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Chronic or recurrent pain is a widespread health issue that affects a large proportion of the population, including adults and children. Family factors in the development of pain have received increasing attention of late as research has shown that pain tends to run in families, A burgeoning literature has also demonstrated the influence of parental factors in children’s responses to chronic and laboratory pain. This review attempts to integrate: first,) the literature documenting an association between parent and child pain both within the clinical chronic pain and laboratory pain literatures; and second,) research accounting for likely mechanisms explaining the parent-child pain association. To this end, we present a conceptual model that incorporates a number of parent and child specific characteristics, such as parental responses, coping and gender role socialization as well as broader socio-demographic factors such as parent and child age and sex, family functioning, socioeconomic status, and race/ethnicity. It is anticipated that consideration of such variables will lead to needed research exploring the mechanisms of parent-child pain relationships, and to interventions designed to prevent and ameliorate child pain sensitivity when it correlates with poor adaptation to pain.
A vast literature documents the association between the experience of pain in parents and the experience of pain in children. Trans-generational pain relationships appear across pain conditions –both within the laboratory and the clinical world – and across relationships, such that children with chronic pain very often have parents with chronic pain, and parents with chronic pain often have children with chronic pain. It is the purpose of this review to integrate the current psychosocial literature exploring possible mechanisms that underlie the link between parent and child pain. A recent review has described important parent and family factors in pediatric chronic pain (1). We attempt to build on the integrative framework presented previously by including child/parent and family factors in children’s chronic and experimental pain, as well as highlight the role of parental pain in understanding child pain.
Considering both chronic pain and responses to acute, laboratory pain allows an understanding of pain relationships across situations and for the development of a general parent-child pain model. As discussed below, children may learn an entire repertoire of pain responses. Parent-child pain relationships are relevant for chronic pain, where children may model precise symptoms, and acute pain, where children call on their knowledge of general pain behavior and where anxiety, fear, and perceived threat play a salient role. It is argued that “real world” medical procedures are subject to inherent variations in stimulus intensity, and/or duration, and meaning/context, leaving laboratory studies, where the pain stimulus and environment are controlled, as preferable in assessing acute pain responses where experimental models can be manipulated.
Below we discuss a model that accounts for a number of explanatory variables that likely lead to familial pain as assessed through chronic pain and acute laboratory pain studies. While biological and genetic factors in family transmission of pain are important, we focus on psychosocial contributions. As befitting a theoretical causal model, we first present an overview of research demonstrating an association between parent and child pain.
The presence of pain models in the family environment has been associated with increased risk for child pain and pain-related disability. A broad social learning perspective (2–5) encompassing vicarious learning, modeling, and reinforcement has provided the framework for research showing that parents can have a direct impact on their offspring’s pain experiences through modeling responses to painful stimuli. Studies of pain modeling (6–9) and family history of pain (10–13) demonstrate strong effects.
Family predictors of child pain have been studied in several chronic pain samples. Relationships have been reported between child juvenile arthritis and parent pain history (14) with higher levels of current parent bodily pain correlated with higher levels of child arthritis pain. Studies have also shown relationships between child and parent headache and migraine (15–17), child fibromyalgia and multiple chronic pain conditions in parents (18) and child-mother abdominal pain (19). Aromaa et al. (20) assessed familial aggregation of headache and found increased estimates of pain sensitivity in both mothers and fathers of children with headaches compared to non-headache controls. Laurrell et al. (15) reported that first-degree relatives of children with headaches suffered more migraine and other pains compared with first-degree relatives of children without headache.
Laboratory studies offer a unique opportunity to investigate the parent-child pain relationship in a controlled environment. Thastum et al. (21) investigated cold-pressor pain in 15 children with juvenile arthritis (JA), 25 healthy children and their parents. Child and parent responses were correlated for pain intensity and tolerance, and parents of JA children showed greater pain intensity relative to parents of healthy children, suggesting that parent/child pain relationships may be stronger in chronic pain samples. A further study providing evidence for a social learning approach found that healthy children’s responses to the cold pressor task were related to their mothers’ style of responding, such that children who viewed their mother exaggerating displays of pain had lower pain thresholds than did children whose mothers were not given instructions on how to respond (22). Two studies have examined the relationship between family pain and young adults’ experimental pain responses. In one, the number of family members with bodily pain was related to greater daily pain and a counterintuitive finding of decreased pain intensity in response to the cold pressor task (23). In the second study, a positive family history of pain was related to increased pain episodes and sensitivity to experimental thermal pain only in females, not males (11). This study points to the possible moderating role of parent and child sex, a topic we discuss presently.
Another line of research has explored the parent-child pain relationship in a ‘top-down’ manner by examining parents with chronic pain, and determining whether their children are also at risk of pain. Clinical and population-based research that has taken such a parent-focused approach shows conflicting results. Many studies have revealed that parents with a number of pain conditions, including migraine, backache and general somatization tend to have children with a range of physical and psychological heath issues (15,24); however, not all do (25). Recent work has indicated that the relationship between parental pain and child outcomes may be a function of dose-response, such that multiple pain sites in the parent are associated with increased risk for children (26). Parental pain may have to reach a certain threshold or level of salience before children are affected.
Research documenting the accuracy of parental pain histories by offspring may also shed light on why we see stronger parent-child pain relationships when focusing on child pain as opposed to parent pain. In one study, adult offspring and their parents independently reported on parental chronic pain histories. The offspring were inaccurate in their recollections of parental pain; however, it was offspring recollection of parental pain, and not confirmed parental pain, that predicted adult children’s own pain status (27). It appears that not every parent with pain will have children with increased pain sensitivity, perhaps because not every child is aware of parental pain models. However, children with pain tend to come from families with pain, and these children may have been the ones who either witnessed or focused on parental pain.
Taken together, the literature suggests that child and parental pain are closely tied, especially when examined from the child’s viewpoint. This observed parent-child pain association appears to exist within chronic pain and acute laboratory contexts, suggesting that children may model both general pain behavior and precise symptoms or behaviors (28). It is possible that through social learning and family dynamic mechanisms, children develop an entire repertoire of pain responses in pain affected families.. It is also possible that family pain relationships exist due to shared environmental factors that trigger the risk of pain in parents and children (26). The model and accompanying literature discussed below attempts to explain family pain relationships using the framework that parents serve as pain models, and the possibility that shared demographic and family factors lead to an increased risk of pain in children.
The relationship between parent and child pain is likely characterized by complex, bi-directional influences operating in the parent-child environment. The conceptual model presented in figure 1 accounts for a number of psychosocial mechanisms that can be gleaned from the literature as discussed below, as well as hypothesized where empirical research is absent. For example, research has not yet examined feedback loops between mechanisms linking parent and child pain, but such bidirectional influences represent an important addition to parent-child models. Although no one study to date has tested an entire model of parent-child pain relationships, various studies have examined individual mechanisms.
The conceptualization of negative affect is based on the tripartite model (29) in which “negative affectivity” is a broad, pervasive disposition to experience negative emotions (30), representing the nonspecific shared factor between anxiety and depression. Most studies examining parental psychological factors in relation to children’s pain have focused on pediatric chronic pain populations. Studies in mothers of children with recurrent abdominal pain (RAP) found higher levels of anxiety (31–33) and depression (31–34), compared to mothers of children without RAP. Evidence regarding fathers is mixed (31–33). A study in children aged 3–11 years found that lifetime history of maternal depression was 1.5 times more likely in children with headache and 2.3 times more likely in children with RAP (35).
Mothers of pre-school children with recurrent headaches and stomachaches were significantly more likely to be depressed compared to healthy children (34). Maternal anxiety has also been associated with increased child distress during painful medical procedures in children with cancer (36–41), but not in healthy children in relation to blood draws (42). However, the primary outcome of these studies was child behavioral distress/degree of cooperation and/or child anxiety rather than pain per se. As most of these studies have been conducted in clinical populations, parent psychological distress may be a consequence of having a child with recurrent pain as well as play a role in the etiology or maintenance of children’s pain (33). Longitudinal studies that assess parental negative affect and children’s pain will likely illuminate their relationships and relevant mechanisms.
Psychological vulnerability, a construct posited to include child anxiety sensitivity and temperament, may be an important determinant of child chronic and laboratory pain. A recent study found that anxiety levels in mothers and fathers in the child’s first year of life as well as the child’s temperament (specifically, irregular feeding and sleeping) were related to later childhood recurrent abdominal pain (43). Anxiety sensitivity (AS) refers to the specific tendency to interpret anxiety-related bodily sensations (e.g., rapid heart beat) as dangerous (44,45). AS is related to but conceptually distinct from trait anxiety (46). In a laboratory study assessing parent negative affect and children’s pain, maternal AS predicted child AS which in turn predicted children’s laboratory pain intensity for girls but not for boys (47). These findings highlight the role of parent and child negative affect in children’s laboratory pain, as well as the possible moderating role of child sex, and potentially of parent sex.
It is likely that a variety of coping strategies are involved in parent and child pain. Pain catastrophizing, comprised of elements of rumination, magnification, and helplessness, has emerged as a potent predictor of pain and pain-related disability in clinical samples, including patients with low back pain, rheumatoid arthritis, fibromyalgia, headache, and sickle cell disease (48,49). In a recent clinical study, parent’s catastrophizing about child pain played a significant role in children’s pain-related disability and school attendance that was independent of the child’s pain intensity (50). Catastrophizing has been significantly related to increased laboratory pain in healthy child and pediatric pain samples (21, 51–53). Thastum (21) found that catastrophizing predicted 27% to 66% of the variance in cold-pressor pain responses in children with JA and 12% to 39% of the variance in laboratory pain in their parents; compared to 24% to 34% of healthy children’s laboratory pain; and 6% to 30% of healthy children’s parents’ laboratory pain. These findings suggest that catastrophizing plays a role in acute and chronic, clinical and laboratory pain, although it may exert a stronger influence for children with chronic pain.
The social learning view of family pain hinges on parental responses. Parents can set the stage for child pain by providing models for how to feel and deal with pain, as well as reinforcement for children’s pain. This reinforcement may occur through solicitousness, sympathy or exemption from duties or attendance at school, and may be inadvertent. In a study examining maternal health and hypothetical child illness scenarios, mothers with poorer health evidenced higher negative emotion, more caretaking behaviors and tolerated more sick-role behaviors in relation to the scenarios (54). In a chronic pain sample, Walker and colleagues (55) found that protective mothers had children with higher health care costs and more frequent use of healthcare facilities. Similarly, parental solicitous behavior has been related to increased child functional disability, especially for depressed children (56). A recent laboratory study compared healthy children and children with recurrent abdominal pain on a visceral pain task (57). Symptom complaints to the laboratory task nearly doubled when mothers provided attention and were reduced by half when mothers responded with distraction, relative to when mothers were given no instruction on how to respond. The effect of attention on complaints by female pain patients was greater than for male patients or healthy children, These findings suggest that parent responses to children’s symptoms can significantly increase or decrease such complaints, and this relationship holds across chronic and laboratory pain studies.
Parental responses can also include general parenting style. A recent clinical study examining the effects of maternal chronic pain on children’s physical and psychological health reported that parenting mediated the relationship between parent and child health (58). In particular, over-reactive parenting, characterized by authoritarian demands, mediated the relationship between maternal physical functioning and children’s internalizing, externalizing, and health behavior. Mothers with chronic pain also report a greater number of difficulties in day-to-day parenting tasks compared to healthy control mothers (59). Given the extra demands on family members associated with parental pain and child pain, parenting stress may well emerge as an important variable in understanding the clinical parent-child pain relationship. The role of parenting style in children’s laboratory or acute pain is not as clear.
It is widely assumed that the stereotypical masculine gender norm emphasizes the ability to withstand pain as evidence of being tough and “macho” as opposed to appearing sensitive or delicate, characteristics associated with stereotypical femininity. Males are thought to be more motivated than females to appear impervious to pain and independent of the need for help when in pain. Mechanic(60) cited this gender norm when reporting that boys were significantly more likely than girls to indicate they neither feared getting hurt nor paid attention to pain. Gender role expectations in relation to children’s chronic pain are not well understood. However, stereotypical gender-related traits have been studied in the laboratory. For example, adult males higher in stereotypically masculine traits exhibited higher laboratory pressure pain threshold, relative to other males or to females (60,61).
One of the first places that gender role socialization develops is in the family, often through the opinions and actions expressed by parents. Children are likely to learn to embody the gender roles valued by their parents. Studies have shown that females and males experience differing consequences when they transgress gender norms (62,63). Parents, especially fathers, reward boys more than girls for gender congruent behavior, and punish boys more harshly than girls for deviations from gender norms (63). Psychosocial theories of pain behavior have focused on the effects of contingencies on the emergence of and persistence of pain behaviors (64,65). Empirical examinations of the influences of pain modeling and family history of pain demonstrate strong effects, including sex-differentiated effects (10–13). To illustrate how this may work, as a result of sex-differentiated contingencies in families expressing strong gender expectations, boys may be less willing to express pain, which is of key importance because willingness to report pain has been shown to explain a greater portion of the variance in laboratory pain responding than subjects’ sex (66). We recently reported that for healthy children in a laboratory setting, masculinity correlated with lower heat pain ratings in boys but not in girls (67). Boys with higher masculinity ratings were less likely to report pain than boys high in femininity Thus, boys who engaged according to gender-role expectations reported less pain. Further research is needed to untangle the relationships between gender roles, sex and pain in children and parents, especially in chronic pain populations.
Although many of the variables included as contextual factors in the experience of pain have not yet received wide empirical attention, the importance of sex of the parent and sex of the child is evident. Consequences for pain behaviors have been shown to differ in a sex-dependent manner, with consistent findings across chronic pain and laboratory pain studies.
Females appear to be more sensitive to familial pain models compared to males (10). Fearon et al (68) observed children in daycare centers and noted that despite an absence of sex differences in the incidence or reported severity of everyday pains, girls engaged in more distress responses to pain and received more physical comfort from adult caregivers. It is further possible that sex-specific relationships occur in relation to parental chronic pain, such that daughters are more sensitive to maternal pain and sons to paternal pain. A recent pilot study comparing mothers and fathers with chronic pain found that children were more sensitive to maternal pain, however, the sample size was too limited to compare responses according to child sex (69). In terms of laboratory pain findings, we recently reported that among healthy boys and girls, the number of pain sites and laboratory pain responses were associated with the presence of maternal pain, but that these relationships were particularly strong among girls (70). A study of healthy young adults found that a positive family history of pain was associated with increased reports of pain in the past month and enhanced sensitivity to laboratory pain in females but not in males (11). Thus, existing data indicate important relationships between parent models and child pain in both chronic and laboratory pain contexts, with some data suggesting that girls are particularly vulnerable to parental pain modeling.
As yet, no single study has examined the differential impact of mothers versus fathers on girls’ versus boys’ pain either within a clinical or laboratory setting. A study exploring parental physical illness as a risk factor for children’s psychosocial adjustment lends some insight into sex-specific trans-generational influences. During puberty, girls’ and boys’ functioning was adversely affected when the respective same-sex parent had a serious physical illness (71). This study did not examine parent or child pain as such, but it is possible that similar sex-specific relationships operate for pain.
Other socio-demographic variables have received only limited work and primarily in the area of chronic pain. One study that examined a range of parent/child demographic predictors of maternal response to child abdominal pain sheds light on some likely moderators of chronic pain transmission (72). In this study, maternal somatization predicted greater monitoring of children’s symptoms while demographic factors such as a younger or male child, non-Caucasian race, less maternal education and no father in the home predicted greater protectiveness and monitoring. Acknowledging the impact of parenting responses, it is possible that these demographic variables distally lead to reinforcement of child pain. Other research has explored the role of family functioning, showing that increased pain and disability in children with chronic pain are more likely in disruptive families than in adaptive family environments (73). Unhealthy family functioning and lower adolescent autonomy have also been implicated in children’s headache-related disability (74). Studies examining negative life events have found increased family stress associated with child pain for both chronic (75,76) and laboratory pain (77). Despite large gaps in the laboratory pain literature, patterns are beginning to emerge regarding the role of contextual sociodemographic influences in parent-child pain relationships.
Biological, psychological, and sociocultural factors have been proposed as mechanisms underlying the experience of pain. The family plays an integral role in the child’s psychology and sociocultural context by socializing the child’s display and meaning of pain behavior (73,78,79). The model outlined herein identifies parent and child characteristics that may singly or in combination influence parent-child pain relationships, within chronic and acute pain settings. Clearly further work is required to delineate possible variations in the extent that parent and child variables influence acute versus chronic pain. At this time, it appears that similar mechanisms are involved, however, parent and family influences may be more potent for chronic than for laboratory pain (80).
Future research demonstrating underlying mechanisms in the association between parent and child pain can lead to the identification of salient child and parent factors that can form the basis for targeted interventions. If similar mechanisms are identified in children’s acute and chronic pain, skill-based interventions can be developed to target parents of children with pain problems in the laboratory, a context where they can receive immediate feedback on their ability to impact their children’s pain responses. Other practical implications include raising the awareness of health care professionals to the possibility that parental responses, such as inadvertent attention and parenting stress, may give rise to the development of pain or serve to exacerbate existing pain conditions in children. Further acknowledging that certain families, such as those experiencing family discord or reduced resources, may be at risk for family pain behavior could also lead to new insights and family-based interventions.
This review is a further step towards elucidating the influence of psychosocial variables in parent-child pain relationships. As yet, no work has examined the biological, psychological, and sociocultural parent factors that potentially shape children’s pain response within a comprehensive, integrated model. The much larger task of integrating biological and wider social influences is ahead, and with this integrative approach will be the incorporation of pain-associated genetic polymorphisms that may play a role individually as well as together with psychological and sociocultural factors.