An Experimental Investigation of the Role of Anxiety on Children’s Memories of Pain and Their Subsequent Pain Experiences

By Melanie E. Noel, Dalhousie University Mentor: Christine Chambers, PhD

Background and Purposes

Many children are required to repeatedly undergo medical procedures and often find these experiences to be painful and frightening. The deleterious effects of poorly managed pain do not end when procedures are over. The way that children remember painful procedures affects their experience of pain and distress during subsequent procedures (see von Baeyer et al., 2004). Children who develop negatively exaggerated memories of pain and anxiety following lumbar punctures tend to experience more pain and distress at subsequent procedures than children who accurately recall their experience (Chen et al., 2000). Children who have high levels of trait anxiety and who experience more pain during medical procedures are more likely to develop negatively exaggerated pain memories (Rocha et al., 2009; Noel et al., 2010). Individuals who are anxious consistently show a memory bias for threatening information as compared to non-anxious individuals (Mitte, 2008).
This research has only examined adults’ memories for words as opposed to children’s memories for more ecologically valid stimuli, like pain. Cognitive theories hold that anxious individuals develop memory biases because they selectively encode and retrieve threatening information, particularly when they experience high levels of state anxiety (Beck & Clarke, 1997). However, research has neglected to investigate the role of state anxiety, and the interaction between children’s state and trait anxiety, in the development of memory biases, despite the need for such research (Mitte, 2008). Furthermore, only one study (Chen et al., 2000) has directly examined the impact of pain memories on subsequent pain experiences. By using an innovative experimental design and laboratory techniques, the current study systematically examined the impact of state anxiety and stable anxiety-related variables on the development of children’s memories for pain. It also examined the role that these memories play in children’s distress and coping during subsequent exposure to the same painful experience.

Design and Methods

110 children between the ages of 8-12 years participated. Children underwent an ethically acceptable experimental pain task (the cold pressor task; CPT) in which they submerged their hand in a cooler of 10°C ± 1°C water and kept their hand submerged for as long as they could tolerate, up to 4 minutes. Half of the children were randomly assigned to complete a stressful task (a modification of the Trier Social Stress Test for Children) prior to the CPT in which they anticipated having to give a speech and completing a difficult mental arithmetic task in front of judges. The remaining children anticipated having to watch a nature video. Children completed measures of pain intensity (Faces Pain Scale-Revised), pain affect (Facial Affective Scale), and pain anxiety (Faces Anxiety Scale) immediately following the pain task and two weeks later over the telephone. Children repeated the pain task and pain ratings one month later to determine how their memories affected their subsequent distress. Measures of state and trait anxiety (State Trait Anxiety Index for Children- STAIC) and anxiety sensitivity (Children’s Anxiety Sensitivity Index) were also completed.

Potential Clinical/Research Implications

This research will provide innovative data on the role of state anxiety and stable anxiety-related variables on the development of memory biases for painful events. It will also provide pediatric psychology researchers with information about the long-term impact of these memories by showing how memories affect children’s coping during future painful experiences. The findings of this lab-based research project will translate into clinical practice and caregiver-led interventions. If we are able to identify how anxiety contributes to the development of negatively exaggerated memories, we would be able to design individualized evidence-based interventions aimed at reducing child anxiety and distress during medical procedures. Furthermore, if the present findings suggest that positively framed memories are linked to more optimal coping during subsequent painful experiences, interventions aimed at positively reframing children’s memories could also be developed. This would improve not only the experi- ence of children undergoing painful medical  procedures, but also their health outcomes into adulthood.


Beck, A.T., & Clark, D.A. (1997). An information processing model of anxiety: Automatic and strategic processes. Behaviour Research and Therapy, 35(1), 49-58.
Chen, E., Zeltzer, L.K., Craske, M.G., & Katz, E.R. (2000). Children’s memories for painful cancer treatment procedures: Implications for distress. Child Development, 71(4), 933-947.
Mitte, K. (2008). Memory bias for threatening information in anxiety and anxiety disorders: A meta-analytic review. Psychological Bulletin, 134(6), 886-911.
Noel, M., Chambers, C.T., McMurtry, C.M., & McGrath, P.J. (2010). Children’s memory for painful procedures: The relationship of pain intensity, anxiety, and adult behaviors to subsequent recall. Journal of Pediatric Psychology, 35, 626-636.
Rocha, E.M., Marche, T.A., & von Baeyer, C.L. (2009). Anxiety influences children’s memory for procedural pain. Pain Research & Management, 14(3), 233-237.
Von Baeyer, C.L., Marche, T.A., Rocha, E.M., &Salmon, K. (2004). Children’s memory for pain: Overvivew and implications for practice. The Journal of Pain, 5(5), 241-249.