Here we go again – yet another article about how parents are doing things wrong! Everywhere a parent chooses to look, someone is telling them that they are doing things wrong – too much gluten, screen time, sugar, sun, not enough sun, outdoor play,….. Mention breastfeeding, co-sleeping or sleep training and social media has a meltdown! So, in an effort to stay away from parent bashing, I am going to stick fairly close to the science and have a look at the literature around pain in kids, and how their parents play a role in reducing or enhancing that pain experience for their offspring.
It is fairly well understood in the pain community that there is an association between catastrophising (essentially, dwelling on the worst case scenario) and pain related disability (Linton & Vlaeyen, 2012). The theory goes that worrying excessively about our pain or condition makes us less likely to attempt to do things that might make that pain any worse, and subsequently we avoid things. These means that over time we lose function and become less able to do the things that are important to us. The literature also paints us a fairly clear picture about the idea that this tendency to dwell on the worst possible outcomes is a trait that can be passed down to our children. Families can tend to adopt specific ways of thinking about pain, which can ultimately be very unhelpful (Kralkevic, Banozic, Maric, Cosic, Sapunar et al, 2012; Wilson, Moss, Palermo, 2014). Following on from this, it can also be shown that children who have a parent with chronic pain, are far more likely to develop chronic pain themselves, sometimes even pain that is similar to their parent (Umberger, 2013).
These are pretty important findings and ones that we should be paying attention to as a society. Chronic pain is costly, and prevention is always going to be the best way to go. Government bodies are starting to pay attention to this interaction between parents, children and pain and are taking action. Knowing that early exposure to painful procedures and the subsequent distress, tends to “prime” a child’s nervous system and make them more sensitive to painful procedures in the future, (Taddio, Katz, Ilersich, & Koren, 1997), and also armed with a growing body of research to suggest that distraction during procedures such as vaccination and venipuncture are effective measures to reduce pain and distress in the infant (Chambers, Taddio, Uman, McMurtry, HELPinKIDS Team, 2009), initiatives such as the “It Doesn’t Have to Hurt” campaign https://www.painbc.ca/news/it-doesnt-have-hurt-campaign are popping up, and will hopefully draw increasing public attention.
So how does the research help us when dealing with pain in our kids? Firstly, modelling is incredibly important. A study done by Goodman and McGrath in 2002 showed that kids exposed to their mum undergoing a painful experience (cold pressor task), where the mums were asked to either maximize or minimise their pain response, were compared to a control group given no instructions. They found that kids who had seen their mum “carrying on” about the experience tended to demonstrate a significantly lower pain threshold, when they were subsequently given the cold pressor test. Conversely, kids who had watched their mum minimise her pain, were found to display much lower expressions of pain during their testing. Kids are like sponges and the things that we do and say about pain experiences directly shape their own understanding about pain.
Parental protectiveness and parental pain catastrophising also can have a big impact on how children function. For kids, one of the best ways to measure function is school attendance. A study by Logan et al in 2012 showed that parental pain catastrophising and parental protective responses to child pain, both independently predicted child school absences. This tells us again, that kids take their cues from parents, and that in making the decision to take the day off school, parental anxiety plays a big role.
So can we put it all together to provide some evidence based guidance about dealing with pain in kids? Hell no! I wouldn’t dare start telling you how to parent your kids! However, I can tell you how I try to use these ideas in dealing with my own kid’s ouchies.
- Validation – recognise the situation, demonstrate some empathy. “Ouch – that hurt, are you ok?”
- Reassurance – if you are Ok with the situation, they are likely to be Ok with it. “Let me have a look – Oh, yes that would have hurt. It looks Ok though and I’m pretty sure you will be fine”
- Apply placebo procedures as required (if ever placebo has an important role, here is your chance!) “Here let me kiss it better”* and if the big interventions are required “do you think a dinosaur bandaid would help?”
- Distraction – change the subject as quickly as is practical “Look, the kids are waiting for you on the tyre swing, do you want me to take you over there?”
As clinicians we need to be aware when assessing children in pain, that parental anxiety and family traits will play heavily into the situation. As in any pain situation, reassurance is extremely important and in some instances, your time and attention may need to be more on the parent, than the child in pain. Equally, being aware of these factors, you may decide that parental anxiety is playing such a large role in a child’s pain experience that it needs to be addressed in order for the child to get better functional outcomes. This is a delicate situation and how you address it as a clinician is probably best navigated according to the specifics of the circumstances. A referral to a psychologist might ultimately be needed, however you may be able to address some of the issues with the parents using an educational approach.
* Placebo kisses are not routinely applied in our household for any bottom or tongue related injuries
Chambers, C., Taddio, A., Uman, L., McMurtry, C., HELPinKDS Team. (2009). Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clinical Therapy, 31, Suppl 2, S77-S103.
Goodman, J., & McGrath, P. (2003). Mother’s modeling influences children’s pain during a cold pressor task. Pain, 104(3), 559-565.
Kraljevic, S., Banozic, A., Maric, A., Cosic, A., Sapunar, D., & Puljak, L. (2012). Parents’ pain catastrophizing is related to pain catastrophizing of their adult children. International Journal of Behavioural Medicine, 19(1), 115-119.
Linton, S., & Vlaeyen, J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144-1147.
Logan, D., Simons, L., & Carpino, E. (2012). Too sick for school? Parent influences on school functioning among children with chronic pain. Pain, 153(2), 437-443.
Taddio, A., Katz, J., Illersich, A., & Koren, G. (1997). Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet, 349(9052):599-603.
Umberger, W. (2013). Children of parents with chronic noncancer pain: A comprehensive review of the literature. Journal of Child Adolescent Psychiatric Nursing, Oct 14, doi: 10.1111/jcap.12055. [Epub ahead of print]
Wilson, A., Moss, A., Palermo, T., & Fales, J. (2014). Parent pain and catastrophizing are associated with pain, somatic symptoms and pain-related disability among early adolescents. Journal of Pediatric Psychology, 39(4), 418-426