discussion #13 disease


Chronic Pain in the Classroom: Teachers’
Attributions About the Causes of
Chronic Pain*






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-

miologic studies.

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.

The attribution

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

explored mothers’

attributions for their children’s recurrent abdominal

pain and found that about half of mothers in their

sample endorsed a biopsychosocial model (ie, they

identified both psychological and physical factors as

causes of their child’s pain). This was true regardless

of whether their child had a specific medical 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.

Left unad-

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-

cial model.
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

one’s career.

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-

nal scale.

2. Sympathy: This item read, ‘‘Please rate the level

of sympathy you currently feel for Samantha.’’

A 5-point Likert-type scale was used with

responses ranging from ‘‘no sympathy’’ to ‘‘very

strong sympathy.’’


Overall Findings
Three participants were excluded from analyses

due to missing data, resulting in a final sample of 260.

Across schools, overall response rate was 40.9% of

total teaching staff, with rates ranging from 20.6% to

84.7% by school. The sample was 68.1% female. 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

authors’ approach.

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)


Endorsing as
Probable Cause,

n (%)

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

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

Table 1. Descriptive Data on Study Respondents by School*

School Type of School
Rate of


Mean (SD)

Respondents (%)

Females on
Faculty (%)

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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