A conceptual model and practice framework for managing chronic pain in children and adolescents

Pain is a complex phenomenon: a sensory experience originating in traumatized tissues; an emotional (affective) experience that signals danger in the internal (body) or external environment; and a "disposition to act" that results either in "action" that prioritizes escape or in "inhibition of action" to minimize injury or facilitate healing. Recent advances in our understanding of the affective components of pain have significant implications for the treatment of chronic pain in children and adolescents. This article describes a chronic pain clinic for children and adolescents developed by the pain service of a large pediatric teaching hospital. Pain is conceptualized and managed in terms of multiple, interrelating systems (the body level, the psychological level, and the social level). This model of care is illustrated with reference to the management of two cases of children with chronic pain and significant functional impairment. A brief overview of the care utilization of 62 children referred to the Chronic Pain Clinic is also provided, with the clinical characteristics of 40 children with somatoform pain disorder (SPD) being described in more detail. Of 28 children with SPD treated with our systems intervention, 82% reported significant reductions in pain intensity, 71% returned to school full time, and 29% part time. An advantage of this integrated, family-based assessment and treatment approach is the overarching emphasis on identifying the contribution of each system to the child's subjective experience of pain, thereby avoiding the deleterious polarization of the pain as either physical or psychogenic in origin.