When things get complicated: At-risk attachment in children and adolescents with chronic pain

Abstract

Pain is a signal of danger, and danger activates the attachment system. When a parent responds to a child's pain with appropriate protection and comfort, more often than not, the pain resolves. But what happens in families when a child's pain becomes chronic and continues to signal a danger that has long passed? This study explored patterns of attachment in 48 children and adolescents with chronic functional pain and 48 healthy controls using structured attachment interviews. Patterns of attachment were identified using the Dynamic Maturational Model of Attachment. Compared to controls, children and adolescents with chronic functional pain were classified into at-risk patterns of attachment (χ = 76.4, df = 2, p < .001) and had higher rates of unresolved loss and trauma (χ = 10.8, df = 1, p = .001), suggesting a long-standing history of relational stress and the disruption of nurturing relationships. The findings suggest that the quality of attachment relationships contribute to the development and maintenance of chronic functional pain. Ongoing anxiety within the attachment relationship, combined with unresolved loss and trauma, may function much like catastrophising, contributing to chronic functional pain by activating the body's arousal systems. The assessment process for chronic functional pain should include a family assessment to identify ruptures in attachment relationships, as well as unresolved loss and trauma events that need to be addressed through family interventions or individual therapy.

“If You Fall Down, You Get Back Up”: Creating a Space for Testimony and Witnessing by Urban Indigenous Women and Girls

“…Healthy attachment and self-determination are two key aspects of Indigenous wellbeing that have been systematically negated by the Canadian government and popular discourse. Healthy attachment is the relationship between children and their caregivers (Ratnamohan & Kozlowska, 2017;Watt, O'Connor, Stewart, Moon & Terry, 2008). It contributes to an individual's ability to develop important coping skills, and it affects physical health as well as emotional wellbeing (Landa, Peterson, & Fallon, 2012;Maunder et al, 2017).…”

Adaptive functioning of children and adolescents with persistent pain: associations with sensory modulation and attachment ​​​​​​​

“…This may limit awareness of distressing physiological states related to fear or terror, while the individual maintains a high level of vigilance to the environment. Adults with persistent pain report higher levels of childhood abuse and trauma than healthy controls (Davis, Luecken, & Zautra, 2005), and a high proportion of children and adolescents with persistent pain attending tertiary care have been found to have previous adverse life events (Ratnamohan & Kozlowska, 2017). The combined sensory modulation pattern may have developed as a response to exposure to trauma for adolescents with persistent pain.…”

“…There is emerging evidence that children and adolescents with persistent pain attending tertiary care are more likely to have developed insecure patterns of attachment (Ratnamohan & Kozlowska, 2017). In a recent study by Ratnamohan and Kozlowska (2017) of children and adolescents referred for tertiary pain management care, 98% of participants were assessed as having at-risk (insecure) patterns of attachment when measured using the age-appropriate attachment interview (49% Inhibitory Type A+ classification, and 38% Coercive Type C+ classification, 11% Mixed inhibitory/coercive).…”

“…Traumatising life experiences may predispose children and adolescents with persistent pain to developing insecure attachment patterns. Post-traumatic stress disorder is more common in children and adolescents with persistent pain than healthy children (Noel, Wilson, Holley, et al, 2016), and those with persistent pain attending care are more likely to have experienced negative antecedent life events, such as physical illness, parental conflict, bullying, social loss, and have unresolved symptoms of loss and trauma (Ratnamohan & Kozlowska, 2017). Theoretically, Donnelly and Jaaniste (2016) proposed that the activating or immobilising patterns associated with insecure attachment may link with: (1) autonomic responses to threat that increase hypervigilance and neural sensitivity, (2) pain signalling behaviours to elicit responses from care-givers, and (3) cognitive appraisals of threat.…”

“…Relationships between attachment insecurity and atypical sensory modulation have been demonstrated in healthy adults and young children (Jerome & Liss, 2005;Levit-Binnun et al, 2014;Meredith et al, 2016;Whitcomb et al, 2015). Children with persistent pain attending tertiary care have been found to have insecure attachment styles (Kozlowska, 2009;Ratnamohan & Kozlowska, 2017). Although theoretically it has been proposed that the child with persistent pain's attachment pattern may also impact his or her perception of sensory events (Crittenden, 2008;Donnelly & Jaaniste, 2016), the relationships between sensory modulation and attachment patterns have not been investigated in clinical populations.…”