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14 Articles in Volume 18, Issue #9
Assessing Arthralgia in Children
Children, Opioids, and Pain: The Stats & Clinical Guidelines
How to Fit into a New Practice
How to Talk to Your Chronic Pain Patients
How to Treat Opioid Use Disorder in Pregnant Women
Intranasal Ketamine for Acute Pain in Children
Medication Selection for Comorbid Pain Management (Part 3)
MR Neurography: Using Peripheral Nerve Imaging as a Pain Diagnostic
Naloxone in Schools; Buprenorphine Conversions; OUD Management
Opioid Conversion Calculations and Changes
Pes Anserine Tendino-Bursitis as Primary Cause of Knee Pain in Overweight Women
Self-Management of Chronic Pain in Primary Care
The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population

When chronic pain, such as daily headache, strikes a child at a young age, clinicians can help to guide families through school absences and homeschooling as part of the overall treatment plan.
Pages 21-24
Page 2 of 2

As reported in the literature, a history of abuse (whether physical, emotional, or sexual) may predispose a child to chronic severe pain and a stressful childhood may influence the sensitive, developing brain chemistry. Such an environment may also predispose a child to psychiatric conditions. In rare cases, factitious disorders may be present in the homebound adolescent, including those in which the condition is imposed on the child by the parent/guardian. Psychiatric referrals may be helpful in these cases but also have potential for causing the patient/family to not return to the practice for care. In our clinics, we have seen headaches improve after the child graduates high school and is living more independently.

Personality disorders, or personality disorder characteristics, should also be considered as these disorders may be diagnosed prior to age 18. Individuals with personality disorders may have a spectrum of traits that may include: splitting and inability to see “greys” (black and white thinking); poor sense of self; abandonment issues; anger or irritability; thin-skinned (families are “walking on eggshells”); impulsivity; self-harm or suicidal thoughts; ultra-rapid cycling of moods; lack of empathy; narcissism; severe loneliness; constant spending; and other traits. In the authors’ experience, a probable personality disorder may be considered in an adolescent if these behaviors are moderate to severe, persistent, and pervasive. Certainly, many of these personality traits coincide with typical adolescent behaviors, but it is the severity and persistence of the behaviors that raises the possibility of a personality disorder.

True conversion disorder may occur, but is rare. Neurologic symptoms may take various forms, such as: headache, weakness or paralysis, non-epileptic seizures, motor tics, and tremors.

The psychiatric health of the adolescent’s parents is important as well. In the authors’ experience, the most difficult situations occur when a parent has a personality disorder. Mild factitious disorder by proxy (“factitious disorder imposed on another”) is occasionally present. With the mild form, the parent (usually the mother) may drag the child to various healthcare providers, with a variety of medical complaints, including headache. When confronted by the physician, the parent (and adolescent in tow) usually flees the office, never to be seen again. When the factitious disorder by proxy is mild, a non-confrontational “dialectical by proxy” approach may be effective. In these cases, if the adolescent is separated from parents after high school, headaches and behaviors may improve.

From Catastrophizing to Coping

Catastrophizing can be a major contributor toward disability and daily function in chronic headache patients, no matter the age. Physicians, as well as therapists and family members, can help to dial down such feelings over time. It is important, however, to also acknowledge the role of the parent/guardian in catastrophizing. For instance, the authors have heard parents make statements such as: “My child has severe daily headaches. Nobody has pain like this. He can’t possibly go on like this.” Fear of pain and passive (versus active) coping, can be key contributors toward disability.

Working toward “acceptance, but not resignation” may be helpful in this regard. As with any chronic pain condition, accepting that there is not a miracle is part of the pain management and rehabilitation process. While each case is different, when treating adolescents, clinicians may wish to point out that chronic headaches may improve or resolve naturally over time.

Resilience may also come into play. The genetic basis for resilience has been studied mostly in the setting of moderate to severe childhood stress or abuse. The serotonin transporter (SERT or 5-HTT) gene has two “arms,” so to speak, which may be short or long. Two long arms predict a tendency toward higher resilience, while two short arms often lead to a lower level of resilience. Tests for long arm/short arm are commercially available. Beyond genes, various psychological conditions may play a major role in a patient’s resilience. Rather than “punish” adolescents for their lack of resilience or coping skills, it is important to provide coping skills. Modeling of resilience by the parents is worth recommending as is a support team, which may include the patient, physicians, therapists, teachers, and parents all working together.

In fact, individual psychotherapy – and family psychotherapy – may be one of the most effective tools for helping the adolescent patient with chronic pain to manage stresses, coping, insomnia, and any family issues. Since parents/guardians and siblings are also likely profoundly affected by the adolescent with chronic pain, family therapy may prove to be beneficial as well. However, not all adolescents, or families, are ready for psychotherapy; it may take repeated efforts to convince them of its benefits.

Additional Nonpharmacological Approaches

While medications are important, it is also necessary to take a multidisciplinary approach when treating the adolescent patient with chronic headache and comorbidities. In addition to psychotherapy, as discussed above, physical therapists may help to manage posterior head pain, or associated neck or back pain by working with the patient on posture, stretching, and exercise. Biofeedback may be very helpful as well, but if it is deemed as too time-consuming or expensive, meditation may offer a more accessible option. For the patient with sleep issues, working on “sleep rules” may positively impact mood and headache frequency/severity.

The Return To School

When a homebound adolescent returns to school, it is advised that they ease back to their daily routine slowly. Clinicians can help to facilitate the transition with a 504 medical plan. This plan may call for late starts, shortened days, excusal from gym class (or limited physical activity), extra time on exams if appropriate, and permission to step out of class if loud noise exposure becomes a problem. Eating lunch in an alternative, quieter location and wearing sunglasses, usually a mild tint, may also be beneficial.

For students who wish to pursue a part-time schedule (such as half in school and half homebound), some communities offer select classes off-site or summer classes, with a smaller group of students.

Conclusion

Overall, when helping to manage an adolescent with a chronic pain condition, such as daily headache or migraine, a multidisciplinary approach that includes medication management and psychotherapy may be most effective as the family works through the process of homeschooling or a modified schooling schedule. Helping to ease a child’s transition back to school should be considered part of the treatment plan. Once high school is finished, many adolescent headache patients may find that their symptoms improve.

See also our 2018 ACR/ARHP meeting highlight, “Addressing Arthralgia in Children

Last updated on: December 5, 2018
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Managing Headaches in Children and Adolescents
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