title: Depression as a mediator of the relation between family functioning and functional disability in youth with chronic headaches.
abstract: 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 (β = -0.19, P < .01) and protective parenting (β = 0.17, P < .01) were associated with depression, but not disability. Depression was linked to disability (β = 0.24, P < .01). There was an indirect pathway from family functioning to depression to disability (β = -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.
authors.affiliation: Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.|Department of Psychiatry, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Kaczynski
authors.affiliation: Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.|Department of Psychiatry, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
authors.forename: Rupa
authors.initials: R
authors.lastname: Gambhir
authors.affiliation: Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Caruso
authors.affiliation: Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.|Department of Neurology, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
authors.forename: Alyssa
authors.initials: A
authors.lastname: Lebel
mesh_terms: D000223:Adaptation, Psychological; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003863:Depression / Q000150:complications*; D005195:Family Relations / Q000523:psychology*; D005260:Female; D020773:Headache Disorders / Q000523:psychology*; D006801:Humans; D008297:Male; D010290:Parents; D012189:Retrospective Studies; D011795:Surveys and Questionnaires
keywords: children and adolescents; depression; family functioning; functional disability; mediation