Characterization of (In)Validation in Adolescent Chronic Pain Care: Pain Intensity, Pain Disability, and Psychological Correlates

Abstract

BACKGROUND. Pediatric chronic pain is associated with significant personal, familial, and societal burden. The dearth of effective treatments for chronic pain in youth suggests that there may be neglected socioenvironmental determinants in its etiology and occurrence. (In)validation (i.e., communicating that an individual’s feelings, thoughts, or actions are [not] understandable or legitimate) during chronic pain treatment is a patient-identified priority; further, individuals with marginalized identities overwhelmingly report experiences of invalidation in healthcare. Research has yet to systematically describe (in)validation in the clinical encounter. This study aimed to: (1) characterize to what extent physicians (in)validate adolescents with chronic pain (AWCP) and their parents during four distinct sections of a clinical encounter; (2) investigate whether (in)validation differs by AWCP sociodemographic factors; and (3) explore preliminary associations between (in)validation during the clinical encounter and pain correlates at followup. METHOD. Video recordings of 39 AWCP and their parents who presented to a tertiary pediatric pain clinic were coded and analyzed. Separate validation and invalidation scores were assigned using a behavioural coding scheme drawn from the psychopathology field. A subset of 24 participants who completed follow-up questionnaires were included in an exploratory analysis of (in)validation and pain correlates. RESULTS. Physicians were most invalidating towards AWCP and their parents at the beginning of the clinical encounter (i.e., history taking) and least validating towards AWCP during physical examination. Boys and their parents were more invalidated throughout the encounter than girls and their parents. Parents of white AWCP were significantly more invalidated during history taking than the rest of the encounter, whereas invalidation towards parents of racialized AWCP did not differ significantly across encounter sections. Finally, invalidation was associated with worse AWCP pain disability at follow-up. CONCLUSIONS. There is opportunity for physicians to be mindful of invalidation towards patients from the outset of their pain treatment. (In)validation towards AWCP and their families differed depending on demographic characteristics, indicating the need for equity considerations to improve clinical encounters. Invalidation was associated with worse pain disability over time; thus, there is early justification for developing interventions that minimize physician invalidation of families seeking chronic pain care.