Parental Behavior Tied to Greater Disability in Persistent Pediatric Headache

Erik Greb

July 01, 2020

Parental attitudes and behavior predict outcomes in children with new daily persistent headache (NDPH), new research shows.

Investigators from Boston Children's Hospital in Waltham, Massachusetts, found the degree of disability these children experience directly relates to levels of parental catastrophizing, fear of pain, and protective behavior. Furthermore, parents' rating of their own distress was independently associated with their level of protective behavior.

"​These results demonstrate the role parents play in their child's physical and emotional functioning, which is key to success in rehabilitation for NDPH," Rupa Gambhir, PsyD, staff psychologist at Boston Children's Hospital, told Medscape Medical News.​ "Therefore, family-based cognitive behavioral therapy interventions, including parent operant training, may play an important part in youth recovery from NDPH.

The findings were presented at the American Headache Society (AHS) Annual Meeting 2020, which was virtual this year because of the COVID-19 pandemic.

Exceptionally Refractory, Disabling

NDPH is an unremitting chronic headache that is exceptionally refractory and disabling and has an estimated prevalence of between 13% and 35%. Factors that lead to, or perpetuate, the condition are poorly understood. Some research suggests the onset of NDPH may be caused by head trauma or infection, but for many patients, there is no identifiable etiologic factor.

Previous research shows that parents significantly influence children's ability to cope with chronic pain. Research also indicates that parents who engage in catastrophic thinking have more distress and a greater desire to stop the activities that contribute to their children's pain.

The investigators hypothesized that increased levels of pain catastrophizing, fear of pain, and protective responses among parents would be associated with greater disability among children with NDPH. They also proposed that parents' protective responses mediated the relationship between their catastrophizing and fear of pain and children's disability.

To examine the relationship between parents' emotional, cognitive, and protective responses and functional impairment in children, the investigators conducted a retrospective chart review of 155 NDPH patients presenting for evaluation at a tertiary pediatric headache clinic.

The children ranged in age from 8 to 17 years (mean age 14.3 years). Approximately 78% of patients were female and 90.6% were white. Approximately 83% of the parents were mothers.

The diagnosis of NDPH was made using the International Classification of Headache Disorders II criteria. Before the clinic visit, patients completed the Functional Disability Inventory.

Parents completed the Parent Pain Catastrophizing Scale, the Parent Fear of Pain Questionnaire, and the Adult Responses to Children's Symptoms — Protectiveness Subscale. The investigators calculated Pearson correlation coefficients to examine the relationships between the variables.

Kids Respond to "Unspoken Concerns"

Parent catastrophizing (P = .168), fear of pain (P = .467), and protective responses (P = .357) were all associated with disability in children. In addition, parents' protective responses were positively associated with catastrophizing (P = .426) and fear of pain (P = .624).

Parent protective responses did not significantly mediate between parent catastrophizing and children's disability, or between parent fear of pain and children's disability. Parents may not need to exhibit shielding behaviors to impair their child's functioning, the investigators note.

"In addition to direct parental pain-attending responses, based on results demonstrating a significant relationship between parent catastrophizing and children's disability, children seem attuned to parents' internal or private discourse," said Gambhir.

"Children may respond to unspoken concerns, confusion, and uncertainty about parents' thoughts and feelings by withdrawing from regular functioning."

The findings highlight neurologists' role as the medical authorities on NDPH in explaining the biopsychosocial nature of NDPH to parents, Gambhir added.

"They can highlight that minimizing protective behaviors is associated with improvements in children's functional disability, and remaining engaged in important activities of daily living and maintaining positive wellness behavior is essential to the rehabilitation of this type of chronic daily headache."

New Insight

Commenting on the findings for Medscape Medical News, Kenneth J. Mack, MD, PhD, chair of child and adolescent neurology at the Mayo Clinic in Rochester, Minnesota, described the research as "a very nice hypothesis-driven study."

"Some strengths of the study are the large number of patients that they have and the use of validated questionnaires to get quantitative data. The authors also address a critical question.

"NDPH is difficult to treat, and any insight into why NDPH continues and why it is difficult to treat will be important for the field of headache medicine to understand," Mack added.

For some patients, catastrophizing plays an important role in the perpetuation of functional disability and other symptoms. "Catastrophizing is an important construct to appreciate and recognize in the field of headache medicine."

The investigators did not report any funding for their study. Gambhir and Mack have reported no relevant financial relationships.

American Headache Society (AHS) Annual Meeting 2020. Abstract 842274. Presented June 13, 2020.

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