One-way analysis of variances identified significant dyad category differences in child-reported pain intensity (F(3,232) = 2.94, P < 0.05, η2 = 0.04), stress (F(3,232) = 11.45, P < 0.01, η2 = 0.13), functional disability (F(3,228) = 13.93, P < 0.01, η2 = 0.15), and quality of life (F(3,234) = 21.95, P < 0.01, η2 = 0.22). In terms of pain intensity, discordant high C–low P dyads reported the highest pain intensity of the 4 groups and significantly higher pain intensity than discordant low C–high P dyads (MD = 1.77, P < 0.05, Fig. 1). Pain intensity did not significantly differ between additional dyad categories (P > 0.05).
In terms of stress, discordant high C–low P dyads likewise reported the highest stress of the 4 dyad categories and significantly higher stress than discordant low C–high P dyads (MD = 3.34, P < 0.01, Fig. 2), concordant-low dyads (MD = 3.25, P < 0.01), and concordant-high dyads (MD = 1.98, P < 0.01). Reported stress did not significantly differ between all other groups (P > 0.05).
Overall, parents reported higher pain-related injustice perceptions (about their child's pain) than children. Most children and parents indicated concordant injustice perceptions, with those indicating discordant perceptions equally split between low child (C)–high parent (P) and high child (C)–low parent (P) dyads. Both the degree (concordant vs discordant) and direction (discordant low C–high P vs discordant high C–low P) of congruence between child and parent injustice perceptions were associated with several child-reported pain outcomes.
Parents play a unique role in the foundation of their children's justice beliefs,7 as well as their conceptualizations of and responses to pain.23,24 The way parents think about and respond to children's pain seems to be especially important.23 For example, parental catastrophizing about their child's pain is associated with greater child pain intensity, somatic complaints, catastrophizing, school absences, and functional disability.12,19,20,25,46 Our results suggest that pain-related injustice perceptions operate similarly. Parents who endorse beliefs such as “most people don't understand how severe the (my child's) condition is” (item 1 on IEQ-PC) or “my child should not have to live this way” (item 4 on IEQ-PC) may respond differently to their child's pain than parents who do not endorse those beliefs. Overly protective or solicitous parental responses are particularly detrimental and are associated with, among other things, increased impairment and symptom complaints in children.3,14,18,33,36 Parents who frequently think of their child's pain as irreparable (ie, “I feel that this has affected my child in a permanent way”–item 6 on IEQ-PC) may be particularly likely to engage in such protective or solicitous behaviors. Likewise, parents who believe that “most people don't understand how severe my child's condition is” may inappropriately limit their children's activities out of fear of causing further harm. Such parents may also engage in an overabundance of pain check-ins (eg, “How is your pain?” “Are you doing too much?”), thus drawing their children's attention to pain and away from valued life activities.45 However, we did not measure parental responding in the current study, so these hypotheses remain to be tested.
A particularly novel aspect of our study was its focus on the discrepancy between parent and child injustice appraisals. Our findings suggest that pain and functional outcomes for children are associated with the degree to which children and parents share the same justice-related perspective about pain. Both dyad groups containing children with high injustice perceptions had poor pain outcomes. However, dyads in which children hold higher injustice appraisals than their parents reported the poorest outcomes. As above, these findings align with the catastrophizing literature in which high catastrophizing child–low catastrophizing parent dyads report greater child disability21,35 and depressive symptoms21 than other dyads. Child–parent discrepancies in injustice perceptions may engender feelings of invalidation in the child—that their parent is not taking their pain seriously—and lead to maladaptive behaviors intended to communicate the severity of their condition. Indeed, injustice perceptions are associated with heightened displays of pain behavior39 and consequent adverse outcomes27,28 among adults with pain. Of note, discordant high C–low P dyads had an average parent IEQ score above the suggested cutoff of 1930—accordingly, although children within this dyad category endorsed higher injustice than their parents, parents still on average endorsed clinically elevated injustice. Future research could examine if and how these dyads differ from high C–low P dyads where parents do not score above the cutoff. The apparent importance of child–parent concordance notwithstanding, the fact that the best outcomes were observed for dyads where the child scored low on injustice, along with the fact that bivariate correlations between injustice and outcomes were stronger for the IEQ-C than IEQ-PC, suggest that child perceptions may be the primary driver of these relationships.
The current findings have several clinical implications. Scholars have begun discussing interventions for pain-related injustice perceptions in adults.31,40 The current study and those that preceded it,22 (ISPP poster presentation, September 2017) suggest that children and adolescents should be included in these discussions. Our findings also highlight the important role of parents in this context and suggest that injustice-focused interventions for pediatric pain should include a parental component. Our findings further suggest that parental injustice perceptions interact with child perceptions to exacerbate pain outcomes for the child. Discordant injustice perceptions, particularly in the case of high child–low parent combinations, may complicate treatment. Fisher et al.8 found that child–parent agreement on treatment goals was associated with lower pain intensity and may be an important treatment process to consider. Relatedly, disparate child–parent injustice views may influence their level of agreement on treatment goals and, consequently, treatment success. For concordant-high dyads, psychoeducation about and cognitive restructuring of pain-related injustice appraisals may be a first step. Acceptance-based approaches that emphasize values-based living, even while having thoughts about the unfairness of being in pain, may also prove beneficial. For high C–low P dyads, a brief intervention to discuss and bring awareness to the discordance in injustice perceptions may serve to lessen the negative impact on outcomes; such an intervention might even be incorporated into an initial clinical evaluation. Parental training in empathic and validating responding may be an additional treatment component.
Several study limitations should be considered. The cross-sectional nature of the data limits conclusions that can be drawn about the relationship between perceived injustice and pain outcomes. In addition, all constructs were assessed using self-report measures, which are susceptible to problems of common method variance and negative response set; these measures are also predicated on the assumption that participants can think about and accurately report on their psychosocial experiences and pain outcomes. Also, patients were predominately white and female, from 1 clinic, which may limit the generalizability of these findings. We did not collect detailed information about parents/guardians, such as medical history, caregiver status (primary vs secondary), or socioeconomic status, which may be relevant in this context. Sex of the primary caregiver is also potentially relevant, as the injustice perceptions of mothers vs fathers may have differential implications for child outcomes. Furthermore, we did not collect information about length of diagnosis or number of clinic appointments attended, which may influence pain-related injustice perceptions and outcomes.
Future research is needed to replicate these results and continue to examine the extent to which parent and child injustice perceptions impacts the pain experience for children and adolescents. Given that research on injustice perceptions in pediatric pain is in its early stages, many factors remain to be explored. The relationships among parent and child injustice perceptions, parental responding, and child pain behaviors have yet to be investigated. Studying this relationship may help elucidate mechanisms by which injustice leads to poor outcomes. Similarly, investigating injustice perceptions of other central figures—including parents, other family members, teachers, and friends—may yield new insights about the pediatric pain experience that are relevant to clinical outcomes. At the very least, given that much of the pediatric literature focuses on mothers, extending the focus to fathers represents a clear next step in this line of inquiry. Also, exploring the dimensions of pain-related injustice (ie, blame/unfairness vs severity/irreparability of loss), their concordance among parent and child, and their unique and collective impact on the child's pain experience may lead to better targeted and more effective interventions. Prospective studies in adults indicate that perceived injustice is a risk factor for poor rehabilitation outcomes38,41 and decreased likelihood of returning to work.9,38 Future research is needed to explore if similar patterns (ie, poor rehabilitation outcomes and decreased likelihood of returning to school) exist for children with chronic pain. Last, precursors to the development of pain-related injustice perceptions have yet to be explored. Factors such as pain-related stigmatization and violation of just-world beliefs may precede the development of pain-related injustice perceptions. Future research is needed to elucidate such precursors.
There are no conflicts of interest that might be seen as influencing or prejudicing the research.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Preliminary results from this study were presented in a poster session at the 2016 meeting of the International Association for the Study of Pain. We confirm that there have been no closely related manuscripts that have been submitted for simultaneous consideration to this or another journal.
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