Chronic pain patients may have been disobedient children

by Nancy Walsh

Children who are irritable or disobedient, or who steal or bully others, are at risk for chronic pain in middle age, a large prospective study found.

Youngsters who had persistent behavior problems at ages seven, 11, and 16 years had more than twice the risk of of widespread chronic pain at age 45 as other children (RR 2.14, 95% CI 1.43 to 3.21), according to Dong Pang, PhD, of the University of Aberdeen, Scotland, and colleagues.

This finding emerged from analysis of data from the 1958 British Birth Cohort Study, the researchers wrote online in Rheumatology.

The study enrolled 18,558 children born during one week in England, Scotland, and Wales in that year, following them prospectively through childhood.

Parents and teachers were asked to describe the children’s behavior on detailed questionnaires at ages seven, 11, and 16. The study subjects were asked for information on psychological distress at age 42 and chronic widespread pain at age 45.

Among other behaviors evaluated were destructiveness, excessive worry, nail-biting, truancy, and restlessness.

The children were stratified according to behavior scores as normal, having mild-to-moderate behavior problems, or having severe problems.

Behavioral assessments were available for 15,303, 14,761, and 12,537 participants at the three childhood time points, and pain assessments were done for 8,572 adults at age 45.

Chronic pain was reported more frequently by women than men (12.9% versus 11.7%).

The risk of chronic pain rose with each unit increase in score on behavior scales as reported by teachers:

* Seven years, RR 1.02 (95% CI 1.01 to 1.02)
* 11 years, RR 1.02 (95% CI 1.02 to 1.03)
* 16 years, RR 1.04 (95% CI 1.03 to 1.05)

The statistical association remained after adjustment for factors including gender, social class, and childhood symptoms.

Children whose behavioral scores were in the mild-to-moderate and severe ranges at age 16, as assessed by teachers, had an increased likelihood of reporting chronic pain in adulthood (RR 1.68, 95% CI 1.38 to 2.06 and RR 1.69, 95% CI 1.18 to 2.42, respectively).

And children with severe behavior disturbances at age 11 had nearly double the risk of chronic pain in adulthood (RR 1.95, 95% CI 1.47 to 2.59).

These elevated risks also remained after accounting for missing values by multiple imputation analysis.

Risk of chronic pain also rose with each unit increase in behavior score as assessed by parents:

* Seven years, RR 1.02 (95% CI 1.01 to 1.04)
* 11 years, RR 1.03 (95% CI 1.01 to 1.05)
* 16 years, RR 1.05 (95% CI 1.03 to 1.06)

The statistical association remained after adjustment for ages 11 and 16 years.

Compared with children with normal scores, those with severe disturbances at 16 as assessed by parents had an increased risk for chronic pain (RR 1.51, 95% CI 1.09 to 2.10).

Previous research has shown that chronic widespread pain in middle-age patients is related to adult behavioral and emotional factors, and also to adverse events in childhood such as separation from mothers.

This study has further demonstrated that maladaptive or maladjusted behavior in early life — particularly when persistent — is associated with chronic pain in middle age.

Strong points of the study include its prospective design, so the analysis is not biased by inaccurate recall of behavior, as can occur in case-control studies.

The study also had no confounding by age and calendar periods.

In addition, behavior was rated by both parents and teachers, and the teachers’ results were slightly stronger.

“In addition to meeting children regularly, teachers are in a unique position to assess each child because they are able to make a comparison with the child’s peers in situations involving varying formal tasks and social demands,” the researchers wrote.

However, potential biases must be taken into account, such as the attrition that occurred over the 45 years of the study and the potential confounding of adult psychological and emotional distress.

Further study will be needed to determine to what extent chronic pain is a manifestation of a poor health trajectory through life, or if there are specific biologic mechanisms involved.

The researchers hypothesized that long-term dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis may play a role.

As the main neuroendocrine stress response system, the HPA axis has been shown to influence both childhood behavior and chronic pain.

Molecular and genetic studies will be needed to clarify this potential association.

“The study of life-course influences on chronic pain is still in its infancy,” the researchers said.

Nancy Walsh is a MedPage Today contributing writer.

Originally published in MedPage Today. Visit MedPageToday.com for more pediatrics news.

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  • http://somebodyhealme.dianalee.net Diana Lee

    What is this drivel? I’m a daily reader and have never before questioned anyone’s integrity here the way I am at this moment.

    At a time when chronic pain patients struggle to have their needs adequately recognized and addressed by mainstream medicine this writer offers an insulting article based on ancient “research” that belittles an already marginalized population and creates a very real risk of readers seeing this as a reason to blame them for their conditions.

    Please tell me this is a late, extremely misguided April Fool’s joke.

  • Kathy

    “further study is needed”? Ya don’t say. You just lost all credibility with me. Bye!

  • Paynehertz

    In other words, that truck that hit you is not he cause of your chronic pain, it is your lifetime of behavioral problems. Usual quack medicine BS psychopathologizing people with physiological problems. Why are there no studies associating diabetes, asthma or cancer with alleged obedience issues in children? That’s right, it’s because those are recognized as “real” medical problems while chronic pain is merely the physical manifestation of underlying psychological issues.

    Of course, you know what the gist of this all is: because they are so disobedient by nature, this is why they abuse their pain meds.

    If only kids would become more obedient, as defined by their teachers, they would have less pain in life. Slavery is freedom.

    What a load of malarkey.

  • http://bit.ly/bfwpKZ Carol Levy

    Researchers hypothesize physical reason but your headline implies a causal connection between behavior as child and chronic pain in adulthood. That was not the finding or conclusion.
    The statistic for “Chronic pain was reported more frequently by women than men (12.9% versus 11.7%).” is also misleading given that statistically women suffer from more diseases with pain as the primary or sole complaint: such as lupus, ms, trigeminal neuralgia, osteoarthritis, RSD, etc then do men, so it is a foregone conclusion that more women then men would complain of having chronic pain.
    It is sad that this article, by basis of the headline, is being read and quoted by some to give credence to the widely disabused notion that chronic pain is the complaint of malingerers and hypochondriacs.
    Thank you.
    Carol Jay Levy, B.A., CH.t
    author A PAINED LIFE, a chronic pain journey
    founder, Women In Pain Awareness group
    member, cofounder with Linda Misek-Falkoff, PWPI, Persons With Pain International,
    accredited to the U.N. Convention on the Rights of Persons with Disabilities
    member U.N. NGO group, Persons With Disabilities

  • http://www.linkedin.com/in/achievementstrategies Marie

    This study leaves more questions than it answers. Do these children subsequently engage in behaviors that put them more at risk for damaging injuries? Does their lifestyle contribute to their pain? And the objectivity of the people assessing the children is extremely questionable. I think it was poorly designed.

    I suffer from chronic pain related to Multiple Sclerosis. I was an extraordinarily compliant and agreeable child, if I do say so myself, but others support that. My teachers, grandparents and older adults loved me. Mostly I was well behaved because I knew there were consequences for misbehavior and rewards for good behavior. I was not stupid. lol

    Does the study cover calculating children? lol

  • Anonymous

    There is nothing wrong with this article. It is how the information is used or misused that will determine it’s influence. Certainly, if someone has chronic pain they should be seek appropriate treatment. Those providing treatment should understand that mechanisms of chronic pain are complex and different from acute pain. And yes, psychosocial factors to influence the pain experience.

    What I would hope to come from this would be better recognition and management of childhood behavioral issues leading to a decrease in chronic pain in adults.

  • http://fortboise.org/blog/ fortboise

    There is something wrong with this article: the headline. “Disobedience” is both a potential cause, and a symptom of problems that are not simply an individuals, but rather occur in a social context. And it’s one of many behavioral dimensions the researchers asked about.

    Abstract the study far enough and you find that troubled children more often turn out to be troubled adults than less troubled children. Not to belittle the results of what sounds like a remarkable study, but as noted, the study is in its infancy, and the infant sometimes misbehaves.

  • http://www.askdrpickel.com Dr. Jason Pickel

    I totally agree with Payne Hertz that posted above. First of all, this was published in the journal DRUGS and PHARMA so you know this paper was selected for a specific reason.

    It is true that chronic pain can be caused by physical trauma (of course), but it can also be caused by chemical trauma or emotional trauma. Too many variables for this study to be truly accurate.

    “Children who are irritable or disobedient” – that is a total gray area. “Steal or bully” – no kids ever do that except those who are going to end up with chronic pain…..

    It will be interesting how this study ties into a new drug on the market…….

  • Jadedmd

    What an interesting take on things. It actually does make sense for some patients that I see coming thru my clinic. It is pretty subjective though. Maybe these misbehaving kids turned into drug seeking adults, +/- the actual pain?

  • http://paynehertz.blogspot.com Payne Hertz

    One of the problems with “research” into chronic pain is that there is perhaps no other area of medicine where the “science” is so heavily corrupted by political, financial and moralistic considerations.

    People with severe chronic pain have a tendency to be on disability receiving benefits. There is a political agenda of trying to show that cp is largely a psychological/behavioral problem to encourage policies that would force cp’ers off their benefits or back into the work force regardless of whether they are physically fit to work or not. There is also the War on Drugs and the way it impacts the perception of those who use drugs for pain as well as the availability of pain medications.

    There is a financial incentive to portray chronic pain as some sort of nebulous biopsychosocial problem so that as many medical rice bowls as possible can be filled from the bottomless money well that results from the willingness of all humans to do anything to escape the torture of physical pain.

    Then there are the moralistic considerations in our humanity and reality-denying puritanical culture, which perceives pain as either a judgement by God on the unworthy and sinful, or the inability to tolerate and overcome pain as a sign of a degenerate and morally corrupt character. No one tells you you’re a loser, wuss or “drug-seeker” if you ask for drugs to treat male pattern baldness, acne or a yeast infection. But somehow doing so for pain makes you the scum of the Earth. That so many doctors so obviously and proudly feel this way is a great tragedy and sad reflection on their profession.

    Taken together, these factors can and do influence both research into cp and particularly the way cp’ers are treated by the medical profession, and consequently it is probably best to take most such studies with a high degree of skepticism.

  • Jadedmd

    Some people coming through the office only want opiates, they do not want any other modality of treatment. I do not agree with giving a person an addictive, dangerous drug just because it’s the easiest way to get a demanding unpleasant patient out of my office. Some people live with chronic pain and I have to convince them to take an opiate for breakthrough. Which they still won’t do. They are afraid of getting addicted. I’m more afraid of them getting constipated or falling and breaking a hip, really.

    Drug misuse has become such a problem. physicians have a responsibility to be responsible with prescribing them (as with anything we do)

    • http://womeninpainawareness.ning.com/ Carol Levy

      Most pain patients are not drug seekers, We neither enjoy taking narcotics nor do we enjoy the feelings that accompany them; dry mouth, cloudiness, forgetting words, constipation, the possibility of physical dependence (not addiction, as most patients with CP do not get addicted although they may become physically dependent), among other awful sensations. We want to stop or reduce the pain.
      There is often a trade-off that we must accept then and that is the trade off of the awful effects of the narcotic vs. reduction of pain.
      It is bad enough that as a result of the DEA using us as an excuse to say thay are working on the “War on drugs” many of us have to sign contracts that treat us as guilty of a crime rather than ill or disabled with CP, by requiring consent to random urine and blood tests, among other criteria to get our doctor authorized prescriptions. Doctors such as yourself seem to look at us through nothing but a jaded eye. If you are a pain specialist you might want to consider another specialty.
      Thank you.
      Carol Jay Levy, B.A., CH.t
      author A PAINED LIFE, a chronic pain journey
      founder, Women In Pain Awareness group
      member, cofounder with Linda Misek-Falkoff, PWPI, Persons With Pain International,
      accredited to the U.N. Convention on the Rights of Persons with Disabilities
      member U.N. NGO group, Persons With Disabilities

      • Anonymous

        I’m sorry, you have trigeminal neuralgia. But I would not necessarily prescribe opiates for this problem. If you really wanted them, I would refer you to a pain specialist. However, the pain specialists in this area prefer the primary physician to prescribe the medications, as they mainly do procedures, where more of the money is. So I would not be offended if you found another primary physician, as you would not trust my judgment anyway. Thank you.

  • http://womeninpainawareness.ning.com/ Carol Levy

    Not sure who you are but you seem to know me, or at least that I have TN. However, I do not take opiates for that. (Just so we have our facts straight). (Nor have I now or ever “wanted” them.),
    I only see a pain management specialist. I would not expect a GP or FP to prescribe narcotics on any ongoing basis or to deal with my, or truly any, chronic pain disorder(s). Pain management specialists are trained to deal with cp patients, family/general practicioners ae not.
    Thank you.

  • http://paynehertz.blogspot.com Payne Hertz

    Some people coming through the office only want opiates, they do not want any other modality of treatment.

    So what? Some diabetics just want to take insulin, and not go on a diet or watch their carbs. Do you deny them treatment because of it? Some asthmatics just want asthma meds, rather than go through respiratory therapy. Is this grounds for denying them treatment?

    Most of those “other modalities” either don’t work or are not particularly effective, or take months and thousands of dollars before you see meager results. Why is it a crime to want immediate relief from pain? Is there some virtue to torturing people or demanding they be willing to undergo torture?

    I do not agree with giving a person an addictive, dangerous drug just because it’s the easiest way to get a demanding unpleasant patient out of my office. Some people live with chronic pain and I have to convince them to take an opiate for breakthrough. Which they still won’t do. They are afraid of getting addicted. I’m more afraid of them getting constipated or falling and breaking a hip, really.

    Okay, so there are two classes of pain patients:

    1. The unworthy, who ask for pain medications, which are a dangerous and addictive drug.
    2. The worthy, who don’t ask for, refuse or are afraid of becoming addicted to pain medications, which are so benign you are more worried about them getting constipated or breaking a hip.

    That makes as much sense as most everything else doctors say about pain patients, which is to say, none at all. Of course, there are other factors by which doctors judge who is worthy and unworthy of relief from torture, such factors often being different with each doctor, but never revealed to the patient.

    In our culture, it is a crime to want relief from pain, despite the fact that the avoidance of pain is one of the most fundamental drivers of human behavior. Don’t believe me? Try holding your hand over a hot flame and watch how your body instinctively reacts. Avoidance of pain is a purely natural, relexive instinct, yet for far too many in the medical profession, to want relief from pain is a sign of moral degeneracy rather than a normal human response.

    This mindset is twisted, puritanical and depraved.

    Drug misuse has become such a problem. physicians have a responsibility to be responsible with prescribing them (as with anything we do)

    That’s always the fallback excuse for abusing, exploiting and denying treatment to pain patients: there be drugs seekers out there, and we have a responsibility. Where is your responsibility to treat pain and relieve suffering? That’s right, it takes a back seat to your “responsibility” to ensure that none of the “unworthy” ever get a free fix, even if it means 100 chronic pain patients have to suffer.

  • http://womeninpainawareness.ning.com/ Carol Levy

    “It’s amazing how some people in constant 10/10 pain are able to argue with so much vigor to get their narcs. I can just see them jumping around the room, so hopping mad.”
    i don’t see this post but was the mail notification.
    I am sorry but any doc who has this attitude needs to find another specialty. I am reading far too much animus here against those in chronic pain.
    Complaining about these patients who ‘demand’ narcotics 1) is blaming them for their pain and the fact that meds are not helping and they may need more or different and
    2) is like the news reporting on a 30 car pile up. They do so because that is the uncommon, not the common.
    The ‘common’ pain patient does not ‘demand’ narcotics. They want relief. Period.
    Thank you.
    Carol Jay Levy, B.A., CH.t
    author A PAINED LIFE, a chronic pain journey
    founder, Women In Pain Awareness group
    member, cofounder with Linda Misek-Falkoff, PWPI, Persons With Pain International,
    accredited to the U.N. Convention on the Rights of Persons with Disabilities
    member U.N. NGO group, Persons With Disabilities

  • http://www.instant-painrelief.com/category/Blog/ Girl Gone Healthy

    Interesting, I wasn’t aware that there was a causal link between childhood behavior and a late onset chronic pain condition. I guess, further research would prove to be more helpful, especially if it can help a lot of young kids escape a life of pain.

  • http://womeninpainawareness.ning.com/ carol

    Girl gone healthy this ‘study’ also gives a biological explanation. It is not causal by any stretch. Just another poorly done report to further demonize chronically pained patients.

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