The pediatric pain equation: Where do parental injustice appraisals of pain fit in?

Pain is not a singular physical sensation. It can be amplified or reduced by a multitude of physical, psychological, and social factors. For example, we recently found that when children view their pain as “unfair” or “unjust” (pain-related injustice appraisals) they also report more pain, impairment, and worse functioning, even after we accounted for the effects of pain catastrophizing [1]. While interesting, these findings do not represent the whole picture. Particularly in the case of children, we need to consider the role of parents. More specifically, we might ask how parents’ appraisals of their child’s pain fit into this equation. Do parents view their child’s pain as unjust? Do they share similar injustice appraisals as their child? Do these similarities (or lack thereof) impact children’s functioning? There are many questions to answer. We attempted to address several of these questions in a recent cross-sectional study of children and their parents (N=253) who were receiving chronic pain care in our university-based pediatric pain clinic. Both parent and child filled out a questionnaire assessing their injustice appraisals about their own/their child’s pain. Children also filled out questionnaires assessing their pain intensity, stress level, functional disability and quality of life. We were particularly interested in the level of agreement between parent (we sampled mostly mothers) and child injustice appraisals and how this related to child functioning.

We found the following: 1) parents reported higher injustice appraisals about their child’s pain than did their children, 2) most parent-child pairs reported similar injustice appraisals about the child’s pain, and 3) children reported the worse pain-related outcomes (pain, functional disability, stress, and quality of life) when they perceived their pain to be highly unjust but their parent did not [2].

These findings add to the literature highlighting the importance of how parents think about their child’s pain [3]. We hypothesize that parental appraisals of their child’s pain drive their reactions to this pain, which, in turn, affects the child’s own pain-related appraisals and behaviors. Parents who frequently think about their child’s pain as an injustice may be particularly likely to do things like limit the child’s activity or pester the child with questions about their pain (“How bad is it now?” “That looks like it might hurt – you should probably stop.”). Overly protective or solicitous responses from parents are associated with, among other things, increased impairment and symptom complaints in children [4,5]. However, we did not measure parental responding in the current study, so these hypotheses remain to be tested.

A particularly novel aspect of our study was its focus on the discrepancy between parent and child injustice appraisals. As mentioned above, the worse outcomes were reported by parent-child pairs where the child held significantly higher pain-related injustice appraisals than the parent. We speculate that a parent-child discrepancy in injustice appraisals may foster feelings of invalidation in the child – that their parent is not taking their pain seriously. This, in turn, may lead to maladaptive pain behaviors intended to communicate just how severe and serious their condition is (“I’m really hurting!”). Indeed, studies in adults with chronic pain have found that injustice appraisals are associated with heightened displays of pain behavior [6] and consequent adverse outcomes [7,8]. Our future plans are to investigate the mechanisms by which injustice appraisals contribute to poor functional outcomes in pediatric pain.

The current and past findings on pain-related injustice in children may have several clinical implications. A lot of really smart people have been discussing the importance and feasibility of intervening on pain-related injustice appraisals in adults [9,10]. Results of the current study [2] and those that preceded it [1] suggest that children and adolescents, as well as their parents, should be included in these clinical discussions. Moreover, the current study further highlights the important role of parents in the pediatric pain equation and suggests that injustice-focused interventions for pediatric chronic pain likely need to include a parental component.

About Megan Miller

Megan is a graduate student in the Clinical Psychology PhD program (health psychology specialty) and a member of the Pain Research Laboratory at IUPUI. Her emerging program of research seeks to better understand: 1) psychosocial factors (e.g., pain-related injustice, coping, and resilience) that influence pain and functioning in children/adolescents with pain, and 2) sociocultural factors that facilitate and impede the delivery of guideline-concordant care for children/adolescents with pain. Her first line of research focuses on pain-related injustice appraisals and their relationship to functional outcomes in pediatric pain patients. She is also examining how caregiver factors, such as injustice appraisals and catastrophizing, influence children’s pain experience. Regarding her second line of research, she is using Virtual Human patients to examine how provider bias, provider empathy, and pediatric patient and parent characteristics (e.g., race, gender, and SES) individually and interactively affect pain care. In her spare time she dabbles in photography and confectionary creations. Her joys in life include her dogs, good music, great food, and tasty beverages.


[1] Miller, M. M., Scott, E. L., Trost, Z., & Hirsh, A. T. (2016). Perceived Injustice Is Associated With Pain and Functional Outcomes in Children and Adolescents With Chronic Pain: A Preliminary Examination. The Journal of Pain, 17(11), 1217-1226.

[2] Miller, M. M., Wuest, D., Williams, A. E., Scott, E. L., Trost, Z., & Hirsh, A. T. (2018). Injustice perceptions about pain: parent–child discordance is associated with worse functional outcomes. Pain, 159(6), 1083-1089.

[3] Logan, D. E., Simons, L. E., & Carpino, E. A. (2012). Too sick for school? Parent influences on school functioning among children with chronic pain. Pain, 153(2), 437-443.

[4] Claar, R. L., Simons, L. E., & Logan, D. E. (2008). Parental response to children’s pain: the moderating impact of children’s emotional distress on symptoms and disability. Pain, 138(1), 172-179.

[5] Guite, J. W., McCue, R. L., Sherker, J. L., Sherry, D. D., & Rose, J. B. (2011). Relationships among pain, protective parental responses, and disability for adolescents with chronic musculoskeletal pain: the mediating role of pain catastrophizing. The Clinical Journal of Pain, 27(9), 775-781.

[6] Sullivan, M. J., Davidson, N., Garfinkel, B., Siriapaipant, N., & Scott, W. (2009). Perceived injustice is associated with heightened pain behavior and disability in individuals with whiplash injuries. Psychological Injury and Law, 2(3-4), 238-247.

[7] Prkachin, K. M., Schultz, I., Berkowitz, J., Hughes, E., & Hunt, D. (2002). Assessing pain behaviour of low-back pain patients in real time: concurrent validity and examiner sensitivity. Behaviour Research and Therapy, 40(5), 595-607.

[8] Prkachin, K. M., Schultz, I. Z., & Hughes, E. (2007). Pain behavior and the development of pain-related disability: the importance of guarding. The Clinical Journal of Pain, 23(3), 270-277.

[9] Scott, W., Trost, Z., Milioto, M., & Sullivan, M. J. (2015). Barriers to change in depressive symptoms after multidisciplinary rehabilitation for whiplash: the role of perceived injustice. The Clinical Journal of Pain, 31(2), 145-151.

[10] Sullivan, M. J., Scott, W., & Trost, Z. (2012). Perceived injustice: a risk factor for problematic pain outcomes. The Clinical Journal of Pain, 28(6), 484-488.