Overview

Symptoms of chronic or recurrent pain in children and adolescents are common. Research studies show that as many as 30% to 40% of children and adolescents complain of pain that occurs at least once per week. 

Having chronic pain can affect a child's development in many ways.  Pain often hinders the everyday functioning of children in their family relationships, their ability to attend and perform in school, and their social development.  To help reduce the negative impact that chronic pain can have on a child's life, it is important that families seek psychological services as part of the treatment approach to their child's pain problems.  

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Who Should Treat My Child's Pain Problem? 

The state-of-the-art treatment for pediatric chronic pain is the multidisciplinary pain management team approach. The type of approach involves several different health care providers with different areas of expertise. A multidisciplinary pain management team usually consists of:

A Pediatric Pain Management Specialist:  Typically these physicians are pediatricians, anesthesiologists and/or neurologists with extra training in treating children with pain problems.  The physician evaluates the child's pain and makes decisions regarding the best treatment options.  He or she will work with the family to determine what combinations of medication treatments, physical therapy, psychological services, and other medical interventions that would work best for the child. 

A Psychologist: Psychologists who are experts in pain management can help children and families develop skills for coping with pain.  There are a variety of cognitive behavioral approaches (e.g., relaxation techniques, biofeedback) that are effective in relieving pain.  Psychologists often also work with children and families to help them increase the child's level of functioning (i.e., going to school, interacting with other children, doing the things he or she used to do before the pain developed).  They also can address feelings of anxiety, sadness, anger and frustration that may develop in children and adolescents who face chronic pain problems. 

A Nurse or Nurse Practitioner:  Often a nurse or nurse practitioner works as a key member of the team and provides education to the family about pain disorders and pain management and helps the family with questions or concerns that arise during treatment. 

A Physical Therapist:  Physical therapy is a highly effective form of treatment for chronic pain disorders.  Physical therapists work with the child and family to determine the best physical activities, exercises and other treatments to increase the child's strength and endurance and to help him or her deal with day-to-day activity requirements. 

The multidisciplinary pain management team might consult with other health care professionals on an as-needed basis. Other specialists consulted may include psychiatrists, who can help manage medications for pain and mood problems; surgeons; rheumatologists and neurologists.  The core pain management team should also communicate with the child's school to determine how the team can help the child function in the classroom setting. 

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Why is Psychology an Important Aspect of Treating Pediatric Pain? 

Pain is both a physical and psychological experience.  Because the brain plays such a central role in the pain process, interventions (e.g., counseling, relaxation techniques) that target a child's thoughts or feelings related to pain often are effective. When a physician recommends psychological treatment for families of children with pain, some families feel that their doctor is telling them that the pain is "all in their heads" or that the child is crazy—this is not the case.  Psychologists, especially those who specialize in treating pain problems, can provide a number of important services to the child with pain:

Self-management techniques for pain:  These include relaxation strategies such as deep breathing exercises, muscle relaxation, guided imagery, and biofeedback.  Relaxation techniques can give a child an increased sense of control over his/her pain. This can help to reduce pain levels.  With less pain, the child is able to function better. 

Self-management techniques can also include cognitive skills such as "thought stopping" or "reframing," which can help children fend off some of the negative thoughts and feelings that often arise as a consequence of living with pain.

Evaluation and treatment for pain-related disability:  There are a number of ways in which psychologists can help work toward reducing the level of functional disability that the child with pain experiences.  The psychologist may help parents examine their patterns of responding to their child's pain. They can then suggest ways in which responding differently might help both child and parents to deal with the situation.  The psychologist can work with school personnel to find ways of helping a child with pain function in the school environment.  Helping children identify their coping skills and create self-reliance through adaptive coping techniques (e.g., problem-focused coping) are other avenues that pain psychologists may pursue when working with children with chronic pain. 

Evaluation and treatment for pain-related emotional difficulties:  Although chronic pain is not necessarily caused by emotional difficulties, it is very common for children with chronic pain to experience sadness, frustration, anger, and anxiety in response to the challenges of living with pain.  Because their symptoms are invisible and difficult to measure, peers, adults and even some health care professionals may question whether the pain is "real." Feeling misunderstood can give rise to experiences of depression and anxiety in the child and in parents who struggle to find explanations for their child's symptoms.  Because the mind and the body are so strongly inter-related, emotional distress and pain can interact with and amplify one another so that pain becomes worse as the child's sadness or anxiety increases. 

Psychologists can help the family and the rest of the treatment team understand the extent to which mood or anxiety may play a role in the child's pain problem.  They can address these issues in hopes that altering mood or anxiety through cognitive-behavioral or family-centered interventions will help with the ultimate goals of reducing pain and increasing function.

Through comprehensive treatment programs that address the physical, psychological and the social/environmental aspects of pediatric chronic pain, children with chronic pain disorders can gain the tools they need to overcome the potentially disabling effects of chronic pain and continue to grow and develop in a supportive context. 

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Psychological Treatment Approaches for Specific Pain Disorders

Headache

Headache is the most common pain disorder among children and adolescents.  The following psychological approaches have been proven effective components of treatment for both tension and migraine headaches.  The best-proven treatment approaches include: 

• Relaxation/Self-hypnosis.  There are a number of behavioral and cognitive-behavioral strategies that are classified as relaxation techniques.  Children initially work with a psychologist or other trained professional to learn such techniques, but once they have mastered these skills, children can use them on their own to help reduce or prevent painful episodes

  • Deep Breathing – Slow, deep breathing can promote generalized relaxation, which can help to dilate constricted blood vessels and reduce muscle tension that contributes to headache pain. 

  • Progressive Muscle Relaxation – Typically these techniques involve tensing and then releasing large muscle groups throughout the body to heighten awareness of the tension-free state.  Children can improve their ability to recognize and reduce muscle tension.

  • Guided Imagery – Imagery is a cognitive (i.e., brain-based) technique in which children are coached to imagine a pleasant or happy scene that is inconsistent with feelings of tension and pain.  The person guiding the imagery encourages the child to use all his or her senses to develop a vivid image involving sights, sounds, tastes, smells and other sensations.  Imagery has been shown not only to distract the child from pain but also to reduce the perception of pain by eliciting descending signals from the brain that can help to block pain signals.

  • Self-Hypnosis – Hypnosis is a narrowing of attention or consciousness that can counteract stress and pain.  In self-hypnosis, the child learns to focus concentration and reduce energy expenditure.  Deep breathing, muscle relaxation, and often imagery are incorporated into this self-guided relaxation technique. 

   

• Biofeedback:  Biofeedback uses electronic equipment to monitor and "feed back" information about body functions, such as breathing, skin temperature, muscle tension and heart rate.  Although these functions typically operate outside a child's immediate awareness or control, children can gain voluntary control over these functions and use them to promote relaxation and pain control.  Both thermal biofeedback (i.e., learning to increase skin temperature in the extremities) and EMG biofeedback (learning to reduce muscle tension, particularly in the frontalis muscles of the forehead) have been shown to be effective treatments for pediatric headache. 

• Other cognitive-behavioral and environmental interventions:  Other approaches, such as contingency management (teaching parents to reinforce non-pain-related behaviors and to pay less attention to pain-related behaviors) or identifying and altering environmental and behavioral headache triggers, also can be effective treatments for pediatric headache patients. 

• Family interventions:  Because chronic pain in a child can affect the entire family in many ways, it often is helpful for the family to meet with the psychologist.  Together they can identify ways to respond differently to the child's pain and learn how they can be most helpful in encouraging the child to return to his or her previous level of functioning. 

Chronic Pain Syndromes

In pain disorders such as Complex Regional Pain Syndrome Type I and recurrent abdominal pain disorders, there are complex relationships between the body and the mind that can influence the child's level of pain.  Often, children with these types of disorders struggle with the fact that their symptoms cannot be seen by others and thus often are not "believed" to be real. This experience is very frustrating for children and can contribute to feelings of isolation and sadness. Negative emotions such as anxiety, sadness and frustration can increase pain perception.  In this way, a vicious cycle develops between pain and negative emotions.

Psychologists work with children and adolescents with neuropathic pain and recurrent abdominal pain to help them feel more in control of their situations and to help them manage the negative emotions that become part of the pain cycle.   They work with these children and adolescents to help them play a more central role in managing their pain and functioning with pain, rather than waiting for doctors to find something that will make the pain go away.  Some techniques that are used for these pediatric pain syndromes include: 

• Relaxation/Self-hypnosis.  There are a number of behavioral and cognitive-behavioral strategies that are classified as relaxation techniques.  Children initially work with a psychologist or other trained professional to learn such techniques, but once they have mastered these skills, children can use them on their own to help reduce or prevent painful episodes

• Deep Breathing – Slow, deep breathing can promote generalized relaxation, which can help to dilate constricted blood vessels and reduce muscle tension that contributes to headache pain.

•  Progressive Muscle Relaxation – Typically these techniques involve tensing and then releasing large muscle groups throughout the body to heighten awareness of the tension-free state.  Children can improve their ability to recognize and reduce muscle tension.

• Guided Imagery – Imagery is a cognitive (i.e., brain-based) technique in which children are coached to imagine a pleasant or happy scene that is inconsistent with feelings of tension and pain.  The person guiding the imagery encourages the child to use all his or her senses to develop a vivid image involving sights, sounds, tastes, smells and other sensations.  Imagery has been shown not only to distract the child from pain but also to reduce the perception of pain by eliciting descending signals from the brain that can help to block pain signals. 

•  Self-Hypnosis – Hypnosis is a narrowing of attention or consciousness that can counteract stress and pain.  In self-hypnosis, the child learns to focus concentration and reduce energy expenditure.  Deep breathing, muscle relaxation, and often imagery are incorporated into this self-guided relaxation technique. 

• Cognitive interventions:  These are approaches that can be used with children and parents.  Generally, cognitive interventions include techniques aimed at helping the child regain the ability to function in his or her daily life.  Such techniques involve identifying and changing pain-related behaviors that have developed over time.  This can be done by altering how certain behaviors are reinforced at home and school, providing rewards for behaviors that increase functioning, and teaching children self-monitoring strategies to track their own thoughts and feelings related to their pain.

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Conclusions

• Having chronic pain can affect a child's development in many ways, from hindering everyday functioning in family relationships to school and social disruptions. 

• To help reduce the negative impact that chronic pain can have on a child's life, it is important that families seek psychological services as part of the treatment approach to their child's pain problems.

• Sometimes families feel like their doctor is telling them that the pain is "all in their heads" or that the child is crazy when a physician recommends psychological, but this is not the case. 

• Although chronic pain is not usually caused by emotional difficulties, it is very common for children with chronic pain to experience sadness, frustration, anger, and anxiety in response to the challenges of living with pain. 

• Psychologists, especially those who specialize in treating pain problems, can provide a number of important services to the child with pain such as teaching children self-management techniques for pain, evaluation and treatment for pain-related disability, and evaluation and treatment for pain-related emotional difficulties.

• Through comprehensive treatment programs that address the physical, psychological and the social/environmental aspects of pediatric chronic pain, children with chronic pain disorders can gain the tools they need to overcome the potentially disabling effects of chronic pain and continue to grow and develop in a supportive context. 

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Annotated Bibliography

¨       Bursch, B., Walco, G.A., Zeltzer, L. (1998). Clinical assessment and management of chronic pain and pain-associated disability syndrome.  Developmental and Behavioral Pediatrics, 19, 45-53. 

This article is the second in a series describing the assessment and treatment pediatric chronic pain disorders through the biopsychosocial framework.  The article provides a thorough description of the rehabilitation approach to the treatment of chronic pain and coins the term "pain associated disability syndrome" to describe the functional difficulties that often arise from a chronic pain problem. 

¨       Dahlquist, L.M. (1999).  Pediatric Pain Management.  New York:  Plenum Press.

Written primarily for psychologists participating in the treatment of pediatric chronic pain disorders, this book provides straightforward information on addressing the physical, cognitive, and emotional aspects of pain in childhood and adolescence.  

¨       Davis, M., Eshelman, E.R., McKay, M. (1995). The Relaxation and Stress Reduction Workbook, 4^th Edition.  Oakland, CA: New Harbinger Publications. 

This is a handbook that can be used both by patients and pain management practitioners.  Although geared for adults with chronic pain or other syndromes that can be treated through relaxation and stress management, most of the text is easily adaptable to children and especially to adolescents.  The book provides simple instructions for learning breathing, relaxation, meditation, self-hypnosis and other non-pharmacological self-management strategies for coping with pain.

¨       Holden, E.W., Deichmann, M.M., & Levy, J.D. (1999).  Empirically supported treatments in pediatric psychology:  Recurrent pediatric headache.  Journal of Pediatric Psychology, 24, 91-100.

This is one article is a special issue of this journal devoted to empirically supported treatments for pediatric pain problems. This article focuses on pediatric headache.  The review of the literature suggests that relaxation/self-hypnosis is a well-established and effective treatment for recurrent headache.  Thermal biofeedback probably is an effective treatment approach.  Combined treatments look promising, but there are not enough research studies supporting their use. 

¨       Jamison, R.N. (1996). Learning to master your chronic pain.  Sarasota FL:  Professional Resource Press. 

This is the patient handbook that accompanies a practitioner's guide to assessing and treating chronic pain problems.  It is targeted for an adult population, but much of the material can be adapted to children and adolescents (although there is some focus on work-related issues and adult relationship issues). 

¨       Janicke, D.M. & Finney, J.W. (1999). Empirically supported treatments in pediatric psychology:  Recurrent abdominal pain.  Journal of Pediatric Psychology, 24, 115-128.

This is another article in a special issue of this journal devoted to the presentation of empirically supported treatments for pediatric pain problems.  This article on recurrent abdominal pain reviews the research to date and concludes that cognitive-behavioral treatments, such as relaxation, coping skills, social skills, self-monitoring, imagery and cognitive self-control, are "probably" effective for the treatment of recurrent abdominal pain.  

¨       Kuttner, L. (1996) A Child in Pain: How to help, what to do.  Hartley & Marks Publishers. 

This is an easy-to-read guide for parents who want to understand their child's pain and learn what they can do to help their child cope with pain.  The book addresses both acute and chronic pain and also provides information on various pain medications, side effects, and expected benefits. 

¨       Palermo, T.M. (2000). Impact of recurrent and chronic pain on child and family daily functioning:  A critical review of the literature.  Developmental and Behavioral Pediatrics, 21, 58-69.

This article reviews the literature to date on pediatric chronic pain problems and explores the various functional areas – school, family life, etc. – that are affected by chronic pain.  The author suggests directions for future research into the effects of pain disorders on children's and adolescent's functional abilities. 

¨       Varni, J.W. (1984). Pediatric pain: A biobehavioral perspective. Behavior Therapist. Vol 7(2), 23-25.

This article presents the biobehavioral perspective on chronic pain – the model that combines biological and psycho-social influences and consequences of pain.  It is helpful for those wishing to gain a theoretical grounding in this perspective on pain management.

¨       Varni, J.W., Blount, R.L., Waldron, S.A. and Smith, A.J. (1995).  Management of pain and distress.  In M.C. Roberts (Ed.), Handbook of Pediatric Psychology.  New York: Guilford Press, 105-123. 

This book chapter reviews various types of pediatric pain problems and reviews the research on each disorder.  Using the biobehavioral model of pain, the authors thoroughly review a range of approaches to assessment and treatment of pediatric chronic pain, with particular emphasis on the psychologist's role in these areas.

¨       Walco, G.A., Sterling, C.N., Conte, P.M. & Engel, R.G. Empirically supported treatments in pediatric psychology:  Disease related pain.  Journal of Pediatric Psychology, 24, 155-167.

This is another article in the special issue on empirically supported treatments in pediatric psychology.  It covers disease related pain secondary to cancer, juvenile rheumatoid arthritis, hemophilic arthropathy, juvenile primary fibromyalgia syndrome, and sickle cell disease.  The authors conclude that cognitive-behavioral strategies for managing disease pain in children are promising. 

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