The Journal of Pain, Vol 7, No 4 (April), 2006: pp 236-243 Available online at www.sciencedirect.com
The Relationship Between Maternal Chronic Pain and Child Adjustment: The Role of Parenting as a Mediator Subhadra Evans,* Edward A. Shipton,† and Thomas Keenan‡ *Department of Health and Social Care, Brunel University, Isleworth, United Kingdom. †Department of Anaesthesia, Christchurch School of Medicine, University of Otago, Christchurch, New Zealand. ‡Department of Interdisciplinary Studies, Niagara College, Welland, Ontario.
Abstract: The role of parenting in the relationship between maternal chronic pain and negative child outcomes, including internalizing, externalizing, and social and health problems, was investigated. Parenting strategies used by mothers with chronic pain were compared to parenting strategies used by a control group of mothers without pain. Thirty-nine mothers experiencing chronic pain, their 55 children, 35 pain-free mothers, and their 48 children participated in the study. The results showed that for mothers with chronic pain, dysfunctional parenting strategies and the quality of the motherchild relationship were related to negative child outcomes. Mothers with chronic pain were more likely to engage in lax parenting and report reduced relationship quality with children than were control mothers. For the chronic pain group, over-reactive parenting was found to mediate the relationship between maternal physical functioning and child adjustment. Dysfunctional parenting strategies may constitute part of the risk that maternal chronic pain poses for children. The similarities between the impact of maternal chronic pain on child adjustment and that of other maternal stressors, such as depression, are discussed. Perspective: In mothers with chronic pain, poor maternal physical functioning was associated with increased maternal over-reactive behavior that was in turn related to poor child adjustment. Maternal over-reactive behavior did not, however, differ in chronic pain and control mothers. © 2006 by the American Pain Society Key words: Chronic pain, mothers, child adjustment, parenting strategies.
he stressors experienced by a parent are typically not endured alone. Regardless of a parent’s desire to protect others from their stress, family members inevitably share in it.59,60 Children may be at their most vulnerable when witnessing the distress and suffering of a parent. This has been shown in the maternal depression and marital discord literature, with children at risk of developing a range of psychologic health problems, such as depression, anxiety, and acting out.18,28 Maternal chronic pain has recently been paired with a range of similarly negative outcomes in children. These include internalizing and externalizing behaviors, compromised physical health, and attachment insecurity.8,10,21,35,38,49,57 These findings parallel studies of the Received May 25, 2005; Revised October 12, 2005; Accepted October 24, 2005. Address reprint requests to Edward Shipton, Department of Anaesthesia, Christchurch School of Medicine, University of Otago, PO Box 4345, Christchurch, New Zealand. E-mail: [email protected]
1526-5900/$32.00 © 2006 by the American Pain Society doi:10.1016/j.jpain.2005.10.010
effects of parental HIV, depression, and discord on children,27,66,67 where children experience a range of adjustment issues that include internalizing and externalizing behaviors. Variables that explain the impact of these parental stressors on children have been examined by asking about risk and resilience. Key questions include what it is about maternal depression, discord or chronic pain that leaves a mark on some children but not on others.48,62 Some of these mediators include the quality of the interaction between mother and child30 and characteristics of the mother and the child (including negative cognitions and coping strategies).14 These variables have been examined with respect to maternal depression and marital discord, yet research into maternal chronic pain and the family is limited. The present study was undertaken to address this gap by examining parenting as a mediator of the effect of maternal chronic pain on children. Why would maternal chronic pain have an impact on children mediated by parenting? Firstly, there are links between parental physical functioning, parenting, and child
ORIGINAL REPORT/Evans et al outcomes. Chronic pain and illness lead to compromised parenting24,26,50 and to child dysfunction.8,10,21,38,43,49,57 Lack of parental control and support is associated with child behavioral problems including internalizing and externalizing behaviors.6,17,47 Secondly, parents under stress are prone to dysfunctional parenting behaviors,18,28which consistently form an explanatory variable for child outcomes.14 With maternal depression, the hostility and helplessness experienced often produces a general lack of warmth and constancy toward the child.1 Mothers confuse their own needs with those of their children.11 Their affect is less positive.25 This, in turn, can lead to negative and maladaptive responses in the child. With marital or coparental discord, parental hostility can lead to ineffective parenting,19,40 resulting in a more tenuous parent-child relationship.70 A protracted course of dysfunction and actingout problems in children are often the result.20,34 In the case of maternal HIV, the mother-child relationship and the structure and control exercised by the parent play important roles in child outcome.44 As these examples illustrate, the form of stress may vary, but risk is uniformly transfered to children via ineffective parenting. Other mechanisms, such as genetic factors, maternal and child temperament, and environmental factors such as social support are undoubtedly involved in links between maternal stress and child maladjustment.12,42 Parenting is particularly interesting in that it crosses both maternal and child processes. In the present study, parenting was measured by the quality of the mother-child relationship, over-reaction to child behavior, laxness in attending to child issues, and the excessive use of verbal discipline. This is consistent with parenting definitions used previously.22,56 It was first hypothesized that mothers in the chronic pain group would be more likely to employ dysfunctional parenting strategies when compared with control mothers. The maternal pain group should show increased levels of over-reactivity, laxness, and verbosity, as well as a less warm and supportive relationship with their children. It was also hypothesized that parenting strategies would correlate with a number of child adjustment measures, with the parenting strategies mediating the relationship between physical functioning in mothers with chronic pain and their children’s physical health, internalizing and externalizing behaviors, and social adjustment.
Materials and Methods Participants The target group comprised 39 mothers with chronic pain along with their 55 children (25 females; 30 males) aged 6-12 years. The mean age of children was 8 years 10 months (SD 1.97). The mean age of mothers in the target group was 37 years (SD 5.28). Thirty-five pain-free mothers served as the control group along with their 48 children. The mean age of mothers in the control group was 38 years (SD 5.21) and of their children 8 years 4 months (SD 1.82). Participants were recruited by advertising in newspapers and in doctors’ offices.
237 A variety of chronic pain conditions were represented in the target group. These included chronic low back pain, migraine, arthritis, endometriosis, and chronic fatigue syndrome. All met the inclusion criteria for chronic pain, experiencing recurrent or persistent pain for 3 months or more. Over 70% of the mothers experienced pain on a daily basis, whereas control group mothers were free from pain. The remaining 30% experienced pain at least weekly. The painful conditions lasted an average of 11.2 years (SD 8.49). On a verbal pain scale of 1 (mild), 2 (moderate), 3 (severe), mothers rated their pain severity quite high (mean of 2.38). Apart from a significant difference in income level [t (72) ⫽ ⫺2.29; P ⬍ .05], with mothers in the chronic pain group reporting less family income, no other significant differences were found between the groups, including marital status, education, ethnicity, and number, ages, and sex of children. Approximately 83% of the sample were of European descent, and 12% identified themselves as Maori, 3% as Asian, and 2% as “other.” This corresponds closely to the ethnic composition of the general population in New Zealand.65
Measures Maternal Questionnaires Background Information Questionnaire. This contained demographic information, such as the mother’s and partner’s highest levels of education and the total family income. Scores for the education and income levels were determined in two separate questions. These ranged from 1 (no education/income less than NZ$5000) to 9 (PhD/income greater than NZ$100 000). Questions concerning the mother’s health status were also solicited. Mothers with chronic pain were requested to list the length of the painful condition (in years). Answers to questions regarding the pain severity (scales ranged from 1 to 3: 1 ⫽ mild; 2 ⫽ moderate; 3 ⫽ severe) as well as the frequency (scales ranged from 1 to 3: 1 ⫽ infrequent; 2 ⫽ frequent; 3 ⫽ constant) were included. RAND-36 Health Status Inventory. This 36-item measure of general health includes scales concerning physical functioning, role limitations due to physical health problems, pain, and general health perceptions. The measure has been used in a variety of populations experiencing chronic pain or physical ill health.9 Only the physical functioning scale was used in the present analysis. This reflects an individual’s reported limitations relating to the demands of pain or illness. Acceptable reliability as well as convergent and discriminant validity have been reported.32 Scores are reported in T scores, with a mean of 50. Scores below 35 represent significant impairment. Parenting Scale (PS). This scale identifies three stable factors of dysfunctional discipline styles, namely, laxness, over-reactivity, and verbosity.3 The scale is composed of 30 “mistakes” that parents can make. These are paired with their effective counterpart to form a 7-point scale. The laxness scale is related to permissive parenting, overreactivity to an authoritarian parenting style.5 Scoring involves averaging items to create an overall score for
238 each scale. Acceptable reliability and validity have been reported for this scale, with higher scores indicating more functional parenting practices.3 Interaction Behavior Questionnaire (IBQ): This consists of 20 dichotomous (true/false) items that assess the quality of the parent-child relationship with regards to communication and conflict behavior. Mothers complete the form on their relationship with their child. High scores indicate positive relationships and low scores negative relationships. Acceptable internal consistency and discriminant validity have been reported.55,59
Child Functioning Child Depression Inventory (CDI). The CDI measures children’s depressive symptoms. It has been successfully used in children as young as 6 years of age.15,39,45 Its content is relevant to children, requires only a low reading level, and has acceptable reliability and validity.33,61 T-scores of 65 or greater are considered to be clinically significant. Children’s Health Scale (CHS). Questions encompass sleeping patterns (“how often do you wake up at night?”), eating patterns (“how often do you not feel hungry at meal times?”), and general health (“how often do you feel sick or sore?”). It makes use of a frequency scale, from 0 (never) to 4 (every day). Its last dimension refers to general illness behavior with 2 questions about frequency of doctor and sickbay (school nurse) visits. Scores are averaged to create a total score, higher scores denoting rising illness and pain. Perceived Competence Scale for Children (PCS). Adapted from Harter,31 this scale examines social competence in children. Mothers are asked to rate whether four diametrically opposed statements (eg, “this child usually acts appropriately” vs. ‘this child usually does not act appropriately”) were “sort of true” or “really true.” Scores for each statement range from 0 to 4. An average across the four statements is obtained, with higher scores denoting greater social competence. The scale has internal consistency, reliability, and validity.31 Child Behavior Checklist (CBCL). Mothers completed this widely used rating scale of children’s behavior. It can be used to obtain an internalizing score (comprising withdrawal, somatic complaints, and anxious/depressed behavior) and an externalizing score (delinquency and aggression) The CBCL has adequate reliability, validity, and short- and long-tem stability.2
Procedure The principal investigator screened mothers who replied to the study’s advertisements. Mothers in the chronic pain group were required to have experienced pain for at least 3 months. Questions were asked about initial onset of pain and frequency of pain. Mothers in the control group were required to be pain-free for the preceding year. Questions were asked about presence of pain, and any accidents/hospitalizations in the last year that may have resulted in pain. All mothers in the chronic pain group had sought medical advice regarding their
Maternal Chronic Pain and Child Adjustment conditions, but owing to ethical considerations this was unavailable. No reliability data were available on the inclusion of mothers in each group, and participants’ reports of their condition were relied upon. Forty-three mothers initially inquired about the study’s chronic pain group; 1 experienced acute pain (fractured leg) and 3 failed to complete the questionnaires, leaving 39 mothers in the chronic pain group. Forty-one mothers initially entered as the control group; 2 had surgical procedures in the past year that had resulted in postoperative pain and 4 failed to complete the questionnaires, leaving 35 mothers in the control group. Mothers in both groups were told that the study would look at the effects of physical health or lack thereof on their children. The study’s hypotheses were not revealed. Mothers and children included in the study were visited in their homes by a researcher. They completed a battery of psychosocial and health questionnaires and informed consent forms. The children worked through the questionnaires with the researcher. To avoid any bias or discomfort in disclosing information, the children completed their forms separately from their mothers. Ethical approval for the study was obtained from the university’s ethics committee.
Results Preliminary Analyses Descriptive data and group difference data are shown in Table 1. Group differences were analyzed using regression analyses with income entered at step 1 and group status entered at step 2. This ensured that the disparate income levels between the maternal pain and control groups were controlled for. In the chronic pain group, mothers’ mean scores on the physical functioning scale were significantly elevated compared to the control group’s scores. Children’s mean scores on the CDI, health scale, internalizing and externalizing scales, and social skills scale were significantly higher than controls. For parenting differences, mothers in the chronic pain group reported significantly more laxness (R2 change ⫽ .07; F change ⫽ 4.74; P ⬍ .05) and reduced relationship quality (R2 change ⫽ .07; F change ⫽ 5.32; P ⬍ .05) compared to control mothers. Table 2 shows the correlations between child adjustment measures, maternal pain, and parenting variables for the maternal chronic pain group. Poor physical functioning in the mother was significantly related to high levels of maternal reported externalizing behavior (r ⫽ ⫺.26; P ⬍ .05) and internalizing behavior (r ⫽ ⫺.24; P ⬍ .05) in the child, child health difficulties (r ⫽ ⫺.41; P ⬍ .05), and child-reported depression (r ⫽ ⫺.26; P ⬍ .05). Social skills in children were not associated with any of the pain measures. Child age and gender (0 ⫽ girls; 1 ⫽ boys) were generally unrelated to outcome measures. Lower physical functioning scores in the mother were significantly related to high levels of over-reactivity (r ⫽ ⫺.40; P ⬍ .05) and verbosity (r ⫽ ⫺.24; P ⬍ .05) and poorer relationship quality with children (r ⫽ .28; P ⬍ .05).
ORIGINAL REPORT/Evans et al
Descriptive Data for Maternal, Parenting, and Child Variables, With Group Differences Controlling for Income
53.58 (9.11) 42.8 (4.9)
1.75 (0.77) 1.28 (0.65)
58.07 (11.57) 47.42 (9.00)
54.29 (11.57) 43.02 (8.93)
3.33 (0.61) 3.64 (1.54)
2.58 (0.85) 2.29 (0.57)
3.73 (0.83) 3.68 (0.68)
3.01 (0.89) 2.78 (0.75)
14.09 (4.71)* 16.54 (3.25)
MEAN (SD) Maternal variables Pain severity Pain length Physical functioning Pain Control Child variables Age Pain Control CDI Pain Control Child health Pain Control Internalizing Pain Control Externalizing Pain Control Social skills Pain Control Parenting Laxness Pain Control Verbosity Pain Control Over-reactivity Pain Control Relationship quality Pain Control
2.3 (0.69) 10.9 years (8) 26.47 (12.93) 52.31 (7.6)
8.8 years (2.0) 8.3 years (1.83)
Pain group: child n ⫽ 55; mothers n ⫽ 39; control group: child n ⫽ 48; mothers n ⫽ 35. *Significantly different: P ⬍ .05. **Significantly different: P ⬍ .001.
Tests of Mediation Baron and Kenny’s criteria4 were adopted in order to examine any possible mediation links between maternal physical functioning in the chronic pain group and child outcomes. Mediation was analyzed using the Sobel test for mediation.54 Under these conditions, physical functioning affects the given mediator (parenting), as well as the outcome variable (child adjustment). The mediator is in turn associated with the child adjustment measure. Three parenting variables (over-reactivity, verbosity, and relationship quality) met Baron and Kenny’s criteria3 to test for mediation (Table 2). Children’s social skills were not examined further, because there was no significant association with the mothers’ physical functioning scores.
The results from the Sobel tests are presented in Figure 1. Mothers’ over-reactivity emerged as a significant mediator for child internalizing behavior (z ⫽ ⫺2.99; P ⬍ .05), externalizing behavior (z ⫽ ⫺3.19; P ⬍ .05), and physical functioning (z ⫽ ⫺3.10; P ⬍ .05). The quality of the mother-child relationship also significantly mediated the relationship between mother’s physical functioning and child externalizing behavior (z ⫽ 1.98; P ⬍ .05).
Discussion Mothers with chronic pain were more likely to engage in dysfunctional parenting strategies (laxness and reduced relationship quality) than were control mothers. These differences existed after accounting for elevated
Maternal Chronic Pain and Child Adjustment
Correlations Between Maternal Variables and Child Outcome Variables for Chronic Pain Group
⫺.21 ⫺.40** ⫺.24* .28*
⫺.26* .17 .24 .22 ⫺.27*
⫺.41** .20 .52** .49** ⫺.25*
⫺.27* .44** .50** .41** ⫺.40**
⫺.26* .28* .49** .36** ⫺.61*
.15 ⫺.09 ⫺.18 ⫺.33* .58**
Pain variables Physical functioning (PF) Parenting: laxness Parenting: overreactivity Parenting: verbosity Relationship quality Child variables Age Sex
Abbreviation: PF, physical functioning. *P ⬍ .05; **P ⬍ .01.
income in the control group. The findings provide partial support for the first hypothesis, namely, that mothers in the chronic pain group would be more likely to employ dysfunctional parenting strategies when compared to control mothers and that the maternal pain group should show increased levels of over-reactivity, laxness, and verbosity as well as a less warm and supportive relationship with their children. For the maternal chronic pain group, poor quality of the mother-child relationship correlated with child depression (as reported by the child), physical health, internalizing and externalizing behavior, and social behavior (mother report). The relationship between parenting and child outcome for the maternal chronic pain group was again reflected in the mediation analyses. Mothers’ over-reactivity mediated the presence of child internalizing and externalizing and physical health problems. The quality of the mother-child relationship mediated the development of externalizing behavior. These findings provide partial support for the second hypothesis. This was that parenting strategies would correlate with
Parenting: O-R -.40**
Parenting: O-R Maternal
Functioning -.26* (-.10)
Child Physical Health -.50* (.46**) -.40**
Note: O-R: over-reactivity; RelQ: relationship quality * p < .05 ** p <.001
Figure 1. Path coefficients showing the relationship between maternal physical functioning and child adjustment mediated by parenting for the chronic pain group. O-R ⫽ over-reactivity; RelQ ⫽ relationship quality. *P ⬍ .05; **P ⬍ .001.
child adjustment measures, with parenting strategies mediating the relationship between physical functioning in mothers with chronic pain and their children’s physical health, internalizing and externalizing behaviors, and social adjustment. Mediation only held for some of the parenting strategies and only for motherreported child outcome. Over-reactivity was the most consistent variable to mediate the association between maternal physical functioning and child adjustment, emerging as a mediator for children’s externalizing and internalizing behaviors and health problems. Such dysfunctional parenting strategies have been linked to child problems before.3 Authoritarian parenting plays a role in the development of problems in children’s behavior. Parental over-reactivity acts as a mediator for a range of child variables. Children are more likely to engage in withdrawal behaviors (internalizing behavior) in response to harsh demands. They also retaliate by acting out and employing aggressive behavior in the form of externalizing behavior.5 A negative mother-child relationship also promotes the development of aggression in children.50 Maternal coldness may provide an example to children to respond to stress in an antisocial way.41,51 Children may act out to elicit attention from their mother should she respond to pain by being withdrawn and uncommunicative. A negative relationship with their mother may feel better to children than no relationship at all. As the mediational analyses showed, over-reactive parenting seems to be involved in the relationship between compromised physical health in a parent and physical health in the child. Positive authoritative childrearing that fosters autonomy and the use of reason rather than punishment is associated with a range of positive health behaviors in children.6 In contrast, the use of autocratic or authoritarian practices (such as over-reactivity) is associated with less positive health behaviors in children.53 This relationship may be a result of observational learning. Mothers with impaired physical functioning who respond to their children with over-reactivity and emotionality may create negative models for children, who in turn learn to focus on and over-react to their own health problems. Modeling health behavior is a powerful
ORIGINAL REPORT/Evans et al method for socializing children’s health and health behaviors.13 In the present study, the control and chronic pain mothers did not differ on over-reactive behaviors or verbosity. Mothers with chronic pain were more likely to engage in permissive parenting (laxness) and develop a poorer relationship with their child. Given that a difference in over-reactive parenting between mothers with chronic pain and controls was almost significant (P ⬍ .10), the relatively small sample size may have meant that the effect went undetected. Future analyses may reveal such differences. The use of dysfunctional parenting strategies by mothers in chronic pain is not surprising considering the toll that chronic pain takes on a sufferer’s emotional, physical, and cognitive resources.29,63 Yet dysfunctional parenting methods such as over-reactivity would use considerable energy. Overreacting to situations and implementing harsh discipline divert vital energy that a parent may need to cope with the day’s pain. In general, catastrophizing is linked to negative outcomes in chronic pain patients.7 In sufferers who do not deal with their pain effectively, over-reaction to child behavior and the use of excessive punitive measures reflects a tendency to view events in an exaggerated light. Educating parents with chronic pain and providing psychologic intervention in the form of coping skills and effective models for dealing with pain may allow parents to conserve their energy and reduce the negative impact of over-reaction on children. Mothers under stress face disruptions to their parenting and expose their children to risk from their behavior.14,18,28 Although the findings here are preliminary, they once again show the importance of parenting.36 A range of limitations is present in the study. The sample size was small, which may have resulted in type II error, ie, statistical power may have been insufficient to detect effects. Conversely, the relatively large number of analyses employed may have resulted in type I error. Although some differences were detected in the parenting strategies between mothers in the chronic pain and control groups, these were quite small in magnitude. Group status (ie, whether mothers were in the chronic pain or control group) accounted for only an extra 7% of the variance in laxness and relationship quality scores. Larger sample sizes in future studies would remedy these concerns, and determine how important parenting is. The present study focused only on maternal physical functioning. The results may have been different if other maternal variables (eg, social functioning) were examined.58 Another limitation relates to the failure of child-reported depression to emerge in mediation analyses. It may be that mothers with chronic pain over-react to much of the child’s behavior, including children’s internalizing and externalizing behavior and over-report such symptoms. Future work needs to assess children’s behavior in ways that don’t simply rely on mothers’ reports. These limitations restrict claims about the magnitude of the role of parenting. Nevertheless, it is likely that the
241 results are clinically meaningful and interventions designed to assist mothers suffering from chronic pain with child supervision and home-care would provide mothers and children with some relief. Another limitation may be in the self-selection of participants (by advertising). The present study is a starting point in understanding the impact of maternal chronic pain on children. Future studies should include a range of maternal, child, and family processes in families where a parent experiences chronic pain. Parenting strategies are likely to represent merely a part of the equation. As seen in parental HIV, where the child’s coping strategies are important in determining the impact of the illness on children,67 and maternal depression, where the child’s temperament and cognitive skills play important roles,28 the child’s resources may prove to be influential mediators. Caregiving strategies employed by other family members close to the child should also be explored, because effective parenting on the part of the father may ameliorate the mother’s difficulties. Longitudinal studies with a large number of families are needed to understand the complex interplay of child, maternal, and family variables.52 Only then can causal relationships between maternal chronic pain and child outcome be understood. It could be the case that negative child behavior exacerbates the parent’s pain, suffering, and aversive parenting. This was impossible to examine in the present study and should be addressed by future longitudinal work. Longitudinal work may also reveal other pathways that explain the data. For example, it is possible that maternal physical functioning proves to be the mediator of an established association between parenting and child adjustment.16 Eventually, a causal model accounting for a range of variables should be tested in order to more completely understand the risk that children of chronic pain sufferers may live with. Although it may be a little presumptuous to suggest, given the small sample sizes detected, future work may also benefit from an exploration of intervention strategies designed to prevent mothers from over-reacting to their children’s behavior. Indeed, helping mothers to avoid catastrophizing in general may allow sufferers to manage their pain better.68 Epidemiologic studies have shown that chronic pain represents a major public health problem,23,64 resulting in an increasing use of health services and the loss of billions of dollars each year in work absence, health insurance, and health care services.37,46 Chronic pain is a problem that strikes women more often than men.69 Women sufferers, in many cases, have the added challenge of raising and caring for children. Chronic pain imposes physical and emotional suffering and financial burdens on not only these individuals but also their families. Children may suffer inordinately along with their mothers. Only recently have children of chronic pain parents received attention. This study begins the recognition that parenting has some significance in the relationship between maternal chronic pain and child adjustment.32
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