The Smallest Sufferers

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October 2004

By Julie Silver, MD

I was at a medical conference a couple of years ago, and I came across the somewhat pricey medical textbook, Pain in Infants, Children, and Adolescents.¹ The salesman told me that this book was a bit expensive because there were only 1,000 copies printed. This is a small fraction of what a normal print run would be, and when I asked why this was, he told me that not very many health care professionals wanted to read about how to treat pain in children. If this is true, then it is a real shame, because there are millions of children in pain who can benefit from our expertise.

The more educated we as rehabilitation professionals become about what causes pain in children, the better able we will be to offer them a better quality of life. Or, as Helen Keller once noted, "Although the world is full of suffering, it is also full of the overcoming of it." Even if you do not usually treat children in your practice, it is important to understand a bit about them and their pain. After all, the world is filled with children and, unfortunately, their suffering.

WHY CHILDREN ARE UNDERTREATED FOR PAIN
Believe it or not, before the 1970s, the medical literature was basically devoid of any formal reviews or research on pain in children. The prevailing belief prior to that time was that children tolerated pain well and even that they did not experience pain to the same degree as adults because of immature nervous systems. Not true. We now know that even the most immature of all children, infants, may experience quite a lot of pain. Despite this knowledge, many kids continue to be undertreated for their pain.

Of course, all children experience a lot of acute pain. They fall and scrape their knees. They have pain when new teeth emerge. They cry when they get immunization shots. Obviously, we do not need to treat all acute pain with aggressive therapies. For example, a minor scrape on the knee might require a bandage and quick hug while a child who is teething might benefit from a little acetaminophen. None of these interventions are very aggressive, but they are helpful and reassuring to an injured child.

On the other hand, there are instances when children are grossly undermedicated and do not receive the benefit of treatment that is aggressive enough. For example, pediatrician Linda Cozzens recalls an episode when one 7-year-old girl broke both her radius and her ulna. Dr Cozzens says, "It looked like she had two elbows." The child went to the emergency department where the doctor gave her conscious sedation and tried to realign the bones. He then put her in a cast and sent her home with Tylenol. The next day Dr Cozzens saw this child in her office and she was in excruciating pain. She recalls, "I ordered opioids for her right away. This was a bad injury, and if it happened to an adult, he or she would have been given opioids in the emergency room.

WHAT HAPPENS TO CHILDREN IN PAIN
Acute pain is usually pretty obvious, and there is typically a specific inciting event. Chronic pain can be a little trickier. Children can suffer from chronic pain for a variety of reasons. They may have headaches, stomachaches, back pain, or recurrent ear pain or ankle sprains, just to name a few of their potential pain problems. Chronic pain can have a major effect on a child's quality of life and in turn affect the entire family.

For example, Jennifer is a 19-year-old sophomore in college who developed migraine headaches 4 years ago. She has several headaches a month, each lasting for about a day. Her migraines are severe enough that on the days she has them, she needs to spend most of the time lying down in a dark, quiet room. Jennifer has tried a variety of migraine prophylactic and abortive medications without much success. In high school she had difficulty keeping her grades up because of her headaches, and this meant that she was not able to get into a top college as her older siblings had. As in Jennifer's case, while migraines are generally benign, they certainly can enormously influence the quality of life of both children and adults who suffer from them.

Joanie is a 12-year-old girl who suddenly developed migraines a year or so ago. When she got a migraine, she had intense neck pain that would last for weeks afterward. Several times she went to physical therapy, which did help, but only temporarily. Her doctor became concerned about her neck pain and ordered an MRI of her brain, which revealed a mass near the pituitary gland. This mass is now in the process of being worked up and will likely need to be removed by a neurosurgeon. A similar thing happened to 15-year-old John who began complaining of back pain. He had a series of x-rays that were normal and then went to physical therapy. John continued to complain of pain, and his mother brought him to an orthopedist who ordered an oblique x-ray of his spine, which had not been done by his pediatrician. Sure enough, the oblique film revealed a fracture (spondylolysis) that improved when John wore a brace for a few weeks. Although the vast majority of chronic pain in children is relatively benign, it is important to always consider more serious pathology.

HOW PARENTS CAN HELP (OR NOT) THEIR CHILD IN PAIN
There are two major ways that parents either can encourage their children to develop chronic pain problems or can exacerbate an existing chronic pain problem. The first is by being overly sensitive. This can begin early in childhood with a parent who is exceedingly concerned about the child's physical comfort-always checking to see whether he or she is covered by a blanket or has just the right number of layers of clothing on. The too-concerned parent rushes to the child's side every time he or she trips instead of reassuring the child that a minor bump or scrape is not a big deal. This oversensitivity to children's physical comfort can encourage them to become exquisitely aware of any and all physical discomfort. It also teaches children that for any minor physical problem they will receive a lot of attention, so when they want attention, the way to get it might be to complain of physical pain-whether it exists or not.

The second pitfall is the other extreme-the parent who does not validate and take seriously a child's pain complaints. The parent who does not appropriately comfort a child when he or she has an injury sends the message to the child that he or she is not important. This lack of validation of a child's very real experience has detrimental effects. It serves to confuse and anger children-they know they are hurt. Why doesn't Mom or Dad pay attention? Why don't they care? Therefore, it is important to keep in mind as you consider the child who has chronic pain that it is critical for parents to balance their reactions and to strive for an appropriate level of intervention and responsiveness.

Research has also revealed that children and adolescents who have chronic pain experience more emotional distress including anxiety and depression than their peers who are not in pain. Similarly, youngsters who have chronic pain have been shown to have lower self-esteem and more behavior problems than other children do. What is interesting to note is that the severity of pain is not necessarily predictive of whether children will experience these other problems. In fact, what seems to influence children more than any other factor is how their parents cope and teach them to cope with chronic pain.

HOW REHAB PROFESSIONALS CAN HELP
There are many ways that we as rehabilitation professionals can help children in pain. First and foremost is to follow our motto, "focus on function." Children who are suffering with pain are best helped by parents and health care providers who validate their pain and limitations, but at the same time firmly encourage them to continue to participate in school and other activities. This does not mean that they forego medical treatment. We can offer children in pain many things that can help to alleviate their physical suffering.

Of course, as with adults, the treatments will depend on a number of factors including what is the underlying diagnosis, what has been tried in the past, and what treatments the parents and the child are open to trying. As a team of rehabilitation professionals, we can offer everything from oral medications, to injections, to physical or occupational therapy. We can also offer psychosocial intervention if that is deemed to be necessary.

Physical therapy is a mainstay of pediatric musculoskeletal treatment. The therapist should be skilled in treating children who are physically and emotionally immature. It is important to recognize the different stages of childhood as listed in the sidebar. Since acute musculoskeletal injuries are extremely common in children, it is helpful to remember that the acronym PRICE (protect, relative rest, ice, compression, and elevation) works for both children and adults. One important consideration in the pediatric athlete is to understand that people who are not particularly skilled in preventing such conditions as overuse injuries coach many children. For example, often coaches do not know or employ the concept of teaching children to cross-train, and thereby lessen the risk of overuse injuries. As with adults, chronic pain in children generally responds best to a multidisciplinary and multimodality approach-approaches that we rehabilitation professionals are skilled at prescribing.

Of course, there is more to treating children with pain than what is laid out in this article, but if all health care professionals took to heart that pain truly is the fifth vital sign and that this applies to children as well as adults, many little people would have to suffer a lot less.

Chronic Pain and the Family

Chronic pain is the leading cause of disability in the United States, affecting as many as 48 million people in this country alone. It can demoralize and depress both patient and family, especially when there is no effective pain control and no hope for relief. Improperly managed, chronic pain can lead to substance abuse (usually painkillers) and to acute psychological and emotional distress. Pain begets stress and stress begets pain in a wretched downward spiral.

In Chronic Pain and the Family, Silver reviews the causes and characteristics of chronic pain and explores its impact on individual family relationships and on the extended family, covering such issues as employment, parenting, childbearing and inheritance, and emotional health. Silver treats aspects of chronic pain not covered in a typical office visit: how men and women differ in their experience of chronic pain, the effect of chronic pain on a toddler's behavior or an older child's performance in school, the risks of dependence on and addiction to pain medications, and practical ways for relatives beyond the immediate family circle to offer help and support to the person in pain.

How Children Understand and Cope with Pain

THE VERY YOUNG CHILD
Children in this age group are from birth to preschool age. The preverbal child is unable to vocalize where it hurts, and parents must look for clues of discomfort.

As children begin to talk, they can better communicate their pain or at least the fact that they have pain. However, it is impossible for children in this age group to be logical about their experiences. They understand things very concretely, and they believe that whatever they experience is very obvious to others. For example, a 3 year old who falls down without any obvious injury may exclaim, "Put the Band-Aid right there where it hurts! Can't you see it?" In this age group, children typically have fantasies and believe in "magical thinking." They may view pain as a punishment for an action or even a thought they had. The very young child also believes that adults have total control (ie, the ability to instantaneously make everything better). If they develop chronic pain, they may assume that their parents are angry with them and that they are being punished. They may believe that their doctor or therapist could instantly take their pain away but choose not to. In the preschool-age child, changes in behavior are often more important than what the child is able to communicate about his or her pain.

THE OLDER CHILD
School-age children begin to become less egocentric and more logical. They can begin to understand and describe their pain. Most children by the time they enter school are able to have a limited understanding of the word pain and what it entails. Their reasoning is generally based on direct observation, and they tend to be very concrete rather than abstract. A child in this age group typically describes pain as "a sore thing" or "a thing that hurts." Since their ability to understand is based on direct observation, most children in this age group believe that when someone is ill, they go to the doctor and get well quickly. Chronic illness or pain is confusing to them.

THE ADOLESCENT CHILD
Adolescents are able to generalize, reason deductively, and comprehend abstract ideas. Their definition of pain is generally more refined, and when asked to describe what pain is, they will typically respond with answers like "a physical sensation that occurs when the nerves are injured" or "something physical or psychological that hurts a person." Adolescence is a time when teens are excessively focused on their bodies and how they look and perform. It is a time when the "herd mentality" is at its height and children want to be like their peers. For better or worse, adolescence is a time when children are harshly judged by their peers and the need to fit in becomes a primary consideration. The teenager who has chronic pain, particularly if he or she has a condition that is physically obvious to others, may suffer dramatically during adolescence. Even if the condition is not apparent, there may be a stigma associated with reporting to the nurse for medications.

Immense peer pressure can drive many teens to try alcohol and/or drugs, and adolescents who are dealing with chronic pain might be particularly susceptible. They may participate in drinking or illicit drug use as a way to fit in with a particular group of people. Depressed teens might see it as a way to alter their mood, and to feel better about their situation. Both teens and adults can also use these substances to "treat" their pain. Parents of adolescents under the best of circumstances should be concerned about the possibility of their children using drugs and alcohol, but in the chronic pain population, health care providers and parents should be particularly vigilant.

Julie Silver, MD, is an assistant professor at Harvard Medical School and a staff physiatrist at Spaulding Rehabilitation Hospital, Boston.

REFERENCE

Schecter NL, Berde CB, Yaster M, eds. Pain in Infants, Children, and Adolescents. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2003.

SUGGESTED READING

Morris D. The Culture of Pain. Berkeley, Calif, and Los Angeles: University of California Press; 1991.
Rey R. The History of Pain. Cambridge, Mass: Harvard University Press; 1993.
Silver J. Chronic Pain and the Family. Cambridge, Mass: Harvard University Press; 2004.
Vertosick F. Why We Hurt: The Natural History of Pain. New York: Harcourt Inc; 2000.
Wall P. Pain: The Science of Suffering. New York: Columbia University Press; 2000.

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October 2004