Parents’ Pain Catastrophizing is Related to Pain Catastrophizing of Their Adult Children
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- Kraljevic, S., Banozic, A., Maric, A. et al. Int.J. Behav. Med. (2012) 19: 115. doi:10.1007/s12529-011-9151-z
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Parents’ pain behavior is associated with the way their children experience and express pain.
We hypothesized that there is a positive association between levels of pain catastrophizing in parents and their adult children.
Study included 285 participants, 100 patients, 85 spouses, and 100 adult children from 100 families. Pain catastrophizing was assessed with the Croatian version of Pain Catastrophizing Scale. Patients’ pain intensity was measured with the visual analogue scale.
Significant positive correlation was found between pain catastrophizing of adult children and both of their parents. Regression analysis was conducted to test for the role of parents’ pain catastrophizing scores in explaining pain catastrophizing in their adult children. The results showed that parents’ pain catastrophizing scores explain results of their adult children, accounting for 20% of the variance.
The results from the present study indicate that there is a positive association between levels of pain catastrophizing in parents and their adult children. A family may have a specific cognitive style for coping with pain, which is associated to a child’s responses to pain experiences.
Pain catastrophizing is a major determinant of intrapersonal aspects of pain, including increased pain intensity, distress, and disability . According to the communal coping model, pain catastrophizing is conceptualized as being part of a broader, interpersonal, or communal coping style, in which it serves a social communicative function . An argument for communicative dimension of pain is that those who catastrophize about pain seek social support by overt display of pain because they feel threatened and helpless about their pain . Through heightened displays of distress and by communicating an inability to deal effectively with a painful situation, a person may be maximizing the support and assistance from others . Therefore, it is possible that pain catastrophizing may arise as a function of social learning .
Experimental evidence supports the position that there is a positive association between parents’ and children’s pain-related behavior . Children of seriously ill parents had higher scores on symptom scales than did controls . A study that compared psychological and physical functioning of children in three groups: mothers with chronic pain, fathers with chronic pain, and a control group of pain-free parents, found that pain reports between children and parents with chronic pain had significant positive correlation, suggesting support for a familial pain model . Social learning may explain the concordance between parent and child health in families experiencing parental chronic pain , and parental impact on children’s subjective reports of pain .
Studies have addressed how parents’ catastrophizing is associated to pain perception of their children and how parents respond to pain in high catastrophizing children [8, 9], but it is not known whether there is an association between pain catastrophizing in children and their parents. Therefore, in this study pain catastrophizing was measured in a triad mother–father–child to assess whether there is a correlation between pain catastrophizing in adult children and their parents. Secondly, we aimed to explore the differences in the association of pain catastrophizing in parents with chronic pain and pain-free parents on the level of pain catastrophizing in their adult children.
Materials and Methods
The study was a result of collaboration between Laboratory for Pain Research of University of Split School of Medicine and Pain Clinic of University Hospital Split, Croatia. The study was approved by the ethical committee of the University of Split School of Medicine. Informed consent was obtained from each participant.
Study participants were recruited among patients of the pain clinic of the University Hospital Split, Croatia, where 100 patients with chronic pain were asked to participate in the study and to include in the study their pain-free spouses and pain-free adult biological children. To be considered for recruitment, patients from the pain clinic had to have chronic nonmalignant pain lasting at least 3 months and at least one adult biological child with whom they had lived in the same household during their entire childhood at least until age 18. Additional inclusion criteria for patients were age 40–90 and pain intensity of 5–10 on the visual analogue scale (VAS). If one member of a triad failed to return questionnaires, this triad was excluded from the database. Patients with more than one adult biological child were instructed to invite the oldest one to participate.
Patients were recruited consecutively. When the eligible triad consented to participate, the family was included in the study and given questionnaires. If patients were divorced or widowed, and their adult child willing to participate in the study, they were treated as a dyad. All patients and spouses accepted to participate in the study. Only one triad was excluded from the study because daughter of a patient refused to participate.
Research was done using the Pain Catastrophizing Scale (PCS), which was constructed by Sullivan et al. . The PCS is a 13-item self-report inventory that measures the extent to which people catastrophize in response to pain. The 13 items of the PCS are rated on 0–4 Likert-type scales (0 = not at all; 4 = all the time) and items are summed to create a total score (items 1–13), rumination score (items 8–11), magnification score (items 6, 7, and 13), and helplessness score (items 1–5 and 12). Reliability of the PCS in the total sample was α = 0.95 for the 13-item total score, α = 0.90 for helplessness, α = 0.89 for magnification, and α = 0.87 for rumination.
In our sample, we used the PCS in Croatian language, which was tested on 521 healthy volunteers. Questionnaire was translated from English to Croatian using a back-translation procedure, and it was tested for cross-language equivalence. Cross-language equivalence was tested by administering both the translated and original forms of the questionnaire to bilingual persons. Confirmatory factor analysis with oblique rotation was performed to test the factor structure of Croatian version of PCS, which yielded a three-factor solution. The interpretation of the three components was consistent with previous research on PCS scale [11–13].
The visual analogue scale (VAS) was used to measure the patients’ perceived level of pain. Scale ranges from 1 (indicates the absence of pain) to 10 (the most intense pain possible). Patients were asked to provide a numerical estimation of the experienced pain.
Patients included in the study received three envelopes with PCS questionnaires marked with alphanumeric codes. Codes contained one of three letters: P (patient), S (spouse), or C (child), which was explained to a patient so that questionnaires could be distributed accordingly. Each code also contained a number of the triad, which was assigned to each family in the pain clinic database. Patients were instructed to fill out questionnaires independently, without discussing them in the family, and to return questionnaires in a sealed envelope either personally or by mail. Codes were used to preserve participants’ anonymity.
At the moment of patient recruitment, a physician filled in the following data about patients in the study records: numerical code of a triad, diagnosis, VAS pain score, prescribed therapy, age, gender, education, and monthly household income.
Variables were studied using statistical software SPSS 15.0 (SPSS Inc., Chicago, IL, USA). Associations between variables were tested using Pearson’s correlation and Student’s t test. Multiple regression analysis was conducted to evaluate how well the sociodemographic variables and pain intensity relate to patients’ pain catastrophizing scores and to assess the level of association between parents’ pain catastrophizing scores and the same scores in children. Data from descriptive statistics were expressed as mean ± standard deviation.
Characteristics of parents and adult children in the sample
Patients (N = 100)
Spouses (N = 85)
Adult children (N = 100)
55 ± 10
60 ± 10
30 ± 10
BSc, MSc, or PhD
Monthly household income
Below US $1,000
Above US $2,000
Total PCS score (mean ± SD)
31.03 ± 12.61
25.64 ± 13.42
21.80 ± 12.16
The highest mean total PCS score was found in the patient group and lowest in the group of adult children (Table 1). There were statistically significant positive correlations in total pain catastrophizing score between patients and their adult children (r = 0.37, p < 0.01), as well as between pain-free parents and their adult children (r = 0.37, p < 0.01). Comparison of pain catastrophizing values in children and all parents showed that there are statistically significant differences on PCS total score (F(2.28) = 12.79, p < 0.01).
No statistically significant correlations were found between pain intensity measured by VAS and pain catastrophizing scores in patients (r = 0.19, p > 0.05), nor were pain catastrophizing scores associated with patients’ diagnoses (r = −0.12, p > 0.05). Significant association between pain catastrophizing and VAS pain result was found only when considering different diagnoses. The significance was found in the group of patients with musculoskeletal disease (N = 81), r = 0.29, p < 0.01.
Summary of regression analysis of children’s total pain catastrophizing score (PCS) explained by parents’ catastrophizing
PCS of patient
PCS of spouse
Psychosocial factors have become increasingly recognized as important moderators and determinants of the pain experience. One such factor that has garnered great empirical attention is pain catastrophizing . Catastrophizing has been broadly defined as an exaggerated negative mental set brought to bear during actual or anticipated pain experience . Studies have shown that parents model pain experiences of their children and expression patterns through modeling reactions to painful stimuli . In this study, we found that there is a positive association between pain catastrophizing scores in parents and their adult children.
There is evidence from both correlational and experimental studies that social learning is important in shaping an individual’s pain response and pain behavior, even though the exact mechanisms by which this occurs are not fully understood . Learning by observing others or modeling, enables the observer to acquire new patterns of behaviors and rules for regulating behavior, without having to rely on one’s own actions or trial and error experiences . Features of the relationship between the observer and the model also moderate observational learning effects. Family members and other intimates are more likely to serve as models for pain-related responses than strangers, although the benefits of observational learning are not restricted to observing those close to the individual . Therefore, we hypothesized that there could be an association between pain catastrophizing levels of parents and their children.
From the perspective of a model of human communication, the experience of pain is affected by intrapersonal and contextual factors . From a developmental perspective, social influences, which include parental behavior, are extremely important for shaping children’s responses and beliefs related to pain . Many responses are learned by observing and imitating the behavior of others, and this is true for the expression and localization of pain and ways of coping with pain . According to the Fordyce’s operant model, social responses from the environment can encourage or punish certain forms of behavior and in such a way shape behavior of an individual . Since during childhood, parents serve as a model that children imitate; it is possible that children use social and communicative tools for managing distress in a social context that they observe in their parents.
Communal coping model explains catastrophizing as a coping strategy that is connected to an individual’s social environment, e.g., by seeking social support. However, associations between perceived social responses and catastrophizing have varied substantially across studies, and factors such as pain duration  and social contacts [23, 24] potentially moderate these relationships. Both perceived rewarding and punishing responses to pain are associated with higher pain intensity , suggesting that these social influences form a mechanism by which catastrophizing applies its negative effects on pain-related outcomes .
We found significant correlation between parents’ and adult children’s pain catastrophizing scores, and there was no difference in this association between parents with high-intensity chronic pain and pain-free parents. Our findings indicate that a family may have a specific cognitive style for coping with pain, which models pain experience of children through pain catastrophizing phenomenon.
This effect is probably even greater as scores on PCS indicate a patient’s own thoughts and feelings regarding pain that do not necessarily indicate pain verbalizations and behavioral expressions in their child’s presence, which makes sense from an evolutionary perspective, where it was more adaptive for parents to suppress behavioral expressions of pain, in order to protect their offspring. As in the case of other aspects of pain experience, it is likely that expressions of pain depend more upon affective–motivational characteristics, and less upon its sensory characteristics .
In our study, VAS scores were not correlated to pain catastrophizing scores of all patients with chronic pain. There are conflicting studies about correlation of pain catastrophizing scores with intensity of acute pain, as Sullivan et al. found that pain catastrophizing is unique in its explanatory ability for pain ratings, while George at al. reported that pain catastrophizing did not explain acute pain intensity [27, 28]. Multiple studies have found positive association between pain catastrophizing and intensity of chronic pain . In our sample of patients we did find a significant association between pain catastrophizing and VAS pain result in the group of patients with musculoskeletal disease. Our results may be due to the reduced amount of data or due to our selection of patients with high pain intensity scores.
This study had several limitations. First, findings were based on cross-sectional and correlational data, which do not indicate causal effects. A longitudinal or experimental design is stronger, but the present study, using a cross-sectional design, also adds substantially to our knowledge in this field. Observational studies are needed further to investigate both expressive features of pain catastrophizing and its association to pain perception and pain-related behaviors. Second, patients included in this study were in severe pain. Replication of the study is needed on larger clinical samples to further investigate generalizability of the findings. Third, patients received questionnaires to take them home and give to their spouses and children, so we assume that each questionnaire was filled out by the associated individual.
In conclusion, the results from the present study indicate that parental pain catastrophizing is associated to pain catastrophizing in children. A family may have a specific cognitive style for coping with pain, which is associated to child’s responses to pain experiences. Our results confirmed that sociodemographics plays important part in shaping pain experience.
We are grateful to all study participants for contributing to this study. Thanks to Mr. Ian Blair for language editing.