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Pain is an increasingly common symptom in children and adolescents, and nearly 5% of the paediatric population now suffer from severe chronic pain conditions. This manual describes the inpatient treatment programme of one of the world’s largest treatment facility for chronic pain in children – The German Paediatric Pain Centre – and the guidance provided is also applicable to outpatient pain management. Epidemiology, aetiology, diagnostics and treatment principles are all examined in detail. Criteria for inpatient treatment are explained, and the structure and organisation of a treatment centre for chronic pain are described. Therapeutic interventions are presented with the aid of many examples of pain management and health care from clinical practice. Special features of pain therapy for children and adolescents suffering from comorbid mental disorders, family difficulties or physical complaints are also discussed.



1. Epidemiology of Chronic Pain in Children and Adolescents

Chronic pain is common in children and adolescents, affecting 20–25 % of this population. A total of 3 % of all children suffer severe chronic pain. In more than a half of those patients (1.7 %), the criteria for a chronic or somatoform pain disorder are met.
Michael Dobe, Boris Zernikow

2. Pain Disorder: A Biopsychosocial Disease

Pain is an individual and purely subjective experience. Pain processing depends on both somatosensory and emotional brain areas (e.g., the limbic system). Therefore, pain is never a purely sensory perception, but always includes emotional determinants. Finally, the family and other social contexts of the child are important determinants of pain perception. Hence, in order to better understand the origin and perpetuation of pain disorders, biological and psychological factors as well as the social environment have to be taken into account. In this chapter, we describe biological, emotional, cognitive, and social factors that play a role in the origin, perpetuation, and amplification of pain disorders.
Holger Kriszio, Julia Wager, Michael Dobe, Tanja Hechler, Boris Zernikow

3. Diagnostics of Chronic Pain in Children and Adolescents

By definition, a pain disorder is a biopsychosocial phenomenon. Irrespective of their individual proportion, diagnostics in pain disorders must always assess biological, psychological, and social factors in order to get the full picture. Medical diagnostic procedures investigate injuries, physical diseases, or inflammation as possible causes, or contributors, to pain. Psychological diagnostic procedures assess the emotional burden of pain, emotional determinants, the appearance of dysfunctional cognitions or coping strategies, and the degree of pain-related impairment of the child’s life. Diagnostics of social factors check for ­dysfunctional behavior within the family system or elsewhere, and the relationship between the pain disorder and dysfunctional behavior within the family, school, or peer group. Apart from the assessment of problematic influences, it is important to identify the child’s and his/her family’s specific resources. This chapter describes the procedures necessary for a comprehensive assessment.
Julia Wager, Holger Kriszio, Michael Dobe, Tanja Hechler, Boris Zernikow

4. The Basics of Treating Pain Disorders in Children and Adolescents

This chapter presents the basics necessary for professionals to provide effective treatment of pain disorders in children and adolescents. These basics are independent of the actual therapeutic setting or the therapists’ medical or therapeutic backgrounds. The reader will get to know the “Three Thought Traps” favoring the development of pain disorders. We then discuss the necessity of active pain coping strategies and of integrating the family into the therapy. We present important aspects of drug-based pain therapy and medical background information on the most important biological determinants of chronic headache, abdominal pain, or back pain in childhood and adolescence. Finally, we discuss therapeutic attitude and the functionality of pain.
Michael Dobe, Holger Kriszio, Boris Zernikow

5. When to Decide on Inpatient Pain Therapy?

Many children suffering chronic pain can be effectively treated in an outpatient setting. With pain disorders severely affecting the patient’s and his/her family’s life (frequently missing school, social withdrawal), however, we have found the most effective treatment is multidisciplinary inpatient pain therapy. In this chapter, we first discuss the criteria used to determine the need and usefulness of inpatient pain therapy. Then we discuss contraindications.
Michael Dobe, Boris Zernikow

6. Pain Therapy in Childhood and Adolescent Chronic Pain

This chapter focuses on the therapeutic approach to pain therapy in children with a pain disorder, as well as the organizational and structural premises of this approach. We present the evaluated inpatient pain therapy program of the German Paediatric Pain Centre, which is suited to children suffering from a monosymptomatic pain disorder, as well as those with a pain disorder coupled with mental or severe somatic comorbidities. Besides the program’s organization and structure, we present several case studies to elucidate specific aspects of our education program. We also present various clinically approved pain coping strategies and approaches. Finally, we present practical hints on how to integrate therapy into the family system, as well as procedures to follow in case of crisis, relapse, or any other unexpected difficulties.
Michael Dobe, Rebecca Hartmann, Holger Kriszio, Tanja Hechler, Jürgen Behlert, Boris Zernikow

7. Specifics of Pain Therapy in Children with Mental Disorders, Severe Somatic Diseases, or Psychosocial Stress Factors

The main goal of this chapter is to present general treatment aspects of children suffering both a pain disorder and a mental disorder. We pinpoint the specifics for paediatric pain therapy in children with a pain disorder and concomitant depressive symptomatology, anxiety disorder, trauma disorder, or adjustment disorder. We furthermore discuss the specific therapeutic needs of children who are accused of school truancy or who actually have learning disabilities or intellectual giftedness. Finally, we discuss children with chronic pain also suffering a severe somatic disease or living in highly burdening family systems.
Michael Dobe, Boris Zernikow

8. Is It All Worthwhile? – Effectiveness of Intensive Interdisciplinary Pain Treatment

This chapter addresses three topics: First, the evidence for the effectiveness of intensive interdisciplinary pain programs is summarized. Data was gathered from eight studies which report positive short-term treatment results, especially for decreases in pain-related disability and absence from school. Long-term effectiveness was shown in one study with 67 % of the children maintaining positive changes over a 12-month period. Second, characteristics of children in need of intensive interdisciplinary pain treatment are summarized. While grading systems for paediatric chronic pain are scarce, preliminary evidence for the utility of the Chronic Pain Grading System (CPG) of von Korff et al. (Pain 50(2):133–149, 1992) for children is presented. At present, clinicians mainly rely on clinically evolved criteria for treatment allocation, though these have not yet been evaluated. Third, research on process variables which modulate treatment response is presented. There is clearly a paucity of research in this area. The few existing studies demonstrate sex differences in treatment response, the importance of changes in pain coping, psychological flexibility, willingness to change, and adherence to the treatment regimen for treatment response. Future research is warranted to provide evidence for the effectiveness through randomized-controlled trials, to provide validated grading systems for paediatric chronic pain for treatment allocation, and to investigate the specific impact of process variables on treatment outcome.
Tanja Hechler, Michael Dobe, Boris Zernikow

9. Diagnostic Tools

The following pages present some diagnostic tools, the most important instructions for their use, and several worksheets used in our education.
Michael Dobe, Boris Zernikow
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