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. 2014 Oct 15;40(9):926–933. doi: 10.1093/jpepsy/jsu091

“Pain Can’t Stop Me”: Examining Pain Self-Efficacy and Acceptance as Resilience Processes Among Youth With Chronic Headache

Sreeja Kalapurakkel 1,2, Elizabeth A Carpino 2, Alyssa Lebel, Laura E Simons 2,3,4,✉
PMCID: PMC4592326  PMID: 25324532

Abstract

Objective To examine pain self-efficacy and pain acceptance in relation to functioning in pediatric patients with chronic headache. Methods Participants were 209 youth aged 8–17 years who presented for a multidisciplinary pediatric headache clinic evaluation. They completed measures of pain self-efficacy and pain acceptance and a standard battery of clinical measures including indicators of emotional functioning. Results Pain self-efficacy and acceptance were associated with less disability, better school functioning, and fewer depressive symptoms. While taking into account several demographic and pain-related variables, pain self-efficacy had a greater association with less functional disability, while pain acceptance had a greater association with less depressive symptoms and better school functioning. Conclusions These findings indicate that both resilience processes can serve to positively interact with functioning and symptoms of depression. Ultimately, this study suggests that higher levels of pain self-efficacy and pain acceptance in an individual experiencing pain are associated with more positive outcomes.

Keywords: chronic and recurrent pain, headache, psychological functioning, resilience

Introduction

Research in chronic pain has traditionally been focused on factors associated with poor outcomes such as anxiety (Asmundson & Katz, 2009), depression (Romano & Turner, 1985), pain catastrophizing (Lynch-Jordan, Kashikar-Zuck, Szabova, & Goldschneider, 2013), and fear (Crombez, Eccleston, Van Damme, Vlaeyen, & Karoly, 2012)—in other words, factors that make one vulnerable. A more complete model for understanding pain-related outcomes and helping children who are struggling with pain to get better can be made by identifying and targeting resiliency processes in addition to the vulnerability factors. Research examining resiliency factors in adults is quickly accumulating (Sweis, Veverka, Dhillon, Urban, & Lucas, 2013), with recent attention given to children with chronic pain (Weiss et al., 2013).

While it may be easy to identify a resilient child, it is difficult to discern the factors that make him or her resilient. Prior research among adults with chronic pain has led to the development of a multilevel analysis of resilience factors that distinguish the notion between resilience as a process and as a trait (Sturgeon & Zautra, 2010). Within this model, resilience factors can be categorized into stable resilience resources—steadfast character traits of the individual (e.g., optimism, a greater sense of purpose in life)—and fluid resilience factors, or the dynamic psychological processes that are subject to circumstance and fluctuate according to the severity of the pain and the time elapsed since pain acquisition (e.g., daily positive affect, active coping strategies; Sturgeon & Zautra, 2010). Because of the scant literature on resilience theory as it relates to pediatric chronic pain, we have adapted ideas of the theory as it relates to adult chronic pain in our study.

Two processes that have garnered some attention in the context of children with chronic pain are pain self-efficacy and pain acceptance. Pain self-efficacy refers to one’s confidence regarding one’s ability to function effectively while in pain (Nicholas, 2007). Pain self-efficacy has been linked to positive pain-related outcomes in a small sample of children with chronic pain (Bursch, Tsao, Meldrum, & Zeltzer, 2006) and has also been shown to partially mediate the relationship between pain-related fear and outcomes of disability, school functioning, and depressive symptoms (Carpino, Segal, Logan, Lebel, & Simons, 2014). It has been characterized as a protective psychological resource associated with positive pain-related outcomes (King et al., 1998) and better functioning in adults with chronic pain (Miles, Pincus, Carnes, Taylor, & Underwood, 2011; Wright, Zautra, & Going, 2008), thereby suggesting its potential as a resilience process.

Pain acceptance involves one’s willingness to acknowledge pain as part of the life experience without attempts to control or avoid it (McCracken, Vowles, & Eccleston, 2004). Initial studies link pain acceptance to better functioning among adolescents with chronic pain (McCracken, Gauntlett-Gilbert, & Eccleston, 2010; Wallace, Harbeck-Weber, Whiteside, & Harrison, 2011). Pain acceptance has been associated with positive pain-related outcomes (McCracken, Spertus, Janeck, Sinclair, & Wetzel, 1999; Viane et al., 2003) and better physical functioning in adults with chronic pain (Kratz, Davis, & Zautra, 2007; McCracken et al., 1999; Viane et al., 2003). We propose that both pain self-efficacy and pain acceptance are potentially important constructs that serve as fluid resilience factors, or dynamic protective processes (Sturgeon & Zautra, 2010).

This study seeks to determine the association of pain self-efficacy and pain acceptance with the physical, emotional, and school functioning of children and adolescents with chronic headache. Headache is the most common complaint in pediatrics (Perquin et al., 2000). The results of a recent review indicate that 60% of children and adolescents worldwide experience headaches of varying frequency and duration (Abu-Arafeh, Razak, Sivaraman, & Graham, 2010). The majority of pediatric headache patients continue to exhibit headaches up to 40 years after their initial presentation (Bille, 1997). Thus, headaches pose a great problem for youth in their daily activities and may affect their performance in school. Understanding the role of pain-related self-efficacy and pain acceptance among youth suffering from chronic headache is essential for both improving their clinical care and promoting strong, lasting, health-related behavioral outcomes.

The goal of the present study was to examine pain-related self-efficacy and pain acceptance in relation to pain-related outcomes, specifically functional disability, school functioning, and emotional functioning (anxiety, depression), after controlling for average pain intensity and other potentially influential demographic and medical factors (e.g., age, gender). We hypothesized that both pain-related self-efficacy and pain acceptance would significantly predict each of the outcome measures—functional disability, school functioning, depressive symptoms, and anxiety symptoms—beyond the influence of pain intensity and significant demographic and medical factors.

Materials and Methods

Participants and Procedure

Of the 293 children and adolescents aged 8–17 years consecutively seen for a multidisciplinary pediatric headache program evaluation from September 2011 to June 2013, 54 were not approached due to unavailability of research staff or research recruitment conflicting with a busy clinic schedule. Of the 239 families approached, 209 agreed to participate in this institutional review board (IRB)-approved study (88% consent rate), from which the data of 206 patients were sufficient for analysis. Patients received $10 gift checks for their participation.

Some measures were completed for clinical purposes as part of an initial multidisciplinary evaluation, while others were completed as part of this IRB-approved research study on the day of their clinic visit (preliminary results from this larger study were recently published by Carpino et al. (2014). Clinic measures (e.g., functional disability inventory) were mailed to families before the child’s Pediatric Headache Program evaluation. Parents and children were asked to complete measures separately and bring them to the clinic evaluation. During the clinic visit, children were evaluated by a neurologist and psychologist. During the visit, families were approached by the research coordinator in the headache clinic to participate in the current study and completed surveys examining pain self-efficacy and acceptance at the time of their visit in addition to granting access to measures completed as part of their clinic evaluation. Participants received a $10 gift check for completing measures.

Measures

Demographic and Pain Diagnosis Information Was Collected From Each Patient Medical Record

Pain

During the pain evaluation, children were asked to provide their average pain rating on a standard 11-point numeric rating scale from 0 (no pain) to 10 (most pain possible; von Baeyer et al., 2009) to the evaluating psychologist.

Pain Acceptance

The Chronic Pain Acceptance Questionnaire (CPAQ-A) (McCracken et al., 2010) is a 20-item measure that assesses two chronic pain-related dimensions on a 5-point Likert-like scale: (1) engagement in activity and (2) pain willingness. Higher scores on the measure indicate greater pain-related acceptance. The CPAQ-A has demonstrated adequate reliability and validity among individuals with chronic pain, with internal consistency estimates of 0.88 for the current sample.

Pain Self-Efficacy

The Pain Self-efficacy Scale is a 7-item measure assessing child self-efficacy for functioning normally when in pain (PSES-C, PSES-P; Bursch et al., 2006). An example item is “How sure are you that you can take care of yourself when you have pain?” Items are scored on a 5-point Likert scale with lower scores indicating higher self-efficacy. Initial validation provided support for the measure’s validity and reliability, and internal consistency in this sample was strong (α = .90).

Functional Disability

The Functional Disability Inventory (FDI; Walker & Greene, 1991) is a scale that assesses difficulty in physical and psychosocial functioning due to physical health. The instrument consists of 15 items concerning perceptions of activity limitations during the past 2 weeks; total scores are computed by summing the items. Higher scores indicate greater disability. The FDI has good reliability and validity in pediatric chronic pain patients (Kashikar-Zuck et al., 2013), and internal consistency was strong in this sample (α = .91).

School Functioning

Parents reported on school functioning with the school subscale of the Pediatric Quality of Life Inventory (PEDSQL; Varni, Seid, & Rode, 1999). The subscale consists of five items rated on a 5-point scale and is converted into a scale ranging from 0 to 100, with higher numbers indicating better functioning. This measure has had strong reliability and validity in previous studies in patients with chronic pain (Kashikar-Zuck et al., 2013; Logan, Simons, & Carpino, 2012), and internal consistency is this sample was strong (α = .86).

Depressive Symptoms

The Children’s Depression Inventory (CDI) (Gray, Day, Leech, & Richardson, 2005; Kovacs, 1985) is a well-validated 27-item self-report measure of children’s depressive symptoms that has been widely used in pediatric pain studies and is a recommended outcome measure for pediatric chronic pain with strong reliability and validity (Logan et al., 2013). Items are rated on a 3-point scale from 0 to 2 and were summed to obtain a total score that was converted to a T-score. Higher scores indicated higher levels of depressive symptoms. Internal consistency is this sample was strong (α = .90).

Anxiety Symptoms

The Multidimensional Anxiety Scale for Children (March, Parker, Sullivan, Stallings, & Conners, 1997; March & Sullivan, 1999) is a 39-item self-report questionnaire that assesses emotional, cognitive, physical, and behavioral symptoms of anxiety. Items are rated on a 4-point scale from 0 to 3 and were summed to obtain a total score that was converted to a T-score. Higher scores indicate higher levels of anxiety. This measure has strong reliability and validity (March et al., 1997; March & Sullivan, 1999). This measure has been used previously in studies with pediatric patients with chronic pain (Fuss, Page, & Katz, 2011), and internal consistency is this sample was strong (α = .92).

Statistical Analyses

Data were analyzed with parametric tests using SPSS 21.0 for Windows. Descriptive statistics including the means, standard deviations, and ranges were conducted to examine underlying assumptions of normality for all variables of interest. Pearson product moment correlations were used to examine relationships between the proposed outcomes, pain acceptance, and pain self-efficacy.

To examine pain acceptance or pain self-efficacy in relation to the outcomes of functional disability, school functioning, and psychological functioning in children with chronic pain, a series of hierarchical multiple regression analyses was conducted. Total scores from the FDI, PedsQL-School, and CDI constituted the dependent variable for each analysis. In Step 1 of each regression, demographic and medical factors that were significantly associated with the outcomes at the bivariate level were entered. In Step 2, the typical pain rating score was entered. In Steps 3 and 4, the two hypothesized resilience processes, pain acceptance and pain self-efficacy, were entered in each equation to examine the incremental variance accounted for of each on functional outcomes. The standardized regression coefficients were used to compare the relative associations of pain self-efficacy and pain acceptance with each outcome.

Results

Participants

The average age of the sample was 13.6 years (SD: 2.6) and predominantly female (74%). By ethnicity, the majority (89.7%) of children were White, followed by Hispanic (3.4%), Black (3.0%), Asian (2.4%), and multiracial (1.5%). Seventy-nine percent lived with parents who are married; 5.8% with parents who never married; 12.1% single, 1.0% divorced, 1.9% widowed. The average pain duration was 33 months, ranging from 1 to 173 months. The average participant was of upper middle-class socioeconomic status (Hollingshead Index: 46.3; SD: 13.8). Participants presented with the following types of headaches: migraine (25%), tension headache (23%), persistent daily headache (12%), postconcussive headache (8%), comorbid headache (26%), and other (6%).

Preliminary Correlation Analyses

In examining potentially influential demographic and medical factors on outcomes, younger age of the child was significantly associated with lower depressive symptoms (r = .23, p < .01) and higher school functioning (r = −.24, p < .01). Functional disability and age were not significantly related. With regard to gender, females endorsed significantly higher depressive symptoms (M = 51.1, SD = 12.7) compared with males (M = 45.2, SD = 7.69), F(1, 200) = 10.1, p < .01. School functioning and disability did not differ across gender. No significant associations emerged for socioeconomic status or duration of pain, and no differences were noted across headache diagnosis groups across all outcomes of interest.

Average pain was modestly related to functional disability, depressive symptoms, and worse school functioning outcomes, but was not associated with anxiety symptoms. The associations between pain intensity and pain-related self-efficacy and pain acceptance were similarly modest in magnitude. Pain acceptance and pain-related self-efficacy did not differ by gender and did not vary by patient age. Pain acceptance and pain self-efficacy were significantly correlated with one another. As anticipated, pain self-efficacy and pain acceptance were significantly associated with all child outcomes (see Table I).

Table I.

Intercorrelations, Means, and Standard Deviations for Study Variables

Variable 1 2 3 4 5 6 7 8 N M SD
1. Age – .08 .07 .02 .11 −.24** .23** .03 206 13.6 2.62
2. Pain intensity – −.15* −.23** .26** −.15* .17* .07 202 5.92 1.67
3. Pain self-efficacy – .71** −.58** .40** −.39** −.39** 204 22.3 6.38
4. Pain acceptance – −.54** .45** −.47** −.47** 206 45.7 12.4
5. Functional disability – −.41** .40** .29** 201 17.7 11.1
6. School functioning – −.42** −.19** 196 52.1 22.7
7. Depressive symptoms – .47** 202 49.5 11.9
8. Anxiety symptoms – 203 49.3 12.5
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Note. *p < .05, **p < .01; Correlations are two-tailed.

Regression Analyses

Separate regression analyses were run with the pain-related outcomes of functional disability, school functioning, and depressive symptoms. Given the lack of a bivariate relation between pain and anxiety, we did not examine anxiety in the regression analyses. Given the strong correlation between pain acceptance and pain self-efficacy, we examined multicollinearity diagnostics for these two predictors, and they were acceptable (tolerance > .95). Given that gender and age were significantly associated with one or more functional outcomes, they were included in the first step of each regression equation. Average pain intensity was entered in the second step, followed by the addition of pain-related self-efficacy and pain acceptance variables in the third and fourth steps (see Table II for regression results for each outcome).

Table II.

Hierarchical Regressions for Disability, School Functioning, and Depressive Symptoms

Variables β T R2 change
a. Dependent variable: functional disability
1. Age .09 1.24 .02
    Gender .10 1.31
2. Age .07 0.94 .06**
    Gender .11 1.55
    Pain intensity .25** 3.53
3. Age .05 0.78 .29**
    Gender .10 1.68
    Pain intensity .17** 2.88
    Pain self-efficacy −.55** −9.42
4. Age .06 1.05 .02**
    Gender .10 1.68
    Pain intensity .14* 2.46
    Pain self-efficacy −.39** −4.83
    Pain acceptance −.22* −2.63
b. Dependent variable: school functioning
1. Age −.24** −3.28 .06**
    Gender −.01 −0.19
2. Age −.23** −3.19 .02
    Gender −.02 −0.25
    Pain intensity −.13 −1.77
3. Age −.23** −3.39 .14**
    Gender −.01 −0.14
    Pain intensity −.08 −1.13
    Pain self-efficacy .38** 5.79
4. Age −.24** −3.73 .06**
    Gender −.01 −0.17
    Pain intensity −.03 −0.53
    Pain self-efficacy .16 1.79
    Pain acceptance .33** 3.75
c. Dependent variable: depressive symptoms
1. Age .21** 3.01 .08**
    Gender .16 2.33
2. Age .20* 2.81 .02
    Gender .17* 2.41
    Pain intensity .14 1.98
3. Age .19** 2.88 .14**
    Gender .16* 2.48
    Pain intensity .08 1.26
    Pain self-efficacy −.38** −6.01
4. Age .20** 3.30 .06**
    Gender .16* 2.56
    Pain intensity .04 0.64
    Pain self-efficacy −.13 −1.51
    Pain acceptance −.37** −4.27
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Note. *p < .05, **p < .01.

Functional Disability

In the first step, neither age nor gender was significantly associated with disability. In the second step, pain was significant and accounted for 6% of the variance in disability level. When pain self-efficacy was incorporated into the model, an additional 29% of one’s disability could be explained. When pain acceptance was added in the last step, variance accounted for increased modestly, but significantly (2%). In the final model, pain, pain self-efficacy, and pain acceptance were all significant predictors of functional disability, with pain self-efficacy (β = −.39, p < .01) a stronger predictor of disability levels compared with pain acceptance (β = −.22, p < .01).

School Functioning

Although average pain intensity was modestly associated with school functioning at the bivariate level, it was no longer significant when age and gender were accounted for in the model. Higher pain self-efficacy contributed an additional 14% of variance in better school functioning when added to the model, with the variance increasing an additional 6% when pain acceptance was included. In the final model, only younger child age and pain acceptance remained significant, with pain acceptance (β = .33, p < .01) a stronger predictor of better school functioning levels compared with pain self-efficacy (β = .16, ns).

Depressive Symptoms

In the first step, both younger age and male gender were associated with lower depressive symptoms, accounting for 8% of the variance. Pain was a modest predictor of depressive levels, accounting for 2% of the variance. Pain self-efficacy contributed an additional 14% of variance in depressive symptoms when added to the model, with the variance increasing an additional 7% when pain acceptance was included. In the final model, younger age, male gender, and higher pain acceptance remained significant, with pain acceptance (β = −.37, p < .01) a stronger predictor of lower depressive levels compared with pain self-efficacy (β = −.13, ns).

Discussion

Psychological processes are well known to influence the development and maintenance of chronic pain, including among youth experiencing chronic headache (Sturgeon & Zautra, 2010). Understanding resilience processes in children with chronic headache is useful for validating the effect of treatment on a child’s ability to adapt to pain. Pain-related self-efficacy and pain acceptance are two processes found in resilience literature (Stewart & Yuen, 2011) that may be positively linked with pain-related outcomes (Stewart & Yuen, 2011). The results of this study support this assertion, finding that both factors are associated with lower levels of functional disability and depressive symptoms, as well as better school functioning in pediatric headache patients. This suggests that in the presence of a stressor such as chronic headache, one’s pain-related outcomes can be at least partially explained by certain resilience processes. Treatments that enhance these at the time of the stressor may be potentially related to recovery and sustained well-being (Sturgeon & Zautra, 2010). Interestingly, we found subtle differences in the interplay of pain acceptance and pain self-efficacy on child outcomes, which we describe in the following sections.

Of the four outcomes examined in this study, functional disability was seen to have both the strongest inverse bivariate relationship with pain acceptance and pain self-efficacy. This suggests that these specific resilience processes may play a large role in attenuating functional limitations, accounting for a third of the variance in disability, although it may also be the case that fewer limitations contribute to higher levels of acceptance and self-efficacy. Among the two resilience mechanisms, self-efficacy emerged as the stronger predictor. This is consistent with prior literature that has shown a strong relationship between self-efficacy and physical functioning in other adolescent and adult patient samples (Johnston-Brooks, Lewis, & Garg, 2002; Sullivan, LaCroix, Russo, & Katon, 1998) and that self-efficacy has been shown to mediate the relationship between pain and physical functioning in adults (Wright et al., 2008). This finding supports treatment interventions that shift the focus of treatment from eliminating the stressor (pain), which appears to only modestly be associated with disability levels, to building a patient’s confidence in doing specific activities, as is done through exposure-based treatment for pain (Crombez et al., 2012). With regards to the role of pain acceptance and self-efficacy on a child’s ability to function in school in spite of pain, this is the first study to address both resilience processes as predictors of school functioning in the context of chronic pain. Together both factors accounted for 20% of the variance in school outcomes. Of the two resilience processes, pain acceptance was shown to have the greater positive association with school functioning. This may be due to the fact that the school functioning metric primarily focuses on tasks of memory, attention, and learning, which are considered as more thought-oriented processes rather than action-oriented processes; thus, those who are willing to have pain be a part of their experience are likely more able to perform the cognitively demanding tasks required of them in the school environment. These results suggest that a more mindfulness-based acceptance approach (Wicksell et al., 2013), though still largely abstract, may benefit the ability of students with pain to learn in school.

In line with the results for school functioning, pain acceptance emerged as a stronger predictor of depressive symptoms. Given that negative cognitive schemas often underlie depressive symptoms (Disner, Beevers, Haigh, & Beck, 2011) and the thrust of acceptance centers on being “okay” with what shows up (i.e., pain), it makes sense that pain acceptance would have a greater assocation with depressive symptoms. Further mindfulness-based cognitive therapy for depression has wide use and popularity among adult patients (Munshi, Eisendrath, & Delucchi, 2013) and may be of promise among youth with pain (Petter, Chambers, McGrath, & Dick, 2013), tying these findings to empiricaly supported treatments for this particular outcome. It is important to note that depressive symptoms are not merely an outcome in the case of chronic headache; prior research also classifies it as a factor of vulnerability (Sturgeon & Zautra, 2010). This indicates the complex interplay between vulnerability and resilience factors in chronic pain, as shown by previous literature that demonstrates that levels of self-efficacy affect levels of depression (Robinson-Smith, Johnston, & Allen, 2000), while other studies have examined depression as a moderator in the relationship between pain and functional outcomes (Bot, Bossen, Mudgal, Jupiter, & Ring, 2013; Phyomaung et al., 2014).

The correlation between pain intensity and anxiety proved to be insignificant, which is consistent with the often weak bivariate relationship between these two variables (Cohen, Vowles, & Eccleston, 2010; Simons, Sieberg, & Claar, 2012). However, the significant inverse correlation between pain acceptance and anxiety and between pain self-efficacy and anxiety suggests that these are two opposing resilience/vulnerability psychological processes (Sturgeon & Zautra, 2010).

These results must be considered in light of their limitations. First, many of the measures in our study are framed to examine poor outcomes, disability, and depressive symptoms, rather than ones that capture the positive outcomes associated with resilience, such as school functioning. Future studies ought to center the methodology to capture positive adaptive outcomes from the start. Such measures would potentially include health status and health-related quality of life (see the Rand 36-Item Health Survey or SF-36; Ware & Sherbourne, 1992) and benefit finding (see the Benefit Finding Scale for Children; Phipps, Long, & Ogden, 2007). Additionally, although we do not anticipate that the relations found in this study will differ in other pain populations, the results represent patients with persistent headache pain. The cross-sectional nature of these data limits the interpretations we can make about the impact of these resilience processes on outcomes over time. Longitudinal studies would provide more detailed information on how pain self-efficacy and pain acceptance impact pain-related functioning in the short and long term. Furthermore, a longitudinal study would enable us to examine depression not only as an outcome, as it was defined in this study, but also as a potential vulnerability factor, as it can be for those who are predisposed to depressive symptoms even before onset of pain. Both clinical psychological evaluations and self-report measurement methods should be utilized in these subsequent studies so that the experiences of both the individual and the clinician’s perspective may be used to enhance treatment recommendations.

In the presence of the stressor of pain, the ability to identify and target a child’s level of pain self-efficacy and pain acceptance provides a clinician with a tangible starting point to foster positive attitudes, beliefs, and behaviors. This may allow health care providers to tailor their treatment therapies to increase overall levels of pain self-efficacy and pain acceptance, rather than simply focusing on eliminating psychological vulnerability. These results also provide evidence for the ability to reevaluate the efficacy of various prescribed interventions based on the treatment’s ability to strengthen resilience processes in addition to reducing vulnerability factors.

Understanding the role of resilience processes in children with chronic headache seems crucial to prescribing the best possible treatment for children with chronic headache. Pain-related self-efficacy and pain acceptance are two processes that appear to be associated with better pain-related outcomes of less functional disability, better school functioning, and less depressive symptoms.

Funding

This investigation was supported by a K23 Career Development Award from the Eunice Kennedy Shriver National Institute of Child Health and Development HD067202 (L.S.), the Harvard College Research Program, the Sara Page Mayo Endowment for Pediatric Pain Research and Treatment, and the Department of Anesthesiology, Perioperative and Pain Medicine at Boston Children’s Hospital.

Conflicts of interest: None declared.

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