The current findings extend our prior efforts at identifying sociodemographic, parental, and child predictors of medical consultation for pain in healthy children and adolescents (4
). Multivariate analyses indicated that for girls only, parent’s physical health status was a key predictor of HCU for adolescent’s pain. Poorer parent health status was associated with an increased likelihood of girls visiting a health care professional for pain during a roughly 3 month period following a laboratory pain session. For every 1 unit decrease in parent physical health status, the likelihood of girls visiting a provider for pain increased by 0.80 units (see ). This effect held even after controlling for mothers’ educational level. Parents’ mental health status was not associated with pediatric care-seeking for pain. Girls’ laboratory pain responses were not predictive of HCU for pain after accounting for parent physical health status, although bivariate analyses indicated that girls’ anticipated pain and bother for the cold pressor task were significantly correlated with utilization. Among boys, however, no parent or child correlates of HCU emerged. Approximately half of the current sample of youth (n
= 120; 62 girls) completed a measure of physical and mental health status [The Children’s Health Questionnaire or CHQ (21
)] comparable to that completed by the parent. Additional analyses found no relationship between children’s own perceived physical or mental health status and medical consultation for pain in this subset of participants.
Our findings are in accord with those of Levy and colleagues who reported that children of parents with IBS had more clinic visits for both gastrointestinal (GI) and non-GI symptoms compared to controls (17
). Yet, our results diverge somewhat from Levy et al’s in that the observed relationship between parent physical health status and medical consultation for children’s pain was evident only for girls. In contrast to Levy et al, we did not select a parent population with a chronic illness and it is possible that boys and girls alike are impacted when parents experience chronic health conditions. Unlike Levy et al, we only assessed utilization specifically for pain complaints; our results may have differed had we assessed HCU for a broader range of symptoms. In contrast to previous reports indicating a link between maternal psychological distress and child HCU [see review by Moran & O’Hara (6
)], we did not find an association between parent mental health status and pediatric HCU for pain. Nevertheless, it should be noted that other investigators have also failed to find such a relationship (10
). As discussed by Moran & O’Hara (6
), these conflicting results may be due to variation in the assessment of maternal psychopathology and/or pediatric HCU.
The present results are also consistent with our own earlier work indicating no association between the pain responses of youth to the cold pressor task and subsequent visits to a school nurse (4
). The prior research was conducted in a school with an “open system” for nurse visits, meaning that youth were able to self-initiate care without permission from teachers or parents. In the current study, we did find significant bivariate correlations between anticipated pain and bother for the cold pressor task and HCU for pain among girls. However, in multivariate analyses, the contribution of the laboratory indicators to healthcare use was overshadowed by that of parent physical health. Taken together, our work suggests that laboratory pain indicators show only weak associations with pediatric HCU for pain. The current results are also consistent with our previous research indicating significant sex differences in the relationship between children’s pain symptom scores and nurse visits in the aforementioned open system, in which girls generally demonstrated stronger relationships between pain symptoms and care-seeking (5
). As noted above, in the current study we did not find any significant relationships between parent or child characteristics and HCU for pain among boys suggesting that additional work is needed to identify relevant predictors of utilization in this population.
Levy et al (18
) have proposed that the mechanism responsible for the effect of parent health status on children’s symptom reporting and subsequent medical consultation may be modeling, defined as the observation of and imitation of another’s behavior. Levy and colleagues suggest that youth may be modeling their parents’ illness behaviors, i.e., the ways in which people perceive, evaluate and react to somatic sensations that might indicate disease, and as measured by symptom reports, disability days, and medical visits. For example, youth may be modeling their parent’s behavior by engaging in a high level of symptom reporting, which in turn may lead parents to initiate care-seeking. Moreover, parent’s own perceptions (of the child’s as well as their own symptoms) may influence decisions about whether to take the child to a healthcare provider by lowering the threshold for parents to seek care. Our results suggest that girls may be particularly vulnerable to the influence of parent’s perceived health status and by extension, parents’ illness behaviors. Retrospective studies have found that females are more likely than males to report relationships between a positive family history of pain and their own poor general health (22
) and pain complaints (23
). Our own recent work also indicates that perceptions of maternal pain among healthy children and adolescents are more consistently related to girls’ pain than to boys’ pain (24
). Most of the parents in our sample were mothers (85%) and this may partially account for the sex difference in the association between parent health status and child HCU for pain. Mothers are most likely to be the primary decision-makers in seeking healthcare for children, and there may be more overlap between mothers’ and daughters’ symptoms than between mothers’ and sons’. Relatedly, girls may have been more willing than boys to complain of pain to their mothers, although it should be noted that the mean number of visits did not differ between boys and girls (see ). These possibilities are speculative and require further testing.
Several limitations to the current investigation should be mentioned. We relied on youth self-reported medical visits for pain rather than automated utilization data. However, given the paucity of research in this area, our work identifies salient characteristics that may be investigated in future work utilizing automated data. Also, we did not look specifically at role of parents’ own pain in pediatric care-seeking as the SF-12 only generates summary mental and physical health scales. Although bodily pain is one aspect of the physical health summary score, the SF-12 scoring system does not allow examination of individual subscales. Another limitation is that we did not collect data on health insurance status. However, when additional analyses were conducted including mother education, a reasonable proxy for SES our overall results were the same. The current sample was highly educated (nearly 60 % had college degree or higher) and therefore the influence of SES may have been attenuated due to restricted range. Relatedly, in light of the sample’s high SES, the current findings may not generalize to other less affluent populations. Only about half the youth sample completed the CHQ and so we were not able to examine the role of child physical and mental health status in the total sample. It is possible that the failure to find a link between child physical or mental health and HCU for pain in the subsample that completed the CHQ may have been due to low power.
In sum, this prospective study demonstrates that child and parent variables together influence decisions to seek care for adolescent’s pain. Among healthy girls, older age and poorer parent physical health status were predictive of greater HCU for pain. Our findings suggest that girls may be particularly sensitive to parent modeling of illness behaviors; and given that the majority of parents were mothers, that girls may be particularly sensitive to maternal
modeling of illness behaviors. The clinical implications of this study include the possible value of interventions to assist parents in managing their own physical health symptoms to reduce adolescent’s medical consultation for pain. In the general pediatric population, child health accounts for only about one-sixth of the variance in pediatric HCU [see review by Janicke et al (25
)]. Our findings suggest that parent physical health explains at least part of the remaining variance, although only for girls. Future efforts should continue to identify the most relevant predictors for pain-related pediatric HCU, especially for boys.