to the hypotheses of this study. The third factor, cooperative or confrontational parent-teacher interactions, was not hypothesized to relate to teachers' pain attributions and is not discussed here. (Note: data analyses confirm that parent-teacher interactions did not relate to teachers" pain attributions.) The full factorial approach resulted in 8 vignette versions (Figure 1).
Figure 1. Text of Sample Vignette Version, With Manipulated Portions

Version: Medical evidence present; Communication from medical team

Samantha Green is a student in your class. She gets good grades but has
to work hard to do so. She is a dedicated player on the girls' soccer
team. You notice that she sometimes struggles socially and seems a bit
anxious, but she has never been difficult to manage in the classroom.

One day Samantha's hand is injured when another student slams her
locker door against it. Samantha is extremely distressed by the injury.
Her parents take her to her pediatrician who finds no major damage,
just some bruising and swelling. A week later, Samantha starts to
complain of intense pain in her hand. She begins making frequent visits
to the nurse's office and fails to complete her work because the pain
prevents her from writing and interferes with her concentration.
Eventually, as the pain persists, she begins to miss school altogether.
Samantha's parents take her to an orthopedic specialist, who orders
x-rays and bone scans. Mr and Mrs Green inform you that these tests
showed evidence that the nerves in Samantha's hand were functioning
abnormally, and the doctor prescribed a pain medication for her.

The Greens insist that Samantha be excused from all written assignments
and that her academic workload be adjusted significantly because of her
injury. After consulting with school administration and the Guidance
office, you attempt to meet the parents halfway in terms of adjustments
to Samantha's workload (eg, suggesting that Samantha receive
Incompletes on her grades for the term, be permitted additional time to
make up the work, and consider transferring out of some of her very
demanding honors-level classes into less stressful ones). Mr and Mrs
Green agree to give this a try because they recognize the importance of
Samantha staying in school.

After 2 months--during which time Samantha has continued to miss
several days of school a week and been able to do little work when she
does at tend--the Greens inform you that they took Samantha to a pain
management clinic at a local children's hospital, where she was
diagnosed with "Complex Regional Pain Syndrome." You receive a letter
from the pain management team describing Samantha's symptoms and
explaining what Complex Regional Pain Syndrome is and how it might
affect an adolescent in school The healthcare team also includes their
treatment plan and offers specific recommendations for ways to
accommodate Samantha's pain problems in the school setting.

Samantha's guidance counselor has requested a team meeting to discuss
how to respond to Samantha's pain problem. The following questions seek
your individual input and should be based on your own
opinions/suggestions (even if you feel that you would not be expected
to make individual decisions about some of these issues).

Aside from the 3 manipulations, the rest of the vignette was held constant across conditions. The description of the student with pain was based on characteristics commonly observed in youth presenting to tertiary care pediatric pain clinics. The student is described as female, a good student academically, involved in athletics, with some possible mild anxiety traits. The injury involves her hand and occurs in a situation that may or may not contain psychosocial aspects. The description of the initial medical workup is consistent across vignettes, as is the degree of functional impairment in school. Across vignettes, the student is eventually given a diagnosis of Complex Regional Pain Syndrome, a diagnosis based on medical history and pain symptoms, (24) thus allowing for varied presence or absence of documented medical evidence.

Vignettes were pilot tested on 16 teachers (2 per condition) to ensure that they were comprehensible and that manipulations functioned as expected. Pilot participants gave feedback on the vignette and follow-up questions. Pilot testing indicated that the materials were appropriate for the intended population.

Vignette conditions were equally distributed at each school. Cell sizes represented by completed questionnaires ranged from 24 to 39 participants. Chi-square analyses indicate that completed forms were equally distributed by school, teacher gender, teaching experience, personal experience with pain, and number of students with pain encountered in one's career.


Demographic Information. Teachers completed a demographic form reporting gender, years' teaching experience, grade level currently taught, and estimated number of students with chronic pain encountered in their careers.

Manipulation Check. To determine whether the manipulated variables had the intended effects, participants responded to true-false questions regarding the existence of medical evidence supporting the pain complaints and whether the healthcare team communicated with the school. In order to ensure that attributions were based on accurate perceptions of the information presented in the vignette, participants who responded incorrectly were deleted from the relevant data analyses. (11,17)

Causal Attributions for Pain. Teachers reported their beliefs about whether various physical and psychological factors were involved as causes of the adolescent's pain on an adapted version of the Inventory of Causes for Abdominal Pain (ICAP). (15) A 3-point response scale ("probably no," "maybe," and "probably yes") was used with the stem, "Please rate whether you think the following are among the causes of Samantha's pain." Five physical causes (eg, muscle spasms or knotted muscles, repeated injury to the area) and 5 psychological causes (eg, psychological stress, social/peer problems) were presented. Participants could endorse as many causes as they wished. Authors of the original ICAP report that items were generated in consultation with a team of physician and mental health professionals with expertise in pediatric chronic pain and intended to reflect factors linked with pediatric pain in the research literature. (12)

Responses to Pain.

1. Accommodations: Teachers were asked, "If it were completely up to you, what is the extent of accommodations in the school setting to which this child should be entitled?" Five choices ranging from "no accommodations" to "full homebound instruction" were offered as responses. Responses were treated as an ordinal scale.

2. Sympathy: This item read, "Please rate the level of sympathy you currently feel for Samantha." A 5-point Likert-type scale was used with responses ranging from "no sympathy" to "very strong sympathy."


Overall Findings

Three participants were excluded from analyses due to missing data, resulting in a final sample of 260. Across schools, overall response rate was 40.9% of total teaching staff, with rates ranging from 20.6% to 84.7% by school. The sample was 68.1% female. Participants had a mean of 16 years' teaching experience (range = 1-40, SD = 11.6). Median number of students with chronic pain encountered in participants' careers was 3 (range = 0-100). Seventy-three percent of the sample reported some personal experience with chronic pain in either themselves or a close friend or family member (Table 1).

Causal Attributions for Pain

Responses to the adapted ICAP attribution items were dichotomized into "probable" versus uncertain or not probable causes, following the original authors' approach. (15) A factor analysis of the 10 items suggests 3 factors that jointly account for 60.9% of the variance. The 5 psychological attributions accounted for a single unified factor and had a Cronbach's alpha = .80. "Physical disease" and "repeated injury" form a second factor, with the remaining 3 physical attributions ("nerve damage," "muscle spasms or knots," and "swelling, inflammation") representing a separate third factor. The physical items did not hang together as a scale (Cronbach's alpha = .53); rather, respondents making physical attributions for the pain tended to identify a single physical cause.

Across the sample, 58.5% of teachers endorsed at least 1 physical attribution as a cause for the student's pain, and 67.2% endorsed at least 1 psychological attribution. Only 38.1% endorsed both physical and psychological attributions for the student's pain. In other words, almost two thirds of respondents held a dualistic view of the pain rather than endorsing the biopsychosocial model. The likelihood of endorsing a biopsychosocial view of pain did not differ by school. The likelihood of making physical attributions for the pain did differ significantly across schools ([chi square] = 13.53, p < .05), with the percent of participants within individual schools endorsing physical attributions for the pain ranging from 23.1% to 75%. Frequencies for the individual attributions are reported in Table 2.

Bivariate correlations reveal no significant associations between the dichotomized pain attribution variables and background variables including teacher gender, teaching experience, grade level taught, experience with students with pain, or personal pain experience. Because the psychological attributions demonstrated scale properties, the total number of psychological attributions endorsed was examined. Respondents who reported more contact with students with chronic pain in their careers made more psychological pain attributions (r = .14, p < .05).

Influence of Medical Evidence and Communication From the Medical Team on Pain Attributions

Manipulation Check Results. Patterns of responses to the manipulation checks indicate that most participants correctly perceived the presence or absence of communication from the medical team, with 85.8% of respondents passing this manipulation check. Teachers had more difficulty recognizing whether documented medical evidence supporting the pain complaints was present in the vignettes they read. Only 66.2% of respondents passed this manipulation check. There was a greater tendency to interpret that medical evidence was present when it was absent than to interpret that medical evidence was absent when it was present ([chi square] = 55.7, p < .001). Demographic characteristics were examined in relation to patterns of responses on the manipulation checks, but no significant associations emerged. T tests reveal no differences between participants who passed the manipulation checks and those who failed with respect to gender, grade taught, years' of teaching experience, or past experience with chronic pain. Data analyses related to hypothesis 2 include only those participants who passed both manipulation checks, n = 145.

Logistic Regression Analyses. Multivariate logistic regression analyses examined the effects of medical evidence for the pain and communication from the medical team on pain attributions. To control for school effects, dummy variables representing the schools from which participants were drawn were entered on the first step of the regressions. The second step of the equation represents the addition of the independent variables: presence of medical evidence and presence of communication.

Physical Attributions for the Pain. As expected, presence of medical evidence significantly predicted endorsement of physical attributions for pain ([beta] = 1.86, SE = .43, Wald statistic = 19.2, p < .001). Contrary to our hypotheses, presence of communication from the medical team to the school did not predict endorsement of physical attributions.

Endorsement of the Biopsychosocial Model. We also assessed the effects of medical evidence and direct communication from the medical team on the likelihood of endorsing both physical and psychological causes for the pain. The presence of medical evidence significantly predicted endorsement of a biopsychosocial model ([beta] = 2.07, SE = .49, Wald statistic = 17.6, p < .001). The effect of communication was not significant.

No relations were hypothesized between the manipulations and psychological attributions for pain. Regression analyses showed no significant associations.

Effects of Pain Attributions on Responses to Pain in the Classroom. The final hypothesis focused on whether teachers' pain attributions influenced responses to the student with pain, in terms of instrumental support (extent of academic accommodations supported) and emotional support (level of sympathy for the student). The majority (57.8%) of teachers supported minor or no accommodations for the student, 39.3% supported moderate accommodations, 3.2% supported major accommodations, and .8% supported full homebound instruction. Mean level of sympathy for the student was 3.4 (SD = .78) on a 1-5 scale.

Linear regression techniques examined the effects of attributions on responses to pain, with dummy variables again entered on the first step to control for school effects, and pain attributions entered on the second step of each equation. Regarding support for academic accommodations, there was a trend toward significance for teachers who made physical attributions for the pain to support more extensive academic accommodations compared to teachers who made no physical attributions ([beta] = .12, p = .08). There were no differences between teachers who did and did not endorse the biopsychosocial model of pain in terms of support for accommodations. Regarding sympathy, teachers who made physical attributions for the pain expressed more sympathy for the student compared to teachers who made no physical attributions ([beta] = .18, p < .01). Similar results obtained in comparing teachers who endorsed a biopsychosocial model of pain to those who held a dualistic view; support for the biopsychosocial model predicted sympathy for the student ([beta] = .16, p < .01). Endorsement of psychological attributions for pain did not relate to support either for accommodations or for sympathy. No significant school effects emerged in any of these analyses (Table 3).


Previous research suggests that laypeople tend to take a dualistic view of others' illness symptoms, regarding causes of symptoms as either physical or psychological. (25) Mothers of children with chronic pain may be the exception, as past research reveals that mothers are more likely to integrate physical and psychological attributions for children's pain. (15) The current study suggests that teachers--frequently a child's next most significant caregiver after parents--do not as commonly apply this integrated framework in understanding pediatric chronic pain problems.

The multifactorial nature of the pain problem presented in the vignette reflects the complex presentations frequently seen in tertiary care pediatric chronic pain clinics. Past research suggests that when psychosocial stressors exist, individuals often give less credibility to physical symptoms and are more likely to perceive a psychological etiology for illness. (14) Because chronic pain typically has few outwardly observable symptoms and often is comorbid with psychological distress (whether causal or not), teachers confronted with students with chronic pain may be inclined to interpret these problems as more psychological than physical in nature. In clinical settings, young patients with chronic pain accounting for their poor attendance or performance in school often state that school personnel failed to understand their pain or did not believe it was "real." Thus, teachers' ability to convey sincere beliefs about the student's complaints of pain and express a shared perspective of the problem may help to reduce school avoidance and improve school functioning in students experiencing chronic pain. The current study underscores the need to educate classroom teachers about the complex, multifaceted nature of pain to help them understand and respond to it appropriately.

One aim of the study was to assess the effects of medical evidence on teachers' judgments about causes of pain. Results indicate that medical evidence does appear to influence teachers' attributions, such that when this evidence is available, teachers are more likely to make physical attributions for pain. Previous research documents similar effects of medical evidence for pain on individual's judgments of adults with chronic pain. (11-14) Pediatric pain specialists should recognize the weight that this information carries in school and its potential to influence teachers' perceptions of pain away from a dualistic conceptualization toward a more accurate, and potentially more salutary, biopsychosocial framework. Contrary to expectations, direct communication from the medical team to the school did not influence teachers' pain attributions. Past research (26) indicates that teachers perceive communication from the medical team to increase their competence in managing chronic pain in school. Perhaps, communication affects teachers' responses to pain but does not influence causal attributions. Alternatively, the importance of effective communication between the medical team and the school may not have been conveyed adequately through the vignette methods. The quality or effectiveness of such communication may matter more than its simple presence or absence.

The manipulation checks revealed that many teachers believed they were presented with medical evidence supporting the pain problem when in fact such evidence was absent. Perhaps, some respondents interpreted the use of a specific diagnostic label for the pain condition as medical evidence. The confusion also may reflect true confusion that teachers experience when trying to understand chronic pain conditions.

Regarding the influence of causal attributions on responses to pain, teachers who perceived a physical component to the pain--whether in conjunction with psychological causes or in isolation--reported more sympathy for the student. This finding parallels those of Guite et al, (17) who found that peers rated youth with chronic pain as more likable when they perceived the pain as more physiologic in origin. It is interesting to note that the positive effects of physical attributions for the pain on teachers' sympathy for the student were maintained among teachers who made concurrent psychological attributions for the pain. In other words, the legitimacy that physical attributions appear to lend to chronic pain is not mitigated by the inclusion of psychological causes in a biopsychosocial interpretation of the pain.

Although the effect was not as strong as expected, teachers in the sample who made physical attributions for the pain were somewhat more inclined to grant academic accommodations. As with sympathy for the student, the effects of physical attributions were not attenuated by being incorporated within the biopsychosocial model. It is not possible to determine the "appropriate" level of academic accommodations in the hypothetical situation described in the vignettes. For some youth with pain, providing extensive academic accommodations might inadvertently reinforce the pain syndrome by providing an escape from anxiety-provoking academic demands. Conversely, providing too few accommodations might make it difficult or impossible for some students with pain to function adaptively in the school setting. More research is needed to understand the relation between specific responses to pain in school and functional outcomes.

This study has practical implications for both healthcare providers working with youth with chronic pain and teachers who encounter them in school. Particularly, when medical evidence is absent and psychosocial stressors are present, the healthcare team should work closely with schools to help them foster adaptive functioning. Using a biopsychosocial framework for chronic pain will allow teachers to form more appropriate explanations for pain and may help youth with pain to feel better understood, thus increasing their ability to remain engaged in the school setting. Medical and behavioral professionals treating youth with chronic pain should be aware that teachers, who must balance the needs of a student with pain with those of numerous other students, require information about chronic pain and assistance in developing appropriate responses to these conditions. Although there is little empirical research in this area to date, 1 recent randomized controlled trial showed that educating teachers about disease-related pain through written materials and teacher in-service meetings with a member of the healthcare team led to fewer absences among youth with sickle cell anemia. (27) Similar interventions for chronic pain conditions of unclear etiology should be developed and tested.

Several limitations to this research exist. Teachers' responses to a hypothetical scenario may not precisely reflect reactions to actual situations. Furthermore, it is unknown whether teachers' responses to the condition described in the vignette would generalize to other chronic pain conditions, such as headaches or abdominal pain, which are typically less visible. Future research should explore these possible differences. Schools included in the study were selected by convenience and cannot be presumed representative of all schools. Low response rates and small sample sizes from some schools suggest that sampling bias may limit generalizability; participating teachers might have had stronger views about chronic pain or relevant experiences (positive or negative) that motivated participation. Female faculty were overrepresented from some of the participating schools, further limiting generalizability. Additionally, recruitment procedures varied slightly across schools, in accordance with school policies and administrators' views on how best to involve their faculty. This inconsistency may have influenced results.

Our measure of pain attributions was adapted specifically for this study and therefore not fully validated. It is worth noting that the physical attribution items on this measure did not perform as a scale. This is not necessarily a flaw with the measure, but rather could reflect a tendency for individuals to identify 1 dominant cause when making physical attributions for pain, as opposed to viewing these causes additively as they appear to do with psychological causes. Finally, although pilot testing suggested that variable manipulations were clear, the larger sample struggled to determine presence or absence of medical evidence in the vignettes, requiring a significant number of respondents to be excluded from some data analyses.

In conclusion, the study reveals that teachers who encounter youth with chronic pain in school often lack an integrated biopsychosocial framework to help them understand and respond to such conditions appropriately. Future investigations are needed to enhance our knowledge of what aspects of the school setting, the pain condition, and the individual teachers, adolescents, and families are important determinants of teachers' causal attributions for pain and to expand our understanding of how these attributions relate to youths' ability to function with chronic pain in the school context.

Chronic Pain in the Classroom: Teachers' Attributions About the Causes of Chronic Pain

May 2007 issue of Journal of School Health

Earn 1.0 CECH Category I CHES, OH0005

1. Students with chronic pain are often eligible for special services under:

a) No Child Left Behind (NCLB).

b) Individuals with Disabilities Education Improvement Act (IDEIA).

c) Section 504 of the Rehabilitation Act.

d) None of the above. They are not eligible for special services to meet their educational needs.

2. Participants in this study were:

a) Elementary school classroom teachers.

b) Middle school classroom teachers.

c) High school classroom teachers.

d) Both b and c.

3. Data was collected using:

a) 8 written vignette versions and a questionnaire.

b) 3 written vignette versions and a questionnaire.

c) 8 vignette versions in a structured interview.

d) 3 vignette versions in a focus group setting.

4. The response rate across schools:

a) Was fairly consistent.

b) Varied widely.

c) Was fairly consistent across middle schools but varied widely across high schools.

d) Was fairly consistent across elementary schools but varied widely across secondary schools.

5. Less than half of teachers:

a) Attributed pain to at least one physical cause.

b) Attributed pain to at least one psychological cause.

c) Attributed pain to both physical and psychological causes (reflected a biopsychosocial view of pain).

d) Attributed pain to either physical or psychological causes but not both (reflected a dualistic view of pain).

6. Which factor predicted whether teachers attributed pain to at least one physical cause or to both physical and psychological causes (biopsychosocial view)?

a) The presence of medical evidence in the vignette.

b) The presence of communication with the physician in the vignette.

c) The teachers' years of experience.

d) The teacher's personal experience with chronic pain.

7. Teachers' support for more accommodations for a student with chronic pain trended toward significance if the teachers attributed the pain to:

a) Psychological rather than physical causes.

b) Physical rather than psychological causes.

c) Both physical and psychological causes (biopsychosocial).

d) None of the above (no differences existed based on attribution of pain).

8. The authors reported that in clinical settings young patients with chronic pain blamed poor school performance on:

a) An inability to focus due to the pain.

b) Drowsiness due to pain medications.

c) School personnel's failure to believe their pain was real.

d) All of the above.

9. Teachers' expression of sympathy for students with chronic pain was significantly greater if they attributed the cause of pain to:

a) Physical causes only.

b) Psychological causes only.

c) Both physical and psychological causes (biopsychosocial model).

d) Both a and c.

11). The authors recommended that:

a) Physicians formally train teachers about ways to accommodate students with chronic pain.

b) Medical teams increase the frequency of their communication with schools.

c) Pediatric pain specialists recognize the potential that medical evidence of pain has to influence teachers' perceptions of pain.

d) School nurses serve as bridges to translate medical evidence of pain for teachers.

Journal of School Health is written and produced by the American School Health Association. Activity planning, test questions and pilot testing were conducted by Susan F. Wooley, PhD, CHES, and selected members of ASHA's Editorial Board and Professional Development Committee.

The authors express sincere thanks to Kate Nugent, Nell Taylor, and Molly Waring for research assistance; Henry Feldman, PhD, for statistical consultation; Ariel Botta, LCSW; Rebecca Brody, PhD; Dave DeMaso, MD; and Nadja Reilly, PhD, for facilitating recruitment; the Psychiatry Department of Children's Hospital Boston for providing research funding support; and the teachers who participated in the study.


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(25.) Swartzman LC, Lees MC. Causal dimensions of college students' perceptions of physical symptoms. J Behav Med. 1996; 19:95-110.

(26.) Logan DE, Curran JA. Adolescent chronic pain problems in the school setting: exploring the experiences and beliefs of selected school personnel through focus group methodology. J Adolesc Health. 2005;37(4):281-288.

(27.) Koontz K, Short AD, Kalinyak K, Noll RB. A randomized, controlled pilot trial of a school intervention for children with sickle cell anemia. J Pediatr Psychol. 2004;29:7-17.

Address correspondence to: Deirdre E. Logan, Staff psychologist at Children's Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical School, (, Pain Treatment Service, Children's Hospital Boston, 333 Longwood Ave., Boston, MA 02115.

* Indicates CHES continuing education hours are available. Also available at:





(a) Staff psychologist at Children's Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical School, (, Pain Treatment Service, Children's Hospital Boston, 333 Longwood Ave., Boston, MA 02115.

(b) Instructor of Psychiatry and Behavioral Sciences, (, Northwestern University, Feinberg School of Medicine, 150 E Huron St. Suite 1100, Chicago, IL 60611.

(c) Staff psychologist, Children's Hospital Boston, (, Department of Psychiatry and Pain Treatment Service, Children's Hospital Boston, 553 Longwood Ave., Boston, MA 02115.

(d) Associate Director, Pain Treatment Service, Children's Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical School, (, Pain Treatment Service, Children's Hospital Boston, 333 Longwood Ave., Boston, MA 02115.
Table 1. Descriptive Data on Study Respondents by School *

                               Rate of        Teaching
                            Participation    Experience,
School    Type of School     ([dagger])       Mean (SD)

A        Combined               94/111       19.2 (12.6)
         (7th-12th grade)
B        High school           106/294       14.2 (10.5)
C        Middle school          12/53        15.0 (9.6)
D        High school            19/82        17.0 (12.4)
E        Middle school          16/40        11.4 (9.5)
F        High school            13/63        12.7 (11.2)

              Female         Females on
School   Respondents (%)     Faculty (%)

A              57.0              63
B              69.5              57
C              91.7              74
D              61.1              56
E             100                75
F              84.6              61

* Table is modified from Table 1 in Logan et al. (23)

([dagger]) This column reflects the number of teachers who returned
questionnaires out of the total number of classroom teachers on

Table 2. Frequencies of Teachers' Endorsements of Probable Causes of
Student's Pain (n = 260)

Attribution                         Endorsing as
                                   Probable Cause,
                                        n (%)
  Nerve damage                        96 (37.2)
  Muscle spasms or knots              39 (15.2)
  Swelling, inflammation              78 (30.5)
  Physical disease                    13 (5.1)
  Repeated injury to the area         15 (5.9)

  Psychological stress              (150 (57.9)
  Being overly sensitive              55 (21.3)
  Personal or emotional problems      88 (34.1)
  Social/peer problems                62 (24.2)
  Problems in the family              26 (10.2)

Table 3. Summary of Regression Results for Teacher Responses to Pain
Regressed on Pain Attributions ([double dagger])

                              Outcomes: Teacher Responses to
                                     Student With Pain

Pain Attributions                 Academic Accommodations

Physical attributions        [R.sup.2] = .033, [beta] = .12 ([dagger])
Psychological attributions   [R.sup.2] = .029, [beta] = .03
Both physical and            [R.sup.2] = .033, [beta] = .10
psychological attributions
(ie, biopsychosocial

                              Outcomes: Teacher Responses to
                                     Student With Pain

Pain Attributions                   Sympathy for Student

Physical attributions        [R.sup.2] = .032, [beta] = .18 *
Psychological attributions   [R.sup.2] = .007, [beta] = -.07
Both physical and            [R.sup.2] = .033, [beta] = .16 *
psychological attributions
(ie, biopsychosocial

([dagger]) p < .10. * p < .01.

[beta], standardized coefficient beta.

([double dagger]) Dummy variables representing schools were included
in each regression equation. No significant school effects arose.
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Article Details
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Title Annotation:Research Article
Author:Logan, Deirdre E.; Catanese, Sarah P.; Coakley, Rachael M.; Scharff, Lisa
Publication:Journal of School Health
Geographic Code:1USA
Date:May 1, 2007
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