Commentary: Increasing generalizability of parent psychosocial functioning within the context of pediatric chronic pain

Parent psychosocial factors, such as financial status, emotional distress, social support, and personal health, influence children’s experience of pain (Palermo & Holley, 2013; Palermo et al., 2014; Logan & Scharff, 2005). However, parent intervention for those who have children with chronic pain has primarily focused on modifying parent behavior rather than exploring and addressing parent psychosocial functioning needs (Jordan et al., 2007; Palermo & Eccleston, 2009). Christofferson and colleagues’ (this issue) study aimed to address this gap by exploring parent psychosocial challenges among families enrolled in an intensive interdisciplinary pain treatment (IIPT) program. These challenges included parent-reported social functioning (i.e., social isolation), emotional functioning (i.e., anxiety and depression symptoms), and emotional support. The study had several strengths including the identification of psychosocial challenges for parents of children in IIPT along with potential factors that influence parent outcomes, including parent psychological flexibility, cognitive reappraisal, and emotional suppression. However, the study raised additional questions in two primary areas. First, the study did not provide enough contextual information on the family background that explained the differences in psychosocial functioning of male and female parents. Second, the study did not include any demographic data that allows for generalizability.

Christofferson and colleagues (this issue) importantly highlighted differences in male and female parent psychosocial functioning such that female parents typically reported more concerns than male parents. However, there are a few considerations that could strengthen future research and generalizability. For example, knowledge of specific parenting roles within the family, particularly when parenting a child with chronic pain, is a key factor in understanding similarities and differences in psychosocial functioning of parents. Aligned with Christofferson and colleagues’ (this issue) findings, mothers of children with chronic conditions endorse more psychosocial and mental health challenges than fathers (Benjamin et al., 2019). This may be due to traditional primary caregiver roles within a two-parent household, in which mothers manage daily needs, medical care, and routines (Benjamin et al., 2019; Dashiff et al., 2008; Musick et al., 2016) while fathers primarily provide financial support for the family (Goldstein et al., 2013). However, there is also a lack of father inclusion in pediatric chronic illness and chronic pain research (Benjamin et al., 2019; Palermo & Holley, 2013). Given that mothers primarily present to medical appointments and relay medical information from providers to fathers (Yogman et al., 2016), challenges to engage fathers in research may present. The American Academy of Pediatrics released guidelines for pediatricians that include strategies to increase father engagement in ongoing medical care (Yogman et al., 2016). Increased father engagement is crucial, as father inclusion in pediatric chronic illness care, particularly in adolescence, is associated with better child quality of life and psychological adjustment, as well as increased treatment adherence (Wysocki & Gavin, 2004, 2006).

Researchers should make an effort to include all caregivers in future pediatric pain research in order to minimize selection bias and further clarify the mechanisms responsible for differences in male and female parent challenges (Benjamin et al., 2019; Logan & Scharff, 2005). Additionally, as psychosocial experiences differ among caregivers, it is crucial to explore processes that influence a child’s pain experience in order to increase generalizability of findings. Considering the biopsychosocial approach to conceptualizing and managing pediatric chronic pain, families who have children with chronic pain are more likely to experience higher overall family dysfunction, more family conflict, less structure, and less cohesion (Essner et al., 2020). With this in mind, additional parent factors to explore could include primary caregiver roles, two-parent versus single parent household, biological versus other type of caregiver (e.g., step-parent or foster parent), and parent stressors rather than anxiety and depressive symptoms (Benjamin et al., 2019; Logan & Scharff, 2005; Palermo & Holley, 2013).

Though assessment and intervention for caregivers of youth with chronic pain or other chronic conditions is available, clinicians and researchers may have difficulty determining the best way to implement these practices. Specifically, legal, institutional, and ethical barriers may limit implementation of care for caregivers (Salley et al., 2023). Three pathways to providing mental health care to caregivers of youth with chronic medical conditions to consider are: (1) providing caregiver intervention and documenting this care as part of the child’s care, (2) referring the caregivers to outside providers, and (3) providing caregiver intervention within the pediatric care setting (Salley et al., 2023). The latter is an integrated approach to care which is modeled in the Christofferson and colleagues (this issue)’s intervention.

A notable limitation to Christofferson and colleagues (this issue), as discussed in their article, is the lack of demographic information collected for the study. Though information regarding geographic location, conditions of children, and insurance accepted by the IIPT was reported, other demographic information such as, gender identity, age, income, education level, sexual orientation, and race/ethnicity for either the participants (i.e., parents) or their children participating in IIPT were not collected. This greatly affects interpretation and generalizability of results, particularly impacting marginalized populations (Craig et al., 2020). Historically, psychological researchers have failed to report or insufficiently report demographics of participants (Harned et al., 2022; Polo et al., 2019). To address this, there has been a push towards establishing guidelines and standards in an effort to provide more transparency and context with respect to the inclusion of marginalized populations in research. Specifically, the American Psychological Association (APA) published participant reporting standards which should be included in all psychological manuscripts (Palermo et al., 2021).

These standards are particularly important to include given the health disparities in pediatric pain populations (Evans et al., 2010; Hartford et al., 2022). Pain research often lacks inclusivity of certain populations due to barriers to pain identification and care. Social factors such as socioeconomic disadvantage, lack of social support, access to healthcare, and physician bias may impact pain assessment and management (Craig et al., 2020; Nguyen et al., 2005; Wakefield et al., 2018). Demographic information of participants is crucial as it allows researchers and healthcare providers to interpret and generalize findings within a particular sociocultural and historical context. Without this information, it is difficult to inform intervention or identify disparities in need of addressing.

Pediatric chronic pain is a complex experience, and Christofferson and colleagues (this issue) aided in further understanding by identifying psychosocial challenges for parents of children with chronic pain and exploring potential skills and qualities of parent that may influence these challenges. Future research in this area can increase generalizability and help contextualize psychosocial challenges through additional exploration of parent dynamics and increased inclusion of demographic information.

Conflicts of interest: No new data were generated or analysed in support of this research.

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