Pain Among Children and Adolescents: Restrictions in Daily Living and Triggering Factors

Study Sample

After approval by the ethics committee of the University of Luebeck and the State Department for Education, Research, Science, and Culture (Schleswig-Holstein, Germany), the study was conducted in 1 elementary school and 2 secondary schools in the district of Ostholstein, Germany. Because <3% of the schoolchildren in Germany attend private or special schools (such as schools for children with disabilities), we think that there is no obvious selection bias in our sample.

Children and adolescents, as well as their parents or 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.

Study Participants

The total number of schoolchildren in the participating schools was 1003. A total of 933 children and adolescents (93.0%) attended school on the day of the survey; 751 schoolchildren completed the questionnaire (80.5%), 70 children and adolescents were absent from school on the day of the study, and 182 did not complete the questionnaire. We performed no substitute sampling of children and adolescents who were absent from school on the day of the study or did not complete the questionnaire. Two children were excluded from the survey because they did not complete the questionnaire properly (Table 1).

Pain Definition and Pain Recall Period

According to McGrath,^12(p81) “chronic pain is defined in this study as any prolonged pain that lasts a minimum of 3 months or any pain that recurs throughout a minimum period of 3 months.” In accordance with other epidemiologic studies of pain among children and adolescents,^2,13 we investigated a pain recall period of 3 months. Retrospective reports of pain have been shown to be reliable.¹⁴

Survey Methods

Previous studies showed that sufficient response rates result from recruitment of children and adolescents at school. To avoid selection bias, we chose an unselected sample of schoolchildren.

Depending on the age of the children, parental ratings or self-report measurements were obtained. Parental ratings were used for children in elementary school (6–9 years of age), and self-report measurements were used for pupils in secondary schools (10–18 years of age).

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 family life. Previous pilot studies showed that children of the age of 9 years were able to respond correctly to the questionnaire.¹⁵

The questionnaire has 3 versions, depending on the age of the enrolled subject. Version 1 was distributed to the parents of children in grades 1 to 4, version 2 to study participants enrolled in grades 5 to 9, and version 3 to adolescents enrolled in grade 10. The questionnaire was easy to understand and could be completed within 10 minutes, without additional information or aids.

If the answer to the first question of the questionnaire (did your child/did you have pain within the past 3 months?) was no, then no other question needed to be answered. Children who reported pain within the preceding 3 months were asked to describe the body area from which the pain arose. Choices given were head, back, abdomen, arm, leg, ear, throat, chest, pelvis, tooth, or other. For pain that was described as the main discomfort, the participants were asked to specify the duration, frequency, and intensity of the pain with answer categories. For the duration of pain, the categories were only once, <1 month, 1 to 3 months, >3 months, >6 months, or >12 months. For the frequency of pain, the answer options were <1 time per month, 1 time per month, 2 or 3 times per month, 1 time per week, 2 or 3 times per week, or every day. The intensity of pain was assessed with a visual analog scale (VAS) of 1 to 10, combined with verbal end points (hardly noticeable pain versus strongest conceivable pain). In addition, a face-smile (“smiley”) scale depicted 6 faces between laughter and crying. The type and extent of the personal impairment attributable to pain were assessed in the areas of sleep, eating, missed school days, hobbies, social contacts, and health care utilization (doctor's visits and pain medication); the participants were asked to rate the impact of the pain in these areas as never, sometimes, often, or always. Self-perceived triggers of pain and explanations for the first occurrence of the pain were evaluated with the help of a list of possible causes (change of weather, lack of sleep, annoyance/conflicts, school tests, cold, common cold, school situation, sports/physical efforts, family situation, light, noise, computer use, television use, consumption of sweets, nutrition, sadness, excitement, nonspecific factor, or other), as well as open-ended statements. In addition, the participants were asked whether they knew the cause of their pain and/or whether they had a medical diagnosis for their pain. Furthermore, the children and adolescents were asked whether a family member experienced recurrent or chronic pain.

The prevalence of pain was calculated according to age and gender. Computation of standardized rates and school type-specific prevalence rates was not conducted. Data analyses provided absolute and relative frequencies of pain episodes in a descriptive manner. The influence of age, pain intensity, duration of pain, and pain frequency on the extent of impairments was determined with a logistic regression model.

Return Rate and Response Rate

A total of 933 questionnaires were distributed, and 751 questionnaires (80.5%) were returned. Of the returned and completed questionnaires, a total of 749 (99.7%) were evaluated. Two questionnaires did not specify the gender of the study participant and therefore were excluded from the data analysis. The response rate was 80.3% (Table 1).

Sample Characteristics

Table 2 presents the social demographic features of the study sample. The largest group of study participants (38.3%) was between 13 and 15 years of age, and 33.6% of the participants in our study sample were 10 to 12 years of age. The gender distribution in our study was 47.4% male subjects and 52.6% female subjects. German was the primary language at home for 89.9% of all enrolled children and adolescents, whereas 10.1% of the enrolled participants indicated that they also spoke other languages at home.

Prevalence of Pain Within 3 Months

A total of 622 of 749 study participants (83%; 95% confidence interval [CI]: 80.4–85.7%) declared, either through their parents/guardians or by themselves, that they had experienced pain within the preceding 3 months.

Body Areas With Pain

Figure 1 indicates the most common areas of pain in our study population. The head, abdomen, throat, extremities, and back were cited most commonly as locations of perceived pain. The 3-month prevalence rates of symptoms were 60.5% (95% CI: 57.0–64.0%) for headaches, 43.3% (95% CI: 39.7–46.8%) for abdominal pain, 33.6% (95% CI: 30.3–37%) for pain in the extremities, 30.2% (95% CI: 26.9–33.5%) for back pain, and 35% (95% CI: 31.6–38.4%) for sore throat. Eighty-five percent of children and adolescents with pain within the preceding 3 months reported pain in >1 location, and 15% complained of pain in only 1 body region. The 3-month prevalence of pain in >1 location was 70.6%.

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Fig 1.

Three-month prevalence of pain according to body area.

Type of Pain

Of a total of 622 children and adolescents with pain within the preceding 3 months, 604 (97.1%) answered the question, “which type of pain is in your opinion the most bothersome to you?” 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 (Fig 1).

Pain Intensity

The mean pain intensity for children and adolescents with pain was 5.7 on the VAS (SD: 1.9); 17.5% of those suffering pain rated their pain as 1 to 3 on the VAS, 56.9% rated their pain as 4 to 6 on the VAS, and 25.6% scored their pain as 7 to 10 on the VAS.

Frequency of Pain Episodes

Figure 2 depicts the 3-month prevalence of the frequency of pain episodes. A total of 25.6% of the study participants stated that their pain occurred <1 time or 1 time per month, 19.2% declared 2 or 3 pain episodes per month, and 35.2% of children and adolescents reported pain episodes occurring ≥1 time per week or even more often (Fig 2).

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Fig 2.

Pain frequency.

Duration of Pain Episodes

Figure 3 depicts the 3-month prevalence of the duration of pain. For 14.4% of the children and adolescents, the symptoms occurred only once; 11.5% of participants stated that their painful episodes had occurred <1 month earlier, 13% reported that their pain had occurred within 1 to 3 months, 9.5% stated that they had experienced pain off and on for >3 months, 8.7% stated that they had experienced pain for >6 months, and 22.2% remembered episodes of pain persisting for >12 months (Fig 3).

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Fig 3.

Pain duration.

Health Care Utilization Attributable to Pain

Of the 622 participants who had experienced pain, 564 answered the question of whether they had sought medical care for their pain. A total of 50.9% (n = 287) reported that they had seen a doctor for their pain; 37.2% (n = 210) stated that they had seen their doctor sometimes, and 13.7% (n = 77) said often or always (Fig 4).

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Fig 4.

Health care utilization because of pain among children and adolescents with pain in the preceding 3 months.

Of the 622 children with pain, 573 answered the question of whether they had taken any medications for their pain. A total of 51.5% (n = 295) reported that they had taken medications for their pain; 39.1% (n = 224) stated that they sometimes used medications, and 12.4% (n = 71) reported that they used medications often or always (Fig 4).

Health care utilization attributable to pain differed among children and adolescents according to the location of pain. Table 3 shows the prevalence of self-reported health care utilization and restrictions attributable to pain for different pain locations. 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%) (Table 3). In contrast, children and adolescents with headache (59.2%) more often stated that they took medications because of pain 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 significantly increased with age (χ² test) (Table 4). The prevalence of self-reported medication use was significantly higher among girls than among boys of the same age, except for those 4 to 9 years of age (χ² test) (Table 4).

Restrictions in Daily Living Attributable to Pain

A total of 68.2% of all respondents reported restrictions in daily living activities attributable to pain. The prevalence rates of restrictions in daily living activities attributable to pain, according to age and gender, are shown in Table 4. Figure 5 depicts the restrictions in daily activities attributable to pain among children and adolescents with pain in the preceding 3 months; 53.6% of children and adolescents reported sleep disturbances attributable to pain (35.1% sometimes and 18.5% often or always), and 53.3% reported that they had been unable to pursue their hobbies because of the pain (37.5% sometimes and 15.8% often or always). Appetite problems attributable to the pain were reported by a total of 51.1% of the children and adolescents with pain in the preceding 3 months (37.3% sometimes and 13.8% often or always). Absence from school was reported by 48.8% of the study participants (35.8% sometimes and 13% often or always), and 46.7% of the study participants with pain in the preceding 3 months said that they had not met their friends because of their pain (32.9% sometimes and 13.8% often or always).

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Fig 5.

Restrictions in daily activities resulting from pain among children and adolescents with pain in the preceding 3 months.

The prevalence of restrictions in daily activities varied among children and adolescents with pain in different locations (Table 4). A total of 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 (Table 4). Children and adolescents with headache (45.6%) and abdominal pain (48.9%) more often than those with back pain (20.9%) or limb pain (27.5%) stated that they were not able to meet their friends because of pain (Table 4). Children and adolescents with headache (49.6%) and abdominal pain (60.9%) more often than those with back pain (19.4%) or limb pain (18.8%) stated that they had lost their appetite because of their pain (Table 4).

The prevalence of self-reported restrictions resulting from pain increased with age. A total of 73.5% of the 13- to 15-year-old participants and 81.3% of the 16- to 18-year-old participants reported restrictions in daily activities attributable to pain. Sleep disturbances and the inability to pursue hobbies because of pain increased with age (Table 4). The prevalence of restrictions attributable to pain was significantly higher among girls than among boys of the same age, except for the ages of 4 to 9 years (χ² test) (Table 4).

Triggers of Pain Episodes

Of 622 children and adolescents with pain in the preceding 3 months, 603 answered the question, “what do you think caused this pain?” Thirty-three percent of respondents thought that weather conditions (specifically cold weather) were responsible for their discomfort, 30.7% cited illness (eg, common cold or injury), 21.9% cited sports or physical activities, 16.2% reported lack of sleep, 12.8% cited television or computer use, and 10% reported nutrition or consumption of sweets (Fig 6). Anger/disputes (17.6%), agitation (12.6%), school conditions (11.1%), examinations (10%), family conditions (9.5%), and sadness/loneliness (8.5%) were cited as triggers for pain by some of the responding children and adolescents, and 13.8% of children stated that their pain was triggered by nonspecific factors (Fig 6).

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Fig 6.

Self-perceived subjective triggers of pain among children and adolescents with pain.

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%), or 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%).

Context of First Pain Episode

Of 622 children and adolescents with pain, 600 answered the question, “what was the context in which you felt your pain for the first time?” Figure 7 presents their answers. Most children and adolescents (53.7%) had no recollection of an incident or the context in which they felt their pain for the first time. The remaining participants stated that their pain first appeared during an illness (14%), after an injury or an accident (10.3%), after physical strain attributable to school, computer use, or poor diet (8.2%), after physical exercise (5.7%), or after a death in the family (3.5%) (Fig 7).

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Fig 7.

Self-perceived timing of the first pain experience among children and adolescents with pain.

Cause and/or Medical Diagnosis of Pain

A total of 21.1% of children and adolescents with pain stated that they knew a cause or medical diagnosis for their pain, 36.9% denied a cause for their pain, and 42% said that they did not know the cause of their pain. Causes and medical diagnoses reported included common colds, infections, spine or musculoskeletal diseases, menstruation, accidents, and injuries.

Prediction of Health Care Utilization

We used a logistic regression model to predict the likelihood of a child paying a visit to the doctor and/or using pain medication. We labeled this variable as health care utilization. We included age, duration of pain, and frequency of pain in the analysis. Children without pain and those with missing data were excluded from the model, leaving 559 cases for analysis. Health care utilization was predicted by increasing age, greater intensity of pain, and longer duration of pain but not by the frequency of pain.

Prediction of Degree of Restrictions in Daily Life

We used a logistic regression model to predict restrictions in daily activities. We dichotomized these restrictions as no restrictions at all or any restrictions in attending school, visiting friends, eating meals, sleeping, or performing recreational activities. Only the intensity of pain was predictive of the degree of restrictions in daily activities resulting from 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 (Table 5).