Pain, 52 (1993) 311-317 0 1993 Elsevier Science
B.V. All rights reserved
Children of chronic pain patients: risk factors for maladjustment Deborah Y. Chun ‘, Judith A. Turner ‘S and Joan M. Roman0 ’ Departments
of’ Psychology (NI-25), ’ Psychiatry and Beharioral Sciences (RP-IO) and ’ Rehabilitation Medicine, Linker&
Seattle, WA 98195 (USA) (Received
Recent research has documented negative effects of chronic pain problems on patients’ spouses and children. This study examined the adjustment of children of 35 chronic pain patients, compared with children ‘of 29 healthy controls, and the relationship of specific parental characteristics to child adjustment. Pain group children had significantly more teacher-rated behavior problems and significantly lower teacher-rated social competence than did control group children. Children of male patients were rated by parents as significantly less socially competent than children of female patients. Compared with controls, pain patients and their spouses reported significantly more depression, and pain patients were significantly more disabled. Patient functional disability was significantly associated with parent-rated child behavior problems, but group membership, patient gender, patient depression, and patient marital satisfaction were not. Child social competence was predicted by patient gender, but was not predicted by patient depression or disability, group membership, or by patient marital satisfaction. The results suggest that children of chronic pain patients may be at risk for adjustment problems. Summary
Key words: Chronic pain; Pain patients, children of; Child adjustment; Chronic pain, effects of; (Child)
Much recent research has examined family and marital issues in chronic pain problems, such as the effects of chronic pain on the psychological functioning of the spouse, and the quality of the marital relationship. Several studies have found that the spouses of chronic pain patients have increased rates of depression, anxiety and other forms of psychological dysfunction (Chapman et al. 1979; Shanfield et al. 1979; Ahern et al. 1984; Kerns and Turk 1984; Flor et al. 1987). Elevated rates of marital distress in both patients and spouses have also been demonstrated (Maruta and Osborne 1978; Merskey and Boyd 1978; Mohamed et al. 1978; Ahern et al. 1985). These studies indicate that chronic pain problems can have a significant negative impact on the family.
Correspondence to: Deborah Y. Chun, Psychology Veterans Administration, P.O. Box 50188, Honolulu,
Service (116B), HI 96850.
However, few studies to date have examined directly the effect of a parent’s chronic pain problem on his or her children. In one of the few studies conducted, Dura and Beck (1988) found that children of chronic pain patients demonstrated more problem behaviors and a lower level of social competence than did children of diabetic or healthy parents. Children of pain patients were also characterized by more days absent from school and days with illness complaints than were children in the other two groups. Similarly, Rickard (1988) found children of chronic pain patients to have more behavior problems as rated by parents and teachers, compared with children of diabetic and healthy parents. Finally, Raphael et al. (1990) found that children of temporomandibular pain patients were reported by their parents to have experienced significantly more illness and injury than children of healthy parents. These findings suggest that children of chronic pain patients may be at risk for experiencing problems in physical and psychosocial functioning. Little is known about variables that might mediate the association between a parent’s chronic pain prob-
lem and a child’s adjustment problems. However, other areas of research suggest likely avenues to explore. Parental depression, for example, has been shown to be associated with behavioral disturbance and poor physical health in children (Billings and Moos 1983, 1985; Hirsch et al. 1985; Keller et al. 1986; Hammen et al. 1987; Weissman et al. 1987; Downey and Coyne 1990). Numerous studies have found increased rates of depression in samples of chronic pain patients (for review, see Roman0 and Turner 1985). It is not clear whether the gender of the depressed parent makes a difference in child adjustment, as the findings have been conflictual and the preponderance of the research has focused on maternal depression (Downey and Coyne 1990). Further research is needed to address this question in depressed samples with and without chronic pain. It would also be of interest to examine whether there is an interaction between the child’s gender and the gender of the depressed parent in determining child adjustment. Studies of adolescents (Steinberg 1987, 1988) and younger children (Maccoby and Martin 19831 as well as studies across age groups (Block 1983) suggest that mothers and fathers may interact differently with male and female children. Marital distress may also play an important role in adjustment problems in children. In fact, the relationship between parental depression and children’s disturbed behavior may be accounted for largely by concomitant marital discord (Emery 1982). Marital discord has been found to be associated with maladaptive child behavior in families where parents have mental disorders (Rutter and Quinton 19841, physical illness (Folstein et al. 1983), and no chronic illness (Emery 1982; Rutter and Giller 1983). This is pertinent to the study of children of pain patients because research has demonstrated elevated rates of marital distress in chronic pain couples (Maruta and Osborne 1978; Merskey and Boyd 1978; Mohamed et al. 1978; Ahern et al. 1985). Another possible risk factor for behavioral disturbance in children of chronic pain patients is parental functional disability. Chronic pain is frequently associated with significant functional disability and role dysfunction. It seems quite likely that such disability would have a negative impact on children of chronic pain patients, but to date studies have not examined whether this is in fact the case. In sum, child adjustment problems found within families of chronic pain patients in recent studies may have been associated with parent marital difficulties, depression, and/or patient disability, but the relationship of these parent variables to child adjustment has not been examined in a clinical population of chronic pain patients. The purpose of this study was to assess the nature and degree of adjustment problems in children of male and female chronic pain patients, com-
pared with controls, and to examine the relationship of specific parental factors to child maladjustment.
Methods Subjects Thirty-five chronic pain patients and their spouses were recruited from new patients evaluated at a large university medical center pain clinic, To be included in the study, couples must have been married or cohabiting for at least 3 years (to avoid including families with adjustment problems accompanying remarriage and family merger), one partner had to have experienced a pain problem for at least 6 months, and the couple had to have at least one child (which could be a biological child of both parents or a step-child living with the couple) between the ages of 6 and 16 years. If the couple had more than one child at home within this age range, they were asked to identify one child to be the target of evaluation. A target child was identified in each family, rather than evaluating all children in a family, to control for undue weighting of any single family in the analyses. Of 39 pain patients approached, 35 were eligible and agreed to participate in the study. Twenty-nine control group couples were recruited through newspaper advertisements and screened by telephone. Couples who were married or cohabiting for at least 3 years and had children between the ages of 6 and 16 were selected to participate. Exclusion criteria included the presence of a pain or illness problem in either parent during the past year of more than 2 months’ duration which resulted in inability to carry out normal functions for 4 days or more per month. Control couples were selected to be similar to pain couples in socio-economic status and age and gender of their children. One member of the control couple was designated (on the basis of gender) as the ‘patient’ (for purposes of data collection and analysis) to maintain a similar gender distribution of patients and spouses in the pain and control groups. If control couples had more than one child, the target child was selected by age and gender to approximate the age and gender distribution of children in the pain group.
Measures The following measures were completed by each pain and control group parent. (1) The Center for Epidemiologic Studies-Depression Scale (CES-D) (Radloff 1977) is a 20-item self-report measure of depression severity shown to have adequate reliability and validity. The CES-D was selected for this study because it was developed for use in the general population and therefore can be used with both patient and non-patient samples. (2) The Dyadic Adjustment Scale (DAS) (Spanier 1976) is a 32-item measure that yields an overall index of relationship adjustment, as well as subscale scores reflecting satisfaction, cohesion, consensus, and affectional expression. It is a widely used measure, with evidence supporting its ability to discriminate between distressed and non-distressed couples. (3) The Sickness Impact Profile (SIP) (Bergner et al. 1981) is a 136-item measure that yields scores indicating level of physical and psychosocial dysfunction due to illness, as well as a total dysfunction score. The SIP has demonstrated adequate validity and reliability. (4) A questionnaire was used to obtain demographic information about each subject, including age, gender, marital status, employment status, and income. Socio-economic status (SES) was measured by use of Duncan’s Socio-economic Index scale scores (Miller 1983). Based on Duncan’s Index, subjects were placed in 1 of 4 categories determined by their occupation. The 4 categories varied from professional and managerial occupations (category 1) to operative and service occupations (category 4).
313 independently completed the measures described above either while in the clinic, or at home shortly after the clinic visit. Each of the control group subjects independently completed the measures at the medical center or at home, depending on their ability to commute to the medical center. Both oral and written instructions to couples emphasized the necessity of independent completion of forms. Parent data were collected between January 1988 and December 1989. Upon receipt of parent data, the TRF was sent to a teacher designated by the parents as most familiar with their child. Teachers were paid $5 for their participation. They were blind to the purpose of the study and to the group membership (pain or control) of the students. After the 1988-1989 school year, forms were sent to the children’s schools to obtain data concerning the number of days they were absent during this year.
(5) Parents rated their children on the Child Behavior Checklist (CBCL) (Achenbach and Edelbrock 1983) which consists of 118 items grouped into 2 scales: social competence and behavior problems. Normative scales are provided based on the age and gender of the child, with girls and boys divided into age groups of 4-5, 6-11, and 12-16 years. The Teacher Report Form (TRF) (Achenbach and Edelbrock 1986) of the CBCL was used by teachers to rate school behavior. The CBCL and TRF are widely used as measures of child adjustment. They have been shown to possess adequate discriminant validity and test-retest reliability (Achenbach and Edelbrock 1983, 1986), and provide normalized T scores, enabling comparison of children’s scores across age groups. School absenteeism was measured by school records of the total number of entire days missed by each child in the study during the 1988-1989 school year. Data on this variable were available for 16 children in the pain group and 15 controls.
Results Demographic differences between groups
Characteristics of the pain and control groups are shown in Table I. The pain and control groups did not
Pain patients and their spouses were recruited at the time of their initial pain clinic evaluation. Each member of the couple
TABLE I DEMOGRAPHIC
Characteristic Patient sex(n) Male Female Socio-economic status (n) Professional, managerial, technical Clerical, sales Skilled crafts Service, labor Employment status(n) Patient Employed Unemployed Spouse Employed Unemployed Annual income (n) o-19,999 20-39,999 40,000 and above Child sex (n) Male Female Child age group(n) 6- 11 years 12-16 years Pain duration (years) Mean S.D. Patient age (years) Mean SD. Spouse age (years) Mean S.D. Length of marriage (years) Mean S.D. * P
OF PAIN AND CONTROL SUBJECTS Pain group
16 10 2 7
18 5 2 4
12 13 10
0 9 20
x2 (df) 0.00 (1)
17.12 *** (1)
15.82 ** (2)
2.21 * (62)
differ significantly with respect to SES category, number of children in each age group, or gender of children, as tested by x2 analysis, or in length of marriage/cohabitation, age of patient, or age of children, as assessed by f tests. Spouses of pain patients were significantly younger than the control spouses. Although spouses in the 2 groups did not differ significantly in employment status, significantly more pain patients than controls were unemployed, and pain group couples reported significantly lower income than controls, as expected. Differences in marital adjustment, depression, and disability between pain and control couples Mean scores for pain and control group subjects on the DAS, CES-D, and SIP are shown in Table II. A 2 x 2 x 2 multivariate analysis of variance (MANOVA) was performed to determine if the parent measures (marital adjustment, depression, and disability) differed depending on group membership (pain vs. control), gender (male vs. female), and partner status (patient vs. spouse). A significant interaction was found between group membership and partner status (Wilks’ lambda = 0.79, approximate F (3, 111) = 9.94, P < 0.001). The univariate tests indicated that this interaction was due to depression (F (1, 113) = 4.96, P < 0.05) and to disability (F (1, 113) = 27.94, P < 0.001). To interpret the significant interaction, an examination of simple main effects was conducted. Pain group
TABLE II MEANS AND STANDARD DEVIATIONS OF DAS, CES-D. AND SIP SCORES FOR PAIN AND CONTROL COUPLES DAS = Dyadic Adjustment Scale; CES-D = Center for Epidemiologic Studies-Depression Scale; SIP = Sickness Impact Profile. Measure
Marital Satisfaction (DAS) Patient Mean 106.38 S.D. 22.54 Spouse Mean 109.68 S.D. 20.84 Depression (CES-D) Patient Mean lY.X.5 13.55 SD. spouse Il.94 Mean S.D. 7.80 Disability (SIP) Patient Mean 17.94 S.D. 12.24 spouse Mean 4.07 S.D. 5.57
116.45 13.46 117.31 10.34
6.55 x.5 I s.90 6.44
0.61 1.43 0.26 0.64
TABLE 111 DESCRIPTIVE STATISTICS OF CHILD MEASURES CBCL = Child Behavior Checklist; TRF = Teachers Report Form of the Child Behavior Checklist. Measure Child behavior problems Parents (CBCL) Mean S.D. Teachers (TRF) Mean S.D. Child social competence Parents (CBCL) Mean SD. Teachers (TRF) Mean S.D. School absences Mean S.D.
(n = 3.1) 55.82 10.9’) (n = 27) 55.96 7.72
(n = 29) S2.09 x.37 (n = 19) 46.89 9.81
(n = 33) 45.02 0.40 (n = 27) 35.4x IO.‘)7 (n = 16) Y.h3 6.17
(n = 28) 50.52 Y.3X (n = 19) 57.1 I IO..52 (n = 15) Y.20 7.26
patients were significantly more depressed than were control group patients (F (1, 60) = 20.72, P < O.OOl), and pain group spouses were significantly more depressed than were control group spouses (F (I, 60) = 10.88, P < 0.01). Patients in the pain group reported significantly more disability than did control patients (F (1, 59) = 57.40, P < 0.001). Spouses in the pain group also reported significantly greater disability than did control spouses (F (1, 59) = 12.95, P = 0.001). Differences in adjustment between pain and control children Correlations between mothers’ and fathers’ ratings of children’s behavior problems (r (60) = 0.68, P < 0.001) and social competence (r (59) = 0.69, P < 0.001) were significant. Therefore, mothers’ and fathers’ ratings were averaged for use in subsequent analyses in order to obtain a consensual perspective on child adjustment and to decrease the number of variables examined (thus reducing the chance of type-l error). Averaged CBCL ratings by parents and TRF ratings by teachers for each group are shown in Table III. To test the hypothesis that children of pain patients show more behavior problems and less social competence than children of control couples, a 2 X 2 x 2 MANOVA was performed using parent-rated behavior problems and social competence as the dependent variables and group membership (pain vs. control), gender of child (male vs. female), and gender of patient (male vs. female) as the independent variables. A main effect was found for gender of patient (Wilks’ lambda = 0.85, approximate F (2, 52) = 4.62, P < 0.05).
The univariate tests indicated that children of male patients were rated as significantly less socially competent than children of female patients (F (1, 53) = 6.01, P < 0.09. No significant main effects were found for group membership or gender of child, and there were no significant interactions. A similar 2 X 2 X 2 MANOVA was performed using teacher ratings of child behavior problems and social competence as the dependent variables. A main effect was found for group (Wilks’ lambda = 0.73, approximate F (2, 37) = 6.72, P < 0.01) and for gender of child (Wilks’ lambda = 0.82, approximate F (2, 37) = 4.06, P < 0.05). Children of pain patients were rated as having significantly more behavior problems (F (1, 38) = 13.25, P < 0.01) and lower social competence (F (1, 38) = 10.87, P < 0.01) than children of control couples. Male children were rated by teachers as being significantly less socially competent (F (1, 38) = 6.45, P < 0.05) than female children. School record data revealed no significant difference between children of pain patients and control children in number of school absences for the 1988-1989 school year as tested by the t test. Predictors of child adjustment
Two multiple regression analyses were performed, the first to assess the contributions of patient variables to parent ratings of child behavior problems and the second to examine the contributions of these variables to parent-rated social competence. In both analyses, the variables of group membership and patient gender were forced to enter first, with patient depression, patient gender X depression interaction, patient marital satisfaction, and patient total functional disability then allowed to compete for entry in a stepwise fashion. Results are shown in Table IV. Only patient disability accounted for a significant portion of the variance (20%) in child behavior problems. Group membership, patient gender, depression, gender x depression interaction, and marital satisfac-
MULTIPLE REGRESSIONS TO PREDICT PARENT-RATED CHILD BEHAVIOR PROBLEMS AND SOCIAL COMPETENCE FROM PATIENT VARIABLES (n = 61) Predictor
Behavioral problems Group membership Gender Total disability Social competence Group membership Gender
0.19 0.22 0.50
0.04 0.05 0.25
0.04 0.01 0.21
2.21 0.74 15.65 **
3.26 5.01 *
* P < 0.05; * * P < O.ocll.
tion were not significantly associated with behavior problem ratings. Patient gender was the only significant predictor of parent-rated child social competence, accounting for 8% of the variance in this measure.
Discussion Results of this investigation have generally supported earlier findings (Rickard 1988) showing that children of chronic pain patients are rated by teachers as having more adjustment problems than children of healthy parents. However, parent ratings did not significantly differ between groups. The discrepancy between parent and teacher ratings of child adjustment may reflect the results of sampling a child’s behavior across situations rather than a problem with the reliability of reports, as suggested by Achenbach et al. (1987). It is possible that the adjustment problems of children in this study are more likely to be manifested in settings outside the home rather than in the home or may be more apparent to observers outside the family. Observational studies comparing child behavior in the home and in the school might be valuable for exploring this issue. If it appears that children of pain patients are exhibiting more adjustment problems in the school, this setting might be an important target for intervention. Although teachers rated children of pain patients as having more behavior problems and less social competence than children of healthy controls, no significant differences were found in school absences. This may have been the result of a lack of statistical power due to the small number of children for whom absenteeism data were returned. Thus, this finding should be interpreted with caution. This study expanded on previous research by finding that pain patient gender was a significant moderating variable in child social competence as rated by parents, presumably reflecting child behavior exhibited in the home. It appears that a father’s pain problem has a more significant effect on child social competence than a mother’s pain problem. An earlier study found that there was a stronger relationship between patient disability and spouse adjustment for male than female patients (Roman0 et al. 1989). If a father’s pain problem is negatively affecting a mother’s overall adjustment, the home environment might also be affected negatively. Conversely, if a mother’s pain problem has less of an effect on a father’s overall adjustment, the effects on the home environment might also be expected to be less. If this is the case, however, it is not clear why this result was found only for child social competence and not behavior problems. Another possible explanation might be related to the stronger economic impact a father’s disability might
be expected to have on the family than a mother’s disability. Traditionally, fathers provide a larger percentage of a family’s income. One might expect that the decline of a family’s income might negatively impact the child’s active participation in social and organizational activities. Further research is needed to cxplore these and other possible explanations for this finding. This study supported the hypothesis that chronic pain patients and their spouses would report significantly more depression than control couples, consistent with previous studies. However, the findings of this study were not consistent with other studies that have found that chronic pain patients and their spouses report a significant degree of marital distress (Maruta and Osborne 1978; Merskey and Boyd 1978; Mohamed et al. 1978; Ahern et al. 1985). However, in studies that have found a significant degree of marital distress among chronic pain patients and their spouses, it is not clear what proportion of the studied couples had children between the ages of 6 and 16 years. It may be that couples with minor children living at home face different issues, and that the present study examined only a specific subset of the chronic pain patient population. It is also quite possible that less satisfied couples may have tended to decline participation in this study. Examination of the relative importance of patient variables in predicting child adjustment found that only patient total functional disability significantly predicted child behavior problems, and only patient gender significantly predicted child social competence. Additional research is needed to explore which aspects of a mother’s or father’s disability may contribute to the development of child behavior problems. Factors such as parent illness behavior, decreased availability, or social withdrawal might be useful avenues to explore. If specific factors are found to be associated with child behavior problems, it might be beneficial to target families of patients who strongly exhibit these behaviors for intervention. This study was not without limitations. Although the comparison of children of chronic pain patients with children of normal healthy controls has yielded potentially important information, it might be valuable in the future to make comparisons with groups such as depressed parents, or parents with medical illnesses with similar levels of functional disability to determine if the relationships observed are unique to chronic pain patients and families. It might also be useful to measure factors such as child premorbid adjustment and selfesteem to more accurately assess the specific effects of having a parent with a pain problem. The fact that pain group couples with more than one child were allowed to select the target child may have biased results obtained on child adjustment measures. It is possible that parents may have selected a child with few problems.
and therefore that the present findings may be a conservative estimate of child maladjustment in chronic pain families. Control of such aspects of child adjustment is recommended for future studies on this topic. Still another limitation of the present study is the size of the sample. Conclusions based on a small selfselected sample may not replicate or generalize to the population of chronic pain patients and their families as a whole. Larger sample sizes are needed in future research to enhance reliability and generalizability of findings. An important next step in research in this area would be direct behavioral observation of interactions of chronic pain patients and their spouses and children. Other important directions for future studies include comparisons with families of patients with other chronic disorders, longitudinal studies to determine causal relationships, and studies examining age-related differences in child adjustment in relationship to parent pain problems and dysfunction. Effects of a parent’s illness may affect children differentially depending on their developmental stage. Finally, future research is needed to examine how other parental psychological disorders that arc commonly associated with chronic pain, for example substance abuse and personality disorders, may relate to child adjustment. Delineation of parent variables associated with specific aspects of child maladjustment might provide an empirical basis for efforts to treat or prevent the development of maladaptive behavior in children of chronic pain patients.
Acknowledgements This study was supported by a grant from Bristol Myers Squibb Corporation presented to C. Richard Chapman for research on pain. We gratefully acknowledge the assistance of Jill Diesel and Mark Jensen in the data collection, Allan Fruzetti for statistical advice, and Hyman Hops for comments on an earlier version of this paper. We also thank the staff of the University of Washington Multidisciplinary Pain Center for their assistance during data collection.
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