Medicine:Childhood chronic pain

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Short description: Medical condition
Headaches are one of the most common forms of childhood chronic pain.[1]

Childhood chronic pain affects at least 5% of the population under the age of 18, according to conservative epidemiological studies. Rates of pediatric chronic pain have also increased in the past 20 years.[2] While chronic pain conditions vary significantly in severity, they often affect children's mental health, academic performance, activities of daily living, social participation, and general quality of life.[3] The outcomes of childhood chronic pain are affected by a number of factors, including demographic factors, genetics, access to rehabilitation services, and school and family support.[2]

Classification and epidemiology

Chronic pain is defined as pain that lasts at least 3–6 months and, in the case of injury or surgery, remains present after standard recovery time has elapsed.[4] The ICD-11 provides seven categories for diagnosing chronic pain:

  • Chronic primary pain
  • Chronic cancer pain
  • Chronic postsurgical and posttraumatic pain
  • Chronic neuropathic pain
  • Chronic headache and orofacial pain
  • Chronic visceral pain
  • Chronic musculoskeletal pain[4]

Childhood chronic pain can be caused by a number of conditions, including the following:[5]

Condition Symptoms Known causes and risk factors Estimated prevalence Treatments
Chronic abdominal pain Recurrent abdominal pain, usually without a known organic cause[6] Usually unknown[6] 8.4%[7] Drug therapies, cognitive behavioural therapy (CBT)[6]
Chronic headache Recurrent headache (at least 15 days per month, 4 hours per day)[8] Sex (more common in females), psychological disturbances, obesity, overuse of caffeine or headache medication, other chronic pain conditions[8] 1.5% - 3.4% Antidepressants, beta blockers, anticonvulsants, NSAIDs, botulinum toxin, CBT,[8] occupational therapy
Complex regional pain syndrome Severe burning/throbbing pain (usually in a limb), swelling, sensitivity, changes in skin colour and texture[9] Injury or trauma[9] Unknown[10] Pain relievers, corticosteroids, bone-loss medication, sympathetic nerve-blocking medication, intravenous ketamine, physical therapy, occupational therapy, psychotherapy, biofeedback, spinal cord stimulation[9]
Juvenile fibromyalgia Widespread muskuloskeletal pain, headache, sleep disturbances, fatigue[11] Genetics, sex (more common in females), infections, trauma, rheumatic disease[11] 1.2% - 6.2%[12] Antidepressants, anticonvulsants, pain relievers, CBT[11]
Juvenile rheumatoid arthritis Joint pain, swelling, and stiffness[13] Genetics, sex (more common in females)[13] 0.4%[14] NSAIDs, TNF blockers, immune suppressants, corticosteroids, physical therapy, occupational therapy[13]

Management

Chronic pain can be treated in a number of ways, and varies depending on the type and severity of the condition. Common pain medications prescribed to children include paracetamol, ibuprofen, and acetylsalicylic acid.[15] Researchers have also found that psychotherapies are often helpful in reducing functional disability in children with chronic pain. A meta-analysis by Christopher Eccleston and colleagues found that cognitive behavioural therapy (CBT) significantly reduced pain severity for children with chronic headaches.[16] Additionally, biofeedback and relaxation therapy can be used in conjunction with CBT to treat chronic pain. Research thus far has typically found small effects for improving psychological wellbeing, but more robust outcomes for pain relief.[17]

The management of chronic pain in children aims also to help the child and their family reintegrate into a more functional routine and improve their daily struggle. The focus changes from immediate pain relief to enhancing functional improvements while managing the presence of pain. Since pediatric chronic pain can have various complex causes, current data suggest that a comprehensive multidisciplinary treatment is important and is frequently the most successful approach to achieve remission or management of symptoms. This treatment approach typically involves a combination of therapies, including occupational therapy, physical therapy, medications, pain psychology, and parental education.[18][19]

These multidisciplinary treatments usually include applying both pain reduction and coping strategies. For example, occupational therapy helps clients use meaningful activities to feel better. Occupational therapists may teach sensory desensitization strategies as well as provide some adaptations and compensations to perform challenging daily activities and develop a daily schedule to support engagement in meaningful activities.[20] Physiotherapists may improve strength and endurance, while psychologists will focus on psychoeducation, behavioral exposures, and relaxation training. Additionally, parents may receive psychoeducation to develop family strategies for managing pain behaviors and overcoming potential obstacles to facilitate a successful transition to the home environment.[19][21]

Outcomes

Education

Chronic pain often interferes with children's ability to attend and succeed in school. Children with severe disorders are particularly likely to miss school because of debilitating pain, as well as for medical appointments. High rates of school absence are associated with poor adjustment and psychosocial wellbeing among children with chronic illnesses.[22] For children with severe chronic pain disorders, school districts may provide a variety of services, including inpatient, homebound, and special education. Support services such as occupational therapy may provide specialized tools, equipment, and modifications of the environment to improve the child’s participation in educational roles and activities.[23]

Inpatient education

Some hospitals employ or contract tutors to assist children in inpatient care with their schoolwork. Hospital teachers are typically certified to teach a wide variety of ages and subjects. At the same time, in a study by Steinke et al., around one-third of hospital teachers reported teaching ages or subjects beyond their areas of certification.[24] The number of hospital teachers is declining due to reduced hospitalization and shorter hospital stays.[25]

Homebound education

In many school districts in the United States , homebound education is offered to students who miss more than 15 days in a row. Homebound education typically consists of 45 minutes of instruction per day in the child's home.[26] Through an Individualized Education Plan (IEP) or 504 Plan students may also receive access to support services in the home including occupational therapy, physical therapy, or speech therapy when justified. Other nations, including Australia and Belgium, have implemented programs to use technology to include chronically ill students in their regular class sessions, and these programs have generally had positive results.[25][27] Many critics of homebound education believe that it is not a sufficient substitute for classroom learning. Additionally, many children with chronic pain have intermittent rather than extended absences, which makes them ineligible for homebound education services.[28] Even when homebound education is an option, it is often difficult for students from low-income or otherwise disadvantaged backgrounds. Programs typically require a computer, Internet connection, a quiet and well-lit space, and parental supervision, demands that may prove burdensome for economically disadvantaged families.[29]

Special education services

While children with chronic pain are typically not placed in special education classrooms, they may receive health-related accommodations through a 504 Plan. Such accommodations may include shorter school days, exemption from requirements like physical education classes, arrangements to deliver medication and other treatments, and programs to educate classmates about their disorder. These measures require extensive communication between teachers, doctors, therapists, and school nurses.[30]

Family impacts

Paediatric chronic pain often impacts quality of life for the families of children affected, with mothers having particularly low health-related quality of life on average.[31] Parents of children with chronic pain conditions allocate considerable physical, financial, and emotional resources towards health care for their child. For example, a study by Ho and colleagues found that primary caregivers for chronically ill children spent an average of around $8800 and 28.5 hours on medical appointments in the past three months, causing them to miss an average of 4 days of work.[32]

Participation in daily activities

Children with chronic pain often avoid engaging in daily activities due to fear of experiencing pain. These avoidance behaviors can significantly disrupt their physical, social, and emotional functioning and may even worsen their medical condition and pain levels.[33] Multidisciplinary treatment, especially occupational therapy, is designed to address this issue and aims to increase children's engagement in activities of daily living.  Occupational therapy empowers children to heal through creative activities and roles that help distract them from their pain in a purposeful, functional way.

Mental health

Childhood chronic pain often exists alongside mental health conditions like anxiety disorders, depression, and post-traumatic stress disorder (PTSD), with elevated rates of these disorders lasting into adulthood.[34] There are a variety of theories that address this relationship. Chronic pain is emotionally stressful both to the child affected and to his or her family, which may increase their risks for mental illness.[31] Chronic pain and PTSD can also be "mutually maintaining", with cognitive, behavioural, and affective patterns creating a cycle of worsening physical and mental symptoms.[35] Under this model, depressive symptoms (such as reduced activity and increased physiological arousal) aggravate pain symptoms, and unhealthy coping strategies (such as catastrophic thinking) worsen mental health.[36]

Many mental health disorders also share neurobiological mechanisms with psychological disorders, such as activating the HPA axis and increasing the production of stress hormones. Chronic pain, anxiety, depression, and PTSD are also all associated dysfunction involving serotonin and brain-derived neurotrophic factor. New research has also linked both chronic pain and mental illness to inflammation.[34]

Quality of life

In a study of patients at a paediatric pain clinic, researchers found that chronic pain had a significant negative impact on quality of life. Depression was also prevalent, and was correlated with functional disability.[37] Additionally, psychosocial adjustment is a better predictor of school attendance than pain severity, which suggests that it is an important variable in examining outcomes of children with chronic pain.[38] The psychological consequences of chronic pain may be exacerbated with the stigma associated with it. Many people do not typically associate chronic pain with children, and so may minimize or dismiss its impact.[39]

Well-being

Well-being is defind by the World Health Organization (WHO) as "a general term encompassing the total universe of human life domains, including physical, mental, and social aspects".[40] Chronic pain in children has far-reaching effects on their well-being, impacting both the children and their families. These children often suffer from additional symptoms caused by the pain such as difficulty in social participation, learning difficulties and a general decrease in quality of life.

Factors affecting outcomes

Demographic factors

Chronic pain, especially chronic headache, is more common in girls, older children, and children from low socioeconomic status backgrounds.[2] According to researchers Anna Huguet and Jordi Miró, the most common locations for paediatric chronic pain are the head and abdomen. These two locations are more likely to be sources of chronic pain for girls, whereas boys are more likely to experience lower limb pain. Girls are also more likely than boys to experience multiple sources of pain.[15] The prevalence of chronic pain among girls increases sharply between the ages of 12 and 14, which leads some researchers to believe that it is linked to menarche and other hormonal changes during puberty.[41]

Age also has a significant impact on children's experiences with chronic pain. Young children often cannot describe their pain in ways that adults understand, and even older children may lack the vocabulary to clearly communicate with medical professionals.[42] Doctors, especially general practitioners, may also lack experience diagnosing or treating paediatric chronic pain disorders, and so make patients and their families feel "judged, disbelieved, and labeled as difficult or dysfunctional".[43]

Access to creative programs and integrative services that address pain and improve self advocacy skills in the community can vary. Outpatient therapies such as occupational therapy, physical therapy, and counseling can work together to address pain.[44] Access to social opportunities and leisure opportunities that are meaningful and not overwhelming can be helpful; these can often be provided through community organizations such as nonprofits. Mindfulness, yoga, art, music, journaling, or meditative imagery may be utilized. Communication with others who are in the same situation or have seen improvement in pain management can be helpful. Some states or insurances may provide families with funding for services or respite care.

Genetics and family factors

Chronic pain can run in families, with the risk of paediatric chronic pain increasing dramatically for offspring of adults with chronic pain.[34] This is often attributable to genetic predispositions to certain disorders, but can also be associated with individual differences in stress response. Researchers at UCLA found that adults with the 5-HTTLPR S allele had higher cortisol levels, which can contribute both to the progression of chronic pain disorders and to less positive parenting.[45]

For chronic pain patients, family support is an important factor in promoting successful pain management and rehabilitation.[46] While healthy family interaction has a positive impact on paediatric pain patients, overprotectiveness and unhealthy relationship demands can foster depressive symptoms.[47]

School support

School support is also an important factor influencing paediatric chronic pain outcomes. When children receive appropriate support from teachers and school counsellors, and support staff such as therapists they are more likely to achieve attain success and psychological wellbeing.[22] This process can often be facilitated by a paediatric nurse practitioner (PNP), who coordinates a child's education with his or her medical treatment.[30]

Peer education

An important component of school support for many children with chronic pain is peer education. These children often face bullying and exclusion from peers, especially when they have visible markers of disability (i.e. a wheelchair) or are unable to participate in school activities (i.e. physical education classes or recess games).[48] Peer education programs vary based on the child's age and medical condition, but often include informative presentations, role playing, and question and answer sessions. Evaluations of the efficacy of these programs have generally shown positive effects for increasing peers' disease-related knowledge, but uncertainty remains about whether they can produce changes in attitudes and behaviours.[49]

Teacher education

The majority of teachers feel some degree of anxiety about having children with chronic health conditions in their classrooms. Only 40% of teachers in a study by Clay and colleagues received formal training about teaching children with chronic illnesses, and so many were concerned about providing appropriate accommodations and handling any medical emergencies.[50] Teacher education programs have found moderate positive effects in increasing school personnel's knowledge about chronic pain and comfortableness teaching children with chronic pain disorders.[49]

References

  1. ↑ Huguet, Anna; Miró, Jordi (2008). "The Severity of Chronic Pediatric Pain: An Epidemiological Study". The Journal of Pain 9 (3): 226–236. doi:10.1016/j.jpain.2007.10.015. PMID 18088558. 
  2. ↑ 2.0 2.1 2.2 King, Sara; Chambers, Christine T.; Huguet, Anna; MacNevin, Rebecca C.; McGrath, Patrick J.; Parker, Louise; MacDonald, Amanda J. (2011-12-01). "The epidemiology of chronic pain in children and adolescents revisited: a systematic review". Pain 152 (12): 2729–2738. doi:10.1016/j.pain.2011.07.016. ISSN 1872-6623. PMID 22078064. 
  3. ↑ Weiss, K. E.; Hahn, A.; Wallace, D. P.; Biggs, B.; Bruce, B. K.; Harrison, T. E. (2013-08-01). "Acceptance of Pain: Associations With Depression, Catastrophizing, and Functional Disability Among Children and Adolescents in an Interdisciplinary Chronic Pain Rehabilitation Program" (in en). Journal of Pediatric Psychology 38 (7): 756–765. doi:10.1093/jpepsy/jst028. ISSN 0146-8693. PMID 23685451. 
  4. ↑ 4.0 4.1 Treede, Rolf-Detlef; Rief, Winfried; Barke, Antonia; Aziz, Qasim; Bennett, Michael I.; Benoliel, Rafael; Cohen, Milton; Evers, Stefan et al. (2017-02-15). "A classification of chronic pain for ICD-11". Pain 156 (6): 1003–1007. doi:10.1097/j.pain.0000000000000160. ISSN 0304-3959. PMID 25844555. 
  5. ↑ "Pediatric Chronic Pain Management - Academy of Integrative Pain Management Blog" (in en). Academy of Integrative Pain Management Blog. 2016-01-11. http://blog.aapainmanage.org/pediatric-chronic-pain-management/. 
  6. ↑ 6.0 6.1 6.2 Pain, Subcommittee on Chronic Abdominal (2005-03-01). "Chronic Abdominal Pain in Children" (in en). Pediatrics 115 (3): 812–815. doi:10.1542/peds.2004-2497. ISSN 0031-4005. PMID 15741394. http://pediatrics.aappublications.org/content/115/3/812. 
  7. ↑ Chitkara, Denesh K; Rawat, David J; Talley, Nicholas J (2005-08-01). "American Journal of Gastroenterology - The Epidemiology of Childhood Recurrent Abdominal Pain in Western Countries: A Systematic Review". Am J Gastroenterol 100 (8): 1868–1875. doi:10.1111/j.1572-0241.2005.41893.x. ISSN 0002-9270. PMID 16086724. 
  8. ↑ 8.0 8.1 8.2 "Chronic daily headaches Symptoms - Mayo Clinic" (in en). Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/chronic-daily-headaches/basics/symptoms/con-20025386. 
  9. ↑ 9.0 9.1 9.2 "Complex regional pain syndrome Symptoms - Mayo Clinic" (in en). Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/complex-regional-pain-syndrome/basics/symptoms/con-20022844. 
  10. ↑ Tan, Edward C.T.H.; Sandt-Renkema, Nienke van de; Krabbe, Paul F.M.; Aronson, Daniel C.; Severijnen, René S.V.M. (2009). "Quality of life in adults with childhood-onset of Complex Regional Pain Syndrome type I". Injury 40 (8): 901–904. doi:10.1016/j.injury.2009.01.134. PMID 19524904. 
  11. ↑ 11.0 11.1 11.2 "Juvenile fibromyalgia Symptoms - Mayo Clinic" (in en). Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/juvenile-fibromyalgia/basics/symptoms/con-20093409. 
  12. ↑ Neumann, L.; Buskila, D. (2003). "Epidemiology of fibromyalgia". Current Pain and Headache Reports 7 (5): 362–368. doi:10.1007/s11916-003-0035-z. PMID 12946289. 
  13. ↑ 13.0 13.1 13.2 "Juvenile rheumatoid arthritis Symptoms - Mayo Clinic" (in en). Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/juvenile-rheumatoid-arthritis/basics/symptoms/con-20014378. 
  14. ↑ Manners, Prudence Joan; Bower, Carol (2002-07-01). "Worldwide prevalence of juvenile arthritis why does it vary so much?" (in en). The Journal of Rheumatology 29 (7): 1520–1530. ISSN 0315-162X. PMID 12136914. http://www.jrheum.org/content/29/7/1520. 
  15. ↑ 15.0 15.1 Huguet, Anna; Miró, Jordi (2008). "The Severity of Chronic Pediatric Pain: An Epidemiological Study". The Journal of Pain 9 (3): 226–236. doi:10.1016/j.jpain.2007.10.015. PMID 18088558. 
  16. ↑ Eccleston, Christopher; Morley, Stephen; Williams, Amanda; Yorke, Louise; Mastroyannopoulou, Kiki (2002). "Systematic review of randomised controlled trials of psychological therapy for chronic pain in children and adolescents, with a subset meta-analysis of pain relief". Pain 99 (1): 157–165. doi:10.1016/s0304-3959(02)00072-6. PMID 12237193. 
  17. ↑ Palermo, Tonya M.; Eccleston, Christopher; Lewandowski, Amy S.; Williams, Amanda C. de C.; Morley, Stephen (2010). "Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: An updated meta-analytic review". Pain 148 (3): 387–397. doi:10.1016/j.pain.2009.10.004. PMID 19910118. 
  18. ↑ Rabin, Jeffrey; Brown, Mackenzie; Alexander, Sean (2017-07-01). "Update in the Treatment of Chronic Pain within Pediatric Patients" (in en). Current Problems in Pediatric and Adolescent Health Care 47 (7): 167–172. doi:10.1016/j.cppeds.2017.06.006. ISSN 1538-5442. PMID 28716513. https://www.sciencedirect.com/science/article/pii/S1538544217301220. 
  19. ↑ 19.0 19.1 Harrison, Lauren E.; Pate, Joshua W.; Richardson, Patricia A.; Ickmans, Kelly; Wicksell, Rikard K.; Simons, Laura E. (September 2019). "Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain" (in en). Journal of Clinical Medicine 8 (9): 1267. doi:10.3390/jcm8091267. ISSN 2077-0383. PMID 31438483. 
  20. ↑ "Error: no |title= specified when using {{Cite web}}". https://www.aota.org/practice/practice-essentials/quality/quality-resources/role-of-ot-pain-management. 
  21. ↑ Evans, Jenny R.; Benore, Ethan; Banez, Gerard A. (2015-10-28). "The Cost-Effectiveness of Intensive Interdisciplinary Pediatric Chronic Pain Rehabilitation". Journal of Pediatric Psychology 41 (8): 849–856. doi:10.1093/jpepsy/jsv100. ISSN 0146-8693. PMID 26514643. 
  22. ↑ 22.0 22.1 Midence, K (1994). "The effects of chronic illness on children and their families: An overview". Genetic, Social & General Psychology Monographs 120 (3): 311. 
  23. ↑ "Error: no |title= specified when using {{Cite web}}". https://www.aota.org/practice/practice-essentials/quality/quality-resources/role-of-ot-pain-management. 
  24. ↑ Steinke, Sarah Marie; Elam, Megan; Irwin, Mary Kay; Sexton, Karen; McGraw, Anne (2016-05-06). "Pediatric Hospital School Programming: An Examination of Educational Services for Students who are Hospitalized" (in en). Physical Disabilities: Education and Related Services 35 (1): 28–45. doi:10.14434/pders.v35i1.20896. ISSN 2372-451X. 
  25. ↑ 25.0 25.1 "Academic continuity through online collaboration: Mathematics teachers support the learning of pupils with chronic illness during school absence" (in en). https://www.researchgate.net/publication/220095327. 
  26. ↑ Shaw, Steven R.; Clyde, Michael A. J.; Sarrasin, Matthew (2014). "Review article Homebound instruction for students with chronic illness: reducing risk outside of the box" (in en). Health Psychology Report 1 (1): 1–9. doi:10.5114/hpr.2014.42786. ISSN 2353-4184. 
  27. ↑ Boonen, H.; Petry, K. (2012-07-01). "How do children with a chronic or long-term illness perceive their school re-entry after a period of homebound instruction?" (in en). Child: Care, Health and Development 38 (4): 490–496. doi:10.1111/j.1365-2214.2011.01279.x. ISSN 1365-2214. PMID 21722160. https://lirias.kuleuven.be/handle/123456789/315645. 
  28. ↑ Thies, K. M. (1999-12-01). "Identifying the educational implications of chronic illness in school children". The Journal of School Health 69 (10): 392–397. doi:10.1111/j.1746-1561.1999.tb06354.x. ISSN 0022-4391. PMID 10685375. 
  29. ↑ Shaw, Steven R.; McCabe, Paul C. (2008-01-01). "Hospital-to-school transition for children with chronic illness: Meeting the new challenges of an evolving health care system" (in en). Psychology in the Schools 45 (1): 74–87. doi:10.1002/pits.20280. ISSN 1520-6807. 
  30. ↑ 30.0 30.1 Rabin, Nancy B. (1994). "School reentry and the child with a chronic illness: The role of the Pediatric nurse practitioner". Journal of Pediatric Health Care 8 (5): 227–232. doi:10.1016/0891-5245(94)90066-3. PMID 7799191. 
  31. ↑ 31.0 31.1 Jastrowski Mano, K. E.; Khan, K. A.; Ladwig, R. J.; Weisman, S. J. (2011-06-01). "The Impact of Pediatric Chronic Pain on Parents' Health-Related Quality of Life and Family Functioning: Reliability and Validity of the PedsQL 4.0 Family Impact Module" (in en). Journal of Pediatric Psychology 36 (5): 517–527. doi:10.1093/jpepsy/jsp099. ISSN 0146-8693. PMID 19903721. 
  32. ↑ Ho, Ivy K.; Goldschneider, Kenneth R.; Kashikar-Zuck, Susmita; Kotagal, Uma; Tessman, Clare; Jones, Benjamin (2008-01-01). "Healthcare Utilization and Indirect Burden among Families of Pediatric Patients with Chronic Pain". Journal of Musculoskeletal Pain 16 (3): 155–164. doi:10.1080/10582450802161853. ISSN 1058-2452. 
  33. ↑ Pielech, Melissa; Vowles, Kevin E.; Wicksell, Rikard (February 2017). "Acceptance and Commitment Therapy for Pediatric Chronic Pain: Theory and Application" (in en). Children 4 (2): 10. doi:10.3390/children4020010. ISSN 2227-9067. PMID 28146108. 
  34. ↑ 34.0 34.1 34.2 Vinall, Jillian; Pavlova, Maria; Asmundson, Gordon J. G.; Rasic, Nivez; Noel, Melanie (2016-12-02). "Mental Health Comorbidities in Pediatric Chronic Pain: A Narrative Review of Epidemiology, Models, Neurobiological Mechanisms and Treatment". Children 3 (4): 40. doi:10.3390/children3040040. ISSN 2227-9067. PMID 27918444. 
  35. ↑ Sharp, T. J.; Harvey, A. G. (2001-08-01). "Chronic pain and posttraumatic stress disorder: mutual maintenance?". Clinical Psychology Review 21 (6): 857–877. doi:10.1016/s0272-7358(00)00071-4. ISSN 0272-7358. PMID 11497210. 
  36. ↑ Asmundson, Gordon J. G.; Katz, Joel (2009-01-01). "Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art". Depression and Anxiety 26 (10): 888–901. doi:10.1002/da.20600. ISSN 1520-6394. PMID 19691031. 
  37. ↑ Kashikar-Zuck, S.; Goldschneider, K. R.; Powers, S. W.; Vaught, M. H.; Hershey, A. D. (2001-12-01). "Depression and functional disability in chronic pediatric pain". The Clinical Journal of Pain 17 (4): 341–349. doi:10.1097/00002508-200112000-00009. ISSN 0749-8047. PMID 11783815. 
  38. ↑ Weitzman, M (1986). "School absence rates as outcome measures in studies of children with chronic illness". Journal of Chronic Diseases 39 (10): 799–808. doi:10.1016/0021-9681(86)90082-2. PMID 3760108. 
  39. ↑ "Chronic pain in children, teens called a 'silent epidemic'" (in en). CBC News. http://www.cbc.ca/news/canada/calgary/chronic-pain-children-alberta-childrens-hospital-1.3867047. 
  40. ↑ "World Health Organization (WHO)" (in en). https://www.who.int/. 
  41. ↑ Perquin, Christel W.; Hazebroek-Kampschreur, Alice A.J.M.; Hunfeld, Joke A.M.; Bohnen, Arthur M.; Suijlekom-Smit, Lisette W.A. van; Passchier, Jan; Wouden, Johannes C. van der (2000). "Pain in children and adolescents: a common experience=". Pain 87 (1): 51–58. doi:10.1016/s0304-3959(00)00269-4. PMID 10863045. 
  42. ↑ "Symptoms of Pain in Children" (in en). WebMD. http://www.webmd.com/children/recognizing-symptoms-children-pain#1. 
  43. ↑ Carter, Bernie (2016-07-01). "Chronic Pain in Childhood and the Medical Encounter: Professional Ventriloquism and Hidden Voices" (in en). Qualitative Health Research 12 (1): 28–41. doi:10.1177/104973230201200103. PMID 11797923. 
  44. ↑ "Error: no |title= specified when using {{Cite web}}". https://www.aota.org/practice/practice-essentials/quality/quality-resources/role-of-ot-pain-management. 
  45. ↑ Morgan, Julia E.; Hammen, Constance; Lee, Steve S. (2016-05-18). "Parental Serotonin Transporter Polymorphism (5-HTTLPR) Moderates Associations of Stress and Child Behavior With Parenting Behavior". Journal of Clinical Child and Adolescent Psychology 47 (sup1): S76–S87. doi:10.1080/15374416.2016.1152550. ISSN 1537-4424. PMID 27191831. https://escholarship.org/uc/item/1jg8k075. 
  46. ↑ Jamison, Robert N.; Virts, Kitti L. (1990). "The influence of family support on chronic pain". Behaviour Research and Therapy 28 (4): 283–287. doi:10.1016/0005-7967(90)90079-x. PMID 2222385. 
  47. ↑ Fales, J. L.; Essner, B. S.; Harris, M. A.; Palermo, T. M. (2014-05-01). "When Helping Hurts: Miscarried Helping in Families of Youth With Chronic Pain" (in en). Journal of Pediatric Psychology 39 (4): 427–437. doi:10.1093/jpepsy/jsu003. ISSN 0146-8693. PMID 24517921. 
  48. ↑ Prevatt, Frances F; Heffer, Robert W; Lowe, Patricia A (2000-09-01). "A Review of School Reintegration Programs for Children with Cancer". Journal of School Psychology 38 (5): 447–467. doi:10.1016/S0022-4405(00)00046-7. 
  49. ↑ 49.0 49.1 Canter, Kimberly S.; Roberts, Michael C. (2012-11-01). "A systematic and quantitative review of interventions to facilitate school reentry for children with chronic health conditions". Journal of Pediatric Psychology 37 (10): 1065–1075. doi:10.1093/jpepsy/jss071. ISSN 1465-735X. PMID 22718487. 
  50. ↑ Clay, Daniel L.; Cortina, Sandra; Harper, Dennis C.; Cocco, Karen M.; Drotar, Dennis (2004-09-01). "Schoolteachers' Experiences With Childhood Chronic Illness". Children's Health Care 33 (3): 227–239. doi:10.1207/s15326888chc3303_5. ISSN 0273-9615. 



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