Guided by the Roy Adaptation Model of Nursing, the relationship of children's age, gender, exposure to past painful experiences, temperament, fears, and child-rearing practices to their pain responses to a venipuncture was examined. A sample of 94 children aged 8 to 12 years and their female caregivers were recruited from three outpatient clinics. During the venipuncture, children's behavioral and heart rate responses were monitored; immediately after, their subjective responses were recorded. Canonical correlation revealed two variates. In the first, age and threshold(temperamental dimension) correlated with pain quality, behavioral responses, and heart rate responses, explaining 12% of the variance. In the second, age, the temperamental dimensions of distractibility and threshold, and medical fears explained only 5.7% of the variance in pain quality and heart rate magnitude. Significant correlations between pain intensity, quality, behavioral responses, and heart rate responses support the multidimensionality of pain.


Article Content

Venipunctures are described as painful procedures by hospitalized children(Van Cleve, Johnson, & Pothier, 1996; Wong& Baker, 1988) and the most difficult to deal with by adolescent oncology survivors (Fowler-Kerry, 1990). However, not all children respond similarly to venipunctures. Between 4% and 17% of school-age children rated their pain intensity to a venipuncture as severe(Fradet, McGrath, Kay, Adams, & Luke, 1990; Harrison, 1991), and 38% of children ages 3 to 10 had to be physically restrained during a venipuncture (Jacobsen et al., 1990). Manne, Jacobsen, and Redd (1992) reported that the pain intensity and behavioral responses of 3- to 10-year-old children were moderate. In a recent study by Van Cleve et al., hospitalized schoolage children were found to rate venipuncture or intravenous cannulation as moderately painful.


Factors that account for variability in children's responses to venipunctures have not been fully identified. The purpose of this study, therefore, was to examine the relationship of a set of correlates, including age, gender, past painful experiences, temperament, general and medical fears, and child-rearing practices, on school-age children's subjective, behavioral, and heart rate responses to a venipuncture.



Conceptual Framework: The Roy Adaptation Model of Nursing (RAM)(Roy and Andrews, 1991) and the research literature on children's responses to painful procedures guided this study. According to the RAM, the goal of nursing is to facilitate adaptation between the person and the environment through the management of stimuli (Roy& Corliss 1993). One of the assumptions of adaptation-level theory is that the person's "adaptive behavior is a function of the stimulus and adaptation level, that is, the pooled effects of the focal, contextual, and residual stimuli" (Roy & Corliss, 1993, p. 217). The focal stimulus immediately confronts the person; the contextual stimuli contribute to the effect of the focal stimulus; and residual stimuli are factors whose effects on the person's adaptation have not been clearly determined.


The focal and contextual stimuli are processed through coping mechanisms, such as the regulator and cognator subsystems. The regulator subsystem induces physiological responses through neural, chemical, and endocrine processes. The cognator subsystem elicits responses through perceptual/information processing, learning, judgment, and emotion processes(Andrews & Roy, 1991a). Outcomes of these coping mechanisms are the person's responses in four modes: self-concept, role function, interdependence, and physiological. The self-concept mode relates to feelings about one's personal and physical self. The role-function mode is associated with the need for social integrity based on roles assumed within society. The interdependence mode focuses on interactions that fulfill the need for affectional adequacy and support. The physiological mode is described as the person's physical responses to stimuli from the environment. In accordance with the proposition that stimuli serve as inputs to the person to elicit a response, children's pain-related responses were tested as a function of the pooled effects of the focal stimulus, the venipuncture, and the contributory effects of the contextual stimuli congruent with the RAM and the empiric pediatric pain literature. Contextual stimuli relate to culture, family, developmental stage, and cognator effectiveness, as well as those factors that have an effect on the person's adaptive responses in any of the modes (Andrews & Roy, 1991b). The pooled effects of a venipuncture, children's age, gender, exposure to past painful experiences, temperament, fears, and child-rearing practices were studied in relation to children's pain-related responses to the venipuncture.


Roy (1991) defined pain within the physiological mode, as a sensory experience of acute or chronic nature, coded into the somatosensory pathways. Acute pain refers to "discomfort which is intense but relatively short lived and reversible" (p. 166). Using principles from neurophysiology, Roy stated that a sensory experience such as pain involves the transmission of neural activity through specialized receptors, and transmission of information from sensory pathways to the cerebral cortex. A sensation results from receptors' activity and is converted into perceptual activity involving mental representations and interpretations (Roy). Thus, pain can be understood to be both a sensory and perceptual experience.


As a manifestation of the regulator subsystem activity, the sensory dimension was represented in this study by children's behavioral and heart rate responses. The perceptual dimension of pain, which is the response to the cognator subsystem activity, was portrayed by children's subjective responses about the location, intensity, and quality of pain.


Review of the Literature: Empirical evidence supports a negative relationship between the contextual stimulus of children's chronological age and pain intensity (Fradet et al. 1990; Lander & Fowler-Kerry, 1991; Manne et al., 1992) and behavioral responses to venipunctures (Fradet et al., 1990; Humphrey, Boon, van Linden van den Heuvell, van de Wiel, 1992; Jacobsen et al., 1990). Mean pain intensity responses to a venipuncture or intravenous cannulation were found to be greater in preschoolers than in schoolage children; however, it is not clear whether this difference was statistically significant(Van Cleve et al., 1996). Gender has been believed to be a mediator in pain experiences (Katz, Kellerman, & Siegel, 1980). However, researchers have shown that gender has no effect on pain intensity responses (Fowler-Kerry & Lander, 1991; Fradet et al., 1990; Manne et al., 1992) and behavioral responses to venipunctures (Fradet et al.; Humphrey et al.; Jacobsen et al.). In view of the influence of socialization on schoolage children's sex-role stereotypes, it was relevant to reexamine the effects of gender on pain responses.


Several researchers have reported that children's exposure to past painful procedures is inversely related to their behavioral responses to a venipuncture (Fradet et al., 1990; Jacobsen et al., 1990). However, in another study, this relationship did not reach statistical significance (Manne et al., 1992). The effects of past exposure to venipunctures on children's subjective, behavioral, and heart rate responses to a venipuncture remain unclear.


The contextual stimulus of temperament may explain the individual variability of responses across situations. According toThomas and Chess (1977), temperament is the result of an interactive process between child and parent and consists of nine temperamental dimensions: activity, rhythmicity, approach/withdrawal, sensory threshold, intensity of reaction, quality of mood, distractibility, and attention span/persistence, and adaptability. Although the predictive effects of temperament have been studied in children's adaptation to chronic illness(Garrison, Biggs, & Williams, 1990; Wallander, Hubert,& Varni, 1988), the relationship between temperament and pain related to invasive procedures has only been examined in preschool children.Young and Fu (1988) found that a child's rhythmicity had a small effect on pain intensity and that approach accounted for 7% of children's behavioral responses to venipunctures. In view of the brevity of the venipuncture, the theoretical relevancy of each temperamental dimension, and school-age children's increased behavioral mastery, only sensory threshold, intensity, and distractibility were judged important in this study. Sensory threshold reflects sensitivity to stimulation and may be important in self-regulation and defense mechanisms(Rothbart & Derryberry, 1981). Intensity is the energy level of a response irrespective of the direction(Thomas & Chess, 1977). Distractibility, a measure of how sensitive one's attention is to environmental stimulation, may be relevant in children's coping mechanisms and adaptive responses.


Children fearful of medical procedures report higher pain intensity to venipunctures (Broome, Bates, Lillis, Wilson, & McGahee, 1990) and display more behavioral responses (Jacobsen et al., 1990). Nevertheless, investigators have not examined the contextual stimulus of children's medical fears in relation to a multidimensional view of the pain experience or accounted for another contextual stimulus, children's general fears. While fear is an immediate response to a threatening situation, general fears may serve as a context for the development of medical fears.


The family's influence on children's behaviors through the provision of structure and discipline is relevant in the study of children's responses to painful situations (Melamed & Bush, 1985). Parental restrictiveness and nurturance toward a child's behavioral expressiveness may help in understanding children's responses to pain. The contextual stimulus of child-rearing practices was examined in the situation of immunizations(Broome & Endsley, 1989). Children of authoritative(high-control, high-warmth) parents exhibited significantly fewer behavioral responses than those of authoritarian (high-control, low-warmth), permissive(low-control, high-warmth), and unresponsive (low-control, low-warmth) parents. This study extended examination of the influence of child-rearing practices to children's pain responses to venipunctures.


Previous studies of the effects of multiple variables on children's pain intensity and behavioral responses to venipunctures have been informative. However, children's pain has not been measured in a comprehensive fashion. The relationship between children's behavioral display and reported pain intensity has been found to be moderate in school-age children during venipunctures (Fradet et al., 1990; Humphrey et al., 1992; Manne et al., 1992) and during bone marrow aspirations (Jay & Elliott, 1984; Jay, Ozolins, Elliot, & Caldwell, 1983). Inasmuch as pain intensity represents one aspect of the pain experience, children's behavioral responses needed to be examined in relation to a global assessment of pain. Though not specific to pain, physiological responses have been described in acute pain experiences. However, studies involving cardiac rate during painful procedures have yielded equivocal results. Broome and Endsley (1987) found no relationship between preschoolers' behavioral responses and heart rate during a finger stick procedure, whereas Jay and Elliott (1984) reported a moderate correlation between behaviors and heart rate of school-age children and adolescents during bone marrow aspirations. These findings support the need to reexamine the role of sympathetic responses of heart rate combined with other pain measures during an invasive procedure. Based on the RAM and the empirical pediatric pain literature, the hypothesis tested was that there is a relationship between the set of independent variables age, gender, past painful experiences, temperament, medical fears, general fears, and child-rearing practices and the set of school-age children's responses to venipuncture: pain location, pain intensity, pain quality, observed behaviors, and heart rate.



Sample: The sample consisted of 94 children and their female caregivers recruited from three outpatient clinics (gastroenterology, nephrology, and preoperative) at a large pediatric hospital in a mid-Atlantic state. An initial power analysis for multiple regression with 9 independent variables, a power of .80, a medium effect size, and an alpha level of .05 revealed that 119 subjects were necessary (Cohen, 1988). However, the actual obtained power of the main analysis performed to test the study hypothesis was so low that an increase in sample size would not have yielded more meaningful results. Consequently, the study sample was judged sufficient.


Children between 8 and 12 years of age, cognitively normal for their school grade, accompanied by a female caregiver, and expected to receive a venipuncture during their clinic visit were asked to participate. Of the 121 subjects who were approached, 10 refused (8%) for lack of time or personal reasons. Of those who agreed, 17 (15%) were excluded for various reasons; 4 children had cognitive deficits, 2 were not accompanied by a female caregiver, 7 did not require a venipuncture, and 4 caregivers did not have time to complete the questionnaires. Children's mean age was 10.3 (SD = 1.4). The majority of the children were female (54.3%) and white (86.2%).


Instruments: The Child Information Sheet (CHILDIS) was used to record information about the child's gender, age, school grade, number of past hospitalizations, and number of past venipunctures and other painful procedures. The Caregiver Information Sheet (CIS) was used to record demographic information about the caregiver, including age, gender, ethnicity, marital status, education level, employment status, and family income. Caregivers' perceptions about the child's experiences with past hospitalizations and painful procedures were also requested.


The Middle Childhood Temperament Questionnaire (MCTQ)(Hegvik, McDevitt, & Carey, 1982) was used to measure temperament of children 8 to 12 years old. The MCTQ is a 99-item parent report using a 6-point scale from 1 (almost always) to 6 (almost never) for each of nine temperamental dimensions. Three dimensions, distractibility, intensity, and threshold, were included in this study. Higher scores are indicative of higher distractibility and intensity but lower sensory threshold. Satisfactory criterion-related validity was evidenced in comparisons of children's temperament at ages 7 and 12(Maziade, Cate, Boudreault, Thivierge, & Boutin, 1986). For this study, the Cronbach's alpha internal consistency reliability coefficients were threshold, .68, distractibility, .75, and intensity, .81.


The Child Medical Fears Scale (CMFS) (Broome, Hellier, Wilson, Dale, & Glanville, 1988) is used to measure children's levels of reported fears related to medical personnel and diagnostic or therapeutic procedures. Children rate their level of fear for 17 items on a scale of 1 (not at all), 2 (a little), and 3 = (a lot afraid), with higher scores indicating greater fear. Total scores range from 17 to 51. The content validity index for the CMFS is 78% (Broome et al.). Criterion validity was established with the original Fear Survey Schedule(Scherer & Nakamura, 1968), with a correlation of.71 (Broome et al.). The Cronbach's alpha internal consistency reliability coefficient was .87 for this study sample.


The Revised Fear Survey Schedule for Children (R-FSSC)(Ollendick, 1983) is an 80-item questionnaire used to measure children's general fears. Children rate their level of fear to the unknown, supernatural events, bodily injury, small animals, and death on a 3-point scale of 1 (none), 2 (some), and 3 (a lot). Total scores range from 80 to 240, with higher scores indicating greater fear. Construct validity was established by discriminating fears of phobic and normal children (Ollendick) and by supporting a decline in children's fears with age(King, Gullone, & Ollendick, 1991). The generalizability of a five-factor structure has been shown across cultures(Ollendick & Yule, 1990). The Cronbach's alpha internal consistency coefficient for the present study was .95.


The Modified Child-Rearing Practices Report (M-CRPR) (Dekovic, Janssens, & Gerris, 1991; Rickel & Biasatti, 1982) was used to measure two parental attitudes toward child rearing: parental restrictiveness, characterized by a high degree of control and endorsement of strict rules and restrictions, and parental nurturance, characterized by the willingness of parents to share feelings with their children and to show responsiveness to the child's needs. The M-CRPR consists of 40 statements with a 6-point response format, from 1 (not at all descriptive of me) to 6 (highly descriptive of me). Two scores are obtained, with lower scores indicative of low restrictiveness (range 0 to 22) and low nurturance (range 0 to 18). The validity of the M-CRPR was supported by discriminating the childrearing practices of parents of rejected and highly sociable children(Dekovic et al.) and by factor-structuring the scale(Dekovic et al. ; Rickel & Biasatti). In this study, the Cronbach's alphas for the restrictiveness and nurturance subscales were.90 and .92, respectively.


The Adolescent Pediatric Pain Tool (APPT) (Savedra, Tesler, Holzemer, & Ward, 1992) is a self-report measure of location, intensity, and quality of pain in children aged 8 to 17 years. Pain location is measured using a body outline figure on which children are instructed to mark the location(s) of their current pain. The number of locations is summed, with scores ranging from 0 to 43(Savedra, Tesler, Holzemer, Wilkie, & Ward, 1989). Criterion-related validity of the pain location scale was documented when children's markings and investigators' observations reached an agreement of at least 80% (Savedra, Tesler, Holzemer, Wilkie, & Ward, 1990). A postoperative decrease in pediatric surgical patients' pain sites was found, thus supporting construct validity (Savedra et al., 1990). Intrarater reliability estimates of the agreement between subjects' markings and pointings ranged from 83% to 94%(Savedra et al., 1989).


Pain intensity was measured using a 100-mm wordgraphic rating scale, with scores ranging from 0 to 100. A decline in postoperative pain intensity scores supported construct validity (Savedra et al., 1990). Criterion-related validity was established through correlations with four other pain intensity scales (Tesler et al., 1991). Test-retest reliability was .91 (Tesler et al., 1991).


Pain quality was measured using a list of 67 words that relate to the sensory, affective, evaluative, and temporal experiences of pain(Tesler, Savedra, Ward, Holzemer, & Wilkie, 1988). Based on a factor analysis that confirmed only three factors(Wilkie et al., 1990), scores, which range from 0 to 56, are reported only for sensory, affective, and evaluative subscales. Criterion-related validity was evidenced by correlations with pain intensity scores (Savedra et al., 1990). A significant decrease in the number of words used by recovering pediatric surgical patients(Savedra et al., 1990; Savedra, Holzemer, Tesler, & Wilkie, 1993) supported construct validity. Test-retest reliability of total, sensory, affective, and evaluative scores of surgical patients revealed high correlations, .95, .91, .97, and .78, respectively(Tesler et al., 1991).


The Observed Child Distress (OCDS) (Jacobsen et al., 1990; Manne et al., 1992) was used to measure six behavioral responses to venipunctures: pain verbalizations, cry/scream, request for termination of procedure, refusing to assume body position, muscular rigidity, and requiring physical restraint. These behaviors are observed during three phases of the venipuncture (phase 1, from sitting in the chair until the tourniquet is applied; phase 2, from tourniquet application until needle is to be inserted; and phase 3, from piercing the skin to bandage application). They are rated for their presence (1) or absence (0), for a total score ranging from 0 to 18. Construct validity of the OCDS was supported by a positive correlation between behavioral scores and self-reports of pain intensity (Manne et al., 1992). Cronbach's alpha internal consistency coefficient for the study sample was.83.


A Nellcor electronic pulse oximeter (N-10; Haywood, CA) was used to measure heart rate during the venipuncture through a taped sensor to a finger. Heart rate was measured at rest and monitored every 10 seconds throughout the venipuncture. The magnitude of heart rate change (highest heart rate during phase 3 relative to baseline heart rate) was calculated for each child.


Procedure: All subjects were recruited before their clinic appointments. Participation in the study was voluntary, and informed consents from female caregivers and children's assents were obtained in accordance with the institution's Committee for Protection of Human Subjects.


During waiting periods, caregivers completed the CIS, the MCTQ, and the M-CRPR. In the presence of their caregivers, children were asked to answer verbally to the CHILDIS, R-FSSC, and the CMFS. A baseline heart rate was obtained after each child had rested for 15 minutes in a sitting position. Throughout all phases of the procedure, children's behavioral responses were measured using the OCDS, and heart rate was monitored with a pulse oximeter. Data obtained during the third phase of the venipuncture, which is associated with the experience of pain, is reported in this study. Only one caregiver was absent during the venipuncture. Within 10 minutes following the procedure, children completed the APPT.



Examination of the distribution of the pain-related variables(Table 1) led to the exclusion of pain location scores from further statistical analyses due to limited variability. Since the distributions of pain intensity and quality scores were skewed, square root transformations were performed. Though the majority of children reported minimal pain intensity, 20% of the children regarded venipunctures as very painful procedures. Most children (98%) described their pain experiences using sensory descriptors, 75% chose evaluative words, and 40% selected affective qualities. Children's behavioral responses associated with the insertion of the needle were minimal; however, heart rate changes were of greater magnitude. For most children (96.7%), magnitude in heart rate change was within two standard deviations. For 3.3% of the sample, important changes in heart rate were recorded (< or > 3 SD).

Table 1 - Click to enlarge in new windowTable 1. Summary of Children's Scores on Dependent and Independent Variables

As presented in Table 1, data about children's past experiences with venipunctures were not normally distributed. Following transformation, the majority of children (64%) were found to have prior experience with venipunctures. The distributions for the temperamental dimensions of distractibility, intensity, and threshold were found to be normal. Children's scores on general fears were normally distributed; however, medical fear scores required square root transformation. Parental restrictiveness and nurturance scores were not normally distributed and were dichotomized into high and low groups. About half of the caregivers (43.6%) scored low on parental restrictiveness and 46.8% scored low on nurturance.


Correlations were computed between all independent and dependent variables. Threshold was correlated with pain quality (r(94) =.25,p <.05), that is, low sensory threshold was associated with more pain descriptors. Age, r(93) = -.48, p <.001, and threshold, r(93) =.24, p < .05, were correlated with behavioral responses, suggesting that with age, children manifest fewer behavioral responses, and that low sensory threshold is associated with more behavioral responses. Distractibility, r(90) =.33, p<.05, threshold, r(90) =.23, p = .03, general fears,r(87) =.27, p <.05, and medical fears,r(86) =.26, p < .02, were correlated with magnitude in heart rate change. Children with high distractibility, low threshold, and high general and medical fears had greater changes in heart rate. None of the independent variables were related to pain intensity. Consequently, pain intensity was excluded from the main analysis.


Examination of the correlations between the independent variables revealed multicollinearity for general and medical fears, r(87) =.83,p <.001. Consequently, general fears were excluded from the main analysis.


The correlation matrix for the dependent variables revealed low to moderate correlations between pain quality, intensity, behavioral responses, and magnitude in heart rate change. Specifically, pain quality correlated with pain intensity ( r(94)=0.59, p < 0.001), behavioral responses (r(93)=0.41, p < 0.001), and magnitude in heart rate change (r(90)=32, p < 0.05). Lower correlations were found between pain intensity and behavioral responses(r (93)=0.26, p < 0.05) and magnitude in heart rate change (r(90)=0.22, p < 0.05). As expected, behavioral responses were correlated with magnitude in heart rate change(r (90)=0.31, p < 0.01). Together, these findings suggest that as children select more pain descriptors, they report higher pain intensity and exhibit more behavioral responses and greater heart rate responses.


Of the initial variables, only the independent and dependent variables that correlated significantly were retained for the canonical analysis. They were age, distractibility, threshold, medical fears, pain quality, behavioral responses, and magnitude of heart rate change. As can be seen inTable 2, two canonical variates were found to be significant. The first canonical variate (.526) was found for age and threshold, and correlated with pain quality, behavioral responses, and magnitude of heart rate change, explaining 12% of the variance. The second canonical variate (.411) revealed that age, medical fears, distractibility, and threshold correlated with pain quality and magnitude of heart rate change, explaining 5.7% of the variance. Overall, 17.7% of the variance was accounted for. Inasmuch as all variables did not enter the analysis, the study hypothesis was not supported.

Table 2 - Click to enlarge in new windowTable 2. Canonical Correlation Analysis Summary Table Between Age, Distractibility, Threshold, and Medical Fears (Set 1) and Pain Quality, Behavioral Responses, and Heart Rate Magnitude (Set 2)

A closer examination of the first variate in the set of independent variables supported an association between age and threshold. That is, with age, children learn to become less sensitive to environmental stimuli. In the set of dependent variables, pain quality was found to be associated with behavioral and heart rate responses. The second variate of the canonical analysis suggested that younger and fearful child tend to be more distractible and have low sensory thresholds.


Additional findings from t-test and chi-square analyses showed no differences on most independent and dependent variables between subjects from the preoperative clinic and those from the gastroenterology and nephrology clinics. However, children from the preoperative group had less experience with past venipunctures, [chi]2 (1, N = 84) = 4.24, p < .05, and reported higher pain quality, M = 2.7, SD = 1.1, T(93) = -2.1, p < .05. In the total sample, girls had higher general fears than boys, T(90)= -2.0, p < .001, but no difference was found with regard to medical fears. Finally, girls had higher temperamental intensity than boys(girls, M = 3.9, SD = 0.8 vs. boys, M = 3.5,SD = 0.9; T(94) = -2.05, p < .05).


On all dependent variables, children were found to be homogeneous except that girls cried significantly more than boys during the venipuncture,[chi]2 (1, N = 93) = 4.22, p < .05. No differences were noted in children experienced and inexperienced with venipunctures with regard to temperament, general and medical fears, pain intensity and pain quality scores, behavioral responses, and heart rate magnitude. Regardless of children's health problems, family income, and race, there were no differences in children's responses to pain.



Although the study hypothesis was not supported, the results from the canonical correlation revealed several important relationships. Data from the first variate showed that with increasing age and in children with high sensory threshold, fewer words are used to describe pain, fewer behavioral responses are manifested, and lower magnitude of change in heart rate is observed. With increasing age, children are more emotionally and behaviorally organized (Maccoby, 1983). Moreover, school-age children's greater understanding of the procedure, increasing awareness of socially acceptable behaviors, and competency in controlling behaviors may account for the restricted body movements. Finally, children less sensitive to sensory stimuli were less upset by the venipuncture and showed fewer behavioral responses and changes in heart rate.


Findings from the second variate suggest that younger, highly fearful, distractible, and sensitive children report higher pain quality and have higher heart rate reactivity. Lack of familiarity combined with a limited repertoire of coping skills may account for the younger child's increased vulnerability to stressful events. These findings support the need for the implementation of interventions for young children before and even during such relatively brief and simple medical procedures as venipunctures.


Correlations between the dependent variables as shown in the correlational matrix and in the first canonical variate support a relationship between the perceptual and sensory dimensions of pain. However, the relationship is low in magnitude. Gross motor responses may be less relevant in school-age children, suggesting that a focus on muscular rigidity and/or facial activity might be more appropriate for this group. In this study, no relationship was found between the independent variables and pain intensity. It may be that the venipuncture did not evoke enough variability in children's pain intensity or that no relationship can be established with pain intensity since it is essentially a subjective and unpredictable characteristic of pain.


The study results provided limited support for the Roy Adaptation Model. Based on the proposition that focal and contextual stimuli influence responses, empirical support was found for the contextual stimuli of age, medical fears, and the temperamental dimensions of distractibility and threshold. Only the contextual stimuli that affect developmental stage (age), self-concept (medical fears), and interdependence between parent and child(temperamental dimensions of distractibility and sensory threshold) were supported. The lack of a relationship between gender and subjective pain responses, though unexpected, is consistent with prior work on gender and pain intensity (Fowler-Kerry & Lander, 1991; Fradet et al., 1990; Manne et al., 1992). Limited support was found for the relationship between gender and behavioral responses, in that girls cried more than boys. The influence of parental child-rearing styles on responses to venipunctures was not noted in this study.


Contrary to prior research (Fradet et al., 1990; Jacobsen et al., 1990) but consistent with the work ofManne et al. (1992), the findings showed no relationship between experience with venipunctures and children's pain-related responses. This suggests that experienced children did not habituate to the procedure. It may also be that frequency of exposure is not sufficient information for understanding children's responses to pain. Rather, as the RAM suggests, children's coping abilities with procedures need to be taken into account.


Most importantly, findings from the correlational and canonical analyses support the multidimensionality of pain as conceptualized by the RAM. This empirical evidence is consistent with the need for clinicians and researchers to use a comprehensive approach to assess pain by integrating valid and reliable subjective, behavioral, and physiological measures. Such a global approach to understanding pain is in accordance with the RAM.


Several instruments used in the study need further evaluation. The Revised Fear Survey Schedule for Children should be revised to be more sociohistorically appropriate for children. Low scores obtained by the Child Medical Fears Scale suggest a need to reexamine the relevancy of several items with a school-age population. In view of the fact that there was no relationship between behavioral responses and pain intensity, more attention needs to be paid to the meaning of behavioral responses. For example, it is important to understand which behavioral responses are reflective of the pain experience in different age groups. This information is particularly critical in the care of children unable to express their needs verbally.


This study supports the need to assess children's pain and to identify the factors that may aggravate the pain experience. Research on helping children cope with aversive medical procedures has produced somewhat equivocal results(Dahlquist, 1992). While certain strategies may be helpful to some children, others may have no or negative effects. In order to individualize the care of children undergoing procedures, future research may be directed toward matching interventions with children's age, fears, and temperament. The findings of this research have contributed to the extension of the knowledge base on school-age children's pain to venipunctures.




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