Commentary: Intergenerational Associations in Pediatric Chronic Pain: Validity of an Adapted Unified Multifactorial Model of Parental Factors in Pediatric Chronic Pain

Worldwide prevalence rates of pediatric chronic pain are high with an estimated 20–35% of children affected by chronic pain (Friedrichsdorf et al., 2016; King et al., 2011). Family risk factors (e.g., presence of parental chronic pain, parental mental health symptoms) have been associated with pediatric chronic pain (Campo et al., 2007; Eccleston et al., 2004, 2008; Palermo & Eccleston, 2009; Walker et al., 2006; Wilson et al., 2014). While individual parental factors affecting pediatric chronic pain have been widely studied separately, only a few studies have examined the interrelationships of multiple parent factors to explain pediatric chronic pain (Palermo et al., 2014; Simons et al., 2008). In 2019, Poppert Cordts et al. proposed a model (i.e., unified multifactorial model of parental factors in pediatric chronic pain) that suggested bringing together individual parental factors and their interrelations with their child’s experience of pain and functioning to help explain child chronic pain. Poppert Cordts et al. (2019) validated their proposed model using a sample of 146 children with severe chronic pain (primarily headaches) and one of their parents (90% mothers).

Brown et al. (2021) aimed to further validate Poppert Cordts and colleagues’ model (2019) using a nonclinical sample. Prior to validation, authors adapted the model by excluding parental responses to child pain (e.g., catastrophizing about child pain), parental pain frequency, and child pain catastrophizing. Additionally, Brown et al. (2021) added child and parent pain-related disability to allow for the clarification of theoretical differences between pain intensity and pain-related disability. Authors collected cross-sectional data (n = 1,450) from five large secondary schools in Germany with children aged 10–17 years and one parent per child. This commentary focused on three overarching themes of this research: (a) methodological strengths, (b) family and protective factors, and (c) strength-based approaches in interventions.

Strengths of this study include the examination of the unified multifactorial model of parental factors in pediatric chronic pain with a nonclinical sample (all parent and child participants) and three subsamples (all parents of the sample and children with chronic pain, all children of the sample and parents with chronic pain, and both children and parents with chronic pain); assessment of the model in a non-English-speaking European context; and the application of rigorous quantitative methods. Along with these methodological strengths, results from this study confirm that the associations between parental and pediatric chronic pain and psychological characteristics found by Poppert Cordts et al.’s (2019) initial validation study can be extended to a nonclinical population. More specifically, the current study identified that internalizing problems had the strongest intergenerational association across all three subsamples and that this relationship was substantially stronger when both parents and children experienced chronic pain.

These results highlighted the importance of considering risk and protective factors in pediatric chronic pain. Parent modeling of pain behaviors is associated with pain severity and disability (Stone et al., 2018); however, parenting modeling has frequently been considered as a risk factor only and has been overlooked as a possible protective factor. Cousins et al. (2015) proposed the ecological resilience-risk model in pediatric chronic pain. The ecological resilience-risk model suggests incorporating positive individual and family/social environment variables along with risk factors when considering pediatric chronic pain adaptation and trajectory. Bringing Cousins et al.’s model together with the intergenerational model might help to elucidate why some children of parents with chronic pain do not develop chronic pain. For example, a parent with chronic pain who models adaptive coping might positively impact their child’s experience of pain; adaptive family functioning may promote better pain adjustment. This has been demonstrated in a parent-only problem-solving skills training (PSST; Palermo et al., 2016) treatment, with parents of youth with chronic pain; this treatment includes positive and rational problem skills and has shown improvements in parental depression, general parental mental health symptoms, and child’s mental health.

Involving children’s family is key to obtaining better pain outcomes in children (Palermo & Chambers, 2005). For example, social learning and cognitive-behavioral therapy (SLCBT; Levy et al., 2010) includes teaching children and their parents relaxation and cognitive restructuring skills and utilizing social learning, modeling, and reinforcement to decrease pain-related functional disability. In severe pediatric chronic pain populations, the intensive interdisciplinary pain treatment (IIPT) includes family components (Hechler et al., 2015); however, this treatment does not have adequate long-term benefits for all patients (Randall et al., 2018). Building on IIPT, adding an individualized adjunctive module after discharge (e.g., psychosocial aftercare program; Dogan et al., 2021) has had promising results in improving child pain-related and emotional long-term outcomes.

Despite advances in integrating parents into their child’s pain treatment, specific treatment for parents with chronic pain and their own mental health and pain remains unclear. One pathway to potentially increase pain treatment efficacy is to simultaneously treat parental pain and internalizing symptoms. The study by Brown et al. (2021) has identified that parental chronic pain and internalizing symptoms are associated with child chronic pain. Thus, family-based treatments in which parents’ symptoms are also treated along with children’s symptoms could potentially lead to decreased pain disability and severity.

Brown et al.’s (2021) work on adapting and validating Poppert Cordts et al.’s (2019) unified multifactorial model of parental factors in pediatric chronic pain contributes meaningfully to this field by confirming the role of parental factors in pediatric chronic pain in a community-based, non-English-speaking sample. This evidence and model suggest that family-based interventions, which address parental internalizing factors and parent chronic pain, may benefit children’s chronic pain. To continue to improve treatment programs for pediatric chronic pain, further research should include (a) increased sample diversity via multicenter studies, (b) the inclusion of fathers or other child caregivers (e.g., grandparents), (c) the inclusion of both risk and resilience factors, and (d) longitudinal data to examine the potential bidirectional influences in the development and maintenance of chronic pain in children. We hope that resilience and parent’s mental health and pain treatment will be embraced by clinicians and researchers in creating future interventions.

Conflicts of interest: None declared.

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