Pediatric Pain and ADHD
Chronic pain and ADHD are both conditions that are quite common in childhood and adolescence.
It may seem like everyone’s children are getting diagnosed, but these concerns can still seem mysterious.
Both have received a lot of attention in the media, but what do we know about them scientifically? Is there a connection between the two?
A group of researchers out of Oregon decided to investigate the connection between chronic pain and ADHD in childhood by reviewing all of the up to date research on the overlap between the two conditions. They published their results and conclusions about the conditions in the prestigious academic journal Children in 2023 (Battinson, Brown, and Holley, 2023).
First, what are pediatric chronic pain and ADHD?
Pediatric chronic pain is often defined as pain lasting 3 or more months in a young person. Our best prevalence estimate is 23% of children and teens are affected by pain of this duration, occurring at least once per week. For many, the etiology, or the reason why the pain starts, is unknown. The actual diagnosis and location of pain in the body can vary, with some of the most common conditions being headache or migraine, abdominal pain, or widespread or focal musculoskeletal pain (e.g. CRPS, AMPS). Researchers have identified some risk factors, but they still don’t fully understand why or how they contribute to the development of chronic pain. Many, but not all, young people with untreated chronic pain have pain persisting into adulthood, and this can be associated with negative outcomes.
ADHD, or Attention Deficit Hyperactivity Disorder, is considered a neurodevelopmental disorder. It is estimated to affect 3-4% of children and adolescents. The etiology is complex and not well understood. It is commonly understood as a disorder of executive functions, with some individuals exhibiting more symptoms of inattention, others of more hyperactivity, and some a mix of both. Without thoughtful care and management, ADHD can also be associated with negative outcomes in adulthood.
Should there be an overlap?
You may have noticed a few commonalities between pediatric chronic pain and ADHD. Both have complex etiology and both can persist into adulthood. Many have noticed that sensory processing seems to be a common factor. Chronic pain is often associated with psychiatric disorders with related mechanisms and risk factors, but relatively little research has been done on the connection between ADHD and pediatric chronic pain specifically.
Therefore, the researchers in Oregon decided to look into this more. They reviewed research up until 2022, looking at studies of children with ADHD that reported on any existence of chronic pain as well, and any studies of pediatric chronic pain that included reports of any existence of ADHD in their samples. They included studies of children and adolescents ages 3 to 25 years. They decided not to look at studies of headache and migraine, or pain due to known diseases; rather, they focused on other types of primary pain.
What did the researchers find?
They found 11 total studies published between 1993 and 2021.
8 studies reported on the prevalence of ADHD in children and teens with chronic pain. Across these studies, the average prevalence of ADHD in pediatric chronic pain was 15-25% - that’s much higher than the population average! For example, in one study, they found that among children with developmental coordination disorder, 89% of those who also had EDS (Ehler Danlos Syndrome, a painful disorder of hyper mobility) also had ADHD, whereas only 36% of those with only developmental coordination disorder also had ADHD.
Only 2 studies of children with ADHD also reported any prevalence of pain. One study found that 66% of adolescents referred for ADHD had at least weekly pain lasting 3 months. Again, this is much higher than the rest of the population! They also found another study of adult women, which found that those who were diagnosed with ADHD as children had a much higher likelihood of having chronic pain as a result.
Why might there be a connection between ADHD and chronic pain in childhood?
The authors hypothesized 3 mechanisms:
The role of attention. Pain is known to affect areas of the brain associated with cognition and attention, and activation of these areas affects the experience of pain. Persistent pain may affect individuals’ cognitive abilities including perceptive and interoceptive states, and alter emotional regulation.
Motor regulation. ADHD can lead to problems with motor regulation, which can make children and teens more at risk for injuries, leading to pain.
Inflammation. New research is investigating the role of neuroinflammation in the pathology of ADHD and chronic pain, specifically its role in central sensitization, cytokines, and the dopamine system.
Conclusions:
Before we jump to any conclusions, it’s important to realize the limits of all of this research. First, this is a drop in the bucket compared to what we don’t know yet! The results were quite variable, and there as a lack of prospective, longitudinal, and controlled research.
Also, these studies all used a variety of measuring and diagnosing ADHD and chronic pain. When it comes to your individual child, you should prioritize a careful, thorough, and sensitive evaluation to best understand their unique profile and needs. Whether you’re looking for treatment for pediatric chronic pain or to learn whether your child may qualify for a diagnosis of ADHD, click here to get started with a free consultation.
What can you do today?
Talk to your pediatrician, specialist, or health psychologist about the impact of pain and executive functioning in your child’s life.
If you suspect one concern or either, advocate for screening and evaluation for your child in medical, mental health, and school settings.
Recognize the important role of both medical management and psychological/behavioral treatment to set your child up for well-rounded success in life. Psychological treatment is considered front-line in the treatment of pediatric chronic pain, and the AAP has guidelines about incorporating behavioral treatment into management of ADHD in children.
Remember that no matter what, your child is not a statistic. If they are experiencing any concerns like ADHD or chronic pain, they are certainly not alone, and research is coming a long way to informing clinicians about how to help care for both in the short and long-term. But your child is unique, and better understanding and championing their individual needs is the best you can do as a parent. You are also not alone, and help is just a click away.