The adolescent pain experience is influenced by a complex interplay between biological, sociocultural, and psychological factors in which parents are highlighted as an important aspect of the environmental context.1,2
Although much of the research thus far has focused on the pain experience from the adolescent or the parent’s perspective, little attention has been focused on the parent-adolescent dyad as a unit until recently.38
This study begins to explore these dyads, particularly with respect to the effects of parent and adolescent catastrophizing in response to adolescents’ pain, pain behaviors that are an important communication mechanism between adolescents and parents, and the effects of concordance versus discordance in parent-adolescent dyads with regard to catastrophizing as a coping response to pain.
As predicted and consistent with past research findings,11,39,40
increased adolescent catastrophizing was significantly correlated with all indicators of negative adolescent outcomes. These findings are notable given the large sample size of clinically referred adolescents experiencing chronic pain. Specifically, increased adolescent catastrophizing was associated with higher pain intensity, greater functional disability, poorer quality of life, and increased depressive symptoms. These significant relationships remained after partialing out the effects of parent catastrophizing, although the magnitude of the correlations was reduced to a small degree. When the adolescent sample was separated into subgroups of high and low catastrophizers, high catastrophizers showed significant worse outcomes in all domains. The fact that depressive symptoms among the high catastrophizing adolescents were 4 times as high as the low catastrophizing adolescents reflects a strong relationship between this maladaptive coping style and mood symptoms. It has been proposed that this association may represent general negative affectivity, and historically the constructs of catastrophizing and depression were described as ambiguous and redundant. However, further research has shown that catastrophizing plays a unique role over and above broader depressive symptoms in predicting future mood problems as well as explaining pain-related outcomes.8
As predicted, parent catastrophizing about their adolescent’s pain was found to be associated with increased adolescent pain behaviors. Although the reason for this association needs further exploration, it is potentially a bidirectional relationship and may even be a self-reinforcing cycle. Research has shown that children showing greater distress tend to obtain stronger responses (both reinforcing and critical) from others in their environment.41
Parents engaging in pain catastrophizing may elicit more pain behaviors from their adolescents, and their constant vigilance to the adolescent’s pain may inadvertently reinforce more pain expression and result in misinterpretation of even innocuous behaviors as pain and suffering. This is supported by recent community-based research that found mothers of children with chronic abdominal pain have a tendency to interpret ambiguous facial expressions of emotion as pain.42
Conversely, parents who are high catastrophizers may be more likely to perceive pain behaviors resulting in a reporting bias, which in turn may inflate the relationship between parental catastrophizing and pain behaviors.
There are a number of proposed explanations for the role of catastrophizing as a coping response to pain and why this type of coping strategy might cluster in individuals with close/caregiving relationships. The communal model of coping8,9
describes the purpose of catastrophizing as a coping technique used by pain with pain to seek social support and resources from people in their environment. Overt displays of pain are one way for people with pain to communicate distress and solicit support from family and/or caregivers. Pain behaviors may be particularly pronounced if the person with pain desires or expects social support when in pain, but worries about potential negative reactions of directly verbalizing his/her needs.43
Empirical evidence in the adult pain literature has routinely supported the communal coping model of catastrophizing particularly in patient-spouse dyads.8,19,43
In turn, the frequent display of pain behaviors might be reinforced by overly solicitous responses from those in the environment.8
This type of mutually supportive maladaptive communication may be equally as strong in a parent-adolescent relationship characterized by chronic health issues, where adolescents are more heavily dependent on their parents than would be typical for their age for meeting physical, medical, and emotional needs.
Recent research in the pediatric literature continues to refine the communal coping and reinforcement model of catastrophizing and pain behaviors. In a study of experimentally induced pain in school-aged children, high catastrophizers were found to show facial pain expressions indiscriminately, whether or not a parent was present to observe these pain expressions and/or theoretically reinforce them with attention.44
Moreover, for high catastrophizers, youth increased their facial expressions of pain in response to nonreinforcing, nonpain talk from parents. These frequent, indiscriminant pain displays could be the result of repetitive attempts to communicate pain regardless of observer response, signs of generalized emotional and motor dysregulation, or even active attempts to cope with pain rather than inhibit negative emotions. Because pain behaviors can be both automatic and deliberate, it remains unclear whether the pain behavior displayed by high catastrophizers is intentional communication and to what extent behaviors that are shown depend on the “nature of the observer” (eg, parent vs. stranger).45
Clearly, more work in clinical populations of children and adolescents with pain is needed to see whether these relationships work in the same way.
Our exploration of dyadic concordance and discordance in level of catastrophizing revealed that most adolescents and parents tend to share the same (high or low) level of catastrophizing. Given the tendency of other forms of anxiety to run in families,46
this finding might be expected. Of equal interest were the discordant dyads where one member (parent or adolescent) reported high catastrophizing and the other reported low catastrophizing and whether or not this discrepancy in coping style resulted in differential outcomes. Results showed that adolescent-reported functional disability and depressive symptoms were significantly worse when the adolescent, and not the parent, was the high catastrophizer. This finding is particularly interesting given the collective research that suggests observers (parents) who engage in increased catastrophizing tend to be more attentive to pain signals, overestimate pain intensity, and report increased distress themselves,45
suggesting that a high catastrophizing parent might indirectly contribute to their adolescent’s disability based on their parenting decisions. However, if parental decisions about adolescent’s participation in daily activities is based on the adolescent’s level of distress, then even a highly anxious parent may have little reason to make restrictive decisions for adolescents showing minimal moodiness or worry about pain. It is possible that developmental influences also contribute to this finding such that parents may have a greater influence on the daily activities of younger adolescents, and less impact on older adolescents who show increased autonomy and independent decision making. Descriptive data tentatively support this idea, with young adolescents (ages 11 to 13) comprising 37% of the high parent catastrophizing discordant dyads and only 13% of the high adolescent catastrophizing discordant dyads. In the future, empirical work should focus on the nuances of age and development in parent-adolescent dyads.
It is important to consider that the impact of discordant dyads may not be fully captured in the outcome measures collected. For example, there was no measurement of parenting response to pain, such as punitive or solicitous behavior. Recent research found that adolescent catastrophizing is one mechanism of explaining the relationship between overly protective parental behaviors and subsequent adolescent pain-related disability.47
What remains unknown is how this type of outcome variable may differ more observably in a dyad with a high catastrophizing parent compared with a low catastrophizing parent. In addition, inclusion of parent-reported data may provide a richer understanding of these dyads. Cohen et al38
found concordance on parent and adolescent ratings for pain-related outcomes related to more overt behaviors such as physical functioning and shared environmental factors such as family functioning, and significant discordance for internal processes such as depressive symptoms, pain-related anxiety, as well as functional disability on the FDI. Although beyond the scope of this study, future research should determine whether similar results are found in this sample, and if so, whether our conclusions hold true for parent-reported functional disability.
Several limitations should be considered when reviewing these results. Parent catastrophizing almost exclusively referred to maternal catastrophizing in our study, although many adolescents reside with 2 parents. The level of paternal catastrophizing was unknown and consequently we were unable to assess whether or not entire families (both parents and patient) shared a similar style of catastrophizing. It would be interesting to know whether parental catastrophizing may only be relevant for the parent who engages in medical and caregiving decisions, such as when to seek treatment, call health care providers, or keep the adolescent home from school, and if catastrophizing levels of a less involved parent are less meaningful. Also, if parental discrepancies in catastrophizing exist, it is unknown whether this might serve as a protective factor, that is, one parent buffering the anxiety of the other for the adolescent.
It should be noted that pain behavior was measured based on parent report of adolescent’s pain behaviors, which may result in skewed data for high catastrophizers. An objective assessment would confirm parental impressions, and sophisticated facial or behavioral coding systems could better quantify pain behaviors. Nonetheless, parental observation and impressions of their adolescents’ pain behaviors remain important as they form the basis for making judgments and decisions about their adolescent’s pain.
Future studies should look at the impact of catastrophizing and pain behaviors on parent responses to pain, and whether differential parent responses are a function of parent level of catastrophizing. Further, recruitment for research protocols should focus on fathers, given the paucity of data on paternal responses to adolescent chronic pain. Because outcome measures were primarily reported by adolescents, it would be beneficial to determine whether the findings for discordant dyads are replicated using parent-proxy report. From the perspective of adaptive coping, it would be interesting to study how parents who are “low catastrophizers” function. For example, do parents who are “low catastrophizers” show bias whereby they underestimate adolescent pain-related disability or do they accurately perceive disability but register low levels of distress? Finally, replication of the current research with larger samples of discordant dyads may yield more fruitful outcomes.
The present study further explores how the family milieu affects the complex connections between pain catastrophizing, pain behaviors, mood, and functional out comes for adolescents experiencing chronic pain. Analyzing a large clinical sample, it describes parent-adolescent pain coping characteristics from a dyadic perspective. This view offers an initial exploration into the realm of family implications of chronic pain in adolescents and invites further research on resiliency and vulnerability factors for these families.