Parental catastrophizing about children's pain and selective attention to varying levels of facial expression of pain in children: a dot-probe study

The attentional demand of pain has primarily been investigated within an intrapersonal context. Little is known about observers’ attentional processing of another’s pain. The present study investigated, within a sample of parents (n = 65; 51 mothers, 14 fathers) of school children, parental selective attention to children’s facial display of pain and the moderating role of child’s facial expressiveness of pain and parental catastrophizing about their child’s pain. Parents performed a dot-probe task in which child facial display of pain (of varying pain expressiveness) were presented. Findings provided evidence of parental selective attention to child pain displays. Low facial displays of pain appeared sufficiently and also, as compared with higher facial displays of pain, equally capable of engaging parents’ attention to the location of threat. Severity of facial displays of pain had a nonspatial effect on attention; that is, there was increased interference (ie, delayed responding) with increasing facial expressiveness. This interference effect was particularly pronounced for high-catastrophizing parents, suggesting that being confronted with increasing child pain displays becomes particularly demanding for high-catastrophizing parents. Finally, parents with higher levels of catastrophizing increasingly attended away from low pain expressions, whereas selective attention to high-pain expressions did not differ between high-catastrophizing and low-catastrophizing parents. Theoretical implications and further research directions are discussed.     

Parental catastrophizing about child's pain and its relationship with activity restriction: the mediating role of parental distress

Recent research has demonstrated that parental behaviors have an important impact upon child and adolescent pain outcomes. At present, however, we do not know which parents engage in particular behaviors and why. In 2 studies, the impact of parental catastrophizing about their child’s pain upon parental tendency to stop their child’s pain-inducing activity was investigated. Further, the mediating role of parental distress was explored. In study 1, a sample of schoolchildren (n = 62; M = 12.48 years; SD = 1.72) took part in a cold-pressor task. In study 2, a clinical sample of adolescents with chronic pain (n = 36; M = 15.68 years; SD = 1.85) performed a 2-min walking task designed as a pain-inducing activity. In both studies, the accompanying parent was asked to watch their child performing the pain task. Findings revealed, for both studies, that parents with a high level of catastrophic thinking about their child’s pain experienced more distress and a greater behavioral tendency of wanting to stop their child’s pain-inducing activity. Further, parental feelings of distress mediated the relationship between parental catastrophic thinking and parents’ tendency to restrict their child’s activity. The findings are discussed in light of an affective-motivational conceptualization of pain and pain behavior.     

Social modulation of facial pain display in high-catastrophizing children: an observational study in schoolchildren and their parents

The present study examined existing communal and operant accounts of children’s pain behavior by looking at the impact of parental presence and parental attention upon children’s pain expression as a function of child pain catastrophizing. Participants were 38 school children and 1 of their parents. Children completed a cold pressor pain task (CPT) twice, first when told that no one was observing (alone condition) and subsequently when told that they were being observed by their parent (parent-present condition). A 3-minute parent-child interaction occurred between the 2 CPT immersions, allowing measurement of parental attention to their child’s pain (ie, parental pain-attending talk vs non-pain-attending talk). Findings showed that child pain catastrophizing moderated the impact of parental presence upon facial displays of pain. Specifically, low-catastrophizing children expressed more pain in the presence of their parent, whereas high-catastrophizing children showed equally pronounced pain expression when alone or in the presence of a parent. Furthermore, children’s catastrophizing moderated the impact of parental attention upon facial displays and self-reports of pain; higher levels of parental nonpain talk were associated with increased facial expression and self-reports of pain among high-catastrophizing children; for low-catastrophizing children, facial and self-report of pain was independent of parental attention to pain. The findings are discussed in terms of possible mechanisms that may drive and maintain pain expression in high-catastrophizing children, as well as potential limitations of traditional theories in explaining pediatric pain expression.     

Parental emotional responses to their child's pain: the role of dispositional empathy and catastrophizing about their child's pain.

Little is known about how a child's experience of pain affects his or her parents. Using a vignette methodology, this study investigated the emotional responses of parents who were asked to imagine different painful situations that their child might experience. A sample of 650 parents of school children (325 mothers; 325 fathers) read 8 short stories/vignettes about their child, which varied in terms of type of situation (pain vs other stressful situation), intensity (high vs low), and frequency of occurrence (high vs low). The role of individual differences in parental catastrophizing about their child's pain, catastrophizing about their own pain, dispositional empathy, and gender was also investigated. Parents' dispositional empathy was found to have an impact on parental distress and concern for their child. Catastrophizing about their child's pain had a unique contribution to parents' emotional responses to the vignettes describing their child in pain, beyond the influence of other variables. The impact of parental catastrophizing about their child's pain was most pronounced for parental distress, probably reflecting the high threat value that they attribute to their child's pain. The findings are discussed within recent models of empathy and pain, delineating possible relationships with parents' behavioral responses to their child's pain. PERSPECTIVE: This vignette study found preliminary evidence for the importance of parent characteristics, beyond situational characteristics, in parental emotional responses to their child's pain. The findings provide indications for the processes implied in parental helping behavior.     

Postoperative Pain in Children: Association Between Anxiety Sensitivity,Pain Catastrophizing,and Female Caregivers' Responses to Children's Pain

This study investigated the association between anxiety sensitivity and pain catastrophizing in children, caregivers' anxiety sensitivity and catastrophizing about children's pain and responses to children's pain, pain intensity reported by children, and pain intensity estimated by caregivers. The participants were 102 children scheduled for outpatient surgery and their female caregivers. Before the operation, caregivers' catastrophizing about children's pain, children's pain catastrophizing, and their anxiety sensitivity were assessed, as well as caregivers' responses to children's pain. Pain intensity reported by children and estimated by caregivers was evaluated after the operation and 24 hours afterward. Analyses were performed via path analysis. The results indicated that children and caregivers characterized by higher levels of anxiety sensitivity reported higher levels of pain catastrophizing and catastrophic thinking about children's pain, respectively. Caregivers with higher levels of catastrophic thinking about the children's pain reported higher levels of solicitousness and higher estimations of the children's pain intensity after the operation. Higher levels of children's pain catastrophizing were associated with more frequent responses of discouragement and higher pain intensity reported after the operation. These findings highlight the relevance of catastrophizing about children's pain and children's pain catastrophizing in the experience of postoperative pain in children.PerspectivePath analysis was used to test a hypothetical model of the associations between anxiety sensitivity, catastrophizing, parental responses, and postoperative pain in children. The results highlight the association between children's and parents' pain catastrophizing and discouragement and solicitous responses and the role of anxiety sensitivity as a traitlike factor associated with catastrophizing.     

Children’s selective attention to pain and avoidance behaviour: The role of child and parental catastrophizing about pain

The present study investigated selective attention to pain in children, its implications for child avoidance behaviour, and the moderating role of dimensions comprising child and parental catastrophizing about pain (ie, rumination, magnification, and helplessness). Participants were 59 children (31 boys) aged 10-16 years and one of their parents (41 mothers). Children performed a dot-probe task in which child facial pain displays of varying pain expressiveness were presented. Child avoidance behaviour was indexed by child pain tolerance during a cold-pressor task. Children and parents completed measures of child and parent pain catastrophizing, respectively. Findings indicated that both the nature of child selective attention to pain and the impact of selective attention upon child avoidance behaviour were differentially sensitive to specific dimensions of child and parental catastrophizing. Specifically, findings showed greater tendency to shift attention away from pain faces (ie, attentional avoidance) among children reporting greater pain magnification. A similar pattern was observed in terms of parental characteristics, such that children increasingly shifted attention away from pain with increasing levels of parental rumination and helplessness. Furthermore, child attentional avoidance was associated with greater avoidance behaviour (ie, lower pain tolerance) among children reporting high levels of pain magnification and those whose parents reported greater rumination about pain. The current findings corroborate catastrophizing as a multidimensional construct that may differentially impact outcomes and attest to the importance of assessing both child and parental characteristics in relation to child pain-related attention and avoidance behaviour. Further research directions are discussed.     

Parents who catastrophize about their child's pain prioritize attempts to control pain

How parents respond to their child in pain is critically important to how both parent and child attempt to cope with pain. We examined the influence of parental catastrophic thinking about child pain on their prioritization for pain control. Using a vignette methodology, parents reported, in response to different pain scenarios, on their imagined motivation for 2 competing goals: to control their child's pain (ie, pain control) or to encourage their child's participation in daily activities (ie, activity engagement). The effects of parent gender, pain intensity, and duration on parental goal priority were also explored. Findings indicated that higher levels of parental catastrophic thoughts were associated with the parents prioritizing child pain control over activity engagement. This effect was significantly moderated by pain duration. Specifically, pain control was more of a priority for those high in catastrophic thinking when the pain was more acute. In contrast, parental catastrophic thoughts had no effect on the pain control strategy favored by parents in situations with longer-lasting pain. Furthermore, independently of parental catastrophic thoughts, heightened priority for pain control was observed in highly intense and chronic pain situations. Moreover, in highly intense pain, priority for pain control was stronger for mothers compared with fathers. Theoretical and clinical implications and directions for future research are discussed.     

Too sick for school? Parent influences on school functioning among children with chronic pain

Parental responses to children with chronic pain have been shown to influence the extent of the child’s functional disability, but these associations have not been well studied in relation to children’s pain-related school functioning. The current study tests the hypothesis that parental pain catastrophizing and parental protective responses to child pain influence the extent of school impairment in children with chronic pain. A mediational model was tested to determine whether parental protective behaviors serve a mediating role between parental pain catastrophizing and child school impairment. Study participants were a clinical sample of 350 children ages 8-17 years with chronic pain and their parents. Measures of pain characteristics, demographic characteristics, child depressive symptoms, school attendance rates, overall school functioning, parental pain catastrophizing, and parental protective responses to pain were collected. Results show that, controlling for the known influences of pain intensity and child depressive symptoms, parental pain catastrophizing and parental protective responses to child pain each independently predict child school attendance rates and reports of overall school impairment. Parental protectiveness was found to mediate the association between parental cognitions (i.e., parent pain catastrophizing) and child school functioning outcomes. These findings underscore the importance of intervening with parents to foster parental responses to child pain that help children engage and succeed in the school environment despite pain.     

Parental catastrophizing about their child's chronic pain: Are mothers and fathers different?

Preliminary evidence suggests that parental catastrophizing about their child's pain may be important in understanding both parental responses to their child's pain and the child's pain experience. However, little is known about potential differences between mothers and fathers. There were three aims of the present study addressing this lack of knowledge: (i) to investigate the three‐factor structure of the German version of the Parental Pain Catastrophizing Scale (PCS‐P) ( Goubert et al., 2006 ) in mothers and fathers of children with chronic pain, (ii) to explore differences between mothers and fathers in parental catastrophizing, (iii) to investigate the contribution of parental catastrophizing on the child's chronic pain problem and pain‐related parent behavior. In a sample of 128 mothers and fathers of paediatric chronic pain patients, the invariance of the PCS‐P was evaluated. Results replicated the previously established three‐factor structure (i.e. rumination, magnification and helplessness) in both groups. Mothers reported higher levels of catastrophizing as compared to fathers. Specifically, mothers and fathers differed on levels of rumination; the two groups did not differ in magnification and helplessness. Maternal but not paternal catastrophizing contributed significantly in explaining the child's pain intensity whereas neither mothers' nor fathers' catastrophizing were significantly related to the child's disability. Both maternal and paternal catastrophizing contributed significantly to heightened parental solicitous responses. Fathers' but not mothers' catastrophizing also contributed to heightened distracting responses. The present findings attest to the importance of maternal and paternal catastrophizing for the child's pain characteristics and pain‐related parent behavior, which are both relevant for treatment conceptualization.     

Social environment moderates the association between catastrophizing and pain among persons with a spinal cord injury

Catastrophizing, or exaggerating the negative consequences of a situation, is associated with higher pain intensity, emotional distress, and functional disability among persons with chronic pain. According to the 'communal coping' model, catastrophizing in persons with pain may function as a social communication directed toward obtaining social proximity, support, or assistance. We tested the hypothesis, based on this model, that social factors would moderate the association between catastrophizing and sensory and affective pain. Seventy-four persons with a spinal cord injury and chronic pain completed measures of catastrophizing, solicitousness, depression, and sensory and affective pain before beginning a randomized controlled medication trial. Catastrophizing was significantly associated with solicitousness and pain reports. The association between catastrophizing and sensory pain scores was stronger for those who lived with a spouse or partner than for those who lived with someone else. In addition, there was a stronger association between catastrophizing and affective pain for those who reported greater solicitousness in their relationship. The results provide partial support for the communal coping model of catastrophizing.     

Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain

Pain-related coping, particularly catastrophizing, plays a significant role in shaping pain responses. One way catastrophizing is hypothesized to amplify pain and disability is via its effect on patients' social environments (e.g., communal coping model), though empirical support is limited. The present study tested whether the association between catastrophizing and deleterious pain-related outcomes was mediated by patients' perceptions of significant others' responses to their pain in a sample of 1356 pain patients. Regression analyses showed that perceived significant other punishing responses partially mediated catastrophizing's relationship with pain-related disability, and with depressive symptoms. Further, several variables moderated the association between catastrophizing and perceived social responses to pain. Catastrophizing was more strongly associated with greater perceived solicitous responses for patients of relatively short pain duration. Also, higher catastrophizing was more strongly associated with perceived punishing responses among patients perceiving lower social support. In addition, the mediational effects of perceived punishing responses on catastrophizing's relationship with depressive symptoms, and with pain-related disability were only found in individuals reporting low levels of perceived social support. In sum, perceived social responses were found to play a small role in mediating the relationship between catastrophizing and pain-related outcomes, and these mediational effects may be strongest in particular patient subgroups. The present data suggest that interpersonal mechanisms may not constitute a primary route by which catastrophizing exerts its maladaptive effects on pain responses. The study and further understanding of what principal factors mediate catastrophizing's deleterious effects on pain will be important in illuminating the biopsychosocial model of pain.     

Parental catastrophizing about their child's pain. The parent version of the Pain Catastrophizing Scale (PCS-P): a preliminary validation

Numerous studies have found evidence for the role of catastrophizing about pain in adjustment to pain in both adults and children. However, the social context influencing pain and pain behaviour has been largely ignored. Especially in understanding the complexities of childhood pain, family processes may be of major importance. In line with the crucial role of pain catastrophizing in explaining adjustment and disability in adults and children, this study investigates the role of parental catastrophic thinking about their child's pain in explaining child disability and parental distress. To study parental catastrophizing, a parent version of the Pain Catastrophizing Scale (PCS-P) was developed. An oblique three-factor structure emerged to best fit the data in both a sample of parents of schoolchildren (N=205) and in a sample of parents of children with chronic pain (N=107). Moreover, this three-factor structure was found to be invariant across both parent samples. Further, in the clinical sample, parents' catastrophic thinking about their child's pain had a significant contribution in explaining (a) childhood illness-related parenting stress, parental depression and anxiety, and (b) the child's disability and school attendance, beyond the child's pain intensity.     

Emotion regulatory function of parent attention to child pain and associated implications for parental pain control behaviour

We investigated the function of parental attention to child pain in regulating parental distress and pain control behaviour when observing their child performing a painful (cold pressor) task (CPT); we also studied the moderating role of parental state anxiety. Participants were 62 schoolchildren and one of their parents. Parental attention towards or away from child pain (ie, attend to pain vs avoid pain) was experimentally manipulated during a viewing task pairing unfamiliar children’s neutral and pain faces. Before and after the viewing task, parental distress regulation was assessed by heart rate (HR) and heart rate variability (HRV). In a subsequent phase, parents observed their own child perform a CPT task, allowing assessment of parental pain control behaviour (indexed by latency to stop their child’s CPT performance) and parental distress, which was assessed via self-report before and after observation of child CPT performance. Eye tracking during the viewing task and self-reported attention to own child’s pain confirmed successful attention manipulation. Further, findings indicated that the effect of attentional strategy on parental emotion regulation (indexed by HR, self-report) and pain control behaviour depended on parents’ state anxiety. Specifically, whereas low anxious parents reported more distress and demonstrated more pain control behaviour in the Attend to Pain condition, high anxious parents reported more distress and showed more pain control behaviour in the Avoid Pain condition. This inverse pattern was likewise apparent in physiological distress indices (HR) in response to the initial viewing task. Theoretical/clinical implications and further research directions are discussed.     

Impact of parental catastrophizing and contextual threat on parents' emotional and behavioral responses to their child's pain

Limited research has addressed processes underlying parents' empathic responses to their child's pain. The present study investigated the effects of parental catastrophizing, threatening information about the child's pain, and child pain expression upon parental emotional and behavioral responses to their child's pain. A total of 56 school children participated in a heat pain task consisting of 48 trials while being observed by 1 of their parents. Trials were preceded by a blue or yellow circle, signaling possible pain stimulation (i.e., pain signal) or no pain stimulation (i.e., safety signal). Parents received either neutral or threatening information regarding the heat stimulus. Parents' negative emotional responses when anticipating their child's pain were assessed using psychophysiological measures- i.e., fear-potentiated startle and corrugator EMG activity. Parental behavioral response to their child's pain (i.e., pain attending talk) was assessed during a 3-minute parent-child interaction that followed the pain task. The Child Facial Coding System (CFCS) was used to assess children's facial pain expression during the pain task. Results indicated that receiving threatening information was associated with a stronger parental corrugator EMG activity during pain signals in comparison with safety signals. The same pattern was found for parental fear-potentiated startle reflex, particularly when the child's facial pain expression was high. In addition, parents who reported high levels of catastrophizing thought about their child's pain engaged, in comparison with low-catastrophizing parents, in more pain-attending talk when they received threatening information. The findings are discussed in the context of affective-motivational theories of pain.     

Children's catastrophic thinking about their pain predicts pain and disability 6 months later

Catastrophic thinking about pain has been identified as an important determinant of adjustment to pain, in both adults and children. No study has investigated the prospective and unique role of catastrophizing in explaining later pain and disability in children. The aim of the present study was to investigate the prospective roles of catastrophic thinking about pain, pain intensity, and trait anxiety and their putative relationship with pain and disability tested 6 months later. Participants were 323 schoolchildren. Analyses revealed that the child's pain catastrophizing at baseline had a small but unique contribution to the prediction of pain and disability 6 months later, even when controlling for the initial pain and disability levels. In line with expectations, moderation analyses revealed that the effects of catastrophizing upon pain and disability at follow‐up were only true for those children reporting low levels intensity of pain at baseline. The variability in disability and pain complaint could not be explained by trait anxiety. Instead anxious disposition might be best conceived of as a precursor of catastrophizing in children; i.e. children with higher levels of trait anxiety at baseline were more inclined to report higher levels of catastrophizing at follow‐up. The findings are discussed in terms of potential mechanisms through which catastrophizing might exert its negative impact upon pain and disability outcomes in children.     

Catastrophizing about their children's pain is related to higher parent–child congruency in pain ratings: An experimental investigation

Little is known about the variables that account for why parents underestimate the pain of their child. In the present experiment, the joint impact of parental catastrophizing about their child's pain and children's facial pain expressions was examined upon pain estimates of their child undergoing a pressure pain test. In line with previous research, parents underestimated their children's pain. Interestingly, it was found that pain was estimated as higher when the child showed more facial pain expressions and when parents catastrophized more about their child's pain. An intriguing finding was that catastrophizing about their child's pain was related to less parent–child incongruence in pain ratings. The discussion addresses the possible functions of catastrophizing of parents about their children's pain, and delineates avenues for future research.     

Parental response to children's pain: the moderating impact of children's emotional distress on symptoms and disability

Parental responses play a central role in the development and maintenance of children’s pain behavior. Previous studies examining the impact of parental responses on children’s pain have focused mainly on protective or solicitous responses. This study examined the impact of parental responses, including protectiveness, minimization of pain, and encouraging and monitoring responses, on children’s functional disability and somatic symptoms. Participants included 327 patients with chronic pain, ages 8–17, who completed measures of pain, disability, somatic symptoms, depression, and anxiety. Patients’ parents completed a measure assessing parental responses to their children’s pain. Results show that for children with higher levels of emotional distress, maladaptive parental responses to pain (e.g., criticism, discounting of pain, increased attention to pain, and granting of special privileges) were associated with increased disability and somatic symptoms. Results of this study demonstrate the important ways in which parents can influence how their children cope with and manage chronic pain. Children whose parents are overly protective or critical of their pain may experience more impairment or somatic symptoms, particularly those children who are already at risk for difficulties due to higher levels of emotional distress.     

Parent perceptions of adolescent pain expression: the adolescent pain behavior questionnaire

Pain behaviors provide meaningful information about adolescents in chronic pain, enhancing their verbal report of pain intensity with information about the global pain experience. Caregivers likely consider these expressions when making judgments about their adolescents’ medical or emotional needs. Current validated measures of pain behavior target acute or procedural pain and young or non-verbal children, while observation systems may be too cumbersome for clinical practice. The objective of this research was to design and evaluate the Adolescent Pain Behavior Questionnaire (APBQ), a parent-report measure of adolescent (11-19 years) pain expressions. This paper provides preliminary results on reliability and validity of the APBQ. Parent-adolescent dyads (N = 138) seen in a multidisciplinary pain management clinic completed the APBQ and questionnaires assessing pain characteristics, quality of life, functional disability, depressive symptoms, and pain catastrophizing. Principal components analysis of the APBQ supported a single component structure. The final APBQ scale contained 23 items with high internal consistency (α = 0.93). No relationship was found between parent-reported pain behaviors and adolescent-reported pain intensity. However, significant correlations were found between parent-reported pain behaviors and parent- and adolescent-reported functional disability, pain catastrophizing, depressive symptoms, and poorer quality of life. The assessment of pain behaviors provides qualitatively different information than solely recording pain intensity and disability. It has clinical utility for use in behavioral treatments seeking to reduce disability, poor coping, and distress.     

Medical evaluation of children with chronic abdominal pain: Impact of diagnosis,physician practice orientation,and maternal trait anxiety on mothers’ responses to the evaluation

This study examined the effects of diagnosis (functional versus organic), physician practice orientation (biomedical versus biopsychosocial), and maternal trait anxiety (high versus low) on mothers’ responses to a child’s medical evaluation for chronic abdominal pain. Mothers selected for high (n = 80) and low (n = 80) trait anxiety imagined that they were the mother of a child with chronic abdominal pain described in a vignette. They completed questionnaires assessing their negative affect and pain catastrophizing. Next, mothers were randomly assigned to view one of four video vignettes of a physician-actor reporting results of the child’s medical evaluation. Vignettes varied by diagnosis (functional versus organic) and physician practice orientation (biomedical versus biopsychosocial). Following presentation of the vignettes, baseline questionnaires were re-administered and mothers rated their satisfaction with the physician. Results indicated that mothers in all conditions reported reduced distress pre- to post-vignette; however, the degree of the reduction differed as a function of diagnosis, presentation, and anxiety. Mothers reported more post-vignette negative affect, pain catastrophizing, and dissatisfaction with the physician when the physician presented a functional rather than an organic diagnosis. These effects were significantly greater for mothers with high trait anxiety who received a functional diagnosis presented by a physician with a biomedical orientation than for mothers in any other condition. Anxious mothers of children evaluated for chronic abdominal pain may be less distressed and more satisfied when a functional diagnosis is delivered by a physician with a biopsychosocial rather than a biomedical orientation.     

When the child's illness is life threatening: impact on the parents

An investigation of the impact on parents of children with life threatening (LT) and parents of children with non-life threatening (NLT) chronic illnesses measured satisfaction with social support received, perception of the impact of the child's illness, and coping behaviors. Eighty fathers and 80 mothers of children completed four questionnaires: (a) The Sociodemographic and Illness-related Questionnaire (Krulik, Hirschfield, & Sharon, 1984); (b) Social Support Questionnaire (London, 1988); (c) Perception of the Impact of the Child's Chronic Illness on the Parent Questionnaire (Katz, 1994); and (d) Coping Health Inventory for Parents (CHIP) (McCubbin, McCubbin, Patterson, et al., 1983). The results of parents together and fathers and mothers separately, and parents of LT and parents of NLT chronic illnesses were compared using ANOVA, MANOVA, and Doubly multivariate analysis. Parents of children with LT and NLT illnesses reported significant differences in social support, perception of the impact of the illness, and coping behaviors. Although fathers and mothers reported significant differences in the use of the medical team as a coping behavior, no significant differences were found between fathers and mothers related to social support and perception of the impact of the illness.