Appraisal and Coping with Daily Stressors by Pediatric Patients with Chronic Abdominal Pain

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain (American Academy of Pediatrics and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, Subcommittee on Chronic Abdominal Pain, 2005), affects 5–20% of youth (Apley & Naish, 1958; Kristjansdottir, 1997; Oster, 1972), is associated with high levels of impairment and pediatric health service utilization (Campo, Comer, Jansen-McWilliams, Gardner, & Kelleher, 2002), and may continue into adolescence and adulthood (Campo et al., 2001; Walker, Guite, Duke, Barnard, & Greene, 1998). It is rarely associated with organic disease, but instead typically reflects a functional gastrointestinal disorder (Boyle, 1997; Walker, et al., 2004). Several investigations have linked chronic abdominal pain to stressful life events. In prospective studies, higher levels of negative life events predicted symptom maintenance 3 months (Walker & Greene, 1991) and 1 year (Walker, Garber, & Greene, 1994) following children’s medical evaluation for abdominal pain. Moreover, results of a diary study showed that the intraindividual relation between daily stressors and somatic symptoms was significantly stronger in abdominal pain patients than in well children (Walker, Smith, Garber, Van Slyke, & Claar, 2001). Investigation of pain patients’ subjective experience and behavioral responses to stress might shed light on the relation between stress and somatic symptoms observed in these patients. Theories of life stress emphasize that the manner in which individuals appraise and cope with stress determine the impact of stress on health (Lazarus & Folkman, 1984; Monroe & Kelly, 1995; Sandler, Wolchik, MacKinnon, Ayers, & Roosa, 1997). This perspective suggests that pediatric abdominal pain patients may differ from well children in the way that they appraise and cope with stress, and, moreover, their particular style of stress appraisal and coping may be associated with high levels of symptoms and disability. Accordingly, this study aimed to (a) examine stress appraisal and coping by pediatric abdominal pain patients in comparison to well children and (b) examine the relation of children’s appraisal and coping with daily stressors to their somatic and depressive symptoms and disability. Our specific predictions were based on the model of stress appraisal and coping advanced by Lazarus & Folkman (1984) (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986), which asserts that individuals’ appraisals of stressor severity and their perceived coping potential predict the nature of the coping strategies they use when confronting a particular stressor. Those strategies, in turn, determine the impact of the stressor on their health (Lazarus & Folkman, 1984). Appraisals of coping potential can be differentiated into two major types: problem-focused coping potential (PFCP)—the perceived ability to alter the circumstances to make them more desirable—and emotion-focused coping potential (EFCP)—the perceived ability to handle or adjust to the circumstances, even if they cannot be improved (cf. Lazarus & Folkman, 1984; Smith & Lazarus, 1990; Walker, Smith, Garber, & Claar, 2005). We predicted that abdominal pain patients would appraise both their PFCP and EFCP as lower compared to well children. The particular combination of perceived PFCP and EFCP is thought to predict one’s response to a stressor (Folkman, 1984; Lazarus & Folkman, 1984; Walker et al., 2005), as shown in Fig. 1. Individuals who appraise their PFCP as high are hypothesized to engage in strategies aimed at improving their circumstances—strategies that have been referred to as active coping in some typologies (e.g., Brown & Nicassio, 1987; Walker, Smith, Garber, & Van Slyke, 1997). Individuals who appraise their PFCP as low, in contrast, are hypothesized to engage in either accommodative or passive coping, depending on whether they appraise their EFCP as high or low. If they appraise their EFCP as high, and thus believe that they can accept and adjust to their circumstances, they are expected to engage in accommodative coping strategies such as acceptance and positive reappraisal, which theoretically foster adaptation to unchangeable stressful circumstances (see Lazarus, 1991; Smith & Lazarus, 1990). Conversely, if they appraise their EFCP as low, and thus believe that they cannot adjust to unchangeable stressful circumstances, they are expected to engage in passive coping strategies characterized by negative cognitions and lack of active problem-solving efforts (e.g., Brown & Nicassio, 1987; Walker et al., 1997). Thus, we predicted that, in comparison to well children, pediatric abdominal pain patients would report more passive coping strategies and fewer active and accommodative coping strategies when dealing with daily stressors. Figure 1 Hypothesized relations of appraised problem-focused coping potential (PFCP) and emotion-focused coping potential (EFCP) to active, passive, and accommodative coping. We also examined the relation of children’s appraisal and coping with daily stressors to their symptoms and disability. We expected that appraisals of coping potential would predict the nature of coping strategies and that these strategies, in turn, would predict symptoms and disability. Thus, we hypothesized that coping strategies would mediate the relations between appraisals of coping potential and symptoms and disability. Specifically, we hypothesized that higher levels of passive coping, itself predicted by lower levels of both PFCP and EFCP, would be associated with greater functional disability and higher levels of somatic and depressive symptoms. In contrast, higher levels of active coping (itself predicted by higher levels of appraised PFCP) and higher levels of accommodative coping (itself predicted by higher levels of EFCP) would be associated with less disability and lower levels of somatic and depressive symptoms.