Things to know about pain in children

The work I do that relates to pain in children has been mostly with moderate to severe pain. Our team includes Erin Brown, Alexandra De Young, Belinda Dow, Rebecca Moore and Jo Butler. We are psychologists working with traumatically injured and critically ill children and their families. The type of traumatic injury that we have had most to do with is burn injury. We have also focused part of our work on children undergoing intensive care and those who have had a brain injury. So what I am describing is based largely on these experiences and learnings from them.

In general we tend to know less about child pain than adult pain. This may be in part explained by the greater uncertainty about the experience of pain that a child has. Nonetheless, many children will experience some significant pain at some time during their childhood and the most common experiences of pain in children are abdominal pain and headache pain. About 15 per cent of children will have chronic pain of some sort (Goodman & McGrath, 1991).

Pain in children

Adults and children experience and express pain differently. This is related to both physical and cognitive development. For example, neonates have the same number of pain receptors as adults; but they have not fully developed the pain inhibitory synaptic connections that an adult will have, this means that neonates may be predisposed to experience more significant pain than adults (Scanlan, 1991). Similarly, the younger child will have less cognitive capacity to verbally express and describe pain than older children and adults. This means non-verbal, behavioural and non-specific expressions of pain will be the more standard way of pain being manifest in younger children. For example, younger children tend to express their pain through non-specific physical symptoms such as tummy aches, distractibility, social and emotional withdrawal, or conversely irritability and acting out, changes in sleep and appetite. Rather than make judgments about actual pain levels, their parent will observe changes in the younger child from their usual selves.

Pain can be initiated by a physical stimulus, but it is the psychological processes that are at the core of the experience of pain. While pain is by its nature unpleasant, it is the sensitivity to and distress associated with the pain that makes it more or less bearable. Pain for a child can be very distressing for developmental reasons described earlier, but that pain can also be equally distressing for their parent or carer.

From our work we know that there are directional relationships between pain and clinical levels of distress in children. For example, while early pain predicts later pain, early distress also predicts later pain as well as distress in children (Brown at al., 2014). We also know that parents react and behave quite differently towards their children’s pain and distress. For example, children might express pain and distress verbally (crying, verbal statements) or non-verbally (aggression, pushing away). Parents may respond through behaviours that promote coping in the child (distracting talk or actions, humour) or promote distress in the child (reassurance, asking child about pain, expressing distress).

Our research (Brown et al., 2019) found that distress-promoting behaviour by the parent predicted increased distress behaviour in the child, and coping-promoting behaviour in the parent predicted coping behaviour in the child. Furthermore, heightened psychological distress that parents reported beforehand was associated with decreased coping-promoting and increased distress-promoting behaviours, and these behaviours mediated the impact of the parents’ initial distress on their child’s distress and coping.

Acute pain

Assessment

The Faces Pain Scale-Revised (Hicks et al., 2001) is the most widely used and arguably best-validated measure of acute child pain. It is brief, does not require the child to read, but instead uses six faces displaying response to differing pain intensity. The Verbal Numeric Pain Scale (Bailey et al., 2010) is one of a range of brief acute pain measures used to assess pain in children including visual analogue scales (VAS). The child is asked to rate their pain experience from no pain to the worst imaginable on a 10-point scale. It is brief, simple and convenient to use.

Intervention

In non-pharmacological acute pain management, distraction from a focus on pain, hypnosis-guided relaxation and imagery are the two approaches with the most evidence in children (Birnie et al., 2014). Because of the specialised skills and training required to deliver hypnotic interventions, distraction tends to be the most commonly applied approach. Strategies that encourage calming and supportive communication (both parent and child) can facilitate coping.

How can psychologists help with acute pain?

• Be aware of pain as a possible explanation for psychological and behavioural changes in children.
• Understand the developmental dimension to pain in children.
• Recognise that earlier intervention for pain and distress should be the priority.
• Understand the important role that parents, caregivers and other healthcare providers can have in reducing the impact of pain and improve coping with pain, particularly through their communications with the child and managing the parents’ and child’s distress.

Chronic pain

As with adults, children can experience chronic pain. This is most often associated with a chronic medical condition such as arthritis. Chronic pain can have a significant impact on many aspects of the child’s development, such as physical, social, emotional and cognitive. An important role for psychologists is to provide assistance to the child and their family to enable better coping with the pain and management of the pain impacts.

Assessment

The Bath Adolescent Pain Questionnaire (Eccelston et al., 2005) is a comprehensive measure of pain experience, behaviour and cognition. It has excellent psychometric properties and is one of the only comprehensive measures of pain for children. The Pain Catastrophizing Scale for Children (Crombez et al., 2003) is a widely used measure of pain catastrophising designed for this age range. It has excellent psychometric properties. Fear of pain is an emerging concept in management of chronic pain in children. The Fear of Pain Questionnaire for Children (Sieberg, Williams, & Simons, 2011) is perhaps the most widely used of the recently developed measures.

Intervention

In comparison to chronic pain in adults there is a much more limited evidence-base available for children and that evidence is generally of poor quality. Furthermore there is very little evidence on interventions that target the parents of children with chronic pain. The available evidence supports cognitive behaviour therapy targeting pain behaviour and cognitions as a valid part of chronic pain management (Fisher et al., 2018).

How can psychologists help with chronic pain?

• Collaborate with other professions to address both physical and psychological aspects of pain.
• Build motivation for behavioural change.
• Consider lifestyle changes that may help.
• Address outcomes of chronic pain like sleep problems and anxiety.
• Parent education and skills training is essential.

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