RE S E A R C H AR T I C L E
Chronic Pain in the Classroom: Teachers’
Attributions About the Causes of
DEIRDRE E. LOGAN, PhDa
SARAH P. CATANESE, PhDb
RACHAEL M. COAKLEY, PhDc
LISA SCHARFF, PhD
BACKGROUND: School absenteeism and other impairments in school function are sig-
nificant problems among children with chronic pain syndromes; yet, little is known about
how chronic pain is perceived in the school setting. The purpose of this study was to
examine teachers’ attributions about the causes of chronic pain in adolescent students.
METHODS: Classroom teachers (n = 260) read vignettes describing a hypothetical
student with limb pain. They were presented with a list of possible physical and
psychological causes for the pain and asked to identify the causes to which they
attributed the pain. Vignettes varied by the presence or absence of (1) documented
medical evidence for the pain and (2) communication from the medical team.
Teachers also responded to questions assessing their responses to the student in
terms of support for academic accommodations and sympathy for the student.
RESULTS: Teachers tended to endorse a dualistic (ie, either physical or psychological)
model for pain rather than a biopsychosocial model. Documented medical evidence
supporting the pain was the most influential factor affecting teachers’ attributions
about chronic pain. Teachers who attributed the pain to physical causes—either in
isolation or in combination with psychological causes—responded more positively
toward the student.
CONCLUSIONS: Many teachers lack a biopsychosocial framework through which to
understand chronic pain syndromes in students. How chronic pain is described to
school personnel may affect how teachers understand the pain and respond to it.
Keywords: adolescent; attributions; chronic pain; pain; teachers.
Citation: Logan DE, Catanese SP, Coakley RM, Scharff L. Chronic pain in the
classroom: teachers’ attributions about the causes of chronic pain. J Sch Health.
2007; 77: 248-256.
Staff psychologist at Children’s Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical School,
([email protected]), Pain Treatment Service, Children’s Hospital Boston, 333 Longwood Ave., Boston, MA 02115.
Instructor of Psychiatry and Behavioral Sciences, ([email protected]), Northwestern University, Feinberg School of Medicine, 150 E Huron St. Suite
1100, Chicago, IL 60611.
Staff psychologist, Children’s Hospital Boston, ([email protected]), Department of Psychiatry and Pain Treatment Service, Children’s Hospital
Boston, 553 Longwood Ave., Boston, MA 02115.
Associate Director, Pain Treatment Service, Children’s Hospital Boston and Assistant Professor of Psychology, Department of Psychiatry, Harvard University Medical
School, ([email protected]), Pain Treatment Service, Children’s Hospital Boston, 333 Longwood Ave., Boston, MA 02115.
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, ([email protected]), Pain Treatment Service, Children’s Hospital Boston, 333 Longwood Ave., Boston, MA 02115.
The authors express sincere thanks to Kate Nugent, Neil 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.
*Indicates CHES continuing education hours are available. Also available at: www.ashaweb.org/continuing_education.html
248 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association
hronic and recurrent pain is a common experi-
ence among school-age children. Rates of pain
problems lasting 3 months or longer range from
15% to over 30% among school-age youth in epide-
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
incorporating biological, psychological, and
social factors that jointly shape the pain experience.
However, individuals experiencing chronic pain syn-
dromes and laypersons who encounter such individ-
uals vary in their understanding and acceptance of
this multifactorial model of pain.
According to attribution theory, one’s explana-
tions for causes or events predict behavior and emo-
tions in response to stressful events.
of illness to physical or psychological causes appears
to have particularly marked ramifications for percep-
tions of symptomatic individuals and expectations
for their role fulfillment and standards of perfor-
Previous research indicates that when ill-
ness is attributed to psychological causes, the ill
individual evokes less pity, less liking, more anger,
and fewer resources than when the illness is attrib-
uted to physiological causes.
Chronic pain com-
plaints have been judged ‘‘more legitimate’’ when
attributed to physical versus psychological causes.
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;
when such evi-
dence is absent, symptoms are more likely to be dis-
credited and attributed to emotional distress or
attempts to elicit secondary gain.
from healthcare professionals may also serve to vali-
date 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 fac-
tors can influence individuals’ pain attributions. A
few studies have examined attributions about child-
ren’s pain. Claar and Walker
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 diagno-
sis 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.
presence of organic disease in children with abdomi-
nal pain predicted peers’ ratings of relief from
responsibility, with children indicating that a hypo-
thetical peer should be relieved from responsibility
more often when organic disease was present.
Research into the influence of others’ attributions
for pain has examined parents’ and peers’ under-
standing 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 adoles-
cents. Youth with chronic pain disorders experience
numerous difficulties in school, including frequent
absences, decreased academic performance, comprom-
ised social functioning, and impaired ability to cope
with the demands of the classroom.
dressed, 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.
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).
Despite clear evidence that chronic pain adversely
affects school function,
little is known about the
mechanisms through which this occurs. How teach-
ers 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,
teachers’ perceptions about
causes of students’ pain are potentially important in
determining whether their responses to pain encour-
age or discourage adaptive functioning in school. If
children or parents feel that teachers fail to compre-
hend the nature of their pain, they may be less will-
ing 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 biopsychoso-
cial model of chronic pain is unknown.
The aim of this study was to explore teachers’
attributions about chronic pain in students. Specifi-
cally, 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 biopsycho-
social model of pain, (3) the effects of documented
medical evidence supporting the pain complaints and
Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 249
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:
d Teachers will be more likely to endorse a dualis-
tic model in which they attribute the pain to either
physical or psychological causes than a biopsychoso-
d Teachers will be more likely to endorse physi-
cal 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
d Teachers’ pain attributions will influence re-
sponses 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
This study was part of a larger project investigating
teachers’ responses to chronic pain.
Data were col-
lected 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
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 pre-
sented the project at school faculty meetings or dis-
tributed 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 class-
room supplies for their participation.
Teachers were presented with a written hypothet-
ical scenario describing an adolescent girl who devel-
ops 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 com-
munication from the medical team, were relevant to
the hypotheses of this study. The third factor, coop-
erative or confrontational parent-teacher interac-
tions, was not hypothesized to relate to teachers’
pain attributions and is not discussed here. (Note:
data analyses confirm that parent-teacher interac-
tions did not relate to teachers’ pain attributions.)
The full factorial approach resulted in 8 vignette ver-
sions (Figure 1).
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 present-
ing to tertiary care pediatric pain clinics. The student
is described as female, a good student academically,
involved in athletics, with some possible mild anxi-
ety traits. The injury involves her hand and occurs
in a situation that may or may not contain psycho-
social 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,
allowing for varied presence or absence of docu-
mented 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
Demographic Information. Teachers completed a
demographic form reporting gender, years’ teaching
250 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association
experience, grade level currently taught, and esti-
mated number of students with chronic pain en-
countered in their careers.
Manipulation Check. To determine whether the
manipulated variables had the intended effects, par-
ticipants 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, partici-
pants who responded incorrectly were deleted from
the relevant data analyses.
Causal Attributions for Pain. Teachers reported
their beliefs about whether various physical and psy-
chological factors were involved as causes of the
adolescent’s pain on an adapted version of the
Inventory of Causes for Abdominal Pain (ICAP).
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 profes-
sionals with expertise in pediatric chronic pain and
intended to reflect factors linked with pediatric pain
in the research literature.
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 ordi-
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
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. Par-
ticipants 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
A factor analysis of the 10
items suggests 3 factors that jointly account for
Figure 1. Text of Sample Vignette Version, With Manipulated Portions Italicized
Version: Medical evidence present; Communication from medical team present
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 in-
terferes 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 re-
commendations 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).
Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association d 251
60.9% of the variance. The 5 psychological attribu-
tions 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, inflamma-
tion’’) representing a separate third factor. The phys-
ical items did not hang together as a scale
(Cronbach’s alpha = .53); rather, respondents mak-
ing physical attributions for the pain tended to iden-
tify a single physical cause.
Across the sample, 58.5% of teachers endorsed at
least 1 physical attribution as a cause for the stu-
dent’s pain, and 67.2% endorsed at least 1 psycho-
logical attribution. Only 38.1% endorsed both
physical and psychological attributions for the stu-
dent’s pain. In other words, almost two thirds of
respondents held a dualistic view of the pain rather
than endorsing the biopsychosocial model. The like-
lihood of endorsing a biopsychosocial view of pain
did not differ by school. The likelihood of making
physical attributions for the pain did differ signifi-
cantly across schools (v2 = 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 associa-
tions between the dichotomized pain attribution var-
iables 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 stu-
dents 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 partic-
ipants 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 (v2 = 55.7, p , .001). Demo-
graphic 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 manipula-
tion checks, n = 145.
Logistic Regression Analyses. Multivariate logistic
regression analyses examined the effects of medical evi-
dence for the pain and communication from the med-
ical team on pain attributions. To control for school
Table 2. Frequencies of Teachers’ Endorsements of Probable
Causes of Student’s Pain (n = 260)
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 1. Descriptive Data on Study Respondents by School*
School Type of School
A Combined (7th-12th grade) 94/111 19.2 (12.6) 57.0 63
B High school 106/294 14.2 (10.5) 69.5 57
C Middle school 12/53 15.0 (9.6) 91.7 74
D High school 19/82 17.0 (12.4) 61.1 56
E Middle school 16/40 11.4 (9.5) 100 75
F High school 13/63 12.7 (11.2) 84.6 61
*Table is modified from Table 1 in Logan et al.
This column reflects the number of teachers who returned questionnaires out of the total number of classroom teachers on faculty.
252 d Journal of School Health d May 2007, Vol. 77, No. 5 d ª 2007, American School Health Association
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 indepen-
dent variables: presence of medical evidence and pres-
ence of communication.
Physical Attributions for the Pain. As expected,
presence of medical evidence significantly predicted
endorsement of physical attributions for pain (b =
1.86, SE = .43, Wald statistic = 19.2, p , .001). Con-
trary 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 psychologi-
cal causes for the pain. The presence of medical evi-
dence significantly predicted endorsement of
a biopsychosocial model (b = 2.07, SE = .49, Wald
statistic = 17.6, p , .001). The effect of communica-
tion was not significant.
No relations were hypothesized between the
manipulations and psychological attributions for
pain. Regression analyses showed no significant
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 instru-
mental support (extent of academic accommodations
supported) and emotional support (level of sympathy
for the student). The majority (57.8%) of teachers sup-
ported 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 (b = .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 (b = .18, p , .01). Similar
results obtained in comparing teachers who
endorsed a biopsychosocial model of pain to those
who held a dualistic view; support …
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