Authors

  1. Wakefield, Emily O. PsyD
  2. Jerson, Bradley PhD

Article Content

Learning Objectives/Outcomes: After participating in this CME/CNE activity, the provider should be better able to:

  

1. Describe the importance of the biopsychosocial approach to adolescent chronic pain evaluation and treatment.

 

2. Identify 2 reasons why social aspects of chronic pain are important to understand in the context of the adolescent pain experience.

 

3. Explain the main components of a multidisciplinary treatment approach for adolescent chronic pain.

 

Pain is common and often contributes to significant functional impairment in those who suffer from it on a chronic basis. When individuals experience pain during the critical developmental period of adolescence, further social isolation, academic difficulties, and identity disruption these young patients can experience. The developmental intersection of adolescent biological, psychological, and social factors complicates clinical evaluation of pain for health care providers. This article briefly underlines these multifactorial contributions to chronic pain among adolescents and describes psychosocial competencies for health care providers in the evaluation and treatment of chronic pain in adolescents.

 

Definitions, Terminology, and Prevalence of Adolescent Chronic Pain

Chronic pain conditions among pediatric populations have been on the rise over the past 25 years. According to the International Association of the Study of Pain, chronic pain is defined as pain lasting more than 3 months1 that can be intermittent or persistent in nature. Common pain symptoms within this population include headache and abdominal, back, and diffuse musculoskeletal pain2 and are often unexplained by medical findings. This article focuses on chronic pain that is not linked to an underlying disease process definitively through medical evaluation. Terms that have been used to describe this type of pain include "pain amplification syndrome," "functional pain," "pain without organic cause," and "medically unexplained symptoms." We use the term "chronic pain" to describe these overarching concepts and discourage the use of terminology that implies a lack of biological contributions to pain symptoms within this population. A dualistic view of this condition underappreciates the complexities of chronic pain. Instead, we present an integrative conceptualization of biological, psychological, and social factors that comprehensively reflect the underlying processes contributing to chronic pain.

 

Research on the prevalence of pediatric chronic pain has been inconsistent; however, a well-conducted systematic review by King and colleagues3 determined the median prevalence for pediatric chronic headache as 23% and 11% to 38% among other pain sites without a known medical pathology. There was evidence to suggest higher prevalence among females and among older ages.3 Psychosocial stressors, including low socioeconomic status, have also been linked to a higher incidence of chronic pain.4

 

Biopsychosocial Conceptualization of Chronic Pain

Adolescent chronic pain is influenced by several factors that are both biological4,5 and psychological6,7 in nature. Biologically, a family history of chronic pain increases the risk of developing chronic pain conditions among pediatric populations. There is evidence to support unique attribution of pubertal development in the onset and development of pain symptoms among adolescents of both sexes.5 Several other important biological contributions to chronic pain include, but are not limited to, neurobiological and high hypothalamic-pituitary-adrenal axis reactivity.8 As we have focused primarily on psychosocial aspects, and thus do not explore these biological elements in greater detail, readers are encouraged to review these references for more information.

 

Psychological contributions are salient in the evaluation and treatment of adolescents with chronic pain. The ability to cope and manage stress along with other emotional symptoms can influence the impact of pain symptoms on daily functioning within this population. For example, functioning among adolescents with chronic pain does not depend on the severity of the pain intensity, but rather is better accounted for by depressive symptoms.7 Moreover, evidence from the National Comorbidities Survey Replication Adolescent Supplement shows that 25% of adolescents with chronic pain reported a mental health disorder in their lifetime,9 most commonly anxiety and depression. Thus, the use of a biopsychosocial conceptualization is considered the gold standard in the evaluation and treatment of chronic pain (Figure 1).

  
Figure 1 - Click to enlarge in new windowFigure 1. Biopsychosocial model of adolescent chronic pain.

A biopsychosocial conceptualization of pediatric chronic pain is best viewed through a "systems" lens. With this approach, providers are able to perceive that a child or adolescent's environmental systems contribute to his or her individual developmental experiences. For example, there is an ongoing interaction between environmental influences such as immediate families, schools, or health care teams (and potential subsystems, such as sibling or parent-child relationships).

 

The exchange between these different environmental systems influences adaptation; for example, the relationship between the health care team and the family, or the school's relationship with the health care team. At the more distal level, individuals are indirectly influenced by parental levels of social support, employment, or even medical team morale. We briefly explore these various spheres of influence and discuss why they are important to consider when developing treatment plans for an adolescent with chronic pain.

 

Individual Factors of Adolescence

There are many developmental considerations for youth with chronic pain, given the impact on psychosocial and daily functioning. Compared with children, adolescents and young adults are likely to seek more autonomy, which is associated with greater physical and cognitive change and increased responsibilities. They are more able than children to understand and internalize complex processes and value sets. Considering Erikson's theory of psychosocial development, this time is a period for consolidation of identity; a failure to complete essential developmental tasks may result in role confusion.10 Compared with individuals in their early teen years, older adolescents and young adults are more capable of planning, delaying gratification, stabilizing their interests, and making independent decisions.

 

Successful developmental growth during childhood and adolescence is imperative for adjustment in adult life,11 and chronic pain may disrupt milestones and the natural progression of autonomy and skill building. Achieving autonomy over dependency is a key developmental experience for adolescents. Without this development, individuals may experience problematic social, emotional, and physical outcomes. In addition, just as in healthy adolescents, those with chronic pain attempt to negotiate their own development with the demands of their families, peers, and surrounding culture. This becomes problematic for adolescents with chronic pain because sequelae can sometimes impede their capacity for autonomy and reinforce dependency. Possibly because of the common failure to negotiate this time successfully, there is a greater incidence of psychosocial dysfunction in adolescents with chronic medical conditions.12 In addition, cognitive advances in the problem-solving abilities of adolescents may not directly translate into effective medical management; decline in treatment adherence during adolescence is remarkably common across illnesses.13,14

 

Family Environment

Adolescence should be a time in which the parent-adolescent bonds are loosened in conjunction with an adolescent's increased desire to form relationships outside the family. Most healthy families typically restructure their existing boundaries to accommodate the movement into and out of the family; however, a chronic medical condition typically brings families closer together, initiating centripetal forces that lead to an increase in family cohesion.15

 

Although this closeness can be helpful during the initial onset of symptoms, the process of adolescent-adult separation can be in danger if the family ties are strengthened too much. Thus, adolescents dealing with chronic pain can struggle with balancing the extreme closeness that emerges because of dealing with an illness and the appropriate distancing they are expected to desire as part of normal development. This sequence subsequently may have adverse implications for mastery of peer relationships throughout adolescence and emerging adulthood.

 

Families also play an important role in modeling the style of cognitive appraisal regarding pediatric chronic pain. For example, positive, optimistic, confident perceptions of the adolescent's ability to function despite the pain may improve cohesive family functioning and can help the child feel less stressed and adjust more successfully. By the same token, families also can easily exacerbate symptoms through models of pain catastrophizing, negative modeling, and excessive accommodation to the pain.

 

Peers

Adolescence is considered a crucial period for peer development, as an individual increases his or her differentiation from caregivers. Social relationships increase in complexity and importance, as does the need to navigate these relationships successfully. Adolescents with chronic pain are subject to functional limitations, often leading to social isolation from peers.16 Thus, the development of new friendships or interaction with their current peer group is impaired. This setback can be particularly troubling for adolescents who participate in competitive athletic activities because of both the loss of physical engagement and associative friendships. Typically, reduced participation in sports is associated with peer distancing.

 

Just as healthy peer interactions can play such a protective and beneficial role in nurturing an adolescent's social and educational environment, the opposite is also unfortunately true. For individuals with pain, the impact of peer difficulties is just as well known as the healthy interactions are. Peer victimization and bullying has emerged as a primary potential target of intervention in children and adolescents who experience chronic pain. Those with chronic pain are often isolated from their peers and at risk for greater interpersonal victimization and bullying.16

 

In a prospective diary study, adolescents with chronic pain completed daily diaries assessing pain intensity, disability, and peer victimization experiences, among other variables. Fifty percent of the sample reported at least 1 instance of peer victimization, with greater victimization being related to greater disability.17 This finding is not unique. For example, in a qualitative study, more than one-third of children with chronic medical concerns reported being bullied or teased, in the forms of verbal harassment, practical jokes, or public ridicule.18

 

It remains unclear whether these negative peer interactions precede the pain or are a response to the functional or developmental limitations in individuals with pain. In addition, as discussed earlier, the achievement of normal developmental milestones (including mastering positive peer relationships) and gaining autonomy may be less likely in those with chronic pain.

 

School Environment

Research supports that children and adolescents with greater pain intensity experience poor school outcomes, including more school absences and bullying experiences and lower school satisfaction and academic performance.19 According to Vervoort et al,19 there was no relationship between pain intensity and academic performance, but rather teacher support was a protective factor to academic outcomes. In addition, when children return to school after prolonged absences, ensuring a return to "normality" is often difficult. Such long absences create discontinuity and may result in perpetual difficulty in "catching up" and in underachievement compared with peers. In addition to these academic concerns, difficulties with social inclusion for children have been well documented.20

 

One study found that 47.1% of the nurses surveyed believed children were faking or seeking attention for their pain symptoms. This further emphasizes the vital role of collaboration between schools and medical teams.

 

Middle- and high-school personnel (including teachers, administrators, and nurses) have reported difficulties working with adolescents with chronic pain, noting several barriers to providing accommodations, such as with school policies.21 Regarding the knowledge and attitudes of school nurses toward youth with chronic pain, there seems to be a need for education and training. One study found that 47.1% of the nurses surveyed believed children were faking or seeking attention for their pain symptoms.22 This further emphasizes the vital role of collaboration between schools and medical teams.

 

Medical Environment

Adolescents need to rely on health care providers, teachers, peers, and family to accurately assess and understand their pain symptoms even if they are not able to provide physical evidence of their distress. Because of the subjectivity of pain self-report, others may be less likely to believe an individual's reported symptoms, as evidenced in adult chronic pain populations.23 As discussed earlier, families are vital to adolescents' appraisal of their pain. Similarly, medical teams' appraisal of the family unit is just as relevant. Medical team members hold both explicit and implicit judgments about families with whom they interact.

 

Adolescents and their families, when recounting their experiences with health care providers, report at times feeling "judged, disbelieved, and labeled as difficult or dysfunctional." Patients and parents typically see a number of subspecialists to rule out differential diagnoses. Research supports that families feel the need to justify a child's experience of pain without physical evidence.24

 

In a qualitative evaluation of families' "journeys" to find an accurate diagnosis and subsequent successful treatment plan, Carter25 describes how both positive and negative encounters with pediatric medical teams can significantly affect families' adherence to treatment plans. Families reported how they often felt ignored when their pain was reinterpreted through professional lenses, rather than believing children at face value for their perceptions of pain. In comparison, families reported that they thought providers who took the time to develop an understanding of the patient's narrative and unique experiences were more "trustworthy."

 

Although it is known that families may often adversely contribute to symptom exacerbation, professionals should restrain from leaping to conclusions independently. When negative assumption about family modeling is assumed, families may perceive that professionals are blaming them for their child's pain. Although these factors are essential to consider, as discussed earlier, the family should be included within the medical team's decision-making and be viewed as a valuable resource.

 

Implications for Practice

A comprehensive multidisciplinary treatment approach that includes medication management, physical therapy, and psychological intervention (specifically cognitive-behavioral therapy, or "CBT") has been well documented as an effective component in the treatment of chronic pain.26 It is important for families to understand that not all "therapy" is created equal. Unfortunately, there continues to be a stigma associated with accessing mental health services, thus the label of "psychology" may be prohibitive for individuals who could greatly benefit from incorporating psychological strategies into their care plan. Particularly for adolescents, they may be quick to hear provider recommendations for psychotherapy as "the symptoms are all in your head."

 

Adolescents with chronic pain endure significant disruptions to their daily routines and may perceive the possibility of "being a normal teen" as an unattainable goal. It is helpful to access pockets of motivation they may have for improvement (eg, wanting to return to a sports team, spend more time with friends with less pain, and being able to attend college away from home), while dispelling some of the myths associated with psychotherapy.

 

Medical providers can be influential in preparing adolescents with chronic pain and their families for psychotherapy by describing the bidirectional relationship of pain and stress in the context of the biopsychosocial model of chronic pain. Palermo,27 in her discussion of cognitive behavioral therapy (CBT) for pediatric chronic pain, shares the following narrative:

 

Before we get any further, I want you to know that you are not here because anyone thinks that your pain is all in your head or made up. Even if we don't know for sure the causes for your pain, we know that the pain is real. Lots of different things contribute to pain, including your genetics (genes that mom and dad passed along to you); your body (like how much your joints move and how sensitive your intestines are); and your behaviors and emotions. Research tells us that psychological interventions are an effective way to help children with various health conditions and their families. This does not mean that emotions or behaviors caused your symptoms, although we know they certainly can make them worse. And we know that just having these symptoms can cause significant stress for children and their families.27

 

So what is CBT? CBT emphasizes the role of thoughts and behaviors in how we feel and what we do. For adolescents with chronic pain, the situation of pain sensitivity or other life stressors may not specifically change. Therefore, it is important for them to learn how to change the way they think about the situations to influence the way they feel.

 

CBT is not "just talking about the problem," but rather has been referred to as "collaborative empiricism."28 It is brief, instructive, goal directed, and adolescents are expected to be active participants in the treatment. The expected outcome is not to completely eliminate pain, but to improve daily functioning and reintegrate into routines and activities despite the pain.

 

Strategies in CBT include behavioral stress management techniques (eg, diaphragmatic breathing, progressive muscle relaxation, and guided imagery), improving sleep hygiene, addressing parent and patient perception of threat levels of pain, and reframing and reevaluating evidence for catastrophic predictions. These strategies target parts of the brain that are involved in pain/discomfort perception, and specifically changing daily behaviors affects long-term change. A vital part of this comprehensive rehabilitative approach is the reinforcement of physical activity.

 

Most adolescents with chronic pain experience a reduction in physical activity that furthers muscular atrophy and reinforcement of pain hypersensitivity. Physical therapy treatments specifically include a progressive graded approach to exercise and pain desensitization within the context of multidisciplinary treatment. Therapeutic exercises can improve aerobic endurance, strength, and range of movement, which are important goals, particularly for adolescents with musculoskeletal pain. Physical therapists also can offer other methods to relieve pain, including heat or ice, transcutaneous electrical nerve stimulation, and massage. The integration of behavioral interventions can improve adherence to physical activity goals among adolescents.

 

In addition, intensive multidisciplinary rehabilitation programs have been established within the pediatric pain literature to rapidly improve health outcomes, including pain intensity, functional ability, and psychological distress.27 Research specific to the exercise and desensitization components of rehabilitation among pediatric chronic pain with complex regional pain syndrome demonstrates maintenance of long-term outcomes.29 Although these rehabilitation services are offered in both outpatient and inpatient settings, there is less availability of inpatient pain rehabilitation programs. The level of intervention tends to be determined based on the severity of functional impairment and lack of therapeutic success using outpatient modalities.

 

Conclusion

Health care providers evaluating and treating chronic pain among adolescents need a broad appreciation for the complex nature of adolescent chronic pain in the context of the aforementioned developmental and social influences. Given these complexities, health care providers should be cognizant of communication that minimizes or invalidates an adolescent's report of his or her pain symptoms in the scenario of negative medical findings. Rather, providing an explanation and reassurance of the adolescent's pain condition within a biopsychosocial context can improve treatment expectations and recovery. A biopsychosocial conceptualization and treatment recommendations are salient for health care providers to use in their evaluation and treatment of adolescents given the multifactorial nature of chronic pain.

 

The importance of a positive working relationship between medical teams and the families of pediatric patients with chronic pain cannot be overstated. The use of metaphors has been shown to be a helpful tool in the explanation of chronic pain. According to Coakley and Schechter30:

 

You can think about pain signals being like trains passing through a railroad crossing gate. When the gate is all the way open, trains pass right through. Similarly, when the gate to your brain is open, pain signals have free access to your brain. Medication might close the gate partway, but for many people, medications do not close the gate completely. Other interventions such as learning cognitive behavioral therapy skills, distraction, engaging in acupuncture, and increasing activity can all be effective ways to close the gate and help to keep it closed.30

 

There is evidence to suggest that endorsement of the biopsychosocial conceptualization of chronic pain is associated with readiness for change and adherence among adolescents with chronic pain and their parents.31 Evaluating the impact of pain on social activities is salient in appreciating the developmental complexities of adolescent chronic pain. Although social stressors also can be addressed through psychological intervention, health care providers can be influential in addressing the educational needs of school personnel, including nurses, teachers, and guidance counselors, regarding how to approach and promote functioning in adolescents with chronic pain.

 

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Adolescent chronic pain; Biopsychosocial contributors; Integrative approach