When Everything Hurts: Chronic Pain in Neurodivergent Youth

Pain is the body’s alarm system, designed to protect us from harm. In some people, this alarm can become overprotective, altering how the nervous system processes pain in ways that affect daily functioning and wellbeing. And in children, persistent pain like this can make everyday activities — playing at recess, carrying a backpack, holding a pencil, getting dressed — feel unbearable.

Chronic pain — twice as common in neurodivergent youth — is as real as it is invisible and misunderstood. (Veterinarians receive more education about the neurobiology of pain than do human doctors!) As awareness grows, so has our understanding of why autism and ADHD place children at higher risk for chronic pain, and of the supports that help their unique nervous systems feel safe and heal.

The Neurobiology of Pain

Chronic pain, which is defined as pain that lasts for more than three months, is often the result of a nervous system imbalance rather than ongoing tissue damage.

The brain and nervous system work to keep us safe by shifting between two branches: the sympathetic system, which activates the fight-or-flight response to mobilize the body during challenges, and the parasympathetic system, which calms and regulates us.

Chronic pain occurs when the fight-or-flight system stays activated, amplifying pain signals, intensifying danger perception, disrupting sleep and mood, and further dysregulating the body – creating a cycle of overactivation.

But what triggers overactivation?

The Chronic Pain-Neurodivergence Overlap

Pain is influenced by biological, psychological, and social factors, as described by the fear-avoidance model of pain.¹ This framework also illustrates how neurodivergence can make children more susceptible to sympathetic activation and chronic pain.

 

Neurodivergence and Pain

• Sensory sensitivity amplifies pain and discomfort in response to everyday sensory input.
• Differences in interoception heighten awareness of bodily sensations.
• Emotional dysregulation intensifies worry, distress, and overwhelm caused by pain.
• Hyperfocus, cognitive inflexibility, and perseveration lock attention on pain.
• Uncertainty intolerance undermines coping beliefs and fuels hypervigilance.
• Social challenges increase stress and trigger the fight-or-flight response.
• Co-occurring conditions — sleep disturbances, anxiety and depression, developmental conditions, migraines, autonomic dysregulation and more — predict and contribute to chronic pain.^{2 3 4 5 6}

About 16 percent of autistic children experience frequent or chronic pain — nearly twice the rate seen in neurotypical peers — and the rate rises to 20 percent among those with developmental conditions.⁵ In our study, we found:⁶

• About 30 percent of pediatric pain clinic patients are autistic.
• More than half report widespread rather than localized pain.
• About 60 percent are girls, reflecting the higher chronic pain rates found in women likely due to factors like hormones, co-occurring conditions, stress, and medical bias.

About one-quarter of youth with chronic pain have ADHD, while 65 percent of children with ADHD report chronic pain.⁷ Women diagnosed with ADHD in childhood show higher chronic pain rates in adulthood.

Signs of Chronic Pain

Expressions of pain may include:

• Guarding a body part or favoring one side
• Avoiding movement or reduced range of motion
• Tenderness to light touch
• Increased sensory sensitivity
• Sudden or increased irritability or meltdowns
• Sudden or increased anxiety, clinginess, or fear of being alone
• Needing help with tasks previously done independently
• Frequent nurse visits, requests to go home, or school refusal
• New or worsened sleep problems
• Fatigue, low stamina, need for frequent breaks
• Reduced engagement with special interests and enjoyable activities

Pain Management: Regulating the Nervous System

Managing chronic pain requires coordinated approaches that calm a dysregulated nervous system over time and restore function. Treatment must be tailored to each child’s needs, abilities, and context.

Pain Management Programs

Chronic pain programs include pediatric anesthesiologists, pain psychologists, occupational and physical therapists, and other specialists. Many programs are housed in pediatric hospitals with specialists who have experience with neurodevelopmental differences.

These programs focus on function beyond pain reduction, helping kids return to daily activities. Most are outpatient, but inpatient or day treatment options exist for severe cases.

For neurodivergent children, treatment plans should address:

• Sensory regulation
• Executive function challenges
• Activities of daily living (e.g., bathing, dressing, eating)
• School-based behavioral and social supports

School Advocacy

Educators will benefit from understanding chronic pain and how the school environment influences it. A pain psychologist can explain the chronic pain and school connection, provide documentation of your child’s needs, and advocate for accommodations supporting gradual school participation, including:

• Quiet space for short breaks
• Sensory-regulating tools (noise-reducing headphones, sunglasses)
• Reminders to use pain-management strategies (deep breathing, muscle relaxation)
• Alternative seating options
• Excused absences, tardies, and extra transition time between classes
• Note-taking accommodations (access to notes, speech-to-text, typing)
• Adapted physical education with low-impact options

What Caregivers Can Do

1. Validate your child’s pain.
Most of us equate pain with acute, nociceptive forms — broken bones, cuts, burns. But that is just one type of pain. Nociplastic pain, common with chronic pain, can occur without tissue or nerve damage. Believing your child helps to calm their nervous system. Remember that neurodivergence alters pain processing. Avoid viewing your child as noncompliant or attention-seeking, as this leads to power struggles that can increase stress and dysregulation.

2. Start low and go slow.
Begin with tiny steps to help your child heal and regain function. Increase demands only when manageable. If walking to the driveway is challenging, start with a few steps, gradually increasing. Use fitness trackers and rewards for motivation.

3. Redirect.
Shifting focus from pain can reduce its intensity. Say, “It makes sense that you’re experiencing pain and that hyperfocus makes it hard to think of anything else. Let’s try taking a smaller step this time.” Psychologists can also help shift your child’s thinking patterns related to pain and come up with replacement behaviors.

Other ways to redirect your child:

• Ask for help with a task (e.g., deliver a message to a family member, think of grocery list items, brush the family pet)
• Count objects by color
• Name things they can see, touch, hear, smell, and taste

4. Create a comfort toolbox with calming activities:

• Breathing exercises
• Music, coloring, puzzling
• Guided imagery and meditation
• Special interests

5. Provide visual cues to remind your child of preferred coping strategies.

6. Maintain routines to establish predictability and reduce anxiety.

7. Prioritize quality sleep.

Quality sleep reduces pain and supports self-regulation. Ensure your child is screened for sleep disorders and receives adequate treatment. Support healthy sleep habits, too:

• Dim lights and turn off screens one hour before bed
• Follow a short bedtime routine with a visual schedule
  (e.g., bath, brush teeth, put on pajamas, bedtime story or relaxation exercise)
• Use timers to indicate transitions
• Choose comfortable pajamas and bedding (remove scratchy tags)
• Keep the bedroom dark, cool, and quiet
• Maintain consistent sleep-wake times, even on weekends
• Reserve the bed for sleep only

8. Educate others.
Help family and friends understand how chronic pain is different. This explanation works well for children: My body is like a pot of water. Sometimes, the water boils and overflows, which hurts. I’m getting help to keep water from overflowing!

9. Keep calm.
Chronic pain is highly treatable. You did not cause your child’s pain — we all have different nervous systems and are shaped differently by life’s experiences. However, your calm presence can significantly influence how they respond to pain over time.

Gradual exposure to uncomfortable activities is part of healing — it’s how fear subsides and pain fades. A pain psychologist can help you understand how to best support and encourage your child in breaking the fear-avoidance cycle and regaining their life.

Gloria T. Han, Ph.D., is a pediatric pain psychologist at Vanderbilt Children’s Hospital in Tennessee and an assistant professor at Vanderbilt University Medical Center.

Anna C. Wilson, Ph.D., is a pediatric pain psychologist at Oregon Health & Science University Doernbecher Children’s Hospital and a professor at OHSU.

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