Parent Responses to Their Child's Pain

Systematic Review and Meta-Analysis of Measures

Lauren E. Harrison, PHD; Inge Timmers; Lauren C. Heathcote; Emma Fisher; Vivek Tanna; Tom Duarte Silva Bans; Laura E. Simons


J Pediatr Psychol. 2020;45(3):281-298. 

In This Article

Abstract and Introduction


Objective: Parent responses can have a major impact on their child's pain. The purpose of this systematic review is to (a) identify and describe measures assessing pain-related cognitive, affective, and behavioral responses in parents of children with chronic pain and (b) meta-analyze reported correlations between parent constructs and child outcomes (i.e., pain intensity, functional disability, and school functioning). Prospero protocol registration ID: CRD42019125496.

Methods: We conducted a systematic search of studies including a measure of parent/caregiver responses to their child's chronic pain. Study characteristics and correlations between parent measures and child outcomes were extracted. Data were summarized and meta-analyzed.

Results: Seventy-nine met inclusion criteria using 18 different measures of cognitive/affective (n = 3), behavioral (n = 5), and multidimensional responses (n = 10). Measures were used a median of three times (range 1–48), predominantly completed by mothers (88%), and primarily in mixed pain samples. Psychometrics of measures were generally adequate. Meta-analyses were based on 42 papers across five measures. Results showed that each of the cognitive, affective, and behavioral parent constructs we examined was significantly associated with pain-related functional disability. A small number of measures assessing parent cognitions and affective functioning were associated with higher child pain intensity; however, the majority were not.

Conclusion: Findings demonstrate that there is a wealth of measures available, with adequate reliability overall but a lack of psychometrics on temporal stability. Synthesizing data across studies revealed small effects between parent responses and child functioning, and even smaller and/or absent effects on child pain intensity.


Chronic pain (i.e., pain lasting more than 3 months; Merskey & Bogduk, 1994) is a common experience during childhood (King et al., 2011), negatively impacting academic, social, emotional, and behavioral functioning (Fales, Essner, Harris, & Palermo, 2014; Gaughan, Logan, Sethna, & Mott, 2014; Goubert, Eccleston, Vervoort, Jordan, & Crombez, 2006; Jordan, Eccleston, McCracken, Connell, & Clinch, 2008; Palermo, Valrie, & Karlson, 2014; Simons, Smith, Kaczynski, & Basch, 2015). Children with chronic pain also experience significant functional impact, which extends to family members (Palermo & Chambers, 2005). Over the last several years, there has been increased attention toward parent cognitive, affective, and behavioral responses in the context of their child's pain, and how this contributes to the child's pain experience and associated disability.

Historically, two frameworks, the biopsychosocial model and the ecological model, have been used to better understand the experience of chronic pain and disability in children. Developed in part from a social learning theory perspective, the biopsychosocial model (Fordyce et al., 1973) suggests that biological, psychological, and social factors are all potential contributors to the child's experience of pain and related disability. The ecological model (Bronfenbrenner, 1979), influenced by family systems theory, emphasizes the individual's behavior within the context of family situations. Although components of these theories have been applied to pediatric chronic pain populations, these models generally lack an examination of specific pathways by which family factors may influence children's pain and associated disability.

In an attempt to overcome these limitations, intergenerational and interpersonal models have been developed by integrating the aforementioned frameworks and focusing on the bidirectional relationships between the child's pain experiences as well as the influence that parent and family variables have on chronic pain and related disability (Goubert & Simons, 2013; Palermo & Chambers, 2005; Palermo et al., 2014). Palermo and Chambers (2005) proposed an integrative model of parent and family factors in pediatric chronic pain. Within this model, individual parenting variables (e.g., parenting style, parental reinforcement) are situated within a broader context of dyadic variables (e.g., quality of parent–child interaction), which is further embedded within the more global familial environment. This model highlights the shared influence of pain and related disability, as well as child and parent variables, interacting with individual, dyadic, and family variables as they relate to pediatric chronic pain. More recently, the Interpersonal Fear Avoidance Model of Pain (IFAM; Goubert & Simons, 2013; Simons et al., 2015) was put forth. This model further emphasizes parent cognitive-affective and behavioral variables and their impact on child functioning. Within the IFAM, parents interpret their child's pain expression through the lens of their own catastrophic appraisals and pain-related fears, leading some to engage in parenting behaviors that may result in negative consequences for the child (e.g., functional decline).

There is building evidence to support interpersonal models. For example, parents report significant distress as a result of parenting a child with chronic pain (Fales et al., 2014; Gaughan et al., 2014; Goubert et al., 2006; Jordan et al., 2008; Palermo et al., 2014; Simons et al., 2015). Moreover, certain parent cognitions and affective responses (e.g., catastrophizing, fears related to their child's pain) are associated with poorer pain-related outcomes in children (Chow, Otis, & Simons, 2016; Fales et al., 2014; Logan, Simons, & Carpino, 2012; Palermo et al., 2014; Simons et al., 2015). Parent behavioral responses, including protective behaviors, minimizing, and encouragement/reinforcement of symptoms, have also been associated with poorer child outcomes, including increased pain intensity and functional disability (Noel et al., 2015; Peterson & Palermo, 2004; Sieberg, Williams, & Simons, 2011). While these parental responses are understandable, normative, and care-promoting in the context of acute pain, prolonged and high levels of distress and protective behaviors within the context of chronic pain is maladaptive. On the other hand, other cognitive and behavioral responses (e.g., psychological flexibility and pain acceptance) might serve as resilience factors by promoting child functioning through effects on parent behaviors as well as on child coping (Gauntlett-Gilbert, Alamire, & Duggan, 2019; Kanstrup et al., 2016; McCracken & Gauntlett-Gilbert, 2011; Timmers, Simons, Hernandez, McCracken, & Wallace, 2019; Wallace, Woodford, & Connelly, 2016).

Taken together, there is accumulating evidence on the instrumental influence of parent pain-related cognitive, affective, and behavioral responses on their child's pain experience and associated functioning. Given this, sound assessment of parent responses in the context of their child's pain is important for building upon current research, as well as identifying treatment targets within this population. Thus, it is timely to systematically review measures assessing these parent variables. This systematic review has two aims: (a) identify measures used to assess parent pain-related responses to their child's pain, summarizing their use and psychometric properties; (b) meta-analyze correlations between parent constructs and child outcomes (i.e., pain intensity, functional disability, and school impairment). In relation to the second aim, we hypothesize that higher parent cognitive and affective distress is associated with higher child pain intensity, functional disability, and school impairment. We also hypothesize that higher reports of parents' protective, solicitous, monitoring, and minimizing behavioral responses are associated with higher child pain intensity, functional disability, and school impairment. Additionally, we hypothesize that higher parental psychological flexibility and pain acceptance will be associated with lower child pain intensity, functional disability, and school impairment.