At the time of clinic intake, children had experienced pain symptoms for a mean of 36 months (sd= 39.17). As shown in , there were significant differences between boys and girls on pain and functioning variables. Girls demonstrated higher VAS pain intensity scores compared to boys’ scores and girls reported higher anxiety sensitivity (CASI) scores than that of boys. Levene’s test for equality of variance indicated no significant differences in the variance of boys’ and girls’ scores despite the presence of more girls than boys in the sample.
Means and standard deviations for child and mother pain and functioning variables by child sex
The most common child pain conditions included headaches (46%), myofascial pain (38%), functional neurovisceral pain disorders including abdominal pain (37%), fibromyalgia (10%) and complex regional pain syndrome (6%); 23% of children had multiple pain diagnoses. There was a sex difference for fibromyalgia (X2 = 4.19, p<.05), with girls significantly more likely to experience this condition than boys. Maternal pain locations included head (n = 42), back (n =40), fibromyalgia or widespread bodily pain (n = 29), arm/leg (n = 21), abdominal pain (n =6) and other (n = 12). Paternal pain locations included back (n =35), head (n = 18), arm/leg (n = 18), fibromyalgia or widespread bodily pain (n = 11), abdominal pain (n =5) and other (n = 19). Mothers did not complete pain data for 20% of fathers (n =36).
Parent-child pain relationships: Quantitative data
The overlap between parent and child pain was examined separately for boys versus girls, and results are illustrated in . In terms of the mother-child pain relationship, 62% of mothers of girls reported experiencing pain compared to 47% of mothers of boys. Although the findings evidence a trend for mothers of girls to be more likely to experience pain than are mothers of boys, this difference was not significant (X2 = 3.05, p=.08). In contrast, 58% of boys had fathers with pain compared to 38% of girls, a statistically significant difference (X2 = 3.74, p=.03).
Mother-child and father-child pain overlap for boys versus girls
Next, mother-daughter versus mother-son pain relationships were examined for concordance in the location of pain. Information about pain locations was collected differently for children and mothers; headaches and widespread body pain were the only pain locations that could be compared between children and mothers. Thus, the number of daughters with headache who had mothers with headache was compared to sons with headache who had mothers with headache. Similarly, the number of daughters with widespread body pain who had mothers with similar pain was compared to boys with widespread body pain who had mothers with similar pain. The results are illustrated in . Among children with headaches, girls were more likely to have mothers with headaches (43%) vs. boys (19%) (X2 = 3.84, p<.05). For children with widespread bodily pain (myofascial and/or fibromyalgia pain) more girls (35%) than boys (16%) had mothers with bodily pain, a trend that was not statistically significant (X2 = 2.51, p=.11). The findings suggest a sex-specific concordance rate between maternal and daughter incidence of chronic head pain that is higher than for sons and mothers. Due to the high rate of missing father data, pain specific analyses were not carried out for paternal pain.
Mother-child pain overlap for specific pain conditions for boys versus girls
Correlations between maternal and child pain and functioning variables revealed a number of significant mother-daughter associations. In contrast, few significant associations were evident for mother-son relationships. As shown in , maternal depression was correlated with daughters’ functional disability, somatization, depression, anxiety sensitivity, and pain intensity. Maternal anxiety was related to all of these daughter variables except for daughters’ anxiety sensitivity; maternal somatization was related to all the daughter variables except for daughters’ anxiety sensitivity and depression. Maternal anxiety sensitivity was only related to parent-reported pain intensity in daughters. As shown in , the only significant mother-son association to emerge was for maternal anxiety sensitivity and son anxiety sensitivity (r = .53, p<.05). The sex-specific correlations show consistent associations between maternal psychological functioning and daughter pain and psychological functioning, while the only relationship for mothers and sons was for anxiety sensitivity.
Bivariate correlations between mother and daughter pain and functioning variables
Bivariate correlations between mother and son pain and functioning variables
Parent-child relationships: Qualitative data
Closeness of relationships
An apparent sex difference emerged in the closeness of parent-child relationships and the satisfaction of mothers and children with these relationships. Nearly all children reported high levels of interaction with their mothers and involvement of the mothers with management of their pain and health care. However, girls reported seeking substantially more emotional and behavioral support from mothers than did boys. Virtually all the girls described themselves as “close” to their mothers, spending a lot of time with them, shopping or cooking, and helping with a work project; only four boys described themselves as close to their mothers. For example, one girl described her day-to-day relationship with her mother:
I usually talk to my mom… We always play games together. She's always the one who takes me out when we go out, which is nice. Yeah, I mean -- and we watch TV together. I'll help her cook. We do everything together.
Mothers corroborated the high degree of intimacy that daughters sought; with some commenting that their relationship became closer since the pain, including this mother of a 16-year old girl: She went from being an extremely independent kid to being very clinging, very -- not separation anxiety but constantly wanting my attention. And you can't blame her for that given what she was going through. It was just such a shift from -- it was just a very big change.
A number of mothers appeared concerned about this increasing dependence: She's like a two-year-old. She needs Mommy all the time. Because she wants me to fix it. Another mother described her daughter’s dependence as a possible social barrier: Emotionally, you know she stays very close to home. She’s very scared to- I mean she doesn’t do things like go to camp. She doesn’t do things like spend the night out. She’s completely scared when it comes to flying the coop. It’s just developmentally I see her being young for her age in that way.
Mothers may have had cause for concern as over-reliance upon parents to take care of social needs meant that many girls did not develop interactions outside the home. Over-reliance upon mothers included displays of affection that reverted to younger developmental stages, such as wanting to sit on the mother’s lap, cuddle and sleep in the same bed or room as the mother and needing to be physically close to her. In many cases, mothers were the exclusive role models, friends and source of support. A highly enmeshed mother-daughter relationship was actually seen as contributing to pain by this 12-year old girl: When I see my mom isn’t happy I’m not happy, and until my mom’s happy I feel sad. The more she is sad, the more I am and sometimes it could affect the way—how my head hurts.
Although the additional closeness borne from pain was not always welcomed by mothers, they rarely discouraged it. A sense of helplessness to alleviate their child’s pain was common, and permitting or even encouraging a high level of inter-dependence may have been one source of comfort that mothers felt confident they could provide. As one mother expressed: ‘let me love you through it.’
In contrast, mothers of boys did not express reservations about their son’s increased ties due to the pain. Many mothers readily took on the role of their sons’ nurse, with few reporting impositions on their time and most willing to go to great lengths to take the pain away. This included wishing the pain upon themselves, or as this mother reported: I wish I could climb inside of his body and feel what he's feeling so that I could better help him figure it out.
As discussed below, overly concerned mothers of sons often engaged in solicitous behaviors that may have inadvertently rewarded the pain and contributed to boys’ disability. Many mothers treated their sons with pain differently to their other children, leading to perceived favoritism. One mother of a 12-year-old boy became heavily involved in her child’s life, leaving little time for his siblings: and I suppose you know no doubt he gets far more attention than the other kids.
Some younger boys expressed a similar level of dependence on their mothers as girls when it came to dealing with pain-related tasks. However, this closeness was distinct from girls in that it generally did not extend to sharing hobbies and non-pain tasks. In addition, many older adolescent boys attempted to pull away from their mothers’ displays of care, concern and affection. This marked a striking sex difference in how boys versus girls responded to mother-child relationships. While girls of all ages seemed to enjoy the closeness, older boys often expressed a desire for independence or for their mothers not to worry so much about them.
The following quote from a 17-year old male demonstrates a desire for independence including when arguing with other family members:
Yeah, I tell her all the time (not to defend him). Some times I’ll push her away. Not like push her, but just like you know (tell her to back off). He went on to describe his mother as ‘paranoid’ about his pain and heath. His mother recognized these concerns; however it was almost as though her son’s desire for space fueled her efforts to control: Sometimes he get a little frustrated with me because I’m a very paranoid mom. I’m terrified of something happening to my kids. So that’s when we have a little bit of problem because he’s- out of the 3, he’s my daring one. He’s very independent so.
Many mothers of boys were unwilling to relinquish their ties, even though they may have recognized the disadvantages of being overly involved: The one thing is, maybe because I am so nurturing, maybe I do need to back off a little bit. Maybe I’m not doing the right thing for him. Although I don’t know how much further I can back off because I want him still in my life.
The lack of father interviews made it difficult to gauge the closeness of relationships with fathers. However, some interviews with mothers and children gleaned information about the father’s role. Four fathers were highly involved with the child and the pain problem; however, most fathers were reported as not aware or as getting all their information from mothers. Most of these fathers were also described as having low levels of interaction with the children, either because they “work all the time” or because of divorce or separation.
One way that fathers may have played a role in parent-child pain relationships was by serving as models for pain behavior. Although few girls discussed pain in their fathers, a number of boys reported this as significant for them. One example included a 12-year old boy with back pain, who reported his father experienced similar pain:
In a way, we help each other. We know what it feels like and so more than anybody else really in our family. We know and so uh we know what the other person’s going through.
Similarly, mothers were often pain models for their daughters. A majority of mothers with daughters either reported they experienced on-going pain, or their daughters reported their mothers had pain. Although most mothers didn’t make a connection between their own pain and health and their daughter’s pain behavior, a number did: Melissa knows I have headache- and I would lie down with a washcloth on my head. Melissa would come in when she was six years old and tell me she had a headache and she would get herself a washcloth and lie next to me. This child’s headaches had escalated to the point that she would now break down in a crying ‘hysteria’ when she experienced head pain.
For both boys and girls reporting pain, many mothers regularly encouraged passivity, and near-daily reliance upon the parents to facilitate rest, suggest distractions, and provide comfort measures such as massage or ice packs. Maternal over-protection was also evident, with many mothers carefully monitoring their children’s symptoms and controlling the child’s own management strategies. Most fathers were not described as deeply involved with their children and, where they were involved or concerned, as supporting the same type of behavior as the mothers.
Parental solicitousness and over-protection emerged as a differential, in that the parents of boys – either mothers acting alone or mothers with fathers’ support – were more likely to use protective and reinforcing strategies when dealing with their child’s pain than were mothers of girls. In fact, the majority of mothers of sons allowed or encouraged their sons to rest, stay home from school, and rely on them for help. One mother went to the extent of holding the cup to her son’s lips when he wanted to drink and holding the telephone to his ear when he made calls. Some parents encouraged solicitousness by creating a nestlike environment, as one 16-year-old boy told the interviewer: My mom likes to ask me where I want to be to be comfortable[and] get me comfortable. My dad will say I'll go out and get you a movie to watch or food or anything.
The mother of a 14-year-old boy answered, when asked what was the most helpful thing she did for her son:
I think I just give him moral support. And the (mommy) comfort. I’ll try to rub his head, I’ll give him a hug, or something. When asked about the daily school decision, she said, I made those decisions. In the morning. There were days when I would force him, and we’d get all the way to the car and he would just cry. He can’t make it. His head hurts too much- so he would come back into the house.
Another mother described the impact of her over-protectiveness on her son’s normative development:
I think we’ve become overly protective of him and he’s not had a chance to do some of the things kids his age have normally done because we worry too much which probably causes him to have a headache or something
Several parents, particularly parents of girls, were less protective and encouraged the child to “get going,” “deal with it,” and “work through the pain.” Thus, mothers of daughters were more likely to take a “tough love” approach to school attendance, by trying to facilitate normal activities – providing a quieter place for homework or a supply of healthy snacks – or by helping with self-help approaches, such as the use of yoga poses.
Encouragement of functioning might involve striking a balance between being directive and letting her child to make decisions, as described here by the mother of a 13-year-old girl:
She needs to make her own decisions. And I understand that I need to pull back and not impose myself on her. And that's fine. But then at some point you have to still be a parent, and you have a child who's -- everybody has a kid that they don't want to go to school for one reason or another.
In a few cases, parents were described as negative, not believing in the child’s pain or not treating it seriously. Some parents even questioned whether their child was malingering. Generally, boys were more likely to report attempts to minimize their pain. One boy felt that he had to exaggerate his pain around several of his relatives so they would believe in his pain: It's like they were watching my every move, and it just - it's annoying that I now have to act like I'm in more pain than I am in around them just to make them be quiet about it. This boy went on to describe how his uncle had repeatedly told him to ‘toughen up.’
Although data regarding fathers’ parenting strategies are less detailed than mothers, it appeared that fathers were more likely to be critical of or dismiss their children’s pain. Critical or questioning behavior was most likely to be perceived by both boys and mothers as coming from fathers or other male relatives. For example, one mother of a 16-year-old boy, who was separated from her husband, reported:
And going to see his dad, he doesn’t particularly -- he has a problem with that. His father doesn’t understand. He thinks he just doesn’t want to do anything and wants to lay around the house.
As a result of pain-parenting strategies that restricted children’s independence, children’s autonomy or ability to self-regulate behavior was often affected. For girls, emotional autonomy was particularly compromised. An overly enmeshed mother-daughter relationship meant that many girls came to rely on their mothers for emotional support, often to the detriment of establishing their own peer networks. For boys, a high level of parental solicitousness and over-protection often interfered with their ability to engage in independent tasks. For both boys and girls, dependence on parents to take care of pain-related tasks, including pain reducing strategies was common and may have increased pain-related disability. Some children wished it was otherwise:
I wish that my parents would not…sometimes they’re just like too helpful, and it’s just like, “I can do that.” I’m capable of doing that, so I love them being helpful, but too helpful just gets me – uncomfortable.
Limited autonomy meant that many children displayed low self-efficacy - that is - limited confidence in their ability to perform activities. Reduced self-efficacy extended to school, peer relationships and other daily activities but was most often the case with pain-management tasks, such as expressed by this 13-year-old girl:
I don't care who knows what to do. If I could just do something to stop it, I would do it. But I don't know what to do either. Some parents were aware that their child’s dependence meant a limited sense of competence: Because of all the things she’s been through she has all these problems with separation from me so I’m trying to get her a little more independent so I’m hoping she can learn ways to make herself feel better on her own.
Children appeared to take on board the messages they received from their mothers about how to respond to pain and symptom management. Where mothers supported autonomy, both girls and boys were more likely to attend school regularly, use distraction, and continue most activities; where mothers encouraged passive or dependent behavior, children coped with pain primarily by staying home and resting or sleeping. The high level of concordance between behavior encouraged and behavior adopted by children demonstrates that boys and girls with chronic pain are highly receptive to the messages generated by their parents regarding appropriate behaviors.
Mothers’ behaviors reflected
In exploring some of the possible reasons for the use of different parenting strategies in dealing with sons versus daughters, it was apparent that differences existed in how mothers handled their own concerns or anxieties about the child’s pain. The majority of mothers who tended towards solicitousness in their sons were ‘worriers’ and projected a high degree of anxiety and felt overwhelmed by themselves and by their sons. In this sense, mothers of boys tended to ‘externalize’ their concern.
One mother of an 11-year-old boy described the multiple ways she expressed her feelings:
Awful. I think I cry when he's not around so he doesn't know that I'm upset. I try and do that. I pray a lot. I call my mom and talk to her. I think a lot. And I don't sleep well at night because I'm thinking, okay, what haven't we done?I wake up in the middle of the night just sick to my stomach. This mom treated her son like an invalid, and stayed at home with him (she’s just always there). Both this boy’s parents had had painful accidents, which he described as frightening. As his own pain developed, he became scared that something really bad would happen, and now thinks about it probably all the time- it’s the thought of hurting longer. Not only was the mother’s freely expressed anxiety conveyed to her son through her constant attentions, he seemed to have taken on her worry about the possible risks of pain, both in the case of his father and himself. Similar patterns were identified in the interviews of several boys whose mothers were over-protective.
In contrast, the majority of mothers of daughters were more likely to keep their worries to themselves, in attempting to be “the good mom.” One such mother of a 16-year-old-daughter described herself this way:
Actually, my family is pretty used to me fixing everything. I'm kind of that fix-it person. Mom was the rock, and then I became the rock. This mom had had an “excruciating” pain episode of her own: they've seen me in pain, but I'm the type that I hide it from my kids. I have to put the Mom hat on when the kids are around. Her daughter described her own role in the family: My mom's not home till late- so I do help with my sisters and tell them to take a bath, and take a shower now - I'll fix dinner for my grandpa. I'm here all the time, so I fix breakfast and lunch for my grandpa- and I'm more than happy to do it for them. This daughter both modeled her mother’s behavior and internalized the message that she should “deal with it.” She also wished her mother would do more to help her.
Although all mothers expressed similar concerns about their child’s pain, mothers of daughters were more likely to put on a brave face. Accordingly, girls may model their mothers in trying to play “the perfect daughter,” as well as in modeling the mother’s demonstrations of pain. In contrast, boys may have greater exposure to their mothers’ external manifestations of worry.