Abstract
We set out to evaluate the friendships and social behaviour of school-aged children with migraine. Concern exists regarding the impact of paediatric migraine on daily activities and quality of life. We hypothesized that children with migraine would have fewer friends and be identified as more socially sensitive and isolated than comparison peers. Sixty-nine children with migraine participated in a school-based study of social functioning. A comparison sample without migraine included classmates matched for gender, race and age. Children with migraine had fewer friends at school; however, this effect was limited to those in elementary school. Behavioural difficulties were not found. Middle-school students with migraine were identified by peers as displaying higher levels of leadership and popularity than comparison peers. Concern may be warranted about the social functioning of pre-adolescent children with migraine; however, older children with migraine may function as well as or better than their peers.
Introduction
Although rare in preschool children, the prevalence of headache increases throughout childhood, reaching a peak at about 13 years of age (1). Estimates of prevalence rates vary according to age, definition of headache and method of data collection. Migraine is one of the most common forms of paediatric headache and usually first appears during the early school-age years (2). Given the chronic and often debilitating nature of migraine, concern has mounted regarding the quality of life of affected children (3, 4). Although this concern is not new, the limitations of this literature have gained recognition, and calls have been made for rigorous research that will help clarify the association between paediatric migraine and diverse emotional, behavioural and functional outcomes (5).
A preponderance of studies on the quality of life of children with migraine have emphasized assessment of psychological difficulties such as depression and anxiety (6–11), but fewer efforts have addressed developmental indices such as social functioning. Given the unpredictable nature and intensity of migraine pain and its associated symptoms, it is not surprising that there is concern about the impact of migraine on the day-to-day lives of affected children. Disruption in school attendance and performance has been one of the most consistently noted consequences of chronic headache (2); however, attention to migraine-associated disability has expanded to include participation in leisure activities with peers (12). Surprisingly, inconsistent findings have indicated that children with migraine may participate in fewer, higher or comparable numbers of extracurricular, athletic and social activities than other children (8, 11, 13–15).
There has been strong criticism of measures that equate participation in activities with social competence (16). For example, the commonly used Social Competence Index of the Child Behavior Checklist (17) assesses the quantity of activities in which a child is engaged and parental perceptions of how well the child performs those activities and gets along with others. These ratings incorporate aspects of performance that are social and non-social (e.g. completing chores, demonstrating athletic skill) and weigh the volume of activities equally with the quality of performance. Most of all, this type of indicator does not incorporate the wide range of social skills, patterns of behavioural interaction, indicators of social adjustment and relationships included in contemporary definitions of social competence (18, 19). It would be advantageous to understand whether children with migraine demonstrate alterations in behaviour when they are with peers and whether the results of their interactions with others (e.g. peer acceptance, quantity or quality of friendships, or satisfaction with social relations) vary from that of healthy peers.
A handful of studies have examined the extent to which children with migraine have friendships and close relationships with others. Persson found that adults who developed migraine as children retrospectively reported having fewer friends in childhood than their siblings (20). Carlsson et al. found that school-aged children with chronic headache, including those with migraine, reported having fewer supportive relationships despite participating in more extracurricular activities than headache-free controls (8). However, Karwautz and colleagues (21) found that children with tension headache but not migraine were reported by parents to have fewer friends than headache-free children. Differences in assessment techniques may have contributed to the discrepancies in these findings. We did not identify any studies that assessed friendship as mutually recognized dyadic relationships as recommended by developmental psychologists (22). This approach, using friendship nominations with an entire classroom or peer group, has been used successfully in community samples (22) and studies of children with chronic illness (23, 24).
A growing number of studies have examined whether children with migraine demonstrate disruptions in behavioural functioning, including the nature and quality of their interactions with peers. Parents of children with migraine have described those in elementary (25) and middle school (11) as demonstrating difficulties getting along with peers, including being socially withdrawn and bullied by others. In addition, Kowal and Pritchard (26) have reported that children with migraine described themselves as more shy and sensitive than those who were headache-free.
Less consistent results have been obtained with respect to indicators of externalizing behavioural difficulties or aggression in the peer group. Two recent reports have suggested that children with migraine may also demonstrate heightened levels of externalizing behaviour relative to headache-free peers or siblings (27, 28). Although the Pakalnis et al. (27) study emphasized oppositional behaviour toward adults, Virtanen and colleagues reported elevations in aggressive behaviour with peers for children with migraine (28). This contrasts with research examining the social behaviour of children with other chronic illnesses and pain disorders, which have found that these children demonstrate less aggressive behaviour with peers (29, 30).
We could not identify any studies that directly assessed peer perceptions of children with migraine, despite longstanding recognition by developmental scientists that peer nomination and sociometric procedures provide reliable, valid indices of social behaviour and acceptance (31). Although Virtanen and colleagues (28) used a measure developed to assess peer perceptions of classmate behaviour, they adapted the measure to obtain parent and teacher report instead. Peer nomination and rating procedures combine the perspectives of numerous classmates who interact daily at school and yield scores that are predictive of concurrent and future academic, emotional and psychiatric outcomes (31–35). These techniques allow assessment of friendship in a way that captures the nature of friendship as a mutually acknowledged relationship between two individuals (34). Peer nomination techniques have been used successfully to investigate the social interactions and relationships of children with a variety of chronic disorders (24, 36–38).
The primary aim of this study was to evaluate the friendships and social behaviour of children with migraine diagnosed by a paediatric neurologist according to the International Classification of Headache Disorders, 2nd edition (ICHD-II) criteria (39). Data were gathered from multiple sources (i.e. peer, teacher and self-report) and compared with a demographically similar group of children who attended the same schools. Our first hypothesis was that children with migraine would have fewer friends than comparison peers. Our second hypothesis was that children with migraine would be described as more socially sensitive and isolated than comparison peers. A secondary aim of the study was to explore whether the pattern of friendship and social behaviour associated with migraine varied as a function of child gender or age. Gender and developmental differences in the impact of migraine on the social functioning of children have not been studied extensively. We felt this was warranted given the broad age range and balanced gender composition of our sample.
Methods
Procedures
Eligible children were identified following an initial evaluation by a paediatric neurologist at a headache centre in a large, Midwestern children's hospital. Children aged 8–14 years meeting ICHD-II (39) criteria for migraine with aura or without aura were eligible. Children were excluded if they were home-schooled or enrolled in full-time special education classes. After obtaining parental consent, permission was sought from the school principal to work with the child's teacher to complete classroom data collection. A meeting was held with the child's teacher to obtain teacher-report data, introduce procedures for obtaining parental consent from classmates, and review safeguards for maintaining confidentiality. All work was completed in the primary classroom for elementary school students and a required academic class (e.g. English) for middle-school students.
The study was introduced to students as a project about friendships and how classmates viewed one another's behaviour without any mention of headache, the hospital, or any particular student as the focus of the study. This was done to protect the confidentiality of the child with migraine. Although nothing prevented these children from sharing their role in the study with their classmates, we do not believe that this was regularly done. Data collection with students often occurred many months after recruitment, and our past experience with this protocol suggested that similar ‘target’ children often forgot the focus of the study themselves (40). Parental consent forms were distributed by the teacher to all classmates, and only those who returned signed forms were allowed to participate. Questionnaires were administered in a fixed order in a classroom setting by study staff in a session lasting 30–45 min. Participants were instructed to write down their answers and not discuss them with one another during or after the session. Although these instructions may not have always solicited student compliance, previous research suggests that the risk of negative self-perceptions and student conflicts are not heightened after completion of similar sociometric measures (41–43). All procedures were approved by the local Institutional Review Board.
Participants
Eighty-eight children meeting the study inclusion criteria were identified. Parents of most of these children (n = 85, 97%) consented to school contact, and 81% (n = 69) of principals allowed their school to participate in the study. This resulted in a migraine sample of 31 girls and 38 boys. Thirty-two children (14 girls, 44%) were enrolled in elementary school (grades 2–5) and 37 children (17 girls, 46%) attended middle school (grades 6–8). Sixty-four of these children (93%) were White and the remainder were African-American (n = 5, two in elementary grades and three in middle school). Medical and demographic characteristics of the 69 target children are presented in Table 1. Children in these two grade groups differed with respect to migraine frequency, but not reported severity. Differences were also found for age of onset of first migraine, but not time elapsed since onset.
Characteristics of children included in the migraine sample
Non-directional tests d.f. = 51–67 due to some missing values; age of onset and aura only recorded for n = 53 participants.
A sample of comparison peers (n = 69) included one classmate of each child in the migraine sample, who was matched for race, gender and date of birth. Comparison peers were screened to ensure the absence of migraine or severe chronic illness. Screening regarding migraine and other severe chronic illness (e.g. cancer or diabetes) was completed with teachers for all children. In addition, families of 47 comparison children (68%) subsequently participated in further data collection outside school, and parents of these children confirmed that they had not been diagnosed with migraine or any other severe chronic illness. It should be noted that none of the classmates identified for inclusion in the comparison group was excluded due to parental disclosure of health concerns, building confidence in reliance on classroom identification procedures for the remaining 22 children in the comparison group.
Sixty-nine teachers and 1392 classmates (84%) provided data. Seven per cent of classmates (n = 108) were absent the day of data collection and 9% (n = 157) were present but did not have parental consent to participate. The number of participating classmates per classroom ranged from 11 to 30 (M = 20) classmates.
Measures
Diagnostic and archival data
Diagnosis of migraine was completed by a board-certified paediatric neurologist applying ICHD-II criteria (39) to data obtained by clinical interview. Written questions completed by each child and parent regarding headache frequency and average severity were also clarified during the clinical examination. The average number of migraines experienced per month and the average pain severity (0 = no pain to 10 = most pain possible) were recorded in the clinic database. These data, including proportion of the sample diagnosed with chronic vs. episodic migraine and migraine with and without aura, are summarized in Table 1. Finally, 53 of 69 participating schools provided a count of how many days each child in the participating class had been absent that school year.
Best friend nominations (34)
Students were asked to nominate their three best friends from a list of classmates. This yielded a total score for the number of nominations received and a reciprocated friendship score indicating how many of their nominated friends identified them as a friend in return. The total score is considered a general measure of acceptance or popularity, whereas the reciprocated score more directly reflects friendships or mutually recognized dyadic relationships. Scores were standardized or converted to z scores (M = 0,
Peer acceptance ratings (35)
Students completed 5-point ratings of how much they liked each classmate. Mean acceptance ratings were computed and standardized within gender in each class to facilitate comparison with other sociometric measures.
Revised Class Play (44)
The Revised Class Play (RCP) uses a descriptive matching technique to describe patterns of social behaviour characterizing a group of classmates. Students and teachers were asked to imagine that they were the director of a play and to ‘cast’ members of their class into 39 hypothetical ‘roles’. Factor analytic work has identified four behavioural subscales for the RCP: (i) leadership-popularity, (ii) prosocial, (iii) aggressive-disruptive and (iv) sensitive-isolated behaviour with a broad age range of elementary to high-school classrooms (45). Three additional items reflecting illness behaviour (i.e. someone who is sick a lot, misses a lot of school, or is tired a lot) were added by our research group (24, 40) for assessment of children with chronic illness.
Nominations on the RCP were limited to students who were the same gender as the target child to avoid sex–role stereotyping. Item scores, reflecting numbers of nominations received for each role, were standardized within each class. Teachers also completed the RCP to assess their perceptions of student behaviour, and item scores were also summed and standardized to create scale scores. Finally, self-perceptions were assessed by asking students to complete a second RCP indicating whether it would be easy or hard for them to play each role. Item scores were summed and standardized for each reporting source to create scale scores that paralleled those from the peer and teacher RCPs. Self-report subscales were computed from item scores and standardized.
Statistical analyses
Independent-group, non-directional t-tests were conducted to test hypotheses regarding group differences in levels of friendship, child attributes and social behaviour. Analysis of variance (
Results
Group differences in social acceptance and friendship
Descriptive statistics, t-test and effect sizes for each indicator of social acceptance and friendship are presented in Table 2. No differences were found between children in the migraine and comparison samples in the average acceptance ratings or number of friendship nominations received from classmates. Children with migraine did have significantly fewer reciprocated friendships compared with classmates, providing support for our first hypothesis.
Friendships and social acceptance for children with migraine and comparison classmates
Non-directional tests using d.f. = 133–136 due to some missing values.
Scores were standardized within classrooms, resulting in M = 0 and
Indicates significance of statistic after adjustment for multiple (3) comparisons for that sample or subsample involving subscales within this domain.
BFN, best friend nominations; d, Cohen's d index of effect size.
Group differences in social behaviour
Descriptive statistics, t-tests and effect sizes for peer, teacher and self-report on the RCP are presented in Table 3 for the full sample. Results of group comparisons did not support the hypothesis that children with migraine would be described as more sensitive and isolated than comparison peers. Several exploratory analyses did find evidence of other differences.
Social behaviour for children with migraine and comparison classmates
Non-directional tests using d.f. = 130–134 due to some missing values.
Indicates significance of statistic after adjustment for multiple (4) comparisons for that sample or subsample involving subscales from the same measure.
Scores were standardized within classrooms, resulting in M = 0 and
d, Cohen's effect size index; RCP, Revised Class Play.
Peer descriptions of social behaviour
Overall, children with migraine received scores on all four subscales of the RCP that were similar to comparison peers (Table 3). One significant interaction was found between group status and child gender. Boys with migraine were described by peers as less aggressive and disruptive (M =−0.44,
Teacher report of social behaviour
One overall group difference was found on subscales of the RCP completed by teachers once adjustments for multiple comparisons were implemented (Table 3). Specifically, teachers identified children with migraine as less aggressive and disruptive than comparison classmates. No significant interactions were found between migraine status and either gender or grade level.
Self-report of social behaviour
One significant difference was found in the self-report of children with migraine and comparison peers once adjustments for multiple comparisons were implemented (Table 3). Higher overall scores were found for leadership-popularity for children with migraine. No significant interactions were found to suggest that the self-perceptions of children with migraine vs. comparison peers varied as function of gender or grade group.
Migraine frequency and average pain severity
Exploratory analyses were conducted to examine whether indices of social behaviour, friendship and peer acceptance were associated with variability in migraine frequency and severity recorded at clinic at the time of recruitment of the entire sample. Pearson correlations were computed with friendship scores, mean acceptance ratings, and all behaviour subscales from the peer, teacher and self-report RCPs. None of these correlations was statistically significant for the sample as a whole or within elementary and middle school grades separately.
School absences and peer perceptions of illness behaviour
Data obtained from school records indicated that children with migraine were absent from school significantly more often than comparison classmates (t(102) = 2.51, P < 0.05). Children in the migraine sample had missed an average of 7.1 days of school (
Discussion
The aim of this study was to evaluate the peer relationships of school-aged children with migraine. Assessments evaluated both friendships and patterns of social behaviour at school from multiple sources. A strength of this investigation was the collection of data directly from children's peers by employing assessment procedures widely used in social development research. Another advantage was the inclusion of a group of demographically similar comparison children who lived in the same neighbourhoods, attended the same schools, but did not have migraine or other severe, chronic illness.
We hypothesized that children with migraine would have fewer friendships and demonstrate more social sensitivity and isolation at school. Our results indicated that children with migraine had fewer mutually identified friendships with classmates than comparison peers without migraine; however, this difference was limited to children in elementary school. These students had half the number of reciprocated friendships than classmates without migraine or middle-school students with or without migraine. Nearly half of the elementary school students in our migraine sample did not have a reciprocated friendship in their class. In contrast, middle-school students with and without migraine were just as likely to have friendships. These findings are commensurate with prior work examining quality of life, in which parent and self-report indicated better social functioning amongst adolescents than younger children with migraine (47). It will be important for future research to consider the quality as well as quantity of friendships amongst both younger and older children (19).
Despite evidence of deficits in friendship, we did not find support for our hypothesis that the social behaviour of children with migraine would be characterized by greater social sensitivity and isolation than peers. No significant differences were found in peer, teacher or self-report of this behavioural dimension. Although previous work has suggested that children with migraine have more problems with social withdrawal and getting along with others (11, 25), this work has relied primarily on the reports of parents, who may have limited opportunity to observe peer interactions directly (31). In prior research, peer reports of difficulties with sensitivity and social isolation have been primarily documented for children with central nervous system disease or damage rather than those with chronic pain or conditions without neurocognitive impairment (23, 36, 48, 49).
We found unexpected evidence that youth with migraine viewed themselves as demonstrating higher levels of leadership and popularity in the peer group than comparison classmates. This difference was limited to self-perceptions for elementary school students; however, peers also described middle-school students with migraine as demonstrating these behavioural attributes. Items reflecting leadership on the RCP include items such as ‘someone with good ideas for things to do’ and ‘someone who can get others to listen’ that children may feel they possess even if this is not recognized by peers. Our results indicate that there may be a discrepancy between what younger children with migraine thought they were capable of doing and the behaviour that was actually enacted and observed by others. It is unclear whether our findings with middle-school students reflect a shift in behaviour over time or a difference in how migraine symptoms are managed by older children or viewed by their peers. Only longitudinal research will be able to examine whether actual behaviour or the perceptions of others shift over time to become more congruent with self-perceptions. In addition to being better able to cope with migraine symptoms at an older age, it is possible that the peers of older children are more empathic regarding their migraine symptoms.
Unlike previous reports of parent perceptions of behavioural adjustment (27, 28), we did not find evidence that migraine is associated with increased rates of aggressive or disruptive behaviour. This finding is consistent with studies of children with a variety of chronic illnesses (29, 30). In fact, teachers described children with migraine as less aggressive and more prosocial than peers without migraine. Peers also described boys with migraine as less aggressive and disruptive than comparison boys, perhaps reflecting greater discrepancy between observed behaviour and what is generally accepted as gender-appropriate behaviour. It is important to note that the behavioural items we assessed on the RCP do not specifically address forms of relational aggression that may have particular relevance for interactions between girls (50).
Clinicians who work with children with migraine in primary or tertiary care settings should be aware of the possibility of social difficulties, particularly amongst students in elementary school grades. Further research is needed to understand whether children are more successful in establishing and maintaining friendships if treatment is successful at reducing the frequency or severity of headache and associated somatic symptoms. Consideration should be given to the possibility that children may benefit from assistance in developing and utilizing skills for promoting friendships with peers along with pharmacological and behavioural strategies for minimizing perceived pain and somatic symptoms.
Several considerations should be kept in mind when interpreting this work, in particular the evidence we found of developmental differences in the social deficits associated with migraine. Although our use of data from multiple sources outside the family was innovative for this area of research, the data describe the social interactions and friendships of children with migraine only in the school setting. Even though school is a significant setting in the lives of children, many children participate in social interactions and develop friendships away from school, and those relationships would not be reflected in the present data. Relations with peers in alternative settings may become more prevalent as children become older, and this may attenuate the importance of school relations in middle and high school. It is also possible that classmates in our middle-school grades had spent less time with one another, in less varied activities, than the elementary school students. Even though peer report measures appear to be reliable and valid when administered in secondary school settings (45), there may be systematic differences in the operation of these measures of which we are unaware. Classroom friendships may be more transient or less important in middle-school classes.
Additional work will be needed to replicate and extend the current work. The relatively small sample size in this study precludes definitive conclusions about developmental or gender differences in the impact of migraine on social outcomes. It is possible that the differences observed between elementary and middle-school students with migraine could reflect other variables than development that were confounded with grade level in the current study. Although we found systematic differences in the migraine characteristics of children in our elementary and middle-school samples, it is uncertain whether these differences could account for the differences found for older and younger students. Although older and younger students had experienced migraine symptomatology for comparable lengths of time, middle-school students reported more frequent headaches and were more likely to be diagnosed with daily or chronic migraine. In addition, we found no evidence of ‘dose effects’ between the severity of migraine symptoms and social functioning, However, we utilized rather poor summative, retrospective indices of migraine severity. Future prospective, longitudinal work will be needed to delineate the emergence of migraine symptoms and migraine-related coping skills that could influence social interactions and relationships.
Footnotes
Acknowledgements
This work was supported by a grant to K.V. from the American Headache Society (formerly the American Association for the Study of Headache). The authors would like to thank the families, students and schools who participated in this work.