Assessment of Childhood Chronic Pain: Focus on Functioning

by Jack H. Nassau, PhD

Chronic pain in childhood is a common medical problem with many potential detrimental biological, psychological, and social effects. Over time, chronic pain can influence, and be influenced by, biological systems (e.g., sleep patterns, the way the nervous system processes pain signals), psychological functioning (e.g., emotional well-being, ability to concentrate), and social functioning (e.g., school attendance, participation in peer and family activities). Importantly, these effects often interact with one another. For example, sleep disruption may lead to fatigue that interferes with school attendance. Or, decreased physical and social activity may lead to poorer mood. And on top of it all, pain hurts!

CABL logoThis article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” This definition highlights that pain is both a physical and emotional experience. The experience and expression of pain differs among people and is always subjective. In other words, different people may feel and express the same exact physical injury very differently and the same person may feel and express their own pain differently in different situations (e.g., with a friend, at school, at home). This is especially true in chronic pain as the ongoing pain experience exerts effects on the person (e.g., their thoughts, feelings, and behaviors) and as the environment (e.g., how others respond to the pain) exerts effects on the pain.

Assessment of Childhood Chronic Pain

Despite the complexity of the experience, expression, and effects of chronic pain, traditional assessment of chronic pain has often focused on pain location and intensity, sometimes including pain frequency and duration. For example, a child who frequently comes to the school nurse with pain may be asked “Where does it hurt?” and “How much does it hurt?” In this scenario, the child may also be asked “How often are you having the pain?” and “How long does the pain last?” Pain intensity, the most frequently assessed aspect of pain, is either measured with a numeric scale (the child is asked to give a number between 0 and 10 to define pain intensity), a visual analogue scale in which the child marks on a line how bad the pain is, or a FACES scale on which the child picks from an ordered series of facial expressions how bad the pain feels. Each pain intensity assessment ultimately yields a numerical score. Unfortunately, as many parents and nurses can attest, these scores are often off the scale (e.g., a child reporting “12!” on a 0 to 10 scale) or seem inconsistent with what the child is observed to be doing (e.g., the child picks the face showing the worst pain while joking with a friend). Such inconsistencies can be confusing and frustrating and provide a basis for complementing traditional pain assessment with measures that assess functioning in the moment and over time.

The Case for Functional Pain Assessment in Chronic Pain

As discussed earlier, chronic pain can take a significant toll on daily functioning. In addition, most chronic pain treatment programs emphasize improving functioning as the core treatment intervention and outcome. Thus, assessment that focuses on functioning with respect to what the child is doing on a daily basis and in the moment (e.g., is he attending school or sleeping through the day, is she playing sports or being inactive, is he seeing friends and spending time with family or secluding himself), and with respect to what the child is doing (or not doing) to manage or cope with pain, is consistent with the effects of chronic pain as well as desired treatment outcomes.

The first step in functional pain assessment is to change the assessment of pain intensity from a numeric rating to an assessment of how much the pain is interfering with functioning. The traditional numeric rating inadvertently suggests that pain intensity is an objective measure, whereas a functional rating supports the notion that the pain is subjective and influences functioning in different ways.

For example, in functional pain assessment, a child might rate his pain as “mild” (the pain is there, but it isn’t bothering me much), “moderate” (the pain is bothering me, but I can still do things), “severe” (the pain is bothering me a lot; I can’t do very much), and “very severe” (I can’t do anything but rest). Although there is still a component of how the pain is feeling (i.e., how much it is bothering the child), the focus is on how the pain is affecting what the child believes he can do. This encourages the child to consider what he can do in the moment, and also gives the parent or nurse a context in which to interpret the pain. It also provides a strategy for increasing the child’s functioning (e.g., asking the child what he will be able to do next).

The second step in functional pain assessment is to include questions about how the child is functioning in the moment to manage the pain. In the traditional pain assessment model, reports of pain often lead to medication administration. Although daily medications may be prescribed for chronic pain, the reliance on additional as-needed medications can be problematic, even increasing pain over time. Therefore, in cases of chronic pain, it is important to respond to pain reports with support that encourages a range of nonpharmacological pain management strategies. These include: comfort measures (a cold or warm compress); distraction techniques (squeezing a stress ball, drawing, or listening to music), some of which may also provide for emotional expression; relaxation training techniques (diaphragmatic breathing, guided imagery visualization, or progressive muscle relaxation); physical activity (physical therapy or other exercise); and re-engagement in current activity (going back to class, going out with friends). Of course, it is helpful to have a pain management plan already in place so that it can be put into action quickly when needed. For example, the child may know to use different techniques based on the functional assessment of the pain (e.g., do something physical or go back to class to treat mild or moderate pain, but use a cold or warm compress to treat very severe pain). That way, the child can be prompted to use a pain management strategy by completing the functional pain assessment and being asked “What are you doing to manage the pain?” or “Which strategy will help you manage the pain best?” In this way, the child is empowered to manage the pain with the goal of getting back to full functioning.

Challenges to Using Functional Pain Assessment

Shifting from a more traditional pain assessment to a functional pain assessment is not without challenges. First, the child in pain (and perhaps his family or others, too) may interpret a focus on functioning as a belief that the child’s pain is not real (i.e., that it is “all in the child’s head”). It is imperative that everyone working with the child appreciate that the child’s pain is real and that everyone empathize with how difficult it can be physically and emotionally to recognize the impact pain has had and also to respond to pain with nonpharmacological strategies and activity. Second, the child (and others) may be fearful of causing more pain by reducing reliance on medications and by using parts of her body that already hurt. It is imperative to normalize this fear and to provide anticipatory guidance that, in fact, pain may increase in the short run, particularly if the child has become deconditioned. This pain can be interpreted as progress in that it is a sign that the child is becoming more active. Third, the child (and others) may believe that a focus on functioning means that caregivers are not continuing to explore medical underpinnings for the pain. Although it is true that some families will need to be supported in not continuing to pursue medical testing and intervention, there is no inherent conflict in adopting a functional approach to pain assessment while also continuing the medical workup.

Jack H. Nassau, PhD, is chief psychologist in the Hasbro Children’s Partial Hospital Program at Rhode Island Hospital/Hasbro Children’s Hospital. He is a clinical associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University.


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