All multidisciplinary team members: The pediatric pain physician, physical therapist, behavior psychologist, and child psychiatrist are reviewing the case.

All multidisciplinary team members: The pediatric pain physician, physical therapist, behavior psychologist, and child psychiatrist are reviewing the case.

Many physicians do not understand the complex nature of chronic pain. Whereas patients with acute pain improve fairly predictably and rapidly, chronic pain patients often do not. Physicians may become frustrated because chronic pain appears to lack any identifiable biological purpose, and they see no consistent correlations among physical variables, pain perception, and disability, despite the fact that these patients present with pain behaviors and are often not working, attending school, or leading functional lives.

In the course of their treatment, many pediatric patients with chronic pain go several months with undertreated pain or ineffective treatments. These patients often lose hope and exhibit anxiety and depression that affect their daily life, social functioning, and education. Social, psychological, and environmental factors affect chronic pain (J Pain 2010;11:1039-46; Pain 2007;131:132-41; Pain 2012;153:437-43; J Pediatr Psychol 2009;34:882-92; Pain 2008;138:11-21). The patient may be unaware of these factors, resulting in treatment failure, drug dependence, depression, and disability.

A multidisciplinary approach encompassing integrated, multimodal, interdisciplinary care is effective and safe (Clin J Pain 2015;31:375-83; Clin J Pain 2017;33:535-42; Arch Dis Child 2003;88:881-5; Pain 2014;155:118-28; Clin J Pain 2012;28:766-74; Pain 2012;153:1863-70; J Pediatr Psychol 2010;35:128-37; Clinical Practice in Pediatric Psychology 2019;7:116-26; J Pediatr Psychol 2013;38:213-23). Its goal is to improve pain assessment and promote coordinated care across the continuum of pain in order to conform to the biopsychosocial model (Clin J Pain 2015;31:375-83; Clin J Pain 2017;33:535-42; Pain in Infants, Children, and Adolescents. 2003; Arch Dis Child 2003;88:881-5; Psychol Bull 2007;133:581-624; Pain 2014;155:118-28; Clin J Pain 2012;28:766-74; Pain 2012;153:1863-70; Pain 2012;153:437-43; J Pediatr Psychol 2010;35:128-37; Clinical Practice in Pediatric Psychology 2019;7:116-26; J Pediatr Psychol 2013;38:213-23; J Dev Behav Pediatr 1997;18:413-22). This approach provides value, as defined by predetermined outcomes of care.

The multidisciplinary approach involves eliminating narcotics, identifying appropriate non-narcotic medications that can calm overactive nerves, and managing anxiety and depression without creating drug dependence. This approach also addresses patients' psychological, social, and emotional difficulties while educating them about chronic pain management. Multidisciplinary models include a pediatric pain physician, pain psychologist, physical therapist, education specialist, and psychiatrist.

Psychiatric disorders are a common comorbidity of chronic pain. The most common psychiatric comorbidities are depression and anxiety, with depression being more prevalent in the pediatric inpatient chronic pain population (Pediatrics 2013;132:e422-29) and anxiety being more common in the outpatient community (Pain Res Manag 2012;17:93-7; J Pain 2015;16:1054-64). Adolescents with chronic pain have higher lifetime rates of anxiety and depressive disorders (Pain 2016;157:1333-8). Additionally, among children admitted with chronic pain, 6% have a disorder with related somatic symptoms, and 2.4% have post-traumatic stress disorder (Pediatrics 2013;132:e422-29). Boys with conduct disorder show a greater prevalence of headaches, and boys with oppositional defiant disorder and attention deficit hyperactivity disorder show a greater prevalence of stomach aches (J Am Acad Child Adolesc Psychiatry 1999;38:852-60). Adolescents with chronic pain also have an elevated risk of suicide and should be screened for any suicidal ideation and gestures (J Pain 2011;12:1032-9). This association between chronic pain and psychiatric disorders can be explained in part by shared neurobiological pathways (J Psychiatry Neurosci 2001;26:21-9) and further emphasized by the negative impact on physical and psychosocial aspects of a child's life. Pain appears to decrease the probability that a patient will experience remission of depressive symptoms when treated with antidepressants (Pain Med 2010;11:732-41). Therefore adequate management of a patient's pain affects and improves several aspects of the child's life (Mayo Clin Proc 2016;91:955-70). It is also imperative to treat psychiatric symptoms in conjunction with the treatment of chronic pain to achieve positive outcomes (Can J Pain 2017;1:37-49). Treatment approaches for youth with chronic pain and psychiatric disorders have been extrapolated from adults; therefore, additional research with randomized controlled trials is required to inform pediatric strategies.

Conceptually, multidisciplinary treatment aims to decrease patients' pain behavior and replace it with “wellness behavior.” Importantly, it also educates patients and family caregivers that “hurt” is not “harm” and that activity can be beneficial by strengthening them and gradually retraining their brain to decrease pain perception (Clin J Pain 2015;31:375-83; Clin J Pain 2017;33:535-42; Pediatrics 2015;136:115-27; Pain 2014;155:118-28; Clinical Practice in Pediatric Psychology 2019;7:116-26). The goal is to de-emphasize pain, disability, and negative thinking in every patient interaction and replace these with an emphasis on health, wellness, and positive behaviors affirmations (J Consult Clin Psychol 1994;62:306-14; Chronic Pain: Management Principles. 1985; Seminars in Pain Medicine 2003;1:90-8; Oxford Textbook of Paediatric Pain. 2014).

Cognitive-behavioral therapy (CBT) is the cornerstone of psychological treatment for pain management. Children with chronic pain are taught to cope with pain through relaxation and focusing techniques, not dissimilar from the breathing and focusing techniques taught to parturients to help manage the pain of labor. Through CBT, patients living with chronic pain can decrease their focus on and perception of pain, enabling them to regain control of their daily functioning (Cognitive-Behavioral Therapy for Chronic Pain in Children and Adolescents. 2012; Pain 2016;157:174-85; PM R 2013;5:697-704). Increasing a sense of self-efficacy and gaining skills to manage pain are the ultimate goals. These skills decrease their affective reaction to chronic pain and reduce the catastrophic thoughts that frequently accompany the experience of pain (Children (Basel) 2016;3:30; Pain 2012;153:1863-70; J Pediatr Psychol 2013;38:756-65).

Today, image-guided pediatric chronic interventional pain medicine is a new subspecialty of pain management that uses techniques such as spine injections, joint injections, musculoskeletal injections, and nerve blocks. These treatments are effective for sports injuries, and children require fewer injections than do adult patients who have degenerative changes. However, the outcomes of patients who receive pediatric interventional techniques for chronic pain are dependent on the experience and skill of the operator, especially when these interventions are performed in children who are under sedation or general anesthesia. Therefore, practitioners must be trained in an accredited fellowship program. Moreover, pediatric interventional chronic pain management is a new specialty without sufficient data regarding success rates.

The multidisciplinary team concluding the diagnosis and treatment plan with the patient and family.

The multidisciplinary team concluding the diagnosis and treatment plan with the patient and family.

The concept of a multidisciplinary facility for the diagnosis and treatment of complex pain problems has been increasingly embraced by medical professionals (Pediatrics 2015;136:115-27). As noted by Vasudevan, “Unlike unimodal, uncoordinated and ‘quick fix’ pain treatment, multidisciplinary pain programs use a rehabilitation approach in which a ‘cure’ for the pain or the underlying condition causing the pain is not the goal/aim.” (Multidisciplinary Management of Chronic Pain, 2015) In fact, it is counterproductive to imply that patient improvement requires waiting until an explanation and cure can be found. Children living with pain, and their families, can improve their quality of life by replacing pain-related behaviors and negative thinking with behaviors and perspectives that reinforce quality of life. This approach allows individuals with chronic pain to return to a more functional and satisfying life. Thus, chronic pain in the pediatric population is reversible when treated through a multidisciplinary approach.

M-Irfan Suleman, MD, FAAP, FASA, Assistant Professor, Founding Director of the Pediatric Interventional Pain Program, Johns Hopkins Children's Center, and Founding Medical Director, Multidisciplinary Pediatric Chronic Pain Rehabilitation Program, Kennedy Krieger Institute, Baltimore.

M-Irfan Suleman, MD, FAAP, FASA, Assistant Professor, Founding Director of the Pediatric Interventional Pain Program, Johns Hopkins Children's Center, and Founding Medical Director, Multidisciplinary Pediatric Chronic Pain Rehabilitation Program, Kennedy Krieger Institute, Baltimore.

Souraya Torbey, MD, Assistant Professor, Child and Adolescent Psychiatry, Kennedy Krieger Institute, Johns Hopkins University, Baltimore.

Souraya Torbey, MD, Assistant Professor, Child and Adolescent Psychiatry, Kennedy Krieger Institute, Johns Hopkins University, Baltimore.

Keith J. Slifer, PhD, Professor of Psychiatry and Behavioral Sciences and Pediatrics, Director, Pediatric Psychology and Pain Rehabilitation Programs, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore.

Keith J. Slifer, PhD, Professor of Psychiatry and Behavioral Sciences and Pediatrics, Director, Pediatric Psychology and Pain Rehabilitation Programs, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore.