What You Need to Know About ACEs (Adverse Childhood Experiences) and Chronic Pain

Adverse childhood experiences or ACEs are potentially traumatic events that occur during childhood. The experiences can include being a victim of violence, abuse, or witnessing these events during the formative years of childhood. Growing up in a family with mental or substance use problems or even being financially vulnerable and not having enough food to eat or clean clothing can be considered as adverse events. While one often thinks of one tragic situation as an adverse childhood experience, we now know that many adverse events can build up over time to be just as negatively impactful as one traumatic event, perhaps affecting neurobiological processes to a greater degree.

PTSS or post-traumatic stress symptoms occur earlier than 30 days after experiencing a traumatic event. These symptoms are grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. In many situations, these symptoms are a normal response to a challenging situation and may subside over several days and don't have long-lasting consequences. However, PTSD or post-traumatic stress disorder implies persistent of troublesome nightmares, flashbacks, or constant reminder of the situation and is a clinically-diagnosed condition listed in the Diagnostic and Statistical Manual of Mental disorders or DSM-5.

Incidence of ACEs

Approximately 30% of youth experienced one or more traumatic events by age 16, with 13% of those youth endorsing symptoms of post-traumatic stress. Predictors of development of PTSS include previous trauma history, presence of an anxiety disorder and family factors (parent PTSS and family adversity).

Risk factors for heightened trauma reactions include...

- pre-trauma child characteristics (age and psychological functioning)

- contextual factors during trauma (perceived threat, level of exposure)

- post-trauma variables (parental responses, support, stressors)

The lifetime prevalence of PTSD ranges 20-35% in child cancer survivors and 27-54% in their parents. Risk factors in this population for increased PTSS severity include female sex (of both child and parent), prior stressful events, family functioning and social support. The rates of PTSS in other samples of hospitalized or injured children vary widely (10-44%).

Why think about ACEs?

ACEs have gotten a lot of attention over the past several years and some advocate for consistent screening for ACEs by healthcare professionals. While there are different approaches as to how to address adverse childhood experiences and how they impact relationships, self-esteem, and the vulnerability of being a patient, one needs to be mindful of how to best treat these individuals who come to us for care despite us not knowing if they have had these negative experiences.

Many of the risk factors described above, while have been shown to be associated with pain and disability in youth, current models do not incorporate the experience of traumatic events per se or the development of PTSS or PTSD in youth.

Mechanism of ACEs

The presence of pain can shape the PTSD experience and vice versa. Research demonstrates altered pain processing in adults with PTSD and that the presence of even subsyndromal PTSD symptoms is associated with greater pain complaints. The perpetual avoidance model (PAM) describes PTSD symptoms as contributing to the development of chronic pain through hyperarousal, muscle tension and avoidance.

Chronic pain and PTSD are both complex experiences that involve multiple neural networks with shared brain regions and similarities in activation patterns. The amygdala, medial prefrontal cortex and the hippocampus reveal increased connectivity and activation during states of hyperarousal and symptom re-experiencing.

Characteristics of trauma (perceived threat and level of exposure) and the pain experience are tightly associated and together shape an individual' psychological responses and impairment. The experience of pain can invoke fear and helplessness, central features of PTSS.

The current approach to pain, specifically the biopsychosocial approach (rather than the biomedical approach), takes into consideration that our pain experience is more than a simple process of neurotransmission. It is that point, that it is an experience, which acknowledges that a pain episode is filtered through our emotions and our past history, favorable and not-so-favorable, These experiences then shape how we perceive the pain and what it might tell us about ourselves.

Roles of parents, family and peers

The influences of parent and family are important determinant's of children's adaptation at the time a traumatic event occurs and immediately afterwards, influencing both the child's interpretation of the event and the subsequent adaptation. Here are some factors that should be considered in both PTSS and chronic pain.

- Witnessing high parental distress increases children's own PTSS

- Specific parent behaviors (overprotectiveness and coping assistance) are associated with maladaptive child reactions.

- Maternal factors (emotional sensitivity) predict PTSD symptoms

-Children's functional status predicted both PTSS levels in parents and children. In other words, children and adolescents who participate in typical age-appropriate activities despite adversity are more likely to be more resilient and manage the adversity in healthier ways.

-Peer difficulties such as teasing and bullying have been documented as having impact on both pain and PTSS. The importance of a child being able to achieve typical developmental milestones such as establishing positive peer relationships and individuating from parents is becoming more evident with extensive study of ACEs and chronic pain. Peer relationships play a key role in shaping a child's psychological responses to stress and the availability of coping resources.

Cognitive biases

These include attentional and memory biases, threat appraisal and catastrophizing.

Attentional biases towards pain and trauma-related cues are thought to underlie the development and maintenance of both chronic pain and PTSD. This facilitates a focus on symptoms and potential threat and increases the risk for PTSS in youth. Children with higher pain catastrophizing tend to shift attention away from pain, exhibit more avoidance behavior and have parents who also catastrophize more about their pain.

Catastrophic thinking about pain and anxiety has been shown to influence the development of children's expectancies and memories of pain, with higher catastrophizing and anxiety linked to increasingly distressing pain memories over time.

Avoidance and activity limitations

Avoidance of thoughts, feelings, and external reminders (people and places) connected to trauma are characteristic of PTSS. But rather than being helpful, effortful avoidance has been shown to be associated with impairment. Children's avoidance of pain is also important to consider in the development and/or maintenance of PTSS. Avoidance can increase risk for pain chronicity. The Pediatric Fear Avoidance Model surmises that a child's fear of pain leads to a self-perpetuating cycle of avoidance and activity limitations, fueled by psychological factors such as catastrophizing and depression. Avoidant coping in youth with chronic pain has been associated with activity disengagement, self-isolation, depressive symptoms, disability and low perceived school and social competence.

Hyperarousal

Sleep disturbance and hypervigilance are key features of PTSS and may be present in those with chronic pain. Hyperarousal to bodily sensations is incompatible with sleep and potentially increases pain sensitivity, lowers pain tolerance and decreases a child's ability to cope. Pain can trigger hyperarousal and both pain and hyperarousal are associated with poorer functioning.

Anxiety sensitivity

These individuals interpret anxiety symptoms as signalling physical, psychological, and social threat. Anxiety sensitivity develops early in life and is shaped by interactions with parents around health and illness; these include reinforcement of sick behaviors, the sick role, and personal responsibility during illness. Anxiety sensitivity predicts greater pain-related fear and anxiety and poorer health, social functioning, and quality of life.

Depression

Depression is a common factor underlying both PTSD and chronic pain. Activity restriction and fatigue characteristic of depression is thought to maintain both disorders by fuelling disability and impeding exposure to avoided stimuli. The presence of depression is a risk factor for pain persisting into adulthood. Parental depression has recently been implicated in the development of pediatric chronic pain and severity of PTSS in youth.

Perceived injustice

Defined as a person's feelings of loss, blame and unfairness, including negative appraisals of the severity and irreparability of limitations. Questions like 'Why me?' or 'My life is changed forever' may perpetuate arousal and a focus on pain symptoms, leading to an increase in psychological symptoms or functional limitations.

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A quick summary

High co-occurrence of PTSD and chronic pain in adulthood

Chronic pain often first emerges in adolescence and is linked to development of anxiety disorders

Well-validated measures of PTSS and PTSD are available for assessment of children.

https://www.ptsd.va.gov/understand/what/teens_ptsd.asp

Combined intervention for PTSD and chronic pain has shown efficacy in several adult populations.

In pediatric pain populations, interoceptive exposure [as a component of the pain provocation technique (PPT)] has shown preliminary effectiveness in reducing pain intensity and school avoidance.

Modification of Our Care in the Setting of ACEs

While it may not always be possible or prudent to screen for ACEs in our patient population, we do need to consider that many individuals have a higher chance of having experienced adverse events than not. Trauma-informed care is the 'universal precautions' for mental health of all of our patients and guides us to conduct our evaluation and treatment in a manner that is thoughtful, compassionate, and aware of the potential vulnerabilities of our patients. I'll talk about this in an upcoming post based on a discussion I had with others on the social media platform Clubhouse.

If you are interested in the full print article this post was based upon, click this link below.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/ejp.879

Do you have any thoughts on how we as healthcare professionals could do a better job in treating those with a history of experiencing adverse events? Whether you are a healthcare professional yourself, treat children or adults for medical or psychological issues, or are a layperson, I'd love to hear your thoughts about this paper.