Chronic pain in children

Bchav. Res. Ther. Vol. 25, No. 4, pp. 263-271, 1987 Printed in Great Britain

CHRONIC

0005-7967187 53.00+ 0.00 Pergamon Journals Ltd

PAIN IN CHILDREN

CkARLES H. ELLIOTT University of New Mexico, Department of Psychology, Albuquerque, NM 87131, U.S.A.

SUSAN M. JAY University of Southern California, School of Medicine, 4650 Sunset Boulevard, Los Angeles, CA 90027, U.S.A. Summary-Chronic pain in children was reviewed in two major categories: disease-related pain and recurrent pain syndromes. Problems with the traditional dichotomy of organic versus psychogenic origins of such pain were noted. Additionally, disturbing trends in the pharmacological management of children’s chronic pain were discussed. Furthermore, applications of psychological interventions to both pain categories were outlined and have shown exciting potential for the amelioration of a number of children’s chronic pain problems. However, research in this area is only beginning to demonstrate efficacy and controlled outcome studies are few in number. Finally, a brief review of strategies for the assessment of children’s chronic pain was presented and revealed an area also in its infancy.

INTRODUCTION

The traditional approach to children’s pain has tended to rely on an overly simplistic dichotomy between organic and psychological origins. In this regard, Schechter (1984) has noted that since a clear organic cause is determined in less than 10% of children’s recurrent pain syndrome cases (e.g. abdominal pain), the vast majority of these children have generally been assumed to be largely suffering from psychological problems. However, data generally have failed to support such an hypothesis. In fact, Barr (1981) has observed that many types of recurrent chronic pain syndromes probably result from an interaction of subtle psychological and physiological variables which may lack clear cut signs of pathology. Thus, the actual distinction between organic and psychogenic pain is blurred at best. For the purposes of this review, children’s pain will be classified into two major categories: disease-related pain (such as that associated with hemophilia and juvenile rheumatoid arthritis) and recurrent pain syndromes (such as headaches and abdominal pain). In this categorization scheme, no a priori assumption is made concerning a strict organic/psychogenic distinction. Thus, a child’s recurrent pain syndrome may or may not involve both sides of the organic/psychogenic dichotomy. In the same manner, a child with a disease-related pain could have a pain that is largely derived from psychological sources, organic origins, or some interaction involving both.

DISEASE-RELATED

PAIN

Children’s disease-related pain may consist of repeated acute pain episodes in addition to chronic, persistent, disabling pain. Once again, with regard to the organic/psychogenic distinction, children’s disease-related pain can lead to pitfalls. For example, it is easy to conclude that if a child with cancer has pain that is alleviated merely with the use of tranquilizers, then it is not likely to be due to a metastatic lesion. Along a similar line, it is also easy to assume that if a child who suffered from a well-defined and localized pain at one time and subsequently complains of a vague, generalized pain without clear signs of organic pathology, then he or she is now experiencing a ‘psychogenic’ pain (Beales, Kean and Lennox-Holt, 1983). Both of these examples illustrate a common failure to recognize the potential for cognitive variables to augment (or diminish) physiologically based pain signals. Thus, tranquilizers might simply act to reduce so-called cerebrocortical augmentation of pain signals and a child’s vague pain complaint might be based on cerebrally augmented signals from sites of damage as yet too slight to be detected by standard medical means (Beales et al., 1983). Clearly, a thorough assessement of a child’s disease-related chronic pain is essential, not so much to determine if it is organically or psychologically based, 263

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but rather to ascertain (as best as one can) the relative contribution and Jay, 1987).

of both sets of factors (Dolgin

Pharmacological intervention Pharmacological management of children’s chronic disease-related pain is worthy of mention. Excellent reviews of pharmacological agents for this purpose are available elsewhere (e.g. Schechter, 1985). What makes this approach interesting from a psychological perspective is the variety of factors which infhtence prescription d~sion-making and delivery. An increasing amount of documentation has been collected which demonstrates that children are undertreated for their pain relative to adults, who themselves tend to be given inadequate treatment, especially for severe pain (Marks and Sachar, 1978). Eland and Anderson (1977) were among the first to report this problem in a study which found striking differences in prescribed medications for a group of 18 children matched with a group of 18 adults with similar diagnoses. In fact, the children in that study reportedly received less than one tenth the number of m~i~tion doses prescribed for the adults. A more recent study (Schechter, Hanson and Allen, 1984) utilized better methodological procedures and found less dramatic data, although a group of 90 adults still received one and a half to three times as many doses of narcotic medications than did a matched group of 90 children. The reasons for this apparent undertreatment are varied and worthy of study. Apparently, several myths may be contributed to the problem. One of these myths is the assumption that children don’t experience pain as intensely as adults. In that regard, the current weight of evidence favors the ideal that children’s distress in response to painful1 stimuli may actually be inverseiy related to age (e.g. Katz, Kellerman and Siegel, 1980; Jay, Ozolins, Elliott and Caldwell, 1983). A second, perhaps even more widely disseminated myth, is that children will become addicted to narcotic medication more easily than adults. However, no evidence exists to support this notion. The fear of addiction may be att~butable, at least in part, to a common confusion between the concept of physical dependence and addiction. Physical dependence generally refers to an altered physiological state which occurs after repeated drug administration and which results in the manifestation of withdrawal symptoms upon discontinuance of the drug (Newburger and Sallan, 1981). Such dependence ilr common with repeated administration of narcotics, but can usually be controlled fairly easily in the hospital through gradual tapering of the medication (Schechter, 1985). Addiction is more often thought of as a behavior pattern involving compulsive drug use, the attaining of a drug supply, involvement with use of the drug, etc. (Jaffe, 1975). Newburger and Sallan (198 1) summed up this issue quite well when they stated: “a child awaiting undertreated for pain desperately and single-mindedly awaiting his next dose of medication, comes closer to Jaffe’s definition of addiction than the properly treated patient at peace to pursue other concerns.” Without question, further study into prescription decision-making processes would appear to be an area deserving of more investigational effort, It is quite possible that children’s suffering could be reduced by improvements in these practices as much as by anything else. Nevertheless, pharmacological agents are not likely to be the whole answer to this problem even if the blockades to their judicious use were removed. Furthermore, the risk of so-called addiction in all probability is increased in patient requiring long-term narcotics on an outpatient basis. Psychological inte~ention Psychological interventions for disease-related pain can be generally classified according to those which are primarily designed for pain perception regulation versus those primarily designed for pain behavior regulation (Varni, Jay, Masek and Thompson, 1986b). Pain perception regulation strategies are designed to alter the perception of pain and include guided imagery, meditation, relaxation, self-hypnosis, biofeedback, autogenic training, etc. By contrast, pain behavior regulation strategies are designed to alter pain behavior and involve the identification and modifi~tion of environmental stimulus and consequent events as originally suggested by Fordyce (1976). However, pain perception strategies may indirectly affect pain behavior and pain behavior strategies may indirectly affect pain perception. For example, pain perception regulation may allow for developmentally more appropriate behaviors to be emitted once the patient is no longer as overwhelmed by perceptions of pain, and pain behavior regulation may actually serve to distract the patient when he or she increases mobility (Vami et al., 1986b). This ‘distraction function’ of

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pain behavior regulation strategies is useful to keep in mind since a common misconception regarding operant conditioning techniques for pain behavior regulation is that they are inap propriate when pain is largely organically based. With regard to the implementation of both pain behavior and perception regulation, it is also useful to note that acute pain episodes can provide an important signal in chronic disease-related pain. Thus, the goal in managing chronic pain associated with diseases (such as hemophilia, sickle cell anemia, juvenile rheumatoid arthritis and cancer) is not the total elimination of all pain behavior and perception. Rather, discrimination between chronic pain and acutely dangerous episodes as well as control of the more debilitating aspects of both is a more desirable outcome. Hemophilia. Hemophilia is an hereditary disorder of the blood coagulating process and is characterized by repeated internal bleeding episodes which can effect any body part but most often the extremities and joints. These episodes more often than not result in an osteoarthritis-like condition in one or more of the affected joints (Dietrich, 1976). The chronic pain resulting from this condition can be quite debilitating, significantly impair life functioning, and at times lead to analgesic dependence (Varni and Gilbert, 1982). Anti-inflammatory drugs are often employed but tend to be of limited utility (Vami and Gilbert, 1982). Vami (1981) and Vami and Gilbert (1982) investigated the potential for a set of self-regulation techniques to aid in the management of chronic arthritic pain perception in five children with hemophilia. In these accounts, they employed a multiple base-line design across subjects to demonstrate the efficacy of self-regulation skills training (including relaxation, breathing and guided imagery). The training was designed to induce relaxation, vasodilation and increased peripheral blood flow because of previous findings indicating that reductions in perceived arthritic pain was often associated with sensations of body warmth such as that experienced during warm weather or hot showers (Vami, 1983). These initial accounts demonstrated substantial efficacy of the self-regulation training for reducing perceived chronic pain and analgesic-need in all of the patients which was maintained over an extended follow-up period. Hemophilia can also produce severe acute pain in association with episodes of uncontrolled hemorrhage. This acute pain provides a useful signal that indicates the need for factor replacement therapy which usually provides prompt relief. However, approximately 10% of these children develop what is called a Factor VIII inhibitor which renders factor replacement therapy ineffective. For these children, narcotic analgesics are generally necessary. In some cases, the number of extreme pain episodes and need for analgesics increases to an alarming degree. For such cases Vami, Gilbert and Dietrich (1981) reported on an exploratory study of a g-year-old hemophiliac child who had developed the replacement inhibitor. This child had demonstrated a steadily worsening cycle which had led to his becoming wheelchair-bound close to 50% of the time. Training in self-regulation of pain perception was instituted along the lines reported earlier by Vami for the control of chronic arthritic pain associated with hemophilia (the only change being in a modification of the guided imagery technique). Improvements, once again, were dramatic across many areas of functioning, including mobility measures of his arthritic knee. The improvements even in physical functioning might seem surprising. The authors speculated that a deteriorating cycle may have been evident prior to the intervention in the following way: bleeding episodes occurred which led to significant pain which then led to the use of analgesics and joint immobilization, which led to an atrophy of muscles adjacent to the joints in addition to further joint deterioration which then led to further episodes of hemorrhaging (Dietrich, 1976). It may be that Vami’s self-regulating techniques broke this cycle at the point of pain severity, which provided the possibility for increasing therapeutic activities while improving the range of motion in the knee. Clearly, these initial reports by Vami and colleagues are promising. One must keep in mind that the number of subjects has been limited to date, thus precluding overly enthusiastic generalization of the results. Nevertheless, the dramatic nature of the findings is intriguing, as is the possible demonstration of a psychological/physiological feedback loop in this type of pain. Sickle cell disease. Sickle cell anemia is a relatively common disorder with an incidence of close to 1% among American blacks (Lanzkowsky, 1980). Most of the pain associated with sickle cell anemia occurs during intermittent vaso-occlusive crises. During these crises, pain apparently derives from obstructed blood flow in the capillaries due to an accumuiation of misshapen sickle cells. Reduced blood flow can cause hypoxia as well as tissue damage and pain. Crises vary in length

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from a few days to several weeks. Treatment of these crises consists of supplemental oxygen, keeping the patient warm, hydration and administration of analgesics (most often morphine) according to Schechter (1985). Since vasoconstriction seems to be responsible for much of the sickling crises, once again, therapies aimed at producing vasodilation and warmth have been proposed for ameliorating the painful crisis. Thus, Zeltzer, Dash and Holland (1979) taught an adolescent with sickle cell anemia self-hypnosis strategies which included eye fixation and progressive relaxation as well as guided imagery techniques, along with suggestions for increased vasodilation and body warmth. The patient was encouraged to practise these procedures at the moment of any sickling crisis onset. Marked reductions in pain-related outpatient visits and days of hospitalization as well as increases in peripheral skin temperature while using guided imagery were obtained. Unfortunately, the significant incidence rate of sickle cell anemia has not been matched by an equally intensive investigational effort in the area of its psychological management. Cancer. It has been observed that children with cancer may be less likely to exhibit severe disease-related pain than adults, although empirical documentation of this observation is lacking (Jay, Elliott and Vami, 1986a). If this observation is valid, it may be due to the fact that adults and children have different types of cancers. Thus, adults are more likely to have cancer involving organ systems such as stomach, breasts, lungs and ovaries (Hammond, 1985) which often result in severe and prolonged pain (Bonica, 1980). Children, however, are considerably more likely to have blood-related malignancies (e.g. leukemia) and brain tumors which sometimes cause relatively less pain. Furthermore, in those instances when internal disease-related pain does occur, young children may assign less sinister meaning to the sensations because they do not have a very good understanding of the potential negative implications of the pain’s sensations (Beales, 1979). The threat of death can lead to hopelessness and depression which potentiates the cycle of pain, but younger children may not develop this hopelessness to the same degree as older patients. Possibly for these reasons, chronic disease-related pain in children with cancer has received almost no attention in the literature. This fact is unfortunate since, though it is less common in children, chronic disease-related pain does occur. Jay and Elliott (1983) presented a review of psychological interventions for the treatment of chronic pain in children with cancer that appeared to, at least, hold promise. These interventions included operant conditioning, stress management techniques, hypnosis, and family systems therapy. However, systematic research on these techniques is non-existent with regard to this particular application. Children with cancer are also subjected to numerous repeated painful medical procedures such as bone marrow aspirations and lumbar punctures. While the pain associated with such procedures is generally thought of as acute pain, it is repeated over such long time periods (often several years) that it can be thought of as overlapping with chronic pain. Furthermore, as happens with most chronic pain, children’s pain and distress associated with these procedures often appears to fall at least partially under the control of environmental stimuli. In a recent review, Jay et al. (1986a) noted that hypnosis has demonstrated some promise for the amelioration of children’s distress associated with bone marrow apirations and lumbar punctures. However, this approach has not been used with younger children, possibly due to children’s difficulty in manipulating imagery at younger ages (Elliott and Ozolins, 1983). A cognitive-behavioral approach (consisting of filmed modeling, positive incentive, breathing exercises, imagery/distraction, and behavioral rehearsal) to this problem has also demonstrated efficacy, in this case with children of ages 3 to 13 yr (Jay, Elliott, Ozolins, Olson and Pruitt, 1985; Jay, Elliott, Katz and Siegel, 1986b). Rheumatoidarthritis.Juvenile rheumatoid arthritis may affect as many as 250,000 American children and has an estimated incidence of approximately 1.1 cases per 1000 school age children per year (Petty, 1982). This disorder apparently represents a syndrome of diverse etiologies rather than a single disease (Vami and Jay, 1984). At this time no psychological intervention strategies have received empirical investigation for children with juvenile rheumatoid arthritis to our knowledge. However, the aforementioned strategies developed by Vami and colleagues which were applied to arthritic pain associated with hemophilia appear to hold significant promise. Research on this possibility would be highly desirable. Furthermore, preliminary evidence by Thompson, Vami and Hanson (1986) has

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implicated the potential role of family behavior patterns in this disorder. Patterns of rigid control, enmeshment, and lack of conflict resolution were implicated as possible mediators of pain expression in children with juvenile rheumatoid arthritis, although whether they play a causative role could not be established. Family variables were also implicated in a chronic disease-related pain case reported by Zimmerman and Elliott (1984). In this case of a ldyear-old female, the pain was associated with an esoteric disease known as hereditary angioneurotic edema. The girl had developed a negative cycle of pain behavior which proved refractory to both medical interventions as well as a stress management program. However, analysis of the girl’s family dynamics revealed a variety of dysfunctional family behavior patterns which were likely to be providing an array of reinforcement contingencies for her pain behavior. Thus, a combination of family therapy and hehaviour management proved to be far more successful than the initial effort which utilized stress management techniques alone. This report served to suggest that when basic stress management techniques fail to alter chronic pain behavior, the family system may be an important area for assessment and intervention in order to prevent family issues from sabotaging other approaches_ RECURRENT ASSOCIATED

PAIN WITH

SYNDROMES SPECIFIC

NOT

DISEASES

Recurrent abdominal pain and headaches represent two of the most common types of chronic recurrent pain in children which are not associated with specific diseases. They often present interesting diagnostic dilemmas and are not often associated with clear organic dysfunctions or psychological disturbances. Rather, they generally appear likely to involve interactions of subtle psychological and organic variables (Barr, 1981).

Most estimates of the prevalence of recurrent abdominal pain ‘suggest that it affects approximately l&15% of children (Apley, 1975; Oster, 1972). Clear cut, identifiable organic causes are found in less than 7% of all cases (Apley, 1975). Schechter (1984) has reviewed considerable evidence suggesting that ambiguity over etiology of this disorder frequently provokes a veritable barrage of medical tests and evaluations that all too often fail to clarify the situation. Apparently, it is quite rare for these tests to reveal positive findings in the absence of indications in the clinical, medical assessment {Sills, 1978). Furthermore, as the number of tests increases, the probability of obtaining spurious results concomitantly increases, which can lead to even more aversive and expensive tests. Although blatant organic pathology is not usually present in recurrent pain, evidence is increasing that subtle physiological dysfunctions may play a critical role. These dysfunctions may include intestinal gas syndromes, colonic inertia, colonic spasm, and chronic stool retention (Barr, 1981; Feldman, McGrath, Hodgson, Ritter and Shipman, 1985). Rather impressive (albeit indirect) evidence supporting the role of these factors in at least a percentage of these disorders was obtained by Feldman et al. (1985). They examined the effects of adding dietary fiber to the diets of children with recurrent abdominal pain. The study was conducted in a randomized double-blind fashion, tith one-half of the children receiving a high fiber cookie and the other half a ‘placebo’ cookie. Half of the children receiving the high fiber cookie demonstrated at least a 50% reduction in frequency of attacks, while only about 6% of the children receiving the ‘placebo’ cookie showed a similar reduction. The mode of action of the fiber was speculated to be related to reductions in colonic spasm and transit times. This approach is quite cost effective and could prove to be the best initial therapeutic intervention, with other strategies to be reserved for non-responders. Psychological factors have also been implicated in the development and maintenance of chronic abdominal pain. In particular, Whitehead, Winget, Fedoravicus, Blackwell and Wooley (1982) reviewed evidence which at least indirectly provides support for the role of factors such as modeling, reinforcement, and possibly a learned increase sensitivity to bowel symptoms in the etiology of this disorder. The role of the family in recurrent abdominal pain was supported in a study by Dunn-Geier, MeGrath, Rourke, Latter and D’Astous (1986). These authors studied a group of adolescents with chronic, benign intractable pain (50% abdominal, 20% knee, 30%

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headaches), half of whom were ‘copers’ and half of whom were ‘non-cope&, in the sense that they had missed a significant number of school days. An objective observation of motherxhild interactions suggested that mothers of ‘non-cope& more actively discouraged coping behavior than mothers of the ‘cope&. Finally, a common clinical observation is that at least some cases of recurrent abdominal pain probably are a direct result of mere ‘school phobia’, which itself may or may not result from dysfunctional family patterns. In terms of psychological interventions for recurrent abdominal pain, two case studies have suggested the potential for contingency management (in the form of various positive reinforcement techniques and time out) to ameliorate the problem (Miller and Kratochwill, 1979; Sank and Biglan, 1974). Obviously, additional controlled research is needed. Recurrent abdominal pain appears to be a multi-faceted, multiply-determined problem calling for collaborative research and treatment efforts. Headache

The importance of recurrent headache is underscored not only by its high frequency (according to Oster (1972) approximately 20% of school-age children and adolescents), but also by the fact that headaches continue to plague approximately half of these children into adulthood (Bille, 1981). Generally, only a small percentage of children’s headaches are found to be caused by serious organic pathology (Shinnar and D’Souza, 1981). Although the majority of children’s headaches appear to be of the tension type (Gascon, 1984), migraine headaches have received by far the most attention in the literature to date, possibly because they are often assumed to be associated with relatively more intense pain. Classic and common migraines have a somewhat different symptom picture (Jay and Tomasi, 1981), but most intervention studies have included both types while treating them in the same manner. Medical interventions for acute episodes have included analgesics which tend to have unreliable effects (Shinnar and D’Souza, 1981), and Ergotarmine preparation which is a potent vasoconstrictor that may be inadvisable for children’s self-administration (Barlow, 1984). Prophylactic drugs have most often included propranolol and antidepressants (Artman, Grayson and Boerth, 1982; Shinnar and D’Souza, 1981). Ludvigsoon (1974) confirmed the efficacy of propranolol as a prophylactic agent for migraine headaches in a double-blind study of 32 children (ages 7-16 years). Propranolol administration led to almost complete headache elimination in about 70% of the subjects. Psychological interventions for children’s headaches have most often utilized biofeedback (either thermal or EMG) and/or relaxation training. A series of case reports and uncontrolled studies (Olness and McDonald, 1981; Houts, 1982) have been followed by controlled, limited N studies (Labbe and Williamson, 1983, Masek, 1982; Mehegan, Masek, Harrison, Russo and Leviton, 1984) as well as comparative group outcome studies (Fentress and Masek, 1982; Larson and Melin, 1986; Richter, McGrath, Humphreys, Goodman, Firestone and Keene, 1986) which have found that relaxation and biofeedback are of approximately equal effectiveness for the reduction of children’s headaches. Furthermore, they appear to reduce headaches at least as effectively as similar treatments for adult’s headaches. As yet, little has been done to assess the contribution of variables such as expectancy, demand characteristics, self-efficacy, etc., on these therapeutic outcomes for children. Headache studies are usually heavily dependent on self-reported data and thus demand effect are of particular concern. This concern is even greater with children since they may have an increased need to please adult investigators. Furthermore, it would be imprudent to assume that the mechanisms responsible for therapeutic outcome are the same for both children and adults. Clearly, considerable research will be necessary to untangle the web of potentially contributing variables, but improved treatment efficacy may not be possible without it.

ASSESSMENT

Although a thorough discussion of assessment measures is beyond the scope of this article, a detailed review of these can be found in Jay (1984).

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Multimodal assessment of behavioral, cognitive-affective, and physiological response systems are often r~ommended in the investigation of pain. Behavioral observation scales have demonstrated adequate reliability and validity for the assessment of the behavioral response system of pediatric cancer patients when undergoing acute medical and surgical procedures (Jay ef al., 1983; Jay and Elliott, 1984; Katz et al., 1980; Elliott, Jay and Woody, 1987). These scales might also be useful for assessing the behavioral dimensions of pain in children who are experiencing intensely painful acute episodes of pain associated with chronic diseases such as hemophilia and sickle cell anemia. These scales are likely to be less useful as children approach adolescence and beyond, given that older children display less salient responses to pain (Jay et al., 1986a). Additional measures of the behavioral response system in chronic pain often include records of ambulation, pain complaints, medication requests, groaning and grimacing (Sanders, 1979). Care must be taken when using measures such as these with children, due to clinical observations suggesting that children may be more likely to engage in activities in spite of pain and secondly due to children’s fear of needles which may at times inhibit requests for pain medication (Jay et al, 1986a). Even in cases in which chronic pain is clearly associated with disease processes, enviromental contingencies in the form of subtle reinforcement and attention still have the potential to iniluence and exacerbate pain behaviors, thus necessitating an assessment of these contingencies as recommended by Fordyce (1976). Jahanshahi and Philips (1986) have noted that avoidance behavior may be a particularly difficult aspect of the pain-related behavioral dimension to quantify since it could require prolonged time sampling strategies. They have presented initial investigations of a laboratory technique involving the tolerance of an auditory sitmulus with adult headache sufferers but no similar applications of this approach have heen made with children. The cognitive-affective response system may be assessed through measurements such as patient’s self-reported pain, depression, anxiety and relevant cog&ions. In order to obtain self-reports of pain from children, a variety of modified visual analog scales have been developed which use concrete visual representation of pain on a continuum (e.g. happy-sad faces, pain the~ometers, color measures) (McGrath, Cunningham, Goodman and Unruh, 1986). However, questions have been raised as to the utility of these techniques for children under the age of seven (McGrath et al., 1986; Elliott et al., 1987). Hester (1979) has reported on a technique involving poker chips which may have some promise for the self-report of pain in children as young as the age of four. Anxiety questionnaires and depression inventories generally have not been utilized to assess these dimensions of chronic pain in children, but would seem quite appropriate given the potential of these variables to moderate the experience of pain. Self-statement inventories, adjective checklists such as the Vami/Thompson Pediatric Pain Questionnaire (Vami and Thompson, 1985) and Daily Pain Diaries also may have utility for evaluating the cognitiv+affective component of children’s chronic pain. To date, the physiolo~~l assessment of children’s chronic pain has received scant attention possibly because with chronic pain, it is more difficult to identify when or if nociceptive stimuli have occurred. Indeed, it may be that the assessment of physiological responses will prove to be more useful in the evaluation of repeated acute pain episodes such as that associated with certain diseases (e.g. hemophilia and sickle cell anemia) and painful medical procedures. Measures such as heart rate, blood pressure, sweat gland activity and respiration have yielded interesting data for these types of applications (e.g. Sanders, 1979; Jay and Elliott, 1987). Obviously, the multimodal assessment of pain can result in an endless enterprise. investigators thus would be well advised to a priori target the dependent variables that are especially pertinent to the investigation. Peterson (1984) noted that this approach can help reduce the problem associated with ever increasing numbers of dependent variables which can serve to increase the probability of obtaining chance findings. CONCLUSION It is interesting to note that the literature base for this review was less than half of its current volume a mere five years ago. Obviously, interest in children’s chronic pain has significantly increased. In spite of this increased attention, in the area of treatment outcome data, we have only begun to scratch the surface. Exciting potential has been shown for psychological interventions

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with several types of disease-related pain, but studies have been largely restricted to initial demonstrations of efficacy. Possibly, limited access to these populations of children has hampered the evolution to controlled, group outcome research. In the area of recurrent pain syndromes, headaches have at least been studied on an initial controlled group basis. However, much remains to be done in terms of clarifying the nature of the therapeutic mechanisms involved. As exciting as the potential for psychological interventions of children’s pain is, one must also remember the disturbing trends concerning medication management of children’s pain that were reviewed. Studies on the psychological issues governing prescription practices would certainly appear warranted. Hopefully, an awareness of this and some of the other key issues reviewed in this paper will prove useful to future investigations. Clearly, the area of children’s chronic pain is replete with numerous areas demanding greater inquisition. Correspondence-Requests

for reprints should be addressed to Charles H. Elliott.

REFERENCES Apley J. (1975) The Child wirh Abdominal Pains. Blackwell Scientific Publications, Oxford. Artman M., Grayson M. and Boerth R. C. (1982) Propanolol in children: Safety-toxicity. Pediarrics 70, 30-31. Barlow C. F. (1984) Headaches and Migraine in Childhood. Clinics in Developmenral Medicine, Vol. 91. S.I.M.P. with Heinemann, London; Lippincott, Philadelphia. Barr R. (198 1) Recurrent abdominal pain. In Behauioral Problems in Childhood: A Primary Care Approach (Edited by Gabel S.). Grune and Stratton, Inc., New York. Beales J. G. (1979) Pain in children with cancer. In Aduances in Pain Research and Therapy, Vol. 2 (Edited by Bonica J. J. and Ventafridda V.), pp. 8%98. Raven Press, New York. Beales J. G., Kean J. H. and Lennox-Holt P. J. (1983) The child’s perception of disease and the experience of pain in juvenile chronic arthritis. J. Rheumarol. 10, 6145. Bille B. (1981) Migraine in childhood and its prognosis. Cephaiagia 1, 71-75. Bonica J. J. (1979) Introduction to management of pain of advanced cancer. In A&mces in Pain Research and Therapy (Edited by Bon& J. J. and Ventaftidda V.), Vol. 2. Raven Press, New York. Bonica J. J. (1980) Cancer pain. In Pain (Edited by Bonica J. J.), pp. 335-362. Review Press, New York. Dietrich S. L. (1976) Medical management of hemophilia. In Comprehensioe Managemenr of Hemophilia (Edited by Boone D. C.). FA Davis, Philadelphia. Dolgin M. J. and Jay S. M. (1987) Pain management in childhood. In Behaviora Treatment of Childhood Disorders (Edited by Mash E. J. and Barkley R. A.). Guilford Press, New York. Dunn-Geier B. J., McGrath P. J., Rourke B. P., Latter J. and D’Astous J. (1986) Adolescent chronic pain: The ability to cope. Pain 26, 23-32. Eland J. M. and Anderson J. E. (1977) The experience of pain in children. In Pain: A Source Book for Nurses and other Health Professionals (Edited by Jacox A.). Little Brown and Co., Boston. Elliott C. H. and Ozolins M. (1983) Imagery and imagination in the treatment of children. In Handbook of Child Cfinicaf Psychology. (Edited by Walker C. E. and Roberts M.), pp. 1026-1049. John Wiley and Sons, New York. Elliott C. H., Jay S. M. and Woody P. (1987) An observation scale for measuring children’s stress during medical procedures. J. Pediat. Psychol. In press. Feldman W., McGrath P., Hodgson C., Ritter H. and Shipman R. T. (1985) The use of dietary fiber in the management of simple childhood idiopathic, recurrent abdominal pain. Am. J. Dir. Child. 139, 1216-1218. Fentress D. W. and Masek B. J. (1982) Behavioral treatment of childhood migraine. Unpublished manuscript. Fordyce W. (1976) Behavioral Merhodc for Chronic Pain and Illness. Mosby, St Louis. Gascon G. G. (1984) Chronic and recurrent headaches in children and adolescents. Pediat. Clin. Norrh Am. 31(5), 1027-1051. Hammond G. D. (1985) Multidisciplinary clinical investigation of the cancers of children. Cancer 55, 1215-1225. Hester N. (1979) The preoperational child’s reaction to immunization. Nurs. Res. 28, 25&255. Houts A. C. (1982) Relaxation and thermal feedback treatment of child migraine headaches: A case study. Am. J. C/in. Biof. 5. 154-157. Jaffe i H: (1975) Drug addiction and drug abuse. In The Pharmacological Basis of Therapeurics, 5th Edn (Edited by Goodman L. S. and Gilman A.),,- __ DD. 245-283. Macmillan, New York. Jahanshahi M. and Philips C. (1986) Validating a new technique for assessment of pain behavior. &bun Res. Ther. 24, 3542.

Jay S. M. (1984) Pain in children: An overview of psychological assessment and intervention. In Healrh Psychology: Trealment and Research Issues (Edited by Zeiner A., Bendell D. and Walker C.). Plenum, New York. Jay S. M. and Elliott C. H. (1983) Psychological intervention for pain in pediatric cancer patients. In Adrenal and Endocrine Tumors in Children (Edited by Humphrey G., Grundey B. B., Dehmer L., Acton R. T. and Pysher T. J.), pp. 123-154. Martinus Nijhoff Publishers, Boston. Jay S. M. and Elliott C. H. (1984) Behavioral observation scales for measuring children’s distress: The effects of increased methodological rigor. 1. consulr. clin. Psychol. 52, 1106-1107. Jay S. M. and Elliott C. H. (1987) Multimodal assessment and response concordance in children undergoing _ __Dainful medical _ procedures. Submitted ibr publication. Jar G. W. and Tomasi L. G. (1981) Pediatric headaches: A one year retrosuective analysis. Heaakche 21. 5-9. Jai S. M., Ozolins M., Ellioti C. h. and Caldwell S. (1983) A&ssment df children’s_distress during painful medical procedures. Heallh Psychol. 2, 133-147.

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