Special Interest Group on Pain in Childhood
Pediatric Pain Letter

:: Home ::
Contact ::
Current issue ::
Past issues ::
For authors ::
Links ::
Search ::

Carl L. von Baeyer, PhD
University of Saskatchewan
Saskatoon, Canada

Copyright © 2011,
Special Interest Group on
Pain in Childhood,
International Association
for the Study of Pain®,

ISSN 1715-3956

Information appearing in Pediatric Pain Letter is not reviewed by, and is not necessarily endorsed by, the Special Interest Group on Pain in Childhood, nor by IASP ®.

Vol. 13 No. 1

April 2011


Shaping the future of research on chronic pain in children

Anna Huguet, Patrick J. McGrath, Jennifer Stinson, Christine T. Chambers and Jordi Miró

printable version (PDF)

Chronic pain is becoming recognized as a significant health problem in children. Moreover, pain during these early ages is at high risk of persisting into adulthood with associated morbidity. Understanding how pain becomes chronic and disabling is essential in order to identify children at risk, and for implementing effective prevention and interventions. There have been increasing efforts to identify risk factors for the development and maintenance of pain and related disability in children. However, research has traditionally largely been without guidance from relevant specific theoretical models beyond the general biopsychosocial model of pain (Turk, 1996). This commentary will briefly describe the steps which have been taken to gain knowledge from a biopsychosocial perspective by critically evaluating the current state of use of a theoretical approach to guide research and give recommendations for future research.


Chronic pain is a significant health problem in children. Recent epidemiological studies in several countries estimate that the prevalence of chronic pain in children ranges from 15% to 38% (e.g. Stanford et al., 2008). Chronic pain can negatively impact all aspects of functioning including physical, psychological, social, and role functioning (Palermo, 2000). Epidemiological studies report that approximately 5% of children in the general population have moderate or severe chronic pain-related disability (e.g. Roth-Isigkeit et al., 2005; Huguet & Miró, 2008), which is defined as difficulty that impairs the ability to perform daily activities due to his/her health status (Walker & Greene, 1991). Chronic pain in children may also negatively affect the child’s family (e.g. Jordan et al., 2007) as well as society in general by increasing health care costs and reducing work productivity due to time off to care for the child suffering chronic pain (e.g. Sleed et al., 2005). Understanding how pain becomes a chronic disorder as well as how it causes disability is essential in order to prevent this significant health problem and its negative consequences. Unfortunately, neither the development nor the trajectory of pediatric chronic pain is satisfactorily understood.

State of the art

The biopsychosocial model (Turk, 1996) suggests that chronic pain and related disability result from the interaction of biological, psychological and sociocultural factors, yet it does not provide a detailed and precise account of the underlying mechanisms. Research using this general biopsychosocial model has focused on identifying various factors that are predictive of pediatric chronic pain and related disability. Researchers have examined many risk factors at different levels and units of analysis, with relatively limited attention paid to resilience factors, such as positive expectations about the ability and responsibility to exert control over pain (e.g. Huguet et al., 2009). Table 1 provides a summary of the most commonly studied prognostic factors.

Table 1
Potential risk factors that have been under investigation examining their role in either chronic/recurrent pain or functioning (i.e. defined in terms of functional disability or quality of life)


Factor domain

Prognostic factors


Internal personal characteristics of the child

Sociodemographic characteristics

Age, gender, socioeconomic status, ethnicity

Larsson & Sund, 2005

Pathophysiological characteristics

Heritable and genetic factors

El-Metwally et al., 2008

Anthropometric characteristics and physical condition

Body mass index, weight, height, fatigue, mobility of joints

Bejia et al., 2005

Health-related behaviors and lifestyle

Smoking, physical exercise, sleep, use of alcohol or other drugs, sedentary lifestyle

El-Metwally et al., 2004

Pain characteristics

Pain frequency, pain intensity, duration of pain episodes

Lynch et al., 2006

Psychological characteristics

Depression, psychological distress, pain coping responses

Gauntlett-Gilbert & Eccleston, 2007

External personal characteristics of the child

Parental and family characteristics

Parental pain, parental stress, family functioning

Logan & Scharff, 2005


The identification of prognostic factors using an empirical approach is a good starting point for understanding the development and trajectory of chronic pain and pain-related disability. However, this atheoretical approach is not generally helpful in identifying potential mechanisms that would link these factors to the development and maintenance of chronic pain and related disability. Prognostic factors that are identified empirically should be incorporated into new or already existing theoretical pain models to gain a better understanding of the development and trajectory of the problem. This is currently difficult to do because the mechanisms through which a factor increases or decreases the risk of chronic pain or related disability are still unknown. In the past, most researchers have merely observed and collected data on potential prognostic factors derived primarily from cross-sectional studies, without building and testing theory and uncovering (or exploring possible) mechanisms. Such a basic empirical approach is not surprising since the understanding of pediatric chronic pain is at an early stage of development in which little unifying theory exists to serve as a guide (e.g. Palermo, 2000; Stanford et al., 2008).

Atheoretical fact gathering will clearly not improve our understanding of the phenomena or guide clinical practice. For instance, studies have shown that pain is influenced by a child’s sex: girls are more likely to suffer chronic pain and related disability than boys (Unruh & Campbell, 1999). However, without considering the underlying mechanisms, we cannot explain the link between pain and a child’s sex and provide a focus for treatment. A recent review by Fillingim and colleagues (2009) synthesizes the literature on sex, gender, and pain and suggests a number of potential mechanisms through which social and psychological processes (e.g. coping processes and catastrophizing) are likely to contribute to the repeatedly observed sex differences in pain. This type of sophisticated conceptualization could help focus our attention more productively on possible sex-linked mechanisms of action.

The primary goal of a theory (Bacharach, 1989) is to propose and examine how, when and why factors contribute to an outcome such as chronic pain. A constant interplay between empirical work and theory-driven analysis is what is most needed to advance our knowledge (Gelso, 1991). This knowledge would allow scientists and clinicians to design and deliver effective early protective and preventive strategies with children at risk of chronic pain and associated disability. A good theory must be unique and differentiated from other existing theories. It cannot be replaced by another theory unless the new theory is superior in its virtues. It must be generalizable and applicable to different settings. A good theory must be fertile by expanding the area of investigation into new conceptual areas. It must be parsimonious and internally consistent by providing an adequate explanation of all the relationships between the variables. It also must be empirically risky and abstract, that is, it must exist, to a certain extent, independently of time and space (Quine & Ullian, 1980). Very few researchers in pediatric pain have adopted a theory-driven approach by formulating and testing theories in an attempt to understand pediatric chronic pain (Minuchin, 1977; Lewin & Dahl, 1999; Walker, 1999; Palermo & Chambers, 2005). However, there are already promising examples of theory-based accounts of the development and trajectory of chronic pain in the general population using operant conditioning (Fordyce et al., 1968), modeling (Bandura, 1965), fear-avoidance (Vlaeyen et al., 1995), perceived self-efficacy (Bandura, 1977), childhood traumatic stress (Charmandari et al., 2003; Goffaux et al., 2008), attachment (Bowlby, 1969), disuse (Bortz, 1984), and central sensitization (Woolf, 2011). The evidence regarding the validity of these theories is different across theories. Some are well-supported by evidence (the fear avoidance model, theory of primary central sensitization), whereas others are not (attachment theory, theory on childhood trauma). These theories, which are not mutually exclusive, could provide useful templates to further our understanding of chronic pain and related disability in children. None of the theories individually capture the entire complexity of the phenomena. However, they could be combined to better understand chronic pain and related disability, since each theory may contribute a unique piece to the pain puzzle.

Recommendations and directions for future research

We offer the following directions for future research to advance our understanding and build testable theories of chronic pediatric pain.

Testing of existing theories. Testing is suggested for theories that have been shown to be useful with the general population but need to be validated with children to determine their appropriateness, and theories that have already been formulated in the field of chronic pediatric pain and have yet to be fully tested. It is important to reformulate theories that have been shown to be useful in adults in order to make them developmentally oriented (at the biological, cognitive, emotional, or social level) when exploring the applicability of these theories towards a younger population (Walco, 2004). In the process of testing existing theories, both comprehensive, integrated theories and micro theories have merit in guiding research as long as each key construct in the theory is operationalized.

Use of different, more sophisticated approaches and methodologies to test specific mechanisms informed by theories. Studies contrasting theories often will benefit from sophisticated quantitative techniques such as structural equation modeling using longitudinal data from prospective cohort studies (e.g. Nelson et al., 2008). Research that has been conducted in this area has tended to be descriptive and correlational, and therefore, experimental methodology should be used in the future. Theory-based experimental intervention studies such as randomized controlled trials are useful to test and refine theories of the etiology and continuity of chronic pain and disability. These studies can provide valuable information about the mechanisms of change (e.g. how the treatment yields positive outcomes) and about the boundary conditions of effectiveness (e.g. who benefits, who does not, and why).

Increased research in key areas. More research is needed examining what resilience factors protect against chronic pain and pain-related disability. In addition, studies concerning the potential transition from acute to chronic pain are needed, as this is a particularly fertile time period to examine mechanisms of chronic pain and disability.

Systematic reviews of prognostic factors. These can synthesize the most relevant factors available in the literature and be instrumental in elaborating new or better working hypotheses about underlying principles or apparent relationships of the observed phenomena (e.g. Forgeron et al., 2010; Gieteling et al., 2011). Systematic reviews should take into consideration that different types of chronic pain in children and youth may have different prognostic factors, and prognostic factors of chronic pain and disability may also differ (Miró et al., 2007).

To sum up, the application of theory-driven approaches is a step in the right direction to a better understanding of chronic pain and related disability in children.


We would like to thank Josiane Mapplebeck for her help with revisions on the final manuscript. Dr. Huguet’s work on this manuscript was supported by a postdoctoral fellowship awarded by the Canadian Institutes of Health Research Strategic Training Program on Pain in Child Health. Drs. McGrath and Chambers are supported by Canada Research Chairs. Dr. Stinson’s work is supported by a Career Scientist Award from the Ontario Ministry of Health and Long-term Care. Dr. Miró’s work is supported by the Spanish Ministry of Science and Innovation (SEJ2006-15247/PSIC, SEJ2006-1430/PSIC, PSI2009-12193/PSIC) and the Agency for Universities and Research of the Government of Catalonia (2009SGR-434), and by a research grant from La Fundació de la Marató de TV3.

Anna Huguet, PhD
IWK Health Centre and Dalhousie University, Halifax, NS, Canada
email: anna.huguet[at]dal.ca

Patrick J. McGrath, PhD
IWK Health Centre and Dalhousie University, Halifax, NS, Canada

Jennifer Stinson, PhD
The Hospital for Sick Children, and Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada

Christine T. Chambers, PhD
IWK Health Centre and Dalhousie University, Halifax, NS, Canada

Jordi Miró, PhD
Unitat per a lEstudi i Tractament del Dolor, Centre per a lAvaluació i la Mesura de la Conducta, Institut dInvestigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Catalonia, Spain

Cite as: Huguet A, McGrath, PJ, Stinson J, Chambers CT, Miró J. Shaping the future of research on chronic pain in children. Pediatric Pain Letter 2011;13:7-12. ppl.childpain.org 


Bacharach SB. Organizational theories: some criteria for evaluation. Acad Manage Rev 1989;14:496-515.

Bandura A. Influence of model’s reinforcement contingencies on the acquisition of imitative response. J Pers Soc Psychol 1965;36:589-595.

Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215.

Bejia I, Abid N, Ben Salem K, Letaief M, Younes M, Touzi M, et al. Low back pain in a cohort of 622 Tunisian schoolchildren and adolescents: an epidemiological study. Eur Spine J 2005;14:331-336. PubMed Abstract

Bortz WM 2nd. The disuse syndrome. West J Med 1984;141:691-694. www.pubmed.gov/6516349

Bowlby J. Attachment and loss. Vol. 1: Attachment. New York: Basic Books, 1969. Link

Charmandari E, Kino T, Souvatzoglou E, Chrousos GP. Pediatric stress: hormonal mediators and human development. Horm Res 2003;59:161-179. PubMed Abstract

El-Metwally A, Mikkelsson M, Ståhl M, Macfarlane GJ, Jones GT, Pulkkinen L, et al. Genetic and environmental influences on non-specific low back pain in children: a twin study. Eur Spine J 2008;17:502-508. PubMed Abstract

El-Metwally A, Salminen JJ, Auvinen A, Kautiainen H, Mikkelsson M. Prognosis of non-specific musculoskeletal pain in preadolescents: a prospective 4-year follow-up study till adolescence. Pain 2004;110:550-559. PubMed Abstract

Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL 3rd. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 2009;10:447-485. PubMed Abstract

Fordyce WE, Fowler RS Jr, Lehman JF, DeLateur BJ. Some implications of learning in problems of chronic pain. J Chron Dis 1968;21:179-190.

Forgeron PA, King S, Stinson JN, McGrath PJ, MacDonald AJ, Chambers CT. Social functioning and peer relationships in children and adolescents with chronic pain: a systematic review. Pain Res Manag 2010;15:27-41. PubMed Abstract

Gauntlett-Gilbert J, Eccleston C. Disability in adolescents with chronic pain: patterns and predictors across different domains of functioning. Pain 2007;131:132-141. PubMed Abstract

Gelso CJ. Galileo, Aristotle, and science in counseling psychology: to theorize or not to theorize. J Couns Psychol 1991;38:211-213.

Gieteling MJ, Bierma-Zeinstra SMA, van Leeuwen Y, Passchier J, Berger MY. Prognostic factors for persistence of chronic abdominal pain in children. J Pediatr Gastroenterol Nutr 2011;52:154-161. PubMed Abstract

Goffaux P, Lafrenaye S, Morin M, Patural H, Demers G, Marchand S. Preterm births: can neonatal pain alter the development of endogenous gating systems? Eur J Pain 2008;12:945-951. PubMed Abstract

Huguet A, Eccleston C, Miró J, Gauntlett-Gilbert J. Young people making sense of pain: cognitive appraisal, function, and pain in 8-16 year old children. Eur J Pain 2009;13:751-759. PubMed Abstract

Huguet A, Miró J. The severity of chronic pediatric pain: an epidemiological study.J Pain 2008;9:226-236. PubMed Abstract

Jordan AL, Eccleston C, Osborn M. Being a parent of the adolescent with complex chronic pain: an interpretative phenomenological analysis. Eur J Pain 2007;11:49-56. PubMed Abstract

Larsson B, Sund AM. One-year incidence, course, and outcome predictors of frequent headaches among early adolescents. Headache 2005;45:684-691. PubMed Abstract

Lewin DS, Dahl RE. Importance of sleep in the management of pediatric pain. J Dev Behav Pediatr 1999;20:244-252. PubMed Abstract

Logan DE, Scharff L. Relationships between family and parent characteristics and functional disabilities in children with chronic recurrent pain syndromes: an investigation of moderating effects on the pathway from pain to disability. J Pediatr Psychol 2005;30:698-707. PubMed Abstract

Lynch AM, Kashikar-Zuck S, Goldschneider KR, Jones BA. Psychosocial risks for disability in children with chronic back pain. J Pain 2006;7:244-251. PubMed Abstract

Minuchin S. A conceptual model of psychosomatic illness in children: family organization and family therapy. In: Wittkower ED, Warnes H, editors. Psychosomatic medicine: its clinical application. New York: Harper & Row, 1977. pp. 116-129.

Miró J, Huguet A, Nieto R. Predictive factors of chronic pediatric pain and disability: a Delphi poll. J Pain 2007;8:774-792. PubMed Abstract

Nelson TD, Aylward BS, Steele RG. Structural equation modeling in pediatric psychology: overview and review of applications. J Pediatr Psychol 2008;33:679-687. PubMed Abstract

Palermo TM. Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature. J Dev Behav Pediatr 2000;21:58-69. PubMed Abstract

Palermo TM, Chambers CT. Parent and family factors in pediatric chronic pain and disability: an integrative approach. Pain 2005;119:1-4.

Quine WV, Ullian JS. Hypothesis. In: Klemke ED, Hollinger R, Rudge DW, Kline AD, editors. Introductory readings in the philosophy of science. Amherst, NY: Prometheus Books, 1980. p. 404-414.

Roth-Isigkeit A, Thyen U, Stöven H, Schwarzenberger J, Schmucker P. Pain among children and adolescents: restrictions in daily living and triggering factors.Pediatrics 2005;115:e152-e162. PubMed Abstract

Sleed M, Eccleston C, Beecham J, Knapp M, Jordan A. The economic impact of chronic pain in adolescence: methodological considerations and a preliminary costs-of-illness study. Pain 2005;119:183-190. PubMed Abstract

Stanford EA, Chambers CT, Biesanz JC, Chen E. The frequency, trajectories and predictors of adolescent recurrent pain: a population-based approach. Pain 2008;138:11-21. PubMed Abstract

Turk DC. Biopsychosocial perspective on chronic pain. In: Gatchel RJ, Turk DC, editors. Psychological approaches to pain management: a practitioner’s handbook. New York: Guilford Press, 1996. pp. 3-32. Link

Unruh AM, Campbell MA. Gender variations in children’s pain experience. In: McGrath PJ, Finley GA, editors. Chronic and recurrent pain in children and adolescents: Vol. 13. Progress in Pain Research and Management. Seattle, WA: IASP Press, 1999. pp. 199-241. Link

Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62:363-372. PubMed Abstract

Walco GA. Toward an integrated model of pain over the life course. Pain 2004;108:207-208.

Walker LS. The evolution of research on recurrent abdominal pain: history, assumptions, and a conceptual model. In: McGrath PJ, Finley GA, editors. Chronic and recurrent pain in children and adolescents: Vol. 13. Progress in Pain Research and Management. Seattle, WA: IASP Press, 1999. pp. 141-172. Link

Walker LS, Greene JW. The functional disability inventory: measuring a neglected dimension of child health status. J Pediatr Psychol 1991;16:39-58. PubMed Abstract

Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2011;152(Suppl 3):S2-S15. PubMed Abstract