- Email: [email protected]
A comparison of family functioning when mothers have chronic pain
79
Pain, 35 (1988) 79-89 Elsevier
PAI 01279
A comparison of family functioning when mothers have chronic pain Jason R. Dura and Steven J. Beck Department of Psychology, Ohio State University, 1885 Neil Avenue Mall, Columbus, OH 43210 (U.S.A.) (Received
16 November
1987, revision
received 27 April 1988, accepted
5 May 1988)
Multiple aspects of family functioning &ere assessed when mothers experienced either chronic pain, a chronic illness Summary (diabetes), or no illness. Mothers’ and fathers’ self-report measures of depression, anxiety, and family environment were collected. Children’s self-report measures of depression and anxiety, as well as information about their overall adjustment, were collected. Family communication patterns were also assessed. Families with a mother who had chronic pain had poorer perceived family environments and higher levels of depression and anxiety compared to the other two groups of families. Children from chronic pain families also appeared to be adversely affected. The data suggest that level of disability appeared more salient than the type of chronic illness. Implications of the findings are discussed in light of the fact that mothers with chronic pain in the present sample reported relatively mild disability and were not actively seeking treatment for their condition. Key words:
Pain; Family
Inhwduction To date there has been a paucity of studies examining the degree of distress reported by family members of chronic pain patients 1231. Obviously, an individual’s experience with chronic pain does not occur in a vacuum, but impacts on every aspect of his or her vocational, recreational, and familial life. By virtue of the fact that chronic diseases or conditions extend over time, they are likely to have significant consequences for the family of the identified patient. The way the family copes with the financial difficulties, the mood alterations in the patient, and the additional family strains argues for the necessity of examining
Correspondence to: Dr. S.J. Beck, Department of Psychology, Ohio State University, 1885 Neil Avenue Mall, Columbus, OH 43210, U.S.A. 0304-3959/88/$03.50
0 1988 Elsevier Science Publishers
chronic pain in the context of the patient’s primary social network, the family. While research has not rigorously explored issues of family functioning where a family member has chronic pain, investigators are now recognizing that the family of the pain patient may experience negative consequences of this health problem [e.g., 6,14,20]. As an example, a recent study of 58 chronic pain male patients demonstrated that 49% of the patients and 26% of the spouses displayed significant levels of depressed mood [9]. These findings generally corroborate the findings of Rowat and Knafl [20] who found that the major problem spouses of chronic pain patients face was uncertainty about their spouses’ pain condition and subsequent feelings of helplessness and hopelessness. However, these previous studies have only examined the impact of a spouse’s adjustment to her husband’s chronic pain. Little is known about the impact of the spouse on the family when the woman experiences chronic pain.
B.V. (Biomedical
Division)
x0
The present study assesses the impact of chronic pain on multiple areas of family functioning. The present study is noteworthy for several reasons. First, this study examines family functioning when the wife is the identified patient. Due to different family roles played by husbands and wives, research is needed to determine if the chronic pain of wives (and mothers) similarly affects the family as it appears to do when the husband experiences the chronic condition. Secondly, the present research is the first known study collecting objective data on the impact of parental chronic pain on children [23]. Thirdly, while previous studies have underscored the need to examine family members who live with the pain patient, past studies have not compared the level of functioning in spouses of chronic pain patients relative to spouses who experience a chronic medical illness. While data accumulate indicating that spouses of chronic pain patients can be adversely affected by the chronic pain condition, the question remains as to whether the degree of distress is greater, similar, or less than spouses of chronic medically ill patients. Only with such comparisons can the negative consequences of chronic pain upon family functioning be better understood. Consequently, the present study also assesses families with mothers who
TABLE
I
DEMOGRAPHIC Variable
CHARACTERISTICS
OF SUBJECT
GROUPS
Diabetes
Pain family Mothers
Fathers
Children 7
7
I
M S.D.
36.2 5.4
37.6 6.4
Race White Black
6 1
6
6
1
1
n
have insulin-dependent onset diabetes. This chronic medical condition was chosen since family functioning appears to affect glycemic control in adult onset diabetic patients [7]. Patients with diabetes mellitus require possible disruption of family functioning given the complex treatment requirements such as balanced food intake, pharmacologic therapy, structured physical therapy, weight reduction, glucose monitoring, special self-care, and periodic follow-ups required by patients. Consequently, the present study examined 3 groups of families: pain families, chronic illness families, and no-illness control families. Another strength of the present study is that previous studies have examined just one or a few variables of family functioning when a spouse presents with chronic pain. The present study assesses several global and specific aspects of family functioning. Paper and pencil measures of family members’ perceptions of their family functioning, as well as family members’ global dysphoric mood and anxiety, and children’s functioning on several objective and self-report measures were collected. In addition. specific family communication patterns were assessed to determine if these 3 groups of families interacted with each other in significantly different ways. Previous research has found that normal and poorly adjusted
Mothers
family
No-illness
Fathers
Children
Mothers
control
family
Fathers
Children 7
7
I
7
7
7
35.6 5.9
36.3 6.9
10.7 1.1
34.0 3.8
35.7 3.3
9.0 2.0
6 1
6 1
6 1
6 1
6
6 1
NA NA
13.0 3.7
13.0 3.7
NA NA
15.3 3.2
17.6 3.3
4.1 2.0
Age 9.4 2.4
Length of marriage M 15.1 S.D. 5.1
15.1 5.1
NA NA
15.3 6.9
15.3 6.9
Education M S.D.
14.7 4.1
3.9 2.7
14.0 2.5
14.1 4.4
14.0 4.5
5.9 1.6
I
81
families’ communication patterns differ in a semistructured family discussion (e.g., poorly adjusted families display high rates of defensive and nonfacilitation communication patterns) [4].
Method Subjects Twenty-one families served as subjects. Families were contacted through newspaper advertisements and were paid $25 for participating. Families were matched on socioeconomic status, parent and child age, sex, and employment status (see Table I). All families consisted of a mother, a father and a child between 7 and 13 years of age. In all families the parents were the child’s biological parents and all members resided in the same household. Sex of children varied by group, with 5 male and 2 female children in the pain family group, 2 male and 5 female children in the diabetes family group, and 4 male and 3 female children in the no-illness control group. The range of children’s ages was 7-13 years, lo-13 years, and 7-12 years, respectively. Mothers in the pain families reported radiating low back pain (N = 4) or radiating head and neck pain (N = 3) and were required to report pain of at least 6 months duration along with an examination that failed to find an acute etiology (e.g., brain tumor). The 7 chronic illness families were required to have a mother with insulin-dependent adult onset diabetes of at least 6 months duration. The remaining family members in the pain and diabetic families reported no serious illness, while the 7 control families reported no serious illness in any family member. Dependent
measures
Adult measures Family Environment Scale (FES). Parents’ and children’s perceptions of the family environment were assessed using Form R of the FES. This questionnaire assesses multiple domains within the larger concept of family environments [16].
Form R consists of 90 true-false items. When scored, the FES yields 10 subscale scores that fall into 3 domains. The first domain is the Relationship dimension which includes the cohesion, expressiveness and conflict subscales. These subscales measure ‘the degree of commitment, help, and support family members provide for one another; the extent to which family members are encouraged to act openly and to express their feelings directly; and the amount of openly expressed anger, aggression, and conflict among family members’ [16]. The second dimension measured by the FES is the Personal Growth dimension which includes the independence, achievement orientation, intellectual-cultural orientation, active-recreational orientation, and moral-religious emphasis subscales. These subscales measure ‘ the extent to which family members are assertive, self-sufficient, and make their own decisions; the extent to which activities (such as school and work) are cast into an achievement-oriented or competitive framework; the degree of interest in political, social, intellectual, and cultural activities; the extent of participation in social and recreational activities; and the degree of emphasis on ethical and religious issues and values’ [16]. The System Maintenance dimension is the final domain of the FES and consists of the organization and control subscales. These subscales measure the degree to which clear organization and planning are emphasized within a family along with assessing the amount of emphasis placed on rules [16]. Normative data are available and previous research supports the scale as both internally consistent and reliable [16]. Beck Depression Inventory (BDI). Depression was assessed in adults using the Beck Depression Inventory [5]. This 21-item self-report inventory determines the level or extent of depression based on the presence of depressive symptomatology. The subject is asked to choose which sentence in each item best describes his or her feelings during the most recent week. Items are scored O-3 and total scale scores range from 0 to 63 with increasing scores reflecting increased report of depression. State-Trait Anxiety Inventory (STAI). Adults’ anxiety was assessed using the State-Trait Anxiety
82
Inventory [22]. Two separate scales combine to form the STAI. The S-Anxiety Scale (STAI Form Y-l) has 20 items that measure current anxiety. The T-Anxiety Scale (STAI Form Y-2) has 20 items that measure how anxious the person generally feels. The STAI has been used extensively in a multitude of settings and populations. It has consistently shown both good reliability and validity
P21. Disability. Disability secondary to chronic pain and diabetes was assessed in mothers in the pain and diabetes families using the original and a modified version of the Pain Disability Index [17]. The modified version of the index substituted the word diabetes for pain. In all other respects, the two versions of the index were identical. This 7-item self-report inventory was developed to measure disability associated with chronic pain in 7 areas of life functioning: family/ home responsibilities, recreation, social activity, occupation. sexual behavior, self-care, and life-support activity. On each life area, subjects were asked to rate impairment from 0 (no disability) to 10 (total disability).
Children’s measures Children’s Depression Inventory (CDI). Children were assessed for depression using the Children’s Depression Inventory. This 27-item self-report inventory was modeled after the BDI and is similar in that depression is assessed relative to symptomatology [13]. Children are asked to pick the sentence in each item that best describes him or her over the most recent 2 weeks. The CD1 is written so that children aged 8-13 should be capable of completing it with little or no assistance. Previous research reports the CD1 as both reliable and clinically valued [12]. State-Trait Society Scale for Children (STAIC). Children’s anxiety was assessed using the StateTrait Anxiety Inventory for Children [20]. The STAIC consists of 2 self-report inventories with 20 items each. The first scale (A-State Scale) was designed to measure how anxious the child currently feels. The second scale (A-Trait Scale) was designed to measure how generally anxious the child feels.
Child Behavior Checklist (CBCL). The CBCL was used to assess the children’s behavioral problems and social competence through parent report [1,2]. This 118-item inventory asks parents to enumerate child activities as well as rate the child’s competence in the activity. The CBCL provides a Behavior Problems Profile and a Social Competence Profile by way of T-scores. Children 2 Illness Behavior. Children’s illness behavior was assessed in 3 ways. The first involved the mother rating the child as to overall health on a 7-point Likert scale with 1 representing very poor health and 7 representing excellent health. In the second measure, the mother was asked to recall the number of days in the past 2 weeks that the child complained of not feeling well (e.g., headaches and stomachaches), in the absence of observable symptoms of an illness. This third measure of illness behavior was days absent from school during the 1985-1986 school year due to illness (i.e., days absent due to vacation were not included in days absent for illness). School absences were collected from the attendance record on the child’s report card with days absent due to vacation subtracted from the total. Family Interaction Task. Family communication patterns were assessed among family members during 2 structured family interaction tasks. The first task involved planning an itinerary for a hypothetical 2 week vacation. The instructions were to outline daily activities under the assumption of unlimited funds with a total of 10 min to complete the task. A vacation planning task was used since such a discussion can involve the opinion of all family members, thus children may share in the task as equals [II]. The second task was a problem-oriented discussion in which the family was asked to spend 10 min filling out a questionnaire as a family. The questionnaire was adapted from a similar instrument designed to evoke mild conflict and asks how often and in what manner common points of family conflict are discussed [19]. Both tasks were audiotaped and verbal behaviors were coded using Robin’s and Fox’s ParentAdolescent Interaction Coding System [ 191. This system separates verbalizations into 15 categories relative to 3 content areas. The first content area
83
is positive communication and consists of the subcategories of agree-assent, appraisal, consequential thinking, facilitation, humor, problem solution, and specification of the problem. The second content area is negative communication and includes the subcategories of command, complain, defensive behavior, interrupt, and put down. The third and final content area is neutral communication and consists of the subcategories of no response, problem description, and talk.
TABLE
Procedure Each family was assessed during a 2 h assessment in which the mother, father, and target child were asked to complete the paper and pencil measures as well as engaging in the 2 structured family interactions. The family assessments occurred in the family’s home.
Results Demographic
characteristics
There were no significant differences between families with regard to age, length of marriage, education and family income. Self-reported disability for mothers with pain and mothers with diabetes is presented in Table II. Correlations were calculated between self-rated total disability and self-rated depression and selfreported state and trait anxiety for mothers with chronic pain and diabetes. Pearson product-moment correlations were r = 0.71 for disability and depression, r = 0.70 for disability and state anxiety, and r = 0.78 for disability and trait anxiety. All correlation coefficients were statistically significant at the P < 0.01 level. The above correlations were repeated with the effect of chronicity partialed out. Chronicity was not found to significantly affect the correlations. Interrater
reliability
Audiotapes of the interaction tasks were by trained raters. Interrater agreement was lated for each type and category of verbal ior in 24% of the audiotapes coded by the
scored calcubehavaudio-
II
SELF-REPORTED DISABILITY DIABETES MOTHERS Pain family
Area of disabilitv
RATING
Diabetes
Family home responsibilities 4.6 * Mean 1.7 S.D.
0.7 1.5
Recreation Mean SD.
4.6 * 2.5
1.1 1.5
Social activity Mean S.D.
4.1 ** 2.7
1.4 2.3
Occupation Mean SD.
4.3 * 2.0
1.0 1.9
Sexual behavior Mean SD.
4.1 * 2.6
1.3 2.2
Self-care Mean S.D.
2.7 ** 2.8
0.3 0.5
3.0 ** 2.3
1.0 1.3
Life support Mean S.D.
OF PAIN
AND
family
activity
Total disability Mean S.D.
score 21.4 * 14.6
6.9 7.9
* Means significantly different at P =c0.05. * * Trends towards significance at P -C0.10.
tape raters. Interrater agreement was calculated by dividing agreements by agreements plus disagreements. Overall interrater agreement among positive behaviors was 0.81, with 0.68 for agree-assent, 0.74 for appraisal, 0.86 for facilitation, 0.87 for humor, and 0.89 for specification of the problem. Overall interrater agreement for negative behaviors was 0.88 with 1.0 for complain and 0.75 for put down. Overall interrater agreement for neutral behaviors was 0.79 with 0.92 for problem description and 0.65 for talk. Family environment In order to assess family of their family’s functioning,
members’ perception a 2-way (group: pain,
x4
diabetic, and no-illness families x family member: father, mother, and child) analysis of variance was performed. A significant main effect was found for group on the cohesion scale F (2, 54) = 6.22, P -c 0.01, and conflict scale F (2, 54) = 3.79, P -c 0.03, of the FES. A univariate analysis was performed with post hoc tests to elucidate the main effect. All post hoc analyses were performed using Tukey’s (HSD) test. Post hoc analyses found the no-illness families to have a mean cohesion scale score (X = 8.1) significantly higher (P < 0.05) than both the pain families (X = 6.5) and the diabetes families (X = 6.4). On the conflict scale, post hoc tests found the no-illness families’ mean score (X = 2.5) to be significantly lower (P -C 0.05) than the mean score of the pain families (X = 4.0) while the mean score for the diabetes family was not significantly different from the mean score of either the pain or no-illness control families. The overall family environment data were grouped by dimensions (relationship dimensions; personal growth dimensions; and system maintenance dimensions) and analyzed in a 2 between (group x family member) and 1 within (FES dimensions) subjects factor multivariate analysis of variance (MANOVA). MANOVA was used to control for type I error. A significant main effect was found for family member using Wilk’s criterion (F (6, 104) = 2.68, P < 0.02). No significant effect was found for the group or group x family interaction effect. Uni-
variate analyses were performed to explore the family member effect. A significant effect for family member was found on the relationship dimensions (F (2, 60) = 5.29. P < 0.01). Post hoc analyses found mothers to rate the family significantly higher (P -C 0.05) on the relationship climensions than children. The mean FES profiles are presented by group in Fig. 1 and illustrate the similarities and differences between groups. A close inspection of Fig. 1 indicates that in addition to significant group differences between groups on the cohesion and conflict scales, group means are divergent on the expressiveness. active-recreational orientation. and the control scales. To briefly summarize these results, Fig. 1 indicates that family functioning appears more dysfunctional for the pain and diabetic families compared to the no-illness families given the higher expressiveness, less control and more active-recreational activities displayed by the no-illness families. Family interactions
Family communication patterns were assessed by audiotaping and then coding verbal behavior during a discussion of a hypothetical family vacation (the no induced conflict condition) and a discussion centered on filling out a questionnaire about common points of conflict between parents and children (the mild induced conflict condition).
P N
D “PD
D
DN
N P
N
N
P
D
D P
DN
P
P
P:
Pain family
D z Dnbetes N : NO illnes
01 Cohesion
Expressiveness
Conflict
Independence
Achievement orientot10n
lntekctuolcultural orlentatlon
Active recreational orientation
Fig. 1. Mean FES profiles plotted by group.
Moral religious emphasis
fom~ly family
Organization
Control
85
TABLE III DEPRESSION AND STATE AND TRAIT ANXIETY SCORES OF FATHERS AND MOTHERS BY GROUP Variable
Beck Mean SD.
No-illness family
Diabetes family
Pain family
Mothers
Fathers
Mothers
Fathers
Mothers
Fathers
7.6 * 6.1
15.0 * 14.4
3.1 2.1
5.4 6.1
2.0 2.2
4.6 3.9
STAI (state) Mean S.D.
33.0 8.5
42.0 17.0
33.1 9.0
33.4 10.5
26.9 6.6
30.4 5.6
STAI (trait) Mean SD.
41.3 ** 14.3
46.1 13.4
34.1 6.9
40.3 6.2
28.3 4.4
37.1 6.2
* Fathers’ and mothers’ scores significantly different from diabetic and no-illness fathers’ and mothers’ scores at P < 0.05 * * Parent mean scores significantly different from the no-illness parent mean scores at P < 0.05.
Rate of verbal behavior was calculated per minute, subject, and category (positive, negative, and neutral). A 2 between factors (group X family member) and 1 within-subjects factor (category of verbal behavior) MANOVA was performed for both the no conflict and mild induced conflict discussions. Using Wilk’s criterion, a trend for a significant effect appeared for family member in the vacation discussion (F (6, 104) = 2.08, P < 0.06), and a significant main effect appeared for family member in the family issues discussion (F (6, 104) = 3.91, P < 0.01). No significant effect was found for group or the group x family member interaction effect in either condition. Univariate analysis of variance found a trend for a simple main effect for family member on positive behaviors during the vacation discussion (F (2, 60) = 2.49, P < 0.09) and a significant simple main effect for family member on positive behaviors using the family conflict discussion (F (2, 60) = 10.96, P < 0.01). To summarize the family interaction results, there were no significant differences between groups on positive or negative communication patterns. However, mothers in all 3 groups displayed more positive verbal behaviors in the conflict condition than fathers and children.
are presented by group and family member in Table III. A 2-way (group x family member) analysis of variance was performed with total depression score as the dependent variable. There was a significant main effect for group F (2, 36) = 5.06, P-c 0.01, and a trend for family member F (1, 36) = 3.35, P < 0.08. The interaction effect was not statistically significant. Post hoc comparison of group means found fathers and mothers in the pain families to have a significantly higher (P < 0.05) mean depression score when compared to the diabetes and the no-illness control parents. Mean depression scores of parents in the diabetes
TABLE IV CHILDREN’S DEPRESSION AND STATE AND TRAIT ANXIETY SCORES BY GROUP Variable CD1 Mean S.D.
Pain family 9.4 * 2.8
Diabetes family
No-illness family
6.6 4.8
2.6 2.2
STAIC (state) Mean 32.0 S.D. 5.4
29.4 4.5
21.1 2.1
Depression
STAIC (trait) Mean 39.3 S.D. 9.1
34.4 5.4
32.1 4.8
Depression was assessed in fathers and mothers using the BDI. Mean depression scores of parents
* Significantly higher than children from diabetic and no-illness families at P c 0.05.
86
and no-illness control group were not significantly different. The trend for family member found mothers to generally report greater depressive symptomatology when compared to fathers. Depression was assessed in children using the CDI. Mean depression scores are presented in Table IV. A l-way analysis of variance found a significant simple main effect for group F (2, 18) = 7.01, P < 0.01. Post hoc pairwise comparison of depression scores found children who had mothers with chronic pain had significantly higher (P < 0.05) mean depression scores when compared to the no-illness children. The mean depression score for diabetic family children was between the other 2 children groups’ means and was not significantly different from either. Anxiety Anxiety was measured by self-report. All subjects completed a paper and pencil measure of both state and trait anxiety (STAI for adults and STAIC for children). Mean anxiety scores for adults are presented in Table III. A 2-way (group x family member) analysis of variance was performed with state and trait anxiety scores as the dependent variables. On state anxiety, a trend for group was found F (2, 36) = 2.64, P c 0.09. No significant effect was found for family member or the group by family member interaction effect. However, an inspection of Table III shows that the mean state anxiety score was substantially higher for the pain family parents than any other parent by group score. The failure to reach statistical significance in state anxiety was likely due to the relatively low number of subjects per group and the high variability found in mothers with chronic pain. These data indicate that the level of state anxiety, while higher for mothers with chronic pain. varied considerably across chronic pain mothers. To examine the possibility that state anxiety varies by level of self-reported disability, mothers with chronic pain were divided into high (total disability scores greater than 22) and low (total disability scores less than 22) groups and their mean state anxiety scores were then compared. As expected, chronic pain mothers with high rated disability were found to have signifi-
cantly higher state anxiety (T = 9.68, df‘= 5, P < 0.01). On trait anxiety, a significant main effect was found for group F (2, 36) = 5.15, P < 0.01, and family member F (1, 36) = 5.55, P-c 0.02. No significant interaction effect was found. Post hoc pairwise comparisons found parents in the pain family group to have a mean score significantly higher (P < 0.05) than the no-illness control group parents’ mean trait anxiety score. The significant effect for family member found mothers to generally report greater trait anxiety when compared to fathers. Differences between groups on children’s mean state and trait anxiety scores were analyzed using a l-way analysis of variance. Mean anxiety scores for children are presented in Table IV. No significant effect for group was found for either state 01 trait anxiety. Children’s variables Children’s level of social skill, behavior problems, days absent from school, mother’s rating of health, and days with illness complaints during the 2 weeks preceding assessment were not statisti-
TABLE
V
CHILDREN’S GROUP
SCORES
Variable
Pain
ON
VARIOUS
VARIABLES
Diabetes
No illness
54.4 9.7
51.4 13.1
Problem 58.7 14.0
T score 58.3 10.1
50.4 11.0
Days absent Mean SD.
from school 10.5 6.1
8.3 5.9
5.7 3.7
Health rating Mean SD.
6.1 1.1
6.4 0.8
6.7 0.5
1.9 3.0
0.3 0.5
CBCL Social Skill T score Mean 46.6 S.D. 12.9 CBCL Behavior Mean S.D.
Days with illness complaints Mean 2.1 S.D. 1.1
BY
tally different among groups. The means for these variables are presented in Table V. Though not statistically significant, a consistent trend is apparent in the data. Children from families with a mother who had chronic pain had lower social skill T scores and higher behavior problem T scores from the CBCL, lower rated health, more days absent from school and more days with illness complaints when compared to children with diabetic mothers and children who had mothers with no illness, respectively. Data from children with diabetic mothers consistently fell between the other 2 groups.
Discussion The present study assessed multiple aspects of family functioning when mothers experience chronic pain, chronic illness, or no illness. The study collected data from both parents and their preadolescent child, and assessed global self-report measures of depression, anxiety and perceptions of their family environments. Communication patterns between family members were also assessed in a no conflict and mild conflict situation. Families with a mother who experiences chronic pain were found to perceive their family environments as less cohesive and more controlling compared to the chronic illness and no-illness families. Chronic pain families also reported more conflict and less expressiveness compared to the no-illness families. Mothers and fathers in the pain families reported significantly more depressive symptoms than mothers and fathers in the diabetes and no-illness groups. Likewise, children with chronic pain mothers reported more depressive symptomatology compared to children with mothers with no illness. Mothers and fathers in the pain families also reported significantly more trait anxiety (i.e., a more enduring sense of anxiety) than parents in the no-illness group. Previous research shows that a husband’s chronic pain has an adverse effect on his wife [3,9]. The present study extends this line of research by showing that husbands similarly experi-
ence negative effects if their wives have chronic pain. Likewise, the present study is the first to empirically demonstrate that preadolescent children with chronic pain mothers experience significantly more self-reported depressive symptomatology compared to children whose mothers report no illness. In general, children with mothers who report no illness appear physically healthier and better adjusted than children whose mothers have diabetes, who, in turn, appear healthier and better adjusted than children who experience chronic pain. The finding that mothers with chronic pain report more disability than mothers with diabetes, independent of chronicity of their respective conditions, suggests that the actual type of chronic illness is less important than the degree of disability involved. In the present study self-rated disability and depression and anxiety were highly correlated for mothers with chronic pain and diabetes. Mothers with chronic pain with higher disability scores reported significantly higher state anxiety (i.e., current anxiety) compared to chronic pain mothers with lower disability scores. It is also important to note that while chronic pain mothers in the present sample reported disability, their self-rated level of disability was lower than levels of disability rated by a group of chronic pain patients seeking treatment for their condition [17]. Similarly, the finding that differences in family communication patterns were not observed in the present study suggests that these families were not necessarily clinically distressed. Previous studies using the same family interaction task procedure found differences in the rate of positive and negative verbalization between families who were seeking treatment at a mental health facility from those who were not [4,18]. While chronic pain parents generally differed in their perceptions of their family environment and self-reported measures of depression and anxiety compared to the other two groups of parents, chronic pain families were not actively seeking treatment for their chronic pain. It is also important to note that diabetic mothers, because of the chronicity of their illness, presumably had more contact with medical personnel than mothers in the present sample with chronic pain. The
88 frequent use of medical consultation could possibly attenuate the degree of distress (i.e., depression and anxiety) experienced by the diabetic mothers compared to the chronic pain mothers. While mothers with chronic pain reported clinically significant levels of depressive symptoms on the BDI [lo], the overall data in the present study, particularly the verbal communication patterns between family members, do not necessarily suggest that the chronic pain families are severely distressed. In fact, a recent review of the BDI suggests that a BDI score of 15 (the average score for mothers with chronic pain in the present sample) indicates dysphoria, but scores above 17 indicate a depressive state, with scores above 20 indicating moderate depression ff3]. These cut-off scores suggest that the chronic pain mothers, while displaying wide va~abi~ty in the BDI scores with a standard deviation of 14, on the average fall close to being in a depressive state. Nonetheless. given that the present sample of chronic pain mothers report some disability, significant levels of depression, anxiety, as well as conflict and lack of cohesion in the family, the results suggest that if the level of disability would increase for the pain mothers, there would be a similar increase in family dysfunction. The present study is limited by certain factors. The sample size was small due to the attempt to assess as homogeneous a group of families as possible, with such requirements that each family had a preadolescent child and that ail other family members were in good health. Previous research has shown that chronic pain patients’ spouses often experience chronic pain [8), which was observed in several potential families who had to be excluded in the present study. Generalizations from the present study should be limited to families with similar demographics. Future research needs to assess family functioning when a father or mother is actually seen for evaluation and treatment in a pain clinic. The present findings suggest that by the time a spouse’s chronic pain is severe enough to seek ireatment, there would be a similar exacerbation of family functioning to have occurred. Now that there appears to be sufficient clinical [e.g., ZO] and research evidence that a parent’s chronic pain af-
fects family functioning, researchers need to determine the actual extent of distress in family members when a spouse seeks treatment for his or her chronic
pain.
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15
16
Achenbach, T.M., The child behavior profile. I. Boys aged 6-11, J. Consult. Clin. Psychol., 46 (1978) 478-48X. Achenbach, T.M. and Edelbrock, C.S., The child behavior profile. II. Boys aged 12-16 and girls aged 6-11 and 12-16. J. Consult. Clin. Psychol., 47 (1979) 223-233. Ahem. D.K. and Follick, M.J.. Distress in spouses of chronic pain patients, Int. J. Fam. Ther., 7 (1985) 247-270. Alexander. D.F., Defensive and supportive communications in normal and deviant families, J. Consult. Clin. Psychol., 40 (1973) 223-231. Beck. A.T., Ward. C., Mendelson, M., Mock, .I. and Erbaugh, J.. An inventory for measuring depression. Arch. Gen. Psychiat., 4 (1961) 53-63. Block. A.R., An investigation of the response of the spouse to chronic pain behavior, Psychosom. Med., 43 (1981) 415-422. Cardenas, L., Vallbona. E., Baker, S. and Yusim. S.. Adult onset diabetes mellitus: glycemic control and family function, Am. J. Med. Sci., 293 (1987) 2X-33 Crook, J., Rideout, E. and Browne, G., The prevalence of pain complaint in a general population, Pain, 18 (19X4) 299-314. Flor, H., Turk, D.C. and Scholz, O.B.. Impact of chronic pain on the spouse: marital, emotional, and physical consequences. J. Psychosom. Res., 31 (1987) 63-71. Gregory, LG. and Smeltzer, D.J.. Psychiatry: Essentials of Clinical Practice, 2nd Edn.. Little, Brown and Co.. Boston. MA. 1983. Grotevant. H.D. and Cooper, C.R., Patterns of interaction in family relationships and the development of identity exploration in adolescence, Child Dev., 56 (19X5) 415-42X. Kazdin. A.E. and Petti. T.A.. Self-report interview meacures of childhood and adolescent depression, J. Child Psychol. Psych&.. 23 (1982) 437-457. Kendall, P.C., Hollon, S.D.. Beck. A.T., Hammen. C.L. and Ingram. R.E., Issues and recommendations regarding use of the Beck Depression Inventory, Cogn. Ther. Res., 11 (19X7) 2X9-299. Kovacs, M. and Beck, A.T.. An empirical clinical approach towards a definition of childhood depression. In: J.G. Schulter-Brandt and A. Raskin (Eds.), Depression in Children: Diagnosis. Treatment and Conceptual Models. Raven Press, New York, 3977. Mohamed. S.N.. Weisz, G.M. and Waring, E.M.. The relationship of chronic pain to depression, marital adjustment and family dynamics, Pain, 5 (1978) 2X5-292. Moos, R.H. and Moos, B.S., Family Environment Scale Manual. Consulting Psychologists Press, Palo Alto. CA. 19X1.
89 17 Pollard, C.A., Preliminary validity study of the pain disability index, Percept. Mot. Skills, 59 (1984) 974. 18 Prinz, R.J., Rosenblum, R.S. and O’Leary, K.D., Affective communication differences between distressed and nondistressed mother-adolescent dyads, J. Child Psychol., 6 (1978) 373-383. 19 Robin, A. and Fox, M., Parent Adolescent Interaction Coding System, University of Maryland Baltimore County, Baltimore, MD, 1979. 20 Rowat, K.M. and Knafl, K.A., Living with chronic pain: the spouse’s perspective, Pain, 23 (1985) 259-271.
21 Spielberger, C.D., Manual for the State-Trait Anxiety Inventory for Children, Consulting Psychologists Press, Palo Alto, CA, 1973. 22 Spielberger, C.D., Gorsuch, R.L. and Lushene, R.E., Manual for the State-Trait Anxiety Inventory, Consulting Psychologists Press, Palo Alto, CA, 1970. 23 Turk, D.C., Flor, H. and Rudy, T.E., Pain and families. I. Etiology, maintenance and psychosocial impact, Pain, 30 (1987) 3-27.
Pain, 35 (1988) 79-89 Elsevier
PAI 01279
A comparison of family functioning when mothers have chronic pain Jason R. Dura and Steven J. Beck Department of Psychology, Ohio State University, 1885 Neil Avenue Mall, Columbus, OH 43210 (U.S.A.) (Received
16 November
1987, revision
received 27 April 1988, accepted
5 May 1988)
Multiple aspects of family functioning &ere assessed when mothers experienced either chronic pain, a chronic illness Summary (diabetes), or no illness. Mothers’ and fathers’ self-report measures of depression, anxiety, and family environment were collected. Children’s self-report measures of depression and anxiety, as well as information about their overall adjustment, were collected. Family communication patterns were also assessed. Families with a mother who had chronic pain had poorer perceived family environments and higher levels of depression and anxiety compared to the other two groups of families. Children from chronic pain families also appeared to be adversely affected. The data suggest that level of disability appeared more salient than the type of chronic illness. Implications of the findings are discussed in light of the fact that mothers with chronic pain in the present sample reported relatively mild disability and were not actively seeking treatment for their condition. Key words:
Pain; Family
Inhwduction To date there has been a paucity of studies examining the degree of distress reported by family members of chronic pain patients 1231. Obviously, an individual’s experience with chronic pain does not occur in a vacuum, but impacts on every aspect of his or her vocational, recreational, and familial life. By virtue of the fact that chronic diseases or conditions extend over time, they are likely to have significant consequences for the family of the identified patient. The way the family copes with the financial difficulties, the mood alterations in the patient, and the additional family strains argues for the necessity of examining
Correspondence to: Dr. S.J. Beck, Department of Psychology, Ohio State University, 1885 Neil Avenue Mall, Columbus, OH 43210, U.S.A. 0304-3959/88/$03.50
0 1988 Elsevier Science Publishers
chronic pain in the context of the patient’s primary social network, the family. While research has not rigorously explored issues of family functioning where a family member has chronic pain, investigators are now recognizing that the family of the pain patient may experience negative consequences of this health problem [e.g., 6,14,20]. As an example, a recent study of 58 chronic pain male patients demonstrated that 49% of the patients and 26% of the spouses displayed significant levels of depressed mood [9]. These findings generally corroborate the findings of Rowat and Knafl [20] who found that the major problem spouses of chronic pain patients face was uncertainty about their spouses’ pain condition and subsequent feelings of helplessness and hopelessness. However, these previous studies have only examined the impact of a spouse’s adjustment to her husband’s chronic pain. Little is known about the impact of the spouse on the family when the woman experiences chronic pain.
B.V. (Biomedical
Division)
x0
The present study assesses the impact of chronic pain on multiple areas of family functioning. The present study is noteworthy for several reasons. First, this study examines family functioning when the wife is the identified patient. Due to different family roles played by husbands and wives, research is needed to determine if the chronic pain of wives (and mothers) similarly affects the family as it appears to do when the husband experiences the chronic condition. Secondly, the present research is the first known study collecting objective data on the impact of parental chronic pain on children [23]. Thirdly, while previous studies have underscored the need to examine family members who live with the pain patient, past studies have not compared the level of functioning in spouses of chronic pain patients relative to spouses who experience a chronic medical illness. While data accumulate indicating that spouses of chronic pain patients can be adversely affected by the chronic pain condition, the question remains as to whether the degree of distress is greater, similar, or less than spouses of chronic medically ill patients. Only with such comparisons can the negative consequences of chronic pain upon family functioning be better understood. Consequently, the present study also assesses families with mothers who
TABLE
I
DEMOGRAPHIC Variable
CHARACTERISTICS
OF SUBJECT
GROUPS
Diabetes
Pain family Mothers
Fathers
Children 7
7
I
M S.D.
36.2 5.4
37.6 6.4
Race White Black
6 1
6
6
1
1
n
have insulin-dependent onset diabetes. This chronic medical condition was chosen since family functioning appears to affect glycemic control in adult onset diabetic patients [7]. Patients with diabetes mellitus require possible disruption of family functioning given the complex treatment requirements such as balanced food intake, pharmacologic therapy, structured physical therapy, weight reduction, glucose monitoring, special self-care, and periodic follow-ups required by patients. Consequently, the present study examined 3 groups of families: pain families, chronic illness families, and no-illness control families. Another strength of the present study is that previous studies have examined just one or a few variables of family functioning when a spouse presents with chronic pain. The present study assesses several global and specific aspects of family functioning. Paper and pencil measures of family members’ perceptions of their family functioning, as well as family members’ global dysphoric mood and anxiety, and children’s functioning on several objective and self-report measures were collected. In addition. specific family communication patterns were assessed to determine if these 3 groups of families interacted with each other in significantly different ways. Previous research has found that normal and poorly adjusted
Mothers
family
No-illness
Fathers
Children
Mothers
control
family
Fathers
Children 7
7
I
7
7
7
35.6 5.9
36.3 6.9
10.7 1.1
34.0 3.8
35.7 3.3
9.0 2.0
6 1
6 1
6 1
6 1
6
6 1
NA NA
13.0 3.7
13.0 3.7
NA NA
15.3 3.2
17.6 3.3
4.1 2.0
Age 9.4 2.4
Length of marriage M 15.1 S.D. 5.1
15.1 5.1
NA NA
15.3 6.9
15.3 6.9
Education M S.D.
14.7 4.1
3.9 2.7
14.0 2.5
14.1 4.4
14.0 4.5
5.9 1.6
I
81
families’ communication patterns differ in a semistructured family discussion (e.g., poorly adjusted families display high rates of defensive and nonfacilitation communication patterns) [4].
Method Subjects Twenty-one families served as subjects. Families were contacted through newspaper advertisements and were paid $25 for participating. Families were matched on socioeconomic status, parent and child age, sex, and employment status (see Table I). All families consisted of a mother, a father and a child between 7 and 13 years of age. In all families the parents were the child’s biological parents and all members resided in the same household. Sex of children varied by group, with 5 male and 2 female children in the pain family group, 2 male and 5 female children in the diabetes family group, and 4 male and 3 female children in the no-illness control group. The range of children’s ages was 7-13 years, lo-13 years, and 7-12 years, respectively. Mothers in the pain families reported radiating low back pain (N = 4) or radiating head and neck pain (N = 3) and were required to report pain of at least 6 months duration along with an examination that failed to find an acute etiology (e.g., brain tumor). The 7 chronic illness families were required to have a mother with insulin-dependent adult onset diabetes of at least 6 months duration. The remaining family members in the pain and diabetic families reported no serious illness, while the 7 control families reported no serious illness in any family member. Dependent
measures
Adult measures Family Environment Scale (FES). Parents’ and children’s perceptions of the family environment were assessed using Form R of the FES. This questionnaire assesses multiple domains within the larger concept of family environments [16].
Form R consists of 90 true-false items. When scored, the FES yields 10 subscale scores that fall into 3 domains. The first domain is the Relationship dimension which includes the cohesion, expressiveness and conflict subscales. These subscales measure ‘the degree of commitment, help, and support family members provide for one another; the extent to which family members are encouraged to act openly and to express their feelings directly; and the amount of openly expressed anger, aggression, and conflict among family members’ [16]. The second dimension measured by the FES is the Personal Growth dimension which includes the independence, achievement orientation, intellectual-cultural orientation, active-recreational orientation, and moral-religious emphasis subscales. These subscales measure ‘ the extent to which family members are assertive, self-sufficient, and make their own decisions; the extent to which activities (such as school and work) are cast into an achievement-oriented or competitive framework; the degree of interest in political, social, intellectual, and cultural activities; the extent of participation in social and recreational activities; and the degree of emphasis on ethical and religious issues and values’ [16]. The System Maintenance dimension is the final domain of the FES and consists of the organization and control subscales. These subscales measure the degree to which clear organization and planning are emphasized within a family along with assessing the amount of emphasis placed on rules [16]. Normative data are available and previous research supports the scale as both internally consistent and reliable [16]. Beck Depression Inventory (BDI). Depression was assessed in adults using the Beck Depression Inventory [5]. This 21-item self-report inventory determines the level or extent of depression based on the presence of depressive symptomatology. The subject is asked to choose which sentence in each item best describes his or her feelings during the most recent week. Items are scored O-3 and total scale scores range from 0 to 63 with increasing scores reflecting increased report of depression. State-Trait Anxiety Inventory (STAI). Adults’ anxiety was assessed using the State-Trait Anxiety
82
Inventory [22]. Two separate scales combine to form the STAI. The S-Anxiety Scale (STAI Form Y-l) has 20 items that measure current anxiety. The T-Anxiety Scale (STAI Form Y-2) has 20 items that measure how anxious the person generally feels. The STAI has been used extensively in a multitude of settings and populations. It has consistently shown both good reliability and validity
P21. Disability. Disability secondary to chronic pain and diabetes was assessed in mothers in the pain and diabetes families using the original and a modified version of the Pain Disability Index [17]. The modified version of the index substituted the word diabetes for pain. In all other respects, the two versions of the index were identical. This 7-item self-report inventory was developed to measure disability associated with chronic pain in 7 areas of life functioning: family/ home responsibilities, recreation, social activity, occupation. sexual behavior, self-care, and life-support activity. On each life area, subjects were asked to rate impairment from 0 (no disability) to 10 (total disability).
Children’s measures Children’s Depression Inventory (CDI). Children were assessed for depression using the Children’s Depression Inventory. This 27-item self-report inventory was modeled after the BDI and is similar in that depression is assessed relative to symptomatology [13]. Children are asked to pick the sentence in each item that best describes him or her over the most recent 2 weeks. The CD1 is written so that children aged 8-13 should be capable of completing it with little or no assistance. Previous research reports the CD1 as both reliable and clinically valued [12]. State-Trait Society Scale for Children (STAIC). Children’s anxiety was assessed using the StateTrait Anxiety Inventory for Children [20]. The STAIC consists of 2 self-report inventories with 20 items each. The first scale (A-State Scale) was designed to measure how anxious the child currently feels. The second scale (A-Trait Scale) was designed to measure how generally anxious the child feels.
Child Behavior Checklist (CBCL). The CBCL was used to assess the children’s behavioral problems and social competence through parent report [1,2]. This 118-item inventory asks parents to enumerate child activities as well as rate the child’s competence in the activity. The CBCL provides a Behavior Problems Profile and a Social Competence Profile by way of T-scores. Children 2 Illness Behavior. Children’s illness behavior was assessed in 3 ways. The first involved the mother rating the child as to overall health on a 7-point Likert scale with 1 representing very poor health and 7 representing excellent health. In the second measure, the mother was asked to recall the number of days in the past 2 weeks that the child complained of not feeling well (e.g., headaches and stomachaches), in the absence of observable symptoms of an illness. This third measure of illness behavior was days absent from school during the 1985-1986 school year due to illness (i.e., days absent due to vacation were not included in days absent for illness). School absences were collected from the attendance record on the child’s report card with days absent due to vacation subtracted from the total. Family Interaction Task. Family communication patterns were assessed among family members during 2 structured family interaction tasks. The first task involved planning an itinerary for a hypothetical 2 week vacation. The instructions were to outline daily activities under the assumption of unlimited funds with a total of 10 min to complete the task. A vacation planning task was used since such a discussion can involve the opinion of all family members, thus children may share in the task as equals [II]. The second task was a problem-oriented discussion in which the family was asked to spend 10 min filling out a questionnaire as a family. The questionnaire was adapted from a similar instrument designed to evoke mild conflict and asks how often and in what manner common points of family conflict are discussed [19]. Both tasks were audiotaped and verbal behaviors were coded using Robin’s and Fox’s ParentAdolescent Interaction Coding System [ 191. This system separates verbalizations into 15 categories relative to 3 content areas. The first content area
83
is positive communication and consists of the subcategories of agree-assent, appraisal, consequential thinking, facilitation, humor, problem solution, and specification of the problem. The second content area is negative communication and includes the subcategories of command, complain, defensive behavior, interrupt, and put down. The third and final content area is neutral communication and consists of the subcategories of no response, problem description, and talk.
TABLE
Procedure Each family was assessed during a 2 h assessment in which the mother, father, and target child were asked to complete the paper and pencil measures as well as engaging in the 2 structured family interactions. The family assessments occurred in the family’s home.
Results Demographic
characteristics
There were no significant differences between families with regard to age, length of marriage, education and family income. Self-reported disability for mothers with pain and mothers with diabetes is presented in Table II. Correlations were calculated between self-rated total disability and self-rated depression and selfreported state and trait anxiety for mothers with chronic pain and diabetes. Pearson product-moment correlations were r = 0.71 for disability and depression, r = 0.70 for disability and state anxiety, and r = 0.78 for disability and trait anxiety. All correlation coefficients were statistically significant at the P < 0.01 level. The above correlations were repeated with the effect of chronicity partialed out. Chronicity was not found to significantly affect the correlations. Interrater
reliability
Audiotapes of the interaction tasks were by trained raters. Interrater agreement was lated for each type and category of verbal ior in 24% of the audiotapes coded by the
scored calcubehavaudio-
II
SELF-REPORTED DISABILITY DIABETES MOTHERS Pain family
Area of disabilitv
RATING
Diabetes
Family home responsibilities 4.6 * Mean 1.7 S.D.
0.7 1.5
Recreation Mean SD.
4.6 * 2.5
1.1 1.5
Social activity Mean S.D.
4.1 ** 2.7
1.4 2.3
Occupation Mean SD.
4.3 * 2.0
1.0 1.9
Sexual behavior Mean SD.
4.1 * 2.6
1.3 2.2
Self-care Mean S.D.
2.7 ** 2.8
0.3 0.5
3.0 ** 2.3
1.0 1.3
Life support Mean S.D.
OF PAIN
AND
family
activity
Total disability Mean S.D.
score 21.4 * 14.6
6.9 7.9
* Means significantly different at P =c0.05. * * Trends towards significance at P -C0.10.
tape raters. Interrater agreement was calculated by dividing agreements by agreements plus disagreements. Overall interrater agreement among positive behaviors was 0.81, with 0.68 for agree-assent, 0.74 for appraisal, 0.86 for facilitation, 0.87 for humor, and 0.89 for specification of the problem. Overall interrater agreement for negative behaviors was 0.88 with 1.0 for complain and 0.75 for put down. Overall interrater agreement for neutral behaviors was 0.79 with 0.92 for problem description and 0.65 for talk. Family environment In order to assess family of their family’s functioning,
members’ perception a 2-way (group: pain,
x4
diabetic, and no-illness families x family member: father, mother, and child) analysis of variance was performed. A significant main effect was found for group on the cohesion scale F (2, 54) = 6.22, P -c 0.01, and conflict scale F (2, 54) = 3.79, P -c 0.03, of the FES. A univariate analysis was performed with post hoc tests to elucidate the main effect. All post hoc analyses were performed using Tukey’s (HSD) test. Post hoc analyses found the no-illness families to have a mean cohesion scale score (X = 8.1) significantly higher (P < 0.05) than both the pain families (X = 6.5) and the diabetes families (X = 6.4). On the conflict scale, post hoc tests found the no-illness families’ mean score (X = 2.5) to be significantly lower (P -C 0.05) than the mean score of the pain families (X = 4.0) while the mean score for the diabetes family was not significantly different from the mean score of either the pain or no-illness control families. The overall family environment data were grouped by dimensions (relationship dimensions; personal growth dimensions; and system maintenance dimensions) and analyzed in a 2 between (group x family member) and 1 within (FES dimensions) subjects factor multivariate analysis of variance (MANOVA). MANOVA was used to control for type I error. A significant main effect was found for family member using Wilk’s criterion (F (6, 104) = 2.68, P < 0.02). No significant effect was found for the group or group x family interaction effect. Uni-
variate analyses were performed to explore the family member effect. A significant effect for family member was found on the relationship dimensions (F (2, 60) = 5.29. P < 0.01). Post hoc analyses found mothers to rate the family significantly higher (P -C 0.05) on the relationship climensions than children. The mean FES profiles are presented by group in Fig. 1 and illustrate the similarities and differences between groups. A close inspection of Fig. 1 indicates that in addition to significant group differences between groups on the cohesion and conflict scales, group means are divergent on the expressiveness. active-recreational orientation. and the control scales. To briefly summarize these results, Fig. 1 indicates that family functioning appears more dysfunctional for the pain and diabetic families compared to the no-illness families given the higher expressiveness, less control and more active-recreational activities displayed by the no-illness families. Family interactions
Family communication patterns were assessed by audiotaping and then coding verbal behavior during a discussion of a hypothetical family vacation (the no induced conflict condition) and a discussion centered on filling out a questionnaire about common points of conflict between parents and children (the mild induced conflict condition).
P N
D “PD
D
DN
N P
N
N
P
D
D P
DN
P
P
P:
Pain family
D z Dnbetes N : NO illnes
01 Cohesion
Expressiveness
Conflict
Independence
Achievement orientot10n
lntekctuolcultural orlentatlon
Active recreational orientation
Fig. 1. Mean FES profiles plotted by group.
Moral religious emphasis
fom~ly family
Organization
Control
85
TABLE III DEPRESSION AND STATE AND TRAIT ANXIETY SCORES OF FATHERS AND MOTHERS BY GROUP Variable
Beck Mean SD.
No-illness family
Diabetes family
Pain family
Mothers
Fathers
Mothers
Fathers
Mothers
Fathers
7.6 * 6.1
15.0 * 14.4
3.1 2.1
5.4 6.1
2.0 2.2
4.6 3.9
STAI (state) Mean S.D.
33.0 8.5
42.0 17.0
33.1 9.0
33.4 10.5
26.9 6.6
30.4 5.6
STAI (trait) Mean SD.
41.3 ** 14.3
46.1 13.4
34.1 6.9
40.3 6.2
28.3 4.4
37.1 6.2
* Fathers’ and mothers’ scores significantly different from diabetic and no-illness fathers’ and mothers’ scores at P < 0.05 * * Parent mean scores significantly different from the no-illness parent mean scores at P < 0.05.
Rate of verbal behavior was calculated per minute, subject, and category (positive, negative, and neutral). A 2 between factors (group X family member) and 1 within-subjects factor (category of verbal behavior) MANOVA was performed for both the no conflict and mild induced conflict discussions. Using Wilk’s criterion, a trend for a significant effect appeared for family member in the vacation discussion (F (6, 104) = 2.08, P < 0.06), and a significant main effect appeared for family member in the family issues discussion (F (6, 104) = 3.91, P < 0.01). No significant effect was found for group or the group x family member interaction effect in either condition. Univariate analysis of variance found a trend for a simple main effect for family member on positive behaviors during the vacation discussion (F (2, 60) = 2.49, P < 0.09) and a significant simple main effect for family member on positive behaviors using the family conflict discussion (F (2, 60) = 10.96, P < 0.01). To summarize the family interaction results, there were no significant differences between groups on positive or negative communication patterns. However, mothers in all 3 groups displayed more positive verbal behaviors in the conflict condition than fathers and children.
are presented by group and family member in Table III. A 2-way (group x family member) analysis of variance was performed with total depression score as the dependent variable. There was a significant main effect for group F (2, 36) = 5.06, P-c 0.01, and a trend for family member F (1, 36) = 3.35, P < 0.08. The interaction effect was not statistically significant. Post hoc comparison of group means found fathers and mothers in the pain families to have a significantly higher (P < 0.05) mean depression score when compared to the diabetes and the no-illness control parents. Mean depression scores of parents in the diabetes
TABLE IV CHILDREN’S DEPRESSION AND STATE AND TRAIT ANXIETY SCORES BY GROUP Variable CD1 Mean S.D.
Pain family 9.4 * 2.8
Diabetes family
No-illness family
6.6 4.8
2.6 2.2
STAIC (state) Mean 32.0 S.D. 5.4
29.4 4.5
21.1 2.1
Depression
STAIC (trait) Mean 39.3 S.D. 9.1
34.4 5.4
32.1 4.8
Depression was assessed in fathers and mothers using the BDI. Mean depression scores of parents
* Significantly higher than children from diabetic and no-illness families at P c 0.05.
86
and no-illness control group were not significantly different. The trend for family member found mothers to generally report greater depressive symptomatology when compared to fathers. Depression was assessed in children using the CDI. Mean depression scores are presented in Table IV. A l-way analysis of variance found a significant simple main effect for group F (2, 18) = 7.01, P < 0.01. Post hoc pairwise comparison of depression scores found children who had mothers with chronic pain had significantly higher (P < 0.05) mean depression scores when compared to the no-illness children. The mean depression score for diabetic family children was between the other 2 children groups’ means and was not significantly different from either. Anxiety Anxiety was measured by self-report. All subjects completed a paper and pencil measure of both state and trait anxiety (STAI for adults and STAIC for children). Mean anxiety scores for adults are presented in Table III. A 2-way (group x family member) analysis of variance was performed with state and trait anxiety scores as the dependent variables. On state anxiety, a trend for group was found F (2, 36) = 2.64, P c 0.09. No significant effect was found for family member or the group by family member interaction effect. However, an inspection of Table III shows that the mean state anxiety score was substantially higher for the pain family parents than any other parent by group score. The failure to reach statistical significance in state anxiety was likely due to the relatively low number of subjects per group and the high variability found in mothers with chronic pain. These data indicate that the level of state anxiety, while higher for mothers with chronic pain. varied considerably across chronic pain mothers. To examine the possibility that state anxiety varies by level of self-reported disability, mothers with chronic pain were divided into high (total disability scores greater than 22) and low (total disability scores less than 22) groups and their mean state anxiety scores were then compared. As expected, chronic pain mothers with high rated disability were found to have signifi-
cantly higher state anxiety (T = 9.68, df‘= 5, P < 0.01). On trait anxiety, a significant main effect was found for group F (2, 36) = 5.15, P < 0.01, and family member F (1, 36) = 5.55, P-c 0.02. No significant interaction effect was found. Post hoc pairwise comparisons found parents in the pain family group to have a mean score significantly higher (P < 0.05) than the no-illness control group parents’ mean trait anxiety score. The significant effect for family member found mothers to generally report greater trait anxiety when compared to fathers. Differences between groups on children’s mean state and trait anxiety scores were analyzed using a l-way analysis of variance. Mean anxiety scores for children are presented in Table IV. No significant effect for group was found for either state 01 trait anxiety. Children’s variables Children’s level of social skill, behavior problems, days absent from school, mother’s rating of health, and days with illness complaints during the 2 weeks preceding assessment were not statisti-
TABLE
V
CHILDREN’S GROUP
SCORES
Variable
Pain
ON
VARIOUS
VARIABLES
Diabetes
No illness
54.4 9.7
51.4 13.1
Problem 58.7 14.0
T score 58.3 10.1
50.4 11.0
Days absent Mean SD.
from school 10.5 6.1
8.3 5.9
5.7 3.7
Health rating Mean SD.
6.1 1.1
6.4 0.8
6.7 0.5
1.9 3.0
0.3 0.5
CBCL Social Skill T score Mean 46.6 S.D. 12.9 CBCL Behavior Mean S.D.
Days with illness complaints Mean 2.1 S.D. 1.1
BY
tally different among groups. The means for these variables are presented in Table V. Though not statistically significant, a consistent trend is apparent in the data. Children from families with a mother who had chronic pain had lower social skill T scores and higher behavior problem T scores from the CBCL, lower rated health, more days absent from school and more days with illness complaints when compared to children with diabetic mothers and children who had mothers with no illness, respectively. Data from children with diabetic mothers consistently fell between the other 2 groups.
Discussion The present study assessed multiple aspects of family functioning when mothers experience chronic pain, chronic illness, or no illness. The study collected data from both parents and their preadolescent child, and assessed global self-report measures of depression, anxiety and perceptions of their family environments. Communication patterns between family members were also assessed in a no conflict and mild conflict situation. Families with a mother who experiences chronic pain were found to perceive their family environments as less cohesive and more controlling compared to the chronic illness and no-illness families. Chronic pain families also reported more conflict and less expressiveness compared to the no-illness families. Mothers and fathers in the pain families reported significantly more depressive symptoms than mothers and fathers in the diabetes and no-illness groups. Likewise, children with chronic pain mothers reported more depressive symptomatology compared to children with mothers with no illness. Mothers and fathers in the pain families also reported significantly more trait anxiety (i.e., a more enduring sense of anxiety) than parents in the no-illness group. Previous research shows that a husband’s chronic pain has an adverse effect on his wife [3,9]. The present study extends this line of research by showing that husbands similarly experi-
ence negative effects if their wives have chronic pain. Likewise, the present study is the first to empirically demonstrate that preadolescent children with chronic pain mothers experience significantly more self-reported depressive symptomatology compared to children whose mothers report no illness. In general, children with mothers who report no illness appear physically healthier and better adjusted than children whose mothers have diabetes, who, in turn, appear healthier and better adjusted than children who experience chronic pain. The finding that mothers with chronic pain report more disability than mothers with diabetes, independent of chronicity of their respective conditions, suggests that the actual type of chronic illness is less important than the degree of disability involved. In the present study self-rated disability and depression and anxiety were highly correlated for mothers with chronic pain and diabetes. Mothers with chronic pain with higher disability scores reported significantly higher state anxiety (i.e., current anxiety) compared to chronic pain mothers with lower disability scores. It is also important to note that while chronic pain mothers in the present sample reported disability, their self-rated level of disability was lower than levels of disability rated by a group of chronic pain patients seeking treatment for their condition [17]. Similarly, the finding that differences in family communication patterns were not observed in the present study suggests that these families were not necessarily clinically distressed. Previous studies using the same family interaction task procedure found differences in the rate of positive and negative verbalization between families who were seeking treatment at a mental health facility from those who were not [4,18]. While chronic pain parents generally differed in their perceptions of their family environment and self-reported measures of depression and anxiety compared to the other two groups of parents, chronic pain families were not actively seeking treatment for their chronic pain. It is also important to note that diabetic mothers, because of the chronicity of their illness, presumably had more contact with medical personnel than mothers in the present sample with chronic pain. The
88 frequent use of medical consultation could possibly attenuate the degree of distress (i.e., depression and anxiety) experienced by the diabetic mothers compared to the chronic pain mothers. While mothers with chronic pain reported clinically significant levels of depressive symptoms on the BDI [lo], the overall data in the present study, particularly the verbal communication patterns between family members, do not necessarily suggest that the chronic pain families are severely distressed. In fact, a recent review of the BDI suggests that a BDI score of 15 (the average score for mothers with chronic pain in the present sample) indicates dysphoria, but scores above 17 indicate a depressive state, with scores above 20 indicating moderate depression ff3]. These cut-off scores suggest that the chronic pain mothers, while displaying wide va~abi~ty in the BDI scores with a standard deviation of 14, on the average fall close to being in a depressive state. Nonetheless. given that the present sample of chronic pain mothers report some disability, significant levels of depression, anxiety, as well as conflict and lack of cohesion in the family, the results suggest that if the level of disability would increase for the pain mothers, there would be a similar increase in family dysfunction. The present study is limited by certain factors. The sample size was small due to the attempt to assess as homogeneous a group of families as possible, with such requirements that each family had a preadolescent child and that ail other family members were in good health. Previous research has shown that chronic pain patients’ spouses often experience chronic pain [8), which was observed in several potential families who had to be excluded in the present study. Generalizations from the present study should be limited to families with similar demographics. Future research needs to assess family functioning when a father or mother is actually seen for evaluation and treatment in a pain clinic. The present findings suggest that by the time a spouse’s chronic pain is severe enough to seek ireatment, there would be a similar exacerbation of family functioning to have occurred. Now that there appears to be sufficient clinical [e.g., ZO] and research evidence that a parent’s chronic pain af-
fects family functioning, researchers need to determine the actual extent of distress in family members when a spouse seeks treatment for his or her chronic
pain.
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