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. 2020 Nov 16;46(3):280–285. doi: 10.1093/jpepsy/jsaa108

Topical Review: Examining Multidomain Pain Resilience in Late Adolescents and Young Adults

Shreela Palit 1,2,✉, Tonya M Palermo 3,4, Roger B Fillingim 1,2, Emily J Bartley 1,2
PMCID: PMC7977437  PMID: 33197259

Abstract

Objective

Upwards of 14% of late adolescents and young adults (AYAs) experience chronic pain; however, limited research has focused on factors specifically influencing late AYAs as they transition to adulthood. In this topical review, we propose a conceptual model of multidomain pain resilience (MDPR) in late AYAs with chronic pain that extends existing pain resilience literature, including the Ecological Resilience-Risk Model for Pediatric Chronic Pain.

Method

A conceptual framework for MDPR in late AYAs was developed from the existing literature on resilience in young people with chronic pain. Gaps in knowledge specific to late AYAs are identified, and relevant research examining MDPR in adults with pain are summarized to inform applications of this concept to youth as they transition to adulthood.

Results

Few studies have explored resilience factors in pediatric pain. Of note, these endeavors have largely neglected late adolescence and young adulthood, despite unique considerations germane to this crucial developmental period. Existing research has also focused exclusively on assessing resilience as a unitary, rather than a multidimensional construct. Although limited, MDPR has been examined in midlife and older adults with chronic pain, highlighting the need to expand prior models of pain resilience and extend these principles to emerging adulthood.

Conclusions

Understanding MDPR in late AYAs with chronic pain may provide insights regarding measurable and modifiable resilience factors (e.g., adaptive and personal resources) that promote healthy pain-related outcomes (e.g., reduced pain and enhanced physical functioning) and optimize prevention and/or treatment strategies for this group.

Keywords: pain, chronic and recurrent pain, health promotion and prevention, quality of life, resilience

Introduction

Chronic pain impacts up to 38% of children and adolescents, leading to significant disruptions in psychosocial and physical functioning (King et al., 2011). A subset of youth grow up with enduring pain and associated disability into adulthood (Rosenbloom et al., 2017), and nearly 17% of adults with chronic pain report pain onset in childhood or adolescence (80% of which endorse the continuation of the same pain) (Hassett et al., 2013). Despite the persistent burden of pain across the life span, specific factors that impact pain-related outcomes in late adolescents and young adults (AYAs, ages 16–29) as they transition to adulthood have been largely overlooked. Existing literature has focused almost exclusively on childhood risk and vulnerability factors influencing pain (e.g., negative affect and parental stress) as important predictors of pain persistence during adulthood (King et al., 2011; Palermo & Eccleston, 2009). Further, the influence of protective resources that promote resilience has been left unexplored in late AYAs with chronic pain.

Resilience is a dynamic, malleable process and refers to positive adaptation in the face of life stressors, challenges, or adversity (Sturgeon & Zautra, 2010, 2013). Chronic pain is one such challenge. Importantly, resilience is not the antithesis of vulnerability, rather it is a construct independent of risk which may not only protect against the development of maladaptive health outcomes but likely also buffers against the impact of risk factors on exacerbation of those outcomes. As conceptualized by Sturgeon & Zautra (2010, 2013), resilience factors include both resilience resources (i.e., stable, personal traits, such as dispositional optimism) and mechanisms (i.e., malleable, situational responses, such as positive affect) which contribute to healthy pain adaptation. For example, several psychosocial factors confer pain resilience, including positive affect, self-efficacy, hope, pain acceptance, and optimism. However, much of this work has centered on adults with chronic pain. Because resilience likely serves as a protective and preventative agent to support pain reduction and higher quality of life during adolescence and young adulthood, understanding variables that foster optimal functioning during this formative developmental period is an important directive.

The Ecological Resilience-Risk Model for Pediatric Chronic Pain (Cousins, Kalapurakkel, et al., 2015) provides a guiding framework for understanding resilience resources and mechanisms in youth with chronic pain. This model extends the principles described by Sturgeon & Zautra (2013) to a pediatric population and integrates resilience factors across individual, cultural, and family/environmental domains. Though this model outlines the multidimensional nature of resilience and highlights the importance of sociocultural and developmental contributors, the majority of existing research continues to examine pain resilience from a unidimensional (almost exclusively psychosocial) perspective. This approach neglects the consideration of resilience across multiple domains of functioning [which we refer to here as multidomain pain resilience (MDPR)], including psychological, biological, social, and health/lifestyle contributors (Liu et al., 2017; Puterman & Epel, 2012). MDPR has recently been examined in midlife and older adults with chronic musculoskeletal pain conditions (Bartley et al., 2019; Johnson et al., 2019) but has yet to be applied to younger cohorts.

In this review, we underscore the importance of exploring resilience factors during emerging adulthood and highlight recent attempts to examine resilience in pediatric and adolescent pain since the introduction of the Ecological Resilience-Risk Model. We also propose a conceptual framework for extending these principles specifically to late AYAs, including incorporating multidimensional, pain-specific resilience factors in future investigations, and the clinical implications therein.

Pain During Emerging Adulthood

The developmental period of emerging adulthood presents unique challenges that can complicate pain-related coping and adjustment in AYAs with chronic pain. These considerations may include challenges related to shifting of roles leading to difficulty with health advocacy and independence, disruption in health insurance coverage, and changes in healthcare access as a result of no longer being under direct parental guidance or influence (Forgeron et al., 2017; Higginson et al., 2019). Moreover, youth to adult transition of healthcare services for managing chronic pain is virtually nonexistent (Forgeron et al., 2017).

Late AYAs with chronic pain experience the same psychological, behavioral, neurobiological, and social changes as their healthy peers (Arnett, 2000), but also experience unique effects of these developmental changes (e.g., increased substance use, reductions in physical activity and sleep quality) (Anastas et al., 2018; Bonar et al., 2020) on their pain condition. These considerations coupled with limited resources/strategies available to adequately manage pain-related concerns (e.g., mental health distress and disrupted quality of life) can increase risk for the adverse outcomes (Anastas et al., 2018). Functional and psychosocial impairments associated with chronic pain during this formative developmental period often persist throughout the life course (Brattberg, 2004). Recent evidence highlights the long-term socioeconomic implications of chronic pain as youth approach adulthood, including adverse academic (lower education level), vocational (decreased career satisfaction), and social (poorer quality of peer/romantic relationships) consequences (Murray et al., 2020; Rosenbloom et al., 2017), suggesting this is a critical timeframe during which pain prevention and intervention strategies may attenuate a lifelong pattern of negative pain outcomes. Importantly, resilience factors may vary across developmental stages and influence individuals differentially across the age spectrum (Puterman & Epel, 2012), thereby supporting the examination of pain resilience factors unique to this cohort.

Recent Research on Pediatric Pain Resilience

Cousins et al. (2015) highlighted the value of examining pain-related resilience factors in children and adolescents, spurring research on this topic. We briefly summarize these efforts since the Ecological Resilience-Risk Model was proposed. Recent investigations have demonstrated associations of optimism (Cousins, Cohen, et al., 2015), self-efficacy (Kalapurakkel et al., 2015; Tomlinson et al., 2017), youth and parent pain acceptance (Feinstein et al., 2018) and psychological flexibility (Beeckman, Hughes, et al., 2019; Beeckman, Simons, et al., 2019), and a combination of these variables (Lee et al., 2020) with adaptive outcomes (improved mental health, less functional disability) in youth with chronic pain. Greater trait resilience is also associated with attenuated disease severity in adolescents with chronic musculoskeletal pain (Gmuca et al., 2019). A strength of some studies is the inclusion of parental resilience factors (Beeckman, Hughes, et al., 2019; Beeckman, Simons, et al., 2019; Feinstein et al., 2018; Gmuca et al., 2019; Lee et al., 2020; Ross et al., 2018). However, existing studies include methodological shortcomings, such as small sample sizes and limited selection of instruments (e.g., exclusive use of general resilience scales) (Gmuca et al., 2019; Skrove et al., 2015). Overall, continued investigation of pain resilience in youth is warranted, especially given that prior research has focused almost exclusively on children and early to mid-adolescents (failing to incorporate late AYAs), has been cross-sectional, and has not considered resilience across multiple domains of functioning.

Multidomain Pain Resilience

Factors that contribute to resilience extend beyond psychological variables and encompass multiple domains of functioning (e.g., biological, social) (Liu et al., 2017). Further, both individual and environmental/contextual resilience mechanisms are likely involved in healthy pain adaptation. For example, parental variables (e.g., psychological distress) impact pain and disability in youth (Palermo & Eccleston, 2009) and parental influences (including resilience factors, such as parental hope, optimism, etc.) persist beyond childhood into adolescence and young adulthood. Social engagement, perceived social support from peers, and adaptive family functioning positively impact chronic pain coping, especially in AYAs (Ross et al., 2018; Skrove et al., 2015). Moreover, health and lifestyle factors such as sleep (de la Vega et al., 2019) and exercise/physical activity (Fransen et al., 2015), as well as biological markers (e.g., autonomic variables such as heart rate variability and efficient post-stress cardiovascular recovery) (Sturgeon et al., 2014; Walker et al., 2017) influence pain regulation.

Understanding how dynamic, modifiable variables sampled across these multiple domains (and the potentially synergistic effects of these factors) confer resilience in chronic pain is critical. Possible synergistic effects include an interaction between positive affect and enhanced immune function to promote adaptive pain coping (Cohen et al., 2006; Stone et al., 1994; Sturgeon & Zautra, 2010). Similarly, optimism may moderate the relationship between health behaviors (i.e., sleep) and pain interference (Mathur et al., 2018). We propose a conceptual framework (Figure 1) that incorporates pain-related resilience factors measured across multiple domains of functioning, utilizing the Ecological Resilience-Risk Model as an important foundation. This framework acknowledges that MDPR evolves throughout the life course and can be applied to specific developmental periods including late AYAs with chronic pain. Thus far, studies of MDPR have exclusively examined midlife and older adults, dictating a need to expand the investigation to include lifespan/developmental considerations. In adults ages 45–89 with or at risk for symptomatic knee osteoarthritis, a recent study found that a comprehensive biobehavioral (abstinence from tobacco use, waist-to-hip ratio) and psychosocial (optimism, positive/negative affect, active coping, perceived stress, social support) resilience composite was a stronger predictor of adaptive cellular aging (i.e., longer telomere length) than a psychological resilience composite alone (Johnson et al., 2019). Moreover, four distinct MDPR profiles have been characterized in older adults with chronic low back pain such that those with a more resilient profile (i.e., higher psychosocial functioning, healthy body composition, and fewer health comorbidities) demonstrated lower levels of disability and depression, and enhanced functional performance, compared to individuals with lower resilience (Bartley et al., 2019).

Figure 1.

Figure 1.

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A framework of multidomain pain resilience across the lifespan. Our conceptual framework proposes that pain resilience derives from the interactions between and potential synergistic effects of factors (including both intraindividual and contextual, family/social environment variables) across multiple domains of functioning. Moreover, pain resilience evolves across and is potentially influenced by developmental stages and the historical (e.g., early life events), sociocultural (e.g., sex/gender and culture), and environmental (e.g., geographic location) factors encountered by the individual over the life course. We consider in this review the application of this framework to studying the specific developmental period of the transition from late adolescence into young adulthood.

Although the constructs important to measure in late AYAs may not fundamentally differ from those previously measured in adult studies of MDPR, how these factors evolve during this important developmental stage may diverge (e.g., the influence of parental factors may manifest differently in late AYAs pain experience than it does with children). Emerging adulthood is a prime period for facilitating empowerment and individuation, thus, it provides an optimal window during which resilience-enhancing and strengths/skills-based pain management approaches would likely be fruitful.

Applications to Emerging Adulthood: Future Directions

The Ecological Resilience-Risk Model of Pediatric Chronic pain was an integral first step in recognizing the importance of protective factors that mitigate negative pain outcomes and improve the health and quality of life of youth living with chronic pain. In addition to gaining a better understanding of resilience during the transition to adulthood, we recommend efforts to systematically explore modifiable pain resilience factors within these domains, including their synergistic effects. Cousins et al. (2015) highlighted the importance of expanding this area of investigation and developing additional theoretical models that guide resilience-based research in young people with chronic pain.

Many traditional treatment approaches focus on mitigating risk factors while neglecting to foster the most optimal treatment outcomes. In contrast, resilience-enhancing interventions may provide additional avenues for promoting adaptive outcomes not addressed by conventional methods. Given considerable heterogeneity in how patients respond to interventions, homogeneous subgrouping can provide important information for informing treatment selection and predicting treatment response. Though patient subgroups comprised of primarily psychological/behavioral vulnerability factors (e.g., catastrophizing, negative affect) have been classified in youth with chronic pain (Walker et al., 2012), pain resilience profiles have yet to be delineated in this population. MDPR profiles would provide unique information to identify youth who could benefit differentially from particular prevention and intervention strategies.

To achieve these aims, we urge future work to address the following research agenda:

  1. Identify resilience resources and mechanisms specific to late AYAs. Researchers should incorporate developmentally-relevant considerations when elucidating resilience factors in this population, including the role of executive functioning (e.g., attentional control) and identity formation (e.g., gender identity and cultural identification), among others. Interactions among resilience factors and known risk/vulnerability factors should also be considered.

  2. Empirically characterize MDPR profiles in late AYAs (e.g., using multivariate approaches such as cluster analysis). Table I outlines potential variables to assess within each domain. Investigators should begin by targeting factors that have demonstrated associations with pain resilience (e.g., positive affect, fewer health comorbidities, and social support) and expand these efforts to consideration of additional factors within each domain which have yet to be examined in MDPR, but are known to be related to adaptive pain outcomes (e.g., heart rate variability and sleep quality). Measurement of parental factors is also important, given the population of interest.

  3. Explore individual differences in MDPR profiles (e.g., stratified by sex and race/ethnicity), given that sociocultural (e.g., identity formation, cultural beliefs, and media influence), historical (e.g., exposure to natural disasters/other early life stressors and political climate), and environmental (e.g., geographic location) contributors likely influence MDPR.

  4. Examine the extent to which MDPR profiles are associated with pain and functional outcomes (e.g., disability) and with response to psychological/behavioral treatments.

  5. Use longitudinal studies to investigate the trajectory of these relationships and establish the predictive utility of MDPR profiles, highlighting the clinical relevance of their use over time.

Table I.

Representative Individual and Parental Factors to Consider for Multidomain Pain Resilience Assessment in Late Adolescents and Young Adults with Chronic Pain.

Domain Factors
Psychological

Positive Affect and Well-beinga

Pain Self-Efficacya

Hopea

Optimisma

Psychological Flexibility (e.g., Pain Acceptance, Emotion Regulation)a
Social

Peer Support/Relationship Qualitya

Family Functioning/Cohesion

Socioeconomic Status
Biological

Heart Rate Variability

Cardiovascular Recovery

Neuroendocrine Markers

Inflammatory Markers
Health/Lifestyle

Anthropometric Measuresa

Sleep Quality

Physical Activity/Exercise

Health Comorbiditiesa

Nutrition/Diet

Substance Use
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a

Note. Previously examined construct with empirical support for either their individual associations with pain adaptation in youth with chronic pain and/or multidomain pain resilience in mid- to older adult populations.

Conclusion

Understanding MDPR during emerging adulthood has the potential to inform multidisciplinary prevention and intervention efforts to promote adaptive pain outcomes across the lifespan. These data could help identify modifiable resilience factors that serve as treatment targets relevant to this population, thereby promoting the development of individually-tailored, strengths-based prevention and intervention strategies sensitive to the needs of late AYAs.

Funding

This work was supported by the National Institute of Health (NIH) and National Institute of Aging (Grant #R00AG052642) awarded to E.J.B., PhD., and NIH/NIA grant (T32AG049673) provided to the University of Florida to S.P., PhD.

Conflicts of interest: None declared.

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