"Why Isn't It Going Away?": A Qualitative Exploration of Worry and Pain Experiences in Adolescents with Chronic Pain.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For children, a Pain Catastrophizing Scale, Child Version score greater than 26 would be considered high and associated with greater pain-related disability.

“For children, a PCS-C score >26 would be considered high and associated with greater pain-related disability [34].”

• cites [34] Pielech, 2014, Pain catastrophizing in children with chronic pain and their parents: Proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure, Pain sourceSupported

May combine two claims.

A diary study of everyday worries recorded by adolescents with and without chronic pain in the community found no differences in the types of worry between groups, though within the category of health worries pain-related worries were common for both groups.

“A diary study of everyday worries recorded by adolescents with and without CP in the community [15] found no differences in the types of worry between groups, though they did find that within the category of “health worries” pain-related worries were common for both groups.”

• cites [15] Fisher, 2017, Everyday worry in adolescents with and without chronic pain: A diary study, Psychol Heal Med sourceSupported

May combine two claims.

The cohort mean Penn State Worry Questionnaire for Children score was within the range found for children with clinical levels of anxiety and between the 80th and 90th percentiles of a community sample.

“The mean total score for the PSWQ-C (SD) was 21.5 (12.14); possible scores range from 0 to 42, where higher scores reflect higher levels of worry, placing our cohort mean within the range found for children with clinical levels of anxiety and between the 80th and 90th percentiles of a community sample [31,35].”

• cites [31] Chorpita, 1997, Assessment of worry in children and adolescents: An adaptation of the Penn State Worry Questionnaire, Behav Res Ther sourcePartly supported

  The Between-group comparisons section reports PSWQ-C scores for children with diagnosed anxiety disorders and finds them higher than scores for controls. Table 3 reports scores for a community-school sample, but the paper does not give an 80th–90th percentile range or establish that a score of 21.5 falls between those percentiles. Its clinical comparison supports the general context, not the precise placement claimed. (LLM, conf=0.82)

  Experimental — accuracy not yet measured
• cites [35] Esbjørn, 2013, Penn State Worry Questionnaire: Findings form normative and clinical samples in Denmark, J Psychopathol Behav Assess sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The psychometric measures have been shown to have good psychometric properties: construct validity, internal consistency, and concurrent validity.

“However, the respective measures have been shown to have good psychometric properties; that is, construct validity, internal consistency, and concurrent validity [29][30][31][32].”

• cites [29] Crombez, 2003, The child version of the Pain Catastrophizing Scale (PCS-C): A preliminary validation, Pain sourceNot checked — no full text of the source
• cites [30] Varni, 2001, PedsQLTM 4.0: Reliability and Validity of the Pediatric Quality of Life InventoryTM Version 4.0 generic core scales in healthy and patient populations, Med Care sourceNot checked — no full text of the source
• cites [31] Chorpita, 1997, Assessment of worry in children and adolescents: An adaptation of the Penn State Worry Questionnaire, Behav Res Ther sourceSupported

Classified as probably not a substantial claim.

The fear avoidance model posits that pain perceived as threatening and associated with catastrophic thinking is likely to lead to fear and subsequent avoidance behaviors, resulting in functional disability.

“The FA model posits that pain that is perceived as threatening and is associated with catastrophic thinking is likely to lead to fear and subsequent avoidance behaviors, resulting in functional disability [8][9][10].”

• cites [8] Simons, 2012, The fear avoidance model of chronic pain: Examination for pediatric application, J Pain sourceSupported
• cites [9] Lethem, 1983, Outline of a fear-avoidance model of exaggerated pain perception-I, Behav Res Ther sourceNot checked — no full text of the source
• cites [10] Vlaeyen, 1995, Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance, Pain sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Papers on quality in qualitative research were consulted to enhance the integrity of the methodology, informing decisions around sample size, coding, and theme identification.

“Papers on quality in qualitative research were also consulted to enhance the integrity of the methodology, informing decisions around sample size, coding, and theme identification [27,28].”

• cites [27] Hayter, 2014, Data collection and sampling in qualitative research: Does size matter?, J Adv NursNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [28] Levitt, 2018, Journal article reporting standards for qualitative primary, qualitative meta-analytic, and mixed methods research in psychology: The APA Publications and Communications Board Task Force report, Am Psychol sourceSupported

May combine two claims.

Pain catastrophizing was evident, as per previous research, though evoking these cognitions often required more in-depth exploration, suggesting that some pain fears may not be immediately accessible by clinical interview.

“Pain catastrophizing was evident, as per previous research [11,14], though evoking these cognitions often required more in-depth exploration, suggesting that some pain fears may not be immediately accessible by clinical interview.”

• cites [11] Tran, 2015, Distinct influences of anxiety and pain catastrophizing on functional outcomes in children and adolescents with chronic pain, J Pediatr Psychol sourceSupported
• cites [14] Vervoort, 2010, Children’s catastrophic thinking about their pain predicts pain and disability 6 months later, Eur J Pain sourceSupported

May combine two claims.

Data from standardized measures indicated that average worry levels were within the clinically elevated range and pain-specific worry was heightened.

“Data from these measures indicated that average worry levels were within the clinically elevated range [31,35] and pain-specific worry was heightened [34].”

• cites [31] Chorpita, 1997, Assessment of worry in children and adolescents: An adaptation of the Penn State Worry Questionnaire, Behav Res Ther sourceSupported
• cites [35] Esbjørn, 2013, Penn State Worry Questionnaire: Findings form normative and clinical samples in Denmark, J Psychopathol Behav Assess sourceNot checked — no full text of the source
• cites [34] Pielech, 2014, Pain catastrophizing in children with chronic pain and their parents: Proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure, Pain sourceSupported

Classified as probably not a substantial claim.

The pediatric fear avoidance model proposed by Asmundson et al. explains functional disability as following directly from escape and avoidance behavior, which follows from fear of pain and pain-related anxiety.

“The pediatric fear avoidance model proposed by Asmundson et al. [6] explains functional disability as following directly from escape and avoidance behavior, which follows from fear of pain and pain-related anxiety.”

• cites [6] Asmundson, 2012, Pediatric fear-avoidance model of chronic pain: Foundation, application and future directions, Pain Res Manag sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Fisher et al. found no differences in everyday worries among youths with and without CP and found that personal competence worries were common among both groups.

“Fisher et al. [15] found no differences in everyday worries among youths with and without CP and found that personal competence worries were common among both groups.”

• cites [15] Fisher, 2017, Everyday worry in adolescents with and without chronic pain: A diary study, Psychol Heal Med sourceSupported

May combine two claims.

The latter type of health-related worry, the possibility of serious harm, could be considered pain catastrophizing and was often not identified spontaneously but uncovered when responses on the pain catastrophizing questionnaire were explored qualitatively.

“This latter type, which could be considered pain catastrophizing, was often not identified spontaneously but uncovered when responses on the pain catastrophizing questionnaire were explored qualitatively, when participants were asked to explain their scoring decisions, which frequently led to broader discussions around the experience of painspecific worries:”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

One participant, Rory, described that stress and worry caused his pain to worsen and affected his ability to study.

“Well stress and worry, they like, in a lot of people they make them feel sick and then whatever they're stressing about like tests or anything, that's like a big thing with me, like, was with all the pain and I started stressing and it got worse and I wasn't able to study as well as I had hoped.”

May combine two claims.

Personal competence worries were related to participants' concerns about performing well in school, work, or hobbies and were identified to varying degrees across all participants and in some instances related to the potential impact of pain on their competence.

“Personal competence worries were related to participants' concerns about performing well in school, work, or hobbies and were identified to varying degrees across all participants and in some instances related to the potential impact of pain on their competence:”

May combine two claims.

Only one other participant directly referred to an association between worry and chronic pain symptoms, suggesting that links between these states were either not salient for most participants or not easily accessed via interview.

“Only one other participant directly referred to an association between worry and CP symptoms, suggesting that links between these states were either not salient for most participants or not easily accessed via interview.”

May combine two claims.

Participants were reluctant to give in to pain and reported a socially acceptable message of perseverance.

“Participants were reluctant to give in to the pain, and instead reported a socially acceptable message of perseverance:”

May combine two claims.

In terms of their own health, participants described a range of pain-related worries: the functional impact of chronic pain both now and in the future, what might happen at medical appointments, and the possibility of serious harm coming as a result of pain.

“In terms of their own health, participants described a range of pain-related worries: the functional impact of CP both now and in the future, what might happen at medical appointments, and the possibility of serious harm coming as a result of pain.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The third theme describes a complex active response pattern to the pain experience.

“The third and final theme describes the complex active response pattern to the pain experience.”

May combine two claims.

Participants frequently acknowledged that pain impacted their functioning, including difficulties attending school, engaging in preferred hobbies, attending social events, and with sleep and energy levels.

“Indeed, over the course of interviews, participants frequently acknowledged the impact of pain on their functioning, citing difficulties attending school, engaging in preferred hobbies, attending social events, and with their sleep and energy levels.”

May combine two claims.

The construction of worry and its impact on thinking was broadly uniform across participants and could be seen to represent a relatively static, though strong, concept within the mind.

“This construction of worry and its impact on thinking was broadly uniform across participants and therefore could be seen to represent a relatively static, though strong, concept within the mind.”

May combine two claims.

Health-related worries comprised both concern about one's own health and the health of a family member (two participants).

“Health-related worries comprised both concern about one's own health and the health of a family member (two participants).”

May combine two claims.

For the majority of participants, questions remained around the cause or source of the pain, with these questions maintaining an additional underlying level of uncertainty in the pain experience as a whole.

“Third, for the majority of participants, questions remained around the cause or source of the pain, with these questions maintaining an additional underlying level of uncertainty in the pain experience as a whole:”

May combine two claims.

Three main themes were identified: the worry ripple: mind, body, and behavior (with subtheme worry content: personal competence and health); the pain mystery: living in a "scribble of black"; and the resist or avoid conundrum.

“Three main themes were identified: 1) the worry ripple: mind, body, and behavior (subtheme: worry content: personal competence and health); 2) the pain mystery: living in a “scribble of black”; and 3) the resist or avoid conundrum.”

May combine two claims.

While the mind may initially hold worries, worry had a notable ability to take hold of other parts of the self.

“Yet, as worry was explored further it became apparent that while the mind may initially hold worries, the ability of worry to take hold of other parts of the self was notable.”

May combine two claims.

Participants' accounts of treatment attempts were often numerous and varied, and often limited in success.

“This understanding is further reinforced in participants' accounts of treatment attempts, often numerous and varied, and often limited in success.”

May combine two claims.

Qualitative analysis illustrated the ways that worry was conceptualized cognitively and emotionally and highlighted the nature of everyday and pain-related worries, some of which show features of catastrophizing.

“Qualitative analysis illustrated the ways that worry was conceptualized cognitively and emotionally and highlighted the nature of everyday and pain-related worries, some of which show features of catastrophizing.”

May combine two claims.

Worry was conceptualized as a process that initially impacted thinking but soon had other effects such as breeding other worries, and sometimes even worsening pain levels.

“At a broader level, worry was conceptualized as a process that initially impacted thinking but soon had other effects such as breeding other worries, and sometimes even worsening pain levels.”

May combine two claims.

Among the current population, the utility of worry was salient, but its potentially negative influence over behavior, emotion, and performance was perhaps more striking in its descriptions.

“However among the current population, while the utility of worry was rather salient, its potentially negative influence over behavior, emotion, and performance was perhaps more striking in its descriptions.”

May combine two claims.

Constructions of pain as an unpredictable, mysterious, and illogical entity were illuminated, as well as the delicate and constant navigation around this uncertainty in everyday life.

“Beyond this, constructions of pain as an unpredictable, mysterious, and illogical entity were illuminated, as well as the delicate and constant navigation around this uncertainty in everyday life.”

May combine two claims.

Worry and pain were experienced differently, with worry starting in the mind and then rippling out to the rest of the body and pain being a strong, mysterious force that led to uncertainty at different levels.

“Worry and pain were experienced differently, with worry starting in the mind and then rippling out to the rest of the body and pain being a strong, mysterious force that led to uncertainty at different levels.”

May combine two claims.

Narratives revealed both wins and losses: occasions where participants successfully proceeded with activities in spite of pain and were glad to do so, and occasions where they either missed out on planned events or the experience was tainted because of high pain levels.

“Narratives revealed both “wins” and “losses” in this regard-occasions where participants successfully proceeded with activities in spite of their pain and were glad to do so and occasions where they either missed out on planned events or the experience was tainted because of high pain levels:”

May combine two claims.

Participants described frustration with the uncertainty of the pain experience, the mystery around the cause of the pain, and the loss of control over one's life.

“Participants also described frustration with the uncertainty of the pain experience, the mystery around the cause of the pain, and the loss of control over one's life:”

May combine two claims.

The uncertainty of pain led to a conundrum of resist or avoid and a constant process of negotiating these.

“The uncertainty of pain led to a conundrum of resist or avoid and a constant process of negotiating these.”

May combine two claims.

Participants could identify both positive and negative beliefs about worry, a finding in line with worry metacognitions in younger children and metacognitions about pain rumination in adults with CP.

“At a meta-cognitive level, participants could identify both positive and negative beliefs about worry, a finding that is in line with worry metacognitions in younger children [39] and metacognitions about pain rumination in adults with CP [40].”

• cites [39] Wilson, 2011, Worry, beliefs about worry and problem solving in young children, Behav Cogn Psychother sourceNot checked — no full text of the source
• cites [40] Schütze, 2017, I call it stinkin’ thinkin’’: A qualitative analysis of metacognition in people with chronic low back pain and elevated catastrophizing, Br J Health Psychol sourceNot checked — no full text of the source

May combine two claims.

Current participants identified a range of everyday worries that were not specific to pain and instead centered on concern about personal competence in areas of school, work, and hobbies; only a small number of participants immediately identified pain-related worries.

“Similarly, the current participants identified a range of everyday worries that were not specific to pain and instead centered on concern about personal competence in areas of school, work, and hobbies; only a small number of participants immediately identified pain-related worries.”

May combine two claims.

Cognitive behavioral therapy is the most widely investigated psychological treatment for pediatric chronic pain and appears efficacious in the immediate term but less so at follow-up.

“Cognitive behavioral therapy (CBT) is the most widely investigated psychological treatment for pediatric CP and appears to be efficacious in the immediate term but less so at follow-up [5].”

• cites [5] Fisher, 2018, Psychological therapies for the management of chronic and recurrent pain in children and adolescents, Cochrane Database Syst Rev sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Qualitative research allows access to the internal world of young people with chronic pain to begin to tease out questions about cognitive and emotional experience in a bottom-up way.

“While quantitative studies are very useful in allowing us to better understand, compare, and predict the role of such cognitive factors in symptomology, qualitative research allows us to access the internal world of young people with CP to begin to tease out these questions in a bottom-up way.”

• AssumptionRests on an assumption: Knowledge of the lived cognitive and emotional experience of adolescent chronic pain is limited.

Probably not a substantial claim: may not pass S3 (load-bearing).

Of 21 families with whom initial contact was made, 12 participated.

“Of 21 families with whom initial contact was made, 12 participated.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The utility and appropriateness of questions was checked with the first participant following the interview; no changes were suggested, so the guide and the data pertaining to this participant were retained.

“The utility and appropriateness of questions was further checked with the first participant following the interview.No changes were suggested; therefore, the guide was retained, as were the data pertaining to this participant.”

Classified as probably not a substantial claim.

The role of worry in chronic pain has been understood as a misdirected problem-solving strategy, whereby the problem of pain is poorly framed around a persistent search for a solution to remove the pain, which in the context of chronic pain is likely to be fruitless and contribute to a perseverative loop.

“Indeed, the role of worry in CP has been understood as a misdirected problem-solving strategy, whereby the problem of pain is poorly framed around a persistent search for a solution to remove the pain, which in the context of CP is likely to be fruitless and contribute to a perseverative loop [18].”

• cites [18] Eccleston, 2007, Worry and chronic pain: A misdirected problem solving model, Pain sourceNot checked — no full text of the source

May combine two claims.

Participants' accounts of treatment attempts were often associated with a cycle of hope followed by disappointment and served to highlight the limits of traditional treatments in matching the force of their pain.

“Such accounts were often associated with a cycle of hope followed by disappointment and served to highlight the limits of traditional treatments in matching the force of their pain:”

Probably not a substantial claim: may not pass S3 (load-bearing).

The interview was piloted informally with colleagues to ensure that the wording of questions was understandable.

“The interview was piloted informally with colleagues to ensure that the wording of questions was understandable.”

May combine two claims.

The negative effects of pain impact young people's ability to engage in activities, but they often decide to resist this impact by doing those things despite the pain.

“In this dual narrative lies our conundrum: The negative effects on pain impact the ability of young people to engage in activities, but often they make the decision to resist this impact by doing those things despite the pain.”

• AssumptionRests on an assumption: Chronic pain impacts functional ability.

May combine two claims.

Pain catastrophizing has been shown to be a strong predictor of emotional distress and pain-related anxiety has been shown to be associated with greater levels of disability in adolescents with chronic pain.

“Given that catastrophizing has been shown to be a strong predictor of emotional distress and pain-related anxiety has been shown to be associated with greater levels of disability in adolescents with chronic pain [19,20], enhancing our knowledge in this area is imperative to treatment planning.”

• cites [19] Caes, 2015, The role of pain-related anxiety in adolescents’ disability and social impairment: ALSPAC data, Eur J Pain sourceNot checked — no full text of the source
• cites [20] Eccleston, 2004, Adolescent chronic pain: Patterns and predictors of emotional distress in adolescents with chronic pain and their parents, Pain sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Participants' use of common terms such as stress and anxiety may have reflected socially constructed fear-based processes and the use of language for sense-making around internal states.

“Participants' use of common terms such as “stress” and “anxiety” may have reflected socially constructed fearbased processes and the use of language for sense-making around internal states.”

May combine two claims.

For this sample of young people with chronic pain, worry was understood as an influential entity that shows up in the mind but also manifests within the body and influences behavior, sometimes helpfully and sometimes not.

“Ultimately, this theme suggests that for this sample of young people with CP, worry was understood as an influential entity that shows up in the mind but also manifests within the body and influences behavior, sometimes in a way that is helpful, but other times not.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Pediatric chronic pain may have a considerable functional impact in areas such as schooling, sleep, social, physical and emotional functioning, and overall quality of life.

“For affected young people, pediatric chronic pain (CP) may have a considerable functional impact in areas such as schooling, sleep, social, physical and emotional functioning, and overall quality of life [1][2][3][4].”

• cites [1] Eccleston, 2007, Adolescent chronic pain and disability: A review of the current evidence in assessment and treatment, Paediatr Child Health sourceNot checked — no full text of the source
• cites [2] Gold, 2009, Pediatric chronic pain and health-related quality of life, J Pediatr Nurs sourceNot checked — no full text of the source
• cites [3] Kanstrup, 2014, Insomnia in paediatric chronic pain and its impact on depression and functional disability, Eur J Pain sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The study maintained conscious openness to alternative or novel explanations that were in conflict with cognitive behavioral theories and the fear avoidance model.

“However, in line with a critical realist view and the maintenance of ethical rigor in interpretation, we maintained conscious openness to alternative or novel explanations that were in conflict with these ideas [25,26].”

• cites [25] Fletcher, 2017, Applying critical realism in qualitative research: Methodology meets method, Int J Soc Res Methodol sourceNot checked — no full text of the source
• cites [26] Willig, 2012Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

The identified fluidity of the worry experience and its recognized but partially ambiguous influence on mind, body, and behavior indicated the potential role for increased education around mind-body connections.

“The identified fluidity of the worry experience and its recognized but partially ambiguous influence on mind, body, and behavior indicated the potential role for increased education around mindbody connections, particularly given the established links between anxiety and CP.”

May combine two claims.

The negotiation can be seen as an attempt to resist pain and also as an attempt to exert agency by trying to overcome the uncertainty of the pain experience by making one's own decisions, whether to proceed in spite of pain or to choose to avoid certain activities.

“While the negotiation can be seen as an attempt to resist pain, it also seems to be an attempt to exert agency by trying overcome the uncertainty of the pain experience by making one's own decisions, whether that is to proceed in spite of pain or to choose to avoid certain activities:”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

The current findings add further support to the need for specific interventions targeting uncertainty, with acceptance-based strategies likely to be a feasible approach.

“The current findings add further support to the need for specific interventions targeting uncertainty, with acceptance-based strategies likely to be a feasible approach.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

At a clinical level, these findings indicate that acknowledgement of the role of uncertainty in the pain experience by clinicians may be validating for these young people in the first instance, while psychological treatments should incorporate strategies such as acceptance that support young people to manage and cope with both everyday and longer-term uncertainty.

“At a clinical level, these findings indicate that acknowledgement of the role of uncertainty in the pain experience by clinicians may be validating for these young people in the first instance, while psychological treatments should incorporate strategies such as acceptance that support young people to manage and cope with both everyday and longer-term uncertainty.”

Probably not a substantial claim: may not pass S2 (checkable).

Education around mind-body connections may also be beneficial.

“Education around mind-body connections may also be beneficial.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The decision-making process is likely to be further impacted by parents, teachers, health care professionals, and friends, and thus the current theme provides only a partial understanding of the complexity of this experience for young people with CP.

“Such a decision-making process is likely to be further impacted by parents, teachers, health care professionals, and friends, and thus the current theme provides only a partial understanding of the complexity of this experience for young people with CP.”

Classified as probably not a substantial claim. May combine two claims.

These scores indicate the clinical relevance of worry for this sample and highlight the importance of using a more in-depth approach to make sense of the role of these cognitions within everyday life.

“These scores indicate the clinical relevance of worry for this sample and further highlight the importance of using a more in-depth approach to make sense of the role of these cognitions within everyday life.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The qualitative administration of psychometric questionnaires added to the depth of information garnered via interviews and helped to triangulate the data.

“Additionally, the qualitative administration of psychometric questionnaires here added to the depth of the information garnered via interviews and helped to triangulate the data.”

Classified as probably not a substantial claim. May combine two claims.

Participants seemed to experience anger and frustration, and it is possible that these emotions helped them to summon the motivation to resist succumbing to functional disability and instead exert control over the pain and the uncertainty.

“Simultaneously, however, participants seemed to experience anger and frustration, and it is possible that these emotions helped them to summon the motivation to resist succumbing to functional disability and instead exert control over the pain and the uncertainty.”

Classified as probably not a substantial claim. May combine two claims.

Illness uncertainty is a well-documented feature of chronic health conditions that seems to be negatively related to adjustment, and a recent review paper highlighted diagnostic uncertainty as a critical factor in understanding and treatment approaches to pediatric CP.

“Illness uncertainty is a well-documented feature of chronic health conditions that seems to be negatively related to adjustment [43], and a recent review paper highlighted diagnostic uncertainty as a critical factor in our understanding of and treatment approaches to pediatric CP [44].”

• cites [43] Wright, 2009, The illness uncertainty concept: A review, Curr Pain Headache Rep sourceNot checked — no full text of the source
• cites [44] Pincus, 2018, Perceived diagnostic uncertainty in pediatric chronic pain, Pain sourceNot checked — no full text of the source

May combine two claims.

These fears were valid in the context of participants' past experiences but potentially served to further reinforce the complex negotiation between resist and avoid.

“These were valid fears in the context of participants' past experiences, but potentially served to further reinforce the complex negotiation between resist and avoid:”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The current study lacked definitive information about participants' history of psychological contact, and therefore it was not clear whether cognitions and coping skills were influenced by previous knowledge.

“Finally, the current study lacked definitive information about participants' history of psychological contact, and therefore it was not clear whether cognitions and coping skills were influenced by previous knowledge.”