Understanding and managing children’s recurrent pain in primary care: A biopsychosocial perspective

Abstract

Recurrent pains in childhood are those that occur at least three times within three months and interfere with daily activities. The most common reasons for pain are headaches and abdominal pain, and the great majority of these have no serious or treatable physical cause. Instead, a functional analysis of the antecedents and consequences of the pain for the child is needed. This requires time, trust, rapport and acceptance, as well as the development of a shared biopsychosocial understanding of the pain. Some interview questions are suggested for this purpose. These include questions about the physical and social triggers of pain episodes, such as stress at school or at home, and modelling of pain behaviour by family members. Also included are questions about the adverse consequences of pain, such as sleep problems, difficulty in concentration, avoidance of responsibility and of feared situations, and inadvertent reinforcement of pain behaviour by solicitous behaviour on the part of parents. Among the numerous interventions for recurrent pain, those that promote learning of relaxation skills are the best established. A cognitive-behavioural, biopsychosocial approach to treating recurrent pain is well supported by research evidence. Primary care physicians and paediatric consultants can help to prevent and relieve children’s recurrent pain.

Recurrent pain is classically defined as pain that has occurred at least three times in the past three months and is severe enough to interfere with normal activity. Among the numerous types of recurrent pain in school-aged children, the most common are headaches, stomach aches and ‘growing pains’ (1,2).

While many children and parents take such pains in stride and carry on with their lives, for a significant minority, the pain leads to anxiety, school absenteeism and much medical contact, including invasive investigations. Yet for nearly all of these children, no clear or treatable physical cause for the pain is ever found. Given this, pain management and functional improvement are the primary goals. An outline of the following discussion is presented in Table 1.

TABLE 1.

Overview of assessment, conceptualization and intervention

Rapport and trust are the first considerations Talk to the child and parent(s) Use positive and optimistic language Medical assessment, diagnosis and treatment of any medical conditions Follow-up on red flags, if any Fostering a shared interpretation of the pain Develop a biopsychosocial understanding Ask about psychosocial issues and coping when doing physical assessment Functional assessment of pain episodes Assess precipitating factors: Social situations (eg, family conflict, bullying) Physical triggers (physical activity, foods, noise, sleep deprivation) Modelling (significant others with pain problems) Stress (fear or anxiety) Assess adverse consequences of pain (maintaining or reinforcing factors) Avoidance of feared situations, such as school Extra attention from parents and others for pain complaints Physical deconditioning Sleep problems Intervention or counselling Counselling by the physician Medications (often not needed) Referral for pain management to clinical psychology or other mental health service, if necessary and possible Prognosis

A SHARED CONCEPTUALIZATION

Once serious or treatable physical causes are ruled out, most parents need, and are willing to accept, an explanation based on both physical and psychological factors. For example, both headaches and stomach aches can be explained in terms of pain receptors in the head and/or abdomen becoming very sensitive, sometimes as a result of an earlier illness that has since resolved and sometimes as a result of stress or worry. Either way, the important question now is figuring out how to help, rather than determining the original cause.

THE INITIAL ASSESSMENT

To effectively help children with recurrent pain, the first considerations are rapport and trust. This requires allowing for at least one or two appointments that are longer than usual at a busy primary care practice – for example, 30 min, if possible, to allow for a careful history and physical examination. Briefer but regularly scheduled follow-up appointments to monitor symptoms and growth, and to maintain rapport, are also worthwhile. A suggested rule of thumb is to meet with the patient on one-week or two-week intervals for one or two months, and to provide assessment and counselling along the lines summarized below. These extra efforts make the physician’s subsequent recommendations more credible, and have a better chance of correctly identifying the psychosocial contributors to the pain.

The patient’s account of pain should be believed. The physician should explain that in most cases, an underlying physical disorder is not found. And if no such treatable medical disorder is found, then functional improvement is the target. In other words, psychosocial and biomedical contributors to the pain will be introduced and considered concurrently, and given equal weight. Some questions that can help to accomplish this functional assessment are suggested in Table 2.

TABLE 2.

Some suggested questions for a functional analysis of recurrent pain

Pain episodes

How did the pain start? When did it start? How often does it happen? Every day, several times a week, or ... ? What time of day does it happen? Is there a time of day when it’s better? How much does it hurt when it is worst? Tell me a number from 0 to 10, where 0 is no hurt and 10 is the worst hurt you could have. How much does it hurt right now? (Assess correspondence with parent report and observation of child’s behaviour). Exactly where does it hurt? Can you show me with your hand (or on this drawing of a body)? What is the pain usually like? Can you describe how it feels? What do you think is causing the pain? Have you worried that it was something more serious than the doctors have told you?

Antecedents: Precipitating and relieving factors

What makes it worse? What makes it better? (If the child says “Nothing”, ask “What do you do when you have a lot of pain?”) Lots of kids have certain fears or things that make them scared. What fears do you have? Lots of kids feel very sad sometimes. What about you? Do you ever think about hurting yourself? Lots of kids feel very angry sometimes. What about you? Do you ever have a really big tantrum? Do you ever think about hurting someone else? What kinds of things make you feel scared/sad/angry? What do you do about it when you feel scared/sad/angry? Does anybody else in the family have any kind of problem with pain? Looking back to when the pain started, was anything happening in the family that could have contributed? What is school like for you? What’s the most fun? What’s the least fun? What are you looking forward to when this pain is a lot better?

Consequences of pain

Some kids who have pain have trouble sleeping. What about you? Some kids find it hard to concentrate at school when they have pain. What’s that like for you? Have you gotten less exercise because of your pain? What happens when you have pain at home? What do your parents do? What does your brother or sister do? Do you ever have pain while you’re at school? What do you do? Does anybody help you? Some kids get to stay home from school, or come home from school, and watch TV or play video games when they have pain. What about you? (Ask about back rubs, special foods and special time with a parent). Some kids get to not do their chores, like dishes or taking out the garbage, when they have pain. What about you?

This is not a structured interview. The responses provide a baseline to judge the outcome of counselling or treatment. These questions can be adapted for children of various ages and their parents. Children younger than seven years of age understand the word ‘hurt’ better than ‘pain’

Medical assessment, diagnosis and treatment will follow-up on any red flags or positive test results. For recurrent abdominal pain, for example, these include weight loss, growth deceleration, persistent fevers, vomiting or diarrhea, waking up with pain, anemia, bloody stools or a family history of inflammatory bowel disease. For headaches, indications for referral to a paediatric neurologist include a history of head injury, waking with pain, evidence of increased intracranial pressure, or abnormal neurological examination in conjunction with the recurrent headaches. Invasive investigations in the absence of such red flags are unlikely to help in the diagnosis.

After the initial examination, as well as any needed investigations, it is generally possible to suggest that there is no need for further medical investigation. If there are any new symptoms or significant changes in symptoms, then the physician should be consulted, but otherwise, it is recommended that appointments be set up on a regular schedule (eg, every three to six months) to make it clear that medical needs will not be ignored.

It is a good idea to validate the real nature of the pain while not implying a need for further medical investigation at this time. Positive and optimistic language can be used, implying that the problem may well resolve soon. Here are some phrases that could be helpful: “I bet you’ll be happy to know that we don’t need to do any more medical tests now”, or “You’re probably tired of feeling yucky and you’re ready to start feeling better really soon.”

Other ways to provide genuine support and encouragement for improvement include the following. Indicate willingness to follow the child regardless of outcome. Provide a credible diagnostic label if possible, as this may reduce the perception that the pain is a serious or mysterious illness or that further tests are needed. Emphasize return to normal activities, increased quality of life, and reduction of symptoms rather than promising complete resolution of symptoms.

Return to school and other functional goals

Set specific, attainable goals such as a return to school, first for part days, if necessary, and then later for full days. Parents should be encouraged to discuss the plan with the teacher and school counsellor. A safe place should be organized for the child to go to at school (rather than being taken home when pain episodes occur). Sometimes retreating to a ‘nest’ (eg, a blanket or pile of coats) at the back of the classroom suffices for a child to relax for 15 min to 20 min until the pain subsides, and he can then return to classroom activities. The teacher should have a communication book or other method for exchanging information with the parent. The teacher should be provided with a plan for handling pain episodes so that he does not call the parent and send the child home right away. It can be very helpful for the physician to give the parent a letter to the school to demystify the problem and suggest practical actions to take when the child is in pain.

FUNCTIONAL ASSESSMENT OF PAIN EPISODES

Antecedents of pain: What happens before pain episodes?

A functional assessment of pain episodes is often helpful in understanding the triggering and maintaining factors. Common antecedent or precipitating factors include social, physical and emotional triggers. Social situations that elicit anxiety, such as teasing or perceived ostracism, often lead to pain episodes. Physical triggers may include certain foods or physical activities, but one should be cautious in identifying these, because ‘superstitious’ or illusory connections are common. For example, the parent of a child who has a stomach ache after a birthday party may conclude that the pain was caused by chocolate or ice cream, while, in fact, it was coincidental with social anxiety or overexcitement. Emotional triggers are sometimes subtle, involving the child’s intense concern about issues such as conflict between the parents or siblings, or perceived dangers such as storms or abandonment; these are often expressed as pain at bedtime and other times when the child is not occupied or distracted. Some parents frequently ask their child whether he has pain, which, of course, reminds the child of a problem that may not otherwise be salient at that moment.

Another antecedent factor commonly found in children with recurrent pain is modelling of pain behaviour by someone in the family, usually a parent. The words, facial expressions and disabilities associated with pain episodes in the parents are often mirrored in the child. This can, of course, be understood both in terms of inheritance and learning, but parents can be tactfully advised to be aware of their own complaints or nonverbal expression of pain symptoms and to reduce such behaviour in front of the child. Even if modelling is not an issue in a particular case, the child should not be exposed to additional worry about the parent’s pain. One could say something like, “Your child admires you and watches you and learns from everything you do – you can show her how you handle your own pain.”

Consequences of pain: What happens during and after pain episodes?

Another aspect of functional assessment requires consideration of the consequences of pain, which include possible maintaining or reinforcing factors. Pain episodes often have the functional consequence of helping the child to escape from a stressful situation. For example, if the child is afraid of being bullied at school, a stomach ache may lead to a phone call to the parent, who then takes the child home. This, of course, leads to rapid cessation of the fear and pain, reinforcing the symptom but not solving the underlying problem. Similarly, children who complain of pain sometimes get special attention from parents and others, such as back rubs, special foods, time in bed watching TV or playing video games, or escape from responsibilities such as chores. It is helpful to identify and gradually phase out these reinforcers of pain behaviour.

Finally, pain complaints often function to maintain a close relationship with the parent: a child who becomes anxious when separated from the parent may quickly discover that pain brings the parent back into close contact. A simple but helpful remedy is to increase contact (eg, cuddling, one-to-one conversation, play) at times when the child is not in pain.

INTERVENTION OR COUNSELLING

Intervention usually starts with counselling by the physician and may include referral for other services if these are needed and available.

Brief counselling from a physician can be of great help to children with recurrent pain and their parents. The following are some suggestions to include in such counselling: compliment the parents on their efforts to help the child, and let them know that it is no longer necessary to treat the pain as an acute problem; and stress the positive (eg, the good news that further physical tests are not needed for now).

A common complaint of children and parents is that the physician talks to the parents about the child as if the child were not able to answer questions or were not even present. It is wise to talk directly with the child, at eye-to-eye level, and once everyone is comfortable with the situation, offer to meet with the child and parents separately (if they are willing). Often, parents provide surprising insights into the triggers or reinforcing factors of their child’s pain, matters that they would not feel free to discuss in front of the child. Similarly, children may admit to certain events or emotions only when their parent is not present. One might ask, “What else is happening in your family (or at school, or with your friends) that may be connected with your pain?” These individual meetings may provide an opportunity to check for exposure to family violence or abuse, as well as any drug-related and mental health problems the parents may have.

The physician’s rules of confidentiality need to be clear at the outset. Commonly, the physician explains that he or she will not tell the parent what the child says or tell the child what the parent says without first checking privately for permission. The ethical and legal obligations to report possible abuse and danger to self or others should be explained briefly, early in the interview.

Counselling should move on to discuss the sources of stress and other triggers of pain. The parents usually need to develop some detachment from the pain complaints. For example, they should be tactfully advised not to ask often whether the child has pain. They should reduce the attention paid to pain symptoms in favour of more attention paid to functional improvement. ‘Catch the child being good’ in this case means getting engaged with and supporting the child’s interests and activities when the child is productively occupied, rather than expending that effort on attention to the pain symptoms.

Many physicians now have training in relaxation, yoga, meditation, mindfulness, guided imagery and related approaches that form part of cognitive behavioural therapy. Good evidence exists in favour of the effectiveness of these approaches for the prevention and management of recurrent pain episodes (3–7).

It is particularly helpful to find out what children and parents do when the child is experiencing pain. The initial response is often “nothing helps”, but with some encouragement, a list of as many as a dozen ways of coping with pain can be elicited. This list of self-management and parental management strategies, which the physician can write down and clarify for the patient as a way of legitimizing and facilitating self-control of pain, may include rest, heat, cold, massage, distracting activity, thinking about a favourite place, relaxation, exercise, over-the-counter medications, and so on.

Managing pain effectively involves not only coping with the pain, but also reducing the circumstances that lead to it and reinforce it. Thus, if a child’s anxiety about friends at the start of a school year is a common trigger of pain, then parents can help by arranging play dates with their children’s prospective schoolmates. If the problem is bullying, then discussion with school personnel may be needed.

Medications

Only brief comment are provided here about medications. While opioids are very helpful in acute pain, they are less so in recurrent and chronic pain, and may lead to long-term harm. The use of opioids should be avoided unless the physician has experience with, and knowledge of, guidelines for using opioids with children (8,9).

Generally speaking, medications play less of a role in recurrent pain situations than in acute ones. One disadvantage of the use of medications is that they may be interpreted as confirmation that the child has a ‘medical’ problem or a disease requiring treatment, when, in fact, a behavioural change in the parent or child may be more important.

REFERRAL

Referral to a paediatric consultant may be the first option considered for most patients. For more complex or intractable cases, referral to, or consultation with, a multi-disciplinary paediatric pain treatment program is ideal, but such teams exist in only a few major centres. Referral for psychological treatment is often very helpful but may also be hard to arrange in many communities. It is worthwhile for the primary care physician to cultivate a relationship with one or two mental health care providers (clinical psychologist, psychiatrist, social worker or other counsellor). Many mental health professionals do not have adequate training in the use of a biopsychosocial model of care, in evidence-based psychological treatments, or in interdisciplinary collaboration with physicians in this overlapping area of mental and physical health care. In some cases, mental health agencies are explicitly closed to referrals in which the primary complaint is a physical health problem, even if the latter is symptomatic of psychosocial concerns. Moreover, children and parents may be appropriately resistant to referrals that seem to imply that the problem is ‘all in the head’. Thus, the shared biopsychosocial understanding of the problem referred to above is crucial in making effective referrals.

The evidence from numerous studies suggests that cognitive-behavioural therapy, including relaxation (possibly via meditation, guided imagery or other methods), is effective in reducing and preventing recurrent pain in children (3,4,6,7).

Another highly important element of treatment is a return to normal activity. This should be carried out according to a graded, carefully constructed plan, rather than making return to activities contingent on low levels of pain. It can be explained to parents and children that functional improvement often precedes, rather than follows, pain relief.

Family-based cognitive-behavioural therapy, in addition to instruction in relaxation and guided imagery, also helps children and parents to identify and change maladaptive ways of thinking about the problem. The child and parents are assisted to work toward functional goals, rather than always limiting activities based on pain. In other words, patients are encouraged to plan for their activities in a graded, paced fashion, and to reduce the discussion of pain as the limiting factor. Parental modelling and reinforcement of pain behaviour are considered. The function of pain symptoms to maintain unhealthy family relationships are addressed (eg, where the child’s pain symptom serves to ally the child emotionally with one parent and against the other).

A word about complementary therapies is needed. These could include modalities such as massage, acupuncture, chiropractic, diet and yoga. They are often sought out by parents, and they may be a mixed blessing. On one hand, they may provide specific or nonspecific symptom relief. On the other hand, such therapy may reinforce the understanding of the pain complaint as a mainly physical problem, and may detract from attention to the functional triggers and maintaining factors outlined above.

PROGNOSIS

Many functional recurrent pain problems eventually resolve without treatment, or with only assessment and discussion. If the problem persists beyond two months, or if there are concomitant diagnosable psychosocial problems such as depression, anxiety, learning difficulties or family conflict, the patient should be referred for more specialized treatment if possible. In any case, it would be wise to ask the parent to bring the child back periodically until the pain no longer meets the criteria for recurrent pain (three times in three months and interfering with activity).

ADDITIONAL SOURCES

In addition to the sources previously cited, numerous other articles on the management of recurrent pain are available (10–14), and these are recommended to the primary care physician.