The impact of parental attitudes toward children with primary headaches

Abstract

There is a lack of data on parental attitudes toward children with primary headaches. The aim of this study is to determine whether there is a relationship between primary headaches and parental attitudes in the pre-adolescent pediatric population. In this cross-sectional study, 195 children with primary headache and 43 healthy children aged 9–16 years were included. A questionnaire for sociodemographic variables, visual analog scale (VAS), Social Anxiety Scale and Depression Inventory for Adolescents and Children, and Parental Attitudes Determining Scale (PATS), which is an attitude measure specifically designed to evaluate psychological adjustment, were administered. Of 195 children (female/male ratio: 89/106, mean age: 12.59 ± 1.09 years), episodic migraine (n = 90), chronic migraine (n = 25), and tension-type headache (n = 80) were evaluated. There was no significant difference among headache groups and healthy subjects in terms of depression, anxiety, and fathers’ attitude scale scores. However, there were significant differences in mean mothers’ attitude scale scores and VAS scores (p = .002, p = .000). Mean oppressive-authoritarian attitude subscale scores of mothers’ was significantly higher in children with chronic migraine (p = .000). A relationship between depression and VAS scores among all patient groups was detected (p = .000). Parental age was negatively related to PATS scores of children with episodic migraine and tension-type headache (p = .037 and p = .036). Parental attitudes may elevate psychiatric symptoms and influence children’s perception of pain intensity and result in chronification of headache. Our findings support that mothers’ attitude toward children with chronic migraine has strong impacts on the child’s pain experience.

Keywords

Children headache migraine tension-type headache depression anxiety parental attitude

Introduction

Primary headaches are one of the most common neurological complaints of children and adolescents and may result in disruption of child’s daily activities, including missed school days and learning difficulties, and cause socioeconomic burden to families (Tavasoli, Aghamohammadpoor, & Taghibeigi, 2013). Migraine and tension-type headaches (TTHs), the most important cause of primary headaches, are reported at different prevalence rates until present because of promoted different techniques such as completing questionnaires, face-to-face interviews, clinical assessments, and differences of diagnostic criteria (Jeong, Lee, Lee, & Han, 2018; Laurell, Larsson, & Eeg-Olofsson, 2004). It is reported that the estimated prevalence of headache in children and adolescents is 58.4% (Abu-Arafeh, Razak, Sivaraman, & Graham, 2010). The prevalence rates of migraine and TTH were reported to be 7.2% and 7.8%, respectively in our population (Poyrazoglu et al., 2015).

High number of studies reported that characteristics of headaches as well as the psychosocial features and cultural factors may contribute to children’s pain experiences (Machnes-Maayan et al., 2014; Mazzone, Vitiello, Incorpora, & Mazzone, 2006; Pope, Tallon, McConigley, Leslie, & Wilson, 2017). Nevertheless, it seems to be that there are other factors influencing children’s characteristics of the headache and associated symptoms. In addition, parent–child interactions have an important influence on the development of the child’s children’s pain, functioning, and psychological characteristics. Although some work has reported the interactions of parent-child in migraine and chronic diseases (Siniatchkin et al., 2003), to date, the effects of parenting stress and maltreatment, depression, and anxiety have been scarce in migraine and TTH among pediatric population. This study aimed to determine the parents’ attitudes, psychiatric symptoms, and demographic and clinic features of migraine and TTH among school children between the ages of 9–16 using the International Classification of Headache Disorders III, beta version.

Methods

Participants

The study protocol was approved by the research ethics committee at the participating university and carried out in accordance with the Declaration of Helsinki. Informed consents were obtained from the parents. A total of 195 children (female/male ratio: 89/106, age range between 6–16 years, median age: 12.59 ± 1.09 years) with episodic migraine (n = 90), chronic migraine (n = 25), and TTH (n = 80) who have been followed in our headache outpatient unit from September 2016 to June 2018 were included. The diagnosis of headaches was made according to their neurological examination, cranial magnetic resonance imaging (MRI) findings, and all diagnoses were based on the International Classification of Headache Disorders, 3rd edition (beta version) (Headache Classification Committee of the International Headache Society, 2013). In addition, in this cross-sectional, clinic-based study, we enrolled 43 aged and sex-matched healthy children. Children completed all of the questionnaires at the same time.

We collected data on sociodemographic variables such as age, sex, family income, educational levels of parents, type, duration and frequency of headaches, visual analog scale (VAS) for headache severity, MRI findings, family history of headache, and previous treatment in patients. In healthy controls, we obtained data on age, sex, family income, and educational levels of parents. Healthy controls who did not have previous history of neurological disorders were selected among hospital children patients who had previously been diagnosed with any other health condition (i.e., rheumatological disorders, endocrine disorders, and cancer) by a professional were excluded. All other causes of headache disorders also comorbid headache disorders like migraine plus TTH or other causes of headache had been excluded. All subjects’ physical and neurological examinations were normal.

Instruments

Parental Attitudes Determining Scale

Validated Parental Attitudes Determining Scale (PATS) which is an attitude measure specifically designed to evaluate psychological adjustment was used to assess the parental attitudes. This questionnaire is fulfilled by children and includes 50 clauses with 5-point Likert-type questions to determine four different parental attitudes. These parental attitudes which are determined as subscales in the questionnaire are as follows: oppressive-authoritarian parental attitude, protective parental attitude, apathetic parental attitude, and democratic parental attitude. PATS was developed by Lamborn in 1991 and national validation was completed (Lamborn, Mounts, Steinberg, & Dornbusch, 1991; Yilmaz, 2000).

Social Anxiety Scale for Adolescent

The Social Anxiety Scale for Adolescents (SAS-A) is an 18-item self-report measure of social anxiety developed as an adaptation of the Social Anxiety Scale for Children—Revised, a measure of children’s social anxiety. The wording of items was modified to match the developmental phase of adolescence. SAS-A consists of three factors: Fear of Negative Evaluation, Social Avoidance and Distress Specific to New Situations, and Social Avoidance and Distress in General. SAS-A was developed by La Greca and validated into Turkish by Memik (Demir, Eralp-Demir, Turksoy, Ozmen, & Uysal, 2000; La Greca & Lopez, 1998).

Children’s Depression Inventory

To measure depression, Children’s Depression Inventory (CDI), a brief self-report test that helps assess cognitive, affective, and behavioral signs of depression in children and adolescents aged 7–17 years, was used. CDI was developed by Kovacs (1985) and adapted into Turkish by (Oy, 1991). There are five subscales within the assessment that measure different components of depression: negative mood, anhedonia, negative self-esteem, ineffectiveness, and interpersonal problems. Items can be respondent on a two-point scale, ranging from 0 to 2 points. CDI total scores of 65 or above identify potentially clinically depressed individuals.

Statistical analysis

In this study, SPSS 23.0 was used as the statistical analysis program. Descriptive statistics (mean, standard deviation, and frequency) were used for the demographic and clinical characteristics. Statistical analysis was performed using the chi-square test or Fisher’s exact test for categorical parameters and analysis of variance (ANOVA) followed up by post-hoc pairwise comparisons of groups using Tukey’s method for continuous variables. A p value <.05 was considered to be statistically significant.

Results

Details of demographic features of participants are given in Table 1. Because of small sample size of chronic TTH group, both patients with episodic and chronic TTH groups were combined for statistical evaluation. There were no statistically significant difference on parental and children’s mean age and gender of subjects (p > .05). Family members with a history of primary headache were more common in the group with TTH (p = .045). The most common headache trigger for episodic migraine group was exam days; however, stress was the most reported trigger factor for chronic migraine and TTH groups.

Table 1.

Demographic characteristics of study participants.

	Episodic migraine	Chronic migraine	Tension-type headache	Control group	p
Age (mean ± SD)	12.8 ± 1.0	12.2 ± 1.2	12.5 ± 1.0	12.9 ± 1.2	.058
Gender (boy/girl)	48/42	7/18	34/46	19/24	.061
Age of Mothers (mean ± SD)	40.0 ± 5.1	37.9 ± 4.5	38.4 ± 5.0	40.0 ± 4.6	.061
Age of Fathers (mean ± SD)	44.1 ± 5.8	42.3 ± 5.8	42.5 ± 4.6	43.8 ± 4.5	.154
Educational level of mothers (primary/secondary/university)	58/25/7	12/11/2	43/28/9	29/11/3	.534
Educational level of fathers (primary/secondary/university)	39/38/13	10/10/5	35/27/18	16/20/7	.763
Family history of headache (mother/father/other relatives)	41/15/28	9/7/8	31/14/22	16/4/14	−

SD: standard deviation.

Depression and anxiety inventory scores, VAS scores and parental attitude form results are demonstrated in Table 2. There were no significant difference among headache groups and healthy subjects in terms of depression (p = .640), anxiety (p = .712), and fathers’ attitude scale scores (p = .969). However, there were significant differences in mean mothers’ attitude scale scores and VAS scores (p = .002 and p = .000, retrospectively). Post hoc Analysis of mother’s attitude scores and VAS scores of patient groups and controls is given in Table 3. Only mean oppressive-authoritarian attitude subscale scores of mothers’ were significantly higher in patients with chronic migraine (p = .000).

Table 2.

Mean visual analog scale, Social Anxiety Scale, Children’s Depression Inventory, and parental attitudes determining scale scores of patient groups and controls.

	Episodic migraine	Chronic migraine	Tension-type headache	Control group	p value
VAS Score	5.1 ± 1.8	6.6 ± 1.5	4.2 ± 2.0	−	.000
Social Anxiety Score	40.2 ± 12.3	41.6 ± 11.8	38.8 ± 10.5	40.4 ± 12.0	.712
Depression Score	12.8 ± 7.7	14.7 ± 8.7	12.8 ± 6.7	12.5 ± 5.8	.640
Mother’s attitudes score	167.0 ± 15.1	177.0 ± 18.2	165.5 ± 18.6	160.7 ± 13.8	.002
Father’s attitudes score	161.6 ± 18.8	160.3 ± 17.5	160.5 ± 15.6	160.5 ± 15.6	.969

VAS: visual analog scale.

Significant differences are given in bold and italic.

Table 3.

Post hoc analysis of mother attitudes score and visual analog scale scores of patient groups and controls.

	p	Pairwise comparisons (p values)
	p	EM vs CM	EM vs TTH	EM vs control	CM vs TTH	CM vs control	TTH vs control
Mother attitudes score	.002	.038	.929	.172	.013	.001	.428
Oppressive-authoritarian attitude	.000	.005	.498	.695	.000	.001	1.000
Protective attitude	.297	−	−	−	−	−	−
Apathetic attitude	.542	−	−	−	−	−	−
Democratic attitude	.220	−	−	−	−	−	−
VAS score	.000	.002	.003	−	.000	−	−

VAS: visual analog scale; EM: episodic migraine; CM: chronic migraine; TTH; tension-type headache.

Significant differences are given in bold and italic.

Correlation between variables and PATS scores in all patient groups are demonstrated in Tables 4 and 5. In episodic migraine group, there was a positive correlation between VAS and depression scores (p = .005; r = .294). In addition, we observed a significant relationship between depression and anxiety (p = .000; r = .399). In chronic migraine group, VAS and anxiety scores were positively correlated (p = .015; r = .482), in addition to that, anxiety and depression had positive correlation (p = .042; r = .379). In TTH group, there was a positive correlation between VAS and depression scores (p = .002; r = .334). Our results demonstrated a significant relationship between depression and anxiety scores among children with TTH (p = .049; r = .221). None of the other demographic variables showed a significant correlation except for the relationship between age and PATS scores. In episodic migraine group, there was a negative correlation between patient’s age and paternal attitude scores (p = .042, p = .019, respectively) and father’s age was negatively correlated with father’s attitude scores (p = .037; r = –.220). In the TTH group, there was a negative correlation between mother’s age and mother’s attitude scores (p = .036; r = –.234). We also found a negative correlation between patient’s age and mother’s attitude scores in this group (p = .032; r = –.241). Chronic migraine group did not show any correlation between age and psychiatric symptoms scores, pain intensity, and PATS scores.

Table 4.

Correlation between pain severity, psychiatric symptoms, and PATS scores in all patient groups.

		Episodic migraine		Chronic migraine		Tension-type headache
		r	p	r	p	r	p
VAS	Anxiety Scores	.146	.171	.482	.015	.167	.139
	Depression Scores	.294	.005	−.053	.802	.334	.002
	Mother’s attitude scores	.147	.168	−.330	.107	−.050	.661
	Father’s attitude scores	−.002	.989	−.310	.132	−.121	.284
Anxiety	Depression Scores	.399	.000	.379	.062	.221	.049
	Mother’s attitude scores	.237	.025	.167	.425	.159	.158
	Father’s attitude scores	.159	.134	.220	.290	.115	.310
Depression	Mother’s attitude scores	.087	.415	−.166	.427	.233	.038
Depression	Father’s attitude scores	−.048	.652	−.302	.142	.071	.534

VAS: visual analog scale.

Significant differences are given in bold and italic. r: Pearson correlation coefficient.

Table 5.

Correlation between age, psychiatric symptoms, and PATS scores in all patient groups.

		Episodic migraine		Chronic migraine		Tension-type headache
		r	p	r	p	r	p
Patient’s age	VAS scores	.004	.968	−.170	.416	.365	.001
	Anxiety Scores	−.024	.825	−.243	.243	−.104	.358
	Depression Scores	.259	.102	.036	.865	.340	.002
	Mother’s attitude scores	− .215	.042	.055	.792	− .241	.032
	Father’s attitude scores	− .246	.019	−.249	.231	−.171	.130
Mother’s age	VAS Scores	−.077	.472	−.083	.694	−.051	.653
	Anxiety Scores	−.023	.827	−.156	.456	−.100	.380
	Depression Scores	.102	.337	.082	.697	−.214	.057
	Mother’s attitude scores	−.098	.360	−.092	.660	− .234	.036
Father’s age	VAS	.060	.571	.065	.758	−.125	.270
	Anxiety Scores	−.040	.710	−.227	.275	−.112	.322
	Depression Scores	.110	.302	.109	.604	−.191	.089
	Father’s attitude scores	− .220	.037	−.177	.397	−.027	.814

VAS: visual analog scale.

Significant differences are given in bold and italic. r: Pearson correlation coefficient.

Discussion

The aim of this study is to examine the relationship between headache characteristics, depression, anxiety, and parental attitudes in the pediatric population with episodic migraine, chronic migraine, and TTH. The results indicated that pain intensity had a statistically significant positive correlation with the psychiatric symptoms of all three groups. Mothers’ attitude toward children with episodic migraine was related to higher anxiety symptoms. Mothers of children with chronic migraine had a significantly higher oppressive-authoritarian attitude than the other headache groups. Father attitude was not significantly correlated with the psychiatric symptoms and headache severity. Although parental level of education and income did not show a significant correlation, a significant relationship between patient’s and parent’s age and PATS scores were detected. Higher number of age was related to negative parenting. The relationship between headache severity and depression was similar to prior studies (Kashikar-Zuck, Goldschneider, Powers, Vaught, & Hershey, 2001; O’Brien & Slater, 2016). Pediatric patients with primary headaches might frequently suffer from psychiatric symptoms such as anxiety and depression as expected (Pakalnis, Butz, Splaingard, Kring, & Fong, 2007). Comorbid depression and anxiety symptoms may contribute to worsening of clinical symptoms in patients with migraine and TTH even though underlying pain mechanisms are different.

Our findings implicated that chronic migraine may be influenced by mothers’ attitudes particularly oppressive-authoritarian behavior, suggesting that protective parenting may also affect children’s pain experience. This type of parent is generally forced to engage in behavior to impose on children with the belief that children often lose control (Serinkan, 2012; Shaffer, 1999). Palermo, Valrie, and Karlson (2014) suggested that parental emotions and behaviors play a role in children’s pain experiences and protective parental behaviors may cause increased distress, thus so far chronification of migraine in pediatric group may be linked to parental influences independently. Based on our clinical experience, parents of children with chronic migraine have more negative reflection on their child’s pain experience.

In spite of the importance of parental attitudes in pediatric headache, there are currently no published studies regarding the assessment of the parents’ attitudes toward children with primary headaches. Child’s perception of and response to headache might be influenced by psychiatric symptoms, including but not limited to depression and anxiety, and family factors. In general, many different research studies have involved primarily mothers (Evans, Meldrum, Tsao, Fraynt, & Zeltzer, 2010; Palermo et al., 2014); however, we evaluated the fathers attitudes, too. The psychological effects of fathers on children with headache have not been investigated yet. This study provides evidence that mothers’ attitude has greater impact on chronification of migraine rather than the fathers’.

Previous studies indicated that maternal modeling of pain management has significant influences on children’s pain experiences and youth disability (Beyer & Simmons, 2004; Hatchette, McGrath, Murray, & Finley, 2008). The study by Kaczynski, Claar, and Lebel (2013) is unique for assessing the relations between child and parent variables, school functioning, and pain characteristics in adolescents with migraine and TTH. They evaluated both adolescents and their parents, and found that patients with TTH suffered more depression from migraineurs, and their parents endorsed greater difficulties. Children with chronic migraine in this study reported more protective parenting and oppressive-authoritarian mother attitude. Different from our methods, Kaczynski et al. did not evaluate the patients as episodic and chronic migraine groups, and the mean age range of the patients in their study was older than our clinical sample. To our experience, migraine is generally considered by parents to be more serious and severe because of its associated symptoms (e.g., vomiting and authomonic symptoms), for this reason, protective parenting attitudes may be more frequent in pediatric population with migraine than TTH in our sample. Contrary to our results, Kaczynski et al. found that parental protective behavior and difficulties with school functioning were more common in adolescents with TTH than with migraine group (26).

We acknowledge some limitations in our study. Because of small sample size of chronic TTH group, both patients with episodic and chronic TTH groups were combined for statistical evaluation so that we could not evaluate the effects of parental attitudes and psychiatric symptoms on chronification among pediatric patients with TTHs.

The strength of our study includes that we compared our results with healthy subjects. Besides this, we evaluated the psychiatric symptoms and found a relationship between parental attitudes and depression and anxiety. Previous studies were focused on the interaction between mother and child, but we also evaluated the father attitudes from child’s perspective. The findings support that protective parenting has several effects on migraine in children. Parental attitudes may elevate psychiatric symptoms and influence children’s perception of pain negatively. Our study may be improved by assessing parents’ response to their child’s pain experience in future research.

Footnotes

Acknowledgements

The authors thank Mr Mustafa Cem Ertem for assistance with statistical analysis.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics statement

Written consent was taken from children’s parents.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Devrimsel Harika Ertem

Author biographies

Devrimsel Harika Ertem is a Neurologist and Headache Specialist in University of Health Sciences, Istanbul, Turkey.

Ayhan Bingol is a Licensed Clinical Psychologist and interested in headache disorders.

Busra Ugurcan is a Psychologist and PhD candidate in Bahcesehir University.

Ozlem Mercan is a Neurologist and fellowship in pain management in Cerrahpasa School of Medicine.

Ismail Simsek is a resident in Neurosurgery in Marmara University and former medical school student of Cerrahpasa School of Medicine.

Hanife Saglam is medical student in Cerrahpasa School of Medicine.

Aynur Ozge is a Headache and Clinical Neurophysiology specialist who works in the department of neurology, Mersin University.

Derya Uluduz is a Headache and Stroke Specialist who works in the department of neurology, Cerrahpasa School of Medicine, Istanbul University.

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