Children who experience adverse childhood events may have worse chronic pain symptoms
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Children with chronic pain or rheumatic disease who experience adverse childhood events may be at a greater risk for worse symptoms and “functional disability,” according to data published in Pediatric Rheumatology.
Adverse childhood events (ACEs) include a wide array of traumatic experiences ranging from physical, sexual and mental abuse to chronic stressors such as neglect and parental mental illness, Maitry Sonagra, MPH, a research coordinator at the Center for Amplified Musculoskeletal Pain Syndrome at the Children's Hospital of Philadelphia, and co-authors wrote.
“The results indicate that children with chronic pain and/or rheumatologic diseases who are exposed to ACEs are at increased risk of worse functional disability, greater pain-related symptomatology, and a higher burden of co-morbid mental health conditions,” they added
To analyze the association between ACEs and chronic pain manifestations in children, as well as the interactions between such events and pediatric rheumatic disease among those with chronic pain, Sonagra and colleagues conducted a cross-sectional cohort study of 412 patients aged 18 years or younger who visited a pediatric rheumatology clinic between August 2018 and July 2020.
Patients were separated into three groups. The groups consisted of patients who had zero adverse childhood experiences, those who had one experience, and those who had two experiences. Researchers then assessed present signs and symptoms using the Chi-square or Wilcoxon-rank test.
“Of the 412 patients included, more than 75% of patients reported at least one ACE,” the authors wrote. “Most frequent included history of mental illness in a first degree relative (56%) and parental divorce or separation (20%).”
Patients with two or more adverse experiences had “more somatic symptoms, worse functional disability, and a higher proportion of mental health conditions,” according to the researchers.
In addition, higher verbal pain scores, symptom severity scores and autonomic changes correlated with an average increase in functional disability inventory scores (P < .01).
“Patients had similar pain severity and widespreadness of pain regardless of the number of ACEs experienced,” the researchers wrote. “However, median FDI scores varied across the groups, with higher scores (indicating worse functional disability) among the patients with two or more ACEs by both patient-report (P =.05) and parent-report (P =.03).”
Limitations of the study included the fact that there were few especially impactful experiences, such as household members with a substance abuse disorder or a household member attempting suicide, the authors wrote. Additionally, due to the nature of the way adverse childhood experiences are defined, not all relevant experiences may have been evaluated.
The researchers added that the cohort was mostly white, non-Hispanic and of higher socioeconomic status, making the study ungeneralizeable.
“While there was a clear relationship between chronic pain and other rheumatologic disease, we were inadequately powered to determine if this was driven by any particular rheumatologic diagnosis, and we could not explicitly determine the causality or directionality of the relationship between ACEs, chronic pain or rheumatic disease,” the researchers wrote.
Perspective
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As pediatric providers, we work diligently to uncover the source of a child’s pain and recommend treatments to relieve it. When faced with a child presenting with chronic pain, it is often more difficult to dig deep enough to understand the source of the child’s unrelenting pain than simply attribute it to their underlying rheumatic disease.
Sonagra and colleagues, recognizing the growing incidence of pediatric chronic pain, sought to answer a number of questions, including whether or not adverse childhood experiences (ACE) play a role in the onset and severity of pediatric chronic pain, and whether ACE are predictive of the development of a rheumatic disease. For the purposes of this study, the definition of ACE included, but was not limited to, abuse of all types, a parent or family member with an alcohol and/or drug problem, parent separation or divorce, economic hardship and bullying.
Results of the study indicate children with chronic pain experienced at least one ACE. The rate of comorbidity between chronic pain and rheumatic disease is higher than rheumatic disease in the general pediatric population, and the greater number of ACE correlated to a higher functional disability score.
Aside from requiring additional studies that include a more diverse population and collection of specific socioeconomic data, how does this information impact our daily practice? First, it validates what many of us see on a daily basis — that pediatric chronic pain is very real, complex and challenging to treat. Second, it highlights the need for a multidisciplinary approach to the care of these children. And finally, it opens the door for innovative treatment models that encompass the biologic, psychologic and socioeconomic aspects of chronic pain.
Fascinating and worthwhile read.
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