“I hear you”. Validation in the context of children’s pain as an untapped opportunity to prevent chronic pain

Introduction

Social relationships play a critical role in shaping how health is experienced throughout the lifespan. An absence of social supports in people living with chronic pain can become a catalyst for toxic stress and myriad mental health problems[20]. Childhood and adolescence are critical developmental periods during which pain experiences become socialised and may influence physical and emotional wellbeing across the lifespan[32]. Despite this, targeting social contexts during early life, as a means of buffering against the development of future pain problems, has been largely ignored in our field.

In this theoretical review, we draw upon literature in developmental psychology, child mental health, and pain science and management, to argue that validation of children’s pain (i.e., communicating to another that their pain is real and understandable) may be a modifiable social pathway for the prevention of chronic pain. We ground our discussion and argument in the biosocial theory of emotion regulation and consider applications for children across a range of social contexts (e.g., parent and child, healthcare-provider and family) and painful experiences (i.e., common/’everyday’ pains, significant pain/injuries, procedural pain, chronic pain). We address commonly held assumptions around validation and explore how the impact of validation might be enhanced in those from minoritised groups. Finally, we apply a developmental perspective on the potential role that validation may have in supporting children to develop foundational knowledge and skills to build long-term protection against future chronic pain and move towards reducing biases and inequities in pain care.

Validation and invalidation

Validation means taking action to communicate to another that their private experiences (e.g., beliefs, perceptions) and behaviours are real, understandable, and legitimate, based on an individual’s current context or history, particularly when there is no factual evidence to suggest otherwise[13]. Conversely, invalidation means responding to those same experiences and behaviours with disinterest, disbelief, or active criticism[13; 29]. How, when, and who has their experiences (in)validated will depend on the characteristics (e.g., age, gender, racialised identity) of those providing (e.g., caregivers, clinicians) and receiving (in)validation[31].

In the adult pain literature, three models of validation have been considered[7], however direct evidence supporting the use of one over the other is lacking. The operant conditioning model[9] is prominent in the pain field and argues that validation of pain-related experiences has the potential to reinforce both unhelpful pain behaviours (e.g., complaining) and helpful ones (e.g., exercising despite pain). The interpersonal process model of intimacy[27] posits that validating behaviour increases relationship attachment[2]. Linehan’s biosocial model[13], which has received less attention in the pain field, extends the operant conditioning model whereby validation is paired with promotion/reinforcement of adaptive pain behaviours. According to the biosocial model and its therapeutic applications (e.g., dialectical behaviour therapy; DBT) validation not only conveys acceptance/understanding but also encourages problem solving and engagement in adaptive pain management strategies that are aligned with long-term goals (e.g., going to school despite pain). The biosocial model also focuses on the impact of invalidation in dyadic exchanges. This theory has received some empirical support in the pain field[15], however direct empirical evidence in children’s pain is lacking. Also absent from the literature, is a developmental understanding of how validation might influence pain across the lifespan.

Receiving repeated validation is associated with emotion regulation skills[28], a link that has consequences for the maturing child. When a child’s experiences/behaviours are validated and matches their experiences/expressions of vulnerability, their emotional arousal becomes reduced in the moment and over time[28]. Validation may include emotion labelling (e.g., “you seem frustrated”), which can help children identify and understand their emotions, and utilise strategies to regulate the intensity, duration, and frequency of those reactions[28]. Validation is likely to be critical throughout childhood when they are developing foundational skills in emotion regulation and may be particularly important during moments of high vulnerability/disclosure. In contrast, when a child’s experience is invalidated, real-time emotional reactivity becomes magnified, and their ability to learn and use regulatory strategies becomes impaired[28]. Invalidation also punishes the frequency of self-disclosures in dyadic exchanges, giving the impression that the child is “shutting down” by not talking despite having a genuine emotional reaction or experience. Over time, we argue that this may lead to emotion dysregulation across a longer developmental timescale[13].

Pain and emotion are integrally linked[14], with emotion dysregulation commonly co-occurring with chronic pain[12]. Emotion dysregulation moderates vulnerability for chronic pain and mental health problems[1; 12] and has been identified as a mediating factor between adverse childhood experiences and chronic pain[30]. Meta-analyses have shown that psychological interventions (e.g., DBT) can improve symptoms of depression, anxiety, and emotion dysregulation in youth with mental health problems[5], and can improve pain, emotion dysregulation, and depression in people with chronic pain[22; 23]. In minoritised populations (e.g., gender diverse people), emotion dysregulation is associated with poor mental health[3] and suicidality[6]. Pain intensity and functional limitations have been linked to poor emotion regulation in youth with painful chronic idiopathic arthritis[4], but empirical data on pain conditions are otherwise lacking. The adoption of validation of children’s pain may offer the greatest potential for minoritised groups, for whom the accumulation of uncontrollable traumatic experiences, invalidation, and discrimination likely contributes to the disproportionate chronic pain inequities found among these groups[10].

What validation is and what it is not

Validation is inherently dyadic and is observed in response to an expression, behaviour, or disclosure. Validation requires empathy, emotional attunement, kindness, curiosity, and vulnerability from the person delivering validation. Following in on a person’s disclosure, in the form of questions, can be validating in and of itself, and can be an opportunity to learn whether the observers’ interpretations are indeed congruent with the child’s experience. Validation should be sincere, genuine, and authentic, and its success is determined by the individual receiving validation. The depth, context, and number of disclosures expressed provides for varying magnitudes of (in)validation, in response (Table 1).

Table 1.

Example scenarios of validation and invalidation in the context of chronic (Example 1) and procedural (Example 2) paediatric pain. Validation levels are based on the Validating and Invalidating Behaviour Coding Scale (VIBCS) by Fruzzetti 2014¹

Scenario	Patient/child receiving (in)validation	Clinician/parent providing (in)validation	Target and level of (in)validation	Theoretical outcomes
Example 1: VALIDATION	Young girl (~13 years old) walks into chronic pain clinic. She sits down while appearing nervous and protective of her right limb.	Clinician looks at the girl and asks how she is feeling about their consult today.	Clinician has responded to cues of behaviour (protective of arm) and expression (appearing nervous; verbally acknowledging behavioural cues of anxiety). (Validation Level 2)	Patient feels more at ease because she feels that her pain, emotions, and circumstances are acknowledged, understood, and accepted. Helps build trust between patient and clinician.
	Young girl responds cautiously that she is feeling nervous.	Clinician responds saying “It makes sense you’re feeling nervous coming to clinic today. You’ve been coping with pain for a really long time. That’s not easy to do. I applaud your strength and resilience for being here and talking with me today.”	Clinician has responded to the emotion in her disclosure (verbally acknowledging that it is understandable that she is feeling nervous), legitimised her experience with acknowledgment of her past circumstances/history (indicating that the clinician has informed themselves of her history prior to the consult), and praised current behaviours (attending clinic; within the context of validating the long-term goal of seeking help for her pain) through attentive and responsive listening. Through validating the behaviour in addition to the experience (including her history), the clinician is reinforcing helpful pain management behaviours (attending healthcare). (Validation Level 5)
Example 1: INVALIDATION	Young girl (~13 years old) walks into chronic pain clinic. She sits down while appearing nervous and protective of her right limb.	Clinician sits down looking at case notes and asks how they can help her today.	Clinician has missed opportunities to validate her vulnerabilities (nervous, protective of arm; dismissing/ignoring behavioural cues of anxiety), is not informed of her history (asks how they can help; or may be aware of her history but chooses not to acknowledge it) and is not attending to her (looking at notes; missed opportunity for potential targets for validation). (Invalidation Level 2)	Patient feels disbelieved, delegitimised, and anxious about the interaction. Leads to lack of trust of the clinician. May impact future attendance to appointments and adherence to a pain management plan.
	Young girl responds that she has a sore right arm that doesn’t seem to be getting better. It’s been painful for almost 6 months.	Clinicians responds to girl saying “That’s no good. You must not have been doing your physiotherapy exercises. It does seem that you’re able to use it OK”	Clinician uses current complaint to criticise the young girl’s pain management behaviours (clinician makes assumptions of her behaviours without direct evidence). They then suggest that she may be lying or exaggerating about how much pain she is in (dismisses/disbelieves her complaint and verbalises the suggestion that she may be lying). (Invalidation Level 6)
Example 2: VALIDATION	A young boy (~4 years old) and his parent are sitting in a doctor’s waiting room prior to receiving a routine vaccine injection. The young boy is fidgety and unsettled.	The parent turns to the child, rubbing his back, and says “Are you OK? You look a bit anxious”.	Parent has responded to cues of behaviour (fidgety and unsettled; verbally acknowledging cues of anxiety) and attempts to clarify how the child is feeling (addressing child’s emotional state). May also be responding to a previous history of distress during vaccine injections. (Validation Level 3)	The child has had their emotions legitimised, acknowledged, and understood. This helps the child regulate these emotions and build trust in their internal bodily experiences and bodily autonomy. Helps to build attachment and trust between parent and child. Reinforces the child’s ability to engage in helpful coping strategies and future health behaviours, even if challenging.
	Young boy starts to show signs of distress, whimpers, gets off his seat and cries “I don’t want to do it, it hurts too much.”	The parent gets down to the level of the child, touching his hand and says “I know it is scary when you get vaccines. But I know how well you did last time at distracting yourself and getting through it, because you know this is important for your health. I know you can do it again.” Parent helps child to engage in a distraction strategy (e.g., ‘eye-spy’ or other game).	Parent has verbally and physically responded to cues of behaviour (child distress escalating). They get down to the child’s level, provides tactile comforts, validates the experience (through acknowledgement of distress) and the behaviour (acknowledgment of previous behaviour/strategies). Engagement with coping strategy (distraction) encouraged. Through validating the behaviour in addition to the experience, this promotes helpful pain coping behaviours in the moment (distraction) and future (vaccinations improve health). (Validation Level 6)
Example 2: INVALIDATION	A young boy (~4 years old) and his parent are sitting in a doctor’s waiting room prior to receiving a routine vaccine injection. The young boy is a bit fidgety and unsettled.	Parent tells child to sit still and be patient.	Parent has ignored, dismissed, or misinterpreted child’s behavioural cues as signs of impatience or boredom. (Invalidation Level 2)	Child is left feeling that their emotions are wrong and inappropriate. Child does not learn how to regulate their emotions, which leads to greater distress. Reduces trust and attachment between parent and child. This may also have negative consequences for future vaccine injections or doctor’s appointments.
	Young boy starts to show signs of distress, whimpers, gets off his seat and cries “I don’t want to do it, it hurts too much.”	Parent says angrily “Stop being so silly, it doesn’t even hurt. You always make a scene when we go to the doctor’s clinic. Sit down and be quiet.”	Parent responds by attacking the child’s verbal disclosure (tell them to stop being silly; dismissing and trivialising child’s emotional and behavioural response), gaslights the child (telling them it doesn’t hurt and that their experiences/concerns are wrong and not legitimate) and tells them that their behaviour isn’t acceptable. No coping strategies are offered to the child. (Invalidation Level 5 and 6)

Validation levels (from The Validating and Invalidating Behaviour Coding Scale [VIBCS])¹:

1. Active listening and observing

2. Accurate reflection; functionally responsive

3. Articulating the unverbalised; clarifying the experience

4. Acknowledging a person’s medical and personal history

5. Normalising the current experience and praising adaptive behaviours

6. Treating the person as valid and capable of achieving future goals despite current challenges; radical genuineness

7. Reciprocating and matching vulnerable disclosures

Invalidation levels:

1. Inattention

2. Missing opportunities to validate

3. Telling somewhat what their experience should or should not be

4. Using someone’s medical or personal history to make the current situation worse

5. Pathologising age-normative or reasonable experiences

6. Criticising the person as a whole; preventing opportunities to demonstrate success during a challenging situation

7. Assuming a more powerful position in the presence of vulnerability

¹Fruzzetti A. Validating and Invalidating Behaviors Coding Scale. University of Nevada; 2014.

Validation is not reassurance. Reassurance aims to reduce another’s fears or doubts, not to convey understanding and acceptance. Affective reassurance can be validating (e.g., “you can get through this”) or invalidating (e.g., “you’re OK”), and in adult primary care, it is associated with high symptom burden and less improvement over time[25]. In children undergoing painful procedures, affective reassurance exacerbates pain and distress[18] and can signal parental worry[17]. The lack of positive effects of affective reassurance may be because its principles are arguably naïve to both vulnerability and validation. Exploring the role of reassurance through the lens of validation may help to provide a more nuanced understanding of the role of reassurance in pain management.

How validation might protect against future chronic pain

We propose several theoretical mechanisms through which repeated validation throughout childhood may increase resilience against future chronic pain, reduce the transition between acute and chronic pain, and/or help to manage chronic or recurrent pain (Fig. 1). First, validation of children’s pain may reduce arousal and distress, and thereby pain, during painful experiences. This reduction will allow optimal care and, critically, promote the early development of relatively positive pain and injury-related experiences and the development of emotion regulation skills. Second, providing validation that is congruent with a child’s internal experience could buffer against the development of negatively-biased memories of pain, which can lead to pain problems and avoidance of healthcare[21]. While this theory remains to be empirically tested, we suggest that a buffering effect of validation may be mediated by lowering anxiety and distress in the moment, and fostering active problem solving and the development of adaptive emotion regulation, which are powerful drivers of how a child remembers and experiences pain[8]. Third, validating children’s pain experiences may help them better understand their emotional and physical experiences associated with pain/injury. Conversely, invalidation may lead to disconnection and mistrust of their own pain experiences. Finally, validating a child’s pain experience is likely to increase trust between the child and the person providing validation. In a clinical setting, this may facilitate children to have greater trust in the education and advice being provided, leading to greater adherence to advice/recommendations/treatments. Validation promotes confidence that their future pain experiences will be believed and trusted and that they can disclose their pain experiences to others and expect to be believed and supported.

Figure 1. Possible Direct Acyclical Graph for how validation could affect low vulnerability to chronic pain.

Possible mediators through which validation of children’s pain might reduce their vulnerability to the development of future chronic pain (outcome: orange box). Note that minoritised group status may act as a moderator of the effect of validation (blue box), whereby this group may stand to have enhanced benefits due to systemic inequities and biases in pain prevalence, treatment, and care. Green boxes represent alternative mediating pathway for low vulnerability to chronic pain.

The importance of validation in minoritised groups

Validating pain experiences in children from minoritised groups (e.g., racialised identity) presents an opportunity to address inequities in pain prevalence and treatment (Fig. 1). Children from minoritised groups are systematically undertreated for pain[11], face negative attitudes, disbelief, discrimination, and racism[26]. Given the inequities in pain-related care experienced by people from racialised and other minoritised communities[11], increased validation of their pain experiences could be protective if there is acknowledgement and awareness of biases and eradication of damaging labels (e.g., “drug-seekers”), thereby improving therapeutic alliances and opening avenues (and ‘buy-in’) for care. Validation could also target minoritised communities’ experiences of racism/discrimination in healthcare and acknowledge their potential contribution to pain outcomes. How, when, where, and with whom validation can be maximally utilised to understand fundamental pain biases, shift power, and eliminate injustice[16] represents a critical direction for research and aligns with recent calls to action in the pain field[19].

Future directions

Given the urgent need to reduce the burden of chronic pain and the clear intersection with the rising child mental health crisis, empirical research on the role of validation in children’s pain is needed. Research might consider developmental (early childhood to adolescence) and pain (acute, procedural, chronic) spectrums. We need a deeper understanding of how validating behaviours and messages are socialised across society — including parents, caregivers, educators, peers, and the media; how validation might differentially impact children across societies and in minoritised groups; how best to implement and assess validation strategies across home, education, and healthcare settings. Finally, validation ‘after the event’ might be possible during parent-child reminiscing of pain experiences, supporting children’s positive cognitive, emotional, and social development, including empathy and prosocial skills[24].

Conclusions

Validation in the context of children’s pain presents an untapped, modifiable social pathway that could have significant implications for the understanding, treatment, and prevention of chronic pain in the next generation. These implications are likely to be particularly compelling for minoritised groups, who face systemic biases, discrimination, and inequities in their pain care.

Data availability statement:

No original datasets were generated over the course of this research.