MODULE ASSIGNMENT
STUDENT ID: 20204768.
CLASS CODE: DISSERTATION 2023.
COURSE: MA in counselling and psychotherapy- family modalities.
MODULE TITLE: Evidence Based Practice & Research.
ASSIGNMENT TITLE: Research Proposal: A scoping review to examine the relationship of
maternal chronic pain to the emotional and behavioural functioning of children.
LECTURERS: Professor Denis Ryan, Dr. Kevin Stevenson.
SUPERVISOR: Maria Benito.
WORD COUNT:
This dissertation is being submitted for the requirement of MA degree in Counselling and
psychotherapy (family modalities).
Submission Date:
Student Name (Block Capitals): Eimear O’ Neill.
I have read and understand the ICHAS policies on the submission of assessments and on
plagiarism. I confirm that this is my own original work.
Signed: E O’ Neill
Date:
1
DISSERTATION
A scoping review to examine the relationship of maternal chronic
pain to the emotional and behavioural functioning of children.
Submission date:
Word count:
Student name: Eimear O’ Neill.
Student number: 20204768.
2
AUTHOR’S DECLARATION
I work as a qualified doctor within the mental health services. I am a senior registrar on the
psychiatry training scheme under the Irish college of psychiatrists and UCC deanery. My work
and training affords me the opportunity to meet many different people from many different
backgrounds, cultures and histories. Over the course of my training in psychiatry, I have
developed into a more holistic clinician. I utilise a biopsychosocial approach with my patients
and exploring an individual’s family history, inter-generational patterns, psychological
development and socio-cultural contributors to their difficulties and coping, has become
central to my approach to patients or clients. I have realized that, often, an individual’s
relationships and environment contribute largely to a deterioration in mental health. Over
time, I have appreciated that the family of origin are all important in our cognitive and
emotional development and that resultant negative schemas can impact significantly on who
we are and how we cope with change and life events.
I have embarked in a masters in family psychotherapy to gain experience and training in order
to help individuals who suffer with mental health difficulties. I feel that relationships and
attachment figures can offer support and healing in all situations. I have been researching the
relationship between mother and child. This relationship involves a vital attachment process
which supports the physical, emotional and cognitive growth and health of the child. In
particular, I have narrowed my scope to the bonding relationship between mother and child
when a mother is occupied by chronic pain. The impact of chronic pain on the family may
mean that mothers are less attentive to their children. I have been exploring the possible
impact that this may have on the development of the child primarily their emotional and
behavioural development. I hope to gain insight into how such relationships could be
supported and increase awareness of the different stressors which could affect the
attachment between mother and child.
3
Acknowledgements
I would like to express my gratitude to my research supervisor for this project, Maria Benito.
Maria has given me much support and encouragement. She has been readily available when
needed and proved to be useful in focusing my research interest and approach. I hope to
thank her for her enthusiasm in this research topic.
I also hope to thank my clinical research supervisor within my psychiatric training scheme, Dr.
Mary Scriven who has always been interested in my endeavours and is inspiring in her own
commitment to her research and to her work. She exemplifies a person centred and
therapeutic approach.
There are many people who have re-energised me along this project who deserve a big thank
you including Olive O’ Riordan, my supervisor in psychotherapy training and Dr. Peter Braben,
my clinical supervisor within my placement in psychiatric training. Thank you for your
recommendations and advice.
A never-ending thank you to my partner, Adrian Mc Carthy for his care and support.
4
Abstract
Chronic pain effects seventy percent of women, most of which fall within the thirty-five to
fifty-five years age group (Palacios-Ceña, D et al, 2017). Research has indicated that chronic
pain causes much disruption to the lifestyle, relationships, and the mental health of those
who suffer. A concerning effect of chronic pain includes its impact on the family including the
relational functioning of children and hence their development (Silwerski A et al, 2020) (Evans
S et al, 2007). It is useful to consider the utilization of family-based methods in the
management of maternal chronic pain. Aiding family members by supporting their suffering
can alleviate stress, manage expectations, repair bonds, and lessen the chances of mental
illness in the sufferer or family members (Kumpfer K.L, 2003) (Bees F, 1994) (Evans S et al,
2006).
Database and grey literature searches were undertaken using key words/terms to consider
the effects of maternal chronic pain on children and what may improve outcomes in maternal
chronic pain. Search criteria were used to select relevant articles written in any language
which fit inclusion and exclusion criteria. The relevant articles which matched the predetermined criteria were included in the research, of these articles certain ‘key papers’ were
identified. Examination of the literature revealed that chronic pain impacts on almost every
aspect of family life and over time is likely to bring about significant consequences for the
family. Themes explored in this article include the impact of maternal chronic pain separately
on the individual and her children, perpetuation of chronic pain by the family, resultant
developmental difficulties in children and the advantages of family therapy modalities and
other interventions in managing the impact of maternal chronic pain.
There is limited research which examines the impact of maternal chronic pain on childhood
development and on the possible interventions to prevent the effects on children and the
development of negative schema in later life. A scoping review with a broad collection of
literature and thematic analysis is performed to understand the complexities of the
relationship between maternal suffering due to chronic pain and childhood behavioural and
emotional development.
5
List of abbreviations
COVID-19: Coronavirus disease 2019.
MUP: Medically unexplained pain.
PICO: Patient/population, intervention, comparison, outcomes.
PEO: Population/patient/problem, exposure, outcomes.
HSE: Health service executive.
WHO: World health organisation.
PROSPERO: International prospective register of systematic reviews.
PRISMA-scr: Preferred reporting items for systematic reviews and meta-analysis.
6
Definitions and terms
Chronic pain: Pain with no clear underlying cause or pain that is out of proportion to any
observable injury or disease. It is pain which lasts or reoccurs for longer than six months
(NICE) (Katz J et al, 2015).
Authoritarian parenting: Involves a one-way style of communication, strict rules, high
expectations with little to no negotiation or flexibility.
(https://www.ncbi.nlm.nih.gov/books/NBK568743/)
Somatic pain: Pain that arises from any of the tissues of the body. (Encyclopaedia of pain,
2007).
Non-somatic pain: Suffering is intimately linked to the experience of illness (Daneault S et al,
2022).
Nuclear family: A couple and their dependant children, regarded as a basic social unit
(Oxford dictionary, 2023).
Attachment: Attachment is one specific and circumscribed aspect of the relationship between a
child and caregiver that is involved with making the child safe, secure and protected (Benoit D,
2004).
Matriarchal role: A matriarchal society, family, or system is one in which the rulers are female and
power or property is passed from mother to daughter (Collins dictionary, 2023).
Anxious-avoidant attachment style: form of insecure attachment in which an infant
explores only minimally and tends to avoid or be indifferent to the parent. (APA dictionary
of psychology, 2023).
Trans-generational: Characteristics which are passed on between generations with no direct
genetic basis for same. (collinsdictionary.com)
Sick/illness role: Role created with social expectations, tends to be exempt from normal
social roles and responsibilities. Expectations tend to affect how the affected person
behaves and how others react to the individual (Oxfordreference.com).
Parentified: children take on the roles and responsibilities for looking after a parent or other
family members, this tends to be at their expense from a developmental point of view.
(sciencedirect.com/topics/psychology/parentification)
Schemas: An individual’s assumptions or beliefs about themselves, others and their world
which does not tend to fully fit with reality, normally formed in childhood and can be
related to traumatic experiences. (dictionary.apa.org)
Maladaptive schemas: Themes or patterns of beliefs which include emotions, cognitions,
sensations related to self or others, tend to form in childhood or adolescence, be pervasive
throughout life and are dysfunctional.
7
(https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-020-0392y#:~:text=A%20construct%20related%20to%20personality,developed%20during%20childho
od%20or%20adolescence%2C)
Qualitative methods: Such research methods explore and gain insight into created
hypothesis to answer a research question. It involves the collection and/or interpretation of
experiences and perspectives. https://www.ncbi.nlm.nih.gov/books/NBK470395/
Thematic analysis: means to analyse qualitative data and explore commonalities and
meaning within qualitative research.
https://link.springer.com/referenceworkentry/10.1007/978-94-007-0753-5_3470
Systematic review: Research design which uses a particular process and template for
gathering and processing information which can be used to make recommendations. It
involves a structured review of academic papers. https://libguides.rcsi.ie/systematicreviews
Scoping review: involves a preliminary exploration of available studies and research. It is
useful to identify gaps in research, research of complex and heterogenous nature and to
map the themes and details of existing research.
https://touromed.libguides.com/c.php?g=927240&p=6680715
8
Table of Contents
1. AUTHOR’S DECLARATION………………………………………………………………………………………………
2.
3.
4.
5.
6.
7.
ACKNOWLEDGEMENTS………………………………………………………………………………………………..
ABSTRACT………………………………………………………………………………………………………………………….
LIST OF ABBREVIATIONS…………………………………………………………………………………………………….
DEFINITIONS AND TERMS………………………………………………………………………………………………………
TABLE OF CONTENTS………………………………………………………………………………………………………
SECTION 1: LITERATURE REVIEW
1.0 Introduction and hypothesis………………………………………………………………………..
1.1 Rationale for Proposed Research……………………………………………………………………
1.2 Chronic pain……………………………………………………………………………………………………
1.3 Somatic and non-somatic pain……………………………………………………………………….
1.4 The effects of pain…………………………………………………………………………………………
1.5 Pre-morbid factors predisposing chronic pain…………………………………………………
1.6 How pain effects others and familial relationships…………………………………………
1.7 The trans-generational effects of chronic pain and coping……………………………….
1.8 The nuclear family………………………………………………………………………………………….
1.9 Attachment theory……………………………………………………………………………………..
1.10 Maslow’s hierarchy of needs………………………………………………………………………….
1.11 Schema formation………………………………………………………………………………………..
1.12 Aims……………………………………….…………………………………………………………………..…
1.13 Objectives……………………………………..……………………………………………………………..
8. SECTION 2: METHODOLOGY AND DESIGN
2.0 Introduction……………………………………………………………………………………………………..
2.1 Research Methodology…………………………………………………………………………………….
2.2 Design/Methods…………..…………………………………………………………………………………
2.3 Search Method…………………………………………………………………………..…………………….
2.4 Search criteria…………………………………………………………………………………………………………
2.5 Qualitative review…………………………………………………………………………………………….
2.6 Thematic analysis…..……………………………………………………………………………….
9
2.7 Rigor and trustworthiness……………………………………………………………………………...................
2.8 Ethical considerations………………………………………………………………………………………………….
2.9 Budget……………………………………………………………………………………………………………….
9. SECTION 3: RESULTS
3.0 Summary of emerging themes and subthemes………………………………………………………………
……………………………………………………………………………………………………………….
3.2 Theme 1
3.3 Theme 2
3.4 Theme 3
3.5 Theme 4…………………………………………………………………………………………………………………………..
3.6 Table 1.
10. SECTION 4: DISCUSSION
4.0 Factors affecting maternal chronic pain…………………………………………………………………….
4.1 Factors affecting children…………………………………………………………………………………………
4.2 Interactions with children……………………………………………………………………………………..
4.3 Role reversal of children………………………………………………………………………………………..
4.4 Age and sex differences………………………………………………………………………………………
4.5 Spousal relationship………………………………………………………………………………………………
4.6 Outcomes for the child…………………………………………………………………………………………
4.7 The role of family therapy…………………………………………………………………………………
4.8 The benefits of family therapy in the somatising family……………………………………..
4.9 Restructuring roles and communication……………………………………………………………
4.10 Exploration and analysis of main themes……………………………………………………….
4.11 Future directions…………………………………………………………………………………………….
4.12 Limitations……………………………………………………………………………………………………..
4.13 Conclusion……………………………………………………………………………………………………….
Demographics.
3.5 Sex differences in response to maternal chronic pain.
3.6 Age variations in response to maternal chronic pain.
11. SECTION 5: REFERENCES ……………………………………………………………………………………………
12. SECTION 6: APPENDICES……………………………………………………………………………..…………….
10
LIST OF APPENDICES
11
SECTION 1
LITERATURE REVIEW
1.0 Introduction and hypothesis.
My research focused on questioning the relationship between chronic pain suffered by
mothers and the effects which this may have, positive or negative, upon children’s
development. It can be assumed that any difficulty which effects the primary caregiver is
going to have a significant impact upon her children, this relationship has been discussed in
many published books and articles. I have examined the relationship between pain suffered
by the mother and the effects on children’s rearing and growth more closely. I included
explorations which compare somatic and non-somatic pain effects, nuclear and single parent
families, pre-morbid stressors, determinants and demographics which result in positive or
negative effects on children including ages, sex of children and access to other supports. I
hypothesized that the potential impact on maternal functioning and roles due to the chronic
pain experience could affect their children’s development of self and self-esteem, their
attachment to their mother and to others, and their outlook of the world. This will have an
impact on relationships formed, neural development, and emotional capacity which can
culminate in mental health issues and adversity.
As part of this research I explored antecedents to chronic pain, the effects of pain on mothers,
resultant effects on interaction with children and most common outcomes for children.
1.1 Rationale for Proposed Research.
The impact of chronic pain on individuals is a popular topic for research which has been
covered by many neurology, anaesthetic and pain journals. Chronic pain has been proven to
affect more people than heart disease, cancer and diabetes combined (Umberger W, 2014).
Journals tend to discuss how chronic pain affects every part of functioning and the stress it
causes for the sufferer. However, there is little exploration, in the literature, of the impact a
mother’s chronic pain can have on her children. It can be surmised that a mother who suffers
from chronic pain must struggle physically, emotionally and cognitively to achieve daily tasks
but the care of young children must add further hardship which has been infrequently
12
highlighted in the literature to date. The effects that maternal pain have on the child’s
development must be significant and this research hopes to explore and understand this
relationship. Motherhood presents with many challenges and there is much more scope to
explore how specific conditions could effect caregiving and childhood development.
1.2 Chronic pain.
Chronic pain is defined as pain resulting from a non-life-threatening or non-acute causes that
persists for more than six months (Treede R.D et al, 2015) Unlike acute pain, which carries
survival value, chronic pain might be best considered as a chronic illness, with treatment and
psychological implications for both patients and their loved ones. It is estimated that twenty
percent of European adults suffer with chronic pain and that a large proportion of this figure
have children (Kaasboll J et al, 2018). The back is the commonest location impacted by chronic
pain which causes the largest disability (Evans S et al, 2007). This location for pain is
particularly associated with depression and anxiety in sufferers (Katz J et al, 2015).
Chronic pain can impact on a sufferer in many ways, it effects social and occupational
functioning, physical and mental health, relationships and roles within the family and within
society (Anno K et al, 2015). Such difficulties result in distress and a low frustration tolerance
while an individual can struggle to cope with additional demands or stressors. Distress is
believed to affect parenting related to increasing negativity and low responsiveness with
increased expressed frustration and hostility. A parent suffering with chronic pain in this way
is thought to display a tendency towards authoritarian parenting with less expressed affection
and support (Downey G et al, 1999). Chronic pain by it’s nature varies in daily severity
resulting in uncertainty of pain resolution, which tends to result in fluctuations in the quality
of parenting.
It is known that there is a higher likelihood of depression and anxiety in those with chronic
pain. Two percent of those with chronic pain suffer with co-existing depression (Evans S,
Shipton E.A and Keenan T.R, 2005). Research has shown that depression impacts upon
parenting negatively and expressed anger can be transmitted from parent to child (Downey
G et al, 1999).
13
Demographically it has been shown that seventy percent of those who experience chronic
pain are women, most of which fall within the 35-55 years age group (Palacios-Ceña, D et al,
2017). This highlights a significant gender difference in the formation of chronic pain, with a
clear preponderance of the female population who experience chronic pain being mothers
and females within their reproductive years. The prevalence is expected to increase related
to the current COVID-19 pandemic and the associated post-COVID symptoms, which is five
times more likely to effect women in their reproductive years (Taquet M et al, 2021). Mothers
maintain a caregiving role in today’s society, many children seek comfort and help from their
mother when needed and the mother maintains a central role within the family. This position
within the family and increased numbers of female sufferers of chronic pain have focused
research on examining the effects of maternal chronic pain on familial relationships and child
rearing.
1.3 Somatic and non-somatic pain.
Pain can be considered in terms of severity, length of suffering or source. It can also be divided
into somatic pain and medically unexplained pain (MUP) which considers pain to have a
psychological or emotional origin (Katz J et al, 2015). Although of different underlying cause,
there is much overlap between somatic and MUP when considering resultant biopsychosocial
impacts, symptoms and chronicity. Kowlowska K, 2009 describes the impact of pain on
attachment and relationships, this focus article does not distinguish between types of pain
and recognises that pain is the result of emotions. The protective instinct triggered by pain in
this regard results in a cognitive and emotional response from which the sufferer gains
information and seeks to regulate a protective mechanism. The communication of pain
especially MUP is designed to seek care and response from others in order to meet a need,
including emotional, comfort or protective needs (Kowlowska K, 2009). MUP is estimated to
cause increased dysfunction and mental suffering which can led to lifestyle and behavioural
changes when compared to chronic somatic pain (Husain M and Chalder T, 2021). In this
regard MUP is likely to have a greater impact on changes to the relationship between mother
and child. Somatisation of pain symptoms has been shown to be transmitted from parent to
child related to attachment strategies, modelling and poor tolerance of stressors with a
limited capacity for recovery (Craig T.K.J et al, 2002).
14
1.4 The effects of pain.
The effects of chronic pain on mothers are far reaching in terms of the social, functional and
financial impact over time. It is surmised that the effects of uncertainty, regarding longevity
of pain and future functioning, form emotions of fear and dread in sufferers (Duryea M.M,
2008). Individuals develop responses and coping mechanisms to deal with pain which become
more cemented over time (Kowlowska K, 2009). These responses serve a function in that such
behaviour can protect or gain help when needed, this is a necessary part of evolution. Such
mechanisms which involve inherited, biological, emotional and learned responses to pain can
become the norm and reinforce patterns of coping in chronic pain. Physical avoidance can
result in weakness and further pain, emotional expression or inhibition can result in strained
relationships and resentment (Rikard K, 1988).
Chronic pain and it’s associated anxiety in this way can become an all consuming cycle
involving anxiety, avoidance and depression (Holmes H.A and Deb P, 2003) (Umberger W,
2014). It is estimated that fifty percent of chronic pain sufferers experience depression and
anxiety as a consequence (Bushnell M.C et al, 2016). Long term pain is known to cause
cognitive changes involving white and grey brain matter and epigenetic changes (Bushnell
M.C et al, 2016). Studies involving rat models have demonstrated that brain changes seen on
MRI are improved if exercise is employed and social connections are encouraged (Bushnell
M.C et al, 2016).
Although the roles of women and mothers’ have changed over time to allow more variation
and flexibility, the maternal role remains central and important within the family. Children
continue to look to their care givers for cues and to learn regulation (Kowlowska K, 2009).
While influenced by development and age, children respond and learn from the environment
which their care givers create and this contributes to their interpretations of safety, care and
appropriateness within the world. At certain stages children learn patterns of response to
their communications for care or protection. Children also model their parents behaviours
and research has shown a link between maternal chronic pain and the expression of pain in
children (Kaasboll J et al, 2018) (Rikard K, 1988).
Despite the clear connection between chronic pain, lack of functioning and mental health,
research has explored the link between preceding stressors and the ability to cope with later
15
pain development (Addison R.G, 1981). Preceding factors such as personality, transgenerational attachment patterns and life events are believed to function in how we respond
to pain (Agostini A et al, 2010). Maternal responses to pain and the effects of dependency or
emotional expression on familial relationships perpetuates development of internalizing or
externalizing behaviours in children. This relationship does not tend to be unidirectional and
effects on children will impact upon maternal coping and future generations (Agostini A et al,
2010) (Kaasboll J et al, 2018).
1.5 Pre-morbid factors predisposing chronic pain.
Chronic pain affects the functioning of sufferers related to the interaction of physical,
emotional and environmental factors. These contributary factors form long term
complication with the processing of pain signals, management of stress and distribution of
energy. There are certain pre-disposing factors which can impact upon the experience and
development of chronic pain. Such factors include emotional resources, patterns of behaviour
and coping and temperament (Umberger W et al, 2013). Previous experiences of pain,
maladaptive coping related to pain and somatisation can prime the nervous system toward
hypersensitive pain responses (Tanguay-Sabourin C et al, 2023). Interestingly, literature has
reported that those with particular demographics are more likely to suffer from chronic pain.
Such non-modifiable factors include a higher prevalence of chronic pain in females, nonCaucasian groups, those with low income and low educational achievement (Mills S.E.E et al,
2019).
There is a genetic link to the inheritance of a tendency towards chronic pain, pain sensitivity
and responses can be associated with particular genes and inheritance patterns (Mills S.E.E. et
al, 2019). Finally, it is understandable that psychological trauma can also influence the
development of chronic pain. This is believed to be caused by dysfunction of the HPA axis and
the production of cortisol. The stress response involving cortisol production results in hypersensitive stress reactions and responses to pain (Mills S.E.E et al, 2019).
16
1.6 How pain effects others and familial relationships.
The need to study the family in understanding patients with chronic pain was succinctly
explained in an early article published by Livsey in 1972, who said that ‘the drive of individuals
to relate intimately is crucial in human nature. Since the family is the universal institution
where basic relationships exist; investigators should explore the intrafamilial environment to
better understand symptoms that may result from or be exacerbated by disturbed familial
relationships’ (Livsey C.G, 1972). This statement appears particularly pertinent in cases of
maternal chronic pain, where maintaining a matriarchal role in the family and managing a
chronic illness can inevitably pose challenges for both patients and their loved ones. Although
illness in either parent can affect childhood, stressful coping patterns of mothers has a higher
connection to negative effects on children than fathers recorded stress or difficulty (Benzes
K.M, 2001).
The stressors endured by the sufferer are inevitably distributed to other family members;
children often being the most vulnerable when witnessing maternal distress and suffering
(Roy R, 1985). It has been suggested that limited maternal physical functioning can be
associated with over-reactive behaviour which correlates with poorer child adjustment and
an ‘anxious avoidant’ attachment style (Silwerski A et al, 2020). This is perpetuated by a lack
of parental control and support which can occur within the family system in cases of chronic
pain (Kumpfer K.L, 2003). Parental hospitalizations and withdrawal may compromise the
development of healthy attachment relationships and potentially lead to comprised
attachment security in the child (Evans S et al, 2007). Downey G et al, 1999 linked maternal
chronic pain experiences to mother’s distress and to children’s distress, maternal distress to
negative parenting practices, and negative parenting to children feeling a need to manage the
distress of their mother. Children not only model their parents behaviour and coping but are
sensitive to stress within their family system and can absorb or try to compensate for this
stress themselves.
17
1.7 The trans-generational effects of chronic pain and coping.
Interestingly, the ability of an individual to cope with chronic pain is dependant on the
previous coping styles of their parents and their own parental attachment pattern (Addison
R.G, 1981) (Agostini A et al, 2010). Illness will often stress previous negative maladaptive
schemas and attachment patterns. The importance of this stress is due to the far-reaching
effects chronic pain can have on the upbringing and development of children (Hirsch B.J et al,
1985). Mothers, in particular, have a recognised role as warm and supportive carers who
allow safe exploration and learning environments within early childhood for their children.
The literature has connected the chronicity of pain in mothers as resulting in inconsistent
emotional support for children and an inability to attend to all of childhoods demands (Banks
P et al, 2002) (Armsden G.C et al, 1993).
Narratives and belief systems are passed between parent and child and subsequently to the
next generation (Harrison D.J, 2017) (Sójta K and Strzelecki D, 2023). Families often continue
the particular roles and habits which are familiar and comfortable. It is not often that such
narratives or schemas are challenged and many families may not be aware of such patterns
of coping (Wasson S, 2018). As children we learn from and model our parents and develop
our expectations of others around this experience (Beveridge J.K et al, 2018) (Brown D et al,
2021). In this way mechanisms for coping with pain or illness can be passed on and become
established within a family’s history.
1.8 The nuclear family.
The nuclear family is a societal construct of the ideal family, including a father, mother and
children. In todays society, this familial unit is what most people think of when considering
family, schools and institutions often assume the existence of this family set up (Zimmerman
C.C, 1972). Despite our familiarity with this form of family, there is increasingly a move
towards alternative families (Zimmerman C.C, 1972). Families can now include other
members, can have parents of the same sex, one parent systems, or not include children.
Although the Western world can appreciate increasingly diverse forms of family which are
successful and fulfilled units, it remains the case that women continue to engage in the
majority of childrearing duties (Sear R, 2021). Research on adolescents have demonstrated
that children learn many of their social cues from their mothers and rely on the mothers for
18
comfort and advice (Duryea M.M, 2008) (Perdue B.J, 1993). Mothers have proven that they
can balance and excel at being the primary child rearer and work outside the home. As long
as the family unit is flexible and children feel wanted, valued and loved, children will grow
holistically and successfully (Sear R, 2021). The literature indicates that fathers who take on
the caring role within families can compensate for the effects of maternal chronic pain on
children (Kaasboll J et al, 2018).
1.9 Systems theory.
Researchers have examined the effects of chronic pain upon the family and discovered that
members of a family can, unconsciously, maintain a sufferers chronic pain as it serves a
function of benefit to other members of the family (Lewandowski W et al, 2007). The longevity
of chronic pain can mean that the family exist in a familiar balance which they have adapted
to despite its consequences not being helpful to the family system. Conflict can go unresolved
and unrecognised, roles can become entrenched and resolving the behavioural difficulties of
children can become the families focus. Members of the family can support the role of the
sufferer in the family as a means for subsystems to reunite or to avoid conflict or undesirable
roles within another subsystem (Lewandowski W et al, 2007).
1.10
Structural theory.
This theory examines family functioning and roles, any change that occurs within a family
requires the family to reorganise their structure into another working form (James K and
MacKinnon L, 1986). Each family member comprises a role within the family and each
member and their role affects the family. If a family member’s role changes or deteriorates
this result in instability in the family system which can only be resolved by successful
reorganisation. Members of a family who disengage from their role can cause boundaries
between subsystems to become too rigid with the result of distance within relationships and
too much responsibility or autonomy for children (James K and MacKinnon L, 1986). Although
the family contains subsystems, conflict in one subsystem will impact on the entire family and
how it functions.
Chronic pain and the familial reaction to it can potentially result in maternal disengagement
and rigid boundaries with children becoming parentified or coalition formation between
19
family members which can serve to enable help seeking behaviours and the sick role (Hadfield
K, 2000).
1.11
Attachment theory.
Attachment describes the emotional relationship between caregiver and child. If secure,
attachment allows the development of independence and knowledge while feeling safe and
secure (Romeo A et al, 2017). Attachment can be affected when a primary carer suffers from
chronic pain. Chronic pain results in anxiety and avoidance which can affect relationships with
children and result in insecure attachments (Evans S et al, 2007) (Romeo A et al, 2017).
Parents who are unresponsive or inconsistent in their care of children can result in anxiousavoidant attachment patterns. Attachment forms the blueprint for how children see the
world and interpret relationships with others (Romeo A et al, 2017). Insecure attachment can
result in difficulties with self-esteem which can affect all future relationships in life and even
be passed on to the next generation.
Commonly in chronic pain the attachment pattern can change as the parent becomes less
attentive and less available to respond to children’s needs. Attachment which was previously
secure can become insecure or a pattern which was previously insecure can become more
consistent in terms of lacking reliability and responsiveness (Agostini A et al, 2010). The
Attachment Diathesis model of chronic pain by Meredith P et al, 2008, describes the bidirectional relationship between pain and attachment. Insecure attachment can influence
chronic pain which can likewise influence attachment patterns (Evans S et al, 2007). Insecurely
attached individuals have a higher pre-disposition towards depression, help seeking
behaviours and maladaptive coping mechanisms (Meredith P et al, 2008).
1.12
Maslow’s hierarchy of needs.
Maslow’s theory explores the needs of individuals and forms a hierarchical representation of
sequential needs (Rojas M et al, 2023). It proposes that baseline and urgent needs include
safety, nutrition and shelter, these needs form the base of the hierarchy suggesting that these
needs are all important. The top of the hierarchy covers love, belonging and self-esteem in
addition to self-actualization. Many researchers argue that this hierarchy is incorrect in its
20
under-estimation of the importance of family, parenting and relationships in development
(Rojas M et al, 2023). In other publications, it is advocated that each level of the hierarchy
should overlap as each influences the other and is necessary for sustainment and growth
(Kenrick D.T et al, 2010). In Kenrick’s updated model parenting holds a larger proportion of
the hierarchy while remaining at the top of the model. Attachment theory obviates the need
for attachment involving close communication between care giver and child in order for the
base needs in Maslow’s pyramid to be satisfied (Bowen B, 2021). In other words, attachment
and bonded relationships are as important as subsistence needs as the former allows
communication and access to the latter.
The importance of positive parenting and fulfilment of children’s physical and emotional
needs results in the superior development of intelligence, cognitive functioning and empathy
in children (Dykas M.J et al, 2011).
1.13
Schema formation.
Schemas describe our core beliefs which are formed in early childhood and are related to
upbringing and experiences learned through our relationship with our parents (Sójta K and
Strzelecki D, 2023). Such beliefs determine our world view and reactions to subsequent
challenges in life. If a child experiences early maladaptive schemas via insecure attachment,
unresponsive or rejecting parenting, there is a likelihood that the child will develop emotional
and behavioural difficulties which can later impact upon their functioning and mental health
(Sójta K and Strzelecki D, 2023). Early maladaptive schemas related to disconnection or
rejection which may occur in maternal chronic pain can led to feelings of instability, mistrust
of others, and feelings of vulnerability to illness (Sójta K and Strzelecki D, 2023). Children may
develop difficulties and insecurities with their own health and abilities to cope with stressors
in their environment. A mother’s illness schema is believed to be transferred to children
especially girls who can form their own illness schema (Sójta K and Strzelecki D, 2023).
Maladaptive schema are highly transferable and the more intense the schema the higher the
chance of inter-generational schema which are passed on to result in subsequent maternalchild dyad patterns (Sójta K and Strzelecki D, 2023).
21
1.14

The Aims of this Proposed Research
To explore the link between maternal chronic pain to behavioural or emotional
difficulties in children.

To explore children’s behavioural or emotional difficulties where mother has reported
chronic pain.
1.15

The Objectives of this Proposed Research
To perform an extensive review of the literature, using multiple databases, to explore
the relationship between maternal chronic pain and children’s emotional and
behavioural development.

To utilise tools such as the Rayyan programme to select the most relevant articles on
the relationship between maternal chronic pain and children’s emotional and
behavioural development.

To perform a thematic analysis of the common themes/pathways which become
evident during the formation of the scoping review.

To factor in heterogeneity between studies used in scoping review.
22
SECTION 2
METHODOLOGY
2.0 Introduction.
This research study explores the relationship between maternal chronic pain and the
development of emotional and behavioural difficulties in children. Developmental issues in
children includes a broad range of delays to progress across domains such as physical growth,
emotional maturity, cognitive skills and behavioural management. Such delays in
development have many causes and moderating factors which have been widely researched
and recorded. Exploration of how maternal caregiving can be impacted by chronic pain and
its effect on children’s emotional capability and coping has been limited to date and scoping
review has been lacking. This research employs qualitative methods of research in terms of
searching the literature and relevant publications. Qualitative methods allow the best
exploration of how the maternal experience impacts on childhood development.
Review of the literature forms the basis for this scoping review. The literature includes journal
articles, book content, government proposals/guidelines and grey literature. Exploration of
content, other than that which is published in peer reviewed journals, is utilised in order to
gain an expansive and thorough review of all possible sources of information. Despite a wide
and inclusive search of content, information used is reliable, as is possible, by the avoidance
of newspaper or magazine articles, online blog content and articles from nongovernment/official websites. This extensive review of the literature forms the background
information in understanding the effects of maternal chronic pain on children. Relevant
content was gathered, interpreted and presented via thematic analysis of the qualitative
information collected. This work provides an overview of the relevant literature allowing
critical analysis and organisation of important qualitative information from several different
sources and viewpoints in a variety of recognised published sources.
23
2.1 Research methodology.
Scoping reviews developed from the popularity of systematic reviews as a research method
(Munn Z et al, 2018). Systematic reviews afforded a comprehensive and reliable means of
searching for information and exploring topics of interest. Scoping reviews are similar in that
set criteria are used to search the literature and its methods are extensive and strict. Scoping
review is desirable when there are limited publications within the tighter acceptance criteria
of systematic reviews and when the research objectives may change over the course of the
literature review (Munn Z et al, 2018) (Gutierrez-Bucheli L et al, 2022). Scoping review is
more convenient when evidence is unclear or continues to emerge, it creates a map or a
summary of current knowledge. Scoping review can proceed a systematic review which can
then identify relationships or causation more closely. Scoping review is better indicated if the
research question is less direct or precise and there is an unknown connection between
concepts (Munn Z et al, 2018). An exploration of the limitations or bias in a scoping review is
not always required however any difficulties that arise within the research process will be
discussed. Two reviewers or screeners are used in the review of the collected literature to
ensure less error and bias. PRISMA-scr outlines the steps in performance of a scoping review
(Peters M.D.J et al, 2021). See Appendix A.
The scoping review of the literature began with an understanding of how chronic pain can
affect, the person who is often the primary caregiver within the family unit, the mother. The
many widespread effects of chronic pain on adults, including how it impairs functioning in
several areas of life, is outlined with a focus on how this can impact the mental health and
emotional resources of the mother. Following this exploration of the relationship between
the matriarch and her response to chronic pain, the impact of the effects of maternal chronic
pain on children is interpreted from the available literature.
2.2 Design method.
The research question and search criteria were formed using the PICO tool of population,
intervention, comparison and outcome. This was adapted to form the more appropriate PEO
24
tool including population, exposure and outcome. The PEO tool was more fitting for the
search question. See Appendix B. Measures used in searching and selecting the literature
included study name, year, author, design (qualitative), definitions used, inclusion and
exclusion criteria, abstract. Mendeley programme was used to save and export articles
following the searching of databases. Articles to be screened were exported into the
programme Rayyan and Rayyan was used to select and deselect articles. Articles were initially
screened by title and abstract by a team of three screeners. Articles which were chosen to be
included were read in full as the next step in the screening process. Articles which were
included under the maybe section of the screening process were also read in full in order to
include or exclude these articles. The screeners were able to resolve any disagreements which
presented in the selection of articles. This screening process took place from May 2022 to
September 2022. See Appendix C.
Other searches of the grey literature were undertaken during the searching and screening
process. The search of grey literature included the use of search engines and databases google
scholar, World Cat, HSE website, WHO website, PROSPERO and opengrey.eu. In addition,
reference checking of the reference list of relevant articles and hand searching was
completed. Searching of grey literature was undertaken up until October 2023 to facilitate up
to date literature inclusion.
2.3 Search Method.
Combination of search expressions including ‘chronic pain’, ‘maternal’, ‘children’s mental
disorders’, ‘children’s emotional disorders’ ‘exposure’. Sample- ‘’maternal chronic pain’’ OR
‘’maternal pain’’ OR ‘’mother’s chronic pain’’ OR ‘’mother’s pain’’.
The final search keywords and terms evolved, as follows,
SI
(MH ("Mother+" OR "Maternal Exposure" OR "Parent+" OR “Family+”) OR TI (mother* OR
maternal OR parent* OR family*) OR AB ( mother* OR maternal OR parent* OR family*)) N5
(( (TI ( chronic* OR constant* OR persistent OR long standing OR long-term OR long lasting)
OR AB ( chronic* OR constant* OR persistent OR long standing OR long-term OR long
lasting))N3(TI ( pain OR illness OR "ill-health" OR "ill health" OR affliction OR discomfort ) OR
25
AB ( pain OR illness OR "ill-health" OR "ill health" OR affliction OR discomfort )) OR MH (
"chronic pain" OR "chronic illness" ) OR MM "Chronic Pain")
S2
TI ( "mental health" OR well-being OR wellbeing OR welfare OR "emotional functioning" OR
emotion* OR "affective disorder" OR "affective difficult*" OR “behavioural functioning” OR
behaviour* OR development OR psychopathology OR bonding OR relationship OR adjustment
) OR AB ( "mental health" OR well-being OR wellbeing OR welfare OR "emotional functioning"
OR emotion* OR "affective disorder" OR "affective difficult*" OR “behavioural functioning”
OR behaviour* OR development OR psychopathology OR bonding OR relationship OR
adjustment ) OR MH ("Mental Health" OR "Affective Disorders+" OR "Adolescent Health" OR
"Child Behaviour Disorders" OR "Adjustment Disorders+" OR "Social Adjustment" OR
"Psychological Well-Being")
S3
TI ( child* OR children* OR teen* OR adolescent* OR offspring OR infant OR toddler OR
daughter* OR son* OR "pre-schooler" OR youth OR boy* OR girl* ) OR AB (child* OR children*
OR teen* OR adolescent* OR offspring OR infant OR toddler OR daughter* OR son* OR preschooler OR youth OR boy* OR girl* ) OR (MH "Child+" OR “children+” OR "Adolescence+" OR
"Infant+" OR "Daughters" OR "Sons" )
The search terms as combinations of S1, S2 and S3 were copied directly into each database
or search engine during the search of the literature. As part of quality assessment of the
literature the PRISMA tool for relevant content and methodology was used in each of the
papers to be reviewed. For article extraction, Endnote has been used to keep track of
references.
2.4 Search Criteria
An extensive search of the literature has been undertaken using search engines and databases
Pubmed, CINAHL, EMBASE, Cochrane database of systematic reviews, MEDLINE, PsychI,
research gate, World cat, world of science. Preliminary searches, using basic terms such as
‘maternal chronic pain’ AND ‘children’s development’ OR ‘children’s wellbeing’, were
undertaken prior to a formal search of the literature using pubmed and google scholar search
engines to guide the depth of further searches needed. This preliminary search took place in
November 2021. This initial search of the literature allowed development of detailed key
words and terms, search criteria and the exploration of more databases over time. The
detailed database search was undertaken from January 2022 to May 2022 and was aided by
a qualified librarian in database searching and literature review, Liis Cotter, Cork University
hospital.
26
2.5 Qualitative review.
Qualitative methods in research is used when the purpose of the research is to explore
relationships in terms of context, nature, causes, effects and perspectives (Busetto L et al,
2020). The relationships are described, explored and are not numerical which is more
appropriate to quantitative research. Qualitative research aims to explore reasons for
relationships and situations. Such techniques allow more flexibility as researchers can explore
topics and data in a less linear fashion as would be necessary in quantitative methods (Busetto
L et al, 2020).
The methodology used in this research involves a scoping review which gathers current
published evidence related to the research question and research criteria. The sources of
literature gathered and used within the scoping review are mostly qualitative in nature and
each source used involves qualitative techniques including interviews, summary of
experiences, focus groups and questionnaires. Therefore qualitative literature is used in the
scoping review method which in itself cannot be defined as a qualitative technique.
2.6 Rigour and Trustworthiness.
Each source of information used in the scoping review was screened for their individual rigor
prior to inclusion. The criteria used for assessing the rigor of qualitative research include
credibility, dependability, confirmability, and transferability (Forero R et al, 2018). This
ensured the robustness of information gathered and included. The planning and methodology
stages of this research ensured that the criteria was broadly followed including the search
criteria, key word/term searches, databases utilised, use of independent screeners and
PRISMA-scr protocol.
2.7 Narrative synthesis.
A thematic analysis presents particular patterns or themes which become evident during
the literature review. Any modifying factors in connecting maternal chronic pain to
difficulties in the emotional and behavioural development of children are discussed and
heterogeneity within the content collected as part of the discussion of the review.
27
The reflexive method of thematic analysis was utilised to identify the common relevant
themes and patterns. The reflexive method allows for author subjectivity which aids in
the creation of themes while considering the context important to particular texts (Joy E
et al, 2023). This method is beneficial for this qualitative research as it allows
interpretation of patterns and relationships between themes while allowing a robust
scientific method. See Appendix D.
1. Familiarising yourself with the dataset, or developing a theory of the relationship and why.
2. Coding, involves developing a preliminary synthesis of findings of included
studies.
3. Generating initial themes.
4. Developing and reviewing themes and relationships.
5. Refining, defining and naming themes.
6. Writing Up.
The preliminary synthesis involved examination of demographics, methods used, outcomes
and summary of main study findings.
Two independent reviewers categorised themes and any uncertainties were resolved by
discussion amongst the reviewers.
Narratives or themes were included if they were repetitive or reoccurring in nature between
sources used and if a pattern of similarities is noticed when examining the literature. Any
unusual or interesting themes that are not shared between sources of literature used were
considered for inclusion in the narrative synthesis. A thematic map has been created which
illustrates main themes, subthemes and relationships between same (see Appendix ).
Each theme was examined in detail using Braun and Clarke’s method (see Appendix D) (Byrne
D, 2022).

Is this a theme?

If it is a theme, what is the quality of this theme (does it tell me something useful?)

What are the boundaries of this theme (what does it include and exclude?)

Is there enough data or information to support this theme (is the theme thin or
thick?)

Are the data too diverse and wide ranging (does the theme lack coherence)?
28
2.8 Ethical Issues.
There were no human and animal participants in this research project. This research involves
collection, summarisation and interpretation of published literature only which is available
on several online databases. As no persons or animals were included and this research did
not involve any intervention, there was no requirement for application to ethics committee
or the achievement of ethical approval.
I ensured that the works of other researchers used in the formation of this scoping review
were respected and that plagiarism in no form occurred in the creation of this review. The
rules of academic writing were observed within this research and within any published report
which may result from this research.
2.10 Budget.
There were no costs necessary within this research study. The resources used such as
databases were sourced for free from the HSE library, end note was sourced as a free trial,
Mendeley and Rayyan were free online programmes. The use of time and effort involved in
this research project were volunteered for free by those involved. Any publication costs which
may or may not arise in future will be borne by myself, the researcher at my own expense.
29
SECTION 3: RESULTS
3.1 Included studies.
The purpose of this review was to explore the relationship between maternal chronic pain
and the development of emotional and behavioural difficulties in children. The hypothesised
relationship is summarised as follows,
Pre-morbid
preceding factors
Maternal
chronic
pain
Interaction with
children/bonding
Outcomes for
child
The findings of literature review allowed the confirmation of the above relationships however
there were mediating factors which needed further exploration. These mediating factors
could be preceding maternal chronic pain, precipitating factors once chronic pain has
developed or following difficulties in the relationship with her children. Such factors could be
positive or negative in terms of their influence on the relationship between maternal chronic
pain and parenting difficulties, between parenting difficulties and relationship challenges,
relationship challenges and the development of emotional and behavioural difficulties in
children.
At the beginning of data collection, 4867 articles, reports or chapters from database searches
and 8323 articles, reports or chapters from search of the grey literature and bibliography
searches were identified. The screening process using PRISMA-scr guidance, inclusion criteria
and exclusion criteria resulted in 104 articles, reports or chapters being included in the final
research and being examined utilising the research question and aims for relevant
information. 71 of these samples were included in the final reference list for this report.
30
OO
Of all research screened within the review process, 4350 were journal articles, 304 were
thesis, 188 were book chapters, 21 were books, 1 was included in a conference review and 1
was a case report. There were a variety of languages recorded in published articles screened,
567 in English, 10 in German, 6 in French, 4 in Spanish, 2 in Turkish, 2 in Polish and 1 in Dutch.
3.2 Study’s characteristics.
There were twenty-two studies included in data synthesis, the characteristics, strengths and
limitations of these studies were examined (see table 2, appendix F). These studies formed
part of the bibliography and were included in deeper analysis as they proved to be more
relevant to the research questions or aims, were of higher quality, or gave more information
or unique perspectives which contributed to the formation of themes for this study. Overall,
most studies included were systematic, cyclical and analytical within a qualitative framework.
Each study proved to be purposive and had primacy. Each study answered its aims and
31
research question. There was some repetition of information and findings were similar to the
hypothesis of this study and although there were few new insights in the works included, the
findings added strength to the themes and conclusions of this scoping review. Each work was
easily replicable related to the methods used in qualitative work including questionnaires,
interviews, survey and literature review.
Some studies included, although relevant to individual themes or related to the aims of this
scoping review, did not directly fit with the research question of this scoping review. Agostini
A et al, 2010, Perdue B.J et al, 1993 and Turner Cobb J.H et al, 1998, questioned the effects of
chronic illness or arthritis on children and parenting which did not directly fit with the
research question for this review, however these studies offered insights and information
which justified their inclusion. Research by Bees F, 1994, Chun O.Y, 1993, Downey G et al,
1999, Higgins K.S et al, 2015, Rikard K, 1998 and the studies included from the work of Evans
S et al, Kaasboll J et al and Umberger W et al proved to be highly relevant and well written
pieces of research.
The populations used in each study comprised mothers or both parents, children and the
study by Evans S et al, 2007 included teachers. Most sources used a generalizable population
including Bees F 1994, Evans S et al 2008, Hirsch B.J et al 1985 and Turner Cobb J.M et al 1998.
This variation of demographics and ages within the population allowed more generalizability
where information can be thought to refer to the normal population. The article by Bees F,
1994 refers to the recruitment of a population from a pain clinic which had the advantage of
being relevant and allowing the collection of more detailed information however this
population could not be thought to represent the normal population.
The articles included in this scoping review are varied in their strengths and limitations and
were utilised due to having a strength which contributed by adding unique information or
increasing the understanding of the causal link between maternal chronic pain and how it
effects children. Major limitations in many studies include the cross-sectional design of the
work which hindered the understanding of causal links or relationships, bias and some studies
had small sample sizes affecting the power of the research. Despite these weaknesses, studies
included by Chun D,Y et al 1993, Higgins K.S et al 2015, Kaasboll J et al 2012 and 2018 and
Turner Cobb J.M et al 1998 used statistical measures within their qualitative work which gave
more strength to their findings. Higgins K.S et al used a mixed methods approach and Turner
32
Cobb J.M et al 1998 measured cortisol levels at intervals to represent stress within the
maternal-child relationship. Some studies considered and adjusted for mediating or
modifying factors (see table 1, appendix F).
There is some heterogeneity evident between the studies used in this review. For the most
part there is variability between participants in the studies termed clinical heterogeneity.
Participants included mothers of varying ages, numbers of children, varying severity of pain
and disability. Some participants were selected from a cohort of known sufferers of chronic
pain while others from the general population. In some studies children participated however
children were of varying ages and developmental stages, some studies only included
adolescents. Families and subjects included also tended to vary in social supports, socioeconomic circumstances and there was also variation in mental health of mothers which
tended to be a modifying factor for outcomes.
Data synthesis also revealed the likelihood of methodological heterogeneity as there was a
tendency towards bias in some works included in this review. Reporting bias was a limitation
in Turner Cobb J.M et al 1998, Perdue B.J et al 1993 and Umberger W et al 2013 studies.
Perdue B.J et al also discussed recall bias along with articles by Agostini A et al 2010 and Anno
K et al 2015. Sampling bias was determined to be a difficulty in Bees F 1994, Chun D.Y et al
1993 and Evans S et al’s research in 2005 and 2007. Finally, Kaasboll J et al discussed risk of
information bias in their 2018 study and non-responder bias in their 2012 research. Only one
study proved to be longitudinal carried out over six months, as a result it is difficult to
determine causal links with any certainty.
Despite concerns regarding heterogeneity, many studies concluded that there is a
relationship between maternal chronic pain and emotional and behavioural difficulties in
children. The studies that considered modifying and contributing factors and collected the
perspectives of mothers and children via interview afforded strength and robustness to the
hypothesis and subject matter discussed in this review.
3.3 Summary of emerging themes and subthemes.
I have chosen to use a reflexive method for narrative thematic analysis which follows a
framework of Braun and Clarke, 2013. This framework allows a structured and distinct
approach to be utilised in thematic analysis (Maguire M and Delahunt B, 2017). Important
33
stages in this six step guide involves understanding, describing and interpreting the themes
created, rather than conducting a simple summary of the content. There are two approaches
to identifying themes in qualitative data, latent analysis involves interpretation of underlying
meaning and assumptions within themes and semantic analysis interprets explicit meanings
within themes (Maguire M and Delahunt B, 2017). Within this analysis, I have explored both
approaches where possible and have adopted theoretical and inductive reasoning to explore
themes. I have used open coding to develop my chosen themes.
The themes below have been selected following data synthesis and coding, each theme was
selected as it was a common finding across the literature, or gave a unique or interesting
perspective on the research topic. Many themes below are related or overlapping in some
information, see thematic analysis map in appendix . Theme number 2 is broad and contains
a range of presentations/symptoms. It could be argued that this theme is boundaryless and
too diverse however considering its importance to the research question and hypothesis, it
required inclusion. Theme number 2 is broken down into more coherent subthemes. An
interesting subtheme within theme 2 is the variations with age and sex that affects children’s
presentation with emotional and behavioural difficulties. This gives an informative insight into
variations with development however there was not enough information to create a separate
theme for this topic. Theme numbers 1 and 2 below seem to be intuitive when considering
this research however discussion will conclude that both themes and information collected
are relevant and support this research hypothesis. Themes numbers three to six give deeper
insights into the effects of maternal chronic pain on children and the family overall. See
appendix G for a summary of themes, codes and subthemes.
3.4 Theme 1: Changes to parenting and attachment issues in response to chronic pain.
Kowlowska K et al, 2009 outlines attachment theory and focuses on how attachment can be
affected by pain. This work highlights certain patterns termed A1, A2, A3 and A4 associated
with anxious-avoidant attachment. A1 and A2 attachment styles are seen when a parent is
distant and unresponsive to children at times while coping with the physical and emotional
difficulties related to pain. In A3 styles there may be a withdrawal by the parent when a child
is distressed. A4 attachment includes maternal responses which are angry or critical. Type A
attachment pattern tends to result in a tendency for children to aim to please others and gain
their approval. Children may learn to inhibit their pain signals and distress or may learn that
34
the only language that they can use with parents to gain their attention involves physical pain
while emotional distress is not acceptable. If parents responses to children are more severe
and unpredictable, a C attachment style pattern can develop which can result in a range of
threatening, aggressive or punitive behaviours (Kowlowska K et al, 2009) (Benzes K.M et al,
2004) (Umberger W et al, 2014). Agostini A et al, 2010 and Evans S et al, 2007) support the
relationship between parenting changes and attachment difficulties in parents with chronic
pain and it’s negative effects on children. Children reported feeling poor self-esteem related
to their experiences of parental chronic illness in Agostini’s study also supported by Zelkowitz
P et al, 2013. Although interesting this research focused on symptoms of Crohn’s disease,
which can include pain however it’s findings were non-specific with no account of modifiers
and contributing factors.
Mothers who suffer with chronic pain are described as suffering from symptoms of low mood
and depression across the literature which in combination with other mediators is believed
to have a consequent effect on their functioning, coping and parenting (Anno K et al, 2015)
(Kaasboll J et al, 2018) (Zelkowitz P et al, 2013). Much research has found that depression and
it’s effects are an important link between chronic pain and the resultant impact on children
(Umberger W et al, 2014). Depression leads to financial and social changes which tends to
reinforce parental frustration, distress and fear which sensitive children will observe (Anno K
et al, 2015). Mothers have reported feeling guilt and loss of confidence in their parenting
related to their experiences with pain (Duryea M.M, 2008).
An interesting outcome on exploration of this theme was discussed by Agostini A et al, 2010,
attachment was found to have a bidirectional effect in relation to chronic illness. Illness can
affect attachment style through affecting coping and mood, and attachment can affect illness
and cause further ill health. Likewise, parental chronic pain and illness can affect childhood
experiences and development through parenting practices and the latter can affect and
worsen pain and illness. Parents and children can be affected by anxiety and depression in
parental chronic pain which can in turn result in a higher susceptibility to poor coping and
responses to pain in both parties (Brown D et al, 2020). It is reported that children who
previously enjoyed secure attachment will be more vulnerable to changes in parenting than
those who have had long term experiences with unresponsive parenting (Armsden G.C et al,
1993).
35
3.5 Theme 2: Internalizing and externalizing behavours in children.
The most common effects of maternal chronic pain on children are related to other mediators
such as gender of children and parent affected, length and severity of chronic pain, disability
of parent, maternal depression, temperament of children, capabilities of father or other
family members, marital cohesiveness, cognitive development and social development of
children (Armistead L et al, 1995) (Umberger W, 2014) (Umberger W et al, 2014) (Duryea M,
2008). Many published articles discuss internalization of emotions and difficulties which can
result in depression, anxiety, poor self-esteem and difficulties with socialization or
externalizing behaviours in children including conduct disorder, oppositional defiance
disorder, substance misuse, or aggression (Umberger, 2014) (Zelkowitz P et al, 2013). On the
other hand, some papers found no great difference between parental chronic pain and
difficulties in children with emotions (Kaasboll J et al, 2012). Umberger’s studies were smaller
studies in comparison to Kaasboll J et al in 2012. Kaasboll and Umberger both considered
mediators and were both cross-sectional studies, Kaasboll’s work seems to be of higher power
and quality to Umberger’s studies however later Kaasboll discussed parental chronic pains
link to internalizing issues in children in 2018.
Internalizing difficulties are believed to be more commonly seen in girls and is related to low
social competence (Kaasbool J et al,2018). Depressive symptoms and difficulties with social
competence was found to be related to mirroring of a parent affected by chronic pain,
children are believed to observe and mirror parental isolation and emotional difficulties when
stressed (Kaasboll J et al, 2018) (Turner Cobb J.M et al, 1998). In this way children learn
abnormal emotional processing and communication patterns. If children’s stress and
emotions are neglected, they can struggle with mental health difficulties and internalize or
externalize their distress or anxiety in different ways. Children are thought to form their own
understanding or narratives when a parent is unwell or family life is disrupted which can led
to the formation of fears and anxiety (Umberger W et al, 2014).
Children with internalizing difficulties can struggle further at certain ages and developmental
stages, in early adolescence children can be sensitive about making friends, appearing to be
different and social approval. Children who internalize their emotions can be bullied more
36
frequently at school related to their affect, unavailability or hardships at home. The
unpredictability of parents pain and related responses or functioning is believed to be the
main contributor to children’s difficulties in Zelkowitz P et al, 2013. The latent idea in this
paper is that parenting should be consistent and parenting responses or behaviours which
are inconsistent cause more upheaval and have greater effect on children. Zelowitz found
that less monitoring and supervision of children correlates with more aggression and
externalization.
Girls tend to take on caring roles in the home when a parent is unwell and this role can be
beyond their capabilities and cause stress (Kaasboll J et al, 2018) (Umberger W, 2014) (Duryea
M, 2008). This can become a trait by which girls have learned make them acceptable to others
or a way to resolve conflict at home which leads to them adopting future care-taking roles in
life. Caring-roles can develop empathy and resilience however become inappropriate and
even harmful if the role persists, challenging for children or interferes with the normal tasks
or social development of children (Duryea M, 2008) (Evans S et al, 2007). Such children can
be moulded into the person which they feel their parent wants or needs them to be and lose
the formation of their independence at critical stages in their life. Feelings of guilt and
isolation can risk the seeking of inappropriate relationships in future and dependant roles.
This subtheme overlaps with attachment needs and patterns discussed previously.
An interesting subtheme includes the variation of symptoms or difficulties in children
according to age or developmental stage. Young children can experience anxiety differently
to older children and adolescents. They can demonstrate separation anxiety, phobias or
behavioural difficulties like acting out displacement (Armsden G.C and Lewis F.M, 1993). Preadolescents can struggle with self-identification and individuality, experiences of anger,
fantasy as a means of avoidance and sadness can be heightened if the environment is
unstable at home (Armsden G.C and Lewis F.M, 1993). Adolescents, depending on sex and
development, can feel more anxiety and somatic symptoms in response to maternal chronic
pain. In the process of individuation and self-discovery in adolescence, teenagers can
experience guilt if they spend time away from their unwell parent (Armsden G.C and Lewis
F.M, 1993). They could also experience externalizing symptoms dependant more on male sex
and temperament type, such as increased irritability, aggression and extreme behaviours.
Overall children and adolescents have not developed the understanding and mentalization
37
for others which is developed later in life which can led to self-blame, externalization of anger,
and an inability to self-soothe if their supportive parent is unavailable to aid them with same.
Overall, most of the literature involve cross-sectional studies which hinder causality formation
and connection between parental chronic pain and children’s emotional and behavioural
difficulty. On the other hand, numerous studies referencing the connection cannot be ignored
and researchers postulate that the relationship may be bidirectional in which both parents
and children are linked in such a way that their struggles and behaviours are going to
significantly impact eachother (Barroso N et al, 2018). Barroso’s contribution is important
being the most recent work and involving a higher level of evidence via methods used and
the clearer connection made of parental stress being shown to cause children’s behavioural
disorders and mood disorders.
Children whose parent suffers with chronic pain, at the very least, tend to adopt unhealthy
habits which they model from their parent including lack of exercise, smoking, use of
substances (Kaasboll J et al, 2014). The Hunt study by Kaasboll offered rich insight into the
vulnerabilities of children whose parents suffer with chronic pain, a large representative
population was used and confounders were considered, making the results of this research
more reliable. They found that boys in particular were at higher risk of substance misuse due
to lack of supervision, stress and avoidance of demanding roles at home. Girls tended to adopt
the care-giver role which brought its own pressures and tendency towards internalizing
symptoms (Kaasboll J et al, 2014).
3.6 Theme 3: School attendance.
Research on school absenteeism by Allen C.W et al, 2018 described how children with parents
who suffer from chronic illness or pain tend to miss increased school days or periods of
schooling related to care-giving duties at home. These children may be seen as being different
to their peers and suffer more bullying at school (Banks P et al, 2002). Inconsistent parenting
without adequate supervision which is also seen in unwell parents can also result in children
missing school. This theme has some overlap with theme 4 as children can model their parents
behaviours and adopt the ‘sick role’ to avoid unpleasant situations or anxiety associated with
school (Rikard K,1988). This avoidance may vary in how conscious the affected child is of their
intention to avoid school and in the reasons behind absention. It could also be argued that
38
children who grow up in stressful or demanding households become more consumed by
stress and overwhelmed over time resulting in them feeling incapable of coping with the
demands of schooling for periods of time (Turner Cobb J.M et al, 1998). Umberger W et al,
2014 and Sieh D.S et al, 2010 support this idea of limited coping resources in children, along
with modelling of parental behaviours in chronic pain, which leads to greater school absences.
In the same way that depression is believed to contribute to the relationship between
maternal chronic pain and negative parenting practices, marital discord is reported to affect
and be instrumental in children’s behaviour causing difficulties with adjustment in school
(Chun D.Y et al, 1993).
3.7 Theme 4: Modelling of parents responses to pain.
The connection between parental chronic pain and children experiencing pain symptoms has
been found according to Beveridge J.K et al, 2018. When compared to matched controls
children from families with chronic pain suffer increased experiences of pain, catastrophising
of pain responses and poorer understanding of pain. This is believed to be due largely to
modelling of pain responses and coping mechanisms from parents, other factors include pain
behaviours, communication regarding pain, health habits and safety behaviours. Responses
to pain are also affected by intergenerational transmission, genetic susceptibility and
neurobiological factors such as levels of cortisol, serotonin and reactions to stress (Beveridge
J.K et al, 2018). This research by Beveridge refers to measurable chemical and genetic changes
in those with chronic pain, however the research sample used those of white and of higher
socioeconomic background which may be specific to a chronic pain sample however excludes
the middle class and may not be generalizable to all communities.
Psychology and parenting have the greatest influence on the transmission of chronic pain and
related behaviours to children. If such maladaptive mechanisms are reinforced and children
are conditioned to be sensitive and reactive to pain, they will suffer from increased effects of
pain (Boselie J.J.L.M et al, 2019).
3.8 Theme 5: Family’s role in maintaining pain.
3.9 Theme 6: Childrens development of resilience in care-giving.
39
SECTION 4: Discussion:
4.0 Factors affecting maternal chronic pain.
4.1 Factors affecting children.
40
Many qualitative research articles, have outlined the relationship between maternal
chronic pain and absenteeism of children from school, externalising and internalising
behaviours and emotional dysregulation (Allen C.W, 2018) (Umberger W, 2004). Such
difficulties in the emotional and cognitive development of children are important due
to patterns of development which result in a tendency towards mental illness in
adulthood (Anno K et al, 2015). Children have been known to model parental
behaviours and model their mother’s pain behaviours, this is linked to a reduced pain
threshold and avoidance patterns (Rikard K, 1988).
4.2 Interactions with children
4.3 Role reversal of children
4.4 Age and sex differences
4.5 Spousal relationship
The spousal relationship can also be affected in cases of maternal chronic pain. There
may be a loss of intimacy between couples, which may result in separation (Moore J.E,
1985). Financial difficulties when a patient may be unable to work outside the home
can perpetuate intrafamilial stress; particularly when a spouse feels that they are
having to take up both carer and breadwinning roles (Moore J.E, 1985) (Bevan S et al,
2009). Family members believe that their family member has ulterior motives such as
easing anxiety or avoiding their responsibilities, this viewpoint can lead to underlying
feelings of frustration and resentment (Roy R, 1985).
4.6 Outcomes for the child
4.7 The role of family therapy
Family-therapy programs concentrate on changing the difficult patterns of interaction
and communication in families in which behavioural or emotional problems exist
41
(Kerns R.D et al, 2003). Attachment based family therapy, which is heavily influenced
by attachment theory suggests that humans have a desire for meaningful
relationships. According to attachment theory, a secure attachment develops when
parents acknowledge the needs of their children and are available to them (Cassidy J
et al, 2013). Attachment related family therapy has an intergenerational based
approach; whereby its focus is designed to shift the focus away from the identified
symptoms and toward improvements in the relationship between parent and child
(Cassidy J et al, 2013).
The role of family therapy is well established in the management of problematic child
and adolescent behaviour (Fisher C.A et al, 2010). Practitioners utilize the family
system to help support the affected individual using different family therapy methods.
Each has a different emphasis on causative factors, maintaining factors and different
therapeutic targets and outcomes. Analyses of family therapy has found that family
approaches have more impact on improving relationships and on reducing family
conflict (Kumpfer K.L, 2003).
The recognition of children who may be affected by maternal illness or chronic pain is
important. Families who are vulnerable to stress when a parent suffers from chronic
pain should be identified and a family assessment should be completed (Bees F, 1994).
Therapists who bring awareness of the impact of chronic pain on the family can begin
to shift certain dynamics and roles which have formed. The education of families on
chronic pain and its effects should form a large part of the early work with the family
(Bees F, 1994). Communication patterns which are harmful or unhelpful need to be
the focus of family techniques to affect long term change in the familial relationships.
4.8 The benefits of family therapy in the somatising family
4.9 Restructuring roles and communication
4.10
Exploration and analysis of main themes
4.11 Future directions
4.12 Limitations
4.13 Conclusions
42
Reflection of research process
Future drections:
Need longitudinal studies. Generalised to population. Large numbers. Account for
mediators. Age range of children. Gain reports from parents, children, teachers.
Observational studies
Look at income disparites.
Look at somatisers vs non, ?medical records.
Look at risk factors and protective factors.
Look more closely at individual aspects- fathers role, income, supports, childrens
temperament, childrens intelligence.
Look at level of parents dysfunctioning.
References
43
Addison R. G. Treatment of chronic pain: the Centre for Pain Studies, Rehabilitation Institute
of Chicago. NIDA research monograph – 1981, Volume 36, Issue 0, pp. 12-32 - published
1981-01-01.
Agostini A, Rizzello F, Ravegnani G, Gionchetti P, Tambasco R, Straforini G, Ercolani M,
Campieri M. Adult Attachment and Early Parental Experiences in Patients With Crohn’s
Disease, Psychosomatics, Volume 51, Issue 3, 2010, Pages 208-215, ISSN 0033-3182,
https://doi.org/10.1016/S0033-3182(10)70687-3.
(https://www.sciencedirect.com/science/article/pii/S0033318210706873)
Allen C.W, Diamond-Mrysten S, and Rollins L.K. School absenteeism in children and
adolescents. American Family Physician – 2018, Volume 98, Issue 12, pp. 738-744 published 2018-01-01.
Anno, K., Shibata, M., Ninomiya, T. et al. Paternal and maternal bonding styles in childhood
are associated with the prevalence of chronic pain in a general adult population: the
Hisayama Study. BMC Psychiatry 2015, 15, 181. https://doi.org/10.1186/s12888-015-0574y.
Armsden G.C, Lewis F.M. The child's adaptation to parental medical illness: theory and clinical implications. Patient education and counselling, 1993, 22(3), 153–
165. doi:10.1016/0738-3991(93)90095-e.
Banks P, Cogan N, Riddell S, Deeley S, Hill M, Tisdall K. Does the covert nature of caring prohibit the development of effective services for young carers?. British Journal of Guidance &
Counselling, 2002, 30(3), 229–246. doi:10.1080/030698802100002281.
Barroso N, Mendez L, Graziano P, and Bagner D. (2018). Parenting stress through the lens of
different clinical groups: a systematic review and meta-analysis. Journal of abnormal child
psychology, DOI 10.1007/s10802-017-033-6.
Bees F. Depression, life satisfaction and perceived maternal support in adolescents of mothers with chronic pain. Online thesis. 1994. https://escholarship.mcgill.ca/concern/theses/t435gf23h McGill University.
44
Benzes K.M. Relationship of Early Family Environment to Child Behavioural Development at
Age 7 Years. Faculty of Nursing Edmonton, Alberta Spring 2001. Google scholar, accessed
1/9/2022.
Benzes K.M, Harrison M.J and Magill-Evans J. (2004) Parenting and childhood behaviour
problems: mothers’ and fathers’ voices. Issues in mental health nursing, 25:1, 9-24.
Bevan S, Quadrello T, McGee R, Mahdon M, Vavrosky A, and Barham L. Fit for work? musculoskeletal disorders in the European workforce. 2009, Vol. 1 London: The Work Foundation.
p. 1–143. Lancaster University.
Beveridge JK, Neville A, Wilson AC, Noel M. Intergenerational examination of pain and posttraumatic stress disorder symptoms among youth with chronic pain and their parents. Pain
Rep. 2018 Sep 11;3(Suppl 1):e667. doi: 10.1097/PR9.0000000000000667. PMID: 30324168;
PMCID: PMC6172823.
Boselie J.J.L.M, Goossens M.E.J.B, Muris P, and Vancleef L.M.G. (2019). The relation between parental chronic pain and pain-related attention and interpretation biases in painfree adolescents. European journal of Pain, doi: 10.1002/ejp.144.
Bowen B. (2021). The matrix of needs: reframing Maslow’s hierarchy. Health, 13, 538-563.
Brody S. The Concepts of Attachment and Bonding. Journal of the American Psychoanalytic
Association, 1981, 29(4), 815–829. https://doi.org/10.1177/000306518102900403.
Brown D, Rosenthal N, Kupitz A and Wager J. Intergenerational transmission of chronic painrelated disability: the explanatory effects of depressive symptoms. Pain journal, 2021,
1;162(2):653-662. doi: 10.1097/j.pain.0000000000002066. PMID: 32890257.
Busetto L, Wick W. and Gumbinger C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2, 14 (2020). https://doi.org/10.1186/s42466-020-00059-z.
45
Bushnell M.C, Case L.K, Ceko M, Cotton V.A, Gracely J.L, Low L.A, Pitcher M.H and Villemure
C. Effect of environment on the long term consequences of chronic pain. Pain, 2015, 156 (0
1): S42-S49.
Byrne, D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant 56, 1391–1412 (2022). https://doi.org/10.1007/s11135-021-01182-y.
Cassidy J, Jones J.D, and Shaver P.R. Contributions of attachment theory and research: a
framework for future research, translation, and policy. Dev Psychopathol, 2013, 25(4 Pt
2):1415-1434. doi:10.1017/S0954579413000692. Cambridge University press.
Clarke, V. & Braun, V. (2013) Teaching thematic analysis: Overcoming challenges and developing
strategies for effective learning. The Psychologist, 26(2), 120-123.
Craig T.K.J, Cox A.D and Klein K. Intergenerational transmission of somatisation behaviour: a
study of chronic somatizers and their children. Psychological Medicine, 2002, 32(5), 805816. doi:10.1017/S0033291702005846.
Downey G, Purdie V and Schaffer-Nietz R. Anger transmission from mother to child: a comparison of mothers in chronic pain and well mothers. Journal of Marriage and family, 1999,
vol.61, No.1, pp. 62-73.
Duryea M.M. Mothers with chronic physical illness and the parentification of their children.
2008. https://digitalrepository.unm.edu/educ ifce etds/38.
Dykas M.J, Ehrlich K.B and Cassidy J. Chapter 2-links between attachment and social information processing: examination of intergenerational processes. Ed: Benson J.B, Advances in
child development and behaviour, JAI, vol. 40, pp. 51-94.
Evans S, Keenan T.R. and Shipton E.A. Psychosocial adjustment and physical health of children living with maternal chronic pain. Journal of Paediatrics and Child Health, 2007, 43:
262-270. https://doi.org/10.1111/j.1440-1754.2007.01057.x. Wiley.
46
Evans S, Shipton E.A and Keenan T.R. Psychosocial functioning of mothers with chronic pain:
a comparison to pain-free controls, European journal of pain, 2005, 9(6), 683-683.
Evans S, Shipton E.A, and Keenan T. The relationship between maternal chronic pain and
child adjustment: the role of parenting as a mediator. J Pain, 2006, 7(4):236-43. doi:
10.1016/j.jpain.2005.10.010. PMID: 16618467. Elsevier.
Fisher C.A., Hetrick S.E., and Rushford N. Family therapy for anorexia nervosa. Cochrane Database of Systematic Reviews, 2010, Issue 4. Art. No.: CD004780. DOI:
10.1002/14651858.CD004780.pub2. Wiley.
Forero R, Nahidi S, De Costa J. et al. Application of four-dimension criteria to assess rigour of
qualitative research in emergency medicine. BMC Health Serv Res 2018, 18, 120.
https://doi.org/10.1186/s12913-018-2915-2.
Gutierrez-Bucheli L, Reid A and Kidman G. Scoping reviews: Their development and application in environmental and sustainability education research, Environmental Education Research, 2022, 28:5, 645-673, DOI: 10.1080/13504622.2022.2047896.
Hadfield K. (2000). A structural family therapy approach to counselling families. Submission
to the Faculty of social work, University of Manitoba. Sourced on: collectioncanada.gc.ca.
Harrison D.J. The transgenerational transmission of emotion regulation: the effect of maternal coping on child executive functioning. The graduate centre, City university of New York,
2017, pp 1-127. Sourced at: https://academicworks.cuny.edu/cgi/viewcontent.cgi?article=3232&context=gc_etds.
Hirsch B.J, Moos R.J, Reischl T.M. Psychosocial Adjustment of Adolescent Children of a
Depressed, Arthritic, or Normal Parent. Journal of Abnormal Psychology Copyright 1985 by
the American Psychological Association, Inc. 1985, Vol. 94, No. 2, 154-164.
Holmes H.A and Deb P. The effect of chronic illness on the psychological health of family
members. The journal of mental health policy and economics, 2003, 6, 13-22.
47
Husain M and Chalder T. Medically unexplained symptoms: assessment and management.
Clin Med (Lond). 2021 Jan; 21(1): 13–18.doi: 10.7861/clinmed.2020-0947.
James K, and MacKinnon L. (1986). Theory and practice of structural family therapy: illustration and critique. Australian and New Zealand journal of family therapy, 7(4):223-233.
Joy, E., Braun, V., & Clarke, V. (2023). Doing reflexive thematic analysis: A reflexive account.
In F. Meyer, & K. Meissel (Eds.), Research methods for education and the social disciplines in
Aotearoa New Zealand. New Zealand: NZCER Press.
Kaasbøll J, Lydersen S, Indredavik MS. Psychological symptoms in children of parents with
chronic pain-the HUNT study. Pain. 2012 May;153(5):1054-1062. doi:
10.1016/j.pain.2012.02.013. Epub 2012 Mar 21. PMID: 22444189.
Kaasboll J, Lydersen S, Ranoyen I, Nilsen W and Indredavik M.S. Parental chronic pain and
internalizing symptoms in offspring: the role of adolescent’s social competence – the HUNT
study. Journal of Pain research, 2018, 11, 2915-2928.
Katz J, Rosenbloom B.N and Fashler S. Chronic pain, psychopathology, and DSM-5 somatic
symptom disorder. Can J Psychiatry. 2015 Apr; 60(4): 160–167.
doi: 10.1177/070674371506000402.
Kerns R.D., and Otis J.D. Family therapy for persons experiencing pain:
evidence for its effectiveness. Seminars in Pain Medicine, 2003, Volume 1, Issue 2, pages
79-89. Elsevier.
Kendrick D.T, Griskevicius V, Neuberg S.L and Schaller M. (2010). Renovating the pyramid of
needs: contemporary extensions built upon ancient foundations. Perspect psychol sci, 5(3):
292-314.
48
Kowlowska K. Attachment relationships shape pain-signalling behaviour. The Journal of Pain,
2009, vol.10, No. 10, pp. 1020-1028.
Kumpfer K.L, and Alvarado R. “Family-Strengthening Approaches for the Prevention of Youth
Problem Behaviours.” American Psychologist, 2003, 58(6–7): 457–65.
Lewandowski W, Morris R, Burke C and Risko J. (2007). Chronic pain and the family: theorydriven treatment approaches. Issues in mental health nursing, 28:1019-1044.
Livse, C.G. Physical illness and family dynamics. Adv. Psychosom. Med, 1972, vol. 8, pp 237251; Kerger, Basel.
Maguire M and Delahunt B. (2017). Doing a thematic analysis: a practical, step-by-step guide
for learning and teaching scholars. All Ireland journal of higher education, volume, number
3, 3351.
Maslow A.H. A Theory of Human Motivation. Psychological Review, 1943, 50, 370-396.
McArthur BA, Burke TA, Connolly SL, Olino TM, Lumley MN, Abramson LY, Alloy LB. A Longitudinal Investigation of Cognitive Self-schemas across Adolescent Development. J Youth Adolesc. 2019 Mar;48(3):635-647. doi: 10.1007/s10964-018-00981-1. Epub 2019 Jan 5. PMID:
30612293; PMCID: PMC6391197.
Meredith P, Ownsworth T and Strong J. (2008). A review of the evidence linking attachment
theory and chronic pain: presenting a conceptual model. Clinical psychology review, 28, 407429.
Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated
factors in population-based studies. Br J Anaesth. 2019 Aug;123(2):e273-e283. doi:
10.1016/j.bja.2019.03.023. Epub 2019 May 10. PMID: 31079836; PMCID: PMC6676152.
Moore J. E., and Chaney E. F. Outpatient group treatment of chronic pain: Effects of spouse
involvement. Journal of Consulting and Clinical Psychology, 1985, 53, 326– 334.
49
Munn Z., Peters M.D.J., Stern C. et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res
Methodol, 2018, 18, 143. https://doi.org/10.1186/s12874-018-0611-x
Palacios-Ceña D., Albaladejo-Vicente R., Hernández-Barrera V., Lima-Florencio L., Fernándezde-las-Peñas C., Jimenez-Garcia R., López-de-Andrés A., de Miguel-Diez J., and Perez-Farinos
N. Female Gender Is Associated with a Higher Prevalence of Chronic Neck Pain, Chronic Low
Back Pain, and Migraine: Results of the Spanish National Health Survey, Pain Medicine,
2017, Volume 22, Issue 2, pages 382–395. Oxford University press.
Perdue B.J. (1993). Self-perceived competencies of latency age children of chronically, physically ill mothers as a function of maternal psychosocial adjustment to illness and children’s
reports of mothering behaviours. New York university ProQuest dissertations publishing,
9333929.
Peters M.D.J., Marnie C., Colquhoun H. et al. Scoping reviews: reinforcing and advancing the
methodology and application. Syst Rev, 2021, 10, 263. https://doi.org/10.1186/s13643-02101821-3.
Rikard K. The Occurrence of Maladaptive Health-Related Behaviours and Teacher-Rated
Conduct Problems in Children of Chronic Low Back Pain Patients. Journal of Behavioural
Medicine, 1988, Iiol. 11, No. 2.
Rojas M, Mendez A and Watkins-Fassier K. The hierarchy of needs empirical examination of
Maslow’s theory and lessons for development. World development, vol.165, 106185.
Romeo A, Teslo V, Castelnuovo G and Castelli L. (2017). Attachment style and chronic pain:
toward an interpersonal model of pain. Frontiers, psychology for clinical settings, vol. 8.
https://doi.org/10.3389.
Roy R. Engel’s Pain-Prone Disorder Patient: 25 Years After. Psychother Psychosom
1985;43:126-135. doi: 10.1159/000287869.
50
Sear R. (2021). The male breadwinner nuclear family is not the ‘traditional’ human family,
and promotion of this myth may have adverse health consequences. Philosophical transactions Royal society London biological sciences, 376(1827).
https://doi.org/10.1098/rstb.2020.0020.
Sieh D.S, Meijer A.M, Oort F.J, Visser-Meily J.M, Van der Leij D.A. (2010). Problem behaviour
in children of chronically ill parents: a meta-analysis. Clinical child family psychological review, 13(4): 384-97.
Śliwerski A., Kossakowska K., Jarecka K., Świtalska J., and Bielawska-Batorowicz E. The Effect
of Maternal Depression on Infant Attachment: A Systematic Review. Int J Environ Res Public
Health, 2020, 14;17(8):2675. doi: 10.3390/ijerph17082675. PMID: 32295106; PMCID:
PMC7216154. PMC.
Sójta K and Strzelecki D. (2023). Early Maladaptive Schemas and Their Impact on
Parenting: Do Dysfunctional Schemas Pass Generationally?-A Systematic Review. J
Clin Med. 2023 Feb 5;12(4):1263. doi: 10.3390/jcm12041263. PMID: 36835799;
PMCID: PMC9963559.
Tanguay-Sabourin, C., Fillingim, M., Guglietti, G.V. et al. A prognostic risk score for
development and spread of chronic pain. Nat Med 29, 1821–1831 (2023).
https://doi.org/10.1038/s41591-023-02430-4
Taquet M., Dercon Q., Luciano S., Geddes J.R., Husain M., and Harrison P.J. Incidence, cooccurrence, and evolution of long-COVID features: A 6-month retrospective cohort study of
273,618
survivors
of
COVID-19.
PLoS
Med,
2021,
18(9):
e1003773.
https://doi.org/10.1371/journal.pmed.1003773.
Treede R.D., Rief W., Barke A., Aziz Q., Bennett M.I., Benoliel R., Cohen M., Evers S., Finnerup
N.B., First M.B., Giamberardino M.A., Kaasa S., Kosek E., Lavand, homme P., Nicholas M.,
Perrot S., Scholz J., Schug S., Smith B.H., Svensson P., Vlaeyen J.W.S., Wang S.J. A classification
51
of
chronic
pain
for
ICD-11.
Pain,
2015,
156(6):1003-1007.
doi:
10.1097/j.pain.0000000000000160. PMID: 25844555; PMCID: PMC4450869.
Umberger W. Children of Parents With Chronic Noncancer Pain: A Comprehensive Review of
the Literature. Journal of Child and Adolescent Psychiatric Nursing, 2014, 27(1), 26–
34. doi:10.1111/jcap.12055
Umberger W, Martsolf D, Jacobson A, Risko J, Calabro M, Patterson M. Ways of understanding parental chronic pain: a topology. Pain management nursing, 15(4), 854-863.
Wasson S. Before narrative: episodic reading and representations of chronic pain. Medical
Humanities 2018;44:106-112.
Zelkowitz P, Looper KJ, Mustafa SS, Purden M, Baron M; McGill Early Arthritis Research
Group. Parenting disability, parenting stress and child behaviour in early inflammatory arthritis. Chronic Dis Inj Can. 2013 Mar;33(2):81-7. PMID: 23470173.
Zimmerman C.C. (1972). The future of the nuclear family. International journal of sociology of
the family, 2(2), 109-120.
Appendix A
52
53
Figure was downloaded from http://www.prisma-statement.org/Extensions/ScopingReviews on
1/11/23.
54
Appendix B
Table 1: PEO framework.
Patient/population
Exposures
Outcome
Children under 18 years of
age whose mothers suffer
from chronic pain.
Maternal chronic pain.
Emotional and behavioural
developmental difficulties.
PEO is another framework that is especially useful when investigating a prognosis or likelihood of developing a certain condition as a result of a pre-existing condition or exposure.
Patient/Population: how would you describe the patient or population of interest?
Exposure: what pre-existing conditions does the patient/population have or what has
the patient/population been exposed to?
Outcome: the outcome of interest; unlike in PICO, the outcome is almost always used
in the search terms with the PEO framework.
55
Appendix C
Preliminary searches used in process of scoping review:
12,588 for maternal chronic pain AND childhood OR children’s emotional functioning OR
difficulties. Saved 10 articles.
71 for maternal chronic pain OR physical pain AND children’s behavioural functioning OR
difficulties. Saved 3 articles.
14 maternal chronic pain AND children’s emotional difficulties OR dysregulation. Saved 1
article.
Table 2: Examples of database searches using search string and key words 2022.
Time period
Database
Number of articles
March 2022
Pubmed initial search
12,588 articles
Pubmed advanced search
71 articles
Pubmed advanced search
using developed search criteria
14 articles
MEDLINE initial search
62,000 articles
MEDLINE advanced search
1344 articles
Using developed search
criteria
319 articles
April 2022
COCRANE search
0 articles
December 2022
Rayyan results
4867 articles
151 articles.
Table 3: Results of search of Gery literature 2022-2023
Time period
December 2022
December 2022
January 2023
Database
Open grey initial search
Open grey advanced search
PROSPERO initial search
PROSPERO advanced search
Google scholar initial search
Number of articles
0
0
3057
1
5180
56
January 2023
January 2023
January-February 2023
Google scholar advanced
search
NICE initial search
NICE advanced search
HSE website initial search
HSE website advanced
search
Bibliography lists
3
0
0
80
0
11
Note: The above grey literature was searched using full and completed search string. Any
articles previously found in databases were excluded. Only relevant articles were included.
Appendix D
Reflexive thematic analysis: Six domains of Braun and Clarke method.
1. Orientation to data involving review of information and
identification of stand out themes.
2. Coding and focus of meaning. Exploration of explicit and
implicit meanings of information. Examining the rigor of
information used.
3. Qualitative framework- creation of initial themes. Examining
the perspective of the participants and language used,
followed by critical analysis of content.
4. Theoretical frameworks involving gaining insight into the
meaning of information while considering the context of the
information collected. It includes development and review of
themes.
5. Refining, defining and naming themes.
6. Writing up themes.
Adapted from: https://richarddevinesocialwork.com/2021/11/12/reflexive-thematicanalysis-the-what-why-and-how/ on 1/11/23.
57
Appendix E
Thematic analysis map.
Anxiety
Mood instability
Harsh
parenting.
Emotional
distance
Changes to
parenting and
attachment
issues
Inappropriate
care giving
Internalizing and
externalizing
behaviours in
children
Oppositional defiance
disorder/conduct
disorder
Maternal
depression
School attendance
Maternal chronic pain
Modelling of
parents
responses to
pain
Families role in
maintaining pain
Childrens development
of resilience in caregiving
Main themes connect via blue lines to maternal chronic pain.
Themes and subthemes interconnect via red lines.
58
Appendix F
Table 4: Articles and studies used in scoping review.
Authors
Title
Agostini
A et al
Adult
Attachment
and Early
Parental
Experiences
in Patients
With
Crohn’s
Disease
Anno K
et al
Ye
ar
20
10
Paternal and 20
maternal
15
bonding
styles in
childhood are
associated
with the
prevalence of
chronic pain
in a general
adult
population:
the Hisayama
Study.
Place
Italy
Research
method
Questionn
aire in
casecontrol
design.
Findings
Strenghts
Stimulato
n of
attachme
nt
behaviour
s and
patterns.
Linked
chronic
illness to
attachme
nt issues.
patients
exhibit
anxious
and
preoccupie
d
attachmen
t styles
that share
a negative
view of
self. A
negative
model of
self is
associated
with poor
selfesteem
and high
dependen
ce.
Japan
Questionn
aire,
crosssectional
design.
Difficultie
s with
bonding
in
childhood
result in
chronic
pain in
adulthoo
d.
Depressio
n
influences
the link
Associate
d low
care/high
protection
parenting
to later
developm
ent of
chronic
pain and
mental
illness.
Weakness
es
Could not
link
chronic
illness to
parenting
that could
be
confirmed
as being
adverse.
Possibility
of recall
bias.
Could not
rule out
that other
factors
could
contribute
to
attachme
nt style.
Could not
confirm
causal
links.
No causal
ity can be
establishe
d related
to study
design.
Possibility
of recall
bias and
selection
bias.
Mediators
could
have had
59
between
parental
bonding
and
chronic
pain.
Bees F.
Depression, 19
life
94
satisfaction
and
perceived
maternal
support in
adolescents
of mothers
with chronic
pain.
Canad Crossa
sectional,
corrolatio
n
comparati
ve study.
an
influence.
Small
sample
size.
Limited
statistical
power.
The
Examinati Mothers
eldest
on of
were
and
demograp recruited
youngest hics and
from
children
family
general
were
informatio populatio
affected
n.
n rather
more by
than from
maternal
pain
chronic
clinics,
pain.
may have
Most
resulted in
mothers
less
were
accurate
employed
results
, married
when
and aged
exploring
in their
relationshi
40s.
p between
Common
mothers
sites of
pain and
pain were
childrens
the lower
mood and
back or
life
multiple
satisfactio
sites.
n.
Mothers
Cross
who
sectional
suffer
design
from
could not
multiple
identify
sites of
causality.
chronic
pain or
Children
have pain
were
for longer
middle to
tend to
late
correlate
adolescen
with
ce, did not
60
Chun D.Y
et al
Craig
T.K.J et al
Children of
chronic pain
patients:
risk factors
for
maladjustm
ent
19
93
Intergenerat 20
ional
02
transmissio
n of
somatisatio
n
behaviour: a
study of
chronic
somatizers
and their
children.
U.S.A
U.S.A
Crosssectional
questionn
ares
Crosssectional
comparati
ve
investigati
on
increased
depressio
n and less
life
satisfactio
n in their
children.
These
mothers
also had
higher
levels of
depressio
n.
use age
range in
samples.
Difficultie Descriptiv
s with
e statistics
children’s employed.
behaviour
was
noticed
more in
school or
outside of
home.
Small
sample
size.
Children
did not
complete
questionn
aire.
Possibility
of
sampling
bias.
Not an
observatio
nal or
longitudin
al study.
Parents
selected
child to
participat
e in study.
Relations Establishe Maternal
hip
d
reports
between relationshi used, no
maternal p which
reports
somatisat suggests
from
ion of
interchildren
pain and
generatio or other
children’s nal link for family
later
somatisati members.
developm on of pain
ent of
symptoms
somatisat and
ion.
particular
Mothers
patterns
were
of coping.
more
likely to
61
Downey
G et al
Evans S
et al
Anger
transmissio
n from
mother to
child: a
comparison
of mothers
in chronic
pain and
well
mothers.
19
99
Dealing with 20
chronic
08
pain: giving
voice to the
experiences
of mothers
with chronic
pain and
their
children
U.S.A
New
Zeala
nd
have
experienc
ed
neglectful
parenting
and
illness
behaviour
s from
their own
parents.
Daily diary Sample
data
mothers
were
more
angry
however
children
and
parenting
were less
affected
compared
to control
mothers.
Children
allowed
for
reactive
parenting
as there
was a
reasonchronic
pain for
same.
Used
control.
SemiMany
structured mothers
interviews had
relatives
who had
experienc
ed
chronic
pain.
Personal
viewpoint
collected.
Homogen
ous
sampling.
Exploratio
n of
themes.
Method
used
could only
record
current
impact
Used
different
ages of
children.
Large
sample
size.
Used data
from
mothers
and
children.
Reasonabl
e sample
size.
Only used
adolescen
t children.
Controls
used were
older in
age
compared
to sample.
62
There
were
some
positives
to their
experienc
e
however
many
mothers
described
social
impacts
and felt
children
were
lacking
their
attention.
Children
tended to
experienc
e somatic
symptom
s.
Many
children
felt
anxious
about
their
mother.
The effect
on
parenting
was
extensive.
Evans S
et al
Parents with 20
chronic
07
pain: are
children
equally
affected by
fathers as
mothers in
pain?
Crosssectional
questionn
aires
Children
of
mothers
with
chronic
pain tend
to suffer
greater
anxiety
and
functionin
g.
Correlatio
n shown
between
parental
pain and
children’s
pain.
Not
longitudin
al.
Likely
other
mediating
factors.
63
Evans S
et al
Psychosocial 20
adjustment 07
and physical
health of
children
living with
maternal
chronic
pain.
Austr
alia
Crosssectional
questionn
aires
and
illness
behaviour
s.
More
externaliz
ing
behaviour
s seen if
father
suffers
chronic
pain.
Mothers
tend to
vocalise
and
report
more
pain and
parenting
difficulty
compared
to
fathers.
Children
whose
mothers
experienc
e chronic
pain have
more
externaliz
ing and
internalizi
ng
symptom
s, poorer
social
skills,
more
pain
symptom
s and
illness
behaviour
s. Higher
Lack of
validated
tools
used.
Small
sample
size.
Reports
from
children,
mothers,
fathers,
teachers.
Did not
control for
depressio
n or
distress.
Not
longitudin
al study.
Some
children
used were
siblingspossible
bias.
Possible
reporting
bias.
64
Evans S
et al
Psychosocial 20
functioning 05
of mothers
with chronic
pain: a
comparison
to pain-free
controls.
Austr
alia
Crosssectional
questionn
aire
levels of
insecure
attachmn
et to
mothers
reported.
Mothers
with
chronic
pain had
more
financial
and
psychoso
cial
difficultie
s which
impacted
on their
ability to
parent.
Controlled
for mental
illness
Not
longitudin
al.
Small
sample.
Only
mothers
particpate
d.
Mothers
experienc
ed
variation
in their
emotions.
Evans S
et al
The
20
relationship 06
between
maternal
chronic pain
and child
adjustment:
the role of
parenting as
a mediator.
Austr
alia
Crosssectional
questionn
aires
Strain
also on
spouse
and
marriage.
Mothers
with
chronic
pain
engage in
more
reactive,
lax or
verbally
rejecting
parenting
behaviour
s
Controlled
.
Allowed
for
income as
a variable
which
could
affect
outcomes.
Small
sample
size.
Participan
ts
recruited
through
advertisin
g.
Did not
consider
many
variables
65
correlatin
g with
childrens
behaviour
al
difficultie
s
and low
mood.
Higgins
K.S et al
Offspring of 20
parents
15
with chronic
pain: a
systematic
review and
metaanalysis of
pain, health,
psychologic
al and
family
outcomes
Hirsch B.J Psychosocial 19
et al
Adjustment 85
of
Adolescent
Children of
a
Depressed,
Arthritic, or
Normal
Parent.
Canad Systemati
a
c review
and metaanalysis
U.S.A
Crosssectional
questionn
aire.
Children
had more
psycholog
ical and
pain
related
difficultie
s
compared
to
controls.
Infants
suffered
more
adverse
events
following
birth if
mother
suffered
from
chronic
pain.
Children
of
parents
who
suffer
from
arthritis
suffer low
selfesteem
and poor
functioni
ng.
or
mediators
.
Crosssectional
study.
Mixed
methods
approach.
Good
search
methods
and
exploratio
n of data.
Small
number of
included
studies.
Interestin
g
compariso
n between
different
groups.
Small
sample
size.
Did not
measure
mental
health of
mothers
with
arthritis.
66
Kaasboll J Parental
20
et al
chronic pain 18
and
internalizing
symptoms
in offspring:
the role of
adolescent’s
social
competence
– the HUNT
study.
Norw
ay
Results
were
comparab
le to
those
with
depresse
d
mothers.
There
were
different
psychoso
cial
influences
linked to
adolescen
t mental
health as
well as
maternal
disorder.
CrossParental
sectional
chronic
data taken pain
from
affects
previous
children’s
survey.
especially
girls
social
functioni
ng. One
healthy
parent
can offset
the effect
on
children.
May be
related to
nternalizi
ng
symptom
sand girls
having a
carer
role.
Large
sample
size.
Crosssectional
design.
Informatio
n from
both
parents
and
children.
Possibility
of
informatio
n bias
related to
use of cut
off levels
for
classifying
measures.
Use of
SEM to
evaluate
measurem
ent error.
67
Kaasboll J Psychologic 20
et al
al
12
symptoms
in children
of parents
with chronic
pain- the
Hunt study
Lewando
wski W
et al
Chronic pain 20
and the
07
family:
theorydriven
treatment
approaches
Norw
ay
U.S.A
Crosssectional
questionn
aire
Literature
review
Higher
levels of
depressio
n and
anxiety if
a parent
suffers
from
chronic
pain.
Tends to
be linked
to
emotional
difficultie
s in
children.
Higher
tendency
towards
conduct
problems
in girls if
mother
suffers
with
chronic
pain.
Family
system
theory,
CBT and
operant
conditioni
ng can be
used to
understa
nd and
help the
effects of
chronic
pain on
the
family.
Adjusted
for
confoundi
ng factors
and
mental
health.
Possible
nonresponder
bias.
Crosssectional
study.
Large
study.
Statistics
demonstr
ated
correlatio
n and
clinical
significanc
e.
Described
impact
and
effects of
chronic
pain on
the family
unit.
Explored
treatment
strategies.
Did not
outline
methods
used in
review of
the
literature.
Written in
format of
expert
opinion.
68
Payne B
and
Norfleet
M.
Perdue
B.J et al
Chronic pain 19
and the
86
family: a
review
Self19
perceived
93
competenci
es of latency
age children
of
chronically,
physically ill
mothers as
a function
of maternal
psychosocial
adjustment
to illness
and
children’s
reports of
mothering
behaviours.
U.S.A
U.S.A
Literature
review
Crosssectional
survey
Location
of pain
reported
n children
tends to
be the
same as
other
family
members.
These
children
have
inadequat
e
relationsh
ips with
their
mothers.
Family
members
can
reinforce
pain
behaviour
s.
Mothers
are the
primary
agent
involved
in
socialisati
on of
children.
If
parenting
is
affected
by illness
social
developm
ent can
be
impacted.
Good
summaris
ation of
literature.
Method
for review
of the
literature
and
numbers
of articles
included
not
outlined.
Informatio
n included
is
dated.Ma
ny articles
included
did not
use
controlled
samples.
Well
written.
Good
source
material.
Not
longitudn
al study.
Possible
recall and
reporting
bias.
69
Rikard K
Turner
Cobb J.M
et al
The
Occurrence
of
Maladaptive
HealthRelated
Behaviours
and
TeacherRated
Conduct
Problems in
Children of
Chronic Low
Back Pain
Patients.
Adjustment
in patients
with
rheumatoid
arthritis and
their
children
19
88
19
98
U.S.A
U.K
Crosssectional
questionn
aires
Interventi
on study
Children
model
mothers
behaviour
.
Inconsiste
nt
parenting
from
mothers
can affect
childrens
selfconcept.
Children
model
parents
pain
behaviour
s.
Children
showed
behaviour
al change
related to
parents
chronic
pain.
Children
experienc
ed coping
difficultie
s, social
issues
and
behaviour
al
difficultie
s. Cortisol
levels
measured
were
higher in
these
children.
Considere
d possible
mediating
factors.
Not a
longitudin
al study.
Difficulties
in
matching
controls.
Six month
study
using
range of
ages and
controls.
Measured
using a
variety of
questionn
aires and
weekly
cortisol
levels.
Reports
and
questionn
aires filled
in by
parents.
Small
sample
size.
70
Umberge
rW
Umberge
r W et al
Children of
Parents
With
Chronic
Noncancer
Pain: A
Comprehen
sive Review
of the
Literature.
20
14
Ways of
understandi
ng parental
chronic
pain: a
topology.
20
13
U.S.A
U.S.A
Literature
review
Retrospec
tive
interview.
Parental
chronic
pain is
linked to
internalizi
ng and
externaliz
ing
behaviour
s in
children,
and
increased
pain
complaint
s.
Considere
d
mediating
and
moderatin
g factors.
Limited
databases
searched.
Adolesce
nts tend
to
experienc
e parental
chronic
pain in
varying
ways
however
common
experienc
es include
worrying,
questioni
ng, lack of
certainty.
Considera
tion of
adolescen
t
experienc
e of
parental
chronic
pain. Gave
unique
perspectiv
es.
Small
sample
size.
Excluded
qualitative
studies.
Possible
recall bias.
71
Appendix G:
Table 5: Table of themes and codes used in thematic analysis.
Theme 1: Changes to parenting and
attachment in response to chronic pain.
Theme 4: Modelling of parents responses
to pain.
Codes:
Harsh parenting styles.
Codes:
Reflection of parental coping styles and
behaviours.
Emotional distance.
Environmental limitations/restriction.
Energy resources.
Pain narratives within families.
Anxious attachment pattern.
Somatization in families with pain.
Help-seeking behaviours.
Lack of social development.
Changes of role within family.
Dependency and anxious attachment.
Distraction of chronic pain.
Reduced functioning in chronic pain.
Theme 2: Internalizing and externalizing
behaviours in children.
Codes:
Emotional disorder/dysregulation.
Theme 5: Families role in maintaining pain.
Codes:
Responses to pain.
Acceptance of pain.
Anxiety.
Language used around pain.
Compulsive helpers/parentification.
Poor self-esteem.
Benefit of maintaining pain for family
system.
Poor communication/social skills.
Cognitive distortion.
Conduct disorder/Oppositional defiance
disorder.
Substance misuse.
Aggression.
Processing of emotions/communication of
distress.
72
Sex and age differences in children.
Theme 3: School avoidance.
Codes:
Inappropriate care-giving.
Theme 6: Children’s development of
resilience in care-giving.
Codes:
Development of empathy.
Limited coping resources.
Positive aspects of maternal chronic pain.
Reducing demands on development.
Influences of personality/temperament.
Development of practical skills.
Rewards for caring.
73