Post‐traumatic stress symptoms in children and adolescents with chronic pain: A topical review of the literature and a proposed framework for future research

Abstract

Background and objective The co-occurrence of chronic pain and post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) has gained increasing research attention. Studies on associations among pain and PTSS or PTSD in youth have largely been conducted in the context of acute injury or trauma. Less is known about the risk for co-occurrence with paediatric chronic pain. In this review, we (1) propose a conceptual framework to outline factors salient during childhood that may be associated with symptom severity, co-occurrence and mutual maintenance, (2) present relevant literature on PTSS in youth with acute and chronic pain and identify research gaps and (3) provide recommendations to guide paediatric research examining shared symptomatology. Databases and data treatment Electronic databases (PubMed and Google Scholar) were used to identify relevant articles using the search terms ‘child, adolescent, paediatric, chronic pain, acute pain, post-traumatic stress symptoms and post-traumatic stress disorder’. Studies were retrieved and reviewed based on relevance to the topic. Results Our findings revealed that existing biobehavioural and ecological models of paediatric chronic pain lack attention to traumatic events or the potential development of PTSS. Paediatric studies are also limited by lack of a conceptual framework for understanding the prevalence, risk and trajectories of PTSS in youth with chronic pain. Conclusions Our new developmentally informed framework highlights individual symptoms and shared contextual factors that are important when examining potential associations among paediatric chronic pain and PTSS. Future studies should consider bidirectional and mutually maintaining associations, which will be aided by prospective, longitudinal designs.

Mental Health Comorbidities in Pediatric Chronic Pain: A Narrative Review of Epidemiology, Models, Neurobiological Mechanisms and Treatment

“…Central to this model are shared vulnerability and mutually maintaining factors that are thought to influence PTSD, chronic pain and the disorders’ comorbidity in bi-directional ways. While many of the proposed factors are similar to those covered in the previous models (e.g., anxiety sensitivity, avoidance, hyperarousal), the authors drew evidence from pediatric research, confirming the important roles that these factors play in pain and mental health trajectories in childhood and adolescence [31]. Unique to this model is the integration of individual (e.g., trauma and pain-related variables), interpersonal (e.g., parent traumatic stress, peer victimization) and neurobiological (e.g., PTSD and pain influences on the developing brain) factors, all couched within a developmental context [31].…”

“…In a recent topical review, Holley et al [31] proposed a new pediatric model of PTSD and chronic pain comorbidity in youth. Central to this model are shared vulnerability and mutually maintaining factors that are thought to influence PTSD, chronic pain and the disorders’ comorbidity in bi-directional ways.…”

“…At all levels, PTSD and pain symptomatology are thought to reciprocally influence one another. For instance, catastrophic thoughts about pain in youth may lead to behavioral avoidance, and similar cognitions in parents may serve to exacerbate these cognitions and behaviors in their child [31]. Likewise, depressive symptoms characteristic of chronic pain and PTSD might be aggravated or even induced by peer difficulties and social isolation that are also commonly found in both conditions [31].…”

“…For instance, catastrophic thoughts about pain in youth may lead to behavioral avoidance, and similar cognitions in parents may serve to exacerbate these cognitions and behaviors in their child [31]. Likewise, depressive symptoms characteristic of chronic pain and PTSD might be aggravated or even induced by peer difficulties and social isolation that are also commonly found in both conditions [31]. Overall, the proposed model fills a gap in the literature by being the first to integrate evidence from the pediatric PTSD and pain literatures, and positing developmentally relevant mechanisms that might underlie and serve to maintain both conditions in youth.…”

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here?

“…A small body of literature emphasizes a connection between trauma and chronic pain, primarily focusing on abuse (physical or sexual) or injury (e.g., sports injury, accident) [45]. These studies suggest that early posttraumatic stress disorder (PTSD) or trauma-related symptoms predict later functional impairment and pain [45]. However, more research is needed to understand the connection between trauma and pain in the pediatric population.…”