title: Pain among children and adolescents: restrictions in daily living and triggering factors.
abstract: OBJECTIVE
  Pain among children and adolescents has been identified as an important public health problem. Most studies evaluating recurrent or chronic pain conditions among children have been limited to descriptions of pain intensity and duration. The effects of pain states and their impact on daily living have rarely been studied. The objective of this study was to investigate the impact of perceived pain on the daily lives and activities of children and adolescents. In addition, we sought to delineate self-perceived triggers of pain among children and adolescents. In this study, we (1) document the 3-month prevalence of painful conditions among children and adolescents, (2) delineate their features (location, intensity, frequency, and duration), (3) describe their consequences (restrictions and health care utilization), and (4) elucidate factors that contribute to the occurrence of pain episodes among young subjects.
  
  
  METHODS
  The study was conducted in 1 elementary school and 2 secondary schools in the district of Ostholstein, Germany. Children and adolescents, as well as their parents/guardians, were contacted through their school administrators. The teachers distributed an information leaflet, explaining the conduct and aim of the study, to the parents a few days before the official enrollment of the youths in the study. Parents of children in grades 1 to 4 of elementary school were asked to complete the pain questionnaire for their children at home, whereas children from grade 5 upward completed the questionnaire on their own during class, under the supervision of their teachers. The response rate was 80.3%. As previously stated, chronic pain was defined as any prolonged pain that lasted a minimum of 3 months or any pain that recurred throughout a minimal period of 3 months. The children and adolescents were surveyed with the Luebeck Pain-Screening Questionnaire, which was specifically designed for an epidemiologic study of the characteristics and consequences of pain among children and adolescents. The questionnaire evaluates the prevalence of pain in the preceding 3 months. The body area, frequency, intensity, and duration of pain are addressed by the questionnaire. In addition, the questionnaire inquires about the private and public consequences of pain among young subjects. Specifically, the questionnaire aims to delineate the self-perceived factors for the development and maintenance of pain and the impact of these conditions on daily life.
  
  
  RESULTS
  Of the 749 children and adolescents, 622 (83%) had experienced pain during the preceding 3 months. A total of 30.8% of the children and adolescents stated that the pain had been present for >6 months. Headache (60.5%), abdominal pain (43.3%), limb pain (33.6%), and back pain (30.2) were the most prevalent pain types among the respondents. Children and adolescents with pain reported that their pain caused the following sequelae: sleep problems (53.6%), inability to pursue hobbies (53.3%), eating problems (51.1%), school absence (48.8%), and inability to meet friends (46.7%). The prevalence of restrictions in daily living attributable to pain increased with age. A total of 50.9% of children and adolescents with pain sought professional help for their conditions, and 51.5% reported the use of pain medications. The prevalence of doctor visits and medication use increased with age. Weather conditions (33%), illness (30.7%), and physical exertion (21.9%) were the most frequent self-perceived triggers for pain noted by the respondents. A total of 30.4% of study participants registered headache as the most bothersome pain, whereas 12.3% cited abdominal pain, 10.7% pain in the extremities, 8.9% back pain, and 3.9% sore throat as being most bothersome. A total of 35.2% of children and adolescents reported pain episodes occurring > or =1 time per week or even more often. Health care utilization because of pain differed among children and adolescents according to the location of pain. Children and adolescents with back pain (56.7%), limb pain (55.0%), and abdominal pain (53.3%) visited a doctor more often than did those with headache (32.5%). In contrast, children and adolescents with headache (59.2%) reported taking medication because of pain more often than did those with back pain (16.4%), limb pain (22.5%), and abdominal pain (38.0%). The prevalence of self-reported medication use and doctor visits because of pain increased significantly with age (chi2 test). The prevalence of self-reported medication use was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (chi2 test). The prevalence of restrictions in daily activities varied among children and adolescents with different pain locations; 51.1% of children and adolescents with abdominal pain and 43.0% with headache but only 19.4% with back pain reported having been absent from school because of pain. The prevalence of restrictions attributable to pain was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (chi2 test). The self-reported triggers for pain varied between girls and boys. Girls stated more often than boys that their pain was triggered by weather conditions (39% vs 25%), illness (eg, common cold or injury) (35.9% vs 23.9%), anger/disputes (20.9% vs 11.9%), family conditions (12.1% vs 5.2%), and sadness (11.9% vs 3.4%). In contrast, boys stated more often than girls that their pain was triggered by physical exertion (28% vs 17.2%). We used a logistic regression model to predict the likelihood of a child paying a visit to the doctor and/or using pain medication. Health care utilization was predicted by increasing age, greater intensity of pain, and longer duration of pain but not by the frequency of pain. We used a logistic regression model to predict restrictions in daily activities. Only the intensity of pain was predictive of the degree of restrictions in daily life attributable to pain; the duration of pain and the frequency of pain episodes had no bearing on the degree to which the daily lives of the children were restricted because of pain.
  
  
  CONCLUSIONS
  More than two thirds of the respondents reported restrictions in daily living activities attributable to pain. However, 30 to 40% of children and adolescents with pain reported moderate effects of their pain on school attendance, participation in hobbies, maintenance of social contacts, appetite, and sleep, as well as increased utilization of health services because of their pain. Restrictions in daily activities in general and health care utilization because of pain increased with age. Girls > or =10 years of age reported more restrictions in daily living and used more medications for their pain than did boys of the same age. We found gender-specific differences in self-perceived triggers for pain. Pain intensity was the most robust variable for predicting functional impairment in > or =1 areas of daily life. Increasing age of the child and increasing intensity and duration of pain had effects in predicting health care utilization (visiting a doctor and/or taking medication), whereas restrictions in daily activities were predicted only by the intensity of pain. Our results underscore the relevance of pediatric pain for public health policy. Additional studies are necessary and may enhance our knowledge about pediatric pain, to enable parents, teachers, and health care professionals to assist young people with pain management, allowing the young people to intervene positively in their conditions before they become recurrent or persistent.
authors.affiliation: Department of Anesthesiology, University of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, D-23538 Luebeck, Germany. isigkeit@uni-luebeck.de
authors.forename: Angela
authors.initials: A
authors.lastname: Roth-Isigkeit
authors.forename: Ute
authors.initials: U
authors.lastname: Thyen
authors.forename: Hartmut
authors.initials: H
authors.lastname: Stöven
authors.forename: Johanna
authors.initials: J
authors.lastname: Schwarzenberger
authors.forename: Peter
authors.initials: P
authors.lastname: Schmucker
mesh_terms: D000203:Activities of Daily Living; D000293:Adolescent; D002648:Child; D002908:Chronic Disease; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D010146:Pain / Q000453:epidemiology* / Q000209:etiology; D010147:Pain Measurement; D015995:Prevalence; D011795:Surveys and Questionnaires