Journal Logo

Research Paper

Heightened risk of pain in young adult women with a history of childhood maltreatment: a prospective longitudinal study

Beal, Sarah J.a,b,*; Kashikar-Zuck, Susmitaa,b; King, Christophera,b; Black, Williamc; Barnes, Jaclynb; Noll, Jennie G.a,b,d

Author Information
doi: 10.1097/j.pain.0000000000001706

1. Introduction

Adults with chronic pain report a higher incidence of childhood maltreatment (ie, physical, emotional, and sexual abuse; neglect) than the general population, with rates up to 63%15,18,42 compared with 12.5% among US adults.50 Theoretical models identify maltreatment and adversity as risk factors for developing chronic pain, operating through psychological distress, social difficulties, and hyperarousal32,34; however, many studies evaluating the prevalence of child maltreatment in adults with pain rely on retrospective reports.42 Prospective studies evaluating pain in adulthood among those with known child maltreatment have not consistently found elevated risk,44 which may be explained by inconsistencies in reporting of maltreatment4 and combining maltreatment and a broader conceptualization of adversity (eg, natural disasters and family instability).42 If maltreatment uniquely contributes to pain, exposure to maltreatment would be expected to increase risk of pain in adulthood independent of adversity. Child adversity frequently co-occurs with maltreatment and may also contribute to pain in adulthood.34 Furthermore, women are at heightened risk of chronic pain in adulthood9; therefore, understanding the connection between maltreatment and pain is a key women's health issue.

The association of child maltreatment and adult pain may be explained through the experience of post-traumatic stress symptoms (PTSS20), which often follow child maltreatment. Post-traumatic stress symptoms, characterized by re-experiencing traumatic events, heightened arousal to environmental stimuli, and avoiding stressful situations, are elevated in children and adults with chronic pain2,35 and associated with increased chronic pain30 and reduced treatment responsiveness.7 Child maltreatment and adult post-traumatic stress disorder together increase the risk of pain in middle adulthood43; longitudinal studies beginning in childhood are necessary to identify whether child maltreatment and PTSS act together to increase risk of pain in adulthood. Child maltreatment is consistently associated with elevated PTSS31 and dysregulation in stress and inflammatory pathways8,16,19,26,40,41 that are also observed in chronic pain, while findings related to adversity more broadly are variable. For this reason, it may be important to distinguish among types of child adversity when examining adult pain experiences.

The current study longitudinally examined associations among child maltreatment, adolescent PTSS, and pain in young adult women. It was hypothesized that women with a documented history of maltreatment would report more pain in the past week, higher pain intensity, and more pain locations than women without a maltreatment history. Furthermore, child maltreatment was expected to increase adolescent PTSS, which in turn would explain the relations between child maltreatment and young adult pain experiences, such that elevated PTSS would be associated with more reports of experiencing pain and higher levels of pain in young adult women. Finally, child maltreatment was expected to increase adult pain over other forms of childhood adversity. Given that child maltreatment is less common than childhood adversity,17 distinguishing the effects of maltreatment and adversity may be relevant to improve screening procedures in the clinical care of pain patients and help to further elucidate risk factors for the development of chronic pain.

2. Methods

2.1. Participants

Data were obtained from a prospective cohort study, the Female Adolescent Development Study (FADS), aimed at examining the impact of child maltreatment and subsequent female health.36,38 The study included 477 adolescent females matched as case–control. A “case” (ie, maltreated group) was defined as having a substantiated maltreatment report based on child protective services (CPS) records (n = 273; 31% substantiated allegations for physical abuse, 49% sexual abuse, 15% neglect, 5% multiple types) in the previous year. “Control” participants (ie, comparison group; n = 204) were individually matched on gender, race, income, and family constellation (1- or 2-parent households), recruited from primary care clinics at a large pediatric hospital in the US Midwest and from the communities in which the maltreated women resided. Youth eligible to participate were (1) adolescent females, (2) able to read and understand English, and (3) residing with a nonperpetrator of maltreatment for a minimum of 12 months, who could provide written informed consent. Control group participants had no self-report of maltreatment or evidence of maltreatment based on CPS records. Those in the control condition who were found to have experienced maltreatment based on CPS records were excluded (n = 37, original sample N = 514).

2.2. Procedures

2.2.1. Adolescent assessment

Participants between the ages of 14 and 17 years were recruited for the FADS study beginning in 2008. Each participant in the maltreated group had endured at least 1 substantiated case of abuse or neglect within 12 months of study enrollment, where CPS investigators confirmed that child maltreatment had occurred. Participants in the nonmaltreated comparison cohort were without maltreatment at the time of enrollment, based on participant report and CPS record review. This information was then verified later during an audit of CPS records to ensure that no participants in the comparison cohort had experienced substantiated abuse; as a result, 37 adolescent females were excluded from the comparison cohort in these analyses. The institutional review board at Cincinnati Children's Hospital Medical Center (CCHMC) approved all aspects of this study. At the time of enrollment, a nonoffending legal guardian who resided with the adolescent study participant provided informed consent for participation, and the adolescent provided assent to participate. Participants completed annual study visits measuring broad aspects of female health until the age of 19 years, with a retention rate of 97%. At age 18 years, all study participants were reconsented and gave permission to be contacted for future research studies. During the adolescent phase of data collection, interviews to detect child maltreatment and adversity were conducted annually for all participants, along with self-report survey measures. The interviewer conducting the interview was blind to whether the child had substantiated maltreatment allegations. The caregiver consenting to participation also completed surveys reporting on the participant's health and psychosocial functioning. Between visits, participants were contacted quarterly by mail, email, and phone to assist with retention. Study participants also consented/assented to the use of Accurint, a technology used to search public records and locate adults, to maintain contact with participants (if aged 18 years or older) and caregivers (if participants were younger than 18 years).

2.2.2. Young adult assessment

In the fall of 2017, 5 years after FADS data collection ended, study participants were recontacted and invited to participate in an online self-report survey. Participants were recontacted through mailed letters to last known addresses, email to last known email address, phone calls to last known phone numbers, through social media, through address and phone number searches in Accurint, and by searching online public and media records. Study participants who indicated they were interested in participating in a follow-up research study were sent a link through email to complete the online survey, which could be completed on a desktop or mobile device (eg, phone or tablet). Participants who expressed interest but did not have reliable Internet access were mailed a paper version of the survey to complete and return in a prepaid stamped envelope. The institutional review board at CCHMC approved all aspects of the young adult follow-up for this study.

2.3. Measures

2.3.1. Adolescent predictor variables Child maltreatment status

Child maltreatment was dichotomous (0 = no maltreatment and 1 = maltreatment) determined based on substantiated sexual abuse, physical abuse, or neglect within 3 to 12 months of enrollment into the original study for the maltreated cohort or the absence of a substantiated allegation of abuse or neglect and self-reported maltreatment experiences for the control cohort. Post-traumatic stress symptoms

Post-traumatic stress symptoms were collected through participant report during the structured Comprehensive Trauma Interview (CTI5), administered by a trained investigator. The CTI is a validated structured interview protocol that captures trauma history from birth to the time of administration (see Ref. 37 for full details). As part of the CTI, when participants self-identified traumatic experiences, they were asked to report (1) re-experiencing symptoms (6 yes/no items; eg, “Have you ever felt as though what happened was re-occurring—like you were reliving it?”), (2) trauma avoidance (6 yes/no items; eg, “Have you ever avoided doing things or getting into situations that reminded you of what happened?”), and (3) arousal (6 yes/no items; eg, “Have you ever had trouble falling asleep or staying asleep because of what happened?”) using a validated scale47 that is consistent with the Diagnostic and Statistical Manual of Mental Disorders IV.3 Responses were summed to create a scale from 0 (no symptoms) to 6 (all symptoms endorsed) for each subscale, with higher scores indicating greater symptoms.

2.3.2. Young adult outcome variables

Participants received a link through email and were invited to complete the survey online using CCHMC's Research Electronic Data Capture (REDCap) system. Participants were instructed to answer questions about pain symptoms they had experienced over the past week, based on questions from the Brief Pain Inventory12,14 and the Widespread Pain Index.51,52 Survey responses were stored on a secure server. Any pain

Participants were asked “Have you experienced more than ‘every day’ pain in the last week” (1 =yes and 0 = no) to determine the presence of any pain. Pain locations

Participants were asked to indicate which locations they felt pain, across 19 body areas based on the Widespread Pain Index measure used as part of the American College of Rheumatology's guidelines for classification of fibromyalgia.52 The score for pain locations was based on the count of areas that participants endorsed. Average Pain Intensity

Participants reporting that they had experienced pain in the last week were asked to rate their average pain severity using an 11-point Numeric Rating Scale with response options ranging from 0 (no pain) to 10 (pain as bad as you could imagine13,23).

2.3.3. Covariates Demographic variables

Age in years at the time of enrollment and at the young adult follow-up was included. Minority status was based on self-report of race and ethnicity; because of limited heterogeneity, responses were recoded to 0 (minority) or 1 (white non-Hispanic). Household income at baseline was based on caregiver report with responses ranging from 1 (under $10,000) to 12 (over $120,000). Childhood adversity

Child adversity was calculated based on the number of events endorsed during the CTI with the adolescent, classified into 3 previously validated categories6: unexpected tragedy (7 events, eg, “Have you ever been very sick (eg, needing hospitalization)?”); instability (3 events, eg, “Did anyone close to you ever move away from you?”); and exposure to violence (8 events, eg, “Have there been times when you have seen or heard adults that take care of you hit each other or hurt each other physically?”); confirmatory factor analysis indicated this model structure had good fit to the data; comparative fit index (CFI) = 0.93, root mean square error of approximation (RMSEA) = 0.02, standardized root mean square residual (SRMR) = 0.04. In addition, items from this self-report measure were used to identify maltreatment experiences by type (ie, abuse only, neglect only, or both abuse and neglect). Adolescent pain

At the baseline adolescent study visit, caregivers were asked to report lifetime and past 2 year prevalence of various conditions, including frequent abdominal pain, backaches, headaches, swollen or painful joints, pain or pressure in the chest, arthritis, and other physical complaints, which were coded to indicate pain (eg, knee pain). These data were coded to indicate any caregiver report of lifetime pain or pain in the previous 2 years. In addition, adolescents completed the Youth Self-Report,1 which included a somatic symptoms subscale where adolescents could endorse whether they “sometimes” or “always” experienced general aches and pains, headaches, and stomachaches. These items were coded to indicate adolescent report of pain.

2.4. Analysis plan

Descriptive statistics were calculated for the full sample and by the maltreatment group. To evaluate the impact of attrition in young adulthood, differences in adolescent-reported variables (eg, PTSS, age, household income, and childhood adversity) were evaluated using t tests for continuous outcomes and χ2 tests for categorical outcomes. Bivariate analyses examining PTSS and each young adult outcome by the maltreatment group were also conducted, using t tests for continuous outcomes and χ2 tests for categorical outcomes.

To test the hypotheses that maltreatment would elevate risk of adolescent PTSS and young adult pain, and that adolescent PTSS would explain the relations between maltreatment and young adult pain, mediation path analyses were estimated using a SEM framework. Models were estimated using the lavaan package46 in R version 3.5.0. Models estimated the direct effect of the maltreatment group, determined at baseline, as a predictor of adolescent-reported PTSS subscales (ie, re-experiencing, arousal, and avoidance) and young adult physical pain (ie, any pain in the past week, average pain intensity, and number of pain locations), the direct effect of PTSS subscales on young adult physical pain, and the indirect effect of the maltreatment group on adult pain through PTSS subscales, accounting for the effects of covariates listed above (see Fig. 1 for conceptual model). In models estimating continuous outcomes, maximum likelihood estimation with robust standard errors was used; weighted least squares estimation with robust SEs was used for categorical and count outcomes.

Figure 1.
Figure 1.:
Conceptual model linking child maltreatment to young adult physical pain.

Finally, a set of models was estimated to test whether differing indicators of child adversity, based on self-report, were affiliated with pain in adulthood; in these models, child adversity scale scores were included as a predictor of each young adult pain outcome with PTSS subscales and other covariates (described above) included.

3. Results

3.1. Descriptive and bivariate statistics

3.1.1. Adolescent outcomes

Descriptive statistics for all variables included in the analysis are provided in Table 1. The majority (n = 422) of original study participants were located for the young adult assessment time point; 403 (85% of maltreated and 84% of nonmaltreated participants) were able to participate. Factors limiting ability to participate included active deployment with the military, incarceration, or being deceased. Online surveys were completed by 383 women (80% of maltreated and 81% of nonmaltreated participants). Variables collected in adolescence were evaluated for those who did (n = 383) and did not (n = 94) participate in the young adult follow-up. Those results indicated that the sample retained into adulthood was significantly older at baseline (M = 15.32, SD = 1.10) compared with those who were lost to follow-up (M = 15.04, SD = 0.96, t (158.38) = 2.45, P = 0.02). Women who participated in the young adult follow-up also had significantly higher household income in adolescence (M = 4.08, SD = 2.95) compared with women who were lost to follow-up (M = 3.16, SD = 0.14, t (179.41) = 3.39, P < 0.01). All other variables were not significantly different between the 2 groups, and variables did not differ by maltreatment status (P's > 0.10).

Table 1
Table 1:
Descriptive statistics for maltreated and comparison adolescent and young adult women.

In addition, women with confirmed maltreatment had lower household income (t (414.63) = 2.30, P = 0.02) compared to women with no confirmed maltreatment and significantly higher PTSS re-experiencing sum scores, t (463.13) = −7.87, P < 0.01; PTSS arousal sum scores, t (474.52) = −7.61, P < 0.01; and PTSS avoidance sum scores, t (463.86) = −8.13, P < 0.01. The majority (76%) of caregivers of study participants disclosed lifetime pain symptom for their adolescent daughters, and 53% endorsed pain symptom for their adolescent daughters in the previous 2 years (74% in the maltreatment and 80% in the comparison sample for lifetime pain symptoms; 49% in the maltreatment and 59% in the comparison sample for past 2-year pain symptoms). These differences were not significant between the maltreatment and comparison groups for lifetime pain2 = 1.37, P = 0.24) or pain in the previous 2 years (χ2 = 1.41, P = 0.24). Three items assessing pain complaints in the past 6 months (abdominal pain, headache, or other pain) were also reviewed from the Youth Self-Report somatic symptoms subscale. The majority (83%) of participants endorsed some pain in the past year (88% of maltreated youth and 78% of the comparison sample). These differences were statistically significant (χ2 = 7.91, P < 0.01). Of note, these pain assessments are limited; they do not reflect a clinical pain diagnosis but rather overall somatic symptoms, and no measure of chronicity, intensity, or duration was assessed. Finally, women with confirmed maltreatment reported higher childhood adversity [unexpected tragedy: t (443.81) = −5.25, P < 0.01; family instability: t (473.41) = −7.86, P < 0.01; exposure to violence: t (464.48) = −12.60, P < 0.01] and lower household income, t (414.63) = 2.30, P = 0.02.

3.1.2. Young adult outcomes

Bivariate analyses comparing adolescent and young adult variables for women with and without confirmed child maltreatment indicated that women who experienced confirmed maltreatment were more likely to report experiencing pain in the past 7 days, χ2 (1) = 3.87, P < 0.05. The experience of pain did not significantly differ among women experiencing neglect only (1% of the sample), abuse only (67% of the sample), and abuse or neglect (13% of the sample, χ2 = 7.22, P = 0.07). The number of pain locations was also higher in women with confirmed maltreatment, t (380.72) = −2.44, P = 0.02, respectively. Among those who reported any pain, average pain intensity was higher for women with a history of confirmed maltreatment, t (171) = −2.45, P = 0.02.

Irrespective of maltreatment status, bivariate analyses indicated that PTSS in adolescence were associated with experiencing any pain in the past 7 days (t's (381) = 2.29-3.88, P's < 0.05, r's = 0.12-0.19 across the different PTSS subscales) and number of pain areas affected (t's (381) = 2.98-4.01, P's < 0.01, r's = 0.15-0.20 across the different PTSS subscales), but were not associated with average pain intensity (r's = 0.04-0.07, P's > 0.10 across the different PTSS subscales), which was only assessed for women who reported experiencing any pain in the past 7 days.

3.2. Mediation path analyses

A series of mediation path analysis models were estimated using child maltreatment as the primary predictor variable directly associated with young adult pain (ie, any pain, average pain, total pain locations) and indirectly associated through PTSS (ie, re-experiencing, arousal, and avoidance) with age, minority status, and adolescent household income as covariates. Adolescent age was not significantly associated with outcomes and was removed from analytic models. Models had acceptable fit (DWLS = 99.24, χ2 (12) = 74.53, P < 0.01). The results of those models are summarized in Table 2. Post-traumatic stress symptoms fully mediated the relations between child maltreatment and experiencing any pain in adulthood, such that once PTSS and covariates were accounted for, maltreatment significantly increased PTSS re-experiencing, arousal, and avoidance symptoms, and re-experiencing and arousal significantly predicted experiencing pain in the last 7 days (indirect effect B = 0.35, SE = 0.13, P < 0.01; Fig. 2A). Effect sizes (Cohen's d) indicate generally small effects of maltreatment status and PTSS on pain outcomes, a moderate effect of maltreatment on PTSS, and moderate cumulative effect of maltreatment and PTSS on experiences of any pain in adulthood.

Table 2
Table 2:
Mediation path models estimating direct and indirect effects of child maltreatment history on young adult pain through adolescent post-traumatic stress symptoms.
Figure 2.
Figure 2.:
Mediation models estimated to evaluate direct and indirect effects of child maltreatment on young adult pain through adolescent PTSS. Models were estimated for experiencing any pain in adulthood (A), average pain severity ratings (B), and total pain locations (C). PTSS, post-traumatic stress symptoms.

Consistent with bivariate results, there was no significant indirect effect of child maltreatment on average pain severity ratings through PTSS for women who reported experiencing pain (indirect effect B = −0.09, SE = 0.14, P = 0.50; Fig. 2B). Rather, child maltreatment was associated with higher average pain ratings in young adulthood, as was lower household income in adolescence.

Finally, there was a significant indirect effect of child maltreatment on total pain locations through PTSS avoidance (indirect effect B = 0.29, SE = 0.16, P = 0.05; Fig. 2C). Specifically, maltreatment significantly increased PTSS re-experiencing, arousal, and avoidance symptoms, and avoidance significantly predicted an increase in the number of areas with pain (B = 0.11, SE = 0.04, P = 0.02).

To understand the impact of child adversity, an additional set of analyses was estimated where cumulative assessments of unexpected tragic events, indicators of family instability, and exposure to violence were added as covariates in regression models predicting adult pain outcomes. Collinearity among adversity indicators and maltreatment status prevented testing a model where all adversity and maltreatment indicators were included. For that reason, we report here the models including maltreatment and each indicator of adversity, as well as PTSS scales and demographic covariates. In those multivariate models, only cumulative exposure to violence was associated with pain outcomes (additional results available by request). Specifically, cumulative exposure to violence was significantly associated with an increased likelihood of experiencing any pain in adulthood (B = 0.12, SE = 0.05, P = 0.01) above and beyond the effect of maltreatment status, PTSS, and other covariates (Table 3). Effect sizes (Cohen's d) of the association of cumulative exposure to violence and PTSS on any pain in adulthood indicated small effects. Cumulative exposure to violence was not significantly associated with average pain intensity or total pain areas affected.

Table 3
Table 3:
Path models estimating direct effects of child maltreatment history, cumulative exposure to violence-related adversity, and adolescent post-traumatic stress symptoms on young adult pain.

4. Discussion

This study is among the first to evaluate mechanisms linking child maltreatment and young adult pain, using a prospective, longitudinal design in a community sample of adolescents with and without maltreatment histories. Results indicate that the link between childhood maltreatment and pain in adulthood is not simple, unraveling some inconsistencies reported in the literature. As hypothesized, women with a child maltreatment history were significantly more likely to experience pain and report a higher number of pain locations in young adulthood. Furthermore, among women who experienced any pain, those who were maltreated reported somewhat higher pain intensity. Results also showed that elevated PTSS during adolescence were associated with pain in adulthood and more widespread pain.

Importantly, child maltreatment completely operated through adolescent PTSS to impact the experience of any pain and widespread pain in adulthood. However, in women reporting any pain in the past week, pain intensity was directly affected by child maltreatment history. More nuanced relations were also found between PTSS and young adult pain outcomes, such that re-experiencing and arousal were associated with experiencing any pain, while avoidance was associated with number of pain locations. Indicators of child adversity more broadly defined were not generally related to young adult pain outcomes once maltreatment status and adolescent PTSS were taken into account. The only exception was for cumulative exposure to violence and experiencing any pain in young adulthood, where a significant direct effect was identified. Given that family violence encompassed forms of maltreatment that overlapped with confirmed maltreatment from the child welfare record and other definitions of child abuse,53 this finding provides further evidence that maltreatment may be particularly important for predicting pain, beyond other forms of child adversity. Together, these findings explain inconsistencies in the literature linking child maltreatment and adversity to pain in adulthood. Specifically, it appears that vulnerability to pain in adulthood is related at least in part to PTSS, and that not all forms of child adversity are universally associated with the emergence of young adult pain symptoms. Importantly, direct effects of maltreatment, childhood exposure to violence, and PTSS on pain in adulthood were small; however, the combination of maltreatment and PTSS represented moderate effect sizes.

4.1. Relations between childhood maltreatment and pain in adulthood

Childhood maltreatment and pain in adulthood have been inconsistently associated.15,21,28,33,34,42,44 Potential explanations for the variability in previous study findings include inconsistent assessments of maltreatment and adversity, a wide range of methods for establishing maltreatment status, and mediated pathways to adult pain outcomes. Our study used a rigorous standard to establish maltreatment status, which was distinct from other forms of adversity in childhood. Maltreatment status was based on confirmed child welfare record review, with maltreated adolescents recruited within 12 months of substantiation of abuse or neglect. In addition to maltreatment status, adolescents completed the CTI,5 which screened for exposures to a range of adversity, including natural disasters and self-reported exposure to sexual abuse, physical abuse, and other violence. To date, most research has not distinguished between maltreatment (ie, abuse or neglect) and the broader category of adversity (eg, parental divorce or natural disasters) occurring in childhood and adulthood.42 As a result, it has been unclear whether the development of pain in adulthood is better attributed to adversity broadly or to specific types of adversity (eg, maltreatment). It is possible that maltreatment and other adversity in childhood represent a continuum of early life stressors that impact adult chronic pain.21,33,34 However, in the current study, self-reported exposure to violence was associated with experiencing pain in young adulthood, whereas cumulative measures of other life stressors and adversity were not. One important reason for attending to how adversity is defined and measured is that there may be differential effects of adversity type and timing on physiology.17,22,29 Some adversities, including child maltreatment, have more consistently been associated with altered stress responses in the hypothalamus–pituitary–adrenal axis in adulthood.19 Given the role of the hypothalamus–pituitary–adrenal axis in response to pain and the development of chronic pain syndromes,10 distinguishing maltreatment and other forms of childhood adversity may be critical for identifying who is at risk of chronic pain in adulthood. It is also notable that pain did not significantly differ among women experiencing abuse, neglect, or both; however, limitations in sample size and diversity in maltreatment experiences within these broad categories make it difficult to draw conclusions, and more research is needed.

This study also used prospective longitudinal methodology and objectively substantiated childhood maltreatment to establish the presence of substantiated maltreatment in the maltreated cohort and the absence of maltreatment in the comparison cohort. Recent research has demonstrated inconsistencies in prospective and retrospective reporting of child maltreatment, with up to 50% of participants providing inconsistent reports when assessed in adolescence and adulthood.4 This raises the possibility that the impact and risk pathways of childhood maltreatment on pain could differ as a function of child (prospective) vs adult (retrospective) assessments.4 The longitudinal design of this study minimized the risk of reporting inconsistencies over time.

Finally, we found that PTSS in adolescence were important for explaining the relations between child maltreatment and adult pain. Consistent with other studies demonstrating the link between PTSS and pain,2,7,10,20,30,35,45 this study found that higher levels of PTSS were linked to a higher likelihood of reporting any pain, and a greater number of total areas affected by pain, and that these relations were likely not bidirectional. Together, these findings interpreted in the context of the existing literature suggest that as adolescents experience maltreatment and subsequent elevation in PTSS, pain may be a secondary consequence.

Our findings also extend studies linking child maltreatment and adolescent PTSS with adult pain43 by demonstrating that PTSS around the time of maltreatment explain associations between maltreatment and pain in adulthood. One mechanism that could explain the relations among maltreatment, PTSS, and pain is inflammation. Post-traumatic stress symptoms may increase inflammatory markers, triggering physiological changes in nociceptor functioning, leading to increased pain. There has been variability in studies linking maltreatment and inflammation; however, more research is needed.27 Furthermore, it is worth noting that the impact of adolescent PTSS on pain varied by the type of symptom, such that individuals who re-experience their symptoms and are experiencing hyperarousal as a result of their trauma may be at particular risk of developing pain in adulthood. It is possible that re-experiencing maltreatment exposures and maintaining a state of hyperarousal is activating stress responses and triggering dysregulation in a way that avoidance does not. In addition to these mechanisms, impairment in other psychological (eg, attentional control and self-regulation) and behavioral (eg, sleep disturbances) factors can co-occur with maltreatment and PTSS11,24,39 and exacerbate pain.48,49 More work is needed, including replication of these findings, to better understand why particular profiles of PTSS are related to some indicators of pain but not others.

4.2. Limitations and future directions

There are several limitations to this study. First, measures of pain symptoms were based on adult self-report; no data on the onset of pain, chronicity, frequency, interference, or pain-related disability were collected. Pain measures were designed to assess fibromyalgia symptoms—as such, participants without fibromyalgia may have responded differently to these items. Second, this represents pain in early adulthood and is missing the presence and trajectory of pain during adolescence; thus, it is unclear how pain developed during adolescence, a critical developmental period associated with the onset of pain conditions.25 Third, while we are able to link post-traumatic symptoms experienced at the time of maltreatment, these symptoms may not clearly map onto current diagnostic criteria for Post-traumatic stress disorder (PTSD) and may miss some aspect of traumatic reactions captured by current screenings (ie, negative cognitions and mood). Finally, only women are represented; findings might differ for men experiencing maltreatment and chronic pain.

Despite these limitations, this study makes several important contributions to the literature. First, it is one of the few studies to prospectively follow cohorts of maltreated women, confirmed by child welfare record review, and demographically similar peers to understand pain onset in young adulthood. Second, study findings provide some clarification on inconsistencies in the existing literature. In doing so, this study expands the existing literature to create a foundation for future research on the relations between maltreatment and young adult pain. Additional studies examining more comprehensive assessments of pain, pain chronicity, and clinical pain diagnoses using validated measures and protocols are warranted—particularly that follow women longitudinally during periods where chronic pain are known to emerge. These study findings also warrant replication with cohorts of men. Finally, other mechanisms (eg, stress physiology and altered pain processing) may explain links between maltreatment and pain, which are also activated with elevated PTSS. Although more research is needed, these findings provide some preliminary evidence that maltreatment increases vulnerability to pain in adulthood and raises the possibility that treating the sequelae of maltreatment (eg, PTSS) may aid in reducing risk of chronic pain later in adulthood.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Supplemental audio content

Audio content associated with this article can be found online at


This research was supported in part by grants awarded to J.G. Noll by the National Institute for Child Health and Human Development of the National Institutes of Health under award R01HD052533, P50HD089922 as well as by the National Center for Advancing Translational Sciences of the National Institutes of Health, under Award Number 5UL1TR001425. S.J. Beal was supported by the National Institute on Drug Abuse of the National Institutes of Health under award number K01DA041620. S. Kashikar-Zuck was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number K24AR056687. C. King was supported by the National Institute of Dental and Craniofacial Research under award number R00DE022368. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Preliminary findings from this study were presented at the American Pain Society Scientific Summit in March, 2018 and the International Association for the Study of Pain World Congress on Pain in September, 2018.


[1]. Achenbach TM. Manual for the child behavior checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont, 1991.
[2]. Asmundson GJ, Coons MJ, Taylor S, Katz J. PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Can J Psychiatry 2002;47:930–7.
[3]. Association AP. Diagnostic and statistical manual of mental disorders (DSM-IV®): American Psychiatric Publishers, 1994.
[4]. Baldwin JR, Reuben A, Newbury JB, Danese A. Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis. JAMA Psychiatry 2019;76:584–93.
[5]. Barnes JE, Noll JG, Putnam FW, Trickett PK. Sexual and physical revictimization among victims of severe childhood sexual abuse. Child Abuse Negl 2009;33:412–20.
[6]. Beal SJ, Wingrove T, Mara CA, Lutz N, Noll JG, Greiner MV. Childhood adversity and associated psychosocial function in adolescents with complex trauma. Child Youth Care Forum 2019;48:305–22.
[7]. Beck JG, Clapp JD. A different kind of comorbidity: understanding posttraumatic stress disorder and chronic pain. Psychol Trauma Theor Res Pract Policy 2011;3:101.
[8]. Bernard K, Frost A, Bennett CB, Lindhiem O. Maltreatment and diurnal cortisol regulation: a meta-analysis. Psychoneuroendocrinology 2017;78:57–67.
[9]. Bouhassira D, Lantéri-Minet M, Attal N, Laurent B, Touboul C. Prevalence of chronic pain with neuropathic characteristics in the general population. PAIN 2008;136:380–7.
[10]. Burke NN, Finn DP, McGuire BE, Roche M. Psychological stress in early life as a predisposing factor for the development of chronic pain: clinical and preclinical evidence and neurobiological mechanisms. J Neurosci Res 2017;95:1257–70.
[11]. Charuvastra A, Cloitre M. Safe enough to sleep: sleep disruptions associated with trauma, posttraumatic stress, and anxiety in children and adolescents. Child Adolesc Psychiatr Clin N Am 2009;18:877–91.
[12]. Cleeland C. Measurement of pain by subjective report. Adv pain Res Ther 1989;12:391–403.
[13]. Cleeland C, Ryan K. Pain assessment: global use of the brief pain inventory. Ann Acad Med Singapore 1994;23:129-38.
[14]. Cleeland CS. The brief pain inventory: user guide. Houston: The University of Texas MD Anderson Cancer Center, 2009. pp. 1–11.
[15]. Davis DA, Luecken LJ, Zautra AJ. Are reports of childhood abuse related to the experience of chronic pain in adulthood?: a meta-analytic review of the literature. Clin J Pain 2005;21:398–405.
[16]. do Prado CH, Grassi-Oliveira R, Daruy-Filho L, Wieck A, Bauer ME. Evidence for immune activation and resistance to glucocorticoids following childhood maltreatment in adolescents without psychopathology. Neuropsychopharmacology 2017;42:2272–82.
[17]. Font SA, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: the role of adult socioeconomic conditions. Child Abuse Negl 2016;51:390–9.
[18]. Garnefski N, van Rood Y, De Roos C, Kraaij V. Relationships between traumatic life events, cognitive emotion regulation strategies, and somatic complaints. J Clin Psychol Med Settings 2017;24:1–8.
[19]. Heim C. Psychobiological consequences of child maltreatment. The Biology of Early Life Stress. Cham, Switzerland: Springer, 2018. pp. 15–30.
[20]. Holley A, Wilson A, Noel M, Palermo T. Post-traumatic stress symptoms in children and adolescents with chronic pain: a topical review of the literature and a proposed framework for future research. Eur J pain 2016;20:1371–83.
[21]. Jones GT, Power C, Macfarlane GJ. Adverse events in childhood and chronic widespread pain in adult life: results from the 1958 British Birth Cohort Study. PAIN 2009;143:92–6.
[22]. Kaess M, Whittle S, O'Brien-Simpson L, Allen NB, Simmons JG. Childhood maltreatment, pituitary volume and adolescent hypothalamic-pituitary-adrenal axis–evidence for a maltreatment-related attenuation. Psychoneuroendocrinology 2018;98:39–45.
[23]. Keller S, Bann CM, Dodd SL, Schein J, Mendoza TR, Cleeland CS. Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clin J pain 2004;20:309–18.
[24]. Kim J, Cicchetti D. Longitudinal pathways linking child maltreatment, emotion regulation, peer relations, and psychopathology. J Child Psychol Psychiatry 2010;51:706–16.
[25]. King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, MacDonald AJ. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. PAIN 2011;152:2729–38.
[26]. Kuhlman KR, Geiss EG, Vargas I, Lopez-Duran NL. Differential associations between childhood trauma subtypes and adolescent HPA-axis functioning. Psychoneuroendocrinology 2015;54:103–14.
[27]. Kuhlman KR, Horn SR, Chiang JJ, Bower JE. Early life adversity exposure and circulating markers of inflammation in children and adolescents: a systematic review and meta-analysis. Brain Behav Immun 2019. DOI: 10.1016/j.bbi.2019.04.028 [Epub ahead of print].
[28]. Lampe A, Doering S, Rumpold G, Sölder E, Krismer M, Kantner-Rumplmair W, Schubert C, Söllner W. Chronic pain syndromes and their relation to childhood abuse and stressful life events. J Psychosom Res 2003;54:361–7.
[29]. McCrory E, De Brito SA, Viding E. Research review: the neurobiology and genetics of maltreatment and adversity. J Child Psychol Psychiatry 2010;51:1079–95.
[30]. McKernan LC, Johnson BN, Crofford LJ, Lumley MA, Bruehl S, Cheavens JS. Posttraumatic stress symptoms mediate the effects of trauma exposure on clinical indicators of central sensitization in patients with chronic pain. Clin J Pain 2019;35:385–93.
[31]. McLaughlin KA, Koenen KC, Bromet EJ, Karam EG, Liu H, Petukhova M, Ruscio AM, Sampson NA, Stein DJ, Aguilar-Gaxiola S, Alonso J, Borges G, Demyttenaere K, Dinolova RV, Ferry F, Florescu S, de Girolamo G, Gureje O, Kawakami N, Lee S, Navarro-Mateu F, Piazza M, Pennell BE, Posada-Villa J, Ten Have M, Viana MC, Kessler RC. Adversities and post-traumatic stress disorder: evidence for stress sensitisation in the World Mental Health Surveys. Br J Psychiatry 2017;211:280–8.
[32]. Min MO, Minnes S, Kim H, Singer LT. Pathways linking childhood maltreatment and adult physical health. Child Abuse Negl 2013;37:361–73.
[33]. Nelson S, Cunningham N, Peugh J, Jagpal A, Arnold LM, Lynch-Jordan A, Kashikar-Zuck S. Clinical profiles of young adults with juvenile-onset fibromyalgia with and without a history of trauma. Arthritis Care Res 2017;69:1636–43.
[34]. Nelson SM, Cunningham NR, Kashikar-Zuck S. A conceptual framework for understanding the role of adverse childhood experiences in pediatric chronic pain. Clin J Pain 2017;33:264–70.
[35]. Noel M, Wilson AC, Holley AL, Durkin L, Patton M, Palermo TM. Post-traumatic stress disorder symptoms in youth with versus without chronic pain. PAIN 2016;157:2277.
[36]. Noll JG, Haralson KJ, Butler EM, Shenk CE. Childhood maltreatment, psychological dysregulation, and risky sexual behaviors in female adolescents. J Pediatr Psychol 2011;36:743–52.
[37]. Noll JG, Horowitz LA, Bonanno GA, Trickett PK, Putnam FW. Revictimization and self-harm in females who experienced childhood sexual abuse: results from a prospective study. J Interpers Violence 2003;18:1452–71.
[38]. Noll JG, Shenk CE. Teen birth rates in sexually abused and neglected females. Pediatrics 2013;131:e1181–7.
[39]. Noll JG, Trickett PK, Susman EJ, Putnam FW. Sleep disturbances and childhood sexual abuse. J Pediatr Psychol 2005;31:469–80.
[40]. Palmos AB, Watson S, Hughes T, Finkelmeyer A, McAllister-Williams RH, Ferrier N, Anderson IM, Nair R, Young AH, Strawbridge R, Chung R, Frissa S, Goodwin L, Hotopf M, Hatch SL, Wang H, Collier DA, Thuret S, Breen G, Powell TR. Between childhood maltreatment and inflammatory markers. BJPsych Open 2019;5:e3.
[41]. Peckins MK, Susman EJ, Negriff S, Noll J, Trickett PK. Cortisol profiles: a test for adaptive calibration of the stress response system in maltreated and nonmaltreated youth. Dev Psychopathol 2015;27:1461–70.
[42]. Raphael KG, Chandler HK, Ciccone DS. Is childhood abuse a risk factor for chronic pain in adulthood? Curr Pain Headache Rep 2004;8:99–110.
[43]. Raphael KG, Widom CS. Post-traumatic stress disorder moderates the relation between documented childhood victimization and pain 30 years later. PAIN 2011;152:163–9.
[44]. Raphael KG, Widom CS, Lange G. Childhood victimization and pain in adulthood: a prospective investigation. PAIN 2001;92:283–93.
[45]. Ravn SL, Hartvigsen J, Hansen M, Sterling M, Andersen TE. Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies. PAIN 2018;159:2159–69.
[46]. Rosseel Y. Lavaan: an R package for structural equation modeling and more. Version 0.5–12 (BETA). J Stat Softw 2012;48:1–36.
[47]. Shenk CE, Putnam FW, Rausch JR, Peugh JL, Noll JG. A longitudinal study of several potential mediators of the relationship between child maltreatment and posttraumatic stress disorder symptoms. Dev Psychopathol 2014;26:81–91.
[48]. Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev 2004;8:119–32.
[49]. Van Damme S, Kindermans H. A self-regulation perspective on avoidance and persistence behavior in chronic pain: new theories, new challenges? Clin J Pain 2015;31:115–22.
[50]. Wildeman C, Emanuel N, Leventhal JM, Putnam-Hornstein E, Waldfogel J, Lee H. The prevalence of confirmed maltreatment among US children, 2004 to 2011. JAMA Pediatr 2014;168:706–13.
[51]. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 2011;38:1113–22.
[52]. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010;62:600–10.
[53]. World Health Organization. Child maltreatment. Vol. 2019, 2016. Available at: Accessed October 11, 2019.

Child maltreatment; Childhood adversity; Pain; Adolescent; Adult

Supplemental Digital Content

© 2019 International Association for the Study of Pain