Depression as a mediator of the relation between family functioning and functional disability in youth with chronic headaches.

OBJECTIVE: This retrospective chart review examined a mediation model of parent and family functioning, childhood depression, and functional disability in youth with chronic headaches. Specifically, we evaluated whether depression mediates the relations between protective parenting and functional disability and between family functioning and functional disability. BACKGROUND: Children and adolescents with chronic and recurrent headache report elevated symptoms of depression. Children with chronic pain conditions, including chronic headaches, have also been found to originate from families with greater conflict, poorer cohesion, and lower organizational structure, and impaired family functioning is associated with greater disability in youth with chronic pain. METHODS: Three hundred and eighty-two patients ages 5-17 years who underwent a multidisciplinary evaluation at a tertiary pediatric headache clinic were included in this study. Participants completed a pain intensity rating, the Children's Depression Inventory, and the Functional Disability Inventory. A parent completed the Family Relationship Index and the Adult Responses to Children's Symptoms questionnaires. Structural equation modeling was used to examine a mediation model and several alternative models. RESULTS: Mediation was not supported, but an alternative model with both direct and indirect pathways provided excellent fit to the data: χ2(1) = 0.745, P = .39; comparative fit index = 1.00, root mean square error of approximation = 0.00 (CI: 0.00-0.17). Family functioning (ß = -0.19, P < .01) and protective parenting (ß = 0.17, P < .01) were associated with depression, but not disability. Depression was linked to disability (ß = 0.24, P < .01). There was an indirect pathway from family functioning to depression to disability (ß = -0.05, P < .05). CONCLUSIONS: Family context is an important variable to consider in youth with chronic headaches and disability. While many studies have identified family functioning and depressive symptoms as separately linked to functional impairment, to our knowledge, we are the first to demonstrate depression as an intermediary variable between family dysfunction and disability within the pediatric headache population.

The Impact of Sleep on Disability and School Functioning: Results From a Tertiary Pediatric Headache Center.

Pediatric headache patients often experience significant sleep disturbance, which may be a risk factor for poor physical, academic, and emotional functioning, including increased anxiety/fear. The current retrospective cohort study of a clinical sample of youth with persistent headache aimed to examine the impact of sleep on functional outcomes and to explore pain-related fear as a mediator of the association between sleep problems and functioning. A total of 109 youth (aged 7-17 years) with persistent headache presenting to a tertiary pediatric headache center (and their parents) completed measures of sleep problems, fear of pain, functional disability, and school functioning at the time of an initial evaluation and 6 months later. After controlling for age and headache frequency and severity, linear regression analyses indicated that increased sleep problems at baseline were associated with increased functional disability and poorer school functioning at baseline (ß = 0.28, P = .01; ß = -0.42, P < .001, respectively). Poor sleep at baseline was associated with poorer school functioning (but not functional disability) at follow-up (ß = -0.25, P = .02). Mediation models demonstrated an indirect mediating effect of pain-related fear on the association between baseline sleep problems and follow-up functional disability (ß = 0.06, 95% confidence interval 0.01, 0.15) and between baseline sleep problems and follow-up school functioning (ß = -0.06, 95% confidence interval -0.13, -0.004). Sleep disturbance in youth with headache may be a risk factor for poor functional outcomes, both concurrently and over time, and may be explained partially through pain-related fear. Given the frequency with which pediatric headache patients experience co-occurring sleep problems, sleep should be thoroughly assessed and considered as a potential early treatment target.