Parental Reinforcement of Recurrent Pain: The Moderating Impact
of Child Depression and Anxiety on Functional Disability
Catherine Cant Peterson, PHD, and Tonya Mizell Palermo, PHD
Department of Pediatrics, Rainbow Babies and Children’s Hospital,
Case Western Reserve University School of Medicine
Objective To examine whether children’s distress moderates the relationship between
parental responses to children’s pain behaviors and functional disability.
Methods Participants were 215 children (ages 8 to 16 years) diagnosed with either
headaches, juvenile idiopathic arthritis, or sickle cell disease. Children and parents completed
questionnaires assessing sociodemographics, pain, depression, anxiety, parental solicitous
responses to pain behaviors, and functional disability. Results Hierarchical linear
regressions computed for parental responses to children’s pain significantly predicted child
functional disability, controlling for children’s pain intensity. Significant interactions between
parental solicitous behaviors and child depressive symptoms (b 5 .74, p , .01) and between
solicitous behaviors and child anxiety symptoms (b 5 .91, p , .01) indicated that for children
with more psychological distress, parental solicitous behaviors were associated with greater
child functional disability. Conclusions Child psychological distress may exacerbate the
impact of parental solicitous responses to pain on functioning, suggesting the potential role of
family intervention to enhance optimal functioning in children with recurrent pain.
Key words recurrent pain; parental reinforcement; depression; anxiety; functional disability.
Chronic and recurrent pain is estimated to affect more
than 25% of all children and adolescents (McGrath,
1990; Perquin et al., 2000), including those with medical
illnesses (e.g., sickle cell disease [Walco & Dampier,
1990] and juvenile arthritis [Ruperto et al., 1997]) and
those with functional or unexplained pain (e.g., headaches [Mikkelsson, Salminen, & Kautiainen, 1997]).
One recent population-based study reported a pain
prevalence of 54% in a large sample of youth ages 0 to 18
years, with a quarter of the respondents reporting
chronic pain lasting more than 3 months and more than
a quarter of respondents reporting a combination of
multiple locations of pain (Perquin et al., 2000). The
societal and functional impact of chronic pain can be
demonstrated in missed school, limited social and
athletic activities, emotional distress, increased health
care utilization, and possible subsequent economic
costs, with pain-related functional impairment preventing work (Palermo, 2000; Walker, 1999). Recurrent pain
also is associated with poorer quality of life (Hunfeld et
al., 2001) and increased psychological symptomatology,
particularly depression, which can further tax family and
health care resources (Kashikar-Zuck, Goldschneider,
Powers, Vaught, & Hershey, 2002).
Chronic pain is a major complication in several
childhood health conditions, such as sickle cell disease
(SCD), which can result in frequent hospitalizations and
prolonged morbidity and mortality into adulthood. The
frequency of hospitalizations and the extreme nature of
sickle cell pain have a substantial impact on daily
functioning for children, including school attendance,
academic functioning, and emotional functioning (e.g.,
Graumlich et al., 2001). Juvenile idiopathic arthritis
(JIA), another chronic condition known to cause pain-
All correspondence should be sent to Catherine Cant Peterson, Division of Behavioral Pediatrics and Psychology,
Rainbow Babies and Children’s Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, Ohio
44106. E-mail: [email protected].
Journal of Pediatric Psychology 29(5) pp. 331–341, 2004
DOI: 10.1093/jpepsy/jsh037
Journal of Pediatric Psychology vol. 29 no. 5 Q Society of Pediatric Psychology 2004; all rights reserved.
332
Peterson and Palermo
related complications in youth, similarly affects children’s functioning. Children experiencing joint pain and
swelling may miss school and experience limitations in
social and athletic activities. Although most recent
research suggests that children with JIA are no more at
risk for social or psychological adjustment difficulties
than healthy children (e.g., Noll et al., 2000), more
severe disease or exacerbations of disease may contribute
to increased risk for adjustment difficulties and functional disability (e.g., Timko, Stovel, Moos, & Miller,
1992). Further, children with SCD and JIA may be at risk
for higher rates of psychological distress, including
anxiety and depression, compared with healthy peers
(Jacob, 2001), which may exacerbate pain and functional disability.
Many children also report recurrent, unexplained
pains, including headaches, stomachaches, back pain, or
combinations of these. One such type of recurrent pain is
migraine headaches, which affect approximately one
million children and adolescents, leading to school
absence rates of several hundred thousand missed days
per month (Stang & Osterhaus, 1993). Recurrent
headaches and other functional pains also are associated
with depression and anxiety (Liakopoulou-Kairis et al.,
2002; Walker & Greene, 1989) and can lead to limited
social participation and chronic functional disability if
untreated (Holden, Deichmann, & Levy, 1999).
In a review of the literature, Palermo (2000)
identified the need to test models that delineate the
processes underlying the connection between pain and
functioning to target specific child and family factors in
interventions to optimize child functioning. Research
has indicated that both parent and child psychosocial
factors may serve as risk or supportive factors to either
exacerbate or minimize children’s functional disability.
Social consequences of pain, including parental responses, have been examined in children with recurrent
pain (Walker, Claar, & Garber, 2002; Walker & Zeman,
1992). Investigators have examined several styles of
parental responses, such as minimizing (e.g., shifting
focus away from pain behaviors, expressing negative or
punishing reactions to child’s pain) and encouragement
or reinforcement, sometimes referred to as solicitous
responses (e.g., frequent attending to pain symptoms,
granting permission to avoid regular activities) (Walker,
Garber, & Greene, 1993). Parental reinforcement of pain
may vary by disease group (Brace, Smith, McCauley, &
Sherry, 2000), child age (Bijttebier & Vertommen,
1999), and gender (Walker & Zeman, 1992).
Utilizing a behavioral framework, a parental solicitous response style could be considered a reinforcing
consequence of a pain behavior, thus serving to
maintain or increase the likelihood of the behavior
occurring. Support for this model could provide
a foundation for contingency-based interventions within the family system for children with recurrent pain
(Wall, Holden, & Gladstein, 1997). More solicitous or
encouraging responses from parents toward their
children’s pain or illness behaviors have been found
to increase sick role behaviors in children with
recurrent and chronic pain (e.g., Gidron, McGrath, &
Goodday, 1995; Whitehead et al., 1994). Greater
parental reinforcement of children’s pain was also
associated with greater functional disability, independent of stress (Whitehead et al., 1994) and pain severity
(Gidron et al., 1995). Further, Walker (1999) noted
that some children were more likely to be susceptible to
developing chronic, potentially disabling responses to
their recurrent pain than others due to underlying
psychological characteristics, and children may respond
differentially to parental reinforcement of their pain due
to such characteristics. Walker, Claar, and Garber
(2002) found that both positive consequences (e.g.,
positive attention, fewer chores) and negative consequences of pain (e.g., parent frustration) were associated with maintenance of somatization symptoms in
children with recurrent abdominal pain, although this
was moderated by child self-worth. That is, the relation
of consequences of pain, both positive and negative, to
more somatization was stronger for children with lower
perceived self-worth.
Because such individual characteristics may make
some children more susceptible to functional disability
from their pain than others, it is important to distinguish
under what circumstances this maladaptive outcome
occurs. Psychological distress, particularly depressive
symptoms, has been linked to recurrent pain as a predictor of functional disability (e.g., Kashikar-Zuck et al.,
2002). The impact of children’s distress on parental
responses to pain behaviors is unknown. Further, the
specific nature of distress is unclear: Several studies (e.g.,
Liakopoulou-Kairis et al., 2002; Walker & Greene,
1989) have found elevated rates of both anxiety and
depression in children with recurrent pain, but the
relationship between anxiety symptoms and disability
has not been well documented. Given the likelihood that
greater emotional distress may affect children’s pain
experiences, it is noteworthy that little research has
examined how distress may influence the relationship
Parental Reinforcement and Functional Disability
Table I.
Demographic Characteristics of Combined Sample, N = 215
Mean (SD)
Range
Child age, y
n (%)
12.4 (2.5)
7.90–16.98
Parent age, y
40.1 (7.3)
24.2–73.4
Child gender
Male
Female
87 (40.5)
128 (59.5)
Parent gender
Figure 1. Hypothesized Moderator Model of the Role of Psychological
Distress in the Relationship Between Parental Solicitous Behaviors and
Child Functional Disability.
between pain and functioning or make some children
more susceptible than others to disability.
To address this need, the purpose of the current study
was to examine the role of child psychological distress in
moderating the relationship between parental response
and children’s functional disability. Specifically, we
tested a moderator model suggested by previous research
(e.g., Walker et al., 2002) to examine which children may
be more susceptible to excessive pain-related functional
disability. We hypothesized that more solicitous parental
response styles would predict greater functional disability
but that children’s level of psychological distress would
moderate the relationship between parental response and
functional disability. That is, for those children who are
more distressed, greater parental solicitousness would
lead to greater functional disability (see Figure 1).
Male
Female
17 (8)
177 (82)a
Disease group
Headache
98 (46)
Juvenile idiopathic arthritis
63 (29)
Sickle cell disease
54 (25)
Race
White
African American
Hispanic
Other
128 (60)
80 (37)
4 (2)
3 (1)
Family income
a
,10,000
10,000–19,000
25 (12)
16 (7)
20,000–29,000
21 (10)
30,000–39,000
27 (13)
40,000–49,000
12 (6)
50,000–59,000
23 (11)
60,000–69,000
17 (8)
.70,000
61 (28)a
Totals do not equal 100% of N due to missing data.
Methods
Participants
Participants were 215 children ages 8 to 16 years (M 5
12.4, SD 5 2.5), 60% female, in a longitudinal study
(only baseline data presented) of chronic and recurrent
pain in children, approved by the institutional review
board of the study site. The sample included children
diagnosed with either recurrent headaches (n 5 98), JIA
(n 5 63), or SCD (n 5 54). Table I presents sample
characteristics. Children and adolescents were eligible
for participation if they were established patients in the
pediatric neurology, rheumatology, and hematology
practices, respectively, at a Midwest tertiary care children’s hospital. Children were recruited from four
clinical sites (three suburban, one inner-city) during
a routine specialty care visit. Ninety percent of families
approached consented to participate in the study.
Following informed consent from caregivers and assent
from children, participants completed questionnaires
and interviews while in clinic.
Measures
Sociodemographics
Caregivers completed a questionnaire to provide the
child’s age, ethnicity, gender, family income level, and
parent marital and work status.
Pain Intensity and Frequency
Children and parents completed parallel questionnaires
to assess child pain intensity and frequency. Pain
intensity over the previous four weeks was measured
using the validated Faces Pain Rating Scale (Bieri, Reeve,
Champion, Addicoat, & Ziegler, 1990), which consists
of a series of seven faces with anchors at the two ends
representing a scale from no pain to worst pain. Adequate
reliability and validity of the measure have been reported
(Bieri et al., 1990). Pain frequency over the previous four
weeks was measured using a Likert-type rating scale with
four response options ranging from less than once a month
333
334
Peterson and Palermo
to daily. Validity for the pain ratings in the current
sample was evidenced by cross-informant relationships
between child and parent report for intensity (r 5 .55,
p , .001) and frequency (rs 5 .73, p , .001). Intensity
and frequency ratings were also related (rs 5 .25, p ,
.001, and rs 5 .23, p , .001, child and parent report,
respectively).
Anxiety and Depression
The Revised Child Anxiety and Depression Scale
(RCADS) (Chorpita, Yim, Moffit, Umemoto, & Francis,
2000) is a 47-item instrument designed to assess
children’s self-report of depression and anxiety corresponding to several disorders in the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition
(American Psychiatric Association, 1994), including
major depression and several anxiety disorders. Two
subscales were used to characterize symptoms of child
distress in the present study: major depressive disorder
(MDD) and generalized anxiety disorder (GAD). As
conceptualized by Chorpita et al. (2000), the GAD
subscale represents a ‘‘pure anxiety’’ measure (vs.
separation anxiety, social phobia, etc.). Each item
involves rating symptom frequency on a 4-point scale,
from never to always. Items are scored 0–3, with higher
scores indicating greater frequency. T-scores are calculated based on child gender and grade in school. Good
internal consistency (a 5 .76 and .77 for the MDD and
GAD subscales, respectively) has been demonstrated.
Test-retest reliability over one week was adequate, and
validity has been demonstrated through relationships
with other depression and anxiety measures (Chorpita
et al., 2000). Internal consistency in the current sample
was moderate (a 5 .63 and .75 for MDD and GAD,
respectively).
Parental Response Style
The measure used to assess parental responses to
children’s pain behavior was an extension (Van Slyke,
2001) of the Illness Behavior Encouragement Scale
(IBES) (Walker & Zeman, 1992). The measure consists
of 33 items made up from the IBES, the significant-other
version of the Pain-Relevant Response Scales of the West
Haven–Yale Multidimensional Pain Inventory (Kerns &
Rosenberg, 1995), and clinical interviews with families
(Van Slyke, 2001). Respondents rated on a 5-point scale
(0–4) the frequency with which parents engaged in
specific behaviors in response to their child’s pain. Only
the 14-item (range 5 0–56) solicitous subscale was
used. Sample solicitous responses include giving the
child special privileges, bringing the child special treats
or gifts, and letting the child stay home from school.
Parallel child and parent versions were completed.
Internal consistency in the current sample for the
solicitous subscale was good (a 5 .88 and .89 for child
and parent, respectively).
Functional Disability
The Functional Disability Inventory (FDI) (Walker &
Greene, 1991) describes the extent of restriction in
performing 15 daily activities in the domains of school,
home, recreation, and social interaction. Sample activities include walking to the bathroom, being at school all
day, and reading and doing homework. Parallel child
and parent versions were completed. Respondents rated
how difficult it had been for the child to perform each
activity in the past few days on a 5-point scale, with
response categories ranging from 0 5 no trouble to 4 5
impossible (range 5 0–60). Walker and Greene (1991)
reported acceptable internal consistency and test-retest
reliability. Construct validity was established by relationships with school absences and somatic symptoms.
The FDI has been used to assess functional disability in
studies of children with recurrent abdominal pain
(Walker & Greene, 1991), headache, and arthritis (Reid,
Gilbert, & McGrath, 1998). Internal consistency in the
current sample was good (a 5 .90 and .94 for child and
parent report, respectively).
Statistical Analysis
Summary statistics, including means and standard
deviations for continuous data and frequencies and
proportions for categorical data, were used to describe
the demographic and disease characteristics of the
children according to both children and parents. Pearson
product moment correlations were computed to assess
covariance among sociodemographic variables, pain
intensity and frequency, parental solicitousness, psychological distress, and functional disability. Spearman’s
rank correlation coefficients (rs) were computed with
categorical variables. Differences in predictor and outcome variables by disease group were assessed with chisquare analyses for categorical variables and analyses of
variance for continuous variables (Scheffé tests were
used for post hoc comparisons).
Hierarchical linear regression analyses were conducted to predict functional disability. Demographic predictors, based on theoretical evidence and preliminary
correlations, included disease group (dummy coded),
child age, child gender (dummy coded, 0 5 male,
Parental Reinforcement and Functional Disability
Table II.
Descriptive Characteristics of Predictor and Outcome Variables by Disease Group
Headache
JIA
SCD
Combined Sample
Pain frequency, C, n (%)a
4 (4)
18 (29)
25 (46)
47 (22)
1–3/month to 1/week
27 (28)
11 (17)
11 (20)
49 (23)
2–5/week
38 (39)
15 (24)
8 (15)
61 (28)
Daily
28 (29)
18 (29)
5 (9)
51 (24)
,1/month
Pain frequency, P, n (%)
a
4 (4)
15 (24)
25 (46)
44 (21)
1–3/month to 1/week
29 (30)
18 (29)
13 (24)
60 (28)
2–5/week
42 (43)
18 (28)
8 (15)
68 (32)
Daily
22 (22)
12 (19)
4 (7)
38 (18)
Pain intensity, C
4.1 (1.2)b
2.4 (1.7)c
3.5 (1.9)b
3.4 (1.7)
Pain intensity, P
4.3 (1.2)b
2.4 (1.5)c
3.5 (2.0)b
3.5 (1.7)
Solicitous, C
22.6 (10.4)b
21.9 (11.5)b
29.5 (11.5)c
24.1 (11.4)
Solicitous, P
22.2 (10)b
17.9 (9.6)b
29.9 (12.8)c
22.9 (11.5)
Depressive Sx (T-score)
Anxiety Sx (T-score)
50.9 (12.2)b
43.4 (11.8)
45.3 (11.5)c
41.3 (10.5)
49.1 (12.5)
44.6 (12.1)
48.8 (12.3)
43.1 (11.5)
Functional disability, C
16.8 (11)b
10.2 (9.4)c
Functional disability, P
10.7 (11.6)
,1/month
Means (SD)
9.5 (11.8)
11.5 (10.7)c
13.2 (10.8)
13.4 (14.0)
11.0 (12.4)
JIA = juvenile idiopathic arthritis; SCD = sickle cell disease; C = child report; P = parent report; Sx = symptoms.
Not all percentages equal 100% due to missing data.
a
Group proportions were significantly different in chi-square analyses (SCD subjects reported less frequent pain than JIA subjects, who reported less frequent pain than
those in the headache group, p , .001).
b,c
Means in the same row that do not share subscripts were significantly different in analysis of variance and Scheffe post hoc analyses.
1 5 female), and family income. Regression models
tested two hypothesized moderator models: parental
solicitous behaviors with depressive symptoms and
parental solicitous behaviors with anxiety symptoms.
Demographic and disease variables were entered in the
first step, followed by pain intensity and frequency and
main effects of child distress and parental solicitousness.
Interaction terms, calculated by multiplying each childreported distress measure (i.e., depressive and anxiety
symptoms) by parental solicitousness, were entered on
the final step. Separate analyses were conducted for
child-reported data and parent-reported data. All data
analyses were conducted using SPSS (Statistical Package
for the Social Sciences) version 11.0.
Results
Descriptive Statistics
Table II presents descriptive data concerning child and
parent reports of children’s pain, psychological distress
(child report only), parental solicitousness, and functional disability, between and across the three disease
groups. Groups differed on pain frequency according to
both child and parent report, with the SCD group
reporting significantly less frequent pain than the JIA
group, who reported significantly less frequent pain than
the headache group, x2child(6) 5 46.9, p , .001;
x2parent(6) 5 45.6, p , .001. Groups also differed on
pain intensity (SCD and headaches . JIA), Fchild(2) 5
23.4, p , .001, Fparent(2) 5 30.5, p , .001; functional
disability per child report (headache . SCD and JIA),
Fchild(2) 5 7.6, p , .01; child-reported parent solicitous
behaviors (SCD . headache and JIA), Fchild(2) 5 8.4,
p , .001; parent-reported solicitous behaviors (SCD .
headache and JIA), Fparent(2) 5 18.5, p , .001; and
depressive symptom t-scores (headache . JIA), F(2) 5
3.7, p , .05.
Correlation Coefficients
Table III shows the correlation coefficients between
predictor and outcome variables for child report data.
Functional disability was related to the following
predictors: child gender (rs 5 ÿ.18, p , .05), family
income (r 5 ÿ.16, p , .05), pain frequency (r 5 .31, p ,
.001), pain intensity (r 5 .45, p , .001), depressive
symptoms (r 5 .56, p , .001), and anxiety symptoms
(r 5 .30, p , .01). Although the child-report data did
not reveal a correlation between functional disability
335
336
Peterson and Palermo
Table III.
Correlation Coefficients Between Predictor and Outcome Variables, Child Report
Variable
1
1. Age
—
2. Gendera
3. Ethnicityb
2
3
4
5
6
7
8
.14*
ÿ.01
—
ÿ.16*
—
4. Family income
.12
.11
ÿ.52***
5. Pain frequency
.08
.14*
ÿ.23**
6. Pain intensity
.14
ÿ.10
.08
ÿ.09
7. Parental solicitousness
ÿ.19**
ÿ.15*
.29***
ÿ.27***
ÿ.25***
.21**
—
8. Depressive symptoms
.00
ÿ.16*
.09
ÿ.21**
.17*
.28***
.08
—
9
—
.05
—
.25***
—
9. Anxiety symptoms
ÿ.06
ÿ.11
.12
ÿ.17*
.02
.20**
.15*
.60***
—
10. Functional disability
ÿ.05
ÿ.18*
.06
ÿ.16*
.31***
.45***
.13
.56***
.30**
Correlation coefficients with categorical variables computed using Spearman’s rank correlation coefficient; continuous variables, using Pearson product-moment correlations.
a
Gender codes: 0 = male, 1 = female.
b
Ethnicity codes: 1 = white, 2 = African American, 3 = Hispanic.
* p , .05; ** p , .01; *** p , .001.
and parental solicitousness, correlational analyses using
the parent-report data indicated a significant relationship between functional disability and solicitousness
(r 5 .23, p , .01).
Regression Analyses
As shown in Table IV, findings demonstrated that 43% of
the variance in children’s functional disability scores was
predicted by the depressive symptoms and solicitous
behaviors model, F(10, 154) 5 13.45, p , .001, and 31%
of the variance was accounted for in the anxiety
symptoms and solicitous behaviors model, F(10, 155) 5
8.35, p , .001. Demographics, pain, and distress
symptoms were significant predictors in both models,
with membership in the headache group, lower family
income, more intense pain, and more depressive and
anxiety symptoms associated with greater levels of child
functional disability. Solicitous behaviors did not emerge
as a significant main effect predictor in the child models,
although they were significant in the parent models (not
reported here).
As shown on Step 4 in the regression models, the
hypothesized moderator effects were significant for interactions between child depressive symptoms and parental solicitous behavior (b 5 .74, p , .01; change R2 5
.03, p , .01) and child anxiety symptoms and parental
solicitous behavior (b 5 .91, p , .01; change R2 5 .03,
p, .01). Interactions were plotted by calculating the
median split on the depressive symptom and anxiety
symptom measures and plotting the relationships
between solicitousness and functional disability for the
separate groups (see Figures 2 and 3). Among children
with higher levels of depressive symptoms, parental
solicitous behaviors were associated with greater func-
tional disability than they were for children with lower
levels of depressive symptoms. A similar pattern of
moderation was found for solicitousness with anxiety
symptoms. Post hoc probing of whether the slopes were
significantly different from zero revealed that all four
slopes tested approached significance, p , .07. Interaction models were also run with parental reports of
pain, solicitousness, and functional disability, but the
interaction terms (the moderation effect) in the parent
models failed to reach significance.
Discussion
These findings support the hypothesized interaction
between child distress and solicitousness of the parent in
response to their child’s pain, in that for those children
who reported greater depressive and anxiety symptoms,
child report of parental solicitousness was associated
with greater child-reported functional disability. These
findings are consistent with literature on the importance
of maternal responses in various pain situations. For
example, Blount and colleagues (1997) found that
specific parental behaviors during children’s painful
procedures (i.e., cancer-related procedures and immunizations) could serve to reduce or increase child
distress. In an experimental analysis of maternal
responses to children during an experimental procedure
(i.e., cold pressor pain), Chambers, Craig, and Bennett
(2002) found that mothers’ pain-promoting, versus painreducing, behaviors significantly predicted pain reports
for their daughters, supporting the impact of maternal
response style across contexts. Our findings are also
consistent with those of Walker and colleagues (2002),
in that a child’s psychological characteristics may
Parental Reinforcement and Functional Disability
Table IV. Summary of Hierarchical Linear Regression Models
Examining Child-Reported Distress Symptoms and Parental Solicitous
Behaviors in Predicting Functional Disability
Predictor Variable
b
Adjusted R2 R2 R2 Change
F
Depressive symptoms and solicitous behaviors
Step 1
Age
ÿ.03
Gender
ÿ.15
.12
.14
.14***
5.31***
.23
.26
.12***
12.90***
.41
.44
.17***
23.92***
Disease group
HA
.33**
JIA
.07
Family income
ÿ.22*
Step 2
Pain intensity
.33***
Pain frequency
Step 3
.12
Depressive symptoms
.46***
Solicitous behavior
.07
Step 4
Depressive 3 solicitous
Figure 2. Interaction of Child Depressive Symptoms with Parental
Solicitous Behaviors on Functional Disability.
.43
.47
.03**
8.26**
.74**
Anxiety symptoms and solicitous behaviors
Step 1
Age
ÿ.03
Gender
ÿ.14
.12
.14
.14***
5.30***
.24
.27
.13***
8.41***
.28
.32
.05***
8.05***
.31
.35
.03**
8.35***
Disease group
HA
JIA
Family income
.34**
.10
ÿ.25**
Step 2
Pain intensity
.36***
Pain frequency
.09
Step 3
Anxiety symptoms
.23**
Solicitous behavior
.03
Step 4
Anxiety 3 solicitous
.91**
* p , .05; ** p , .01; *** p , .001.
interact with social responses to recurrent pain to affect
child functional outcomes, although our results held for
child report only.
Contrary to expectations, child report of parental
solicitousness was not significantly associated with
functional disability in bivariate correlations, nor was
it a significant predictor of functional disability in the
regression models. In the parent models (not reported,
as the hypothesized interaction was not significant),
solicitousness was a significant independent predictor of
child disability. These findings may reflect differences in
the source of the data. Children with psychological
distress may be more prone to portray their parents’
behaviors in a certain light in relation to their poorer
functioning, whereas children in less distress may report
their perceptions differently. Parents may report on their
own behavior very differently than their children in pain
do, and previous research (e.g., Gidron et al., 1995) has
found that parents’ reports of their own illnessencouraging behavior were more strongly predictive of
child disability than the child reports of parental
behaviors. Because our moderator models for parent
data were not significant, it is difficult to generalize our
findings to parental reports of the child’s pain and the
parents’ own response styles. Because we lacked parental
reports of child distress, we could not test our models
fully with multisource data. Future studies on the
interaction of parent and child factors in predicting
pain-related functioning would be enhanced by incorporating multiple sources (Holmbeck, Li, Schurman,
Friedman, & Coakley, 2002).
As hypothesized, a significant moderation effect was
found for solicitousness with both depressive symptoms
and anxiety symptoms, suggesting that for children with
more psychological distress, parental solicitous behaviors were associated with greater child functional
disability. Although the slopes reflecting the interactions
were significantly different from each other, post hoc
tests to determine if they were significantly different
from zero only approached significance. This may
suggest a modest effect, but Holmbeck (1997) notes
that significant interactions can be difficult to detect at
all using these methods, and the regression results
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338
Peterson and Palermo
Figure 3. Interaction of Child Anxiety Symptoms with Parental
Solicitous Behaviors on Functional Disability.
nonetheless indicate significant differences between the
two groups (high distress vs. low distress).
Of note are the strong correlations between depressive and anxiety symptoms and the similar patterns
of moderation found. This suggests that we may have
been assessing a more global construct of child distress,
given poor specificity between these conceptually
different psychological patterns. Chorpita and colleagues (2000), in their development of the RCADS, as
well as a subsequent examination of the measure
structure (Chorpita, 2002), specify that the measure is
based on the tripartite model of depression, which
distinguishes anxiety from depression based on the absence of positive affect (in depression), despite the
shared symptom of negative affect. Nonetheless, the
MDD and GAD subscales were strongly correlated in
the normative sample as well (r 5 .48, p , .001)
(Chorpita, personal communication, 2003). Thus, our
conclusions may be limited with regard to specific
anxiety or depressive symptoms and more accurately
may reflect the impact of negative affect.
Although the focus of the current study was on
a large, diverse sample of children with chronic and
recurrent pain, some disease-specific findings merit
discussion. Children with headaches reported more
pain, poorer functioning, and more depressive symptoms compared with children with JIA or SCD. In
addition, membership in the headache group was
a significant predictor of child functional disability.
Given the different duration, etiology, and disease
course among these groups, parental response styles
may vary widely. For example, children with headache
who are coping more recently with diagnosis and
treatment and experiencing more frequent pain may
elicit different parental responses compared with children with JIA and SCD who have often been coping with
less frequent pain associated with their disease for many
years. While a strength of the sample is the blending of
disease groups to allow for examination of psychological
and family processes in a broad group of children
experiencing recurrent and chronic pain, it will be
important in future research to explore the impact of
specific disease-related factors such as duration of
diagnosis on child and family outcomes.
Results suggest that distress, of whatever nature, may
exacerbate the impact of parental solicitousness on the
child’s functional outcome. The direction of the relationships, however, is unclear from our cross-sectional
findings: Does child distress elicit a solicitous parental
reaction, or do certain parental styles elicit reports of child
distress? Do children who are in distress and functioning
poorly elicit parent solicitousness, or does parental
solicitousness lead to poorer functional outcomes?
Future longitudinal analyses may reveal causal, rather
than temporal, associations between these constructs.
Nonetheless, these findings contribute to the literature on a broad population of children suffering from
chronic and recurrent pain and reveal complex models of
pain, distress, and functional disability in children within
their families. The findings underscore the importance of
developing family-centered interventions to enhance
functioning in response to pain. Intervention studies,
however, rarely integrate efficacious treatment techniques for pain, psychological distress, and functioning
within the family system. Two studies suggest promising
results of incorporating parent training into an intervention package. Child self-regulatory techniques and parent
behavioral pain management strategies delivered to
a small sample of children with juvenile arthritis had
a positive impact on pain and functioning (Walco, Varni,
& Ilowite, 1992). Similarly, Sanders, Shepherd, Cleghorn, and Woolford (1994) found reductions in pain and
pain-related activity interference following a six-session
cognitive-behavioral family intervention program (addressing parental reinforcing responses) for children with
recurrent abdominal pain. Despite these encouraging
findings, few intervention programs have replicated or
further validated such comprehensive family approaches,
and few interventions have also addressed children’s
psychological distress as it impacts pain and exacerbation
of disability. The current findings suggest the importance
of targeting intervention to those most at risk for
Parental Reinforcement and Functional Disability
disability based on a constellation of child and parent
factors, including significant child distress and parental
solicitousness. Children in distress may benefit from
a multifaceted intervention, including pain management
strategies that explicitly teach coping, self-regulatory,
and problem-solving techniques, as in the Sanders et al.
(1994) and Walco et al. (1992) studies. Further, children
with distinct psychological symptomatology should
receive treatment targeted to their depressive or anxiety
symptoms to improve their coping skills. Parents and
family members may be taught adaptive, nonreinforcing
responses to both distress and pain behaviors in their
children to optimize child functioning.
Acknowledgments
This research was supported by National Institute of
Mental Health grant K23 01837 (TMP) and by National
Institute of Child Health and Human Development grant
HD41923–02 (CCP). The authors thank the children
and families who participated in this study. We also wish
to thank the following individuals for their assistance:
Samantha Cox, MPH, and Duare Valenzuela, BA, for
research assistance; Drs. Berman, Newman, Singer,
Scher, Bass, and Goyal for access to their patients;
Grayson Holmbeck, PhD, for statistical consultation; and
Dennis Drotar, PhD, and Lynn Walker, PhD, for helpful
comments on an earlier draft of this manuscript.
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