Non-organic pain in childhood

It is not uncommon for children to present to general practitioners with pains which the doctor may suspect are principally psychogenic in origin. These pains tend to be non-specific and recurrent. The history should be taken from the child and the parents. All children should be examined, but investigations may not be needed. After excluding organic causes of pain, the possibility of a psychogenic cause should be sensitively discussed. Many children with non-organic pain will spontaneously recover. In cases which do not respond, the health professional should be alert to more serious problems such as child abuse or depression.

Non-organic pain arises from the complex interplay of multiple factors including the child's mental state, temperament and environment. When a child presents with organic pain, the clinician may be able to objectively test for, and diagnose, a physical cause for that pain. This is not the case with non-organic pain, as there is no definitive test for psychosomatic illness. Investigation, at best, will only exclude organic disease; it will not prove a functional origin.

The experience of pain is subjective and unique to each child. It is only when a child describes the pain that the origin, nature and severity of that pain can be understood. The diagnosis of non-organic pain is therefore both intellectually and medically challenging.

Non-organic pain may affect about one third of children, but the true incidence is unknown. Although non-organic pain is uncommon before four years of age, its incidence steadily rises throughout childhood.

As children grow they become cognitively more sophisticated. Younger children tend to express painful symptoms in simple terms. The young child is less likely to describe non-organic pain as being discrete or site specific. Vague stomach aches and headaches are more usual complaints. In adolescence, somatic complaints tend to be more frequent in early puberty (perhaps related to physical changes). At this age, headaches, chest pain, fatigue, limb pains and health worries are more prevalent. The older child's pain descriptions can be quite sophisticated and are often accompanied by other somatic complaints e.g. fatigue, nausea. Before puberty, complaints of painful symptoms are equally expressed by both sexes. After puberty, they are more common in girls.

Most pains of non-organic origin will fall into the 'recurrent pains' group. These include headaches and recurrent abdominal pains. This latter condition is especially common in early to middle childhood and affects at least 10% of the school age population. By definition, it is characterised by at least three episodes of abdominal pain, over a period of three months, which affect the activities of daily living. While there is no evidence to suggest that recurrent abdominal pain has a physiological cause, there is a lot of evidence to suggest that the affected children are different from their peers in that they are more likely to be anxious and depressed. Half the childhood population experience headaches and the incidence tends to increase with age. While classical migraines are acknowledged to have a genetic aetiology, environmental factors influence the frequency of headaches. For example, the incidence of headaches in adolescence can be directly related to lower quality of life measures.

This leaves a group of children (usually older) who present with 'non-recurrent' painful symptoms. There is very little in the literature about these children as they are not easily studied as a group. In adults, true somatiform disorders occur in 0.2% of women and 0.02% of men. At least one third of these people report that their symptoms started at or before adolescence.

As medical practitioners, we are generally trained with an organic focus which can blind us to the psychological lives of our patients. In order to be good clinicians, we often relentlessly pursue the rare, organic condition and remain oblivious to the effects of common unhappiness. By diligently exploring these diagnostic blind alleys, we not only fail to address our patient's principal condition, but we also reaffirm their fears and give credence to their 'illnesses'. When an organic diagnosis proves impossible, it is not uncommon for us to become angry and frustrated with the patient - 'they never had real pain, it was all in their head'. Far better to acknowledge that all patients presenting with pain have a psychological component to their problem - our job is to determine its extent.

Children who present with pain are in distress regardless of whether that pain is organic or non-organic in origin. Therefore, all children with painful symptoms should be treated with respect, their 'sickness' should be acknowledged and the reality of their pain accepted.

As there is no test for 'non-organic' pain, the clinician has to rely on the history and examination. When taking a history, it is well to remember that there is very little concordance between the symptom descriptions given by children and those given by their parents. Asking the child about their symptoms is very important. Even very young children can give good descriptions of their pain.

Interviewing the child can also be very revealing about their mood and affect. Younger children are surprisingly candid and, while their language may not be sophisticated, they can be quite perceptive about family function and how they feel about themselves. Older children tend to be more reticent, especially in front of their parents. This is why it is often useful to set aside time to interview the child by themselves. Ultimately, most children will respond if questions are expressed in a neutral tone e.g. 'What's it like living in your family?' or 'Would I enjoy living at your house?'.

It is important to ask all children about their school life, once again, in a face-saving neutral way. For example, 'Tell me what you like best about school' can be followed by 'and is there anything about school you don't like so much?'. Using qualifiers can soften a question so that admission is not quite so humiliating. So 'Are you lonely at school?' could be better expressed as 'Are you sometimes lonely at school?'. A follow-up question could then be 'Is this just sometimes, or is it a lot of the time?'.

Seeking physical causes (Table 2)

To determine whether a pain is organic or non-organic in origin, doctors must take a thorough pain history. They should specifically inquire about the nature of the child's pain, its triggers, its radiation, duration and timing. If a child gives a consistent description of a pain which is unifocal and persistent, then that pain is more likely to be organic. A child who complains of a recurrent headache which is unifocal is more likely to have an underlying organic cause. Similarly, recurrent abdominal pain is usually felt as a vague, periumbilical pain; if it is discrete and located away from the umbilicus, it is more likely to be organic in origin.

Asking when painful symptoms occur is helpful in differentiating organic from non-organic pain. Pains which occur in the morning, before school, but which do not occur on weekends, are likely to be due to separation anxiety. Similarly, pain which occurs at bedtime, but which does not disturb a child once they are asleep, is likely to be non-organic in origin. A diary may be useful in assessing the pattern of pain (Fig. 1).

Generally, children with non-organic pain eat normally and do not lose weight. Unless they have major symptoms of depression or separation anxiety, they usually sleep well. At presentation, they appear healthy and on examination have little in the way of signs. If they do complain of pain, their descriptions of its severity are usually out of proportion to their demeanour. Often they are easily distracted from their pain e.g. giving them tasks in mental arithmetic while palpating a 'tender' abdomen can be diagnostically useful and a revelation to parents.

Parents are alarmed when their child has pain. In our culture, pain is seen as being an integral part of physical disease. Most parents never think of the possibility that their child's pain could be psychogenic in origin. Talking about this issue needs to be done with appropriate timing and sensitivity.

Before broaching the possibility of a non-organic cause for pain, it is essential that both the parents and the child see that the clinician is listening to their story and accepts that the child has pain. They need to feel that an organic diagnosis has been considered and that the clinician is not denying them access to investigations. Asking the family if they have any particular fears can be helpful e.g. are they worried that the child's pain may be due to cancer? In this circumstance, it is not uncommon to discover that in the past a much loved relative has died of this condition.

Dogmatically stating 'I think the pain is psychological' forces parents into a clear and immediate response. This is likely to take the form of anger or rejection. Further, the word 'psychological' may be interpreted by the family to mean 'not real', 'in his head', or 'mad'.

Proposing a psychogenic cause for pain should be done in an open-ended rather than proscriptive manner i.e. 'Do you think that this pain may be related to stress/school problems?' This allows parents the opportunity to start thinking about the possibility without having to immediately accept or reject the idea. It also allows the clinician to introduce more material such as 'You know this pain is not like anything I have seen before. The symptoms don't fit with a standard, physical diagnosis. This is why I wonder if we should be thinking of unhappiness as a cause of the pain - what do you think?'

The diagnosis of non-organic pain usually requires several consultations. Reviewing the child and family in this way allows time to explore the idea that pain may have a non-organic origin. Any investigations can then be done sensibly, step by step, until everyone is convinced that an organic cause is unlikely.

Investigating pain, even when it is suspected to be non-organic in origin, can be extremely reassuring for both the child and their family. These investigations must of course do the child no harm, must be few in number and should be chosen to give the maximum amount of information. When an investigation is reported as normal, the clinician should use this as a positive outcome. Rather than saying 'I can't find what's wrong', families can be reassured that 'No physical disease has been found'.

Most non-organic pain in childhood can be successfully managed by the family practitioner. As a minimum, the reassurance that there is nothing physically wrong can be quite liberating for both parents and the children. It is not beyond even young children to appreciate that 'sad feelings can make you feel sick'. Often this simple manoeuvre will dissipate anxiety and allow the family room to deal with issues other than physical unwellness. A sympathetic ear and sensible advice is often all that is needed to restore balance to a situation and help a child resolve their painful symptoms.

The family practitioner is ideally placed to recognise children with more serious problems, which may be related to depression, anxiety, separation difficulties or even sexual abuse. Once a non-organic cause for pain has been established, then parents will understand and appreciate an appropriate referral.

Fig. 1 Pain Diaries A pain diary is a useful way for parents and physicians to understand a child's painful symptoms. Although different formats need to be used for different ages they should all contain the following elements: (1) What were the circumstances just prior to the commencement of the pain? (2) How long did the pain last? (3) What was the severity of the pain? (4) How did the child react to the pain? My Pain Diary Name ................................... Date Time Duration Severity Show how strongly you feel pain, by putting a mark on the line (1 = almost none, 10 = extreme pain) Comments Record what you were doing when the pain started and what you did while you had the pain 1.................................................................10 1.................................................................10 1.................................................................10 My Pain Diary Name ................................... Date Time Duration Severity Show how strong the pain is, colour in a face (1 = almost no pain, 2 = a little pain, 3 = some pain, 4 = bad pain and 5 = very bad pain) Comments Record what your child was doing when the pain started and what they did while they had the pain 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Further reading

Sifford LA. Psychiatric assessment of the child with pain. Child Adolesc Psychiatr Clin N Am 1997;6:745-81.

Apley J. The child with abdominal pains. Oxford: Blackwell Scientific Publications; 1975.

The following statements are either true or false.

1. Children with non-organic pain usually have a normal appetite.

2. Recurrent abdominal pain is usually due to a 'grumbling appendix'.

Answers to self-test questions

1. True

2. False