Written by: Chis Soria

Photo by Emma Bauso

When most people think about pain, they think of pain as something that’s “natural.” We think of pain as something that happens exclusively inside our bodies. Although pain is a biological mechanism, produced internally by our brains, it’s not outside of influence from the outside world. How you get along with members of your family, how well you communicate with your parents, their parenting style, and your perceived attachment to them can all affect your experiences with pain. When it comes to understanding chronic pain, families matter.

Chronic pain affects families of all socioeconomic backgrounds and races. An estimated 50 million American adults — over 20% — suffer from some kind of chronic pain. Over 28 million — about 56% of these — are women. Further, people from lower and middle-income backgrounds, and lower levels of education, are more likely to suffer from chronic pain. Women are also more likely to suffer from chronic pain for a longer period of time and experience pain more intensely than men. Therefore, parents who suffer from chronic pain are most likely to be less educated mothers from less privileged economic backgrounds.

Children who suffer from chronic pain are also diverse. Approximately 11.2 million — or about 15% — of kids in the United States suffer from chronic pain. Kids from lower socioeconomic backgrounds were also more likely to suffer from chronic pain, especially if the mother is from a low socioeconomic background and there is a history of chronic pain in the family. Girls, regardless of age, but especially those between the ages of 12 and 14, are more likely to report having chronic pain than boys. Girls are also likely to experience chronic pain more viscerally. Therefore, children who suffer from chronic pain are most likely to be younger girls from low socioeconomic backgrounds who have mothers, and family history, of chronic pain.

In other words, although sons and fathers are also affected, mothers who suffer from chronic pain are more likely to have daughters that suffer from chronic pain.

But why does family history impact children’s experience of chronic pain? Why is it that parents of chronic pain are likely to have children who suffer from it as well? Why do girls, from low socioeconomic backgrounds, suffer from chronic pain most often when their mothers do? The answers to these questions remain unclear, but there‘s evidence to suggest that it’s not all just genes.

Children who suffer from chronic pain are more likely to have parents who suffer from chronic pain. This is because chronic pain is genetically inherited to some degree. Yet, our situations, relationships, attitudes, and families can all impact our experiences with pain.

Our experiences with our families, for example, can have a profound effect on our children’s psychological wellbeing and experiences with chronic pain. Children that suffer from chronic pain are more likely to come from families that are less cohesive, less affectionate, lack functional communication, and are generally more conflictive. Researchers have theorized that this is because of bi-directional feedback from family members to children. In other words, families can reinforce, or exacerbate, a child’s emotional state which in turn helps influence chronic pain.

Parenting styles can also impact children’s chronic pain. Kids with chronic abdominal pain are nearly 5 times as likely to have mothers with a history of depressive disorders compared to healthy kids. Further, mothers of adolescents who suffer from chronic pain are more likely to endorse their child’s anxiety and stress — creating a positive incentive for children to experience negative emotions that contribute to chronic pain. And, mothers who catastrophize their children’s pain contribute to their children feeling that pain more intensely. In other words, there is some degree of chronic illness behaviors that appear to be learned from parents.

There is also evidence that a parent’s attachment style, which has an impact on their children’s attachment style, can have an impact on children’s ability to manage chronic pain. Every human being, but especially children, have a deep and fundamental need to maintain proximity and attachment to nurturing attention from others. If the individual feels “attached” to a figure (loved, secure), he/she is better prepared to confront hardship. How can this influence chronic pain?

Children who receive their parent’s attachment only when they’re experiencing a health issue may subconsciously learn to believe that feeling sick will earn them love. As a result, these children may learn to amplify and elongate feelings of illness. Because pain is, in part, an emotional experience, children who have secure attachment are better at managing their pain, according to researchers. Research has also shown that children who have parents who are more controlling with their attachment style — giving their children positive attention only when they behave in the desired way — are more likely to experience pain more intensely. Even into adulthood, attachment issues continue to impact our experiences with pain.

Interestingly, there appear to be differences in the ways girls react to the mother’s attachment in comparison to boys. Researchers out the David Gefen School of Medicine at UCLA found that girls of mothers who suffer from chronic pain are more likely to suffer from chronic pain themselves — more than boys were. They also found that girls who were overly attached, or “enmeshed,” with their mothers were even more likely to suffer from chronic pain when the mother also suffered from it. They concluded that “Boys and girls appear to have developmentally incongruous levels of autonomy and conformity to maternal expectations.” In essence, girls are more likely to suffer from chronic pain when their mothers do, and the type of relationship they have with their mother appears to be having an impact.

Our families, especially when we are children, are immensely impactful on our emotional and psychological wellbeing. Our parents, and their attachment styles, have deep and long-lasting effects on us which impact our ability to respond to pain.

Could this be part of the explanation for why daughters of mothers with chronic pain are more likely to suffer from chronic pain themselves? Could it be that daughters who have mothers who are more controlling and who depend on their children for their own attachment, are learning the behaviors associated with chronic pain? Perhaps daughters are learning, to some extent, through positive and negative feedback loops from their mothers, the behaviors that trigger their brains to produce pain.

More research will be needed before we can answer any of these questions with certainty. But, what we do know is that pain is not simply learned behavior. It’s a biological mechanism. Our brains produce pain internally and the outside world only contributes to our experiences with it. As usual, the dichotomy between biology and the environment when trying to explain human behavior is false; the truth is somewhere in the middle.

Claudius Galen, from Prints Collection, Reynolds Historical Library, the University of Alabama at Birmingham

In 160 AD, a Greek doctor by the name of Claudius Galen, following in the footsteps of Hippocrates from around 400 BC, set about classifying different illnesses in terms of an imbalance of four essential fluids in the body; Cancer was one of them. Cancer, according to Galen, was the result of excess “black bile.” Generations of doctors henceforth attempted to treat cancer by restoring the body’s “proper” balance of fluids and ridding the patient of “trapped” black bile. It wasn’t until over 1000 years later, in 1538, that a nineteen-year-old student from Germany named Andreas Vesalius decided to actually test the theory of Galen’s bile. He found, after meticulously and systematically sketching out every blood vessel and nerve in the human body, that Galen’s bile was nowhere to be found.

Any cancer treatment, under the assumption that it was the result of an excess of black bile, would not be considered “efficient.”

But, what does all of this have to do with chronic pain? After all, cancer is a completely different condition with different implications and causes. Why bring it up?

Without a clear and precise understanding of pain, and the exact mechanisms of action behind chronic pain, we will not achieve efficient treatments. Just like doctors of the past failed to produce an efficient treatment of cancer because the true cause was unknown, so too today with chronic pain. We cannot begin to fully understand chronic pain without first gaining a deep understanding of pain itself.

Yet, pain is scantily understood.

We know that the feeling of pain is produced in the brain. Normally, pain occurs when the body experiences some sort of damage. Say, for example, you get a paper cut. Pain receptors in the finger send signals to the spinal cord which then get relayed to the brain, the brain then produces localized feelings of pain and sends signals back to the finger so that we know to react.

Pain serves to warn us when something is wrong. Touching fire, excessive cold, bleeding wounds — all of these send signals to our brain telling it to produce “pain.” Pain tells us what to avoid, when to rest, when to refuge, and when to get the treatment that keeps us healthy and alive. We also know, generally, which areas of the brain start working when we’re in pain.

But, pain is neurologically complex. Different people show different patterns of brain functions; some parts of people’s brains become active when in pain whereas in others they don’t. And, scientists have found that pain can be triggered in people without any actual damage to the body — solely by influencing the brain. Others have observed that pain can be influenced by a faulty brain stem — which can be seen as a sort of “gateway” that transmits pain signals between the body and brain.

In other words, pain can exist even when it shouldn’t; it can be dysfunctional. These are scenarios in which pain is not a symptom or indicative of another problem and is itself the problem.

Chronic pain — defined somewhat misleadingly as a pain that extends past 3 or 6 months — is one of these situations in which pain is not a symptom but a condition. It appears to be unique, and distinct, from the “normal” and “functional” process of pain. To attempt to treat sufferers of chronic pain using means by which we would treat “normal” pain is nearly analogous to trying to treat cancer patients for an imbalance of “black bile.” We just don’t know enough about what’s causing people to suffer from this type of life-altering pain. However, the more we learn about chronic pain, and pain in general, the more we realize that it’s not entirely produced by processes outside of our control.

For example, we know that pain can be influenced by thoughts, emotions, and expectations. We know that the anticipation of pain itself can cause pain. We also know that distracting someone from pain reduces their experience of pain and that the act of distracting someone produces pain-relieving hormones in their brains. And, researchers have discovered that “catastrophizing” pain can make it feel worse. Depression, stress, anxiety, feeling lonely, and even religiosity can impact our experiences with pain.

In other words, you’re not completely helpless to your experiences with chronic pain but it’s also not all “in your head.” The division between “environmental” and “biological” does not firmly exist when it comes to chronic pain. In reality, your experience with pain is the result of an interaction between your environment and biology. In order to find proper treatment, we’ll have to understand both the environmental and biological aspects of pain.

However, pain is difficult to understand because, unlike other physiological mechanisms — like the pathological cell division we’ve now learned is behind cancer — pain is a subjective experience. And, just like all other subjectivity, our thoughts and mindsets greatly impact our experience. Chronic pain is not simply an internal mechanism; It is influenced by psychological, emotional, and social factors. In other words, in order to more holistically understand our children’s experience with chronic pain, we must look understand the things that most influence their subjective wellbeing. That is, we must look at their families.

What can be learned here? There are a few things which researchers, and those seeking to treat children with chronic pain, can glean from these findings.

First, there is still much we need to learn about pain. There is “functional” pain that serves to warn us when something is wrong. This type of pain is a symptom of another issue, such as a broken leg or paper-cut. Chronic pain, on the other hand, doesn’t appear to be a symptom of anything but rather is the condition itself. It’s a condition that can’t be treated in the same way “normal” pain can, which disappears as soon as the underlying cause is addressed. Chronic pain treatment requires a unique approach and understanding relative to “functional” pain. It will require us to understand pain at the most fundamental level.

Second, our families and parents can impact our experiences with pain. Children who suffer from chronic pain are more likely to come from families that cause them stress and emotional distress. Parents who notice that their family is in a continuous state of conflict would do well to seek family counseling if they want to help improve their child’s experiences with chronic pain. And, the way our parents interact with us can contribute to how we learn to cope with pain. Parents should be careful in developing a healthy and “secure” attachment with their children.

Lastly, chronic pain treatments should be done at the level of the family. It’s not enough to try and provide the child with behavioral treatments. Parents need to be helped as well. Parents who teach their children to “catastrophize,” and to assume the worst about their pain, for example, are unknowingly making their child’s pain worse. And, by gathering information about parents and their pain history, we can learn to better help their children. The traditional approach of focusing purely on the individual needs to be reexamined when it comes to chronic pain.

Doctors who receive complaints from children suffering from chronic pain often say things like, “it’s all in your head.” That is not an adequate response. The proper response is to examine the child’s family context, understanding their home and school life, and seeking for a cause. The proper response is to take the child’s complaints seriously and make them feel validated about their experiences without making them feel hopeless.

If you’re a parent of a child with chronic pain, and you’ve noticed you may be guilty of some of the behaviors that make chronic pain worse for children, it does not mean that you are a bad person. However, you would do well in seeking to understand what you could to do help your kids better cope with their pain. Getting down on yourself for having potentially negatively affected your child’s chronic pain is not productive. Denying that you have any effect on their chronic pain is worse.