OBJECTIVE: The goal of the current study was to investigate self-reported, health-related quality of life (HRQoL) in a general population of young schoolchildren with recurrent pain (ie, headache, stomachache, or backache).
METHODS: The study was performed in Umeå, a university city in Sweden. All children in grades 3 and 6 were invited, and 97% participated (313 girls and 292 boys in grade 3 [mean age: 9.7 years]; 386 girls and 464 boys in grade 6 [mean age: 12.6 years]). Pain and HRQoL were measured with questionnaires.
RESULTS: Two thirds of the children reported recurrent pain (at least monthly). One third reported weekly pain, and 4 of 10 experienced pain from multiple locations. HRQoL impairment was twice as common among children with recurrent pain, compared with children without pain. All aspects of HRQoL (ie, physical, emotional, social, and school functioning and well-being) were impaired. The level of impairment was classified as considerable, especially for children who experienced pain from multiple body sites and children with weekly pain (Cohen's d = 0.6–0.8).
CONCLUSIONS: This study shows that young schoolchildren with recurrent pain have considerable impairment of their HRQoL.
Recurrent long-term pain has been identified as a common problem in children. Most children with recurrent pain experience pain in the head, stomach, or musculoskeletal system,1–3 with pain at >1 location being noted for at least one half of the children.2–5 Prevalence estimates vary, but epidemiological studies support the occurrence of recurrent or chronic pain in 25% to 35% of the child population,2–4 with increasing prevalence over time.6–8
Although pain conditions are common, both the causes and impact in a general population context are still unclear. The literature suggests that children with recurrent pain conditions may experience general impairment of their health-related quality of life (HRQoL).9–13 HRQoL is a comprehensive multidimensional concept including at least physical, emotional, and social dimensions of functioning and well-being, and it has been acknowledged as helpful for clinical decision-making as well as health care policy-making.14,15 The core dimensions of HRQoL may not only expose the impact of pain. Deprived physical, emotional, and social states have been suggested to induce pain experiences by influencing pain-processing.16–20 Therefore, the aggregate measure of HRQoL may provide important information related to both the causes and impact of pain. Only a few investigations performed standardized HRQoL evaluations for children with recurrent pain; those investigations usually did not take into consideration the meaning of cooccurring pain conditions, and they were performed mostly in clinical settings that were not representative of the child population in general.9–13,21 In general populations, low levels of parent-child agreement in pain ratings and low levels of medical attention-seeking among children with recurrent pain have led to suggestions of low levels of pain-associated impairment.22
The objectives of this study were to address the following questions. (1) Is there a difference in HRQoL between young schoolchildren with and without recurrent pain conditions (ie, headache, stomachache, or backache)? (2) Does HRQoL differ according to the number of pain sites or pain frequency in young schoolchildren with recurrent pain? These questions were studied with girls and boys in different age groups. Expectations were for merely trivial differences in HRQoL between children with and without recurrent pain and for lower HRQoL with higher numbers of pain sites or greater frequency of pain episodes.
Study Population and Procedure
The study was performed in 2003–2004 in Umeå, a university municipality in Sweden with ∼110000 inhabitants. All schoolchildren in grades 3 and 6 (N = 1655) in the city of Umeå were invited, and 97% of the children participated in the study. Children enrolled in special schools for children with intellectual disabilities were not included. Participants were 8 to 14 years of age (mean: 11.3 years) and included 313 girls and 292 boys in grade 3 (range: 8–11 years; mean: 9.7 years) and 386 girls and 464 boys in grade 6 (range: 12–14 years; mean: 12.6 years).
Before the investigation, pupils, parents, and involved school staff members received information about the study. With instruction by one of the investigators (Dr Petersen) and with the teacher present but not participating, children in grade 6 completed coded pain and HRQoL questionnaires confidentially in the classroom. Children in grade 3 completed the HRQoL questionnaire in the classroom and the pain questionnaire at home, assisted by a parent. Parents completed a sociodemographic form. Codes were accessible only to the research leader. If necessary, children in grade 6 could listen to the questions on a minidisc; in grade 3, the investigator read the HRQoL questions aloud one by one.
Pain questions were answered by 1495 children, and 1570 children completed the HRQoL questionnaire. Six HRQoL forms were later excluded because of missing items. Both questionnaires were completed adequately by 1455 children (88%), and 1353 of their parents (93%) completed the sociodemographic form.
Pain was measured with questions from the international, World Health Organization Health Behavior in School-aged Children (HBSC) study.23 These questions have shown adequate face validity and test-retest reliability.24 The questions were framed as, “In the past 6 months, how often have you had a headache?” (alternatively, stomachache or backache), and response alternatives were as follows: 1 = about every day, 2 = more than once per week, 3 = about every week, 4 = about every month (referred to as monthly), and 5 = rarely or never. Categories 1 to 3 together are referred to as weekly or frequent pain and categories 1 to 4 together are referred to as recurrent pain.
Health-Related Quality of Life
The 23-item, Pediatric Quality of Life Inventory (PedsQL) 4.0 generic core scale, self-report form measured HRQoL.25 Eight items captured physical aspects of HRQoL (eg, abilities to walk, to run, and to perform sport activities, pain, and energy). Psychosocial aspects were measured with 15 items encompassing a 5-item emotional domain addressing anxiety, fear, sadness, depression, anger, worries, and sleep problems, a 5-item social domain focusing on peer relationships and participation in social activities, and a 5-item school domain addressing school performance and the ability to be in school.
Recall time was 1 month, and the response alternatives were as follows: 0 = never a problem, 1 = almost never a problem, 2 = sometimes a problem, 3 = often a problem, and 4 = almost always a problem. Categories 0 and 1 together are referred to as almost never problems, category 2 is referred to as sometimes problems, and categories 3 and 4 together are referred to as frequent or often/always problems. A HRQoL problem was classified as present when ≥1 item was scored as ≥2 and the problem was considered frequent when ≥1 item was scored as ≥3 (this classification did not include the question of pain in the physical domain). Mean scale scores were given when ≥50% of item scores were available. For estimation of mean scores, scores were reversed and transformed into a 100-point scale, with higher scores indicating better HRQoL.25
Children reported sex and school grade and, in grade 6, ethnicity and family structure. Parents reported ethnicity and family structure in grade 3, along with parental employment and education. Parents also reported child long- and short-term ill health, along with child health care contacts during the preceding 6 months and the reason for those contacts. Variables were dichotomized to distinguish whether both parents were born in North America/Europe (ethnicity), whether the parents lived together (family structure), whether the father and mother each had >9 years of schooling (education), whether the father and mother each worked full-time or part-time (employment), and whether the child had an ill health condition other than headache, stomachache, or backache (non–pain ill health).
The data were analyzed by using SPSS 11.5 (SPSS Inc, Chicago, IL). Descriptive statistics were computed for age- and sex-specific pain and for HRQoL among children with and without recurrent pain. Pearson's χ2 test and the Mann-Whitney U test for 2 independent samples tested group differences. Cohen's d was used to estimate the magnitude of differences between mean scale scores (impairment). Differences were regarded as meaningful but small at Cohen's d of 0.20, medium at 0.50, and large at 0.80.29 In multivariate logistic regression analyses, pain-HRQoL associations were corrected for sociodemographic characteristics (the dependent variable was the occurrence of >1 HRQoL problem, the independent variable was recurrent, multisite, or frequent pain, and covariates were sociodemographic characteristics). Unless stated otherwise, all differences mentioned were significant at the 95% level (P < .05), with 1 exception; for testing of sociodemographic factors as potential confounders, the significance level was set at P < .10.
The study was approved by the research ethics committee of the Medical Faculty, Umeå University (project 03-352 and 05-152).
Basic Study Characteristics
Two thirds of the children reported recurrent pain in the head, stomach, or back, and one third experienced pain ≥1 time per week (Table 1). The pain occurred at multiple sites for 4 of 10 children, and the majority of children with weekly pain experienced multisite pain. In comparisons of children with and without recurrent pain, children with pain more often were in grade 6 and were girls and less often had cohabiting parents or 2 parents of North American or European origin. During the preceding 6 months, 3% of the children with recurrent pain had been in contact with health care providers because of pain in the head, stomach, or back.
Occurrence of HRQoL Problems
A great majority of children with recurrent pain reported a HRQoL problem (Table 2). Most of them reported >1 HRQoL problem, and the problem occurred frequently (often or almost always) for 38%. In comparisons of children with and without a pain condition, HRQoL problems were more than twice as common among pain-suffering children, and children with weekly or multisite pain had a fourfold increased risk of HRQoL problems (odds ratio [OR]: 3.7 [95% confidence interval [CI]: 2.7–5.0]; data not shown). Adjustment for potential confounders (ie, age, sex, ethnicity, and family structure) resulted in only minor OR changes.
HRQoL Impact According to Pain Characteristics
HRQoL mean summary scores were lower (ie, poorer HRQoL) among children with a pain condition than among those without a pain condition. Impairment was meaningful across all studied HRQoL domains but was less pronounced in the social domain than in other domains (Fig 1). Impairment also was less pronounced in children with single-site versus multisite pain and in children with monthly versus weekly pain episodes (Table 3). Among children with single-site or monthly pain, the magnitude of impairment was small to medium; among children with multisite or weekly pain, the magnitude of impairment was medium to large. Adjustment for age, sex, ethnicity, and family structure resulted in a general decrease of mean scores of ∼2 points, but differences between scores for children with versus without recurrent pain remained.
Stratification according to pain characteristics showed that, regardless of the number of pain sites, the physical scores were lower for children with weekly pain episodes than for children with monthly pain episodes (Fig 2). In contrast, regardless of pain frequency, psychosocial health scores tended to be lower for children with multisite versus single-site pain (the difference between children with multisite/monthly pain and children with single-site/weekly pain was not significant).
Each pain condition (ie, headache, stomachache, and backache) separately demonstrated medium to large HRQoL impairment (Table 4). It should be noted that impairment repeatedly was less pronounced for the minority of children for whom the specific condition was a single-site pain condition.
Age and Sex Perspectives
The HRQoL impairment described above was seen in pain-suffering children in both grades and of both genders (Table 3). Children in grade 6, however, revealed greater impairment than did children in grade 3, which was mainly attributable to more-pronounced impairment of emotional and school scores among children in grade 6. HRQoL levels were generally quite similar for girls and boys but, among children with multisite or weekly pain, grade- and sex-stratified analyses showed greater HRQoL impairment among girls than among boys (difference in Cohen's d of ≥0.2 for both grades). The most-pronounced HRQoL impairment was seen for girls in grade 6 with multisite or weekly pain (HRQoL impairment: Cohen's d = 0.9–1.0; physical impairment: Cohen's d = 0.7–0.8; psychosocial impairment: Cohen's d = 0.9–1.0; emotional impairment: Cohen's d = 1.1; school impairment: Cohen's d = 0.8).
The present study evaluated associations between HRQoL and recurrent pain in a large, population-based sample of young school-aged children. It also investigated relationships between HRQoL and numbers of pain locations. The results show that children with recurrent pain have substantially lower HRQoL than do their peers with no pain condition and multisite pain is associated with poorer HRQoL than is single-site pain. The lower HRQoL in pain-suffering children is expressed as a higher prevalence of children with HRQoL problems, a higher frequency of HRQoL problem episodes, and a larger number of impaired HRQoL aspects.
HRQoL impairment was evident within all studied HRQoL aspects, which is consistent with results from studies of adolescents with recurrent pain (nonclinical sample) and younger as well as older school-aged patients with specific pain conditions, that is, headache, abdominal pain, or musculoskeletal pain.9,11–13,21,30 These results suggest general HRQoL impairment, including all core elements of HRQoL in clinical and nonclinical populations of pain-suffering school-aged children.
The high prevalence of recurrent pain found in the current study is in line with literature findings,2–4 and so is the lower HRQoL with higher pain frequency.31–33 High levels of multisite pain were also described earlier,2–5 whereas the significance of the number of pain sites for HRQoL is relatively unexplored. The current findings of greater HRQoL impairment for children with multisite pain versus single-site pain, however, have some support in a study of adults reporting more HRQoL problems with greater numbers of pain sites.34 Moreover, single HRQoL aspects (eg, emotional and functional problems) have been found to increase with greater numbers of pain sites in both adults and children,35,36 and a study monitoring children from 4 to 10 years of age found that early behavioral problems were associated more closely with later multisite pain than with later single-site pain.37 Multisite pain differs from single-site pain also with respect to pain frequency and age and sex distributions.4 Therefore, multisite pain and single-site pain have a number of different attributes.
Impairment in children with a specific pain condition (eg, headache) has been studied conventionally in groups including children with both single-site pain and multisite pain. We found a marked difference in HRQoL between such “all-inclusive” groups of children with a specific type of pain and the subgroup suffering the pain condition as a single-site pain. Therefore, studying impairment with any of these 3 specific pain conditions without taking into consideration cooccurring pain may give an incorrect impression of the degree of impairment related directly to the specific pain condition.
HRQoL has been known to vary according to age and sex in general populations,38 as well as in populations of children with recurrent pain conditions.10,27,31,33,39 However, HRQoL impairment according to age or sex was not reported in the studies of pain-suffering children, which makes it difficult to evaluate whether the age- and gender-specific results were pain-related. Our study showed HRQoL impairment for both sexes and for both age groups studied, but with greater impairment for older children and in part for girls. Additional research is needed to validate these results.
A notable finding from our study is the level of HRQoL impairment, which contradicts our expectations. The PedsQL has no cutoff values for clinically relevant HRQoL reductions, but clinical samples of school-aged patients with headache and abdominal pain reported medium to large HRQoL impairments (Cohen's d = 0.5–0.7).16,18,19 The current population revealed comparable HRQoL impairment. Furthermore, according to Cohen's criteria, HRQoL impairment could be regarded as highly perceptible in the current population-based sample. This finding is worrisome, especially considering the age group studied. Notably, with a few exceptions, the children with pain had received no health care for the pain conditions. The results should be seen in light of studies demonstrating that children with recurrent pain most commonly are misunderstood, disbelieved, and neglected when they express their pain to parents and health care personal.40–42 The early school ages are important years with regard to developmental issues and acquiring basic knowledge and skills needed for the future. HRQoL impairment may influence these processes negatively. Therefore, prevention and treatment in early years seem important.
The current study design does not allow for conclusions about the causal direction between pain and HRQoL. Previous work suggested that recurrent pain may result in physical, social, and emotional difficulties20,40,43–45 and that social, emotional, and physical states may promote pain experiences.16–20 Theoretically, there may be an interactive loop between recurrent pain and the core elements of HRQoL (ie, physical, emotional, and social functioning and well-being). This suggestion is supported empirically in the present study, giving evidence of associations between recurrent pain and all of these HRQoL elements. One implication of a bidirectional relationship would be that pain prevention and treatment might benefit from a HRQoL focus. For instance, systematic efforts to secure high HRQoL in the general child population (eg, through school programs aiming at optimizing physical, emotional, social, or school functioning and well-being) may have a protective role regarding recurrent pain development and, for children who are experiencing recurrent pain, treatment focusing on improvement in deprived HRQoL aspects may decrease pain experiences. Additional studies are needed to test these hypotheses.
The HBSC study questions used in this study have been demonstrated to be valid for eliciting information on recurrent pain among schoolchildren.46 Asking about monthly or weekly pain over a 6-month period presumably excluded low-intensity pain and pain attributable to insignificant everyday scrapes. The long recall period poses problems at younger ages, however, which is why parents were asked to help younger children recall pain episodes. The influence of this, as well as the influence of different recall periods for the HBSC study (6 months) and PedsQL (1 month) questions, is not known. A drawback of the study is that the PedsQL does not reflect family relationships, which are significant for pediatric HRQoL.47
The rather large sample size and high participation rate ensure that the results can be considered representative of young schoolchildren in Umeå. Because the Swedish population is quite homogeneous and Umeå reflects the Swedish population in several ways (ie, similar family income standard and family structure),48 it can be suggested that the results can be generalized to young schoolchildren, at least in Sweden.
The results of this study confirm that recurrent pain conditions are common among young schoolchildren and, furthermore, that schoolchildren with recurrent pain have considerable impairment of their HRQoL, at a level comparable to that reported for children attending specialist clinics. We also show that HRQoL impairment is greater for children with multisite or frequent pain. The results indicate that recurrent pain conditions in young children in general should be regarded as significant health problem, prompting early interventions. Long-term studies are needed for a full understanding of the natural history of and interplay between recurrent pain and HRQoL, as well as the potential for prevention and treatment.
This research was supported financially by the Vårdal Foundation, the County Council of Västerbotten, Queen Silvia's Jubilee Fund, and the Oscar Foundation.
We thank all participating children, parents, and school staff members. Their great engagement and patience contributed significantly to this study. We also thank Dr Hans Stenlund, statistician at the Department of Public Health and Clinical Medicine, for statistical support.
- Accepted April 10, 2009.
- Address correspondence to Solveig Petersen, PhD, Division of Child and Adolescent Psychiatry, Umeå University, Umeå, SE-90187, Sweden. E-mail:
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject:
Recurrent long-term pain is common in children, but the significance and importance of the problem in a general population context are unclear.
What This Study Adds:
This study presents novel and important information about associations between HRQoL and recurrent pain in young schoolchildren. It also adds novel information on the effects of the number of pain sites on this association.
- ↵Santalahti P, Aromaa M, Sourander A, Helenius H, Piha J. Have there been changes in children's psychosomatic symptoms? A 10-year comparison from Finland. Pediatrics.2005;115 (4). Available at: www.pediatrics.org/cgi/content/full/115/4/e434
- ↵Powers SW, Patton SR, Hommel KA, Hershey AD. Quality of life in childhood migraines: clinical impact and comparison to other chronic illnesses. Pediatrics.2003;112 (1). Available at: www.pediatrics.org/cgi/content/full/112/1/e1
- ↵Youssef NN, Murphy TG, Langseder AL, Rosh JR. Quality of life for children with functional abdominal pain: a comparison study of patients' and parents' perceptions. Pediatrics.2006;117 (1):54– 59
- ↵Varni JW, Burwinkle TM, Limbers CA, Szer IS. The PedsQL as a patient-reported outcome in children and adolescents with fibromyalgia: an analysis of OMERACT domains. Health Qual Life Outcomes.2007;5 (Feb):9
- ↵Koot HM. The study of quality of life: concept and methods. In: Koot H, Wallander JL, eds. Quality of Life in Child and Adolescent Illness: Concepts, Methods and Findings. East Essex, UK: Brunner-Routledge; 2001:3– 20
- ↵Melzack R, Wall PD. Pain mechanisms: a new theory. Science.1965;150 (699):971– 979
- ↵Langeveld JH, Koot HM, Loonen MC, Hazebroek-Kampschreur AA, Passchier J. A quality of life instrument for adolescents with chronic headache. Cephalalgia.1996;16 (3):183– 196
- ↵Currie C, Roberts C, Morgan A, et al, eds. Young People's Health in Context: Health Behaviour in School-aged Children (HBSC) Study: International Report From the 2001/2002 Survey. Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2004. Health Policy for Children and Adolescents Report 4
- ↵Powers SW, Patton SR, Hommel KA, Hershey AD. Quality of life in paediatric migraine: characterization of age-related effects using PedsQL 4.0. Cephalalgia.2004;24 (2):120– 127
- ↵Petersen S. Recurrent Pain and Health-Related Quality of Life in Young Schoolchildren [doctoral thesis]. Umeå, Sweden: Umeå University; 2008
- ↵Cohen J. Statistical Power for the Behavioral Sciences. 2nd ed. New York, NY: Erlbaum; 1988
- ↵Hunfeld JA, Perquin CW, Duivenvoorden HJ, et al. Chronic pain and its impact on quality of life in adolescents and their families. J Pediatr Psychol.2001;26 (3):145– 153
- ↵Konijnenberg AY, Uiterwaal CS, Kimpen JL, van der Hoeven J, Buitelaar JK, de Graeff-Meeder ER. Children with unexplained chronic pain: substantial impairment in everyday life. Arch Dis Child.2005;90 (7):680– 686
- ↵Josephson I, Oldfors-Engstrom L. Pain experiences in girls with idiopathic musculoskeletal pain [in Swedish]. Nord Fysiother.2004;8 :12– 18
- Dell'Api M, Rennick JE, Rosmus C. Childhood chronic pain and health care professional interactions: shaping the chronic pain experiences of children. J Child Health Care.2007;11 (4):269– 286
- ↵Carter B. Chronic pain in childhood and the medical encounter: professional ventriloquism and hidden voices. Qual Health Res.2002;12 (1):28– 41
- ↵Laurell K, Larsson B, Eeg-Olofsson O. Headache in schoolchildren: agreement between different sources of information. Cephalalgia.2003;23 (6):420– 428
- ↵Statistics Sweden. Yearly statistics about children and their families. Available at: www.scb.se/statistik/BE/LE0102_2002A01_BR_BE51ST0307.pdf. Accessed June 6, 2005
- Copyright © 2009 by the American Academy of Pediatrics