Peer Mentorship: An Intervention To Promote Effective Pain Self-Management In Adolescents

Background:

Chronic intractable non-malignant pain, including such functional disorders as irritable bowel syndrome is now recognized as a significant problem in children and adolescents, with potential long-term impact on the child's physical, social, and academic functioning, as well as on the family as a whole. A recent study of more than 5000 Dutch school children under 18 found that more than 25% reported suffering recurrent or continuous pain for more than 3 months, with the prevalence increasing with age; and a survey of 735 German children aged 10-18 using a modified version of the same instrument found the same for 45.5%. The most common types of pain in these two studies were headache, abdominal pain, limb pain, and back pain. This data would appear to confirm earlier estimates that recurrent headache, including migraine, occurs in 11% to 26% of children ages 7-15; recurrent abdominal pain in 10-15% and recurrent limb pain in 4-18% in children ages 7-15. Many such children apparently continue to function effectively, attending school and continuing normal activities, with medical intervention only for acute episodes. A smaller, but significant, number, however, find themselves unable to self-manage their pain. They become patients with chronic pain and disability, falling into a cyclical pattern of pain, impaired functioning in physical, school, social, and even family and self-care domains, "doctor-seeking" and over-utilization of medications, and psychosocial distress, including anxiety and depression.

Functional impairment, particularly in academic work and social participation, is likely to have long-term effects on the individual's quality of life, even aside from the possibility that pain and physical limitations may persist into adulthood. Several well-designed studies using quantitative measures have provided evidence that impaired functioning in children with chronic pain is strongly associated with psychosocial distress and with lower quality of life. In particular, children with unexplained chronic pain, pain not associated with an organic diagnosis, often report significant dysfunctions in normal activities, such as schoolwork, sleep, family activities, and athletic activities. But, although impaired functioning is a major factor in lower quality of life for children with chronic pain, we still know relatively little about the prevalence and severity of functional impairment, why some children experience more limitations than others, and which treatment interventions are the most effective in improving function.

The available evidence also indicates that children show different levels of adjustment to chronic pain over time. Chronic idiopathic musculoskeletal pain has been shown to persist in 59% of cases for as long as nine years; in this study, the authors found the children to have pain and disability levels comparable to children with juvenile chronic arthritis, but lower levels of psychosocial functioning. Hunfeld, Perquin, and colleagues in Rotterdam have traced the persistence of chronic benign pain in 30-45% of cases for up to two years and three years, with no increase in intensity or frequency. In the latter study, open-ended interviews elicited information about functioning and coping skills, and identified continuing problems with physical activity, mental concentration, social interaction, and psychological stress (becoming "moody"), particularly when the pain was severe. The researchers found, however, that several children had developed their own strategies to maximize functionality despite the continuing pain: "...pain had become part of the daily lives of several adolescents, who structured their activities and sleeping hours to prevent aggravation of pain". A recent cluster analysis of 117 children with chronic pain divided them into three groups on the basis of a set of psychosocial and behavioral measures: those who were highly distressed and disabled; those who showed low levels of distress and disability; and those who showed only moderate levels of distress and disability, but whose family environment scored low on cohesion.

Although several factors may account for children's differential ability to function and to adjust to persistent chronic pain, the child's sense of self-competence has been identified as a key variable in recent literature. Claar and colleagues, for example, found that in adolescents and young adults with irritable bowel syndrome, the relationship between pain and functional disability was moderated by the individual's sense of academic, social, and athletic competence. The concept of self-competence (a general sense of mastery) overlaps with that of self-efficacy (a task-specific sense of mastery), developed by Albert Bandura in the late 1970s and early 1980s 18. The concept of self-efficacy suggests an explanation for the relationship between coping skills, perceived ability to cope, and reduction in physical and psychological disability. Bandura argued that a sense of self-efficacy enables the individual to persist even with a task of great difficulty until it is mastered, to reject negative thoughts and to "bring cognitive or cerebral productions into being" that will assist in achieving the goal.