Attentional and Interpretational Biases Toward Pain-Related Stimuli in Children and Adolescents: ASystematic Review of the Evidence

  • Melanie Brookes
    Department of Psychology, University of Sydney, Australia.
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  • Louise Sharpe
    Address reprint requests to Louise Sharpe, University of Sydney, Departmentof Psychology, Brennan MacCallum Building A17, Manning Road, Sydney, NSW 2006, Australia.
    Department of Psychology, University of Sydney, Australia.
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  • Kasia Kozlowska
    Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.

    Disciplines of Psychiatry (Kozlowska, Brown, McLean) and of Paediatrics and Child Health, University of Sydney Medical School, Sydney, New South Wales, Australia.

    Brain Dynamics Centre, Westmead Millennium Institute for Medical Research and University of Sydney Medical School, Sydney, New South Wales, Australia.
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      • There are few studies of cognitive biases and pain in children and adolescents.
      • Evidence for vigilance to pain-related stimuli in youth with chronic pain.
      • No convincing evidence of biases in other attentional processes exists.
      • Youth with chronic pain seem to interpret ambiguous stimuli as pain related.


      This review investigated whether youth exhibit attention or interpretation biases toward pain-related information and whether such biases are more pronounced in youth with chronic pain. Three databases were searched to identify studies that assessed attention or interpretation biases using an accepted experimental paradigm. Ten studies were identified, 8 examining attentional biases and 2 examining interpretation biases. As in the adult literature, there was no evidence of attentional biases toward pain in youth without chronic pain. Three studies investigating youth without chronic pain found evidence for relationships between catastrophizing or anxiety and indicators of vigilance or avoidance (in 2 cases, for youth with low self-reported attentional control). For attentional biases, 5 studies compared youth with and without chronic pain. Two of these studies measured cortical correlates and found evidence of neurologic activity indicating a bias in orienting to pain-related stimuli. Three studies examined biases toward pain-related words or pictures. Of those, 2 found evidence of biases at subliminal presentation times, indicating vigilance (although 1 only after a stressful task). For supraliminal presentations, 1 study found evidence of avoidance, one of difficulty disengaging, and one of general slowing of responses. Only 1 study compared youth with and without pain for interpretation bias in adolescents, and interpretation biases were greater for youth with chronic pain. As with attention, no evidence for interpretation biases were found in youth without chronic pain. Overall, there is weak evidence to support vigilance in youth with chronic pain compared with those without. However, whether pain affects the subsequent deployment of attention is unclear. There is no evidence for biases toward pain in youth without chronic pain, but evidence suggests that anxiety or catastrophizing and attentional control may moderate pain-related attentional biases. There is also weak evidence of interpretation bias in youth with chronic pain compared with those without.


      Children without chronic pain do not show interpretation or attention biases toward pain-related stimuli. However, there is weak evidence for the presence of attention biases, characterized by vigilance toward pain-related stimuli and pain-related interpretation bias in children with chronic pain compared with those without.

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        • Asmundson GJ
        • Noel M
        • Petter M
        • Parkerson HA
        Pediatric fear-avoidance model of chronic pain: foundation, application and future directions.
        Pain Res Manage. 2012; 17: 397-405
        • Bar-Haim YLD
        • Pergamin L
        • Bakermans-Kranenburg MJ
        • Van Ijzendoorn MH
        Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study.
        Psychol Bull. 2007; 133: 1
        • Beck JE
        • Lipani TA
        • Baber KF
        • Dufton L
        • Garber J
        • Smith CA
        • Walker LS
        Attentional bias to pain and social threat in pediatric patients with functional abdominal pain and pain-free youth before and after performance evaluation.
        Pain. 2011; 152: 1061-1067
        • Boyer MC
        • Compas BE
        • Stanger C
        • Colletti RB
        • Konik BS
        • Morrow SB
        • Thomsen AH
        Attentional biases to pain and social threat in children with recurrent abdominal pain.
        J Pediatr Psychol. 2006; 31: 209-220
        • Cooper HM
        Scientific guidelines for conducting integrative research reviews.
        Review of Educational Research. 1982; 52: 291-302
        • Cristea IA MC
        • Mogoase C
        • David D
        • Cuijpers P
        Practitioner review: cognitive bias modification for mental health problems in children and adolescents: a meta‐analysis.
        J Child Psychol Psychiatry. 2015; 56: 723-734
        • Crombez G
        • Van Ryckeghem DM
        • Eccleston C
        • Van Damme S
        Attentional bias to pain-related information: a meta-analysis.
        Pain. 2013; 154: 497-510
        • Dear BF
        • Sharpe L
        • Nicholas MK
        • Refshauge K
        Pain-related attentional biases: the importance of the personal relevance and ecological validity of stimuli.
        J Pain. 2011; 12: 625-632
        • Dear BF
        • Sharpe L
        • Nicholas MK
        • Refshauge K
        The psychometric properties of the dot-probe paradigm when used in pain-related attentional bias research.
        J Pain. 2011; 12: 1247-1254
        • Dudeney JE
        • Sharpe L
        • Hunt C
        Attentional bias towards threatening stimuli in children with anxiety: a meta-analysis.
        Clin Psychol Rev. 2015; 40: 66-75
        • Edwards L
        • Pearce S
        Word completion in Chronic Pain: Evidence for Schematic representation of pain.
        J Abnorm Psychol. 1994; 103: 379-382
        • Field APL
        Is there room for ‘development’ in developmental models of information processing biases to threat in children and adolescents?.
        Clin Child Fam Psychol Rev. 2010; 13: 315-332
        • Fuster JM
        Frontal lobe and cognitive development.
        J Neurocytol. 2002; 31: 373-385
        • Griffith J
        • McLlean M
        • Pearce SA
        Information Processing across three chronic pain groups.
        in: Abstracts of 8th World Congress on Pain. Seattle, WA, International Association for the Study of Pain. 1996: 75
        • Heathcote LC
        • Jacobs K
        • Eccleston C
        • Fox E
        • Lau JYF
        Biased interpretations of ambiguous bodily threat information in adolescents with chronic pain.
        Pain. 2017; 158: 471-478
        • Heathcote LC
        • Jacobs K
        • Van Ryckeghem DM
        • Fisher E
        • Eccleston C
        • Fox E
        • Lau JY
        Attention bias modification training for adolescents with chronic pain: a randomized placebo controlled trial.
        Pain. 2017; (Oct 30 [Epub ahead of print])
        • Heathcote LC
        • Koopmans M
        • Eccleston C
        • Fox E
        • Jacobs K
        • Wilkinson N
        • Lau JYF
        Negative interpretation bias and the experience of pain in adolescents.
        J Pain. 2016; 17: 972-981
        • Heathcote LC
        • Lau JYF
        • Mueller SC
        • Eccleston C
        • Fox E
        • Bosman's M
        • Vervoort T
        Child attention to pain and pain tolerance are dependent upon anxiety and attention control: an eye-tracking study.
        European Journal of Pain (United Kingdom). 2017; 21: 250-263
        • Heathcote LC
        • Vervoort T
        • Eccleston C
        • Fox E
        • Jacobs K
        • Van Ryckeghem DML
        • Lau JYF
        The relationship between adolescents' pain catastrophizing and attention bias to pain faces is moderated by attention control.
        Pain. 2015; 156: 1334-1341
        • Hechler T
        • Chalkiadis GA
        • Hasan C
        • Kosfelder J
        • Meyerhoff U
        • Vocks S
        • Zernikow B
        Sex differences in pain intensity in adolescents suffering from cancer: differences in pain memories?.
        J Pain. 2009; 10: 586-593
        • Hermann C
        • Zohsel K
        • Hohmeister J
        • Flor H
        Cortical correlates of an attentional bias to painful and innocuous somatic stimuli in children with recurrent abdominal pain.
        Pain. 2008; 136: 397-406
        • Jones EB
        • Sharpe L
        Cognitive bias modification: A review of meta-analyses.
        J Affect Disord. 2017; 223: 175-183
        • Khatibi A
        • Sharpe L
        • Jafari H
        • Gholami S
        • Dehghani M
        Interpretation biases in chronic pain patients: An incidental learning task.
        Eur J Pain. 2015; 19:1139-1147
        • Koutantji M
        • Pearce SA
        • Oakley DA
        • Feinmann C
        Children in pain: an investigation of selective memory for pain and psychological adjustment.
        Pain. 1999; 81: 237-244
        • Leeuw GM
        • Linton SJ
        • Crombez G
        • Boersma K
        • Vlaeyen JW
        The fear-avoidance model of musculoskeletal pain: current state of scientific evidence.
        J Behav Med. 2007; 30: 77-94
        • Liossi C
        • Schoth DE
        • Godwin HJ
        • Liversedge SP
        Using eye movements to investigate selective attention in chronic daily headache.
        Pain. 2014; 155: 503-510
        • Lorenz J
        • Garcia-Larrea L
        Contribution of attentional and cognitive factors to laser evoked brain potentials.
        Neurophysiol Clin. 2003; 33: 293-301
        • MacLeod C
        • Koster E.H.W
        • Fox E.
        Attentional bias in emotional disorders.
        J Abnorm Psychol. 1986; 95: 15-20
        • McGowan N
        • Sharpe L
        • Refshauge K
        • Nicholas MK
        The effect of attentional re-training and threat expectancy in response to acute pain.
        Pain. 2009; 142: 101-107
        • Noel M
        • Pavlova M
        • McCallum L
        • Vinall J
        Remembering the hurt of childhood: A psychological review and call for future research.
        Can Psychol. 2017; 58: 58
        • Noel M
        • Rabbitts JA
        • Tai GG
        • Palermo TM
        Remembering pain after surgery: A longitudinal examination of the role of pain catastrophizing in children's and parents' recall.
        Pain. 2015; 156: 800-808
        • Pincus T
        • Pearce S
        • McClelland A
        • Farley S
        • Vogel S
        Interpretation bias in responses to ambiguous cues in pain patients.
        J Psychosom Res. 1994; 38: 347-353
        • Pincus T
        • Pearce S
        • Perrott A
        Pain patients' bias in the interpretation of ambiguous homophones.
        Br J Med Psychol. 1996; 69: 259-266
        • Schoth DE
        • Liossi C
        Biased interpretation of ambiguous information in patients with chronic pain: A systematic review and meta-analysis of current studies.
        Health Psychol. 2016; 35: 944-956
        • Schoth DE
        • Nunes VD
        • Liossi C
        Attentional bias towards pain-related information in chronic pain; a meta-analysis of visual-probe investigations.
        Clin Psychol Rev. 2012; 32: 13-25
        • Sharpe L
        • Ianiello M
        • Dear BF
        • Perry KN
        • Refshauge K
        • Nicholas MK
        Is there a potential role for attention bias modification in pain patients? Results of 2 randomised, controlled trials.
        Pain. 2012; 153: 722-731
        • Sharpe L
        • Johnson A
        • Dear B
        Attention bias modification and its impact on experimental pain outcomes: Comparison of training with words versus faces in pain.
        Eur J Pain. 2015; 19: 1248-1257
        • Sharpe LP
        Attention bias modification for children: What should we make of a null finding?.
        Pain. 2017; (Nov 13 [Epub ahead of print])
        • Sicouri G
        • Sharpe L
        • Hudson JL
        • Dudeney J
        • Jaffe A
        • Selvadurai H
        • Lorimer S
        • Hunt C
        Threat interpretation and parental influences for children with asthma and anxiety.
        Behav Res Ther. 2017; 89: 14-23
        • Simons L
        • Kaczynski KJ
        The Fear Avoidance model of chronic pain: Examination for pediatric application.
        J Pain. 2012; 13: 827-835
        • Stinson JN
        • Jibb LA
        • Lalloo C
        • Feldman BM
        • McGrath PJ
        • Petroz GC
        • Streiner D
        • Dupuis A
        • Gill N
        • Stevens BJ
        Comparison of average weekly pain using recalled paper and momentary assessment electronic diary reports in children with arthritis.
        Clin J Pain. 2014; 30: 1044-1050
        • Todd J
        • Sharpe L
        • Johnson A
        • Perry KN
        • Colagiuri B
        • Dear BF
        Towards a new model of attentional biases in the development, maintenance, and management of pain.
        Pain. 2015; 156: 1589-1600
        • Van den Brink M
        • Bandell‐Hoekstra E
        • Abu‐Saad HH
        The occurrence of recall bias in pediatric headache: a comparison of questionnaire and diary data.
        Headache. 2001; 41: 11-20
        • van der Veek SM
        • Derkx BH
        • Plak RD
        • Benninga MA
        • Boer F
        • Lindauer RJ
        • de Haan E
        Attentional bias to activity of different parts of the body in children with functional abdominal pain: An experimental study.
        J Pediatr Psychol. 2014; 39: 438-449
        • Vervoort T
        • Trost Z
        • Van Ryckeghem DM
        Children's selective attention to pain and avoidance behaviour: The role of child and parental catastrophizing about pain.
        Pain. 2013; 154: 1979-1988
        • Williams JMG
        • Mathews A
        • MacLeod C
        The emotional Stroop task and psychopathology.
        Psychol Bull. 1996; 120: 3-24
        • Za Yang
        • Tab Jackson
        • Xab Gao
        • Hab Chen
        Identifying selective visual attention biases related to fear of pain by tracking eye movements within a dot-probe paradigm.
        Pain. 2012; 153: 1742-1748
        • Zohsel K
        • Hohmeister J
        • Flor H
        • Hermann C
        Altered pain processing in children with migraine: An evoked potential study.
        Eur J Pain. 2008; 12: 1090-1101