Annotation: aspects of pain in children and adolescents

Somatising in children and adolescents. 1. Clinical presentations and aetiological factors

Somatising disorders, characterised by complaints of unexplained physical symptoms, are common presentations in children and adolescents, both in primary and secondary care settings. They have significant impact on the children themselves and on health care resources: as in adults, there is a wide range of severity and resulting handicaps.

Fifteen minute consultation: Practical pain management in paediatric palliative care

Pain and distress in the paediatric palliative care population can be very difficult to manage. Clinical scenarios range from the acute management of cancer-related pain at the end of life to the ongoing long-term support of children with complex multimodal pain related to progressive neurological conditions. Understanding the child's underlying condition, possible causes of pain and their preferred mode of communication are important to the delivery of holistic care. Modification of environmental factors, basic care consideration and non-pharmacological measures have a large role to play, alongside conventional analgesics. Medication may also need to be delivered by novel routes such as transdermal patches, continuous subcutaneous infusion of multiple drugs or transmucosal breakthrough analgesic doses. Two cases are used to illustrate approaches to these clinical problems.

The effectiveness of cognitive behavioural therapy for pain in childhood and adolescence: a meta-analytic review

OBJECTIVES

A variety of chronic painful conditions are present in the paediatric population. Patients with chronic pain often experience considerable scepticism and avoidance by health care providers. This meta-analytic review aimed to utilise well-designed studies, in examining the effectiveness of cognitive behavioural therapy (CBT) in the treatment of chronic pain in children and adolescents.

METHODS

Nine randomized controlled trial studies examining CBT for chronic pain were reviewed. Outcome measures were child reported pain intensity, pain duration and functional disability.

RESULTS

CBT had a large effect on pain intensity for recurrent abdominal pain (RAP), a small effect on headaches, and a medium effect on fibromyalgia. CBT had a medium effect on pain duration across pain types. CBT had a large effect on functional disability for RAP, a small effect on fibromyalgia and a moderate effect on headaches. Findings are limited by the small number of studies and varied control conditions.

CONCLUSIONS

CBT may be effective in reducing child reported pain symptomology. Future studies using a larger sample and examining the differential impact of varied control conditions are needed.

Health care professionals' pain narratives in hospitalized children's medical records. Part 1: pain descriptors

BACKGROUND

Although documentation of children's pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children.

OBJECTIVES

To describe health care professionals' use of written language related to the quality and quantity of pain experienced by hospitalized children.

METHODS

Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used.

RESULTS

Pain narratives were documented a total of 5390 times in 1518 of the 3822 children's medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (e.g., vocal, motor, facial and activities cues), affective and physiological cues, and children's descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers.

CONCLUSIONS

The richness and complexity of vocabulary used by clinicians to document children's pain lend support to the concept that the word 'pain' is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children's pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.

Self-rated pain and perceived health in relation to stress and physical activity among school-students: A 3-year follow-up

The aim of this longitudinal study was to assess changes with age regarding prevalence of pain and perceived health in a student population, as well as change over time at grade level. Pain included frequency of headache, abdominal, and musculoskeletal pain and perceived health included problems sleeping and/or if they often felt tired, lonely, and sad. If gender, age (grade level), stress, physically activity were related to pain and health complaints were tested with multivariate logistic regression analysis. The students (n=1908) came from randomly selected schools throughout Sweden and attended grades 3, 6 and 9 (ages 9, 12 and 15 at the onset of the year) in 2001. Three years later, 67% (n=1276) of the same students answered a questionnaire that was constructed for the purpose of the studies. The responses given by the same students showed that girls' complaints of pain and perceived health increased with age and boys decreased. Over half (56%) of the girls and two-thirds (67%) of the boys reported no frequent complaints either year. At grade level most variables were rated the same as three years earlier by the same age group. Stress was significantly related to pain and health complaints for girls and the risk of complaints, as calculated with odds ratio, was most evident for students who were characterized as being physically inactive in 2001 and remained inactive three years later. Jointly, significant predictors, such as stress, being physically inactive, gender and grade level, explained 8-20% of the frequent complaints.

Assessment and management of pain syndromes and arthritis pain in children and adolescents

Chronic musculoskeletal pain, whether it is idiopathic or disease-related, is common in childhood. Pediatric rheumatologists and other pediatric health care providers must understand the epidemiology of musculoskeletal pain as part of childhood, diagnose pain syndromes in children and rule out rheumatic disease, and be willing to initiate treatment of pain in children and adolescents. Practitioners' ability to carry out these tasks is enhanced by an awareness of the biopsychosocial model of pain, which integrates biologic, environmental, and cognitive behavioral mechanisms in describing the causes and maintenance of children's pain. A growing body of research in rheumatic diseases, such as JIA, and idiopathic musculoskeletal pain syndromes, such as JPFS, highlights the importance of environmental and cognitive behavioral influences in the pain experience of children in addition to the contribution of disease activity. These influences include factors innate in the child, such as emotional distress, daily stress, coping, and mood, and familial factors, such as parental psychologic health, parental pain history, and the nature of family interactions. Addressing these issues, while providing aggressive traditional medical management, optimizes pain treatment and improves overall quality of life for children who have musculoskeletal pain.

Medically unexplained symptoms in children and adolescents

A review is presented of the range of medically unexplained symptoms (MUS) in children and adolescents, with an account of the main presentations that are recognised in clinical settings in paediatric and children's mental health services. A summary of both epidemiological and clinical studies of symptoms and their associations is given, followed by a brief overview of aetiological theories and of management interventions.

Risk factors for development of non-specific musculoskeletal pain in preteens and early adolescents: a prospective 1-year follow-up study

BACKGROUND

Musculoskeletal pain symptoms are common in children and adolescents. These symptoms have a negative impact on children's physical and emotional well-being, but their underlying aetiology and risk factors are still poorly understood. Most of the previous cohort studies were conducted among mid and/or late adolescents and were mainly focused on a specific pain location (e.g. low back pain or neck pain). The purpose of this study is to estimate occurrence of new-onset pain symptoms, in all musculoskeletal locations, in preteens and early adolescents and investigate risk factors for development of these symptoms.

METHODS

1756 schoolchildren (mean age 10.8) were recruited from schools in southern Finland. Information was extracted as to whether they experienced musculoskeletal pain and a total of 1192 children were identified as free of musculoskeletal pain symptoms. Information was collected on factors which could potentially predict the development of musculoskeletal pain: headache, abdominal pain, sadness/feeling down, day-time tiredness, difficulty in falling asleep, waking up during nights, level of physical activity and hypermobility. These children were followed-up 1-year later and those with new episodes of non-traumatic and traumatic musculoskeletal pain symptoms were identified.

RESULTS

A total of 1113 schoolchildren (93% of baseline pain-free children) were found at one-year follow-up. New episodes of musculoskeletal pain were reported by 21.5% of these children. Of them 19.4% reported non-traumatic pain and 4.0% reported traumatic pain. The neck was the most commonly reported site with non-traumatic pain, while the lower limb was the most common site for traumatic pain. The independent risk factors for non-traumatic musculoskeletal pain were headache (OR = 1.68, [95% CI 1.16-2.44]) and day-time tiredness (OR = 1.53, [95% CI 1.03-2.26]). The risk factors for traumatic musculoskeletal pain were vigorous exercise (OR = 3.40 [95% CI 1.39-8.31]) and day-time tiredness (OR = 2.97 [95% CI 1.41-6.26]).

CONCLUSION

This study highlights that there may be two types of pain entities with both distinct and common aspects of aetiology. For primary prevention purposes, school healthcare professionals should pay attention to preteens and early adolescents practicing vigorous exercise (predictor of traumatic pain), reporting headache (predictor of non-traumatic pain) and reporting day-time tiredness (predictor of both types of pain).

Relationship of Common Pain Conditions in Mothers and Children

OBJECTIVES

The scientific evidence is conflicting as to whether there is an association between parental and child pain. The goal of this study was to assess whether there is an association between: (1) site-specific pain conditions in mothers and children and (2) the presence of multiple pain conditions in mothers and children.

METHODS

A population-based sample of 2466 children aged 11 to 17 years who were members of a prepaid health were interviewed about the occurrence of common pain conditions-back pain, headache, facial pain, and stomach pain. Their mothers were also interviewed about the presence of pain.

RESULTS

Children were at significantly increased risk of having back pain, headache, and stomach pain if their mothers also reported pain at the same site (index pain). The association between maternal and child back pain and headache remained significant after adjusting for mother and child demographic variables. A dose-response relationship was observed between maternal multiple pain sites (1, 2, 3, or more) and the presence of back pain, headache, and stomach pain in the child after adjusting for the mother having the index pain and other potential confounders. In multivariate analyses, children were at increased risk of having multiple (2 or more) pain conditions if their mothers had pain at multiple sites, with a dose-response relationship evident with increasing number of maternal pain sites.

DISCUSSION

There was an association between maternal and child pain in this population-based sample. The presence of multiple pain sites in the mother consistently predicted the presence of site-specific pains and multiple pains in the child. Future research on the association of child and parental pain should include multiple pain sites as both outcome and predictor variables.

Prevalence and co-occurrence of self-rated pain and perceived health in school-children: Age and gender differences

In this nationwide study, 1975 students from grades 3, 6, and 9 (ages 9, 12, and 15 at the onset of the year), were recruited from randomly selected schools, which represented different geographical areas throughout Sweden. The main aim of the study was to assess the prevalence of self-reported pain (headache, abdominal, and musculoskeletal pain) and perceived health (problems sleeping and/or if they often felt tired, lonely and sad). A second aim was to study the co-occurrence among different pain and health variables. The students, (n = 1908 distributed by grade 3: 255 girls and 305 boys, grade 6: 347 girls and 352 boys, grade 9: 329 girls and 320 boys) answered retrospectively (three months) a specially designed questionnaire. Fifty percent (50%) of the students reported that they had experienced pain, either as headache, abdominal pain or musculoskeletal pain, within the recall period. Gender differences were especially noticeable for headaches, where twice as many girls (17%, n = 159) than boys (8%, n = 80) reported that they suffered such pain at least once a week or more often. Co-occurrence among the variables was moderate (0.3-0.5). For the total of the seven variables, the perception of pain and health complaints decreased with age for boys from grades 3 to 9, while multiple complaints increased for girls.

Young gymnasts' understanding of sport-related pain: a contribution to prevention of injury

INTRODUCTION

Pain may signal impending or actual injury, or the achievement of optimum workload to produce a physical conditioning effect. These different functions of pain present a challenge for athletes wanting to improve their skill and conditioning level in the most efficient manner without injury. As children may be particularly vulnerable to exacerbating pain and injury owing to limited knowledge, it is important to learn more about the development of their understanding of pain concepts (e.g. pain as a signal of impending injury vs. soreness from exertion).

METHODS

A structured interview and scoring criteria were developed to measure children's understanding of the functions of pain in sport and the consequences of pain and injury. Competitive gymnasts (6-13 years; n = 68; 63% girls) were interviewed and their responses were scored for indices of understanding of different types of pain.

RESULTS

Age differences were found in: number of different types of pain identified; understanding of pain causality; understanding the value of pain; distinguishing pain from exertion; and use of pain descriptors. Analyses revealed that gymnasts responded differently to different types of pain and were aware of the need to stop their sport in some cases and to continue in others. Most did not describe social pressure to continue gymnastics while in pain. Gymnasts demonstrated an understanding that there was little they could do about chronic pain, yet appreciated that pain or damage could worsen with continued practice.

DISCUSSION

This study was a first step in elucidating young gymnasts' understanding of sport-related pain. Further research is needed with athletes from other sports, and comparisons should be made with non-athletic children and those with pain from other sources. Within various sports, it will be important to determine the relative effects of age, sex, and number of hours spent training. Appreciation of individual differences in children's understanding of pain may contribute to prevention of injury in sport. For example, children who understand the difference between soreness from exertion and acute pain owing to injury may be able to make better decisions about pain management and continued practice.

Pediatric pain syndromes and management of pain in children and adolescents with rheumatic disease

This article introduces important issues related to pain in children with musculoskeletal pain syndromes and rheumatic disease, using juvenile primary fibromyalgia syndrome (JPFS) and juvenile idiopathic arthritis (JIA) as models. A brief summary of the prevalence of pain in healthy children is followed by a summary of existing pain-assessment techniques. The remainder of the article describes the pain experience of children with JPFS and JIA and discusses issues related to pain management.

Pediatric procedural pain

Pain is subjective. The pain response is individual and is learned through social learning and experience. Early pain experiences may play a particularly important role in shaping an individual's pain responses. Painful medical procedures such as immunizations, venipunctures and dental care, and minor emergency department procedures such as laceration repair, compose a significant portion of the average child's experience with painful events. Inadequate relief of pain and distress during childhood painful medical procedures may have long-term negative effects on future pain tolerance and pain responses. This article reviews the evidence for long-term negative effects of inadequately treated procedural pain, the determinants of an individual's pain response, tools to assess pain in children, and interventions to reduce procedural pain and distress. Future research directions and a model for conceptualizing and studying pediatric procedural pain are proposed.

The efficacy of hypnosis in the reduction of procedural pain and distress in pediatric oncology: a systematic review

Children who suffer from cancer have to endure regular, painful medical procedures that are associated with a considerable degree of psychosocial distress. Hypnosis has been successfully employed in the management of pain and distress in the adult population, but is not well studied in pediatric populations. This review systematically evaluates the systematic research conducted in the field of procedure-related pain management in pediatric oncology within the context of a nationally agreed framework for the assessment of research evidence. It is concluded that there is not currently enough robust research evidence to recommend that hypnosis should form part of best practice guidelines for the management of procedure-related pain in pediatric oncology. However, there is sufficient evidence to justify larger-scale, appropriately controlled studies. A number of recommendations are made regarding future research.

Temperament and stress response in children with juvenile primary fibromyalgia syndrome

OBJECTIVE

To examine temperament, stress response, child psychological adjustment, family environment, pain sensitivity, and stress response differences between children and adolescents with juvenile primary fibromyalgia syndrome (JPFMS), children with arthritis, and healthy controls. Parental psychological adjustment was also measured.

METHODS

Subjects included 16 children with JPFMS, 16 children with arthritis, and 16 healthy controls. Participants completed the Dimensions of Temperament Survey-Revised (DOTS-R), State-Trait Anxiety Inventory, Children's Depression Inventory, Family Environment Scale (FES), Sensitivity Temperament Inventory for Pain (STIP), and Youth Self-Report. Responsiveness to an acute stressor was assessed by measuring salivary cortisol levels before and after venipuncture. Parents were asked to complete the parent versions of the DOTS-R, FES, STIP, Child Behavior Checklist, and Symptom Checklist-90-Revised.

RESULTS

Children and adolescents with JPFMS demonstrated more temperamental instability, increased levels of depression and anxiety, less family cohesion, and higher pain sensitivity compared with the other 2 groups. Parents of children with JPFMS, in rating themselves, also reported higher levels of anxiety and depression, and lower overall psychological adjustment compared with parents of children in the other groups.

CONCLUSION

These results suggest that a psychobiologic perspective may contribute to an increased understanding of JPFMS in children and adolescents, facilitating an approach to investigating the interaction of factors that appear to place a child at risk for development of a pain syndrome. Because temperamental instability, sensitivity to pain, vulnerability to stress, psychological adjustment, family context, and parental psychopathology are individual risk factors, the interaction of these factors may explain the breadth of symptoms associated with this pain syndrome, as well as its severity.

Incorporating psychological approaches into routine paediatric venepuncture

Studies of paediatric procedural distress have flourished over the past two decades, with psychological intervention strategies showing consistently high efficacy in reducing pain and fear. This review concentrates briefly on the acquisition and treatment of fear, arguing that what is witnessed clinically is not needle fear or phobia, but anticipatory or procedural distress. The main focus is on how such procedures could be amended to incorporate psychological techniques routinely, outlining specific guidelines for clinical practice.

[Effective psychological interventions for coping with painful medical procedures in pediatric oncology: a theoretical review]

Children with chronic diseases have to undergo numerous and repeated painful medical procedures. Psychological interventions have produced good results in the treatment of this kind of pediatric pain and, although they have not been routinely incorporated into pediatric practice, they provide an effective complement to physical and pharmacological therapies. The present article reviews research into cognitive-behavioral treatment of the distress, pain and anxiety associated with medical procedures in pediatric oncology. We present the possible benefits of these interventions and suggest uses for cognitive-behavioral techniques when performing painful medical procedures.

Risk factors for and sequelae of headaches in schoolchildren with clinical implications from a psychosocial perspective

Functional headache, by definition, is a headache not associated with organic diseases. It is a common symptom in school children and can cause potentially serious health problems, affecting their growth and development. Therefore, this report synthesizes the literature about functional headaches in schoolchildren from a psychosocial perspective. This report examines the research on risk factors and sequelae of headaches in children, presents a framework to guide the conceptualization of this phenomenon, and suggests an application of this framework for clinical practice.

Juvenile primary fibromyalgia syndrome

Juvenile primary fibromyalgia syndrome (JPFS) is a common musculoskeletal pain syndrome of unknown etiology characterized by widespread persistent pain, sleep disturbance, fatigue, and the presence of multiple discrete tender points on physical examination. Other associated symptoms include chronic anxiety or tension, chronic headaches, subjective soft tissue swelling, and pain modulated by physical activity, weather, and anxiety or stress. Research and clinical observations suggest that JPFS may have a chronic course that impacts the functional status and psychosocial development of children and adolescents. In addition, several factors have been implicated in the etiology and maintenance of JPFS including genetic and anatomic factors, disordered sleep, psychological distress, and familial and environmental influences. A multidisciplinary approach to treatment of JPFS is advocated, including pharmacologic and nonpharmacologic interventions (eg, psychotherapy, aerobic exercise, sleep hygiene).

Preparing children for venepuncture. The effect of an integrated intervention on distress before and during venepuncture

Venepuncture for routine blood sampling is a very distressing experience for a considerable number of children. Not only do they express high levels of distress during venepuncture but also in anticipation of the procedure. Therefore, prevention or reduction of distress should focus on both phases of the procedure. To this end, three preparation elements were combined: local anaesthesia of the skin, provision of sensory and procedural information, and involvement of the parent. In order to test the effect of this integrated procedure on the distress reactions of young children before as well as during venepuncture, 31 children were randomly assigned to one of two conditions: preparation or no preparation. Independent raters, who were blind to group assignments, scored segments of the videotaped behaviour of the children, according to the Groninger Distress Scale. Prepared children displayed significantly less distress before and during venepuncture than not-prepared children, regardless of their gender, ethnical origin, age, injection history, and the tension of their parent.

Leisure physical activity and various pain symptoms among adolescents

OBJECTIVES

To investigate the association between leisure physical activity and various pain symptoms in adolescents.

METHODS

In this nationwide cohort based cross sectional study in Finland, 698 schoolchildren, 344 girls and 354 boys, aged 10 to 17 years responded to a questionnaire on pain symptoms (neck and shoulder pain, upper back pain, low back pain, upper limb pain, lower limb pain, headache, and abdominal pain) and physical activity habits and also participated in a fitness test.

RESULTS

Reported physical activity correlated with measured fitness. Musculoskeletal pains (p = 0.013) (in particular low back pain (p = 0.022), upper limb pain (p<0.001), and lower imb pain (p<0.001)) were found more often in subjects participating in large amounts of leisure physical activity, while non-musculoskeletal pains (p = 0.065) (in particular headache among boys (p = 0.004)) tended to be less common. Co-occurrence of different musculoskeletal pains was common in subjects participating in sports.

CONCLUSIONS

In addition to its likely long term health benefits, vigorous physical activity causes musculoskeletal pains during adolescence. This should be considered when tailoring health promotion programmes to adolescents. Also, co-occurrence of musculoskeletal pains may occur as the result of sports activity, which should be considered as a confounder in epidemiological studies on fibromyalgia and related issues.

Somatoform disorders in children and adolescents: a review of the past 10 years

OBJECTIVE

To review the literature on somatoform disorders in children and adolescents relevant to recertification by the American Board of Psychiatry and Neurology.

METHOD

The psychiatric, pediatric, and psychological literatures were searched for clinical or research articles in the past 10 years dealing with somatization and somatoform disorders.

RESULTS

Somatizing presentations are organized conceptually; somatization disorder, body dysmorphic disorder, hypochondriasis, conversion disorder, vocal cord dysfunction, pain disorder, and recurrent abdominal pain are described in children and adolescents; empirical evidence for treatment efficacy is scant, but clinically reasonable approaches are applied.

CONCLUSION

More developmentally appropriate diagnostic schemas and better outcome studies are needed in all the somatoform disorders for children and adolescents.

Pain scales in children: a review

This is a review of tools that have been developed to assess pain in children, with a brief evaluation of their practicality and validity. There are some suggestions for the direction of future research in the development and use of the scales.

Psychosocial factors in children with idiopathic musculoskeletal pain: a prospective, longitudinal study

To explore the role of psychosocial factors in the development and persistence of idiopathic musculoskeletal pain (IMP) in children, 23 children with IMP and 52 children with juvenile chronic arthritis (JCA) were compared at first admission to hospital and at 9 y follow-up. Semistructured interviews were performed at both assessments. At first admission, the prevalence of psychiatric diagnoses was high both in patients with IMP and patients with JCA, but patients with IMP more often had pain models, reported more school stress and more often lived with one biological parent. At follow-up, overall psychosocial functioning and level of chronic family difficulties were improved in both groups, but patients with IMP had a higher prevalence of psychiatric diagnoses and more chronic family difficulties and life events than patients with JCA. The persistence of IMP at follow-up was related to pain models, school stress, less parental education and more chronic family difficulties at first admission. Findings support the association between psychosocial factors and childhood IMP.