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American Pain Society
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David A. Williams, PhD, Department Editor
Brenda Bursch, PhD
The Pain in Infants, Children, and Adolescents Special Interest Group (SIG), chaired by Gary A. Walco, PhD, formed a task force that met in August 1999 to write a policy statement on the management of chronic pain in children. Members of the task force are Brenda Bursch, PhD (chair), Julie Collier, PhD, Michael Joseph, MD, Leora Kuttner, PhD, Patrick J. McGrath, PhD, Navil Sethna, MB ChB, Gary Walco, PhD, and Lonnie Zeltzer, MD. The following excerpts from the policy statement reflect the fundamental position of the task force. The statement will be presented to the APS Board for review before it is released in its entirety.
“Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect 15%Ð20% of children (Goodman & McGrath, 1991). Children and their families experience significant emotional and social consequences as a result of pain and disability. The financial costs of childhood pain may also be significant in terms of healthcare utilization as well as other indirect costs, such as lost wages due to time off work to care for the child (Li et al., in press). In addition, the physical and psychological sequelae associated with chronic pain may have an impact on overall health and may predispose for the development of adult chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke, & Greene, 1995).”
“Chronic pain in children is the result of a dynamic integration of biological processes, psychological factors and social/ cultural context considered within a developmental trajectory. This category of pain includes persistent (ongoing) and recurrent (episodic) pain with possible fluctuations in severity, quality, regularity and predictability. Chronic pain can occur in single or multiple body regions and can involve single or multiple organ systems. Ongoing nociception can result in a sensitization of the peripheral and central nervous systems to produce neuro-anatomical, neurochemical and neurophysiological changes. It is important that assessment and treatment strategies be based on this definition and related dimensions.
“To evaluate and treat chronic childhood pain efficiently and effectively the mind/body dualism must be abandoned. It is meaningless to dichotomize chronic pain as organic versus non-organic because all pain is associated with, at minimum, neurosensory changes. Maintaining this dichotomy is harmful because such faulty thinking leads to overmedicalization (inappropriate investigations, procedures, and interventions) or insufficient acknowledgment of the child’s multi-dimensional experience and underlying neurophysiology.
“Chronic pain may include varying amounts of disability, from none to severe, and may be independent of amount of tissue damage and perceived severity (Melzack & Wall, 1965). Biological, psychological, social, cultural, and developmental factors each can impact pain-related functioning.”
“An evaluation of a child with chronic pain should include consideration of the biological, psychological and social cultural factors in the developmental context... (Bursch, Walco, & Zeltzer, 1998).
“Treatment strategies should be based on the findings of the assessment and should address the inciting and contributing factors. A multi-modal approach is often more effective than a single sequential treatment approach. This approach includes specific treatment targeting possible underlying pain mechanisms, as well as symptom-focused management addressing pain, sleep disturbance, anxiety, or depressive feelings... . Treatment should also address pain-related disability with the goal of maximizing functioning and improving quality of life...Evidence based treatments should be used whenever available.”
Bursch, B., Walco, G.A., & Zeltzer, L. (1998). Clinical assessment and management of chronic pain and pain-associated disability syndrome. Journal of Developmental and Behavioral Pediatrics, 19, 4553.
Campo J.V., Di Lorenzo C., Bridge J., Chiappetta L., Gartner J.C., Gaffney P., Kocoshis S., & Brent D. (1999, May 16). Adult outcomes of recurrent abdominal pain: Preliminary results. Paper presented at the meeting of the American Gastroenterological Association, Orlando, FL.
Goodman, J.E., & McGrath, P.J. (1991). The epidemiology of pain in children and adolescents: A review. Pain, 46, 247264.
Li, B., & Baliat, J.P. (in press). Cyclic vomiting syndrome: The evaluation of understanding of a brain-gut disorder. Advances in Pediatrics.
Melzack, R., & Wall, P.D. (1965). Pain mechanisms: A new theory. Science, 150, 971979.
Walker, L.S., Garber, J., Van Slyke, D.A., & Greene, J.W. (1995). Long-term health outcomes in patients with recurrent abdominal pain. Journal of Pediatric Psychology, 20, 233245.
