Positive childhood experiences and chronic pain among children and adolescents in the United States

Abstract

Positive childhood experiences (PCEs) are associated with better mental and physical health outcomes and moderate the negative effects of adverse childhood experiences (ACEs). However, knowledge of the associations between PCEs and childhood chronic pain is limited. We conducted cross-sectional analysis of the 2019–2020 National Survey of Children's Health (NSCH) to evaluate associations between PCEs and childhood chronic pain. Parents of 47,514 children ages 6-17 years old reported on their child’s exposure to seven PCEs and nine ACEs. Associations between PCEs and chronic pain were evaluated using weighted, multivariate logistic regression analyses adjusted for sociodemographic factors. We found that PCEs had dose-dependent associations with pediatric chronic pain; children exposed to higher numbers of PCEs (5-7 PCEs) had the lowest reported rate of chronic pain (7.1%), while children exposed to 2 or fewer PCEs had the highest rate of chronic pain (14.7%). Adjusted analysis confirmed that children experiencing 5-7 PCEs had significant lower odds of chronic pain relative to children experiencing 0-2 PCEs (adjusted odds ratio (aOR): 0.47, 95% confidence interval (CI): 0.39-0.61, p<0.0001). PCEs moderated associations between ACEs and chronic pain: among children reporting 2 or more ACEs, those reporting 5-7 PCEs were significantly less likely to report chronic pain as compared to children only reporting 0-2 PCEs (aOR: 0.64, 95%CI: 0.45-0.89, p=0.009). In conclusion, children with greater PCEs exposure had lower prevalence rates of chronic pain. Furthermore, PCEs was associated with reduced prevalence of chronic pain among children exposed to ACEs.

Perspective:

This article estimates associations between survey-measured positive childhood experiences and pediatric chronic pain among children in the United States. Promoting positive childhood experiences could improve pediatric pain outcomes.

Introduction

Pediatric chronic pain is increasingly recognized as a significant cause of morbidity in the United States. Epidemiological studies estimate that 15% to 25% of children and adolescents have pain-related conditions such as headache, abdominal pain, musculoskeletal pain, and other types of chronic pain²³. Pediatric chronic pain is associated with increased risk for poor physical and psychological functioning and significant health care expenditures^{18, 22, 26}. In addition, multidisciplinary pain treatment centers are unable to meet the clinical demands of children affected by chronic pain³³.

Better understanding of antecedent risk and resilience factors of chronic pediatric pain is important for developing public health prevention programs. Our recent research found that exposure to adverse childhood experiences (ACEs) increases the risk for childhood chronic pain¹⁷. ACEs include events that the child experiences or witnesses, including physical, sexual, or emotional abuse or neglect, and events that undermine a sense of safety and security¹. Before 18 years of age, approximately 45% of children in the United States experience ACEs, which can increase the risk of toxic stress activation, known to disrupt normal brain development and increase risk of physical (e.g., cardiovascular disease and obesity) and mental health disorders (e.g., substance abuse and depression) across the lifespan^{14, 15}. Furthermore, ACEs have a dose-dependent effect, whereby exposure to multiple ACEs further increases the risk for poor mental and physical health outcomes, including chronic pain in childhood^{17, 21}. Studies are needed to identify factors that moderate the adverse impact of ACEs on childhood chronic pain.

Exposure to positive childhood experiences (PCEs) may improve health and moderate the effects of ACEs⁴. PCEs reflect social-environmental, protective experiences before age 18 that increase a child’s sense of belonginess and connection, including access to safe, stable, and nurturing relationships and environments^{6, 12}. Examples of PCEs include being able to talk to family members about their feelings and enjoying participation in community activities⁴. PCEs are known to foster child resiliency, thereby reducing the overall impact of ACE exposure¹⁹. For example, previous studies have shown that PCEs demonstrate a dose-response relationship with mental and relational health, in that those exposed to ACEs with more overall PCEs showed decreased prevalence of depression and/or overall poor mental health relative to those with ACES and with fewer PCEs^{4, 34}. However, while we know there is a link between PCEs and overall improved mental health in those exposed to ACEs, we do not know whether PCEs reduce the risk of chronic pain. Furthermore, it is unknown whether PCEs moderate the known associations between ACEs and chronic pain.

The primary aim of this study was to determine whether exposure to PCEs is associated with lower prevalence rates of chronic pain in a nationally representative sample of children between 6 and 17 years of age in the USA. We hypothesized that exposure to PCEs would be associated with decreased likelihood of having chronic pain after controlling for sociodemographic characteristics. This is the first study, to our knowledge, that examines associations between PCEs and chronic pain in a national childhood sample. The secondary aim was to determine whether PCEs was associated with a reduction in the well-known risk of chronic pain among children exposed to ACEs by evaluating associations between PCEs and chronic pain stratified across different levels of ACEs exposure. We hypothesized that the presence of PCEs reduces associations between ACEs and chronic pain.

Methods

Population and Data

Data for this cross-sectional study originates from the completed 2019–2020 National Survey of Children's Health (NSCH) available at https://www.childhealthdata.org. NSCH is a national survey funded by the Health Resources and Services Administration's Maternal and Child Health Bureau and is fielded by the US Census Bureau. NSCH is designed to produce national level data on the physical and mental health of children 0-17 years of age in the United States. Therefore, the study population is representative of the US childhood population⁴⁴. Households in the United States were randomly selected and contacted by mail to identify those households with children 0-17 years of age. One child was randomly selected to be the subject of the survey. Parents were the primary survey respondents; however, results were weighted to reflect the population of children 0-17 years of age. The final sample for 2019-2020 contained 72,210 participants, however we excluded children 0-5 years of age (n=20,315) as only caregivers with children who were 6 or older were asked the PCE questions, as well as those with missing data on any of the variables of interest (n=4,381) for a final sample of 47,514 participants available for analysis. All participants provided consent. As NHIS data are publicly available and non-identifiable, the Institutional Review Board at Seattle Children’s Research Institute deemed this study exempt from review. We followed the Strengthening the Report of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional analyses.

Chronic Pain

Children were identified as having chronic pain if their parent or caregiver responded “yes” to the question: “During the past 12 months, has this child had frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain?” This measure of pediatric chronic pain has been used in several previous NSCH studies^{18, 43}.

Positive Childhood Experiences

To assess for the occurrence of PCEs exposures within the child’s lifetime, we chose seven questions addressing PCEs in NSCH as established in previously reported research publications^{10, 11, 35}. PCEs included (1) the child volunteering in the community; (2) child participating in after-school activities; (3) child having an adult mentor, other than their parent/caregiver; (4) child being a member of a resilient family; (5) child feels connected with their family; (6) child lives in a supportive neighborhood; and (7) child lives in a safe neighborhood. PCE survey questions, response options, and categorization of responses are detailed in Table 1.

Table 1.

Survey questions, response options, and coding of positive childhood experiences in the National Survey of Children’s Health.

Positive childhood experience	Survey questions	Response options	Categorization of responses
Child volunteers in the community	During the past twelve months did this child participate in any type of community service or volunteer work at school, place of worship, or in the community?	Yes No	If the answer was “yes,” the child was coded as having volunteered in their community
Child participates in after school activities	During the past twelve months, did this child participate in a sports team or did he or she take sports lessons after school or on weekends? Any clubs or organizations after school or on weekends? Any other organized activities or lessons, such as music, dance, language, or arts?	Yes No	If the answer to any of these 3 questions were “yes,” then the child was coded as having participated in an after-school activity.
Child has an adult mentor other than parent/caregiver	Other than you or other adults in your home, is there at least one adult in this child’s school, neighborhood, or community who knows this child well and who he or she can rely on for advice or guidance	Yes No	If the answer was “yes,” then the child was coded as having an adult mentor to go to for advice or guidance.
Child lives in a resilient family	When your family faces problems, how often are you likely to do each of the following? 1)talk together about what to do, 2) work together to solve our problems, 3) know we have strengths to draw on, and 4) stay hopeful even in difficult times.”	None of the time Some of the time Most of the time All the time	The child was coded as residing in a resilient family if their caregiver responded “all” or “most of the time” to all four items.
Child lives in a connected family	How well can you and this child share ideas or talk about things that really matter?”	Very well Somewhat well Not very well Not very well at all	Children were coded as living a connected family if they responded “very well” to this item.
Child lives in a supportive neighborhood	To what extent do you agree with these statements about your neighborhood or community… 1) people in this neighborhood help each other out, 2) we watch out for each other’s children in this neighborhood, and 3) when we encounter difficulties, we know where to go for help in our community.”	Definitely agree Somewhat agree Somewhat disagree Definitely disagree	If caregivers reported “definitely agree” to at least one of the items above and “somewhat agree” or “definitely agree” to the other two items, then the children were deemed as living in a supportive neighborhood.
Child lives in a safe neighborhood	To what extent do you agree with this statement about your neighborhood or community: the child is safe in our neighborhood.”	Definitely agree Somewhat agree Somewhat disagree Definitely disagree	If the caregiver definitely agreed with that statement, children were deemed as living in a safe neighborhood.

All PCEs were categorized as binary (yes/no). In addition, PCEs were summed to calculate a composite score reflecting the total number of PCEs each participant experienced. The summary score was then categorized into the groupings: 0-2PCEs, 3-4PCEs, and 5-7 PCEs to 1) to assure adequate statistical power to detect meaningful associations, and 2) simplify reporting of results by narrowing the number of comparison groups requiring reporting as documented in previous publications.^11-15 Higher PCE scores indicated more positive experiences during childhood.

Adverse Childhood Experiences

The NSCH identifies 9 ACEs, occurring during the child’s lifetime, that has been reported in several studies to date^{9, 17}.Five of these ACEs were adopted from the Behavioral Risk Factor Surveillance System ACE Module (Centers for Disease Control and Prevention), including (1) questions regarding divorce or separation of parents; (2) incarceration of parent; (3) witnessing of domestic violence by child; (4) child cohabitated with someone who is mentally ill and/or suicidal; (5) child cohabitated with someone with substance abuse problems. Additional survey questions included categories surrounding (6) child being treated or judged unfairly due to race/ethnicity; (7) child having experienced death of a parent; (8) child having been victim of or witnessed violence within their neighborhood; and (9) hardship suffered by child because of family with low income. These additional survey items were developed from expert panel input to capture potentially stressful life-course events and experiences. Some of the questions within the survey used a Likert Scale, for which responses categorized as “somewhat often” or “very often” were analyzed as a definitive positive (yes) response and “rarely” or “never” as a definitive negative (no) response. This meant that all ACEs were categorized as binary (yes/no).

The ACEs were summed to calculate a composite score reflecting the total number of ACEs each participant experienced. We created ACE cumulative score groupings of 0 ACEs, 1 ACE, and 2+ ACEs to 1) assure adequate statistical power to detect meaningful associations, and 2) simplify reporting of results by narrowing the number of comparison groups requiring reporting, consistent with previous publications.^11,19 We previously reported on associations between ACEs and chronic pain using data from NSCH.⁹

Covariates

NSCH collected on the following socio-demographic variables: age (6-17 years; responses from parents of children outside of this range were excluded), sex (biologically male versus female), race/ethnicity (reported by parents/caregivers and categorized by NSCH as: White, non-Hispanic; Black, non- Hispanic; Hispanic, and Other, non-Hispanic), household income based on federal poverty status (0-99% Federal Poverty Level (FPL), 100%-199% FPL, 200%-399% FPL, 400% or greater FPL), insurance type (private, public only, uninsured), family structure (two parent, single parent household, or other), primary household language (English versus non-English), parent education (less than high school, high school and some college/associates degree, college degree or higher), and census geographical region (Northeast, Midwest, South, West).

Data Analysis Plan

Data were analyzed using Stata V14.2. Hypothesis testing was 2-sided and p-values set to < 0.05. We adjusted for the complex survey design of NSCH and therefore all estimates presented here are nationally representative of the non-institutionalized childhood population in the United States. We also conducted descriptive analyses to estimate overall rates of PCEs in our sample.

To address our primary aim, we estimated prevalence rates of chronic pain stratified by PCE cumulative score grouping (0-2 PCEs, 3-4PCEs, and 5-7PCEs). Differences in unadjusted prevalence rates of chronic pain based on PCEs score groupings were determined using design-adjusted Pearson chi2 analyses. We then conducted multivariable logistic regression analysis to estimated associations between PCEs and chronic pain adjusting for covariates, including age, biological sex, race & ethnicity, family income, insurance, family structure, primary household language, parent education, and census geographical region. These covariates were included based on existing epidemiological research finding strong associations with both chronic pain and positive/adverse childhood experiences^{9, 23, 25}. We did not included mediators potentially residing in the causal pathways between PCEs and chronic pain to limit overadjustment bias²⁵.

To address our secondary aim, we first conducted multivariate logistic regression analysis, using interaction terms, to formally test whether PCEs moderated the associations between ACEs and chronic pain. We found significant interaction between PCEs and ACEs in multivariate models. These interactions are presented as a contour plot. The nature of this interaction was then further explored by stratifying our sample according to cumulative ACEs score (0 ACEs, 1 ACE, 2+ ACEs). After stratification, we estimated associations between PCEs and chronic pain within each ACEs category using multivariable logistic regression, controlling for covariates, including age, biological sex, race & ethnicity, household income, insurance, family structure, primary household language, parent education, and census region. These analyses are consistent with methods from previous studies examining whether PCEs reduces risk for chronic health conditions associated with ACEs^{4, 27}.

Results

Sample characteristics

Our sample included 47,514 child participants 6-17 years of age. Within this study population, responses were representative of the United States overall population: 50.7% were male (49.3% were female), 51.2% were White, non-Hispanic, 86.3% were from a Primarily English-speaking households (Table 2). Among all participants, 10.1% had experienced only 0-2 PCEs, while about a third were exposed to 3-4 PCEs, and 59.4% of children had experienced 5 to 7 of the PCEs surveyed. PCEs prevalence, in decreasing order, were (1) having an adult mentor (88%), (2) family resilience (83.2%), (3) after-school activities participation (78.1%), (4) safe neighborhood (65%), (5) connected family (63.1%), (6) supportive neighborhood (55.6%), and (7) the child having volunteered in the community (40.6%). Chronic pain was reported in 9.1% of participants.

Table 2.

Sociodemographic characteristics of the total sample.

Variable	Number in sample	%	95% CI
PCE Category
0-2 PCEs	3498	10.1	(9.4-10.9)
3-4 PCEs	12883	30.4	(29.5-31.4)
5-7 PCEs	31133	59.4	(58.4-60.5)
Chronic pain
Yes	43172	9.1	(8.5-9.8)
No	4342	90.9	(90.2-91.5)
Age category
6-11 years	20339	49.4	(48.3-50.4)
12-17 years	27175	50.6	(49.6-51.7)
Biological sex of child
Male	24569	50.7	(49.7-51.7)
Female	22945	49.3	(48.3-50.3)
Race and ethnicity
White, non-Hispanic	32466	51.2	(50.2-52.3)
Black, non-Hispanic	3072	13	(12.3-13.7)
Hispanic	5906	25.1	(24.0-26.3)
Other/Multi-racial, non-Hispanic	6070	10.7	(10.2-11.3)
Household income based on federal poverty level status
0-99% FPL	5306	16.8	(15.9-17.7)
100%-199% FPL	7755	21.7	(20.8-22.7)
200%-399% FPL	14787	29.8	(28.9-30.8)
400% FPL or greater	19666	31.7	(30.8-32.6)
Child insurance status
Private	35787	64.7	(63.6-65.8)
Public only	9436	28.3	(27.3-29.3)
Uninsured	2291	7	(6.4-7.6)
Family structure
Two parent household	35678	72.2	(71.2-73.1)
Single parent household	9966	22.7	(21.8-23.5)
Other	1870	5.2	(4.7-5.7)
Primary Household Language
English	44396	86.3	(85.3-87.3)
Non-English	2937	13.7	(12.7-14.7)
Parent education
Less than high school	1189	9.7	(8.7-10.7)
High School and some college/associates degree	17308	40.4	(39.4-41.4)
College degree or higher	29017	50	(48.9-51.0)
Census region
Northeast	7999	15.4	(14.8-16.1)
Midwest	11070	21.3	(20.7-22.0)
South	14862	38.5	(37.5-39.5)
West	13583	24.8	(23.7-25.8)

Positive Childhood Experiences and Chronic Pain

Children reporting the lowest number of PCEs (0-2) had 2x higher prevalence rates of chronic pain as compared to children reporting the highest number of PCEs (5-7). Among those children who had experienced only 0-2 PCEs 14.7% had chronic pain, while rates of chronic pain decreased to 11.3% among children exposed to 3-4 PCEs, and further decreased to 7.1% among children who had experienced all or almost all (5-7) PCEs (Table 3).

Table 3.

Prevalence and adjusted odds ratio of chronic pain by positive childhood experiences (PCEs).

Number of PCEs	Prevalence of chronic pain			Adjusted odds ratio for reporting chronic pain
	Weighted %	95%CI	p-value	aOR*	95%CI	p-value
0-2PCEs	14.7	(12.5-17.2)	<0.0001	ref
3-4PCEs	11.3	(10.0-12.8)		0.77	(0.61-0.99)	0.05
5-7PCEs	7.1	(6.4-7.7)		0.47	(0.39-0.61)	<0.0001

^*Odds ratios adjusted for child age- child biological sex- child race & ethnicity- family income level- child insurance status- family structure- primary household language- parent education- geographical region

Furthermore, multivariable analysis confirmed that the odds of chronic pain were significantly lower among those experiencing 5-7 PCEs (aOR: 0.47, 95% CI: 0.39-0.61, p<0.0001) and 3-4 PCEs (adjusted odds ratio (aOR): 0.77, 95%CI: 0.61-0.99, p = 0.05) as compared to those experiencing 0-2 PCEs. Similar variations in chronic pain prevalence were observed when each of the 7 PCEs were evaluated separately (Figure 1). Except for community volunteering, each individual measured PCE was associated with a lower prevalence rate of chronic pain (as compared to individuals not experiencing that specific PCE).

Figure 1.

Prevalence and adjusted odds ratio of chronic pain by each individual PCE category.

Positive Childhood Experiences and Chronic Pain: Associations across Adverse Childhood Experiences Levels

We plotted the probability of chronic pain associated with PCEs for different levels of ACEs as estimated by multivariate logistic regression analyses in our contour plot (Figure 2). Children who experienced 2 or more ACES and who also experienced 2 or fewer PCEs, had a predicted probability of chronic pain ranging between 20-25% (Figure 2 and Table 4). Conversely, children who were not exposed to any ACEs, and were exposed to 5-7PCEs had the lowest predicted probability for chronic pain (0-5%).

Figure 2.

Contour plot demonstrating interaction effect of adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) on childhood chronic pain probability. Estimates were derived from multivariable logistic regression analyses as specified in text. Probability of chronic pain is highest among children with 2+ACEs and 0-2 PCEs, while probability of chronic pain is lowest among children with no ACEs and 5-7 PCEs.

Table 4.

Prevalence of chronic pain by PCE scores for each of 3 adverse childhood experiences (ACEs) exposure levels.

ACEs category	Weighted %	95% CI		aOR*	95% CI	p-value
0 ACEs reported
0-2PCEs	9.9	(6.5-14.7)	0.0001	ref
3-4PCEs	7.7	(6.2-9.8)		0.77	(0.46-1.28)	0.309
5-7PCEs	4.8	(4.3-5.5)		0.44	(0.26-0.73)	0.001
1 ACE reported
0-2PCEs	10.4	(7.4-14.3)	0.0033	Ref
3-4PCEs	12.4	(10.0-15.3)		1.28	(0.74-1.95)	0.438
5-7PCEs	7.9	(6.6-9.4)		0.68	(0.44-1.06)	0.090
2 or more ACEs reported
0-2PCEs	22.2	(18.2-26.7)	0.006	ref
3-4PCEs	15.7	(13.0-18.9)		0.67	(0.47-0.95)	0.026
5-7PCFs	14.3	(11.9-17.0)		0.64	(0.45-0.89)	0.009

^*Odds ratios adjusted for child age- child biological sex- child race & ethnicity- family income level- child insurance status- family structure- primary household language- parent education- geographical region

Discussion

Chronic pain is a significant public health concern affecting children in the United States. Previous work found associations between ACEs and chronic childhood pain. However, this is the first study, to our knowledge, examining associations between PCEs and chronic pain using a large national sample. Our study had 2 main findings: greater exposure to PCEs was associated with a lower prevalence of chronic pain, and PCEs was associated with reduced risk of chronic pain among children exposed to ACEs. Indeed, PCEs was associated with lower chronic pain across all levels of ACEs exposure.

Our findings that the vast majority of children were exposed to 3 or more PCEs, while only 10.1% of children were exposed to 0-2 PCEs, are similar to those reported by an adult population from Wisconsin, USA but, are higher than those found in a Chinese adolescent population of whom 72.8% had 3 or more PCEs^{4, 34}. However, direct comparison with previous reports is challenging because types of PCEs surveyed were not consistent between studies. Indeed, the National Survey of Children’s Health is one of the few population-based study that measures PCEs. Extending these efforts to other population health surveys will greatly advance our understanding on the protective effects of positive childhood experiences.

To our knowledge, no study has evaluated the impact of PCEs on pediatric chronic pain in a large national sample. Researchers have evaluated the role of PCEs on other childhood mental and physical health conditions, finding that PCEs are associated with lower rates of childhood depression, anxiety, and obesity^{10, 13, 27, 34}. However, research studies on the associations between PCEs and other childhood conditions are very limited.

Nelson et al. outlined a framework conceptualizing biological, psychological, and social risk factors underlying associations between ACEs and chronic pain³². Biologically, ACEs are thought to increase the risk for chronic pain due to the increased levels of inflammation and epigenetic and hormonal changes. The psychological component stems from cognitive processes and psychological comorbidities that could develop because of ACEs, and the social aspect involves family and peer/social environment. No such framework yet exists linking PCEs and chronic pain, however existing literature point to potential biological, psychological, and social mechanisms also underlying PCEs and chronic pain. We hypothesize that some of these mechanisms may explain links between PCEs and reduced risk for chronic pain. For example, biological studies show that early life exposure to both positive and negative social experiences (along with other environmental events such as toxic stress, hormones, and drugs) may significantly impact maturation of the prefrontal cerebral cortex which is intimately involved in social behavior²⁴. There is also evidence that environmental enrichment can protect against negative behaviors (such as vulnerability to drug addiction) and reverse stress-induced behavioral disorders occurring during adolescence in preclinical models^{29, 39}. Hypothesized psychological mechanisms include that PCEs during adolescence are predictive of better emotional self-regulation, self-control, resilience, and lower stress, leading to healthy adjustment and, which in turn may lead to lower risk of chronic pain^{28, 30, 36}.

Additionally, we found that PCEs moderated the negative associations of ACEs and chronic pain. Specifically, greater number of PCEs was associated with lower prevalence of chronic pain for each level of ACEs exposure. Moreover, children with a high number of positive childhood experiences and no adverse childhood experiences had the lowest rates of chronic pain (4.8%). Likewise, children with a high number of adverse childhood experiences and few or no positive experiences had the highest rates of chronic pain (22.2%). Previous studies have demonstrated similar findings, with PCEs moderating the negative impact of ACEs on childhood depression, anxiety, obesity, and school functioning^{27, 34, 35}. Indeed, researchers have suggested that PCEs play an independent, and perhaps an even greater role in mental and emotional well-being relative to ACEs^{4, 8, 20}. Developmental psychopathology theory can be applied to enhance understanding of the interaction of PCEs and ACEs – or normal and abnormal childhood developmental processes - and their link to future health^{2, 41}. According to this theory, early positive experiences and secure social relationships with family, peers, and teachers or mentors provide the safety and security for children to acquire social-emotional skills (e.g., resilience, emotional regulation, stress management) and act as protective factors for positive mental and physical health functioning even in the presence of adversity.

This study has several limitations that should be acknowledged. Due to the cross-sectional design, it is not possible to confer a definitive cause and effect relationship between PCEs and chronic pain development. Here we hypothesize that positive childhood experiences within childhood and adolescence confer a protective factor against adverse childhood experiences and the development of chronic pain. However, having chronic pain may also increases a child’s vulnerability to heightened stress responses towards adversities and/or less able to participate in positive childhood experiences³¹.Secondly, PCEs and ACEs were retrospectively reported by parents and caregivers, which could lead to the potential for reporting bias and parents being less likely to report sensitive or negative information, and more likely to report positive information. Thirdly, the National Survey of Children’s Health (NSCH) only assesses variables such as family resilience, family connection, and chronic pain on a limited basis. It would be ideal if these variables were asked about within multiple different dimensions and constructs, given the broad definitions of PCEs and chronic pain within the healthcare communities. However, balancing the amount of detail on specific variables, while surveying a wide variety of unobservable data is a known limitation of national surveys. Relatedly, we want to fully acknowledge that our coding of PCEs as binary (yes/no) variables in this study may not fully capture levels of positive events. We decided on this coding scheme to increase reproducibility and ease comparisons between existing NSCH studies examining associations between PCEs and other health conditions, which all use the same coding scheme. Furthermore, NSCH uses a similar coding scheme to communicate findings on its website.

While there are some weaknesses, this study does have significant strengths including the use of a nationally representative database, a large sample of children with chronic pain, inclusion of comparison groups, and a measurement of multiple types of adverse and positive childhood events, all of which allow for greater reciprocity of results across the national pediatric population.

Our findings are useful in evolving nationwide efforts to decrease the burden of chronic pain in childhood, highlighting the need for increased public health attention in the assessment and promotion of positive childhood experiences and child resilience resources more broadly. A paradigm shift has begun in the field of pediatric pain, moving away from a sole focus on “risk” to integrate resilience resources and mechanisms in chronic pain research and treatment^{7, 16, 40}. A resilience-based model of pediatric pain has been proposed to highlight both individual (e.g., emotional, cognitive) and social-environmental resilience processes that may promote adaptive outcomes⁷. However, research investigating the unique role of resilience the development of childhood chronic pain is virtually non-existent. Extending the limited research in this area, our findings highlight the importance of shifting focus toward the measurement of social-environmental resilience in children - including PCEs - that contribute to adaptation to pain. Joint assessment of ACEs and PCEs may improve efforts to assess needs, target interventions, and address adversities through leveraging child and family strengths. While the American Academy of Pediatrics recommend screening for ACEs at pediatrics visits, there are as yet no recommendations guiding screening for PCEs¹⁵. Widespread screening of PCEs, similar to existing initiatives to conduct ACEs screening (e.g., California’s ACEs equity act) may be beneficial for identifying children at risk for current or future chronic pain³¹. Unfortunately, there are few available instruments that have been developed to assess positive childhood experiences. One exception is the newly developed, 10-item measure called the Benevolent Childhood Experiences Scale; however, this screening tool requires further testing and validation in chronic pain and other pediatric populations³⁰.

Promoting positive childhood experiences at the national, state, and community level has the untapped potential to prevent chronic pain and improve the lives of children. However, practical guidelines are needed for healthcare practitioners to adopt effective approaches to identify and enhance PCEs in children at-risk for chronic pain, including trauma-exposed children. One of the few existing resources includes the National Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, which provides recommendations for primary care practitioners to identify and promote family and child strengths⁵.The Health Outcomes from Positive Experiences (HOPE) framework may also serve as a model for extending programmatic and policy efforts to support and promote PCEs³⁸. For example, following this framework, parenting has been highlighted as key, modifiable factor that can protect against adversity and enhance resilience in children^{3, 42}. Wraparound behavioral and mental health services including evidence-based parent- or family-focused interventions (e.g., web-based positive parenting program or Triple P may be integrated into primary care settings and tertiary pain clinics, leading to more effective and holistic treatment plans that reduce risk for, or mitigate impact of, chronic pain and other adverse mental and physical health outcomes³⁷.

In conclusion, in a nationally representative sample of children and adolescents in the United States, we found that PCEs was associated with lower prevalence rates of chronic pain. Furthermore, PCEs moderated the known negative associations between ACEs and chronic pain. Efforts to translate these findings into clinical practice and public health interventions aimed at developing and engaging children in positive experiences across multiple domains (family, society, neighborhoods) may lead to lower rates of pediatric chronic pain and other physical and mental health disorders. Furthermore, chronic pain and primary care providers should ideally screen for ACEs and encourage PCEs throughout childhood to potentially mitigate adverse health events. Overall, these findings highlight the need for identifying and proactively promoting PCEs in children with chronic pain, or children at-risk for the development of chronic pain.

Highlights.

Positive childhood experiences are associated with a reduced risk for pediatric chronic pain.

Adverse childhood experiences are associated with increased risk for pediatric chronic pain.

PCEs moderate the known associations between ACEs and pediatric chronic pain.