ORIGINAL ARTICLE

Relationship of Common Pain Conditions in Mothers and Children

Kathleen Saunders, JD,* Michael Von Kor, ScD,* Linda LeResche, ScD,w and Lloyd Mancl, PhDz

Objectives: The scientic evidence is conicting as to whether there is an association between parental and child pain. The goal of this study was to assess whether there is an association between: (1) site-specic pain conditions in mothers and children and (2) the presence of multiple pain conditions in mothers and children. Methods: A population-based sample of 2466 children aged 11 to 17 years who were members of a prepaid health were interviewed about the occurrence of common pain conditions back pain, headache, facial pain, and stomach pain. Their mothers were also interviewed about the presence of pain. Results: Children were at signicantly increased risk of having back pain, headache, and stomach pain if their mothers also reported pain at the same site (index pain). The association between maternal and child back pain and headache remained signicant after adjusting for mother and child demographic variables. A dose-response relationship was observed between maternal multiple pain sites (1, 2, 3, or more) and the presence of back pain, headache, and stomach pain in the child after adjusting for the mother having the index pain and other potential confounders. In multivariate analyses, children were at increased risk of having multiple (2 or more) pain conditions if their mothers had pain at multiple sites, with a dose-response relationship evident with increasing number of maternal pain sites. Discussion: There was an association between maternal and child pain in this population-based sample. The presence of multiple pain sites in the mother consistently predicted the presence of site-specic pains and multiple pains in the child. Future research on the association of child and parental pain should include multiple pain sites as both outcome and predictor variables. Key Words: adolescents, pain, parental pain, multiple pains, familial aggregation (Clin J Pain 2007;23:204213)

Received for publication January 10, 2006; accepted October 30, 2006. From the *Center for Health Studies, Group Health Cooperative; Departments of wOral Medicine; and zDental Public Health Sciences, University of Washington, Seattle, WA. Supported by NIH Grant No. P01 DE 08773. Reprints: Kathleen Saunders, JD, Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue Suite 1600, Seattle, WA 98101 (e-mail: saunders.k@ghc.org). Copyright r 2007 by Lippincott Williams & Wilkins

ain conditions among children and adolescents are common.17 Common pain problems such as headache, musculoskeletal pain, and stomach pain, cause suering and activity limitations, and adversely aect a childs quality of life.8,9 The causes of common pain conditions among children are poorly understood. A series of studies have focused on attributes of the child such as emotional distress,10,11 stress,12 physical activity,10,13,14 coping strategies,15 and pubertal development1620 that may increase risk of experiencing pain. Other population-based research has assessed whether children are at increased risk of having pain if their parents have pain. There are several reasons why pain in parents might be associated with pain in children. First, some pain conditions, most notably migraine, have a genetic component.2125 Second, researchers have hypothesized that children learn pain behaviors from parental role models.2628 And third, shared environmental factors, such as marital conict2931 or low socioeconomic status3236 may act to increase the risk of pain in both parents and children. Population-based studies have reported conicting results when assessing whether there is an association between child and parental pain status. The specic questions addressed in these studies are: Does a specic pain in a parent(s) increase the risk of a child having that same pain?16,37,38 Does the presence of pain at other anatomic locations in parents increase the risk of a child having a specic pain (eg, does stomach pain in a parent increase the risk of headache in the child)?39 Does the presence of any pain (eg, back or stomach or head or face) in the parent increase the risk of a child having any pain?38,39 Does chronic pain (continuous or recurrent pain for at least 3 mo) in the parent increase the risk of chronic pain in the child?15 Does the total number of pain/symptom conditions in family members, or the total number of signicant others with pain, increase a childs risk of pain?15,40 As mentioned above, prior research has yielded inconsistent results. Several community studies have found that the presence of a specic pain in the parent is associated with the child having pain at the same body site. Apley and Naish41 reported higher rates of abdominal pain among family members of children with recurrent abdominal pain (RAP) compared with family
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members of children without RAP. Deubner16 reported that children were at increased risk for migraine if one of their parents had migraine. In a study of low back pain among children age 8 to 16, Balague et al37 reported an association between low back pain in children and a history of treated low back pain in parents. Groholt et al36 found that same-site pains in parents were associated with same site pains in children among a sample of about 6000 children aged 7 to 17 years. On the other hand, Borge and Nordhagen39 in a study of 229 mother-father-child triads (children age 13 to 15 y) found no signicant association between same site pains (stomach, arms and legs, back, head, shoulder and neck) across generations except for neck and shoulder pain. Similarly, Jones et al38 did not nd an association between low back pain among 1326 schoolchildren age 12 to 15 years and the same pain in their parents. In a later study among older students age 12 to 17, Balague et al42 did not replicate their earlier ndings of an association between child low back pain and a history of parental treated back pain. Kovacs et al13 found no association between low back pain among children and parents in a study of 7048 13 to 15-year-old schoolchildren and their parents. When examining whether parental pains in other locations predicted a specic child pain condition, Borge and Nordhagen39 generally found no signicant relationships. Similarly, Groholt et al36 found that only same-site pains in the parents were predictive of same-site pains in the children; parental back pain was not associated with child headache, for example. In contrast, Apley and Naish41 found that family members of children with RAP were more likely to report other kinds of pain, as well as abdominal pain, compared with family members of children without RAP. When examining the association between any pain in the parent and any pain in the child, Borge and Nordhagen39 reported a 60% increased risk of any pain in the child if both parents had pain (vs. neither parent), but this did not reach statistical signicance. Jones et al38 found in bivariate analyses that any pain in the child was more common if both parents had pain versus both parents being pain-free, but the age-adjusted relative risk was not signicant. Merlijn et al15 found that chronic pain in the parent did not increase the risk of chronic pain in the child. Some studies have examined the relationship between child pain and the total number of pain conditions in family members or the total number of signicant others with pain. Merlijn et al15 found that children with chronic pain reported more signicant others with pain compared with children without chronic pain, but the eect size was small. Laurell et al40 found in bivariate analyses that the total number of reported pains and symptoms (not counting migraine) among rst-degree relatives was associated with migraine in a representative sample of 130 children aged 7 to 17. However, in multivariate analyses, the number of pains among relatives did not predict headache in the child. We
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are unaware of any community studies that have assessed the association of number of pain conditions in the child and parental pain, even though multiple pain conditions in children are common.43 In summary, population-based studies have examined the relationship between parental and child pain from many dierent angles, with no clear picture emerging. In a 2000 commentary, Kristjansdottir44 referred to the evidence related to familial aggregation of pain as inconclusive. Further, little is known about the association between child and parental multiple pain conditions. The purpose of this report is to add to the knowledge base related to the association of parental and child pain. Using data from a large, population-based study among children aged 11 to 17, we examined the association between maternal and child pain. The focus of this report is on childhood back pain, headache, stomach pain, and facial pain because these are among the most prevalent pain conditions among children.1 The specic questions addressed in this report are: (1) Does the presence of site-specic pain conditions and multiple pain conditions in mothers increase the probability of site-specic pain conditions occurring in their children? (2) Does the presence of multiple pain sites in mothers increase the probability of their children experiencing pain at multiple sites?

MATERIALS AND METHODS Study Sample

Participants were children aged 11 to 17 years old and their parents. Children were sampled from the enrollment database of Group Health Cooperative, a large, prepaid health plan in Washington State, on a monthly basis between April 2000 and May 2001. Because one of the study aims was to develop a cohort of 11-yearold participants to follow longitudinally through puberty, 11-year olds were sampled at a higher (nearly 100%) rate than older children. Thus, 11-year-old children, by design, constituted about 2/3 of the study sample. Potential participants were telephoned by a female interviewer. If the child and the childs parent or legal guardian provided informed consent, the child completed a 30-minute baseline interview about his or her pain experience, pubertal development, psychologic distress, and demographics. The parent (either mother or father) or legal guardian was also asked to participate in a brief telephone interview concerning his or her own pain experience, educational level, relationship to the child, and marital status. Given that the majority (85%) of the parent interviews were completed by the mother, we limited our analyses to mothers (excluding stepmothers) and their children. Combining data from mothers and fathers and their children to analyze the association between parent and child pain would be misleading given the dominance of mothers in the sample. The number of fathers providing data in this study was insucient to

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provide reliable estimates of the association of paternal and child pain status.

Measures Presence of Pain

Children were asked if they had experienced back pain, headache, stomach pain (not including menstrual pain), and facial pain (pain in any of the following places: the muscles of the face, the joint in front of the ear or inside the ear, other than an ear infection) in the last 6 months. These 4 pain conditions were selected because they are very prevalent among children.1 In addition, facial pain was a primary focus of the original grant. During the interview, children were told: We are interested in pain youve had that lasted a whole day or more, or that you had several times in a year. Please do not include little aches and pains that didnt last very long, like a short headache or sore muscles after exercising. Participants who reported ever having experienced a given pain condition were reminded of the severity criteria before being asked about pain in the last 6 months. Mothers were also asked about pain they had experienced in the last 6 months, with the same proviso that the pain was not brief or eeting, but rather lasted a day or more or occurred several times in a year. In addition to questions about back pain, headache, stomach pain, and facial pain, the parent survey included items about chest and joint pain. Children and mothers were classied as having the relevant pain condition if they reported that they had experienced it in the last 6 months.

rates were weighted for nonresponse. To assess the impact of nonresponse, all parents, whether or not they or their children participated in the study, were asked to report whether their child had at least one of the 4 pain conditions in the last 3 months. Participation in the study was higher for parents who reported that their child had at least one of the 4 pain conditions. To adjust for this response bias, weighted logistic regression analyses were used to estimate the prevalence rates, where the weighting was based on parents report of the child having any of the 4 pain conditions in the past 3 months, child sex, and child age.45 The weighting resulted in only a minor attenuation0% to 10%of the prevalence estimates.

Child Site-specic Pains

We rst conducted descriptive analyses examining the prevalence of each child pain condition by the presence or absence of that same pain condition in the mother. Next, 4 logistic regression models (one for each pain site) were used to model the prevalence of each pain condition (back pain, headache, facial pain, and stomach pain) in the last 6 months for children. These models included maternal status for each index pain in the last 6 months as the main independent variable (eg, if the dependent variable was the presence of back pain in the last 6 mo for the child, the independent variable was the presence of maternal back pain in the last 6 mo). These logistic models also included the following independent variables: mothers age (continuous), child sex, child age (11, 12 to 13, 14 to 15, 16 to 17 y), mothers marital status (married or living as married, never married, separated/divorced/widowed), and mothers educational attainment (less than high school, high school, some college, and college graduate). These variables were adjusted for in the models because parental marital status and educational level (a proxy measure of socio-economic status46) have been shown in some studies to be related to child pain3136 and modeling may be inuenced by the age42 and sex47 of the child. In addition, maternal age is related to mothers pain status, and, thus, is a potential confounder. We ran each logistic regression model a second time, adding mothers number of pain sites (0, 1, 2, 3 to 5) as an independent variable to determine the relative impact on the childs pain of the mother having the same pain condition and of the mother having multiple pain conditions. We made an empirical decision to group 3 or more pain sites into 1 category based on the distributional characteristics of the variableonly about 14% of mothers had 4 or more pains. In this analysis, the mothers number of pain sites did not include the sitespecic pain (eg, if the dependent variable was the presence of back pain in the last 6 mo for the child, the maternal number of pain sites in the last 6 mo did not include back pain).

Number of Pain Sites

The number of pain sites (back, head, stomach, face) reported by children in the last 6 months could range from 0 to 4. Maternal number of pain sites (0 to 6) indicated the number of pain conditions (back, head, stomach, face, joint, chest) reported by the mother in the last 6 months.

Demographics
Child sex and age were identied from health plan records and conrmed by both mother and child. Mothers age, highest level of educational attainment and current marital status were gathered in the parent interview.

Statistical Analysis Baseline Characteristics

We compiled descriptive baseline demographic and pain-related statistics for mothers and children.

Weighted Prevalence Estimates

Age-sex specic 6-month prevalence rates for the 4 pain conditionsback pain, headache, facial pain, and stomach painwere calculated for children. Because the response rate to the survey was 49%, these prevalence

Child Multiple Pain Sites

We employed a similar approach in analyzing the presence of multiple pain sites (0 to 1 vs. 2 or more) in the
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child in the last 6 months. First, we conducted descriptive analyses examining the prevalence of multiple pain sites in the child by the number of pain sites (0, 1, 2, 3, or more) in the mother. A logistic regression model was then run to model the prevalence of multiple pain sites (0 to 1 vs. 2 or more) in the child. This model included maternal number of pain sites (0, 1, 2, 3, or more), maternal and child age, child sex, and mothers education and marital status. We categorized the dependent variablechild multiple pain sitesinto categories of 0 to 1 vs. 2 or more because only 10% of children had pain at more than 2 sites.

TABLE 1. Baseline Characteristics for Mothers and Children (n = 2466)

Children (n = 2466) Age, mean (SD) years Female, % White race (child), % Age (child), % 11 y 12-13 y 14-15 y 16-17 y Education (mother), % Less than high school High school graduate Some college College graduate Marital Status (mother), % Married or living as married Never married Separated/divorced/widowed Pain Prevalence last 6 mo, % Back pain Headache Facial pain Stomach pain Chest pain Joint pain No. pain sites last 6 mo %* 0 1 2 3 4 5 6 12.2 (1.9) 51.3 69.2 65.7 11.6 11.4 11.3 24.9 26.9 12.7 34.5 43.2 28.8 17.3 7.4 3.3 Mothers (n = 2466) 41.5 (6.1) 100.0 3.6 23.5 31.4 41.5 74.7 5.1 20.2 46.9 40.9 14.5 20.5 12.7 44.5 21.1 27.4 22.2 15.5 8.5 4.3 1.0

RESULTS
A sample of 7723 children was initially identied. Of these, 6349 were determined to be eligible based on age, residence within the Seattle area and health plan membership. Among the eligible participants, 55% of parents or guardians provided consent for their children to be interviewed and 88% of the adolescents whose parents had consented agreed to participate, for a nal sample size of 3101 adolescent participants, that is, 49% of those eligible. Of the 3101 adolescent participants, 2466 are included in the current report because the analyses were restricted to children whose mothers completed the parent survey. Table 1 presents the baseline characteristics of the mothers and children included in this analysis. The child sample was split fairly evenly between boys and girls. Because of the design of the study, nearly two-thirds of the children were 11 years old at the time of the baseline surveys, with the remainder of the sample evenly divided among ages 12 to 17 (grouped in 2-y increments). Typical of the Group Health population,48 mothers in the sample tended to be highly educated with almost three-quarters completing at least some college. Threequarters of the mothers were married or living as married and about one-fth were separated, divorced, or widowed. Fifty-seven percent of children reported at least one of the 4 pain conditions (back pain, headache, facial pain, stomach pain) in the previous 6 months. The prevalence of stomach pain, back pain, and headache among children was roughly similarfrom a low of 24.9% with back pain to a high of 34.5% with stomach pain. Facial pain was less common among children (12.7%). About 30% of children reported a single pain problem in the last 6 months and a little more than one-quarter had from 2 to 4 pain problems. The prevalence of headache and back pain among mothers in the last 6 months was 11 2 to 2 times the comparable 6-month prevalence for children. Stomach pain was less common in mothers than in children (20.5% vs. 34.5%) whereas rates of facial pain were quite comparable (14.5% vs. 12.7%). About four-fths of mothers reported at least one pain condition in the last 6 months (including chest and joint pain), with about half reporting 2 or more pains (range of 2 to 6). Table 2 reports the 6-month age-sex specic prevalence rates among children for back pain, headache,
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*Range for children (0-4); range for mothers (0-6).

stomach pain, and facial pain, weighted for nonresponse. The weighting resulted in only a minor attenuation0% to 10%of the prevalence estimates. Prevalence rates of all 4 pains among 11-year-old boys and girls appear comparable; however, the sex gap widens with increasing age, with prevalence rates of headache, facial pain, and stomach pain among 16 to 17-year old girls 11 2 to 2 times higher than the comparable rates among boys of the same age. In contrast, rates of back pain among 16 to 17-year old boys and girls are similar. Among girls, prevalence rates for all pain sites except stomach pain seem to increase with age. Rates of stomach pain peak among 12 to 13-year-old girls and then decrease. The picture for boys is dierent: rates of back pain steadily increase with age, whereas headache and stomach pain rates tend to decrease over time, with facial pain rates remaining fairly stable. We also examined the weighted prevalence estimates for all children in the survey (ie, including children whose fathers, rather than mothers, completed the interview) and the results were very similar. Thus, restricting our analyses to mothers and their children did not aect the pain prevalence rates.

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TABLE 2. Prevalence of Pain Conditions (Past 6 mo) Among Children by Age and Sex*
Girls Age Back pain 11 12-13 14-15 16-17 Headache 11 12-13 14-15 16-17 Facial pain 11 12-13 14-15 16-17 Stomach pain 11 12-13 14-15 16-17 % 19.5 35.2 37.7 41.0 24.9 28.1 28.1 34.1 11.2 16.4 12.3 21.1 35.0 39.2 31.0 33.6 (95%CI) (16-22) (27-44) (30-46) (33-49) (22-28) (21-36) (21-36) (26-42) (9-14) (11-23) (7-19) (15-28) (31-38) (31-48) (23-39) (26-42) % 17.4 22.3 25.9 37.0 24.3 24.4 20.3 15.5 11.0 8.9 12.1 14.1 32.0 34.0 23.8 19.4 Boys (95%CI) (14-20) (16-30) (19-34) (29-46) (21-27) (18-32) (14-28) (10-23) (8-13) (5-15) (7-19) (9-21) (28-35) (26-42) (17-32) (13-27)

TABLE 3A. Child Pain Prevalence by Mothers Pain Status

Mother has Same Pain Problem All Children No Yes P Boys No Yes P Girls No Yes P Stomach Pain 33.4% 38.6% (0.03) 30.7% 33.6% (0.37) 36.0% 43.6% (0.03)

Back Pain 20.3% 30.2% (<0.0001) 17.4% 26.8% (<0.0001) 22.9% 33.7% (<0.0001)

Headache 23.0% 32.4% (<0.0001) 20.7% 29.6% (0.0004) 25.2% 35.2% (0.0001)

Facial Pain 12.4% 14.9% (0.18) 11.2% 13.0% (0.50) 13.4% 17.3% (0.19)

TABLE 3B. Child Prevalence of Multiple (2 or More) Pain Sites by Number of Mothers Pain Sites
No. Mothers Pain Sites* 0 1 2 3 or more P Percent With 2 or More Pain Sites All Children 18.5% 23.7% 31.1% 36.6% (<0.0001) Boys 17.4% 19.6% 25.0% 33.1% (<0.0001) Girls 19.6% 27.4% 36.8% 40.2% (<0.0001)

*Weighted for nonresponse.

Table 3 reports the results of the descriptive analyses for all children and for boys and girls separately. Table 3A, the site-specic results, shows that for all 4 pain conditions, children were more likely to have the specic pain if their mother reported that pain condition. For example, among mothers with back pain in the last 6 months, the 6-month prevalence of back pain among their children was 30.2% versus 20.3% among children whose mothers did not report back pain. With the exception of facial pain, which had lower prevalence than the other pain conditions, all associations between maternal and child index pains were statistically signicant. A similar pattern emerged for boys and girls separately. Prevalence rates for each pain condition were consistently higher among both boys and girls if their mother reported that pain condition. Although overall prevalence rates among girls tended to be higher, the magnitude of the dierence in the prevalence rates by mothers pain status was similar in girls and in boys for back pain and headache, but was somewhat larger in girls for facial and stomach pain. Table 3B shows a dose-response relationship between the number of maternal pain sites and the presence of multiple (2 or more) pain sites in children. More than 36% of children whose mothers reported pain at 3 or more sites reported multiple pain sites themselves, compared with 31%, 24%, and 19% of children whose mothers had 2, 1, or 0 pain sites, respectively. Similar dose-responses patterns were observed for boys and girls separately, except that the overall prevalence of multiple pain sites was higher in girls. Table 4 shows the results of the pain site-specic logistic regression analyses without adjustment for the

*Range for children (0-4); range for mothers (0-6).

number of maternal pain sites (see the numbers in the table without parantheses). After controlling for child age and sex, maternal age, and mothers education and marital status, children whose mothers had back pain or headache were at about 50% to 60% increased odds of having the condition versus children whose mothers did not have the index pain. The increased risk for those whose mothers had facial pain or stomach pain was 20% to 30%, although these associations were not statistically signicant. Table 4 also shows the results when mothers number of pain sites is added to the model (see the numbers in the table in parantheses). The magnitude of the association between mother and child pain is slightly attenuated for all 4 pain conditions, although the associations remain statistically signicant for back pain and headache. Mothers number of pain sites (0, 1, 2, 3, or more) was signicantly associated with the presence of back pain, headache, and stomach pain in the child even after controlling for the mother having the same pain. A dose-response relationship between the number of mothers pain sites and an increased odds of a child having the pain condition was evidenced for all 4 pain conditions, although the relationship with facial pain was not statistically signicant. The odds ratios for the remaining independent variableschild age and sex and mothers age, education,
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TABLE 4. Multivariate Logistic Regression Results for Child Pain (2 Models: 1 With, 1 Without, Adjustment for Number of Maternal Pain Sites)
Odds Ratios for Child Pain Back Pain Mother has index pain Mothers no. pain sites 3 or more pain sitesy 2 pain sitesy 1 pain sitey 0 pain sites Child is female Childs age 16-17 14-15 12-13 11 Mothers educational level <high school High school Some college College graduate Mothers marital status Separated/divorced/widowed Never married Married or living as Mothers age 1.60*w (1.46*)z NA (1.67*) NA (1.37*) NA (1.54*) J 1.38* (1.40*) 3.14* (3.19*) 2.15* (2.13*) 1.61* (1.60*) J 1.58 (1.54) 1.45* (1.42*) 1.41* (1.38*) J 1.30* (1.28*) 1.08 (1.05) J 0.99 (0.99) Headache 1.51* (1.33*) NA (1.76*) NA (1.44*) NA (1.26) J 1.30* (1.32*) 1.23 (1.20) 1.02 (1.02) 1.05 (1.03) J 1.29 (1.17) 1.37* (1.30*) 1.25 (1.20) J 1.54* (1.50*) 1.58* (1.54*) J 0.98* (0.98*) Facial Pain 1.29 (1.17) NA (1.41) NA (1.10) NA (0.86) J 1.27 (1.27*) 2.15* (2.11*) 1.19 (1.19) 1.17 (1.14) J 1.10 (0.98) 0.98 (0.94) 0.89 (0.86) J 1.16 (1.13) 0.47* (0.46*) J 0.96* (0.97*) Stomach Pain 1.22 (1.08) NA (1.82*) NA (1.62*) NA (1.40*) J 1.33* (1.35*) 0.69* (0.68*) 0.72* (0.71*) 1.06 (1.05) J 1.67* (1.57) 1.51* (1.45*) 1.35* (1.30*) J 1.16 (1.13) 1.13 (1.09) J 1.0 (1.01)

*Signicant at P <0.05. wOdds ratio (not in parantheses) from logistic model which excludes maternal number of pain sites as an independent variable. zOdds ratio (in parantheses) from logistic model which includes maternal number of pain sites as an independent variable. All other variables in the 2 models are the same. yExcludes index pain. JReference group. NA indicates not applicable because variable was not included in the model.

and marital statusremained fairly constant regardless of whether mothers number of pain sites was included in the model (compare numbers with and without parantheses in Table 4). Female sex increased the odds of a child reporting the index pain by about 30% for all 4 pain conditions. The risk of child back pain and facial pain increased with age, whereas the risk of child stomach pain seemed to decrease with age. The results with respect to mothers education level are not consistent across pain sites, but there is a suggestion that lower maternal educational attainment increases the odds of their children experiencing back pain, headache, and stomach pain. The association of the mothers marital status with the childs index pain is also inconsistent across pain sites. We examined the interaction between maternal pain and child sex for each of the 4 pain sites. None of the interaction terms were signicant (results not shown), indicating that the relationship between maternal and child pain did not signicantly dier for boys and girls. Table 5 reports the results of the logistic regression analysis for child multiple pains (2 or more sites) as the dependent variable. There was a dose-response relationship between number of mothers pain sites and the odds ratio for the child having multiple pain sites. Compared with children whose mothers reported no pain conditions, the odds for having multiple pain conditions were 2.4 times greater for children whose mothers had 3 or more pain sites, 1.9 times greater for children of mothers with 2
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pain sites, and 1.4 times greater for children with mothers with only 1 pain site. Female children and older children (16 to 17) were at increased odds of reporting multiple pain conditions. The interaction between parent number of pain sites and child sex was not signicant, indicating that the relationship between maternal and child number of pain conditions did not dier signicantly for boys and girls (results not shown).

DISCUSSION
Results from this population-based sample of children and their mothers showed that specic pain conditions cooccurred within mother-child pairs. For back pain, headache, and stomach pain, children were signicantly more likely to experience the specic pain condition if their mother reported that pain as well. In logistic regression analyses controlling for potential confounders such as maternal education and marital status, maternal back pain and headache continued to be statistically signicant predictors of the childs index pain, whereas the relationship between stomach pain was no longer signicant. Similarly, multiple pain sites also tended to cooccur in mothers and their children, with evidence of a dose-response relationship between number of mothers pain conditions and presence of multiple pains in the child.

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TABLE 5. Multivariate Logistic Regression Results for Child Multiple Pains (2 or More Sites)
Odds Ratio (95% CI) Mothers no. pain sites 3 or more pain sites 2 pain sites 1 pain site 0 pain sites Child is female Childs age 16-17 14-15 12-13 11 Mothers educational level <high school High school Some college College graduate Mothers marital status Separated/divorced/widowed Never married Married or living as Mothers age
*Signicant at the 0.05 level. wReference group.

2.38* (1.8, 3.1) 1.90* (1.4, 2.6) 1.39* (1.0, 1.9) w 1.45* (1.2, 1.8) 1.38* (1.0, 1.9) 1.11 (0.8, 1.5) 1.25 (0.9, 1.6) w 1.34 (0.8, 2.2) 1.53* (1.2, 2.0) 1.21 (1.0, 1.5) w 1.28* (1.0, 1.6) 1.22 (0.8, 1.8) w 0.98 (0.97, 1.0)

Several studies have similarly concluded that parental and child pains are associated,16,37,40,41 But notably, several recent population-based studies have not found an association between parental and child pain.13,15,38,39,42 There are several potential reasons for the discrepancy. The relationship between child and maternal/parental pain may depend on the denition of pain. The denition of pain varied across studies, ranging from a report of pain in the last 6 months in the current study, to having the pain at least weekly for at least 2 months,39 to having recurrent or continuous pain for at least 3 months.15 Some studies may not have been able to detect an association between parent and child pain due to small sample sizes.39,44 Some studies relied on proxy pain reportsin some cases the child reported on the parents pain42 and vice versa.36 McGrath has suggested that it is preferable to obtain pain reports directly from the source, as was done in the current study.49 The varying age ranges of the samples could also partially explain the discrepant results. For example, Balague et al42 found a relationship between low back pain in children and a history of treated back pain in parents in younger children but not in older children, leading the researchers to hypothesize that parents pain history might play a bigger behavioral role among younger vs. older children. However, the current study included a wide age range (11 to 17) and the relationship between maternal and child pain persisted after controlling for child age. Finally, the sources of the samples could inuence the relationship between parental and child pain. There is less disagreement in the scientic literature on the association between multiple pain conditions in

parents and site-specic or multiple pain conditions in children, although this association has not been extensively studied. Borge and Nordhagen39 and Groholt et al36 collected data on the prevalence of pain in multiple body sites in parents and/or children but did not include these variables in the reported analyses. Laurell et al40 found a bivariate relationship between child migraine and number of pains or symptoms in rst degree family members but number of pains did not predict child headache in multivariate analyses. However, the small sample sizeonly about 80 children had migraine or tension-type headachemay have limited the studys ability to assess the impact of family members number of pains and symptoms on child headache. In a clinical study among children recruited from a pediatric rheumatology clinic, Schanberg et al50 found that children whose families had a history of multiple pain conditions were more likely to report more pain locations than children whose families did not have such a history. There are several possible explanations for our ndings of a relationship between maternal and child pain. Our nding of a site-specic relationship between maternal and child back pain and headache is in accord with the theory of specic site modeling proposed by Osborne et al.26 That is, children are more likely to model the exact symptoms of the parent. However, multiple pain conditions in the mother seemed to be an even more consistent predictor of site-specic child pains than the mother having the site-specic pain itself, with maternal number of pain sites showing essentially a dose-response relationship with the presence of all 4 pain conditions in the child, although the association for facial pain did not reach statistical signicance. The strong relationship between multiple maternal pain sites and child pain may be due to several factors. We showed evidence of a dose-response relationship between parental and child painthat is, the more pain (ie, number of pain sites) expressed by the parent, the more opportunities for modeling. Consistent with this, Walker et al51 showed an association between higher somatization scores in mothers and fathers and higher somatization scores in children with RAP. Jones et al38 hypothesized a similar dose-risk relationship between parental widespread pain (WPextreme musculoskeletal pain syndrome) and child pain (eg, WP constituted a greater exposure), but did not nd an association. Varying denitions and time periods may partially explain the dierent results in that study versus those reported here. Roughly 5% of parents experienced WP in the last month in the Jones study. In contrast, almost 50% of parents in the present study reported 2 or more pain conditions over the last 6 months. This doseresponse line of thinking is consistent with Kristjansdottirs44 recommendation that future research look at the number of pains among signicant others and the number of signicant others with pain, not just sitespecic parental pain or any parental pain. An alternative, not necessarily mutually exclusive, explanation of the impact of maternal number of pain
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sites on child pain is that the presence of parental multiple pains may be a proxy measure for family stress or distress. Multiple pains have been shown to be associated with depression.52 Parental depression might result in family dysfunction or stress, attributes that have been implicated in a higher risk of somatization in children.31 Thus, a parent with multiple pains might impact a childs pain status through 2 mechanismsmodeling and contributing to a stressful family environment. In addition to these explanations, it is, of course, possible that children and their biologic mothers share genetic factors that increase both the mothers and the childs susceptibility to develop pain conditions. A number of genes have been postulated to increase pain susceptibility in humans.53 For example, Belfer et al54 identied genes for interleukin 6, neuronal nitric oxide synthetase, and interleukin 1b as high priority candidate genes for susceptibility to neuropathic pain in humans. We were not able to examine genetic factors in this study. Multiple pains are prevalent in children and are not well understood.43 In adults, the presence of multiple pains is associated with depression52 and may also predict onset55 and persistence56 of chronic pain at other body sites. Similar sequelae may await children who have pain at multiple sites. Our nding that multiple pains in parents seem to increase the risk for multiple pain conditions in children has potential clinical implications. As suggested by Schanberg et al,50 parents should be included in interventions targeting pain in children. Although we found a strong relationship between maternal and child pain, it is possible that shared environmental stressors might explain this association. For example, marital conict could increase the risk of pain in both the child and the mother, and thus could provide an explanation for family pain aggregation totally independent of the presence of pain in the mother. In the current study, the impact of maternal pain status on child pain report generally remained signicant after adjusting for important family environmentvariables maternal educational attainment (a proxy for SES)46 and marital statusleading to the conclusion that the cooccurrence of child and maternal pain in this study cannot be attributed solely to shared family environment variables. However, it is possible that maternal and child pains were related to other environmental stressors that we did not control for. Nonmarried marital status and lower educational status were themselves sometimes signicant predictors of child pain after adjusting for maternal pain. This nding, though secondary to this papers primary goal of assessing the association between maternal and child pain report, lends support to the existing literature showing an increased risk of childhood somatic complaints or pain among distressed families31 or among those of lower social class.3236 The relationship between parental and child pain seemed to be similar for boys and girls, although the overall prevalence of most pain conditions was higher for girls. Because our sample was limited to mothers, we were
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unable to examine whether the association between child and parent pain diered for mothers and fathers. This is a limitation because the eects of modeling may be inuenced by the sex of the parent and the child.47 For example, Walker et al57 found that fathers somatic symptoms are more consistently related to childrens symptoms than are mothers somatic symptoms. It is possible that our results may not be generalizable to fathers and in addition, our ndings do not provide information on the relationship between parental and child pain when both parents have pain. Childhood facial pain was not signicantly associated with any of the maternal pain variables. However, the relationship between facial pain and maternal number of pain sites mirrored that for the other pain sites. It may not have reached statistical signicance due to the relatively small number of children who reported facial pain relative to the other pain sites under study. A strength of this study is that it is a populationbased sample of parents and children, rather than a clinical sample.2 Parents and children reported their own pain conditions, which is preferable to surrogate reports.49 A potential limitation of this study is the low response rate. However, the sample seems to be demographically similar to the underlying population. Child age was not associated with participant response (P = 0.73), nor was there a dierence in participant response overall by sex (P = 0.14). Further, the racial distribution of the study sample was similar to the racial distribution of adolescents in other Group Health studies. Prevalence rates for the various parental pain conditions found in this study were similar to the rates found in a prior investigation of the same adult population (response rate = 80%) using similar questions,58 and the dierences (ranging from 0.5% to 5.9%) were not systematic in direction. This similarity further indicates that the sample in this study was fairly representative of the underlying population. We did nd that the response rate was higher for parents who reported that their child had at least one of the 4 pain conditions in the last 3 months, but adjusting for nonresponse had a minimal eect on the child pain prevalences. Whatever response bias existed, it is unlikely that the relationship between child and parent pain would be aected by such a bias. Our sample was relatively well educated so it is possible that the results are not generalizable to other populations. In conclusion, our analyses indicate that specic pain conditions and multiple pain conditions tend to cooccur in mothers and their children. Multiple pain conditions in mothers were a consistent predictor of both site-specic and multiple pains in children, with evidence of a dose-response relationship. Future research on the association between parental and child pains should include multiple pain sites as predictor and outcome variables. REFERENCES
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