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. 2008 Mar 28;33(8):894–904. doi: 10.1093/jpepsy/jsn029

Chronic Pain in Adolescence: Parental Responses, Adolescent Coping, and their Impact on Adolescent's Pain Behaviors

Laura E Simons 1,2,✉, Robyn Lewis Claar 1,2, Deirdre L Logan 1,2
PMCID: PMC2493514  PMID: 18375447

Abstract

Objectives The aim of this study was to examine relations among parental responses, adolescent pain coping, and pain behaviors in adolescents with chronic pain. Methods This study included 217 adolescents (12–17 years) evaluated at a multidisciplinary pain clinic and their parents. Adolescents completed measures assessing their pain, pain coping responses, functional disability, and somatic symptoms. Parents reported on their responses to their adolescent's pain. Results Passive and active coping interacted with parental protective behavior to predict adolescents’ pain behaviors. Contrary to expectations, among adolescents who reported infrequent use of passive or active coping strategies, higher levels of parental protective behavior were associated with higher levels of disability and somatic symptoms. Discussion Among adolescents who report infrequent use of passive and active coping responses, parental protective responses to pain may inadvertently promote greater disability and symptom complaints. Parental responses to pain may be an important target to treat adolescent chronic pain.

Keywords: adolescents, biopsychosocial model, chronic pain, parents, social learning

The biopsychosocial model of chronic pain often has been used to explain how numerous internal and external forces can affect the experience of chronic pain in children and adolescents. In this theoretical framework, chronic pain is conceptualized as a centrally mediated phenomenon, shaped jointly by physiologic, psychological, social, and environmental forces (Drossman, 1998; Engel, 1977; Gatchel, Peng, Peters, Fuchs, & Turk, 2007; Wood, 1995). Within this framework adolescents' coping strategies are one well-studied individual characteristic known to affect pain outcomes. There is extensive literature substantiating the relation between adolescent pain coping behaviors and adolescent pain behaviors (Reid, Gilbert, & McGrath, 1998; Walker, Smith, Garber, & Van Slyke, 1997). For example, passive coping strategies—which generally involve orientation away from the stressor and include responses such as self-isolation, catastrophizing, and disengagement—have been associated with higher levels of pain, somatic symptoms, depressive symptoms (Kaminsky, Robertson, & Dewey, 2006; Varni et al., 1996; Reid et al., 1998; Walker et al., 1997), and functional disability (Kaminsky et al., 2006; Walker, Smith, Garber, & Claar, 2005). In contrast, accommodative coping strategies that involve efforts to accept or adapt to the stressor (including acceptance, minimizing pain, self encouragement, and distraction) have been associated with both lower initial pain reports and decreases in pain over time (Walker et al., 1997), fewer somatic complaints, and lower levels of anxiety and depressive symptoms (Thomsen et al., 2002).

Research on active coping strategies that focus on taking action to change or influence stressful circumstances (e.g., problem solving and social support seeking) have yielded surprisingly mixed results. Some research indicates an association between active coping and higher reports of somatic symptoms, pain, and disability (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Walker et al., 1997), while other studies indicate that these strategies are associated with decreases in disability (Reid et al., 1998). The inconsistent findings related to active coping may reflect how the construct has been operationalized in frequently used measures of pain coping strategies. Although active coping is generally defined as “doing something” in response to pain, these reactions, as operationalized, range from using behavioral relaxation strategies to reactions such as resting and massaging the painful area. When these less productive strategies are included under the rubric of “active coping,” active coping may be more likely to lead to poor outcomes.

Although past examinations of child coping have furthered our understanding of the complex relations between a child's pain experience and subsequent pain behaviors, it is important to look beyond the individual child when attempting to develop a comprehensive picture of the influences on child behaviors in the context of chronic pain. Social learning theory (Bandura, 1977) often has been used to describe the relationship between a child's pain experience and family factors (Chambers, Craig, & Bennett, 2002). Learning occurs through either parental modeling or parental reinforcement of pain behaviors. For example, parental protective responses to pain that function as positive reinforcement, such as letting a child stay home from school or spending more time than usual with a child, have been associated with increased somatic symptoms (Walker, Claar, & Garber, 2002), greater functional disability (Peterson & Palermo, 2004), more frequent school absences (Brace, Smith, McCauley, & Sherry, 2000), greater child health care utilization (Walker, Levy, & Whitehead, 2006a), and slower recovery from surgery (Gidron, McGrath, & Goodday, 1995). Beyond protective responses, parental minimization, defined as discounting and criticizing the child's pain as excessive, has been associated with increased somatic symptoms (Claar, Simons, & Logan, 2008). Consistent with social learning theory, how parents behave toward their child may provide cues to the adolescent regarding the ability to function or even elicit greater symptom reporting from the adolescent through positive and/or negative reinforcement.

These patterns are further supported through recent laboratory investigations that have examined the relations between parental responses and child pain behavior. In a study of children with chronic abdominal pain, parental attention increased child pain complaints whereas parental distraction reduced this behavior (Walker et al., 2006b). Similarly, when parents were trained to interact with their child in pain-promoting ways (i.e., provide empathy, apologies, mild criticism) during a cold pressor task, their child reported higher levels of pain during the task, whereas when parents engaged in pain-reducing behaviors (i.e., verbal distraction with humor, encouragement), their child reported the lowest levels of pain as compared with both the pain-promoting group and a control group (Chambers et al., 2002). These more controlled, experimental studies provide initial data to support a causal relation between parental responses and child pain behaviors.

As the biopsychosocial model suggests, no single factor can adequately account for the wide range of child behaviors associated with chronic pain. Rather, complex interactions between physical, psychological, and social factors all influence the pain experience (Drossman, 1998; Engel, 1977; Gatchel et al., 2007; Wood, 1995). Recent studies have begun to explore the interactions between individual characteristics of the child that potentially increase susceptibility to adverse outcomes in the presence of maladaptive parental responses. For example, Walker et al. (2002) found that child self-worth and academic competence moderated the relation between positive and negative parental response and somatic complaints. For adolescents with low self-worth and low academic competence, increased positive and negative parental responses resulted in greater somatic symptom maintenance. Peterson and Palermo (2004) continued this line of research examining the moderating role of child anxiety and depressive symptoms in the relation between solicitous parental responses and functional disability. They found that child psychological distress intensified the relation between parental response and functioning. Most recently, Claar et al. (2008) extended the Peterson and Palermo (2004) research to include parental minimization and the child outcome variable of somatic symptoms, and found that for adolescent 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 more negative child functioning.

With initial evidence that child characteristics interact with the effects of parent responses on pain behaviors, the purpose of this study was to examine whether adolescent coping would moderate the effects of parental responses on adolescent's functioning. Specifically, we hypothesized that when adolescent engage in higher levels of passive or active coping strategies, high levels of parental protective or minimizing behavior would result in more extensive functional disability and somatic complaints. Conversely, we expected that for adolescent who engage in low levels of passive or active coping strategies, parental protective or minimizing behaviors would not significantly influence adolescent pain behaviors. We acknowledge that the findings have been mixed for active coping, but we believe that strategies such as rest within the construct of active coping will preclude any positive outcomes and resultantly this construct will be associated with poor outcomes. In contrast, because accommodative coping is associated with adaptive functioning, we hypothesized that when adolescent engage in low levels of accommodative coping strategies, high levels parental protective or minimizing behavior would result in more extensive functional disability and somatic complaints. Conversely, for adolescent who engage in high levels of accommodative coping strategies, we expected that parental protective or minimizing behaviors would not significantly influence adolescent pain behaviors.

Methods

Participants

Participants included all patients 12–17 years with at least 3 months’ duration of pain who underwent a multidisciplinary pain evaluation at a tertiary pain clinic in a large, urban northeast pediatric hospital between October 2004 and October 2006. Of the 524 patients seen during this time, 102 were too young (only patients 12 years and older complete the Pain Response Inventory in this clinic), 46 had pain for <3 months, and 158 were ineligible due to missing, incomplete, or invalid questionnaire data (>25% responses left blank). No differences were found between patients with missing data and those with complete data in terms of the adolescent's age, gender, or pain diagnosis. Only one patient refused to complete the questionnaires.

The total sample was comprised of 217 patients who were predominantly Caucasian (92.5%) and female (77.4%), reflecting the composition of patients seen in this tertiary care clinic. The mean age was 14.8 years (SD = 1.5). Pain diagnoses designated by the attending physician in this sampled ranged from neuropathic pain (n = 50; 23%), chronic headache (n = 37; 17.1%), joint pain, one site (n = 33; 15.2%), abdominal pain (n = 29; 13.4%), diffuse pain (n = 25; 11.5%), migraine (n = 22; 10.1%), and low back pain (n = 21; 9.7%). Duration of pain ranged from 3 months to 13 years, with mean duration somewhat over 2 years (M = 24.2 months; SD = 2.3 months). Family socioeconomic status (SES) based on the four-factor index of social status (Hollingshead, 1975) ranged from 22 (semi-skilled workers) to 66 (business owner; professional), with a mean of 48.5 (SD = 11.1).

Measures

Pain Rating

As part of the semi-structured interview with the clinical psychologist, adolescent were asked to provide their current pain rating on a standard 11-point numeric rating scale (Varni, Thompson, & Hanson, 1987) from 0 (no pain) to 10 (most pain possible).

Basic Demographic Information

Parents provided basic demographic information (e.g., adolescent's age and gender, parents’ occupations, education, and marital status) on the Pain Treatment Service Demographic Information form.

Adult Responses to Adolescent's Symptoms (ARCS)

The ARCS (Van Slyke & Walker, 2006) was completed by parents and includes three subscales assessing parents’ responses to their adolescent's pain: parental protectiveness, minimization of pain, and encouraging and monitoring responses. Only the protective and minimization scale were examined in this study, as these subscales have received previous support in the literature (Claar et al., 2008; Peterson & Palermo, 2004). The stem for each item is, “When your child has pain, how often do you …?” Responses are rated on a 5-point scale ranging from “never” (0) to “always” (4), and subscale scores are computed by calculating the mean ratings for items on each subscale. Higher scores equate to more frequent use of a particular response. Items on the Protect scale refer to protective parental behavior such as giving the child special attention and limiting the child's normal activities and responsibilities. Examples include: “bring your child special treats or little gifts,” and “let your child stay home from school.” Items on the Minimize scale discount and criticize the child's pain as excessive. Sample items include: “tell your child not to make such a fuss about it,” and “tell your child that he needs to learn to be stronger.” Alpha reliabilities for the three subscales in the current sample were:.85 for Protect and.66 for Minimize.

Pain Response Inventory (PRI)

The PRI (Walker et al., 1997) is a 60-item self-report measure completed by adolescent that assesses their typical ways of coping with pain. Individuals respond to each question using a 5-item Likert format, ranging from never to always. The PRI consists of three higher order scales: Passive Coping, defined as attempts to distance oneself from the stressor; Active Coping, involving taking action to potentially change or influence the stressor; and Accommodative Coping, defined as efforts to accept or adapt to the stressor. Each of the three higher order scales are further classified into 12 subscales (Passive: Self-isolation, Behavioral disengagement, Catastrophizing; Active: Problem-solving, Seeking social support, Rest, Massage/guard, Condition-specific strategies; Accommodative: Acceptance, Minimizing pain, Self-encouragement, Distract/ignore). The condition-specific subscale was removed from this analysis as it was developed specifically for abdominal pain, and our sample consists of a diverse pain group. Higher scores indicate more frequent use of the coping response. The PRI has extensive support for its reliability and validity (Blount et al., 2007). Alpha reliabilities for the three higher order subscales in the current sample were.88 for Passive,.85 for Active,.94 for Accommodative.

Functional Disability Inventory (FDI)

The FDI (Claar & Walker, 2006; Walker & Greene, 1991) was completed by adolescent and assesses their self-reported difficulty in physical and psychosocial functioning due to their physical health. The instrument consists of 15 items concerning perceptions of activity limitations during the past 2 weeks; total scores are computed by summing the items. Higher scores indicate greater disability. The FDI has demonstrated reliability and validity. Alpha reliability for the current sample was.89.

Adolescent's Somatization Inventory (CSI)

The CSI (Walker, Garber, & Greene, 1991) was completed by adolescent and assesses the severity of their nonspecific somatic symptoms (e.g., “weakness,” “dizziness”) that need not have organic disease etiology (Walker et al., 1991). Respondents rate the extent to which they have experienced each of 35 symptoms during the last 2 weeks using a 5-point scale ranging from “not at all” (0) to “a whole lot” (4). Higher scores indicate higher levels of somatic symptoms; total scores are computed by summing the items. The CSI has been found to have adequate reliability and validity (Walker et al., 1991). Alpha reliability in the current sample was.87.

Procedure

Approval from the hospital's Institutional Review Board was obtained prior to conducting the retrospective chart review. All of the questionnaires were mailed to families prior to the child's multidisciplinary pain clinic evaluation. Parents and adolescent were asked to complete the questionnaires individually and return them on the date of the evaluation. Adolescent then underwent evaluation by a physician, physical therapist, and clinical psychologist or psychology fellow. Patients’ pain diagnoses, assigned by a pain management physician during the multidisciplinary evaluation, were obtained from a review of their medical records.

Data Analyses

Data were analyzed with parametric tests using SPSS 14.0 for Windows. For preliminary analyses, we examined the relations among demographics, medical factors, and adolescent pain behaviors (functional disability and somatic symptoms) using Pearson product moment correlations and One-way ANOVAs. After conducting correlation analyses to determine significant associations between parental responses and adolescent pain behaviors, a series of hierarchical multiple regression analyses were conducted to examine the extent to which adolescent's pain coping responses (passive, active, accommodative) interacted with parental responses (protective, minimizing) to predict adolescent's pain behaviors (functional disability, somatic symptoms).

Moderation analyses were based on techniques described by Baron and Kenny (1986) and Holmbeck (1997). Moderation analyses were conducted for each significant bivariate association between parental response and adolescent pain behavior. Scores on the FDI or CSI constituted the dependent variables for each analysis. In the first step of each regression equation, we controlled for demographic and medical variables that significantly correlated with the dependent variable. In the second step, parental behavior and adolescent's coping behavior were entered. Finally, the two-way interactions between parental behavior and adolescent's coping were entered on the third step of each equation. Evidence of adolescent's coping moderating the relations between parental behavior and adolescent pain behaviors was obtained when significant interactions between adolescent's coping and parental behavior predicted adolescent's pain behaviors.

Results

Preliminary Analyses

For patient demographics, there were no significant associations between adolescent pain behaviors and age or gender. SES was inversely associated with functional disability (r = −.17, p <.05), but not with somatic symptoms. Current pain intensity was significantly associated with functional disability (r =.30, p <.00) and somatic symptoms (r =.25, p <.00) (Table I).

Table I.

Intercorrelations, Means, and Standard Deviations for Predictor and Outcome Variables

Variable 1 2 3 4 5 6 7 8 9 M SD
Control
    1. SES – −.09 −.05 −.11 .00 −.03 .06 .17* −.04 49.5 11.1
    2. Pain – .07 .06 .02 −.02 .10 .30** .25** 4.43 2.88
Parent responses
    3. Protect – .11 .14* .30** .00 .24** .21** 1.50 .61
    4. Minimize – .04 −.08 −.05 .05 .17* .66 .56
Adolescent coping behaviors
    5. Passive – .46** .10 .15* .30** 1.22 .64
    6. Active – .23** .29** .29** 1.47 .56
    7. Accommodative – .05 .17* 2.03 .63
Adolescent functional outcomes
    8. Functional disability – .44** 21.5 11.4
    9. Somatic symptoms – 27.5 15.5
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Correlations are two-tailed. *p < 0.05, **p < 0.01.

For medical variables, pain diagnosis was significantly associated with somatic symptoms, F(6,204) = 3.33, p <.00. Pain diagnosis was dummy coded to compare adolescent with diffuse pain and other pain complaints. As would be expected, adolescent with diffuse pain (M = 38.0, SD = 18.3) reported significantly more somatic symptoms than adolescent with other pain complaints (M = 26.2, SD = 14.7). There were no significant differences across pain diagnoses for functional disability. Pain intensity and SES were included as control variables for the functional disability regression models. Pain intensity and pain diagnosis were included as control variables for the somatic symptom regression models.

In examining the relative frequency of coping responses among adolescents in this sample, accommodative strategies were most frequently used, followed by active coping, and lastly passive coping (Table I). In examining the relative proportion of coping strategies chosen, the average proportion of accommodative strategies was 44% (SD = 12%), for active coping the mean proportion was 32% (SD = 8%), and for passive coping strategies the average proportion was 25% (SD = 10%).

Correlation and Regression Analyses

Correlations were conducted between parental responses and adolescent's pain behaviors (Table I). Parental protective behavior was significantly associated with functional disability (r =.24, p <.00) and somatic symptoms (r =.21, p <.00). Parental minimization was significantly associated with somatic symptoms (r =.17, p <.05), but not with functional disability (r =.05, ns). Moderation analyses were conducted for each significant bivariate association between parental behavior and adolescent's pain behaviors (i.e., parental protective behavior with functional disability and somatic symptoms; parental minimization with somatic symptoms).

Does Adolescent Coping Moderate the Relation between Parental Protective Behavior and Adolescent's Functional Disability?

A significant two-way interaction emerged between adolescent's passive coping and parental protective behavior in predicting disability, F(5, 193) = 10.49, p <.000, R2 =.22 (Table II). To examine the nature of this interaction, regression lines were plotted for adolescent with high (+1 SD) and low (−1 SD) levels of passive coping responses. This interaction is illustrated in Fig. 1. Contrary to expectations, for adolescents using higher levels of passive coping strategies, parental protective behavior did not predict their levels of disability. In contrast, for adolescents who reported infrequent use of passive coping strategies, higher levels of parental protective behavior predicted higher levels of disability.

Table II.

Adolescent Coping and Parental Protective Behavior on Adolescent's Functional Disability

Variables β Beta CI for Beta T R2 change Cohen's f
Step 1: Control variable .10** .13
    Pain .27 1.08 .55 to 1.61 3.98**
    SES −.14 −.15 −.29 to −.01 −2.05*
Passive coping
        Step 2: Predictor variables .06** .08
            Adolescent passive coping .12 2.30 −.13 to 4.73 1.86
            Parental protective behavior .20 3.82 1.26 to 6.38 2.94**
        Step 3: Two-way interaction .06** .08
            Passive × protective −.83 −7.64 −11.7 to −3.53 −3.67**
Active coping
        Step 2: Predictor variables .11** .14
            Adolescent active coping .27 5.40 2.70 to 8.08 3.96**
            Parental protective behavior .13 2.53 −.05 to 5.12 1.93*
        Step 3: Two-way interaction .01 .01
            Active × protective −.37 −2.84 −7.06 to 1.39 −1.32
Accommodative coping
        Step 2: Predictor variables .05** .06
            Adolescent accommodative coping .04 1.23 −1.78 to 3.07 .52
            Parental protective behavior .21 1.30 1.56 to 6.68 3.17**
        Step 3: Two-way interaction .00 .00
            Accommodative × protective −.34 −2.51 −6.40 to 1.38 −1.27
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*p < 0.05, **p < 0.01. f2 effect sizes of 0.02, 0.15, and 0.35 are considered small, medium, and large (Cohen, 1988).

Figure 1.

Figure 1.

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Estimated regression lines showing predicted functional disability scores for adolescent with low (−1 SD) and high (+1 SD) levels of passive coping. Graphed lines were plotted by selecting values 1 SD above and below the mean for passive coping and parental protective behavior; these values were multiplied by their unstandardized regression coefficients to obtain values for plotting the predicted regression lines.

For active coping, there were significant main effects, indicating that both parental protective behavior and active coping predicted functional disability; however the interaction was not significant. Pain, SES, parental protective behavior, and active coping accounted for 22% of the variance in functional disability. For accommodative coping, neither significant main effects nor interactions emerged (Table II), with 15% of the variance in functional disability accounted for by pain, SES, and parental protective behavior.

Does Adolescent Coping Moderate the Relation between Parental Protective Behavior and Adolescent's Somatic Complaints?

A significant two-way interaction emerged between adolescent's passive coping and parental protective behavior in predicting somatic symptoms, F(5, 201) = 11.70, p <.000, R2 =.23 (Table III and Fig. 2). Again, contrary to expectations, for adolescents reporting greater use of passive coping strategies, higher levels of parental protective behavior did not predict adolescent somatic complaints. In contrast, among adolescents who reported infrequent use of passive coping strategies, higher levels of parental protective behavior predicted more somatic complaints.

Table III.

Adolescent Coping and Parental Protective Behavior on Adolescent's Somatic Complaints

Variables β Beta CI for Beta T R2 change Cohen's f
Passive coping
Step 1: Control variable .11* .14
    Pain .23 1.22 .50 to 1.93 3.37*
    Pain diagnosis† .20 10.08 3.56 to 16.6 3.05*
Passive coping
        Step 2: Predictor variables .10* .13
            Adolescent passive coping .27 6.41 3.41 to 9.41 4.22*
            Parental protective behavior .16 3.98 .77 to 7.19 2.44*
        Step 3: Two-way interaction .02* .03
            Passive × protective −.46 −5.43 −10.66 to −.19 −2.04*
Active coping
        Step 2: Predictor variables .10* .13
            Adolescent active coping .27 7.27 3.74 to 10.8 4.06*
            Parental protective behavior .11 2.73 −.63 to 6.08 1.60
        Step 3: Two-way interaction .03* .04
            Active × protective −.81 −8.24 −13.7 to −2.83 −3.01*
Accommodative coping
        Step 2: Predictor variables .05* .06
            Adolescent accommodative coping .15* 3.65 .51 to 6.79 2.29*
            Parental protective behavior .18* 4.74 1.46 to 8.02 2.85*
        Step 3: Two-way interaction .00 .00
            Accommodative × protective −.03 −.26 −5.21 to 4.70 −.10
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*p < 0.05, **p < 0.01. †Pain diagnosis is dummy coded (1, diffuse pain; 0, all other pain diagnoses). f2 effect sizes of 0.02, 0.15, and 0.35 are considered small, medium, and large (Cohen, 1988).

Figure 2.

Figure 2.

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Estimated regression lines showing predicted somatic symptom scores for adolescent with low (−1 SD) and high (+1 SD) levels of passive coping. Graphed lines were plotted by selecting values 1 SD above and below the mean for passive coping and parental protective behavior; these values were multiplied by their unstandardized regression coefficients to obtain values for plotting the predicted regression lines.

There also was a significant interaction between adolescent's active coping and parental protective behavior in predicting adolescent's somatic complaints, F(5, 201) = 12.62, p <.000, R2 =.24 (Table III). This interaction is illustrated in Fig. 3. Contrary to our predictions, for adolescents who frequently employed active coping strategies, parental protective behavior did not predict adolescent's somatic symptoms. In contrast, for adolescents who reported infrequent use of active coping strategies, higher levels of parental protective behavior predicted increased somatic complaints.

Figure 3.

Figure 3.

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Estimated regression lines showing predicted somatic symptom scores for adolescent with low (−1 SD) and high (+1 SD) levels of active coping. Graphed lines were plotted by selecting values 1 SD above and below the mean for active coping and parental protective behavior; these values were multiplied by their unstandardized regression coefficients to obtain values for plotting the predicted regression lines.

For accommodative coping, detailed in Table III, there were significant main effects, with both parental protective behavior and accommodative coping accounting for 16% of the variance in adolescent's somatic symptoms; however, the interaction was not significant.

Does Adolescent Coping Moderate the Relation between Parental Minimizing Behavior and Adolescent's Somatic Complaints?

As outlined in Table IV, there were significant main effects for passive, active, and accommodative coping predicting adolescent's somatic symptoms; however, none of the interaction terms was significant. For the passive coping model, 20% of the variance in somatic symptoms was explained by pain ratings, pain diagnosis, passive coping, and parental minimization. Similarly, 23% of the variance in somatic complaints was explained by pain ratings, pain diagnosis, passive coping, and parental minimization. Lastly, 15% of the variance in somatic complaints was accounted for in the accommodative coping model.

Table IV.

Adolescent Coping and Parental Minimizing Behavior on Adolescent's Somatic Complaints

Variables β Beta CI for Beta T R2 change Cohen's f
Step 1: Control variable .11* .14
    Pain .23 1.22 .50 to 1.93 3.37*
    Pain diagnosis† .20 10.08 3.56 to 16.6 3.05*
Passive coping
        Step 2: Predictor variables .09* .11
            Adolescent passive coping .28 6.78 3.79 to 9.76 4.47*
            Parental minimizing behavior .13 3.58 .16 to 6.99 2.06*
        Step 3: Two-way interaction .00 .00
            Passive × protective .15 2.55 −2.62 to 7.72 .97
Active coping
        Step 2: Predictor variables .12* .15
            Adolescent active coping .33 8.50 5.17 to 11.8 5.22*
            Parental minimizing behavior .16 4.53 1.14 to 7.91 2.63*
        Step 3: Two-way interaction .00 .00
            Active × protective .21 1.53 −4.30 to 7.35 1.09
Accommodative coping
        Step 2: Predictor variables .04* .05
            Adolescent accommodative coping .16 3.96 .80 to 7.13 2.47*
            Parental minimizing behavior .15 4.07 .54 to 7.60 2.27*
        Step 3: Two-way interaction .00 .00
            Accommodative × protective .23 2.95 −2.83 to 8.72 1.01
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*p < 0.05, **p < 0.01. †Pain diagnosis is dummy coded (1, diffuse pain; 0, all other pain diagnoses). f2 effect sizes of 0.02, 0.15, and 0.35 are considered small, medium, and large (Cohen, 1988).

Discussion

This study examined whether adolescent coping strategies moderated the relations between parental responses and adolescent pain behaviors. Several interesting finding emerged. First, we predicted that when adolescents engaged in higher levels of passive or active coping strategies, increased parental protective behavior would result in more extensive adolescent functional disability and somatic complaints. However, contrary to our expectations, protective parental responses had no added impact on adolescent pain behaviors for adolescent engaging in high levels of passive and active coping. Quite surprisingly, we found that for adolescents employing lower levels of passive coping strategies, higher levels of parental protective behavior resulted in greater functional disability and more somatic complaints. In addition, for adolescents engaging in fewer active coping strategies, high levels of parental protective behavior resulted in more somatic complaints. Thus, in the absence of using passive and active coping responses, parental protective responses to pain may inadvertently promote greater disability and symptom complaints in adolescents with chronic pain.

Given the strong association between passive coping and functional disability, a possible explanation for this pattern of results is that when adolescents rely heavily on unhelpful coping strategies their disability and somatic symptoms are high such that parental responses to pain cannot make matters worse. In contrast, adolescents who do not frequently engage in these unhelpful coping strategies are more vulnerable to negative effects of parenting behavior. These results build on previous moderation analyses that have demonstrated the impact of adolescent specific variables such as anxiety and depression on the relations between parental responses and functional disability and somatic symptoms (Claar et al., 2008; Peterson & Palermo, 2004), suggesting that a biopsychosocial perspective is essential to understand the complex interplay of individual and social factors. In fact, focusing exclusively on either parental responses or adolescents’ methods of coping with pain may result in a limited understanding of what is maintaining an adolescent's disability and physical symptomology.

We also hypothesized that adolescent coping would moderate the relation between parental minimizing behavior and adolescent outcomes. Although the passive, active, and accommodative coping models demonstrated that adolescent coping and parental minimization each uniquely contributed to increased somatic symptoms, no interaction between coping and this parental response was found. In addition, parental minimization was unrelated to functional disability. These findings are consistent with a modest literature that discourages parental criticism and minimization due to its negative influence on somatic and pain complaints (Chambers et al., 2002; Claar et al., 2008). Notably, parental minimization was a relatively rare behavior in this sample (M = 0.66, SD = 0.56), decreasing the degree of variability among high and low parental minimization and possibly precluding the detection of moderation. However, despite its relatively rare occurrence, our results indicate that minimization has a direct and unique impact on adolescent symptoms.

We also hypothesized that accommodative coping would be associated with more positive outcomes. Accommodative coping did not significantly contribute to or mitigate functional disability, and surprisingly, it contributed to increased somatic complaints in the presence of parental protective behavior and in the presence of parental minimization. Although accommodative coping strategies are generally encouraged as appropriate ways to respond to pain and involve strategies such as acceptance, self-encouragement, minimizing pain, and distraction, it may be that rather than accommodative coping contributing to higher somatic complaints, adolescents who are experiencing several somatic symptoms used any and all coping methods to attempt to alleviate their symptoms. This possibility is further supported with evidence that each of the three coping responses significantly predicted somatic symptoms in each respective regression model.

The results of this study must be viewed in light of its limitations. First, the pain coping measure used in this study was developed for adolescent with abdominal pain, with extensive evidence supporting its use in that population (Blount et al., 2007). To adapt this measure adequately for our diverse pain population, we omitted the Condition-Specific subscale and recalculated internal consistency estimates, which were all in the acceptable range or above. We believe that this study provides support for using the Pain Response Inventory with a diverse pain sample. Second, the high rates of female and Caucasian patients limit the generalizability of findings to males and diverse ethnic groups; however, this demographic pattern is commensurate with other pediatric multidisciplinary chronic pain clinic samples (Bursch, Tsao, Meldrum, & Zeltzer, 2006; Eccleston, Crombez, Scotford, Clinch, & Connell, 2004). In addition, as with all correlation research, we cannot establish causality between parent behavior, adolescent coping, and adolescent pain behaviors. This is particularly salient for our moderation analyses, as both passive and active coping clearly are associated with higher levels of adolescent pain behaviors, in the presence or absence of parental protective behavior. It is possible that protective responses from parents may actually serve as the moderator between adolescent coping responses and functional disability and somatic symptoms. Although laboratory studies seek to determine causality under controlled conditions (Chambers et al., 2002; Walker et al., 2006b), longitudinal studies are needed to further understand the interplay of parental responses and adolescent coping with chronic pain. In addition, the effect sizes for the predictive models were small to medium, suggesting that parental responses and adolescent coping are among several variables that influence adolescent pain behaviors. Although these results further our understanding of these variables, they also raise new questions of potential variables that could add to predictive models of adolescent pain behaviors such as parental catastrophizing (Vervoort, Goubert, Eccleston, Bijtterbier, & Crombez, 2006) and adolescent self-efficacy (Bursch et al., 2006). Finally, measuring an inherently dynamic construct such as coping poses a challenge in relation to an ever-changing experience such as pain. Coping often changes in response to the demands of the stressor (Lazarus & Folkman, 1984), suggesting that the coping responses reported at this pain clinic evaluation may differ as the adolescent's pain symptoms change over time.

The current study provides further support for incorporating the family into treatment when working with adolescents coping with chronic pain. In the past decade, there has been a growing emphasis on the role of parent and family factors on adjustment (Drotar, 1997; Eccleston et al., 2004) and functional outcomes (Levy et al., 2004; Logan & Scharff, 2005; Schanberg, Keefe, Lefebvre, Kredich, & Gil, 1998) in adolescent with pain and other health conditions. This study demonstrated that for adolescent who engage in few passive and active strategies for coping with pain, parental protective responses can result in higher levels of disability and more somatic complaints. In addition, parental minimization uniquely contributed to somatic complaints along with adolescent coping. Thus, it is essential to provide a family-based intervention, as treatment gains may not generalize to the family environment if parents do not learn appropriate ways to support their adolescent's positive coping efforts. Teaching parents to depart from being overly protective or solicitous as well as discounting or criticizing the adolescent's pain as excessive to a middle ground of validating the individual's pain experience and encouraging functioning even in the presence of pain may lead to better outcomes for these adolescent (McCracken, 2005). In addition, parents of adolescent with chronic pain may need additional support to cope themselves as they struggle to accept some degree of uncertainty with an often vague diagnostic picture (Jordan, Eccleston, & Osborn, 2007). Equipping parents with tools to help their adolescents while simultaneously teaching adolescents’ means of coping with their pain will ultimately result in better outcomes for the adolescent and parent.

Conflicts of interest: None declared.

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