Role of the Attachment Style in Determining the Association Between Headache Features and Psychological Symptoms in Migraine Children and Adolescents. An Analytical Observational Case-Control Study

Long-Term Effects of COVID-19 Pandemic on Migraine in Adolescents. A Retrospective Analysis of the Population Attending the Headache Center in Different Phases of the Pandemic

BACKGROUND

Literature data report that the first COVID-19 pandemic had an impact on the progression of migraine both in adults and children. The present study aimed to verify how the migraine course and psychological aspects varied in adolescent patients in relation to some of the different phases of the COVID-19 pandemic and compared with the months before COVID-19. In addition, the relationship between the characteristics of headache episodes and psychological and school-related aspects were analyzed.

METHODS

The study included 418 adolescents. Based on the timing of the evaluation, they were categorized into patients observed before the COVID-19 pandemic (pre COVID) or during the first (COVID 1) or second (COVID 2) wave of the pandemic. Subjects were also categorized into three further groups: those who had high or low frequency of migraine attacks during the month, those who had mild or severe pain during the attack, and those who were taking prophylactic drugs. The Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) scales were utilized to assess depression and anxiety.

RESULTS

We observed a significant increase in the frequency of attacks and the use of prophylactic drugs during the COVID 2 period compared to the COVID 1 and pre-COVID periods (p < 0.05). Patients showed higher levels of anxiety and depression during each of the two COVID periods compared with the pre-COVID months (p < 0.05), especially during the COVID 2 period (p < 0.05).

CONCLUSION

Our results show long-term negative impacts of the COVID-19 pandemic on clinical parameters and psychological symptoms in adolescents with migraine.

Parenting Styles, Mental Health, and Catastrophizing in Women with Chronic Pelvic Pain: A Case-Control Study

Chronic pelvic pain (CPP) in women is a highly prevalent condition worldwide and requires multimodal treatment. Adverse childhood experiences have been associated with CPP in women, while allodynia and poor outcomes have been linked to pain catastrophizing in these patients. Pain perception has been associated with parenting style during childhood. The objective of this study was to investigate the association between parenting style, pain catastrophizing, anxiety, depression and CPP in women. A case-control study was conducted between May 2018 and August 2021 with 123 women with CPP and 123 pain-free controls. Questionnaires were used to collect participants' data. The association between parenting style and CPP was assessed using multiple logistic regression, with odds ratios (OR) and 95% confidence intervals (CI) being calculated. The correlation between catastrophizing, pain intensity, pain duration, anxiety, depression, and parenting style in women with CPP was assessed using Spearman's rank correlation coefficient (r). A higher frequency of low maternal care (60.7% versus 45.2%; p = 0.026), anxiety (79.7% versus 56.9%; p < 0.001), depression (73.2% versus 56.1%; p = 0.008) and physical violence (31.7% versus 14.6%; p = 0.003) was found in the CPP group compared to the controls. There was no association between parenting style and CPP in the adjusted analysis. A positive correlation was found between catastrophizing and pain intensity (r = 0.342; p < 0.001), anxiety (r = 0.271; p = 0.002), depression (r = 0.272; p = 0.002), and maternal overprotection (r = 0.185; p = 0.046). A negative correlation was found between anxiety and maternal (r = -0.184; p = 0.047) and paternal (r = -0.286; p = 0.006) care and between depression and maternal (r = -0.219; p = 0.018) and paternal (r = -0.234; p = 0.026) care. The present results suggest a significant but weak association of parenting style with pain catastrophizing, the mental health of women with CPP, and the way in which they experience pain.

Assessment of Parenting Attitudes by Children and Adolescents with Migraine

Purpose: We aimed to investigate the parenting attitudes reported by patients and their relationships with the characteristics of headaches in children and adolescents with migraine. Methods: We conducted a retrospective review of medical records of children and adolescents with migrainous headaches (n=115; 59.1% female; mean age, 11.89±2.00 years). Children evaluated parental attitudes using the Parenting Attitude Test-Youth (PAT-Y), which comprises eight subscales and four newly devised secondary subscales. Headache severity was calculated by the visual analog scale (VAS), monthly frequency (MF), and VAS×MF/4 (VF). The scores of PAT-Y subscales and the correlations between PAT-Y scores and headache severity were analyzed by age group and sex. Scores for children’s depression inventory, childhood behavior checklists, and an attention deficit hyperactivity disorder scale were also analyzed. Results: In the elementary school age group, VAS was weakly negatively correlated with the “achievement press” (r=–0.28, P<0.05) and “high expectation” (r=–0.25, P<0.05) attitudes, and VF was weakly negatively correlated with “achievement press” (r=–0.32, P<0.05), “punishment” (r=–0.27, P<0.05), and “high expectation” (r=–0.29, P<0.05). In the middle-school age group, MF and VF were moderately positively correlated with the “achievement press” attitude (r=0.48, P<0.01 and r=0.48, P<0.01, respectively), VF was weakly positively correlated with the “neglectful” attitude(r=0.31, P<0.05), and MF was weakly positively correlated with scores for depression (r=0.29, P<0.05) and internalized problems (r=0.31, P<0.05). Conclusion: Parenting attitudes perceived by children and adolescents with migrainous headaches varied by age, and some parenting attitudes were related to headache severity. Education on age-appropriate parenting attitudes may help cope with migrainous headaches.

The Role of Attachment Style, Adverse Childhood Experiences and Dissociation in Migraine

Migraine and chronic migraine are caused by a combination of modifiable and non-modifiable genetic, social, behavioral and environmental risk factors. Further research of possible modifiable risk factors for this headache disorder is merited, given its role as one of the leading causes of years lived with disability per year. The first aim of this online cross-sectional study was to investigate the psychosocial risk factors that predicted chronic migraine and severe migraine-related disability in 507 Irish and UK participants, focusing specifically on childhood maltreatment, attachment and tendency to dissociate, or experience depressed mood and/or anxiety. Additionally, this study aimed to examine variables that mediated the relationships between these psychosocial risk factors and migraine chronicity or severe migraine-related disability. Adjusted binary logistic regression revealed that shutdown dissociation (Odds Ratio [OR] 4.57, 95% Confidence Interval [CI] 2.66-7.85) and severe physical abuse (OR 4.30, 95% CI 1.44-12.83 had significant odds of predicting migraine chronicity, while depression (OR 3.28, 95% CI 1.86-5.77) significantly predicted severe migraine-related disability. Mediation analyses indicated that shutdown dissociation mediated the relationship between seven predictor variables and both chronicity and severe disability including possible predisposing factors emotional abuse, physical neglect, avoidant attachment and anxious attachment. These findings suggest that early life stressors (such as childhood trauma and avoidant attachment style), shutdown dissociation and depression may impact on migraine trajectory. To investigate whether these psychosocial factors are risk factors for migraine chronicity or disability, prospective research should be conducted in this area to account for fluctuations in migraine chronicity over time.

Attachment representation to caregivers and mentalizing ability in early adolescents with primary headache

Primary headache (PH) is a common somatic disorder in childhood with a strong impact in terms of quality of life. There are several risk factors related to the development of this disorder including environmental factors as attachment bonds. However, studies in this direction are relatively few and have often used self-report or semi-projective measures looking at the only maternal attachment. Moreover, several studies have shown a link between somatoform pains and mentalizing abilities, but the relation between mentalizing and PH in childhood is unexplored. Therefore, this study aims at exploring attachment bonds, focusing on both maternal and paternal representations and mentalizing abilities in early adolescents with and without PH within a cross-sectional case-controlled design. A sample of 94 early adolescents aged 10-14 years (47 with PH and 47 without PH as a comparison group) completed the Child Attachment Interview to assess attachment representations to caregivers. Mentalizing abilities were assessed applying to the interviews in the Child and Adolescent Reflective Functioning Scale. PH adolescents showed a greater percentage of insecure-preoccupied attachment to both parents, with higher level of preoccupied anger especially to father than the comparison group (p values from 0.000 to 0.014, effect size values from.31 to.45), while no differences emerged about mentalizing (p values from.264 to 0.312). The over-representation of insecure-preoccupied attachment to both parents suggests a key role of parent-child interaction in early adolescents with PH, while the role of mentalizing abilities remains controversial and further studies are needed to address this issue. Clinical implications are discussed.

The Direct and Indirect Influences of Adverse Childhood Experiences on Physical Health: A Cross-Sectional Study

A growing and significant body of research has documented the close relationship between adverse childhood experiences (ACEs) and health outcomes in adults. Less is known about the complex pathways through which ACEs exert their influence. This article examines the direct relationship between the quality of perceived physical health and childhood adversities. The association between the adversities and the physical health with other psychological and social variables is also analyzed. Data were collected from a sample of 170 subjects, using tools to assess adverse childhood experiences, physical health-related quality of life, socioeconomic vulnerability, emotion regulation, coping strategies, attachment, and social support. Results showed a high frequency of ACEs among the adult population, and the correlation with poor physical health was highly significant. Regression equations to predict physical health also revealed the following as significant variables: wishful thinking, social withdrawal, and cognitive restructuring as coping styles; reappraisal to achieve emotion regulation; fear of rejection or abandonment, and desire for closeness in relation to attachment figures; hardship; and poor financial support. The relationship between the different forms of ACE and social vulnerability identifies the important indirect contribution of childhood adversity to health and socioeconomic conditions in adulthood.

Anxiety, Depression, and Body Weight in Children and Adolescents With Migraine

Background: There is a lack of studies that explore the possible association between body weight, psychological symptoms, and migraine severity in pediatric populations. The purpose of the study was to explore: (1) the association between body weight and the frequency of migraine attacks, (2) the possible differences in anxiety and depression symptoms according to the frequency of attacks and body weight, and (3) the possible mediating role of anxiety and/or depression in the association between body weight and frequency of migraine attacks in children.

Methods: One hundred and eleven children/adolescents with migraine were included (47 boys and 64 girls; mean age 11.7; ±2.4 years). The patients were classified as: (1) high frequency patients, reporting from weekly to daily episodes and (2) low frequency patients, with ≤3 episodes per month. According to their body mass index percentiles, the patients were divided in “Normal weight” (from ≥5 to <85 percentile), “Overweight” (from ≥85 to <95 percentile), and “Obese” (≥95 percentile). Given the low number of obese patients, the overweight and obese groups were considered together in the “Overweight” group. Anxiety and depression symptoms were assessed by the Self-Administered Psychiatric Scales for Children and Adolescents (SAFA).

Results: Fifty-four patients were normal in weight (49.6%), while 56 patients (50.4%) were overweight. The overweight patients showed a higher frequency of migraine attacks (64.7%; p < 0.05). Patients with a high frequency of attacks reported higher scores in all SAFA-Anxiety subscales (SAFA-A Tot: F = 15.107; p = 0.000). Overweight patients showed a significantly higher score in the “Separation anxiety” subscale (F = 7.855; p = 0.006). We found a mediating role between the overweight and high frequency for total anxiety (z = 2.11 ± 0.03; p < 0.05) and social anxiety (z = 2.04 ± 0.03; p < 0.05).

Conclusions: Our results suggest that, among the children suffering from migraine, the overweight status is associated with a higher frequency of attacks and separation anxiety symptoms. In particular, our study provides the first evidence of the role of anxiety in linking overweight and the frequency of migraine attacks in children and adolescents.

When a Head Is about to Burst: Attachment Mediates the Relationship Between Childhood Trauma and Migraine

Background: People exposed to childhood trauma show insecure attachment patterns and are more prone to chronic and pain-related conditions, including migraine. The aim of this study was to explore the mediating role of attachment in the association between childhood trauma and adulthood chronic health conditions, with a focus on migraine. Methods: Respondents from a representative sample of citizens of the Czech Republic (n = 1800, mean age: 46.6 years, 48.7% male) were asked to report various chronic and pain-related conditions, childhood trauma (The Childhood Trauma Questionnaire, CTQ), and attachment anxiety and avoidance (The Experience in Close Relationships Revised, ECR-R) in a cross-sectional, questionnaire-based survey conducted in 2016. Structural equation models (SEM) adjusted for sociodemographic variables were used to assess the relationship between childhood trauma, adulthood attachment, and adulthood chronic health conditions (migraine, other pain-related conditions, chronic health conditions other than pain, no chronic health complaints). Results: After adjusting for sociodemographic variables, SEM confirmed a significant mediation of the relationship between childhood trauma and migraine through adulthood attachment. There was no mediation effect of adulthood attachment found in other health complaints. Conclusion: This study highlights the mediation effect of attachment in the link between childhood trauma and migraine. Attachment-based therapeutic interventions can be useful in the treatment of patients with migraine.

The Relationship Between Parental Care and Pain in Children With Headache: A Narrative Review

PURPOSE

In migraine or primary headache in children, parents play a fundamental role in pain management. For this narrative review, PubMed, Google Scholar, and Psych Info were searched using the terms "parent headache", "mother/father headache", "parental impact headache", "alexithymia parents headache", "catastrophizing parent headache", "family headache", "children parent headache", and "quality of life family headache". Articles were chosen for inclusion based on their relevance in to the topic.

OVERVIEW

Several parental and psychological characteristics can influence in children and adolescent headache, such as parental attitudes as oppressive or overprotective; punitive parenting styles; familial psychological symptoms, especially anxiety and depression; catastrophizing about their child's pain or excessive worry about their child's headache; inability to express emotions; and feelings that may lead to somatization problems.

DISCUSSION

Parents' attitudes and behaviors toward their child's headache have a strong relation with the severity of headache attacks. Mothers seem to have more influence than fathers on children's pain and emotional regulation. We suggest that the presence of caregiver-child transmission of maladaptive coping strategies, arising from difficulties expressing emotion, may lead to incorrect management of headache pain, further facilitating headache chronification.

ATTACHMENT STYLE IN CHILDREN WITH CHRONIC DISEASES: A COMPREHENSIVE REVIEW

Objective:

To investigate how attachment style has been studied in children with chronic disease in the scientific literature, and what repercussions this attachment has on this population.

Data sources:

An integrative review of the literature was carried out from a survey in the LILACS, MEDLINE and SciELO databases, including original national and international publications in Portuguese, Spanish and English from 2007 to 2018, using the descriptors “apego” and “criança” in the Health Sciences Descriptors (DeCS), and “attachment” and “children” for the Medical Subject Headings (MeSH). Sixteen (16 articles) were obtained for the sample analysis.

Data synthesis:

The chronic diseases found in the research were neurobehavioral disorders such as attention deficit hyperactivity disorder (ADHD) and autism, childhood obesity, and chronic migraine. The predominant attachment style was insecurity, which could compromise the biopsychosocial development of the child.

Conclusions:

The type of attachment between child and primary caregiver may be considered a protective or risk factor for child development. Considering this premise, it is important to equip/inform families based on dialogic educational practices, in which professionals create opportunities and means for families to develop their skills and competencies, and acquire resources which meet the child’s needs. It is important that this professional helps the family to build secure bases for their child with chronic disease, understanding that the main focus for promoting child development is in the family unit.

Individual differences in attachment anxiety shape the association between adverse childhood experiences and adult somatic symptoms

BACKGROUND

Although prior research has documented the link between adverse childhood experiences (ACEs) and somatic symptoms, it remains unclear why some individuals exposed to ACEs developed somatic symptoms while others did not.

OBJECTIVE

Framed by a biopsychosocial perspective, this study investigated the role of attachment anxiety in the association between ACEs and somatic symptoms in adulthood.

PARTICIPANTS AND SETTING

A total of 662 emerging adults attending college were recruited to respond to an online survey in a computer lab.

METHOD

The computer-based survey included demographic form, the Adverse Childhood Experience Scale, the Experience in Close Relationship Scale-Short Form, and the Somatization Scale of the Symptom Checklist-90-Revised for somatic symptoms. Multivariate regression analyses were used to examine the role of attachment anxiety in the association between ACEs and somatic symptoms.

RESULTS

The results indicated that ACEs positively correlated with attachment anxiety and somatic symptoms; and attachment anxiety and somatic symptoms were positively correlated. Moreover, the results indicated a significant effect of interaction between ACEs and attachment anxiety on somatic symptoms, suggesting a moderating role of attachment anxiety. Subsequent simple slope test revealed that attachment anxiety intensified the strength of relation between ACEs and somatic symptoms; but when the level of attachment anxiety was low, ACEs and somatic symptoms were not related.

CONCLUSION

Individual differences in attachment anxiety shape the association of adverse childhood experiences with somatic symptoms. Targeting and reformulating anxious working models of attachment may help ameliorate vulnerability to somatic symptoms in individuals exposed to ACEs.

The relationship between attachment and somatoform symptoms in children and adolescents: A systematic review and meta-analysis

OBJECTIVE

Problems in childhood and adolescence are often present with recurring physical signs of illness, called somatoform symptoms. These symptoms are a common reason for consultation at both paediatric care and psychotherapeutic/psychiatric praxis. We propose that attachment is a possible predictive factor. This article provides a systematic overview of the existing research literature concerning the relationship between attachment and somatoform symptoms in children and adolescents.

METHODS

A systematic search for empirical articles from 1990 up to August 2018 focusing on this association was conducted. Out of six databases, 4994 studies were detected by using defined keywords. One study was added identified by checking reference lists. Finally, 15 studies were selected, which were the bases for the narrative review. Ten studies were included in meta-analysis.

RESULTS

Combining study results, we found that attachment cannot solely predict somatoform symptoms. Mixed results are shown. The quantitative analysis substantiated these narrative results, revealing a small but significant combined effect size of Δ ≈ .12 (95% CI .04 - .19).

CONCLUSIONS

The findings suggest that a relationship exists, but further investigations need to demonstrate that these are not only superficial. There are many developmental factors that affect the relationship between attachment and somatoform symptoms in children and adolescents. Further research should explore this interplay in order to gain a holistic and comprehensive understanding of the underlying mechanisms that lead to these correlations and to discover possible predicting factors.

Associations between attachment and pain: From infant to adolescent

Pain experience is a negative complex phenomenon influenced by several mechanisms. Attachment processes may affect the way in which individuals experience and signal pain. Hence, in the last two decades, the role of attachment quality has drawn attention in pain research and practice. However, previous reviews on this topic focused on adulthood and/or specific types or pain. We conducted a narrative review examining the association between attachment and different pain conditions from infancy to adolescence. Two independent researchers searched scientific databases for relevant papers. A total of 17 articles were included. Results highlight the following: (a) children and adolescents with chronic idiopathic pain showed low rates of attachment security compared to control groups; (b) pain conditions are consistently associated with elevated rates of at-risk pattern of attachment and information processing; and (c) the presence of unresolved trauma or loss is higher in children and adolescent who experienced pain compared to healthy controls. Despite the significance of these empirical evidences, the impact of caregiving environment and interpersonal context on pain experience in infancy and preschool age is poorly investigated compared to adulthood. Research on pain and attachment needs to be extended since the majority of the studies are limited to specific pain conditions. Future research should investigate the role of anxious attachment on procedural pain and transition from acute to chronic pain, testing new conceptual models. These findings shed light on the importance of relational factors and psychosocial vulnerabilities in pain clinical practice. An attachment-informed approach to pain will help health professionals to offer adequate support during procedures and to increase effectiveness of interventions. A developmental perspective is needed to integrate familial and relational contribution into a multimodal assessment and treatment of pain. Longitudinal studies are recommended.

Headache and Alexithymia in Children and Adolescents: What Is the Connection?

Background: Headache is one of the most common complaints in children and adolescents and comorbidity rates are very high and the major associated diseases are depression, anxiety, atopic disorders, sleep, and behavioral disorders. In recent years, it has been highlighted that difficulties regulating emotions such as alexithymia have also been associated with diagnosis of somatization. Methods: We carried out a mini review analyzing the relation between alexithymia and primary headache (e.g., migraine and tension type headache) in children and adolescents by synthesizing the relevant studies in the literature on PubMed, PsycINFO, and Google Scholar. Search terms were "alexithymia" combined with the "primary headache," "migraine," "tension type headache," "children," and "adolescents." Results: All analyzed studies found higher levels of alexithymia in children and adolescents with headache than control groups but there are different opinions about the relationship between headache and alexithymia. For example, some studies suggest that the association between headache and alexithymia in children may be due to an incomplete development of emotive competency or a general immature cognitive development, instead other studies found a correlation between headache symptoms, insecure attachment, and alexithymia. There seems to be also differences between children with migraine compared to those with tension type headache (TTH). Conclusion: There are some studies on adults suffering from headache or migraine and alexithymia, but there is only a moderate amount of research on pediatric age with different opinions and theories about this relationship. Further studies on children and adolescents are necessary to effectively understand this relationship and to help children to reduce headache and improve emotional consciousness.

Maternal Alexithymia and Attachment Style: Which Relationship with Their Children's Headache Features and Psychological Profile?

INTRODUCTION

A growing body of literature has shown an association between somatic symptoms and insecure "attachment style." In a recent study, we found a relationship between migraine severity, ambivalent attachment style, and psychological symptoms in children/adolescents. There is evidence that caregivers' attachment styles and their way of management/expression of emotions can influence children's psychological profile and pain expression. To date, data dealing with headache are scarce. Our aim was to study the role of maternal alexithymia and attachment style on their children's migraine severity, attachment style, and psychological profile.

MATERIALS AND METHODS

We enrolled 84 consecutive patients suffering from migraine without aura (female: 45, male: 39; mean age 11.8 ± 2.4 years). According to headache frequency, children/adolescents were divided into two groups: (1) high frequency (patients reporting from weekly to daily attacks), and (2) low frequency (patients having ≤3 episodes per month). We divided headache attacks intensity into two groups (mild and severe pain). SAFA "Anxiety," "Depression," and "Somatization" scales were used to explore children's psychological profile. To evaluate attachment style, the semi-projective test SAT for patients and ASQ Questionnaire for mothers were employed. Maternal alexithymia traits were assessed by TAS-20.

RESULTS

We found a significant higher score in maternal alexithymia levels in children classified as "ambivalent," compared to those classified as "avoiding" (Total scale: p = 0.011). A positive correlation has been identified between mother's TAS-20 Total score and the children's SAFA-A Total score (p = 0.026). In particular, positive correlations were found between maternal alexithymia and children's "Separation anxiety" (p = 0.009) and "School anxiety" (p = 0.015) subscales. Maternal "Externally-oriented thinking" subscale correlated with children's school anxiety (p = 0.050). Moreover, we found a correlation between TAS-20 Total score and SAFA-D "Feeling of guilt" subscale (p = 0.014). Our data showed no relationship between TAS-20 and ASQ questionnaires and children's migraine intensity and frequency.

CONCLUSION

Maternal alexithymia and attachment style have no impact on children's migraine severity. However, our results suggest that, although maternal alexithymic traits have no causative roles on children's migraine severity, they show a relationship with patients' attachment style and psychological symptoms, which in turn may impact on migraine severity.

The role of attachment insecurity in the emergence of anxiety symptoms in children and adolescents with migraine: an empirical study

Background

It is widely recognised that there are associations between headache, psychiatric comorbidity and attachment insecurity in both adults and children. The aims of this study were: 1) to compare perceived attachment security and anxiety in children and adolescents with migraine without aura and a healthy control group; 2) to test whether the child’s perceived security of attachment to the mother and the father mediated the association between migraine and anxiety.

Methods

One hundred children and adolescents with Migraine without Aura were compared with a control group of 100 children without headache. The Security Scale (measures perceived security of attachments) and the Self-Administered Psychiatric Scales for Children and Adolescents, a measure of anxiety symptoms, were administered to all participants.

Results

The clinical group had lower attachment security than the control group and higher scores on all anxiety scales. Anxiety was negatively correlated with attachment. Children’s attachment to their mother mediated the increase in global anxiety in the clinical group. Insecure paternal attachment was associated with greater insecurity in maternal attachment, suggesting that there is a complex pathway from migraine to anxiety symptoms mediated by perceived insecurity of paternal attachment and hence also by perceived insecurity of maternal attachment.

Conclusion

These results suggest that insecure parental attachment may exacerbate anxiety in children and adolescents with migraine and point to the importance of multimodal interventions, perhaps taking account of family relationships, for children and adolescents with migraine.