Coping with Pain: Polish Versions of the Pain Coping Questionnaire for Both Children and Parents

Abstract

Aim: This article presents the cultural adaptation and evaluation of the psychometric properties of the Polish versions of the Pain Coping Questionnaire for both children and parents. Materials & methods: The study involved children aged 12–17 years (n = 220), who experienced trauma-related pain, and their parents (n = 220). Results: In the questionnaire for children and parents, the Kaisera-Mayera-Olkina (KMO) measure of sample adequacy was 0.457 and 0.455, whereas Bartlett’s test of sphericity: Chi-square = 1523.93, p < 0.001 and Chi-square = 1325.31, p < 0.001, returned a statistically significant result. Cronbach’s alpha for the factors identified in both groups was between 0.833 and 0.904. Conclusion: The linguistic adaptation has shown that the Polish version of the Pain Coping Questionnaire meets the psychometric criteria for reliability and accuracy of the tool.

Lay abstract

This study aimed to find out whether the Pain Coping Questionnaire (PCQ) in Poland, which was translated from an English version of the same questionnaire, was useful for the study of coping with pain by children and their parents. It is important that translated questionnaires be tested to make sure they are still effective in the new language. The PCQ was completed by children experiencing pain, and by their parents, and the results were evaluated. The results show that the PCQ is a questionnaire that can be effectively used in nursing care. The study also shows that children cope with pain most poorly when they rely on their emotions; the same is true also for parents. This research will make possible the use of an appropriate style of coping with pain for children and adolescents and will help in planning and implementing nursing care before the pain can become worse.

Keywords::

• children
• pain coping
• Pain Coping Questionnaire
• parents
• validation

Background

The enormous progress made in medicine in recent years includes pediatric problems, associated with (among others) the pathophysiology of pain, treatment of pain and alleviation of pain and anxiety in hospitalized children [1,2]. For the purposes of this study, the definition of pain of the International Association for the Study of Pain (IASP) has been used: ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’ [3]. This article uses the Lazarus and Folkman theory, which defines coping as ‘continually changing cognitive and behavioral efforts to manage specific external and internal demands that are appraised as taxing or exceeding the resources of the person’ [4]. Pain manifests in children in the same manner as in adults. Children, however, require special attention and evaluation of pain because communicating with the child often proves difficult and the medical procedure or injury itself causes major fear and anxiety [5]. Since the involvement of parents and guardians in the medical treatment of the child has a positive impact on the child’s mental state, the American Academy of Pediatrics and the American Pain Society recommend that the care provider should ensure a comfortable environment for the child, and that parents should actively participate in the child’s care and have access to information about medical actions being performed or planned [6]. It is important to understand the parents’ perception of their children’s complaints of pain. Parental responses play a key role in the development and maintenance of pain behavior in children [7].

Pain relief techniques and behavioral interventions can be used for mild pain, and also as a complement to pharmacological treatment for pain [8]. Studies show that these strategies have proven effective in reducing pain and anxiety associated with, for example, injections in children and adolescents [6,9]. In other studies, it has also been observed that the use of distractions by parents during painful medical procedures caused children to cry less, and anxiety resulting from the procedure was lessened [10].

Although there is a program operating in Poland to combat pain in children, there are no reliable tools for monitoring it. Therefore, in order to optimize the care of a child with pain and its parents, measures were taken to adapt a reliable tool for assessing pain coping.

The goal of this paper is to present the cultural adaptation and evaluation of psychometric properties of the Pain Coping Questionnaire (PCQ), Polish version (PCQ-Pv), and the PCQ-Parent Ratings, Polish version (PCQ-PR, Pv), as well as to present the preliminary results of the study.

When embarking on this research project, based on analysis of the literature, it was assumed that:

1.	The adaptation and validation of the PCQ and PCQ-PR into the Polish language meets the psychometric criteria for reliability and accuracy, and the tools are understandable for the population of children and their mothers.
2.	There is a correlation between children’s coping with pain, and pain coping as perceived by parents. In both children and mothers, the task-focused style dominates.
3.	Children’s feelings in a situation of pain affect the way they cope, and there is a correlation between children’s feelings in a situation of pain, and coping as perceived by parents.

Methods

Study setting

The research project followed an adaptive-diagnostic approach. The study involved 220 children who were experiencing trauma-related pain, and their parents (220 mothers). The study was conducted at the Paediatric Orthopaedics and Paediatric Surgery Wards in Children’s Hospital. Data collection was carried out over the period from May 2019 to February 2020. The inclusion criteria were as follows: the age of the child – between 12 and 17 years; a history of injury or surgery and acute pain experienced in connection with the event (the first or second day after surgery or injury); pain assessed using the Numerical Rating Scale to be at least 4 (moderate pain) on an 11-degree scale; the parent’s and the child’s written consent to participate in the study; and the parent’s consent for his or her minor child’s participation in the study. It was also established that the same number of male and female children would participate in the study. The research tools package was prepared in printed form, with a total of 505 sets of questionnaires distributed.

The study design was approved by the Bioethics Committee of the Medical University of Lublin (no. KE-0254/354/2018). The STROBE checklist was used to guide the submission [11].

Pain Coping Questionnaire (supplementary materials: PCQ Polish version [PCQ-Polish v.])

The study used the PCQ scale, child’s version - Coping with Pain (PCQ) and in the parents’ version - Coping with Pain (PCQ-Parent Ratings), by Graham J Reid, Cheryl A Gilbert and Patrick J McGrath, who agreed to the scale being validated and used in Poland. In order to maintain semantic, conceptual and idiomatic equivalence in the questionnaire, the guidelines for translation and validation of the scale were followed [12,13].

The PCQ by Reid et al. was used in our research. This questionnaire measures the management of pain in children and adolescents [14]. To date, the PCQ is the only pain management measurement tool of confirmed psychometric quality. Moreover, the questionnaire was designed specifically for children and adolescents, it has been used for a wide range of pain conditions, and it has been applied and validated in many countries and cultures [14–20].

According to the classification developed by Endler and Parker, there are three ways of coping with stress [21]: the formulated distinctions between a task-focused style (where actions are taken to solve a problem), an emotion-focused style (focusing on one’s own emotional experiences) and an avoidance-focused style (rejecting a problem, performing substitute activities) [22]. In the original version of the PCQ questionnaire, the three higher order scales refer to approach, problem-focused avoidance and emotion-focused avoidance styles [14].

Researchers have validated the PCQ in trials on children most often aged from 8 to 15 years old [16,20]. Although older children (17-year-olds [15] and 18-year-olds [17,18]) did take part in some studies. The study sizes were quite diverse, ranging from 91 to 1225 children. Factor analysis made it possible to distinguish eight subscales and three upper scales [20], or only eight [16] or seven [15,19] subscales without the possibility of isolating higher order scales. In contrast, German researchers have proposed an abbreviated German version of the PCQ: Pain-Related Cognitions Questionnaire for Children (PRCQ-C); their study validated three higher order scales [17]. This research showed satisfactory reliability of the coefficients and internal consistency in the Finnish version (0.76–0.98; 0.78–0.91) [20], the Dutch version (0.78–0.87) [16], and the Catalonian version (0.69–0.89 for children and 0.70–0.91 for adults) [19]. On the other hand, the Danish version achieved coefficients of reliability and internal consistency with a range of 0.60–0.83 [15]. The shortened version of the PCQ achieved reliability and internal consistency at the values of 0.67–0.81 [18] and of 0.72–0.78 [17].

Research on children’s pain and pain coping is very important as it aims to improve the quality of care for children in pain as well as to clarify how children cope with pain and how coping techniques can be applied in healthcare.

The PCQ and PCQ-Parent Ratings are self-descriptive tools designed for children, adolescents and parents to assess how children cope with pain.

The PCQ is designed for children aged 8–18 years. The original version of the questionnaire for children contains 39 items. Participants provide their answers on a 5-point scale stating frequency (1 = never, 2 = almost never, 3 = sometimes, 4 = often, 5 = very often). Children or adolescents are asked to indicate how often they have used each of the 39 statements to cope with pain in response to the question: “When I feel pain or have an injury for several hours, then…” The internal consistency of the tool ranges from 0.78 to 0.86 for children in eight subscales on pain-coping strategies and three higher order scales ranging from 0.87 to 0.89 [14].

The PCQ-Parent Ratings is for parents. The original version of the questionnaire for parents contains 39 items. Participants provide their answers also on a 5-point scale of frequency. Parents, though, answer the same statements in response to the question: “When your child is in pain or has an injury for several hours or days, then…” The internal consistency of the tool ranges from 0.70 to 0.91 for parents in eight subscales of pain-coping strategies and three higher order scales from 0.84 to 0.93 [14].

In addition, three questions are placed at the end of the children’s questionnaire and, in the parents’ version, two questions, measuring the ability to cope with pain as perceived by children and their parents [14].

The parents’ version contains questions addressing the assessment of pain control by children and the effectiveness of their children’s pain management [14].

The time allowed to complete the questionnaire is 10–15 min.

Data analysis

Exploratory factor analysis of the tool was performed with the use of Varimax rotation. The questionnaires for children and for parents were analyzed separately. The analysis made possible the formulation of 38 questions for which factor assignment was sought. A three-factor structure was developed for both the children’s and parents’ versions of the questionnaire. The eight-factor analysis that appears in the original version of the questionnaire was not confirmed in the factor analysis. The Cronbach’s alpha coefficient was applied to assess reliability, understood as internal consistency, of the questionnaires. The Shapiro–Wilk Test was used to determine whether the distributions of the analyzed variables are consistent or whether they deviate from normal distributions. This work also uses Pearson’s correlation coefficient (r), Spearman’s rho correlation coefficient, Pearson’s Chi-square independence test and the Student’s t-test for independent groups. The study results were analyzed with the use of IBM SPSS Statistics 26 software.

Characteristics of the participants

The study involved 220 children and their 220 mothers. Exactly half of the participating children were girls and half were boys. The children were between 11 and 17 years old. The average age of the studied group was about 14 years. The mothers were between 32 and 59 years old. The average age of the studied group was slightly over 41.5 years. More than half of the mothers have had higher education (50.5%), with a lower number having secondary (30.0%) or vocational education (19.5%). Both the children and their mothers expressed similar points of view as regards their financial situation. Slightly more than half of the children (51.8%) and 48.6% mothers believed the financial situation of their family to be ‘good’ or ‘very good.’ The children assessed the level of pain they experienced on the Numerical Rating Scale, in other words, from 0 to 10, where ‘0’ indicates complete absence of pain and ‘10’ indicates the highest level of pain. The pain was declared by the study group to fall within a range of 4–8, with the average assessment of pain level at 5.78 (Table 1).

Table 1. Characteristics of the participants.

Variable		Children						Parents (mothers)
		N	%	M	SD	Min.	Max.	N	%	M	SD	Min.	Max
Sex	Female	110	50.0	–	–	–	–	220	100.0	–	–	–	–
	Male	110	50.0					0	0.0
Age				13.94	1.97	11.00	17.00			41.53	4.99	32.00	59.00
Place of residence	Village	98	44.5	–	–	–	–	106	48.2	–	–	–	–
	City	122	55.5					114	51.8
Financial situation	(Very) good	114	51.8	–	–	–	–	107	48.6	–	–	–	–
	Satisfactory	97	44.1					98	44.5
	Insufficient	9	4.1					15	6.8
Education	Vocational education	–	–	–	–	–	–	43	19.5	–	–	–	–
	Secondary education							66	30.0
	Higher education							111	50.5
Pain intensity – NRS		–	–	5.78	0.97	4	8	–	–	–	–	–	–
Number of days of hospitalization		–	–	3.46	3.11	1	22	–	–	–	–	–	–
Number of children in the family	1	26	11.8	–	–	–	–	23	10.5	–	–	–	–
	2	111	50.5					128	58.2
	3	68	30.9					65	29.5
	4	15	6.8					4	1.8
Location of pain^†	After injury/surgery	220	100.0	–	–	–	–	220	100.0	–	–	–	–
	Arthralgia	139	63.2					138	62.7
	Muscle pain	117	53.2					92	41.8
	Abdominal pain	45	20.5					53	24.1
	Headache	14	6.4					25	11.4
	Back pain	13	5.9					13	5.9
	Earache	0	0					18	8.2

† The results do not add up to 100%, as the respondents could select several answers.

M: The arithmetic mean; Max: Maximum; Min Minimum; N: Number of participate; NRS: Numerical Rating Scale; SD: Standard deviation.

Results

For the children’s questionnaire, the KMO measure of sample adequacy was 0.457 and Bartlett’s sphericity test (Chi-square = 1523.93, p < 0.001***) returned a statistically significant result; the significance of this test indicates sufficient correlation between the variables to proceed with the analysis. At the beginning, an attempt was made to determine the number of factors. The analysis calculated initial eigenvalues for those components (factors) for which the eigenvalues were greater than 1. Three factors together served to provide an explanation for almost half (47.8%) of the variance. Consequently, they seemed to be the optimal number to be singled out.

For the parents’ questionnaire, the KMO measure of sample adequacy was 0.455 and Bartlett’s sphericity test (Chi-square = 1325.31, p < 0.001) returned a statistically significant result; the significance of this test indicates sufficient correlation between the variables to proceed with the analysis. The analysis calculated initial eigenvalues for those components (factors) of eigenvalues greater than 1. Three factors together served to account for almost half (44.6%) of the variance. Consequently, they seemed to be the optimal number for singling out.

Next, exploratory factor analysis with Varimax rotation was performed, once again adopting in advance the three factors in both questionnaires. Table 2 shows (in the children’s and the parents’ questionnaires separately) the load sizes of individual questions in relation to each given factor.

Table 2. Load sizes of individual questions in relation to the proposed components (factors).

Question number	Children					Parents (mothers)
	Component (factor)			M	SD	Component (factor)			M	SD
	Task-focused style	Avoidance-focused style	Emotion-focused style			Task-focused style	Avoidance-focused style	Emotion-focused style
Q1	0.696			3.58	0.95	0.494			3.56	0.95
Q2	0.556			3.58	0.97	0.309			3.66	0.89
Q3	0.777			3.02	1.00	0.644			2.92	1.12
Q9	0.661			3.50	1.07	0.657			3.28	1.23
Q 10	0.723			3.58	0.99	0.581			3.54	0.91
Q11	0.765			3.54	0.99	0.628			3.62	0.78
Q17	0.724			3.16	1.15	0.687			3.26	1.12
Q18	0.540			3.24	1.22	0.514			3.58	0.84
Q19	0.762			3.34	0.96	0.615			3.10	1.27
Q25	0.705			3.02	1.10	0.594			3.48	0.97
Q26	0.684			3.50	1.09	0.672			3.46	0.79
Q27	0.470			3.62	0.90	0.409			3.74	0.90
Q33	0.474			3.18	1.10	0.608			3.18	1.12
Q34	0.664			2.68	1.11	0.588			2.60	1.09
Q4		0.439		3.02	1.17		0.447		2.64	1.08
Q5		0.522		2.22	1.00		0.102		2.02	1.00
Q6		0.636		2.14	0.99		0.477		2.10	0.97
Q12		0.564		3.04	1.07		0.526		2.70	1.18
Q13		0.693		2.28	1.13		0.705		2.12	0.90
Q14		0.577		2.52	1.05		0.560		2.06	0.96
Q20		0.595		3.00	0.95		0.763		2.72	1.14
Q21		0.702		3.10	1.05		0.652		2.98	1.08
Q22		0.621		2.98	1.04		0.587		2.92	1.07
Q28		0.661		3.38	1.05		0.659		3.16	1.06
Q29		0.552		2.24	1.02		0.669		2.38	1.05
Q30		0.621		2.40	1.12		0.702		2.12	1.00
Q35		0.706		3.06	0.93		0.571		2.74	1.01
Q36		0.640		3.30	1.05		0.413		3.14	0.93
Q37		0.653		2.76	1.19		0.747		2.12	0.90
Q7			0.760	1.94	1.11			0.673	2.54	1.28
Q8			0.449	2.88	1.26			0.632	1.92	0.97
Q15			0.764	2.02	1.00			0.772	2.26	1.21
Q16			0.608	2.66	1.14			0.572	3.30	1.04
Q23			0.649	1.70	1.04			0.747	1.82	1.10
Q24			0.703	2.34	1.15			0.665	2.40	1.12
Q31			0.617	1.44	0.79			0.779	1.50	0.91
Q32			0.661	2.52	1.33			0.729	2.30	1.25
Q38			0.572	1.62	1.14			0.550	1.62	0.95
Q39			0.428	3.14	1.32			0.520	2.98	1.15

Bold text indicates the load sizes of individual questions in relation to the proposed components (factors).

M: The arithmetic mean; Q: Question; SD: Standard deviation.

The majority of questions could be clearly classified into a specific factor. The most problematic was question number 5, which in the parents’ questionnaire was not part of any factor. It is worth noting that despite the different ordering of factors in the children’s and parents’ questionnaires (factor 1 in the children’s is factor 3 in parents’, factor 2 in children’s is factor 1 in parents’ and factor 3 in children’s is factor 2 in parents’), their construction is very similar, and when classifying doubtful questions in such a way that in both questionnaires the classification looks the same, the construction of factors in the parents’ and children’s versions prove to be identical. Therefore, it was decided to remove question 5 from the questionnaire, which means that the three-factor structure of the questionnaire became the same for both the parents’ and children’s versions. Ultimately, the factors were numbered as they were in the children’s questionnaire: Factor 1 – task-focused style; Factor 2 – avoidance-focused style; Factor 3 – emotion-focused style. Our three-tier division of factors in the Polish version corresponds to the division of factors into three higher order scales in the original version of the questionnaire. These are: task-focused approach, problem-focused avoidance and emotion-focused avoidance.

After removing question 5 (“He/She is/I am going to play”), the order of questions 6–38 has shifted as compared with the original versions.

Next, analysis of reliability of particular dimensions (factors) was performed separately on the questionnaires for children and for parents.

The Cronbach’s alpha reliability coefficient in the children’s questionnaire for Factor 1 – ‘task-focused’ was 0.904, for Factor 2 – ‘avoidance’ it was 0.881 and Factor 3 – ‘emotions’ was 0.833, which signify very high reliability. The Cronbach’s alpha reliability coefficient in the parents’ questionnaire for Factor 1 – ‘task-focused’ in the parents’ questionnaire, was 0.856, Factor 2 – ‘avoidance’ was 0.880 and Factor 3 – ‘emotions’ was 0.877, signifying very high reliability. All questions have high or very high discriminatory power rates, and removing any of the questions would not increase the reliability of the factor (Table 2).

As already observed, both children and parents achieved the best results in the ‘task-focused’ factor and the lowest in the ‘emotions’ factor. The median (Me) achieved the highest values in the task-focused style factor both in mothers (3.36) and in children (3.32). Based on the student’s t-test statistic and the value of ‘p,’ no statistically significant differences were found between the results of mothers and their children with respect to any of the factors. A difference approaching significance was only recorded for the ‘avoidance’ factor with a significantly higher average in children than in mothers (Table 3).

Table 3. Comparison of results of individual questionnaires for mothers and children.

Factor	Group	Min	Max	Me	SD	t-test
Task-focused style	Child	1.29	4.50	3.36	0.70	t = -0.24
	Mother	2.29	4.86	3.32	0.60
Avoidance-focused style	Child	1.07	4.50	2.86	0.66	t = 1.82
	Mother	1.21	4.07	2.57	0.64
Emotion-focused style	Child	1.00	3.90	2.10	0.72	t = -0.26
	Mother	1.10	4.10	2.10	0.76

None of the t-test values were statistically significant.

Max: Maximum; Me: Median (middle value); Min: Minimum; SD: Standard deviation; t: Statistics of the Student’s t-test.

It was found that in the children’s questionnaire, the individual factors did not correlate with each other. In the parents’ questionnaire, on the other hand, a significant positive correlation was observed between task- and emotion-based coping (p = 0.024) and a negative correlation between avoidance- and emotion-based coping (p = 0.026). In the current study, both children and parents achieved best results in the ‘task’ factor and lowest in the ‘emotions’ factor. No statistically significant differences were found between the results of mothers and their children with respect to any of the factors. A difference approaching significance was only recorded for the ‘avoidance’ factor – a significantly higher average in children than in mothers (Table 4).

Table 4. Correlations between separate factors among mothers and children.

Factors	Group	Task-focused style		Avoidance-focused style
		r	p-value	r	p-value
Avoidance-focused style	Child	0.184	ns	–	–
	Mother	0.038	ns	–	–
Emotion-focused style	Child	0.112	ns	‐0.097	ns
	Mother	0.318	*	‐0.316	*

Three levels of statistical significance were adopted: ***p < 0.001; **p < 0.01; *p < 0.05.

N: Number of participants; ns: Not significant; r: Pearson’s correlation coefficient.

Correlates of the PCQ scales were examined. The age variable is related to the ‘emotion’ factor. A certain tendency can be observed here: the higher the age, the greater the ability to cope with pain through emotions.

However, it was shown that the higher a parent’s age, the higher the score in the avoidance factor. On the other hand, the stronger the pain (according to children), the higher the parent’s score in the avoidance factor.

The following feelings were found to be the most prominent in children experiencing pain: sadness, nervousness and worrying, and anxiety.

It was shown that the greater the negative feelings, the higher the scores in the task and emotions factors, and the lower in the avoidance factor. Particularly strong was a positive correlation between negative feelings and the emotion factor. For their part, among parents there was a statistically significant positive correlation between the emotion factor and the general index of negative feelings in their children. Thus, the stronger the negative feelings in children, the higher the parents’ emotion score (Table 5).

Table 5. Correlations between factors and children’s feelings and general aspects of coping with pain, and children’s attitudes toward individual pain-related statements of children and parents (mothers).

Factors/coping with pain	Children						Parents (mothers)
	Task-focused style		Avoidance-focused style		Emotion-focused style		Task-focused style		Avoidance-focused style		Emotion-focused style
	rho	p-value	rho	p-value	rho	p-value	r	p-value	r	p-value	r	p-value
How the does child feel in situations of injury and/or pain?
Overall indicator of feelings	0.393	**	‐0.289	*	0.492	***	0.080	ns	‐0.137	ns	0.408	**
Dealing with pain
Pain controllability	0.332	*	0.086	ns	‐0.276	ns	‐0.157	ns	0.281	*	0.044	ns
Pain distress controllability	0.360	*	‐0.359	*	0.356	*	0.235	ns	‐0.328	*	0.172	ns
Changing moods or feelings	0.112	ns	0.204	ns	‐0.133	ns	0.200	ns	0.267	ns	0.025	ns
Reflecting on hurt or pain
Overall pain coping index	‐0.068	ns	0.248	ns	‐0.314	*	‐0.006	ns	‐0.026	ns	‐0.305	*

Three levels of statistical significance were adopted: ***p < 0.001; **p < 0.01; *p < 0.05.

ns: Not significant; rho: Spearman’s rho correlation coefficient.

The more the child thinks that pain can be remedied, the higher the tendency to cope with it through tasks. The more difficult (according to the children) it is to cope with pain, the more often the task- and emotion-based techniques are used, and the less frequent the use of avoidance-based techniques. Two out of three statements on coping with pain (according to the parents) correlate with the avoidance-based technique. The more a parent believes that he or she can relieve the child’s pain, the higher the score in the avoidance factor (Table 5).

Among the children, a statistically significant negative correlation was found between the emotion factor and the general index of coping with pain. That is to say, the higher the score on emotions, the worse the coping with pain. It is also interesting that the better children cope with pain, the lower the parents’ emotional scores. The situation is thus analogous to the children’s factors (Table 5).

Discussion

The PCQ questionnaire has been used extensively for various states of pain, and by several international research groups [17].

The Polish version of the children’s and parents’ questionnaires feature a three-tier factor structure and provide 38 pain-coping strategies, with one strategy having been excluded. The same number of items is included in the PCQ questionnaire in the Finnish language version, which also excluded one item – question 27 was removed in this translation due to being a poor match for the proposed eight-factor structure of the child-version of the questionnaire [20]. All of the questions show high or very high discriminatory power rates. This result is similar to those obtained by other authors, in whose research the Cronbach’s alpha coefficient ranged from 0.6 to 0.91 [14,15,19,20]. Preliminary results indicate that the PCQ for the tested sample shows adequate reliability and validity.

In our own research, pain experienced by children was similarly assessed, from moderate to severe. In the Danish PCQ adaptation, children who were experiencing mild pain used diversion as a pain-coping strategy, while children who felt severe pain used behavioral distraction; in addition, the use of internalization/catastrophizing was associated with greater pain intensity [15].

A study by Lee et al. found that parental care constitutes an important mediator between parents’ psychological flexibility and the quality of life of adolescents in pain [23]. In this study, parents were most likely to use nonprocedural-related conversation, support and humor for their pain-experiencing children. In the study, the catastrophizing of pain, frequently used by children, was consistently associated with pain intensity, functional disabilities and emotional stress related to pain. The acceptance of pain helps in coping with it, and increases the child’s participation in daily life, while the catastrophizing of pain contributes to deterioration of the child’s functioning [24] and to anxiety and depression [25]. Based on the PCQ, it was found that high-school students (13–18 years old), as opposed to younger children (8–12 years old), support a higher level of emotion-centered coping [14]. In our study, as far as children’s age is concerned, one can only speak about a close statistical significance in the correlation between age and the ‘emotions’ factor. A certain tendency can be observed here: the higher the age, the greater the ability to cope with pain through emotions. According to Asmundson et al., acute pain is pain that has a sudden onset and disappears upon recovery; the authors also point out that fear of pain is a response to an immediate pain threat [26]. In the current study, the feelings of children in times of pain were shown to significantly correlate with pain-coping techniques. Our own research showed a correlation between coping with pain and the feelings that accompany children in painful situations.

Of the different types of pain, acute pain is one of the most frequent side effects experienced by children, and is also associated with increased child and parental anxiety and additional somatic symptoms [27]. It is widely recognized that parental and family factors can influence pain sensations in children, and that parents’ behavior plays a significant role in children’s response to pain [28,29]. A study by Reid et al. showed a consistent relationship between parents and children on the subject of coping with the child’s pain (median r = 0.34) [14].

In the present study, both children and parents achieved the highest results in the ‘task’ factor and the lowest in the ‘emotions’ factor. When a child feels pain, the family is responsible for performing an initial evaluation of the pain and for seeking appropriate assessment and care; proper functioning of the family improves the child’s ability to cope with the pain [28,30]. As observed in our research, the more that children feel sadness in a situation of pain, the higher the scores obtained by their mothers in the ‘emotion’ factor; the more children experience calm and relaxation, the lower the scores of their mothers in the ‘emotion’ factor.

Relevance to clinical practice

Pain and especially coping with pain are important aspects of working with a sick child who is experiencing pain. Proper assessment of pain and pain management can be helpful in applying the right coping style for children and adolescents, and in planning and implementing nursing care before the pain becomes worse. Appropriate coping strategies can contribute to the achievement of better treatment outcomes and allow the child to feel more in control of his or her pain.

For the sake of consistency between the child and parent scales we propose leaving item number 5 in the parent scale, despite factor analysis in the Polish version suggesting its removal.

Strengths & limitations

Factor analysis of the PCQ – Polish version and the PCQ-Parent Ratings – Polish version questionnaires has provided a structure both culturally and statistically satisfactory in their Polish translations. The internal consistency ranged from acceptable to good for the three factors identified in both questionnaires. All of the questions display high or very high discriminatory power rates. Preliminary results confirm the reliability and accuracy of the PCQ, should it be adopted in the future on a nationwide basis. However, there are some limitations to our study worth mentioning. The main limitation was the modest number of children and mothers who took part in the study. The parents participating in the study were exclusively mothers (100%), which can be explained by the fact that mothers are most often involved in the medical care of their children, which can also be seen in the studies of other researchers [31]. Difficulties in assembling a study group resulted from the age of the respondents. Children are a specific study subject, especially when the study concerns difficult situations involving experience of pain. In general, children displayed a willingness to cooperate and most of them agreed to participate; at the same time, however, parents often would not agree to their child’s and/or their own participation in the study. Furthermore, the potential respondents represented only one region of Poland, which further limited the possibility of generalizing the results.

Conclusion

The language adaptations of the PCQ – Polish version and PCQ-Parent Ratings – Polish version have been shown to be understandable for the population of children and their mothers and meet the psychometric criteria in terms of the reliability and accuracy of the tool.

The dominant style for coping with pain, for both children and parents, is the task-focused style. In our study, both children and parents achieved their best results in the ‘task’ factor and their lowest in the ‘emotions’ factor. A difference approaching significance between the results achieved by mothers and by their children was recorded only for the ‘avoidance’ factor, with a significantly higher average in children than in mothers.

It was found that that the feelings of children in situations of pain correlate significantly with their pain-coping techniques. The study also indicated a link between children’s pain management and parental pain management; the more children feel sadness in a situation of pain, the higher their mothers’ scores in the ‘emotions’ factor, and the more children experience calm and relaxation, the lower their mothers’ scores in the emotion factor.

Additionally, the more children agree with the statement that they have coped well with the pain, the higher the mothers’ scores in the avoidance factor, and the more children agree that this experience has taught them something, the lower the mothers’ scores in the avoidance factor.

Summary points

• Management of children’s and parents’ pain is always a complex process in healthcare.

• Objective measurement of this process offers an opportunity to support children and parents in coping with pain.

• The lack of a scale for this type of measurement in Polish nursing was the reason for undertaking the adaptation–validation process of the Pain Coping Questionnaire (PCQ).

• Analysis results show that the PCQ is a valid and reliable tool for examining how children and parents cope with pain, and the results obtained indicate poorer coping with pain by children and parents who use the emotional style.

• The PCQ can be of aid in distinguishing coping styles of both children and parents, as a means of optimizing health benefits.

Ethical conduct of research

The authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.

Acknowledgments

The authors would like to sincerely thank GJ Reid for permission for validation of the Pain Coping Questionnaire and his commitment to documenting the reliability of the PCQ adaptive procedure. They thank the children and their parents for their willingness to participate in the study despite the suffering they were experiencing. The authors also thank the reviewers for their opinions and all the suggestions for improving their manuscript.

Supplementary data

To view the supplementary data that accompany this paper please visit the journal website at: www.tandfonline.com/doi/suppl/10.2217/pmt-2021-0100

Financial & competing interests disclosure

The publication was financed with funding from the Medical University of Lublin Number DS 514. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Additional information

Funding

The publication was financed with funding from the Medical University of Lublin Number DS 514. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.