A common complaint heard in pediatric primary care offices is “She often has headaches and stomachaches that usually last for hours to days.” Parents also frequently report mood, anxiety, and behavioral problems that coexist with the chronic pain. Chronic pain disorders in children and adolescents can have immediate and long-term consequences, which can lead to poor school attendance as well as problems with learning, social adjustment, and relationships (Landry et al., 2015). If not properly treated, chronic pain can affect the social and emotional growth trajectories of children and adolescents. Approximately one half of children with functional abdominal pain continued to report chronic non-abdominal pain as adults (Walker, Dengler-Crish, Rippel, & Bruehl, 2010).
Child and adolescent psychiatrists and psychiatric advanced practice RNs (APRNs) have considerable knowledge of psychotherapies, medications, comorbid illnesses, and functional outcomes of pain management in this population (Majeed, 2018). However, it is rare to see these health care professionals applying their knowledge as active members of multidisciplinary teams involved in the care of chronic pain disorders in children and adolescents.
Definition and Prevalence of Chronic Pain
Chronic pain is defined as pain that lasts more than 12 weeks or persists beyond the usual tissue healing time (Treede et al., 2015). Chronic pain can be persistent, recurrent, intermittent, or episodic in nature. Chronic pain is more than a mere unpleasant physical sensation, as it often involves emotional and psychological responses, which activate the reward or aversion response pathways in the brain (Treede et al., 2015). The International Association for the Study of Pain defines chronic pain as “an unpleasant sensory and emotional experience” (Merskey & Bogduk, 1994). Chronic pain is considered an illness involving sensory abnormalities of the central nervous system, resulting in an excessive response to sensory stimuli, and it is often associated with dysphoria and the desire to feel better (Apkarian, Baliki, & Geha, 2009).
Chronic pain is one of the most frequently reported complaints in health care settings around the world. Approximately 126 million individuals in the United States experienced some pain in the past 3 months (Nahin, 2015). Although the majority of these individuals are adults, chronic pain is also common in children and adolescents. Stanford, Chambers, Biesanz, and Chen (2008) reported that 31.8% of children and adolescents experience weekly chronic pain episodes. Other studies report chronic pain in 50% to 54% of children and adolescents (Perquin et al., 2000; Sundblad, Saartok, & Engström, 2007). The estimated cost for treatment of pain in youth is $20 billion annually (Groenewald, Essner, Wright, Fesinmeyer, & Palermo, 2014). Visceral, neuropathic, and somatic pain are the most common types of chronic pain conditions among children and adolescents; these are expressed in the form of headaches (8% to 83%), abdominal pain (4% to 53%), backache (14% to 24%), and multiple organ pain (4% to 49%) (King et al., 2011). Chronic pain in youth is more prevalent in females of lower socioeconomic status (King et al., 2011).
Mental Health and Chronic Pain Relationship
There is a considerable overlap between the neuronal pathway of chronic somatic pain and emotional pain, as both involve the mesocortico-limbic dopaminergic pathway and endogenous opioid system (Elman, Zubieta, & Borsook, 2011). Functional magnetic resonance imaging studies of the brain have shown that emotional pain stimulates the somatic pain system, and the somatic pain system activates the nucleus accumbens and ventral tegmental areas, which are the seats of emotion and reward pathways (O'Connor et al., 2008). This biological evidence underscores the complex and bidirectional association between physical and emotional pain.
These neurobiological and neuro-anatomical underpinnings reveal the interface between chronic pain, mood dysregulation, and other psychiatric symptoms. In chronic pain conditions, these neurological pathways are altered and cause cognitive and emotional impairment, which explains the high co-occurrence of pain and mood disorders (Berna et al., 2010). The most common comorbid illnesses with chronic pain are mood disorders, anxiety disorders, illness anxiety disorder, somatic symptom disorder, and behavioral problems (Elman et al., 2011). Sometimes anxiety and mood disorders arise secondary to pain conditions particularly as a consequence of musculoskeletal pain disorders (Landry et al., 2015). Among the most common causes of amplified pain conditions in children and adolescents are psychosocial factors such as psychopathology, parental modeling of pain, personality issues, and poor coping mechanisms (Hoffart & Wallace, 2014).
Pain Disorders in Psychiatry
Somatic symptom disorder with persistent pain is a common condition encountered in primary care settings and may lead to a referral to mental health providers. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 2013) has eliminated pain disorder as a separate category; however, somatic symptom disorder (F45.1) can be specified with predominant pain and further specified as mild, moderate, or severe (APA, 2013). To meet criteria for somatic symptom disorder, symptoms present without any evident medical explanation; thoughts and worry about pain are persistent; excessive time and energy is spent on health concerns; and significant distress and disruption to daily life occurs (APA, 2013).
Mental Health–Centered Approach to Treat Chronic Pain
Although not focused primarily on children and adolescents, psychologists have been leaders in the field of pain medicine for the past half-century. Early pioneers in the field such as Fordyce, Melzack, Wall, Kerns, Turk, and Stone established several research and clinical programs across the country to train a new generation of pain psychologists (Gallagher, 2016). Cognitive-behavioral therapy, biofeedback, and relaxation-based therapies have shown strong evidence of being effective in the treatment of chronic pain disorders in adolescents (Landry et al., 2015). The discipline of pain psychology proliferated over the years, and is now an integral part of primary care practices in the two biggest health systems in the United States—the Veterans Administration and Kaiser Permanente.
Chronic pain in children and adolescents is a complex phenomenon and cannot be treated successfully with medication alone. A mental health–centered multidisciplinary approach is necessary for these patients, with an emphasis on psychosocial interventions to alleviate suffering and foster autonomy by treating pain and coexisting conditions. In the context of a biopsychosocial model, an individualized treatment plan that includes cognitive, behavioral, and biofeedback strategies may be helpful in improving symptoms and obtaining better treatment outcomes.
The discipline of psychiatry provides an ideal framework for treating children and adolescents with chronic pain disorders. Clinicians in child and adolescent psychiatry are well-trained in a biopsychosocial model that can be effectively applied to pain conditions. Moreover, these clinicians are experts in the use of several psychotropic medications and psychotherapeutic interventions for the treatment of chronic pain (Majeed, Ali, & Sudak, 2018a,b). Because there is an inherent risk of addiction, overdose, and death in patients treated with opioid medications for pain, mental health clinicians may have an advantage when managing pharmacotherapy because they have advanced knowledge and training in the treatment of addiction. These clinicians have expertise in applying psychosocial interventions, establishing therapeutic alliance, and setting appropriate treatment expectations, which are necessary in the treatment of chronic pain (Majeed & Sudak, 2017; Majeed, Ali, & Sudak, 2018a,b). This unique skill set provides mental health clinicians an advantage over other professionals in the treatment of chronic pain disorders (Majeed, 2018). The missing piece in a multidisciplinary approach to treating chronic pain in children and adolescents is the presence of mental health clinicians with education and training in the field of pain medicine. Child and adolescent psychiatrists and psychiatric APRNs can play an important role in such teams by contributing centrally to intensive interdisciplinary pain rehabilitation programs and coordinating the care of pain disorders in patients with co-morbid psychiatric illnesses.
Mental health clinicians would benefit from receiving more education and training about pain management during their professional education. Increased training could provide more human capital to treat this underserved patient population. By increasing the active involvement of mental health clinicians, an alternative perspective would help provide a more comprehensive treatment approach, which would likely improve patient care and help better manage the population with comorbid psychiatric illnesses and chronic pain conditions. As a result, care to the often-neglected patient population would likely improve. A mental health professional can coordinate a multidisciplinary care team with relevant clinical help to serve the needs of youth with pain and psychiatric disorders.
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