Ethnicity Matters in the Assessment and Treatment of Children's Pain

One of the most challenging treatment dilemmas facing a practicing pediatrician is the management of a child with chronic pain, because it is well established that pain is a highly complex phenomenon that involves biological, psychological, and social variables such as culture, race, and ethnicity.1,2 Understanding the role of culture in the experience of pain is of particular importance when one considers that nearly 25% of children under the age of 5 in the United States are Latino and 17% of children in this age group are black.3 Consequently, it is important for pediatricians to consider the impact of race and ethnicity on the management of pain in children.In adults, there is substantial literature focused on the role of ethnicity and race in the experience of pain.4–16 Although there have been some contradictory findings, as a whole this literature suggests ethnic differences in perception, assessment, and treatment across settings and types of pain,11 differences that persist even after controlling for potential confounding variables such as socioeconomic status, gender, age, education, marital status, and psychological variables such as emotional state.4,7–10 Survey research suggests that Hispanic individuals may be less likely than white and black individuals to seek treatment by a physician for pain and black individuals may be more likely than white and Hispanic adults to use prescription medication for the treatment of pain.13 In addition, a large survey documented ethnic differences in behavioral responses to pain, including a tendency for Hispanic and black adults to use spiritual methods of coping, such as prayer, in response to pain more often than do white adults.8 Moreover, cultural differences have been documented in predictors of pain coping behaviors. For example, total number of pain sites, frustration, and interference of pain on functioning predicted use of pain coping strategies for blacks; worry and frustration predicted coping responses for Hispanics; and pain intensity and functional interference predicted coping responses for whites.8There have been numerous studies examining differences in the experience of experimental pain among various cultural and ethnic groups.4–6 Specifically, considerable evidence exists that black and Hispanic adults report lower tolerance for experimentally induced pain when compared with white adults.4–6,9 Research in the area of chronic pain has shown increased pain severity and disability and lower pain tolerance in black adults compared with white adults9 and variations in emotional responses to pain and pain coping behaviors.7,10 In fact, research has demonstrated that in adult patients, stronger ethnic group identity predicts greater pain sensitivity.6Many factors have been suggested as contributing to these findings, including documentation of ethnic differences in the physiologic components of pain modulation such as plasma oxytocin,12 blood pressure, plasma norepinephrine, and cortisol.16 However, until these physiologic findings are replicated in studies with infants, it is possible that cultural factors account for the differences in biological markers found in adults. In addition to individual patient variables, contextual factors, such as those relating to health care providers and the larger health care system, have also been suggested to play a role in ethnic differences in pain.8,16Despite the dramatic growth of studies examining ethnic and racial differences in pain in adults, few studies exist that have examined the impact of ethnicity and culture on the experience of pain in children. We were able to locate only 6 published studies that focused on the perception and management of pain within cultural groups in children in the United States.17–22 Only 2 of the articles directly compared 2 or more racial or ethnic groups on measures of pain,17,18 whereas others examined cultural differences in analgesic administration in the emergency department19 or pain characteristics within 1 cultural group.20–22 Unfortunately, there is not enough evidence from these few articles to draw any conclusions about ethnic differences in the experience of pain in children. Nonetheless, these studies point to potential racial differences in the frequency and severity of pain18 as well as potential cultural differences in descriptions and meanings of pain.20–22 Moreover, because of the substantial evidence of ethnic differences in pain perception and response in adults, and the notion that pain is a subjective, learned experience that is related to ethnic identity, it is quite likely that ethnic differences would be evident in children as well. Indeed, research has suggested that Asian American and Hispanic American youth report more social stress and psychological distress and fewer coping resources than their white American counterparts.23 Latino patients, in particular, may be at risk for undertreatment of pain24 and may underreport pain related to a cultural emphasis on stoicism25 and potential language barriers.20Despite lack of research regarding the contribution of culture and ethnicity to the experience of pain in children, the adult literature suggests important information for the practicing pediatrician when confronted with culturally diverse children in pain. For example, it may be necessary to not simply take no for an answer when assessing pain in a Latino child, given that Latino children may be hesitant to acknowledge pain.25 It may be important to include alternatives to self-report when assessing pain of culturally diverse children, such as observational measures of pain. In addition, the use of culturally validated measures of pain is important. An example is the Oucher,26 a pain scale with versions that have been validated for white, black, Asian American, and Hispanic children.26–28 For both Latino and black children, it may be helpful to acknowledge and reinforce spiritual means of pain management in addition to pharmacologic strategies. Black children may experience increased frustration and lower pain tolerance; thus, a focus on the emotional toll of pain may be particularly important. In circumstances in which language is a barrier, the inclusion of an interpreter who is not a family member is vital.It is clear that researchers need to direct efforts to further understanding of the role of ethnicity in the experience of pain in children. Research may best be served by starting with qualitative approaches, such as focus groups and interviews, to understand how children of different ethnic and racial groups perceive and understand pain. This work will pave the way for studies examining cultural differences in the experience of both acute and chronic pain in children. Therefore, this serves as a call to researchers to begin to incorporate aspects of culture and ethnicity in their research on pediatric pain. This commentary is also a call for pediatric practitioners to be sensitive to the issues of ethnicity and culture as they address the challenging area of children's pain management. We are not advocating cultural stereotyping but, rather, that physicians and scientists adopt cultural sensitivity into practice on a consistent basis. To ensure adequate assessment and treatment of a child in pain, the context of the child, including culture, must be understood.