Does parental distress drive childhood pain, or does having a child in pain drive parent distress?
Elliot Krane, MD, FAAP (he/him) • Emeritus Professor of Anesthesiology & Pediatrics
Original article
Beveridge JK, Noel M, Soltani S, Neville A, Orr SL, Madigan S, Birnie KA. The association between parent mental health and pediatric chronic pain: a systematic review and meta-analysis. PAIN 2023. http://dx.doi.org/10.1097/j.pain.0000000000003125
(This PAAD was written after EK interviewed the first author of this paper, Jaimie K. Beveridge, a graduate student working in Dr. Melanie Noel’s and Dr. Kathryn Birnie’s laboratories at the University of Calgary, Canada, to increase his understanding of her publication. Ms. Beveridge was also kind enough to review this before publication to eliminate any errors.)
Those who practice pediatric pain management have doubtlessly observed that the parents of children with chronic pain frequently display anxiety, depression, or other mental health diagnoses, and that children with chronic pain are also often anxious, depressed or have other mental health disorders, leading one to wonder if there is in fact an association between parental mental health disorders and childhood chronic pain; and if there is, are children more likely to develop chronic pain if they have a parent (or two) with a mental health disorder? Or, conversely, are parents at increased risk for poor mental health if they have a child with chronic pain? Or, does a parent’s mental health disorder exacerbate and impede the recovery from chronic pain? And if in fact the answer to any of these questions is yes, what is the effect size of such an association?
There has previously been a rather large number of publications that have described the intergenerational relationship of pain and mental health, and in fact we know that many parents with children with chronic pain have mental health problems, and that poor parental mental health is associated with decreased function in their children. But the literature has large gaps in the mental health diagnoses investigated, having been largely focused on depression and anxiety, has been cross sectional in nature, and the findings have varied widely, thus the strength of this bidirectional relationship of parental mental health and childhood pain is not well understood. Thus, the impetus for this research.
These topics have been fertile ground for investigations by pain psychologists: the authors’ literature search based on a key word search of the observational literature produced more than 32,000 papers. Because studies of this nature are challenging and messy (mental health terminology definitions have changed several times over the many decades of papers searched), this huge number of papers was distilled to only 49 papers that met strict and well defined criteria for meta-analysis and systematic review by using title screening by 3 independent investigators, confirmation of screening by analysis of a random sample of the screened papers by abstract and full text review by one coder, and finally by the overall use of defined phrases (such as symptoms of anxiety, depression, PTSD or “general distress” in parents of children with chronic pain) in peer reviewed journals.
Not at all surprising was the finding that the prevalence of anxiety (29%) and depression (20%) in parents with children with chronic pain was elevated, but not associated with moderators such as type of child pain, timing of parent mental health, or the age / gender / race of the child. The confidence intervals were surprisingly tight for these measures. But not at all surprising is the fact that these rates of parental anxiety and depression did not differ much from that of parents of children with other chronic diseases such as cancer or diabetes. Put another way, it is anxiety-provoking and sad to have a child with chronic pain, and in a proportion of parents these emotions rise to the level of a mental health diagnosis.
The authors also examined this relationship in parents who were described as having “general distress.” This was because many studies used measures that combined depression and anxiety symptoms into a composite score of “distress,” or asked generally about “psychiatric disorders” without specifying diagnoses. But nevertheless, the prevalence of “parent distress” was the same order of magnitude as the above results of anxiety and depression.
Turning the arrow in the other direction pointing from parent to child, asking what is the association between parent mental health and the presence of childhood chronic pain, we again find statistically significant relationships: parents with anxiety or depression are more likely to have children with chronic pain (odds ratio 1.9 with rather tight confidence intervals for both). Significant moderators were found for parent depression, with odds ratios ranging between 1.4 to 3.3 depending on type of sample (clinical vs. community), type of child pain, and timing of parent mental health. There was no statistical effect of child age / gender / race. This is not to say that there is no such relationship, but rather the number of relevant papers was too small to derive a valid conclusion. The same odds ratio magnitude was found in children whose parents had “general distress.”
Similar relationships were found between parental mental health and the child’s functional state. Finally, there were not adequate data to explore these relationships in parents that had more significant mental health diagnoses, such as bipolar disorder, personality disorders, schizophrenia, etc. Finally, due to the limited number of studies using longitudinal methods, all findings from this meta-analysis are considered cross-sectional.
So what we have here is that parents with certain mental health diagnoses are more likely to have a child who experiences chronic pain, and that the parents of children with chronic pain are more likely to have depression or anxiety, but no more so than the parents of children with other severe chronic illnesses, validating the casual observation made by almost everyone who treats chronic pain in children. But why does this occur? Do the children of parents who are susceptible to certain mental health diagnoses have a genetic vulnerability to “chronify” acute pain? Or do parents with such susceptibility parent in such a manner to promote chronic pain disorders by chronification of acute pain or reinforcing pain behaviors resulting in “functional” pain diagnoses? Or put another way, the debates of chicken vs egg, nature vs nurture and association vs causation continue.
Very clearly what is needed are quality longitudinal prospective studies with tightly defined diagnoses, and I’m happy to report that this is exactly what Ms. Beveridge is doing as the next phase of her doctoral dissertation. I hope in 5 years we can explore this again with more clarity.