LAUSR

Children often depend on their parents for help and coregulatory support to manage painful and stressful situations, as the capacity for emotion regulation develops gradually across childhood (Noel et al., 2018; Palermo, 2014). In the context of research on needle procedures, a strong body of literature has demonstrated that children’s experience of distress is bidirectionally related to their parent’s behaviors and responses to the needle procedure (Caes et al., 2014; Campbell et al., 2017). In this issue of JPP, Constantin and colleagues focused on parent behaviors described as “distress-promoting behaviours” that have been associated with increased child pain during medical procedures (i.e. providing reassurance, empathy, apologizing, and giving control to the child). One established method of examining the role of emotional regulation in coping with acute pain has been to look at baseline heart rate variability (HRV), whereby low variability is thought to reflect a lack of autonomic flexibility, and this has been associated with higher reports of pain and distress in adults (and vice versa—higher HRV variability is associated with better pain tolerance and reduced distress). In the first pediatric study to explore the role of HRV and acute pain response, Constantin et al. (this issue) examined the associations between child HRV, parent behaviors (reassurance, giving control, and empathy) and child pain, fear, and distress in children aged between 7 and 12 years undergoing venipuncture. As predicted, they found that children with lower HRV experienced greater distress and may be more vulnerable to distress when faced with parental distress-promoting verbalizations during venipuncture. The findings provide a significant advancement in knowledge in pediatric pain and highlight the importance of considering the interplay of biological factors and the social context in shaping a child’s experience of a painful event. However, the findings also raise some methodological, theoretical, and clinical questions. In terms of methodology, parental behaviors were observed and coded by the research team, including supportive (coping-promoting) behaviors but they were not reported in this article. The integration of these findings within this study would have provided cross-validation if the effect of distress-promoting and distress-reducing parental behaviors were associated with lower and higher HRV, respectively. Of note, a companion publication (Constantin et al., 2022) focused on parental HRV and found that parents with good psychological adaptability (high HRV) had lower rates of both coping-promoting and distresspromoting behaviors (the authors concluded that the parents were not stressed by the procedure). This suggests that parental coping style is an important determinant in the coping supports offered to their children. The clinical status of the children may also be important—62% were described as having a chronic illness, but no further information was provided. Some children may have been more accustomed to venipuncture than others depending on their medical history. The authors also noted that the fact the participants were video recorded may have influenced