Adverse Childhood Experiences and Frequent Headaches in Adults

The Psychiatric Comorbidities of Migraine in Children and Adolescents

PURPOSE OF REVIEW

Understanding comorbidities in migraine is important because it can help us understand disease pathophysiology while also aiding the development of more effective treatment strategies. Additionally, it can provide greater awareness about appropriate diagnosis, the need for additional disease screening, and the natural history of migraine. Psychiatric comorbidities have been independently studied in both adults and children with migraine because their presentations can be distinct, and the physiology in these two groups can be different.

RECENT FINDINGS

While symptoms of anxiety and depression seem to be comorbid with migraine in children, clinically significant disease does not appear to be, though the clarity of these data is limited by overlap between migraine symptomatology and that assessed by many screening tools. Functional neurologic disorders like psychogenic non-epileptic episodes (PNEE) and other functional movement disorders are not common but can be comorbid with migraine in this population and tend to improve with migraine treatment. The number of adverse childhood experiences (ACEs) a child is exposed to seems to be near-linearly associated with risk of migraine, but not with tension-type headache (TTH). The findings from these studies underscore the importance of utilizing appropriate screening methodologies for identifying psychiatric disorders in children with migraine. Additionally, the role of the insula, the hypothalamic-pituitary-adrenal axis, the serotonergic system, and the instability of hyperactivated neural networks may underlie the pathophysiology of both migraine and its psychiatric comorbidities.

Examining Parent Adverse Childhood Experiences as a Distal Risk Factor in Pediatric Chronic Pain

OBJECTIVES

Adverse childhood experiences (ACEs; ie, exposure to abuse, neglect, household dysfunction in childhood) are associated with poor mental and physical health outcomes across the lifespan. Emerging research suggests parent ACEs also confer risk for poor child outcomes. The relation between parent ACEs and child pain in youth with chronic pain has not yet been examined. The aim of the current longitudinal study was to examine the associations among parent ACEs, parent health, and child pain, in a clinical sample of youth with chronic pain.

METHODS

In total, 192 youth (75.5% female, 10 to 18 y old) and one of their parents (92.2% female) were recruited from tertiary pediatric chronic pain clinics in Canada. At baseline, parents completed self-report measures of ACEs, chronic pain status, anxiety and depressive symptoms, and posttraumatic stress disorder symptoms. At a 3-month follow-up, youth completed self-report measures of pain intensity and pain interference.

RESULTS

Regression and mediation analyses revealed that parent ACEs significantly predicted parent chronic pain status and depressive symptoms, but not parent anxiety or posttraumatic stress disorder symptoms. Moreover, parent ACEs were not significantly related to youth pain, either directly or indirectly through parent health variables.

DISCUSSION

Findings suggest that an intergenerational cascade from parent ACEs to parent health to child pain was not present in the current sample. Further research that examines the role of parent ACEs in the development of child chronic pain, as well as other risk and resiliency factors that may mediate or moderate the association between parent ACEs and child chronic pain, is needed.

Adverse Childhood Experiences (ACEs) and Internalizing Mental Health, Pain, and Quality of Life in Youth With Chronic Pain: A Longitudinal Examination

The aims of this longitudinal study were to 1) identify categories of adverse childhood experiences (ACEs) (ie, neglect, abuse, household dysfunction in childhood) that increase risk for internalizing mental health problems, pain-related impairment, and poorer quality of life and 2) examine the moderating role of posttraumatic stress symptoms (PTSS) in these associations, in a clinical sample of youth with chronic pain. At 2 timepoints, youth (N = 155; aged 10-18 years) completed measures of exposure to ACEs, PTSS, depressive and anxiety symptoms, pain intensity, pain interference, and quality of life. Multivariate analyses of variance, linear mixed modeling, and moderation analyses were conducted. Results from cross-sectional and longitudinal analyses were similar; youth with a history of 3+ ACEs reported significantly higher PTSS, depressive and anxiety symptoms, and poorer quality of life than youth with no ACE history. Results also revealed differences in functioning between youth exposed to different types of ACEs (ie, maltreatment only, household dysfunction only, both, none). Finally, PTSS was found to moderate the association between ACEs and anxiety and depressive symptoms. Findings underscore the influence that ACEs can have on the long-term functioning of youth with chronic pain as well as the important role of current PTSS in this association. PERSPECTIVE: This study found that the risk of poorer outcomes imposed by ACEs at baseline remains longitudinally and that posttraumatic stress symptoms (PTSS) moderate the relationship between ACEs and anxiety and depressive symptoms in youth with chronic pain. These results underscore the importance of assessing for ACEs and PTSS alongside chronic pain in youth.

Targeting the stress response in pediatric pain: current evidence for psychosocial intervention and avenues for future investigation

Nonpharmacological treatments for chronic pain in youth have been identified as first-line treatments over and above medication. Therapies such as cognitive-behavioral therapy and mindfulness-based stress reduction have shown good efficacy in reducing the psychological correlates (eg, anxiety, depression, and stress) and social or behavioral sequelae (eg, limited physical activity and lack of school engagement) associated with pediatric chronic pain. However, minimal research has examined the physiological mechanism(s) of action for these interventions. A recent review (Cunningham, et al., 2019) emphasized the need for objective (ie, physiological) assessment of treatment response in pediatric pain populations. The current review adds to this literature by identifying the physiological stress response as a particular target of interest in interventions for pediatric pain. Research indicates that youth with chronic pain report high rates of psychological stress, posttraumatic stress symptoms, and exposure to adverse childhood experiences (abuse/neglect, etc). In addition, a host of research has shown strong parallels between the neurobiology of pain processing and the neurobiology of stress exposure in both youth and adults. Interventions such as narrative or exposure therapy (eg, trauma-focused cognitive-behavioral therapy) and mindfulness-based or meditation-based therapies have shown particular promise in alleviating the neurobiological impact that stress and pain can have on the body, including reduction in allostatic load and altered connectivity in multiple brain regions. However, no study to date has specifically looked at these factors in the context of pediatric pain treatment. Future research should further explore these constructs to optimize prevention in and treatment of these vulnerable populations.

Adverse Childhood Experiences Predict Common Neurodevelopmental and Behavioral Health Conditions among U.S. Children

OBJECTIVE

Adverse childhood experiences (ACEs) can have a significant but variable effect on childhood neurodevelopment. The purpose of this study was to quantify and compare the associations between "household challenge" ACEs and common childhood neurodevelopmental and behavioral health conditions, using nationally representative U.S.

DATA

METHOD

This study used data from the 2016-2019 National Survey of Children's Health, a nationwide, population-based, cross-sectional survey. Seven household challenge ACEs (not including child maltreatment) were reported by parents/guardians: parental death, incarceration, divorce/separation, family violence, mental illness, substance abuse, and poverty. Logistic regression with sample weights was used to estimate the odds ratio (OR) for 15 parent-reported neurodevelopmental and behavioral health conditions, by the number of reported ACEs. A dose-response relationship was examined by applying tests of orthogonal polynomial contrasts to fitted logistic regression models.

RESULTS

Down syndrome, Tourette syndrome and cerebral palsy were not associated with household challenge ACEs, whereas behavior/conduct problems, depression, and substance abuse were strongly associated, with adjusted ORs ranging from 6.36 (95% confidence interval (CI) 5.53, 7.32) to 9.19 (95% CI 7.79, 10.84). Other neurodevelopmental conditions not traditionally associated with childhood adversity showed moderate yet robust associations with ACEs, including autism (adjusted OR 2.15, 95% CI 1.64, 2.81), learning disability (adjusted OR 3.26, 95% CI 2.80, 3.80), and attention deficit hyperactivity disorder (adjusted OR 3.95, 95% CI 3.44, 4.53). The ORs increased with the number of ACEs, showing significant positive linear trends.

CONCLUSION

We found significant dose-dependent or cumulative associations between ACEs and multiple neurodevelopmental and behavioral conditions.

Factors Associated With, and Mitigation Strategies for, Health Care Disparities Faced by Patients With Headache Disorders

OBJECTIVE

To review contemporary issues of health care disparities in headache medicine with regard to race/ethnicity, socioeconomic status (SES), and geography and propose solutions for addressing these disparities.

METHODS

An Internet and PubMed search was performed and literature was reviewed for key concepts underpinning disparities in headache medicine. Content was refined to areas most salient to our goal of informing the provision of equitable care in headache treatment through discussions with a group of 16 experts from a range of headache subspecialties.

RESULTS

Taken together, a multitude of factors, including racism, SES, insurance status, and geographical disparities, contribute to the inequities that exist within the health care system when treating headache disorders. Interventions such as improving public education, advocacy, optimizing telemedicine, engaging in community outreach to educate primary care providers, training providers in cultural sensitivity and competence and implicit bias, addressing health literacy, and developing recruitment strategies to increase representation of underserved groups within headache research are proposed as solutions to ameliorate disparities.

CONCLUSION

Neurologists have a responsibility to provide and deliver equitable care to all. It is important that disparities in the management of headache disorders are identified and addressed.

Adverse Childhood Experiences and Frequent Headache by Adolescent Self-Report

BACKGROUND

The association between exposure to adverse childhood experiences (ACEs) and increased headache in adults has been well characterized. Childhood adversity and its effect on headache in children have not been as robustly investigated. This study examines the relationship of self-reported ACEs to frequent headache in an adolescent cohort.

METHODS

We performed a retrospective cohort study using data from the National Longitudinal Study of Adolescent to Adult Health Wave I (n = 20,745) to examine self-reported ACE exposures and their relationship to frequent headache.

RESULTS

The study population was composed of 20,745 participants; 50.6% male and 49.4% female. The mean age of respondents was 15.9 years (range 12 to 21 years, standard error: 0.12 years). Frequent headache was reported in 29.3% of respondents, and 45% of respondents reported one or more ACE exposures. For each increase in cumulative ACE score, odds of frequent headache increased by 1.22 (95% confidence interval [CI] 1.15 to 1.30). The ACEs that individually showed an association with frequent headache after adjusting for demographic factors were lack of maternal warmth (odds ratio [OR] 1.40, 95% CI 1.12 to 1.74, P = 0.002), lack of paternal warmth (OR 1.47, 95% CI 1.20 to 1.81, P < 0.001), paternal alcoholism (OR 1.21, 95% CI 1.05 to 1.40, P = 0.007), suicide attempt of family member (OR 1.51, 95% CI 1.22 to 1.87, P < 0.001), and living in an unsafe neighborhood (OR 1.22, 95% CI 1.06 to 1.39, P = 0.004).

CONCLUSIONS

Several ACE exposures were associated with frequent headache in adolescents. An increase in cumulative ACE exposure increased the odds of having frequent headache.

Associations between adverse childhood experiences and migraine among teenage mothers in Peru

OBJECTIVE

The objective of this study was to evaluate the association between (1) different types of ACEs and migraine, and (2) the number of ACEs and migraine among adolescent mothers in Lima, Peru.

METHODS

Our cross-sectional study included 787 adolescent mothers (14- to 18-years of age) in Peru. In-person interviews were conducted postpartum, in hospital, within 2-days of delivery. Nine types of ACEs were assessed, including exposure to three categories of abuse, two categories of neglect, and four categories of household dysfunction. Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between ACEs and migraine while adjusting for putative confounders.

RESULTS

Approximately 75% of adolescent mothers reported having experienced at least one type of ACE. Adolescent mothers who reported any childhood abuse had 1.49-fold increased odds of migraine (aOR = 1.49; 95% CI 1.03-2.18) compared to those with no history of childhood abuse. Adolescent mothers who reported experiencing household dysfunction had 1.56-fold increase odds of migraine (aOR = 1.56; 95% CI 1.09-2.24). Compared to participants who reported no ACE, those who experienced four or more ACEs had 3.09-fold (aOR = 3.09; 95% CI 1.80-5.40) increased odds of migraine (ptrend < 0.001).

CONCLUSION

Exposure to ACEs is highly prevalent in adolescent-aged mothers postpartum and is associated with increased odds of migraine. These findings support the importance of screening for ACEs and migraine among adolescent mothers; and the need for providing culturally appropriate, trauma-informed headache care.

Mass Incarceration and Children's Health: A State-Level Analysis of Adverse Birth Outcomes and Infant, Child, and Teen Mortality

Children's health indicators such as mortality and adverse birth outcomes are poorer in the United States than in comparable nations. These measures also show racial inequities within the United States, with Black children experiencing the highest levels. Mass incarceration may partially explain these findings. High incarceration rates can disrupt community functioning, influencing behavior and health. The purpose of the current study was to conduct a macro (state)-level analysis examining whether yearly state incarceration rates predict health outcomes including infant, child, and teen mortality as well as preterm birth and low birth weight. It was hypothesized that prior year incarceration rates would show positive relationships with all outcomes and that relationships would be stronger for Black than for white children. Yearly state-level panel data were gathered from 1990 to 2017. Weighted least squares regression used states' prior year incarceration rates to predict child health outcomes, using controls for overall state effects and year-to-year effects. Time-varying covariates such as state unemployment rate were also included to address the possibility of spurious relationships. Results indicated that as hypothesized, incarceration rates positively predicted infant mortality, child mortality (for Black children only), preterm births, and low-weight births. Relationships tended to be stronger for Black than for white children.

Associations Between Adverse Childhood Experiences and Adult Health Outcomes: Exploring Gender Differences

Objectives: This study aimed to (1) understand the associations between Adverse Childhood Experiences (ACEs) and poor adult health outcomes, specifically looking at both physical and mental health indicators, and (2) examine gender differences in ACEs’ impact on adult health outcomes.Methods: Data were obtained from the 2012 Korean General Social Survey. The study sample comprised 1,396 individuals aged ≥ 18 years who answered the ACE questionnaire. Controlling for sociodemographic factors, linear regression models were run to estimate the relationships between ACEs and adult physical (self-rated poor physical health status) and mental health indicators (depressive symptoms). Furthermore, the Chow test was carried out to ascertain whether there were any gender differences in ACEs’ impact on both adult physical and mental health outcomes.Results: Higher numbers of ACEs were significantly and positively associated with worse adult physical and mental health outcomes, such as poorer physical health status and higher levels of depressive symptoms compared with individuals who reported no adversities during childhood. In addition, gender differences were identified in ACEs’ impact on both health indicators, suggesting that females were at a higher risk of depression, while males were more likely to experience poor physical health.Conclusion: Adults reporting multiple adversities during childhood are more likely to experience poorer physical and mental health, demonstrating a strong, graded dose-response relationship between the number of ACEs and a range of negative adult health outcomes. Gender differences also exist in ACEs’ impact on adult physical and mental health, thus suggesting the need for gender-based intervention strategies to address ACEs in the adult population.

Characterization of chronic overlapping pain conditions in patients with chronic migraine: A CHOIR study

OBJECTIVE

Chronic overlapping pain conditions (COPCs) represent a co-aggregation of widespread pain disorders. We characterized differences in physical and psychosocial functioning in patients with chronic migraine (CM) and those with CM and COPCs.

BACKGROUND

Patients with CM and COPCs have been identified as a distinct subgroup of patients with CM, and these patients may be vulnerable to greater symptom severity and burden.

METHODS

Data were extracted from Collaborative Health Outcomes Information Registry (an open-source learning health-care system), completed at the patients' first visit at a large tertiary care pain management center and electronic medical records. In 1601 patients with CM, the number of non-cephalic areas of pain endorsed on a body map was used to examine the differences in pain, physical and psychosocial function, adverse life experience, and health-care utilization.

RESULTS

Patients endorsing more body map regions reported significantly worse symptoms and function across all domains. Scored on a t-score metric (mean = 50, SD = 10), endorsement of one additional body map region corresponded with a 0.69-point increase in pain interference (95% CI = 0.55, 0.82; p < 0.001; Cohen's f = 0.328), 1.15-point increase in fatigue (95% CI = 0.97, 1.32; p < 0.001; Cohen's f = 0.432), and 1.21-point decrease in physical function (95% CI = -1.39, -1.03; p < 0.001; Cohen's f = 0.560). Patients with more widespread pain reported approximately 5% more physician visits (95% CI = 0.03, 0.07; p < 0.001), and patients reporting adverse life events prior to age 17 endorsed 22% more body map regions (95% CI = 0.11, 0.32; p < 0.001).

CONCLUSIONS

Patients with CM and other overlapping pain conditions as noted on the body map report significantly worse pain-related physical function, psychosocial functioning, increased health-care utilization, and greater association with adverse life experiences, compared with those with localized CM. This study provides further evidence that patients with CM and co-occurring pain conditions are a distinct subgroup of CM and can be easily identified through patient-reported outcome measures.

Cumulative Lifetime Violence Severity and Chronic Pain in a Community Sample of Canadian Men

OBJECTIVE

To create a descriptive profile of chronic pain severity in men with lifetime cumulative violence histories, as a target and/or a perpetrator, and investigate how chronic pain severity is associated with and predicted by lifetime cumulative violence severity and known determinants of chronic pain.

METHODS

Analysis of variance and binary logistic regression were performed on data collected in an online survey with a community convenience sample of 653 men who reported experiences of lifetime violence.

RESULTS

The prevalence of high-intensity / high-disability pain in men with lifetime violence was 35.8%. Total Cumulative Lifetime Violence Severity-44 (CLVS-44) scores were significantly associated with high-intensity / high-disability chronic pain measured by the Chronic Pain Grade Scale (odds ratio= 8.40). In a model with 10 CLVS-44 subscale scores, only psychological workplace violence as a target (adjusted odds ratio [aOR]= 1.44) and lifetime family physical violence as a target (aOR= 1.42) significantly predicted chronic pain severity. In a multivariate model, chronic pain severity was predicted by CLVS-44 total score (aOR= 2.69), age (aOR= 1.02), injury with temporary impairment (aOR= 1.99), number of chronic conditions (aOR= 1.37), and depressive symptoms (aOR= 1.03).

CONCLUSION

The association between lifetime cumulative violence severity and chronic pain severity in men is important new information suggesting the need for trauma- and violence-informed approaches to assessment and intervention with men. This is the first analysis using CLVS-44 subscales to understand which configurations of lifetime cumulative violence may be most predictive of chronic pain severity; further investigation is needed to confirm these findings.

Voluntary Wheel Running Partially Attenuates Early Life Stress-Induced Neuroimmune Measures in the Dura and Evoked Migraine-Like Behaviors in Female Mice

Migraine is a complex neurological disorder that affects three times more women than men and can be triggered by endogenous and exogenous factors. Stress is a common migraine trigger and exposure to early life stress increases the likelihood of developing chronic pain disorders later in life. Here, we used our neonatal maternal separation (NMS) model of early life stress to investigate whether female NMS mice have an increased susceptibility to evoked migraine-like behaviors and the potential therapeutic effect of voluntary wheel running. NMS was performed for 3 h/day during the first 3 weeks of life and initial observations were made at 12 weeks of age after voluntary wheel running (Exercise, -Ex) or sedentary behavior (-Sed) for 4 weeks. Mast cell degranulation rates were significantly higher in dura mater from NMS-Sed mice, compared to either naïve-Sed or NMS-Ex mice. Protease activated receptor 2 (PAR2) protein levels in the dura were significantly increased in NMS mice and a significant interaction of NMS and exercise was observed for transient receptor potential ankyrin 1 (TRPA1) protein levels in the dura. Behavioral assessments were performed on adult (>8 weeks of age) naïve and NMS mice that received free access to a running wheel beginning at 4 weeks of age. Facial grimace, paw mechanical withdrawal threshold, and light aversion were measured following direct application of inflammatory soup (IS) onto the dura or intraperitoneal (IP) nitroglycerin (NTG) injection. Dural IS resulted in a significant decrease in forepaw withdrawal threshold in all groups of mice, while exercise significantly increased grimace score across all groups. NTG significantly increased grimace score, particularly in exercised mice. A significant effect of NMS and a significant interaction effect of exercise and NMS were observed on hindpaw sensitivity following NTG injection. Significant light aversion was observed in NMS mice, regardless of exercise, following NTG. Finally, exercise significantly reduced calcitonin gene-related peptide (CGRP) protein level in the dura of NMS and naïve mice. Taken together, these findings suggest that while voluntary wheel running improved some measures in NMS mice that have been associated with increased migraine susceptibility, behavioral outcomes were not impacted or even worsened by exercise.

Functional difficulties mediate the association between exposure to adverse childhood experiences and headaches among children: Findings from a population-based study

BACKGROUND

Adverse childhood experiences (ACEs) are commonly observed in the general population and often have lasting neurological and physiological effects. Previous studies have found links between exposure to ACEs, headaches, and functional difficulties in adults. However, little is known about the mechanisms through which exposure to ACEs is associated with headaches among children.

OBJECTIVE

To examine the association between exposure to ACEs and headaches in children, and whether functional difficulties mediate this association.

METHODS

Data for this cross-sectional secondary analysis study came from the 2017-2018 National Survey of Children's Health. The sample analyzed in this study was 40,953 children who were between ages 3 and 17 years. We adjusted for the complexity of the sampling design and used structural equation modeling to examine the mediating effect of functional difficulties in the association between exposure to ACEs and headaches.

RESULTS

Based on parent reports, we found that 4.1% (1697/40,953) of the children reported frequent or severe headaches, and 9.5% (3906/40,953) were exposed to three or more ACEs. About one in four children (23.4%; 9601/40,953) had at least one functional difficulty. The results show that exposure to ACEs was directly positively associated with functional difficulties (β = 0.16, p < 0.001, 95% CI = 0.15-0.17), and functional difficulties were in turn positively associated with headaches (β = 0.17, p < 0.001, 95% CI = 0.12-0.22). The Sobel test of indirect effect showed that functional difficulties partially mediated the association between exposure to ACEs and headaches (β = 0.027, p < 0.001, 95% CI = 0.022-0.029). Also, older children and children with brain injury were more likely to report experiencing headaches.

CONCLUSIONS

The findings from this study suggest an association between exposure to ACEs and headaches among children, and functional difficulties partially mediate this association.

A Pilot Study Investigating the Role of Gender in the Intergenerational Relationships between Gene Expression, Chronic Pain, and Adverse Childhood Experiences in a Clinical Sample of Youth with Chronic Pain

Chronic pain is a highly prevalent and costly issue that often emerges during childhood or adolescence and persists into adulthood. Adverse childhood experiences (ACEs) increase risk for several adverse health conditions, including chronic pain. Recent evidence suggests that parental trauma (ACEs, post-traumatic stress disorder (PTSD) symptoms) confers risk of poor health outcomes in their children. Intergenerational relationships between parental trauma and child chronic pain may be mediated by epigenetic mechanisms. A clinical sample of youth with chronic pain and their parents completed psychometrically sound questionnaires assessing ACEs, PTSD symptoms, and chronic pain, and provided a saliva sample. These were used to investigate the intergenerational relationships between four epigenetic biomarkers (COMT, DRD2, GR, and SERT), trauma, and chronic pain. The results indicated that the significant biomarkers were dependent upon the gender of the child, wherein parental ACEs significantly correlated with changes in DRD2 expression in female children and altered COMT expression in the parents of male children. Additionally, the nature of the ACE (maltreatment vs. household dysfunction) was associated with the specific epigenetic changes. There may be different pathways through which parental ACEs confer risk for poor outcomes for males and females, highlighting the importance of child gender in future investigations.

Impact of abuse on migraine-related sensory hypersensitivity symptoms: Results from the American Registry for Migraine Research

BACKGROUND AND OBJECTIVES

Prior studies have established an association between a history of abuse and the development of migraine. This cross-sectional observational study explored the relationship between self-reported abuse history with migraine-related sensory hypersensitivity symptoms.

METHODS

In total, 588 adult patients with migraine from the American Registry for Migraine Research completed questionnaires: Generalized Anxiety Disorder-7, Patient Health Questionnaire-2 for depression, Photosensitivity Assessment Questionnaire, Hyperacusis Questionnaire, and Allodynia Symptom Checklist. Using four binary screening questions, patients were asked to self-report if they believed they had suffered emotional, physical, or sexual abuse in their lifetime. Differences in questionnaire scores between groups with and without a history of abuse were determined. Regression models adjusted for age, sex, and basic headache features analyzed the relationship between abuse history and sensory hypersensitivity symptoms. Moderation analysis explored the role of headache frequency in this relationship. Mediation analysis assessed the indirect (Mediated) effect (IE) of abuse on sensory hypersensitivity through depression or anxiety. Additional models analyzed relationships between sensory hypersensitivity symptoms and abuse subtypes or the number of abuse subtypes.

RESULTS

Of 588 participants, 222 (38%) reported a history of abuse. Patients with a history of abuse reported statistically significantly greater average headache frequency (7.6 vs. 4.7 days, p = 0.030). Patients with a history of abuse also reported higher average or median questionnaire scores: anxiety (7.6 vs. 4.7, p < 0.001, d = 0.56), depression (1.7 vs. 1.3, p = 0.009, d = 0.24), photophobia (0.54 vs. 0.44, p < 0.001, d = 0.32), hyperacusis (19.6 vs. 14.9, p < 0.001, d = 0.49), ictal allodynia (6.0 vs. 3.0, p < 0.001, d = 0.46), and interictal allodynia (1.0 vs. 0.0, p < 0.001, d = 0.30). After controlling for patient age, sex and years lived with headache, abuse maintained a significant association with every sensory hypersensitivity measure. Headache frequency significantly moderated the relationship between a history of abuse with increased ictal allodynia (p = 0.036). Anxiety significantly mediated the relationships between abuse with photophobia (IE = 0.03, 95% CI = 0.01-0.04), hyperacusis (IE = 1.51, 95% CI = 0.91-2.24), ictal allodynia (IE = 0.02, 95% CI = 0.01-0.04), and interictal allodynia (IE = 0.02, 95% CI = 0.01-0.06). Depression significantly mediated the relationship between abuse with photophobia (IE = 0.02, 95% CI = 0.01-0.03) and with hyperacusis (IE = 0.45, 95% CI = 0.11-0.88). The association between the individual subtypes of abuse and the number of subtypes of abuse with sensory hypersensitivity symptoms varied.

CONCLUSION

A history of abuse is associated with greater migraine-related sensory hypersensitivity symptoms. To reduce the impact of abuse on migraine symptoms, future studies should explore mechanistic connections between abuse and migraine-associated symptoms.

Attachment Style Mediates the Relationship between Trauma and Somatic Distress among Individuals with Serious Mental Illness

Objective: Individuals with mental illnesses severe enough to require psychiatric hospitalization often have significant trauma histories, have developed maladaptive attachment styles, and experience comorbid somatic distress. Gaining an understanding about the interaction of such factors may lead to prioritizing interventions that target factors that mediate the relationship between trauma and adverse somatic distress. Prior research has examined various mediation models, but results have been mixed and conducted only on outpatient samples.Method: Participants (47.7% female) in a large sample (N = 2702) with a mean age of 34.62 (SD = 14.7) were enrolled in a specialist inpatient program and completed self-report measures pertaining to demographics, attachment insecurity, lifetime trauma exposure, and somatic distress within 72 hours of admission. The dimensions of attachment insecurity (i.e., attachment anxiety and attachment avoidance) were tested as parallel mediators in the relationship between lifetime trauma exposure and somatic distress.Results: The mediation analyses revealed that attachment anxiety and avoidance partially mediated the relationship between lifetime trauma exposure and somatic distress.Conclusions: These results are the first to date to implicate both attachment anxiety and avoidance as mediators between trauma exposure and somatic distress in a high acuity sample. Although the results do not imply causality, they do call attention to social-cognitive factors related to somatic distress and highlight the importance of considering attachment styles as a possible contributor to comorbid physical symptoms in patients with trauma exposure.

Developing the Concept of Adverse Childhood Experiences: A Global Perspective

BACKGROUND

The relationship between health and adverse childhood experiences (ACEs) has been a major topic in the field of healthcare. In recent years, the study ACEs and health has expanded internationally.

PURPOSE

The purpose of this study was to further develop the concept of ACEs using a global perspective.

METHOD

Rodgers' Evolutionary Model guided the study. PubMed, CINAHL, and PsychINFO databases were searched. A total of 39 publications were selected for review.

FINDINGS

Development of the concept was achieved using a wide global lens. ACEs are influenced by diverse cultural, social, environmental, and economic factors that affect individuals' health worldwide.

DISCUSSION

The developed ACEs concept described in this paper includes a global perspective, adding context to the existing definition, thus broadening its application, and expanding its usefulness in international research. A clear concept for ACEs is valuable to nurses who care for children, adolescents and young adults around the world, who have suffered from ACEs and seek health care.

Adverse Childhood Experiences and Psychological Well-Being in Chinese College Students: Moderated Mediation by Gender and Resilience

Adverse childhood experiences (ACEs), including child abuse/neglect and household challenges, are a prevalent social issue that impacts individuals' well-being worldwide. Relatively few ACEs studies orient to the presence of psychological wellness, especially in ethnically Chinese populations. Furthermore, less is known about resilience as a mechanism between ACEs and psychological well-being, in addition to the moderating effect of gender. This study examined the relationship between ACEs and psychological well-being among Chinese college students and the potential mediating and moderating effects of resilience and gender, respectively. A total of 1,871 college students studying social science from 12 Chinese colleges completed an anonymous online survey between late September and early October 2020. Multiple-group path analyses were conducted to examine whether the relationships among ACEs, resilience, and psychological well-being differed as a function of gender. Results suggested that gender moderated the relationships studied. For female students, resilience mediated the association between abuse/neglect and psychological well-being, where abuse/neglect was negatively associated with resilience, which in turn had a negative relationship with psychological well-being. For male students, household challenges were negatively related to psychological well-being through reduced resilience. Based on the findings, various ACE-informed initiatives may be essential to prevent and protect individuals from ACEs. We also call for resilience-based interventions to enhance individuals' resilience and thus strengthen their psychological well-being.

The intersection of COVID-19, school, and headaches: Problems and solutions

OBJECTIVE

To equip clinicians with recommendations specific to concerns related to the novel coronavirus disease 2019 (COVID-19), which impact the physical, emotional, and social health of youth with headache disorders.

BACKGROUND

COVID-19 has affected societies on a global scale including children and youth with chronic headache disorders. Many concerns are predicted to arise in the 2020-2021 school year, whether classes are conducted in-person or virtually.

METHODS

Clinical impressions were combined with a review of the literature, although limited due to the recent nature of this issue.

RESULTS

We describe recommendations to support caregivers and youth as they face changes expected with the return to school in the fall of 2020.

CONCLUSION

Although there are significant concerns for caregivers and youth with migraine given the context of changes related to the pandemic, there are many recommendations that can help minimize exacerbations of the physical, emotional, and social health of youth with chronic migraine.

The prevalence and impact of migraine and severe headache in the United States: Updated age, sex, and socioeconomic-specific estimates from government health surveys

BACKGROUND AND OBJECTIVES

Accurate, up-to-date estimates of the burden of migraine and severe headache are important for evidence-based decision-making about workforce needs and the distribution of health resources. We used data from US government health surveys to report the prevalence, trends, and impact of this condition by age, sex, and poverty status.

METHODS

We identified the most recent, publicly available summary statistics from the National Hospital Ambulatory Medical Care Survey, the National Ambulatory Medical Care Survey, and the National Health Interview Survey. We extracted and compiled relevant information from each study, with an emphasis on sex, age, and economic-related statistics.

RESULTS

The age-adjusted prevalence of migraine and severe headache in the United States has remained stable over many years. In 2018, the age-adjusted prevalence was 15.9% across all adults. The sex ratio also remains stable, with 21% of women and 10.7% of men affected. Migraine continues to be an important public health problem, accounting for roughly 4 million emergency department (ED) visits in 2016, when headache was the fifth most common reason for an ED visit overall and the third most common reason for ED visits in females 15-64. Migraine also accounted for over 4.3 million office visits. Many adults with migraine or severe headaches are disadvantaged. In 2018, for example, roughly 40% of US adults with migraine were unemployed, and a similar proportion were classified as poor or "near poor." Roughly one in five had no health insurance and about a third had a high school education or less.

CONCLUSIONS

Migraine and severe headaches are a serious public health issue in the United States, with the highest impact in women of childbearing age and those of lower socioeconomic status. Socioeconomic disadvantages also are highly prevalent among those with headaches. The economic consequences of the current coronavirus pandemic are likely to exacerbate all of these inequities. Increased attention to this high impact chronic pain condition, and improved funding for treatment provision and research, are warranted to reduce the future burden of disease.

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

Supplemental Digital Content is Available in the Text.

Parents of youth with chronic pain reported high rates of adverse childhood experiences, including significantly higher rates of physical neglect than a community-based sample.

Introduction:

Adverse childhood experiences (ACEs) are common occurrences that are related to poor health outcomes, including chronic pain, in youth and adults. Research suggests that children of parents exposed to ACEs are also at risk of poor outcomes. However, little is known about the risk that ACEs confer for chronic pain across generations. Parent ACEs may play an important role in pediatric chronic pain, given their association with key parent factors (eg, mental and physical health).

Objectives:

This study evaluated the prevalence of ACEs in parents of youth with chronic pain and compared these rates to a community-based sample.

Methods:

One hundred seventy parents of youth (aged 10–18 years) with chronic pain, recruited from a tertiary-level chronic pain program at a pediatric hospital in Canada, completed a self-report measure of ACEs. A comparison sample (n = 3914) was drawn from a local, community-based study that examined ACEs among adults in primary care.

Results:

Among parents of youth with chronic pain, 67.6% reported ≥1 ACE and 23.5% reported ≥4 ACEs. Controlling for sociodemographic factors, ACEs were similar across samples, except parents of youth with chronic pain reported significantly higher rates of physical neglect (odds ratio = 2.14; 95% confidence interval = 1.35–3.40) than the community-based sample.

Conclusion:

Adverse childhood experiences are prevalent among parents of youth with chronic pain, with physical neglect reported more frequently than the community-based sample. Further research that examines the association between parent ACEs and child chronic pain, as well as neurobiological and psychosocial factors that may mediate this potential relation, is needed.

EMDR Versus Treatment-as-Usual in Patients With Chronic Non-Malignant Pain: A Randomized Controlled Pilot Study

In recent years, different studies have observed a strong association between chronic pain (CP) and psychological trauma. Therefore, a trauma-focused psychotherapy, such as eye movement desensitization and reprocessing (EMDR), could be an innovative treatment option. The aim of this pilot study was to assess whether a specific EMDR protocol for CP leads to (a) a reduction in pain intensity, (b) an improvement in anxiety and depressive symptoms, and (c) an improvement in quality of life. 28 CP patients were randomly assigned to EMDR + treatment as usual (TAU; n = 14) or to TAU alone (n = 14). Patients in the EMDR group received 12 psychotherapeutic sessions of 90 minutes over 3 months. Pain intensity was measured using the Visual Analog Scale and the Pain Disability index, quality of life using the EQ-5D-5L, and anxiety and depressive symptoms using the Hamilton Anxiety and Depression Scale. Measures were taken for both conditions at pre- and post-treatment, and a follow-up in the EMDR condition was taken at 3 months post-treatment. Patients in the EMDR group showed significantly reduced pain intensity and improved quality of life and anxiety and depressive symptoms compared to TAU alone at post-treatment. Improvements were largely maintained at 3-month follow-up. This study suggests that EMDR may be an effective and safe psychological intervention to be used within the multidisciplinary treatment plan of patients with CP.

The association between adverse childhood experiences and quality of partnership in adult women

BACKGROUND

Adverse childhood experiences (ACE) have a significant effect on psychological and physical child development and represent a risk factor for interpersonal difficulties.

OBJECTIVE

This study aims to investigate the association between ACE, in particular physical, sexual, emotional abuse and neglect, and partnership quality during adulthood in women.

PARTICIPANTS AND SETTING

This study is a secondary analysis of a retrospective multi-center study evaluating risk factors and quality of life in women with and without endometriosis, a chronic, disabling gynecological disease. The investigation includes 533 consenting adult women (159 with ACE and 374 women without) recruited from various hospitals in Switzerland, Austria and Germany.

METHODS

To evaluate the association between ACE and partnership, a questionnaire including the Childhood Trauma Questionnaire and a validated partnership questionnaire were used.

RESULTS

Altogether, 29.8 % (N = 159) women experienced maltreatment in childhood, 9.7 % (N = 52) of them more than one type. Women who went through ACE showed a lower level of happiness (P = 0.013) and of quality of partnership (P = 0.001) as well as a higher number of conflict areas (P < 0.001). Emotional (P = 0.03; 95 % CI=-1.27,-0.070) and sexual abuse (P = 0.01; 95 % CI=-1.765,-0.197) had the strongest association with reduced partnership quality.

CONCLUSION

Our study showed a significant association between ACE, in particular sexual and emotional abuse, and reduced partnership quality. As the quality of partnership is a key factor in the quality of life, improvement in social support with a special focus on intimate relationships should be part of the strategy to address the consequences of ACE already during childhood/adolescence.

Adverse childhood experience and adult persistent pain and disability: protocol for a systematic review and meta-analysis

BACKGROUND

A growing body of research highlights the pervasive harms of adverse childhood experiences (ACEs) on health throughout the life-course. However, findings from prior reviews and recent longitudinal studies investigating the association between types of ACEs and persistent pain have yielded inconsistent findings in the strength and direction of associations. The purpose of this review is to appraise and summarize evidence on the relationship between ACEs and persistent pain and disability outcomes in adulthood. The specific aims are (1) to determine whether there is a relationship between exposure to ACE and persistent pain and disability in adults and (2) to determine whether unique and cumulative ACEs exposures (number and type) increase the risk of developing persistent pain and disability in adulthood.

METHOD

A systematic review and meta-analysis of observational studies will be conducted. Our eligibility criteria are defined following a PECOS approach: population, adults with persistent (≥ 3 months) musculoskeletal and somatoform painful disorders exposed to single or cumulative direct ACEs alone (i.e., physical, sexual, emotional abuse or neglect) or in combination to indirect types of ACE (e.g., parental death, exposure to domestic violence) in the first 18 years of life; comparators, unexposed individuals; outcomes, measurements for persistent pain (≥ 3 months) and disability using discrete and/or continuous measures; and settings, general population, primary care. A comprehensive search of MEDLINE (Ovid) and nine other pertinent databases was conducted from inception to 29 August 2019 using a combination of key words and MeSh terms (the search will be updated prior to conducting the analyses). Pairs of reviewers will independently screen records and full text articles, and a third reviewer will be consulted in cases of disagreement. Data will be extracted using Endnote and Covidence and a meta-analysis will be conducted using Review Manager (RevMan) Version 5.3. The Scottish Intercollegiate Guidelines Network (SIGN) and the Joanna Briggs Institute (JBI) checklists will be used to assess the quality of the included studies. If heterogeneity is high, the findings will be presented in narrative form.

DISCUSSION

The present review will help consolidate knowledge on persistent pain and disability by evaluating whether frequency and type of adverse childhood experiences produces the most harm. Findings may help inform practitioners and policy-makers who endeavor to prevent and/or mitigate the consequences of ACEs and promote healthy development and well-being of children, youth, and families.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020150230.

Introducing ACEs (Adverse Childhood Experiences) and Resilience to First-Year Medical Students

INTRODUCTION

Adverse childhood experiences (ACEs) are associated with negative mental and physical health outcomes and predictive of higher sociodemographic risk. Introducing ACEs into undergraduate medical education is key to prevention, early recognition, and intervention.

METHODS

In a 1-hour lecture, held live and viewed online, we delivered a condensed introduction to ACEs to first-year medical students. Live-classroom participants completed pre-/postsession questionnaires self-assessing their knowledge of 10 content areas on a 5-point Likert scale. We analyzed quantitative data to determine mean scores and differences. We synthesized qualitative data obtained from feedback.

RESULTS

One hundred twenty-four students, including 32 live-classroom attendees and 92 online viewers, participated in this activity. Self-assessment scores increased in all content areas measured, with a mean increase of 1.5 (p < .0001). The most significant increases occurred in identifying household dysfunction as ACEs (increase of 2.3), calculating an ACE score (increase of 2.2), differentiating between child abuse acts of commission and omission (increase of 1.9), describing resilience (increase of 1.7), and recognizing the link between ACEs and chronic medical conditions (increase of 1.4). Participants found the lecture informative, appreciating the use of the case illustrating how ACEs impact health and an interactive slide on the risks conferred by cumulative ACEs. Learners welcomed the positive message of resilience.

DISCUSSION

Introducing ACEs in medical student education is feasible. Educating the next generation of health providers on ACEs while highlighting prevention and resilience and teaching trauma-informed care is crucial. This lecture can be readily incorporated into medical student curricula.

Childhood Adversities, Midlife Health, and Elder Abuse Victimization: A Longitudinal Analysis based on Cumulative Disadvantage Theory

OBJECTIVES

Elder abuse victimization is increasingly recognized as a pressing public health concern. However, few empirical studies have investigated whether early life course adversities and midlife sequelae heighten risks for abuse in late life. Guided by cumulative disadvantage theory, the current study examined whether compromised health in middle adulthood (physical, psychological, cognitive) mediates the association between child abuse and elder abuse.

METHODS

This secondary analysis was based on data from the Wisconsin Longitudinal Study, a population-based, multi-wave dataset. We analyzed responses from 5,968 participants (mean age = 71 years; 54% female) on adapted versions of standardized measures: elder abuse victimization (outcome variable), childhood adversities (independent variable), and midlife health (physical health, depressive symptoms, cognitive functioning; mediator variables). Serial multiple mediation models were conducted, controlling for background characteristics.

RESULTS

Rates for any elder abuse and child adversities were, respectively, 16.34% and 47.98%. Multivariate analyses supported the cumulative disadvantage hypothesis. Childhood adversities (0.11, p < .001) and midlife health (physical, -0.10, p < .05; depressive symptoms, 0.09, p < .001; cognitive functioning, 0.02, p < .05) had significant direct effects on elder abuse victimization. Childhood adversities also had an indirect effect on elder abuse through physical health (0.002, p < .05) and depressive symptoms (0.01, p < .001), both in serial.

DISCUSSION

This innovative study advances our understanding mechanisms through which childhood trauma influences abuse in late life. Boosting health in middle adulthood could help prevent elder abuse. Other implications for clinical practice, treatment, and future research on elder abuse are discussed.

When a Head Is about to Burst: Attachment Mediates the Relationship Between Childhood Trauma and Migraine

Background: People exposed to childhood trauma show insecure attachment patterns and are more prone to chronic and pain-related conditions, including migraine. The aim of this study was to explore the mediating role of attachment in the association between childhood trauma and adulthood chronic health conditions, with a focus on migraine. Methods: Respondents from a representative sample of citizens of the Czech Republic (n = 1800, mean age: 46.6 years, 48.7% male) were asked to report various chronic and pain-related conditions, childhood trauma (The Childhood Trauma Questionnaire, CTQ), and attachment anxiety and avoidance (The Experience in Close Relationships Revised, ECR-R) in a cross-sectional, questionnaire-based survey conducted in 2016. Structural equation models (SEM) adjusted for sociodemographic variables were used to assess the relationship between childhood trauma, adulthood attachment, and adulthood chronic health conditions (migraine, other pain-related conditions, chronic health conditions other than pain, no chronic health complaints). Results: After adjusting for sociodemographic variables, SEM confirmed a significant mediation of the relationship between childhood trauma and migraine through adulthood attachment. There was no mediation effect of adulthood attachment found in other health complaints. Conclusion: This study highlights the mediation effect of attachment in the link between childhood trauma and migraine. Attachment-based therapeutic interventions can be useful in the treatment of patients with migraine.

Individual differences in attachment anxiety shape the association between adverse childhood experiences and adult somatic symptoms

BACKGROUND

Although prior research has documented the link between adverse childhood experiences (ACEs) and somatic symptoms, it remains unclear why some individuals exposed to ACEs developed somatic symptoms while others did not.

OBJECTIVE

Framed by a biopsychosocial perspective, this study investigated the role of attachment anxiety in the association between ACEs and somatic symptoms in adulthood.

PARTICIPANTS AND SETTING

A total of 662 emerging adults attending college were recruited to respond to an online survey in a computer lab.

METHOD

The computer-based survey included demographic form, the Adverse Childhood Experience Scale, the Experience in Close Relationship Scale-Short Form, and the Somatization Scale of the Symptom Checklist-90-Revised for somatic symptoms. Multivariate regression analyses were used to examine the role of attachment anxiety in the association between ACEs and somatic symptoms.

RESULTS

The results indicated that ACEs positively correlated with attachment anxiety and somatic symptoms; and attachment anxiety and somatic symptoms were positively correlated. Moreover, the results indicated a significant effect of interaction between ACEs and attachment anxiety on somatic symptoms, suggesting a moderating role of attachment anxiety. Subsequent simple slope test revealed that attachment anxiety intensified the strength of relation between ACEs and somatic symptoms; but when the level of attachment anxiety was low, ACEs and somatic symptoms were not related.

CONCLUSION

Individual differences in attachment anxiety shape the association of adverse childhood experiences with somatic symptoms. Targeting and reformulating anxious working models of attachment may help ameliorate vulnerability to somatic symptoms in individuals exposed to ACEs.

Racial Differences in the Relationship between Neighborhood Disorder, Adverse Childhood Experiences, and Child Behavioral Health

The neighborhood and family context in which children grow profoundly influences their development. Informed by ecological systems theory and social disorganization theory, we hypothesized that adverse childhood experiences (ACEs) mediate the relationship between neighborhood disorder and child externalizing and internalizing behaviors, and that these pathways vary by race/ethnicity. We conducted secondary data analysis using Fragile Families and Child Well-being study data. To test hypothesized pathways, we performed a mediation path analysis on a sample of 3001 mothers of children (ages 3 and 5) living in 20 U.S. cities. A moderated mediation path analysis was used to test racial/ethnic differences in hypothesized pathways. We found that living in disordered neighborhoods increased children's likelihood of exhibiting externalizing and internalizing behaviors through childhood ACEs. Compared to Black and Hispanic children, White children's ACEs were more susceptible to negative neighborhood environment effects, suggesting that White children's behavioral health may be more indirectly affected by neighborhood disorder. The finding that ACEs mediated the pathway from neighborhood disorder to child behavior problems provides opportunity for child psychiatrists and pediatricians to interrupt negative pathways by providing interventions for children and families. Our findings on racial/ethnic differences highlight the need for culturally sensitive programming to address children's behavior problems.

Suicide Attempts among Those with Migraine: Findings from a Nationally Representative Canadian Study

The objectives of this study were to identify the gender-specific prevalence of suicide attempts among those with migraine and to examine what factors are associated with suicide attempts among migraineurs. This study was a nationally representative analysis of the 2012 Canadian Community Health Survey - Mental Health (CCHS-MH) with 21,744 respondents, of whom 2,223 had migraine. Bivariate and logistic regression analyses were conducted. Those with migraine had a much higher prevalence of ever attempting suicide than those without migraine (men: 7.5% vs 1.9%; women; 9.3% vs 2.7%, p < .001). Among migraineurs, the odds of suicide attempts were higher among poorer respondents, those in chronic pain and those with a history of childhood adversities, substance dependence and/or mental illness. Targeted outreach is needed to reduce suicidality in this vulnerable population.

Child Maltreatment, Chronic Pain, and Other Chronic Health Conditions in Youth in Foster Care

Childhood maltreatment is associated with chronic pain in adults. The goals of this study were 1) to examine this relation in youth placed in foster care with high levels of maltreatment exposure, and 2) to investigate the relation between maltreatment frequency and acute pain, and maltreatment frequency and general chronic health condition. Participants included 403 youth ages 8-19 who resided in foster or residential/group homes. Youth with more maltreatment events had higher odds of chronic pain in a dose response fashion. There was no significant relation between maltreatment type and pain diagnosis, or maltreatment and general chronic health condition. This study examined both self- and case file report of maltreatment frequency and type in association with chronic pain, acute pain, and general chronic health condition in a sample of youth in foster care, providing evidence that more maltreatment exposure increases the likelihood of chronic pain, even in youth. This suggests that it may not take decades for the overloaded stress response system to lead to a serious pain condition, but that this process may occur much earlier in the lifespan. The findings have important implications for professionals working to prevent and treat the effects of child maltreatment or chronic pain.

Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis

BACKGROUND

The Center for Disease Control (CDC) and Kaiser Permanente developed the Adverse Childhood Experiences (ACE) scale to identify negative experiences in childhood. The goal of this study is to systematically review outcomes associated with the ACEs in the CDC-Kaiser ACE scale to understand the diversity of outcomes associated with this scale.

METHODS

The authors conducted a search of English language articles published through September 30, 2016 using OVID Medline®; Ovid Medline® Daily; Epub Ahead of Print, In-Process & Other Non-indexed citations; ERIC®; HAPI®; and SCOPUS®. Articles were selected by trained reviewers based on a priori inclusion criteria including: research, healthy sample, used the CDC-Kaiser ACE scale, and assessed some health outcome. Two reviewers used an abstraction form to independently collect data from each study. Unadjusted and adjusted odds ratio associated with ACE scale scores were aggregated and compared.

RESULTS

From 3167 unique titles, we identified 96 articles that assessed health outcomes associated with the ACEs in the CDC-Kaiser ACE scale. There were more studies focusing on psychosocial/behavioral outcomes than medical outcomes. The majority of the included studies were retrospective, observational, and relied on the same data set. Psychosocial/behavioral outcomes had higher odds ratio than medical outcomes with increasing ACE scale scores.

CONCLUSIONS

Exposure to multiple ACEs is associated with a wide variety of outcomes. This data suggests a benefit of screening for ACEs using this scale and highlights the need to find interventions to ameliorate their effects.

Adverse Childhood Experiences in Mothers With Chronic Pain and Intergenerational Impact on Children

Adverse childhood experiences (ACEs; eg, parental divorce, physical or sexual abuse) are more prevalent in individuals with chronic pain compared with the general population. Both increased maternal ACEs and chronic pain have been associated with poor physical and emotional functioning in offspring. However, the mechanisms driving these associations are poorly understood. Thus, this cross-sectional study evaluated the relation between maternal ACEs, mothers' current functioning, and children's physical and emotional functioning in a sample of mothers with chronic pain and their 8- to 12-year-old children. Results indicated a higher prevalence of ≥1 ACE in this sample of mothers with chronic pain (84%) compared with normative data from a community sample of women. Higher maternal ACE scores corresponded with lower physical and social functioning, greater anxiety and depressive symptoms, greater fatigue and sleep disturbances, and greater pain intensity and pain interference in mothers. Higher maternal ACE scores significantly correlated with higher child self-reported depressive symptoms, but not somatic symptoms or functional impairment. A path model indicated that maternal depressive symptoms accounted for the relation between higher maternal ACE scores and children's depressive symptoms. Intervening on maternal depression among mothers with chronic pain may reduce the impact of intergenerational ACE transmission. Perspective: This article presents evidence regarding the intergenerational impact of ACEs in a large sample of mothers with chronic pain and their school-aged children. Maternal depressive symptoms accounted for the relation between maternal ACEs and children's depressive symptoms providing evidence regarding targets for preventive interventions.

Adverse childhood experiences and the onset of chronic disease in young adulthood

This study examined the association of adverse childhood experiences (ACEs) with early-onset chronic conditions. We analyzed data from the 2011-2012 Behavioral Risk Factor Surveillance System (BRFSS), which included 86,968 respondents representing a nine-state adult population of 32 million. ACE questions included physical, emotional, and sexual abuse; substance use, mental illness or incarceration of a household member; domestic violence, and parental separation. Outcomes included chronic conditions (cardiovascular disease, chronic obstructive pulmonary disease, cancer, depression, diabetes, and prediabetes); overall health status; and days of poor mental or physical health in the past month. We estimated Poisson regression models of the likelihood of chronic conditions and poor health status comparing adults reporting ≥4 ACEs to respondents with no ACEs within three age strata: 18-34, 35-54 and ≥55 years. The prevalence of ≥4 ACEs was highest among youngest respondents (19%). There was a dose-response gradient between ACE scores and outcomes except for cancer in older adults. Among younger respondents, those reporting ≥4 ACEs had two to four times the risk for each chronic condition and poor health status compared to respondents reporting no ACEs. With few exceptions (depression, poor mental and physical health in the past month), incidence rate ratios were highest in young adults and successively decreased among older adults. This study is among the first to analyze patterns of association between ACEs and adult health disaggregated by age. Young adults with high ACE scores are at increased risk of early-onset chronic disease. Trauma-informed care and ACEs prevention are crucial public health priorities.

Cumulative Childhood Adversity as a Risk Factor for Common Chronic Pain Conditions in Young Adults

OBJECTIVE

Multiple and specific types of childhood adverse events are risk factors for chronic pain conditions. Although both can covary, no study has evaluated one aspect while controlling for the other. Therefore, the current study examined whether more adverse events would be a risk factor for common chronic pain conditions and pain medication use in young adults after controlling for different adversity types such as physical, emotional, and sexual traumatic events or vice versa.

METHODS

This cross-sectional study recruited 3,073 undergraduates (72% female, mean age = 18.8 years, SD = 1.4 years) who completed the survey for current health status and early life traumatic events.

RESULTS

More adverse events were associated with a 1.2-1.3-fold increase in the odds of any chronic pain, chronic back pain, headache, and dysmenorrhea with adjusting for adversity types, but they were not associated with the risk of comorbid pain conditions and use of pain medications. In contrast, specific adversity types were unrelated to chronic pain conditions when controlling for the number of adverse events.

CONCLUSIONS

Cumulative childhood adverse events may be a more relevant risk factor for chronic pain conditions than the experience of a specific type of adverse event. Clinicians and researchers need to evaluate cumulative childhood adversity when assessing its link to chronic pain.

Could epigenetics help explain racial disparities in chronic pain?

African Americans disproportionately suffer more severe and debilitating morbidity from chronic pain than do non-Hispanic Whites. These differences may arise from differential exposure to psychosocial and environmental factors such as adverse childhood experiences, racial discrimination, low socioeconomic status, and depression, all of which have been associated with chronic stress and chronic pain. Race, as a social construct, makes it such that African Americans are more likely to experience different early life conditions, which may induce epigenetic changes that sustain racial differences in chronic pain. Epigenetics is one mechanism by which environmental factors such as childhood stress, racial discrimination, economic hardship, and depression can affect gene expression without altering the underlying genetic sequence. This article provides a narrative review of the literature on epigenetics as a mechanism by which differential environmental exposure could explain racial differences in chronic pain. Most studies of epigenetic changes in chronic pain examine DNA methylation. DNA methylation is altered in the glucocorticoid (stress response) receptor gene, NR3C1, which has been associated with depression, childhood stress, low socioeconomic status, and chronic pain. Similarly, DNA methylation patterns of immune cytokine genes have been associated with chronic stress states. Thus, DNA methylation changes may play an essential role in the epigenetic modulation of chronic pain in different races with a higher incidence of epigenetic alterations contributing to more severe and disabling chronic pain in African Americans.

Adverse childhood experiences, self-care, and compassion outcomes in mental health providers working with trauma

OBJECTIVE

This study examined the moderating effects of self-care on various compassion outcomes among mental health providers.

METHOD

Mental health providers (n = 371; 94.1% female; mean age = 47.12) were surveyed regarding their level of self-care, history of adverse childhood experiences, and the degree of burnout, secondary traumatic stress, and compassion satisfaction experienced.

RESULTS

Results indicated that providers who endorsed a history of adverse childhood experiences (82.5%) also endorsed greater negative compassion outcomes than those who did not have such a history. Endorsement of self-care activities was a significant predictor of compassion satisfaction and burnout in the expected directions. Self-care served as a moderator between adverse childhood experiences and burnout.

CONCLUSIONS

Self-care is an effective method for decreasing negative compassion outcomes among mental health providers who work with trauma. It is important to develop effective training programs that promote self-care in personal and professional settings.

Epigenetic and Neurological Impairments Associated with Early Life Exposure to Persistent Organic Pollutants

The incidence of neurodevelopmental and neurodegenerative diseases worldwide has dramatically increased over the last decades. Although the aetiology remains uncertain, evidence is now growing that exposure to persistent organic pollutants during sensitive neurodevelopmental periods such as early life may be a strong risk factor, predisposing the individual to disease development later in life. Epidemiological studies have associated environmentally persistent organic pollutant exposure to brain disorders including neuropathies, cognitive, motor, and sensory impairments; neurodevelopmental disorders such as autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD); and neurodegenerative diseases including Alzheimer's disease, Parkinson's disease, and amyotrophic lateral sclerosis (ALS). In many ways, this expands the classical “Developmental Origins of Health and Disease” paradigm to include exposure to pollutants. This model has been refined over the years to give the current “three-hit” model that considers the individual's genetic factors as a first “hit.” It has an immediate interaction with the early-life exposome (including persistent organic pollutants) that can be considered to be a second “hit.” Together, these first two “hits” produce a quiescent or latent phenotype, most probably encoded in the epigenome, which has become susceptible to a third environmental “hit” in later life. It is only after the third “hit” that the increased risk of disease symptoms is crystallised. However, if the individual is exposed to a different environment in later life, they would be expected to remain healthy. In this review, we examine the effect of exposure to persistent organic pollutants and particulate matters in early life and the relationship to subsequent neurodevelopmental and neurodegenerative disorders. The roles of those environmental factors which may affect epigenetic DNA methylation and therefore influence normal neurodevelopment are then evaluated.

Adverse Childhood Experiences Are Not Associated With Patient-reported Outcome Measures in Patients With Musculoskeletal Illness

BACKGROUND

Adverse childhood experiences (ACEs) affect adult mental health and tend to contribute to greater symptoms of depression and more frequent suicide attempts. Given the relationship between symptoms of depression and patient-reported outcomes (PROs), adversity in childhood might be associated with PROs in patients seeking care for musculoskeletal problems, but it is not clear whether in fact there is such an association among patients seeking care in an outpatient, upper extremity orthopaedic practice.

QUESTIONS/PURPOSES

(1) Are ACE scores independently associated with variation in physical limitations measured among patients seen by an orthopaedic surgeon? (2) Are ACE scores independently associated with variations in pain intensity? (3) What factors are associated with ACE scores when treated as a continuous variable or as a categorical variable?

METHODS

We prospectively enrolled 143 adult patients visiting one of seven participating orthopaedic surgeons at three private and one academic orthopaedic surgery offices in a large urban area. We recorded their demographics and measured ACEs (using a validated 10-item binary questionnaire that measured physical, emotional, and sexual abuse in the first 18 years of life), magnitude of physical limitations, pain intensity, symptoms of depression, catastrophic thinking, and health anxiety. There were 143 patients with a mean age of 51 years, 62 (43%) of whom were men. In addition, 112 (78%) presented with a specific diagnosis and most (n = 79 [55%]) had upper extremity symptoms. We created one logistic and three linear regression models to test whether age, gender, race, marital status, having children, level of education, work status, insurance type, comorbidities, body mass index, smoking, site of symptoms, type of diagnosis, symptoms of depression, catastrophic thinking, and health anxiety were independently associated with (1) the magnitude of limitations; (2) pain intensity; (3) ACE scores on the continuum; and (4) ACE scores categorized (< 3 or ≥ 3). We calculated a priori that to detect a medium effect size with 90% statistical power and α set at 0.05, a sample of 136 patients was needed for a regression with five predictors if ACEs would account for ≥ 5% of the variability in physical function, and our complete model would account for 15% of the overall variability. To account for 5% incomplete responses, we enrolled 143 patients.

RESULTS

We found no association between ACE scores and the magnitude of physical limitations measured by Patient-Reported Outcomes Measurement Information System Physical Function (p = 0.67; adjusted R = 0.55). ACE scores were not independently associated with pain intensity (Pearson correlation [r] = 0.11; p = 0.18). Greater ACE scores were independently associated with diagnosed mental comorbidities both when analyzed on the continuum (regression coefficient [β] = 1.1; 95% confidence interval [CI], 0.32-1.9; standard error [SE] 0.41; p = 0.006) and categorized (odds ratio [OR], 3.3; 95% CI, 1.2-9.2; SE 1.7; p = 0.024), but not with greater levels of health anxiety (OR, 1.1; 95% CI, 0.90-1.3; SE 0.096; p = 0.44, C statistic = 0.71), symptoms of depression (ACE < 3 mean ± SD = 0.73 ± 1.4; ACE ≥ 3 = 1.0 ± 1.4; p = 0.29) or catastrophic thinking (ACE < 3 = 3.6 ± 3.5; ACE ≥ 3 = 4.9 ± 5.1; p = 0.88).

CONCLUSIONS

ACEs may not contribute to greater pain intensity or magnitude of physical limitations unless they are accompanied by greater health anxiety or less effective coping strategies. Adverse events can contribute to anxiety and depression, but perhaps they sometimes lead to development of resilience and effective coping strategies. Future research might address whether ACEs affect symptoms and limitations in younger adult patients and patients with more severe musculoskeletal pathology such as major traumatic injuries.

LEVEL OF EVIDENCE

Level II, prognostic study.

A Critical Exploration of Migraine as a Health Disparity: the Imperative of an Equity-Oriented, Intersectional Approach

PURPOSE OF REVIEW

Despite recognition of rising prevalence and significant burden, migraine remains underestimated, underdiagnosed, and undertreated. This is especially true among groups who have been historically, socially, and economically marginalized such as communities of color, women, people experiencing poverty, people with lower levels of education, and people who hold more than one of these marginalized identities. While there is growing public and professional interest in disparities in migraine prevalence, there is a paucity of research focusing on racial/ethnic and socioeconomic disparities, and the social and structural determinants of health and equity that perpetuate these disparities. From a health equity perspective, migraine research and treatment require an examination not only of biological and behavioral factors, but of these identities and underlying, intersecting social and structural determinants of health.

RECENT FINDINGS

Significant disparities in migraine incidence, prevalence, migraine-related pain and disability, access to care, and quality of care persist among marginalized and underserved groups: African Americans, Hispanics, people experiencing poverty, un- or under-employment, the un- and under-insured, people who have been exposed to stressful and traumatic events across the lifespan, and people experiencing multiple, overlapping marginalized identities. These same groups are largely underrepresented in migraine research, despite bearing disproportionate burden. Current approaches to understanding health disparities in migraine largely assume an essentializing approach, i.e., documenting differences between single identity groups-e.g., race or income or education level-rather than considering the mechanisms of disparities: the social and structural determinants of health. While disparities in migraine are becoming more widely acknowledged, we assert that migraine is more aptly understood as a health equity issue, that is, a condition in which many of the health disparities are avoidable. It is important in research and clinical practice to consider perspectives that incorporate a cultural understanding of racial, ethnic, and socioeconomic identity within and across all levels of society. Incorporating perspectives of intersectionality provides a strong foundation for understanding the role of these complex combination of factors on migraine pain and treatment. We urge the adoption of intersectional and systems perspectives in research, clinical practice, and policy to examine (1) interplay of race, gender, and social location as key factors in understanding, diagnosing, and treating migraine, and (2) the complex configurations of social and structural determinants of health that interact to produce health inequities in migraine care. An intentional research and clinical focus on these factors stands to improve how migraine is identified, documented, and treated among marginalized populations.

Factors mediating the impacts of child abuse and intimate partner violence on chronic pain: a cross-sectional study

BACKGROUND

Most research on the health impacts of intimate partner violence (IPV) and child abuse has been conducted in Western countries and may not be generalizable to women living in different contexts, such as Saudi Arabia. Chronic pain, a disabling health issue associated with experiences of both child abuse and IPV among women, negatively impacts women's well-being, quality of life, and level of functioning. Yet, the psychosocial mechanisms that explain how abuse relates to chronic pain are poorly understood. We developed and tested a theoretical model that explains how both IPV and child abuse are related to chronic pain.

METHODS

We recruited a convenience sample of 299 Saudi women, who had experienced IPV in the past 12 months, from nine primary health care centers in Saudi Arabia between June and August 2015. Women completed a structured interview comprised of self-report measures of IPV, child abuse, PTSD, depressive symptoms, chronic pain, and social support. Using Structural equation modeling (SEM), we analyzed the proposed model twice with different mental health indicators as mediators: PTSD symptoms (Model 1) and depressive symptoms (Model 2).

RESULTS

Both models were found to fit the data, accounting for 31.6% (Model 1) and 32.4% (Model 2) of the variance in chronic pain severity. In both models, mental health problems (PTSD and depressive symptoms) fully mediated the relationship between severity of IPV and child abuse and chronic pain severity. Perceived family support partially mediated the relationship between abuse severity and depressive symptoms.

CONCLUSIONS

These results underscore the significance of considering lifetime abuse, women's mental health (depressive and PTSD symptoms) and their social resources in chronic pain management and treatment.

[Influence of early childhood stress exposure and traumatic life events on pain perception]

Adult pain perception is influenced substantially by interactions between mind, body, and social environment during early life. Early stress exposure and traumatic life events induce powerful psychophysical stress reactions that exert multiple neurofunctional processes. This has significant implications for pain perception and pain processing. As part of this review, the complex relationships between traumatic stress experiences and associated psychobiological mechanisms of chronic pain will be discussed. Based on selected studies, psychophysiological findings are presented and possible underlying mechanisms are discussed. The article concludes with a discussion of potential implications for treatment.