Chronic stressors may play an important role in the development of chronic pain, leading to excess cortisol production and disruption to the body's sympathetic and parasympathetic systems.
Children with rheumatologic diseases and/or chronic pain who are exposed to adverse childhood experiences (ACEs), including abuse, neglect, financial insecurity, divorce, and domestic violence, are at an increased risk of functional disability, reoccurring symptoms, and a higher number of symptoms, according to a study published in Pediatric Rheumatology.1
“Chronic stressors, in particular, are thought to play a driving role in the development of chronic pain through biological mechanisms such as central sensitization, a state of increased neuronal activity within the central nervous system (CNS) that amplifies nociceptive signaling,” investigators stated. “These stressors also cause sustained activation of the hypothalamic-pituitary-adrenal (HPA) axis, leading to excess cortisol production and, over time, dysregulation of the body’s sympathetic and parasympathetic systems.”
This cross-sectional cohort study evaluated pediatric patients with chronic pain seen in a rheumatology clinic between August 2018 and July 2020. Thorough examinations were performed by both a clinician and psychologist. Clinical and demographic information such as age, race, ethnicity, sex, medications, family mental health history, and education information was collected. All clinic visits included patient reported outcomes (PROs) and a Functional Disability Inventory (FDI), in which a higher score was indicative of greater impairment.
Patients were placed into 3 groups: no ACEs, 1 ACE, and 2 or more ACEs. Clinical signs and symptoms associated with ACEs were analyzed using a Chi-square or Wilcoxon-rank test. Simple and multivariable linear regression models determined any association between variables, including ACEs, and functional impairment.
A total of 412 patients were included in the assessment, with 76% of patients reporting at least 1 ACE. Most (83%) patients were female and White (75%), with a median age of 14 years. While the median household income ($83,970) was higher than the national average ($65,712), those with 2 or more ACEs reported a significantly lower income ($73,702) when compared with patients with either no or 1 ACE ($86,167 and $89,712, respectively).
The most frequent ACEs were a history of mental illness in a close relative (56%) followed by divorce or separation (20%). Other ACEs included abuse (7%), bullying (6%), and a family member with a substance misuse disorder (3%).
While patients had similar severity and pain across all groups, higher FDI scores were seen in patients with at least 2 ACEs, as described by both patients (p = 0.05) and parents (p = 0.03). When comparing patients with 2 or more ACEs, 1 ACE, and no ACEs, worse functional disability, higher percentages of mental illness (73% vs 59% vs 34%, respectively), and more somatic symptoms were reported in patients with 2 or more ACEs (median symptom of severity score [SSS] of 7) when compared with 1 ACE (median 6) and no ACEs (median 5). Those in the 2 or more ACE group were more likely to have utilized outpatient mental health when compared with the other 2 groups (72% vs 59% vs 53%, respectively). A dose-dependent association was seen between ACEs and functional disability from co-morbid rheumatologic disease, with a higher prevalence of chronic headaches in patients with more ACEs.
Multivariable regression revealed higher pain scores, SSS, and autonomic changes were linked to an increased FDI score (β = 1.05, 1.95 and 4.76 respectively; all p < 0.01).
The low number of severe ACEs, such as substance use disorder or a family member attempting suicide, limited the study due to the inability to perform further subgroup analyses. As these ACEs are linked to greater social stigma, they may not have been reported during evaluations, which may have created ascertainment bias. There is a possibility that all ACEs may not have been accounted for, which opens up the possibility that ACEs are even higher in this patient population than the findings suggest. Lastly, generalizability was limited as the cohort was comprised of mostly White, female patients of higher socioeconomic status.
The study emphasizes how ACEs influence clinical symptomology within this patient population and highlight the need to ask patients about ACEs to understand the role they play in chronic pain and guide treatment protocols.
“Children with pain conditions should be systematically evaluated for exposure to ACEs as a part of early intervention to mitigate the risk of developing chronic pain with severe features,” investigators concluded. “Future studies focusing on systematic screening and assessment of ACEs can help to determine the definite burden of ACEs in the pediatric population with musculoskeletal pain and/or rheumatic disease which will be further helpful to identify those youth with ACEs at higher risk of developing chronic pain before such pain develops and optimize treatment modalities in a patient-centered manner.”
Sonagra M, Jones J, McGill M, Gmuca S. Exploring the intersection of adverse childhood experiences, pediatric chronic pain, and rheumatic disease. Pediatr Rheumatol Online J. 2022;20(1):14. Published 2022 Feb 14. doi:10.1186/s12969-022-00674-x