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Pediatric

Adverse childhood experiences in parents of youth with chronic pain: prevalence and comparison with a community-based sample

Beveridge, Jaimie K.a; Dobson, Keith S.a; Madigan, Sheria,b; Yeates, Keith O.a,b,c; Stone, Amanda L.d; Wilson, Anna C.e; Salberg, Sabrinaf; Mychasiuk, Richellea,b,c,f; Noel, Melaniea,b,c,*

Author Information
doi: 10.1097/PR9.0000000000000866

1. Introduction

Parents play an important role in children's chronic pain experience. The impact of parenting behaviors on the functioning of youth with chronic pain is well-established,16 and research suggests parents' mental health and physical health are also related to children's chronic pain outcomes.10,12,19,26,32,42,47 However, adverse childhood experiences (ACEs) among parents of youth with chronic pain have not been examined.

Adverse childhood experiences (abuse, neglect, and household dysfunction during childhood) can be associated with mental and physical health conditions in a dose–response fashion, with higher numbers (eg, ≥4) conferring greater risk of poor outcomes.1,20,28,30 Individual ACEs and total ACE scores are related to the occurrence and severity of chronic pain in individuals.3,13,29,35,39,43,44,52 However, little is known about the risk that ACEs confer for chronic pain across generations. Research on the intergenerational impact of ACEs, which focuses on associations between parent ACEs and children's health, development, and functioning, has found continuity in risk of poor outcomes.33,34,36,46,50,55,58 Thus, parent ACEs may contribute to chronic pain in youth, especially given their association with parent factors (eg, mental and physical health) that are implicated in pediatric chronic pain.4,14,16,26,42,46

Adverse childhood experiences are common in community-based samples, with 64% of adults in the Centers for Disease Control and Prevention-Kaiser ACE Study reporting ≥1 ACE and 12.5% reporting ≥4 ACEs.11 ACEs are more prevalent among individuals with chronic pain. In 1 study, 84% of women with chronic pain reported ≥1 ACE and 44.5% reported ≥4 ACEs.14 Another study found 81.6% of youth with chronic pain reported ≥1 ACE and 23.4% reported ≥3 ACEs.39 This brief report was the first to evaluate the prevalence of ACEs among parents of youth with chronic pain and compare these rates with a community-based sample. We hypothesized that ACEs would be more prevalent among parents of youth with chronic pain than adults from the community.

2. Methods

2.1. Participants and procedure

Parents of youth with chronic pain were recruited from a tertiary-level chronic pain program at a pediatric hospital in Calgary, Canada. The current aims are distinct from previous studies that used data from the larger study.40,41,45 Study procedures were approved by the institution's health research ethics board and are described in detail elsewhere.40,41,45

Parents were eligible to participate if they were the legal guardian of a child (aged 10–18 years) with ongoing chronic pain (pain lasting ≥3 months), could speak/read English, and had Internet access. Informed consent was obtained through telephone and online consent forms. Parents completed self-report measures online in REDCap.24,25 Data were collected between February 2017 and May 2020. Parents who did not complete the ACE Questionnaire (n = 9) were excluded. To be consistent with the comparison sample, parents who indicated “other” as their gender (n = 1) were also excluded. The final parent sample included 170 participants.

The comparison sample (n = 3914) was drawn from a community-based study examining ACEs and health conditions among adults attending primary care clinics in Calgary.15

2.2. Measures

2.2.1. Sociodemographic information

Participants reported their age, gender, race/ethnicity, marital status, relationship to child, education, employment status, and annual household income.

2.2.2. Adverse childhood experiences

The 28-item ACE Questionnaire, adapted from existing measures8,54,59 for the ACE Study,20 was administered to assess exposure to ACEs (emotional, physical and sexual abuse, emotional and physical neglect, and 5 types of household dysfunction) during the first 18 years of life (see Supplemental Digital Content 1, available at http://links.lww.com/PR9/A85). Adverse childhood experience categories are assessed with 1 or more items, which are rated on dichotomous or 5-point Likert-type scales. If at least 1 item of the category was reported, the ACE was coded as present. Total scores were obtained by summing responses to the relevant categories. Higher scores indicate exposure to more ACEs. This measure has demonstrated good psychometric properties,17,22,23,38 and factor analytic studies support the subdomains of maltreatment and household dysfunction.22,38

2.3. Data analysis

Statistical analyses were performed in SPSS (version 24). Descriptive statistics characterized the samples. Differences between samples on sociodemographic variables were examined using t (continuous variables) or χ2 (categorical variables) tests. Variables that were significantly different between samples were included as covariates in analyses. To compare samples on ACEs, analyses of (co)variance (continuous variables) and logistic regressions (categorical variables) were conducted.

3. Results

The parent and comparison samples were similar on age and race/ethnicity but differed on gender, marital status, education, employment status, and household income (Table 1). Parents were more likely to be female, married/cohabitating, college or university educated, employed, and less likely to report a household income ≤$59,999. Health characteristics of the parent sample are reported in Supplemental Digital Content 2 (available at http://links.lww.com/PR9/A85).

Table 1 - Sociodemographic characteristics of the parent sample (N = 170) and comparison sample (N = 3914).
Sociodemographic variable Parent sample Comparison sample P
n M or % n M or %
Age, y (M, SD) 45.10 (5.34) 44.18 (17.01) 0.070
Gender <0.001
 Female 155 91.2 2673 68.3
 Male 15 8.8 1241 31.7
Race/ethnicity 0.436
 White/Anglo-American 144 84.7 3235 82.7
 Biracial/multiracial 10 5.9
 Latin American 4 2.4
 Asian 284 7.3
 Arab/West Asian 3 1.8
 South Asian 2 1.2 103 2.6
 Chinese 1 0.6
 Filipino 1 0.6
 Aboriginal/First Nations 1 0.6 34 0.9
 Black/African American 1 0.6 38 1.0
 Other 2 1.2 208 5.3
 Did not answer 1 0.6 12 0.3
Marital status <0.001
 Married or cohabitating 136 80.0 2506 64.0
 Divorced, separated, or widowed 28 16.5 507 13.0
 Single or never married 6 3.5 891 22.8
 Did not answer 10 0.2
Relationship to child
 Biological 166 97.6
 Adoptive 3 1.8
 Did not answer 1 0.6
Education 0.024
 High school or less 19 11.2 800 20.4
 Some training, college, or university (no degree) 38 22.4 871 22.3
 College diploma or undergraduate degree 93 54.7 1840 47.0
 Graduate or professional degree 20 11.8 397 10.1
 Did not answer 6 0.2
Employment status 0.001
 Full-time 88 51.8 1821 46.5
 Part-time 49 28.8 831 21.2
 Not working or retired 32 18.8 1250 31.9
 Did not answer 1 0.6 12 0.3
Annual household income, CAD <0.001
 ≤ $59,999 27 15.9 1418 36.2
 ≥ $60,000 120 70.6 2419 61.8
 Did not answer 23 13.5 77 2.0
Because of low cell counts, the χ2 test for race/ethnicity compared White/Anglo-American with the combination of all other race/ethnicity categories. The other comparison analyses included the listed categories except “did not answer.”

Prevalence rates of ACEs are reported in Tables 2 and 3. More than two-thirds (67.6%) of the parent sample reported ≥1 ACE and 23.5% reported ≥4 ACEs. Their average ACE score was 2.05/10, and their most frequently reported ACEs were types of household dysfunction: household mental illness (35.9%), parent separation/divorce (31.8%), and problematic substance use in the household (31.8%). Maltreatment was also frequently reported, with 26.5% of parents reporting sexual abuse and 24.7% reporting emotional abuse. Overall, 45.3% of parents reported ≥1 experience of maltreatment and 57.6% reported ≥1 household dysfunction.

Table 2 - Prevalence rates of total ACEs, experiences of maltreatment, and household dysfunction in parents of youth with chronic pain (N = 170) and the comparison sample (N = 3914).
Variable Parent sample Comparison sample
n % n %
Total ACE score
 0 55 32.4 1115 28.5
 1 38 22.4 906 23.1
 2 26 15.3 614 15.7
 3 11 6.5 439 11.2
 4 13 7.6 290 7.4
 5 10 5.9 160 4.1
 6 8 4.7 129 3.3
 7 2 1.2 88 2.2
 8 3 1.8 67 1.7
 9 2 1.2 29 0.7
 10 2 1.2 10 0.3
Total experiences of maltreatment
 0 93 54.7 2187 55.9
 1 44 25.9 839 21.4
 2 10 5.9 419 10.7
 3 7 4.1 223 5.7
 4 12 7.1 123 3.1
 5 4 2.4 56 1.4
Total household dysfunction
 0 72 42.4 1455 37.2
 1 41 24.1 1113 28.4
 2 29 17.1 637 16.3
 3 19 11.2 377 9.6
 4 5 2.9 193 4.9
 5 4 2.4 58 1.5
ACE, adverse childhood experience.

Table 3 - Comparison of prevalence rates of ACEs between parents of youth with chronic pain (N = 170) and the comparison sample (N = 3914).
ACE score/category Parent sample Comparison sample Logistic regression results
n M or % n M or % OR (95% CI) aOR (95% CI)
Total ACE score, of 10 (M, SD) 2.05 (2.34) 2.00 (2.11)
 ≥1 ACE 115 67.6 2732 69.8 0.85 (0.61–1.19) 0.85 (0.59–1.21)
Maltreatment categories
 ≥1 experience maltreatment 77 45.3 1660 42.4 1.09 (0.80–1.49) 1.15 (0.83–1.62)
 Emotional abuse 42 24.7 1115 28.5 0.81 (0.57–1.15) 0.95 (0.65–1.38)
 Physical abuse 11 6.5 279 7.1 0.89 (0.47–1.65) 1.05 (0.54–2.03)
 Sexual abuse 45 26.5 794 20.3 1.38 (0.97–1.96) 1.30 (0.89–1.90)
 Emotional neglect 28 16.5 566 14.5 1.14 (0.75–1.72) 1.45 (0.94–2.25)
 Physical neglect 27 15.9 364 9.3 1.80 (1.18–2.75)** 2.14 (1.35–3.40)**
Household dysfunction categories
 ≥1 household dysfunction 98 57.6 2378 60.8 0.83 (0.61–1.14) 0.86 (0.61–1.21)
 Problematic substance use in household 54 31.8 1192 30.5 1.03 (0.74–1.43) 1.10 (0.77–1.57)
 Mental illness in household 61 35.9 1733 44.3 0.68 (0.49–0.93)* 0.71 (0.50–1.00)
 Physical violence between parents 21 12.4 500 12.8 0.94 (0.59–1.49) 1.14 (0.71–1.84)
 Household member in prison 6 3.5 196 5.0 0.68 (0.30–1.55) 0.89 (0.38–2.05)
 Parents separated/divorced 54 31.8 959 24.5 1.40 (1.01–1.95)* 1.35 (0.94–1.94)
*P < 0.05, **P < 0.01.
Adjusted for sociodemographic variables that were significantly different between samples: gender (female vs male), education (high school or less vs more than high school), marital status (single, separated/divorced, or widowed vs married or cohabitating), employment status (not working or retired vs working full- or part-time), and household income (≤$59,999 vs ≥$60,000), ns differ depending on the amount of missing data. Target group, parents of youth with chronic pain.
ACE, adverse childhood experience; aOR, adjusted odds ratio; CI, confidence interval; M, mean; OR, odds ratio.

In unadjusted analyses, the parent sample reported significantly higher rates of physical neglect (odds ratio [OR] = 1.80; 95% confidence interval [CI] = 1.18–2.75) and parent separation/divorce (OR = 1.40; 95% CI = 1.01–1.95) than the comparison sample, whereas the comparison sample reported significantly higher rates of household mental illness (OR = 0.68; 95% CI = 0.49–0.93) than the parent sample. In adjusted analyses, only rates of physical neglect were significantly different between samples (OR = 2.14; 95% CI = 1.35–3.40). Total ACE scores were similar across samples in unadjusted, F(1, 4015) = 0.10, P > 0.05, and adjusted, F(1, 3887) = 0.98, P > 0.05, analyses.

4. Discussion

This study found that ACEs were common among parents of youth with chronic pain, with 67.6% reporting ≥1 ACE and 23.5% reporting ≥4 ACEs. The prevalence of ACEs in these parents was similar to a community-based sample from the same city, except for physical neglect, which was more prevalent among parents. This finding is consistent with previous ACE research showing unique associations between physical neglect and chronic pain52,57 and may reflect the high rates of chronic pain observed in parents of youth with chronic pain.10,53 The community-based sample comprised adults attending primary care clinics for various issues and was thus treatment-seeking. Given associations between ACEs and poor health, treatment-seeking adults may be more likely to report ACEs than adults not attending medical appointments. Future research should compare the prevalence of ACEs in parents of youth with chronic pain with other community-based samples (eg, parents of youth without chronic pain, non–treatment-seeking adults).

Further research examining the relation between parent ACEs and child chronic pain, as well as factors that may mediate this potential relation, is needed. Although speculative, parent ACEs may impact parents' health which could, in turn, increase children's risk of chronic pain through parent (eg, chronic pain) and child (eg, depressive symptoms) risk factors.18,26,27 To the best of our knowledge, only 1 study has examined parent ACEs in the context of chronic pain. Dennis et al. examined mothers with chronic pain and their children and found that maternal ACEs were not related to child pain but were indirectly related to child depressive symptoms through maternal depressive symptoms.14 Child pain frequency was low in this sample, which was expected as children were recruited before adolescence, when rates of chronic pain increase.31 The authors suggested that maternal ACEs may be more related to adolescent-onset chronic pain, with depressive symptoms acting as a mediator.14

To inform research and interventions, studies with both clinical samples of youth with chronic pain and at-risk samples (eg, children of parents with chronic pain and youth undergoing surgery) are needed. Neurobiological (eg, epigenetic alterations) and psychosocial (eg, social learning) mechanisms likely underlie any intergenerational continuity. Thus, translational studies incorporating basic and clinical research are critical. Research also suggests maltreatment is a stronger predictor of chronic pain than household dysfunction.6 Therefore, research on parent ACEs should consider the differential impacts of these ACE domains, as opposed to the “ACE score” that equally weighs each ACE, on child pain outcomes. It is also important to note that concerns have been raised about the ACE Questionnaire (eg, narrow focus on 10 adversities, no assessment of chronicity, and potential for retraumatization2,21,37,48). Therefore, use of the ACE Questionnaire should be carefully considered. Finally, exposure to ACEs does not ensure poor outcomes; factors such as supportive relationships can moderate the negative effects of ACEs.5,7,9,49,51,56 Thus, research on protective factors is also needed to identify factors that buffer against the intergenerational transmission of risk of chronic pain.

In conclusion, ACEs, particularly physical neglect, were prevalent among parents of youth with chronic pain. This study was not preregistered, and data were from parents of youth receiving tertiary-level care in Canada with relatively high socioeconomic status. Research that merges neurobiology and psychology to examine possible mechanisms linking parent ACEs to child chronic pain is needed to advance knowledge in this area.

Disclosures

The authors have no conflicts of interest to declare.

Appendix A. Supplemental digital content

Supplemental digital content associated with this article can be found online at http://links.lww.com/PR9/A85.

Acknowledgements

The authors thank the parents who participated in this study. This research was supported by research funding awarded to M. Noel from the Vi Riddell Pediatric Pain Initiative, Alberta Children's Hospital Foundation and Alberta Children's Hospital Research Institute, and the Canadian Institutes of Health Research Strategy for Patient-Oriented Research “Chronic Pain Network.” J.K. Beveridge is supported by graduate studentship awards from Alberta Innovates and the Canadian Institutes of Health Research. S. Madigan is supported by the Canada Research Chairs program. K.O. Yeates is supported by the Ronald and Irene Ward Chair in Pediatric Brain Injury from the Alberta Children's Hospital Foundation. A.L. Stone is supported by T32 GM 108554 from the National Institutes of Health.

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Keywords:

ACEs; Childhood maltreatment; Household dysfunction; Chronic pain; Pediatric pain; Intergenerational

Supplemental Digital Content

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.