Special Interest Group on Pain in Childhood
Pediatric Pain Letter

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Deirdre E. Logan, PhD
Children's Hospital Boston
Boston, USA

Associate Editor:
Abbie L. Jordan, PhD
University of Bath
Bath, UK

Copyright © 2020,
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. 22 No. 1

February 2020


School re-entry following chronic pain and disability: A pathway to success

Ethan Benore, Amy Fahrenkamp, Oleh Zhakunets, and Gerard A. Banez

printable version (PDF)

A brief review of the problem

Chronic pain (pain that persists for at least three months) is more common than teachers may estimate, affecting up to 40% of school-aged children (Stanford et al., 2008; King et al., 2011). A small but significant number of these adolescents (3-8%) experience worsening disability due to chronic pain (Huguet & Miró, 2008). These adolescents often miss numerous days of school, show decline in academic performance, withdraw from social interaction, and are ineligible to fully participate in athletics or other extracurricular events (Logan et al., 2008; Dick & Pillai Riddell, 2010; Kashikar-Zuck et al., 2010; Agoston et al., 2016). Many take online classes or receive home tutoring, yet still fall behind academically; others have simply stopped all academic work. Once a child has been removed from the typical school environment, reintegrating back into school can be stressful and difficult to navigate.

Fortunately, children with significant impairment related to chronic pain respond well to intensive rehabilitation. Multiple treatment centers have published outcomes supporting the clinical effectiveness of intensive interdisciplinary pain management (Hechler et al., 2015), which involves the combined therapies of medicine, physical therapy, occupational therapy, psychology and recreational therapy—offering 4-8 hours of active treatment each day for 2-4 weeks on average. Some programs also target improved school functioning, offering tutoring, structured time to complete missing assignments, and/or active problem-solving for barriers to school performance (Logan & Simons, 2010). However, less attention has been given to educating school personnel on ways to promote student progress once these students return to a school setting (Boutilier & King, 2013; Reid et al., 2016).

School re-entry models already exist for other medical conditions, such as cancer (Katz et al., 1992; Prevatt et al., 2000) and chronic illness in general (Kliebenstein & Broome, 2000), yet less is known regarding recommended models for school re-entry with children experiencing chronic pain (Jones et al., 2014). Some clinical experts propose graduated return to school (Walker, 2004), while others emphasize re-integration into a full school schedule (Banez et al., 2014). Still others underscore that, regardless of specific accommodations for each student, providing school personnel with relevant information regarding students’ medical conditions is an essential component to their success in school (Brown 2006; Jones et al. 2014). This can be extended further to either pain-specific education for teachers (Logan et al., 2007a) or pain-based intervention with school nurses (Larsson & Carlsson, 1996).

Recently, a study was published assessing teachers’ responses to supporting a child with chronic pain in the school classroom in Spain (Solé et al., 2018). Results indicated teachers acknowledge they provide both supportive and unhelpful responses to the student experiencing pain in the classroom. In addition, teachers struggle with modifying academic instruction for students with high frequency of absences—missing both full days or repeatedly missing selective courses/activities. The authors conclude that guidelines are needed to help teachers support the child’s attendance and functioning within the school setting.

As one of several programs across the US treating children with chronic pain, our program evaluates almost 300 children annually and provides intensive interdisciplinary pain rehabilitation for over 100 children per year. Our children report an average of over 11 days of school absences each per month. Our program, like others, reports positive outcomes (Banez et al. 2014; Kempert et al., 2017; Benore et al., 2018); however our program also has a teacher from our local school district embedded in the program to assist with instruction, modeling effective classroom behavior, and supporting school re-entry. Following our program, most children return to their local school, stay in school the full school day, and resume desired school and extracurricular activities (Banez et al., 2014). Based upon over 10 years of clinical practice, this paper provides an updated review of existing literature on school re-entry for children with chronic pain, as well as practical guidelines and accommodations to optimize a child’s successful school re-entry.

Understanding all perspectives

Whether the student has missed weeks of school due to personal choice, doctor’s orders, or involvement in intensive therapy, the key to successful re-entry into school is a thoughtful process with active involvement of all parties (Boutilier & King, 2013)—the student, the parent(s), the school staff, the teachers, and the medical and rehabilitation team. Each party has their own perspective of the student’s history and struggle (Logan & Curran, 2005; Logan et al., 2012; Logan et al., 2017). Each also has their own expectations and goals regarding school attendance, participation, academic progress, and social functioning. Understanding each other’s perspectives is essential to developing and implementing a school re-integration plan for students with chronic pain.

Family and child. While it seems obvious to involve parents and the child in this process, it is important to understand their perspective (Logan et al. 2012; Logan et al. 2017). Some families feel hopeless in this process—dwelling on the months of academic decline and perceived lack of support. Other families become defensive—ready to fight and validate the suffering of their child. Still others fully understand their needs, yet lack the ability to successfully advocate for their child, falling into a passive role in this process.

Children often feel overwhelmed by the demands from parents, teachers, and medical professionals alike. They are often anxious to return to school, fearing failure or embarrassment related to their pain and disability (e.g. Walker et al., 2009). Children also report a sense of social isolation due to the misunderstanding of this invisible illness (Walker, 2004) and many can be victims of bullying (Fales et al., 2018). For these reasons, validating and supporting the child may help him/her feel more confident to contribute to school re-entry planning. It is wise to include the family throughout the entire re-entry process so the child can realize that everyone is on the same team supporting his/her academic success.

School staff. From the perspective of school personnel, mandates by states require students to attend school and complete required assignments. There are models to assess and manage medical concerns in the school setting (Power et al., 1999), yet many school staff struggle to understand chronic pain. Without specific medical instruction, teachers and principals are bound to hold children with chronic pain to the same standards as other students. Truancy is often a topic of debate for children with pain-associated disability. Without adequate education about the student’s condition, teachers may respond to chronic pain symptoms (e.g. fatigue, grimacing, depressed mood) as either lack of motivation or direct opposition (Kliebenstein & Broome, 2000; Logan et al., 2005; Logan et al., 2007b; Solé et al. 2018). Pain complaints and efforts to cope with pain in the classroom (e.g. distraction) may also be perceived as disruptive to the class or efforts to avoid the expected workload (i.e. faking it).

Once the school staff (especially teachers) understand the nature of chronic pain, they can play a valuable role in the success of a school re-entry program. Teachers and administrators possess intimate knowledge of the school environment (physical and social), the curriculum, and the student’s academic strengths and weaknesses. When the goal of academic recovery or course completion is understood within the context of chronic pain, teachers may contribute valuable suggestions on how to modify coursework, restructure the school setting or schedule, and provide the appropriate supports.

Medical/rehabilitation staff. Finally, representatives from every professional discipline in the child’s rehabilitation are helpful in the development and implementation of the student’s re-integration into school. Representatives from psychology, medicine, therapy services, social work, and teaching staff all possess specific expertise in chronic pain and have specific knowledge of the child’s current abilities and limitations. These professionals can accurately explain the nature of chronic pain to the school personnel and provide rationale for accommodations critical to increase the student’s participation and progress in an academic environment.

A shared philosophy of chronic pain

Once the family, student, school personnel, and rehabilitation team adequately appreciate the perspectives of one another, it is important to develop a shared understanding of chronic pain that can support school re-entry (see Appendix A; see also Zeltzer & Schlank, 2005). This philosophical approach to chronic pain, supported by research, is necessary to reduce confusion and increase cooperation among different disciplines. The text box provides a case conceptualization of school re-entry applying this philosophy. A more detailed explanation is below.

  • First and foremost, chronic pain is a real condition. Believing and validating the student’s pain is more helpful than challenging him/her about the veracity of pain, which may create a barrier to collaborative educational planning (Logan et al., 2007b). These children are suffering, but they are often not at higher risk of injury or illness in the school building than at home. Therefore, having chronic pain does not warrant an excused absence.
  • Children must learn to function with pain in school. Continuing appropriate school activities (with modifications) is part of the treatment of chronic pain. However, prolonged conversations or repeated pain assessments are unnecessary and may lead to increased pain complaints and related impairments. Instead of challenging or constantly assessing the student’s chronic pain, targeted encouragement for school attendance and participation despite the constant sensation of pain may help increase their confidence to be successful in school. These children can excel when surrounded by adults and peers who understand them, actively support them, and demonstrate a belief that the child can get better.
  • Chronic pain requires many layers of intervention. Beyond medications, children must adhere to regular physical therapies to strengthen and condition their bodies, as well as mind-body or psychological exercises to calm their nervous system. Although chronic pain is often not directly caused by emotional difficulties, anxiety and depression are common in chronic pain and should be considered an integral component of students’ re-entry planning. Children often are removed from activities that give them a sense of identity and a network of peers; it is stressful reinitiating these activities and friendships, or coping with the loss of them.
  • Finally, pain will not go away immediately—improvement often takes months and this is usually after a child resumes normal functioning. Even after pain improves, most children will have both good and bad days of varying pain intensity. School re-entry involves a healthy dose of patience, hope and perseverance.

Case conceptualization of school re-entry discussion

“Let me begin by putting this school re-entry meeting into context. [Child] has just completed an intensive pain rehabilitation program. The focus of our program is functioning. We do not tell our patients to sit and wait for their pain to go away to start living their lives. The exact opposite is true! We tell them to start living their lives, despite their pain. This is why school plays such an important role in the childs success. Generally, children with chronic pain miss out on significant amounts of school because of chronic pain symptoms. However, it is our expectation and recommendation that they return to school full time and no longer miss school days because of chronic pain. This means that the child will return to you still having chronic pain. Unfortunately, no magic pill exists that takes away chronic pain. However, [Child] has learned enough skills and strategies to manage the pain and successfully get through a typical school day. We now want to discuss your goals and expectations for [Child] and give you specific information about the chronic pain condition and some conservative strategies that we think will help [Child] be successful in the academic environment.”

For school personnel, implementation of this philosophy will likely shape their interaction with the student, helping them to develop and apply a limited number of accommodations within the classroom. They will focus on a child’s functioning (e.g. attendance, participation, using pain management skills in the classroom) before any academic success. Teachers can reinforce the student at each step in this process. Teachers can also include the student in classroom activities and address interactions between students so that the student with chronic pain feels included and supported, without feeling special or different. Teachers can also be on the lookout for both overt and subtle forms of bullying, a common concern for children with chronic pain which makes school an unsafe environment.

Teachers and school personnel also have to support each other when teaching children with chronic pain. Using a shared philosophy, teachers can avoid unhealthy forms of support or splitting among teachers—conflict between teachers about the student creates a barrier to success. Teachers must be careful not to over-accommodate when supporting functioning. Teachers should avoid interpersonal battles, guilt trips, belittling, or other unhealthy forms of manipulation to encourage class participation or academic performance. Finally, the school should set up a process for ongoing monitoring and management of academic supports. It is likely as a child improves that some supports may be removed. However, the child should be encouraged to advocate for himself/herself in the case that some supports need to be added or modified.

Careful planning

School re-integration for students with chronic pain begins as soon as the family is committed to chronic pain rehabilitation. Whether periodic outpatient visits or intensive hospital-based programming, rehabilitation begins with goals for discharge (i.e. school attendance and academic progress) and with the focus on improving independent functioning. Parents are responsible for making connections with appropriate personnel in the school to prepare the child for eventual return. Often, school counselors serve as the point of contact. Ongoing communication should address the following: compiling a concise list of assignments/materials to aid with academic recovery, introducing school personnel to resources regarding chronic pain in children, and arranging the school re-entry planning conference.

If the child enrolls in an intensive rehabilitation program, a contact person (e.g. teacher/educational specialist) from the treatment team should communicate with the school to gather relevant information for eventual re-entry (e.g. school contact list, academic data, history of school involvement). It may be helpful for professionals working with the child outside of school to assist with study skills and assess learning difficulties (Dick & Pillai Riddell, 2010) as these can complicate academic progress and often go unnoticed in the presence of chronic pain.

After initial contact has been made to bring together all perspectives of the student’s care team (i.e. family, student, school, rehabilitation team), a conference between medical/rehabilitation staff and school staff lays the foundation for school re-entry. This serves as a planning meeting, a team-building exercise, and even a rite of passage for this child who is working so hard in rehabilitation with hopes to transition back to school. A successful conference may take as little as 15-20 minutes and can even occur over the phone. As suggested in previous literature regarding school re-integration (Prevatt et al., 2000), these meetings target a review of the student’s medical condition and related psychosocial issues that may impact their learning or functioning in school (see Appendix C). This meeting allows the medical and therapy staff to share information with the school to help them better understand chronic pain and embrace the returning student, providing appropriate classroom accommodations and emotional support. Standard recommendations for students with chronic pain should be discussed (see Appendix D), yet it is important to consider adaptations to these accommodations for the specific needs of a given student. This meeting also allows school personnel to ask relevant questions as they consider what accommodations and services to provide (see Appendix E for Frequently Asked Questions).

Detailing common recommendations

The following recommendations describe important areas to consider to maintain students’ progress in using pain management and coping skills for their chronic pain (see Appendix D). However, there may be condition-specific recommendations (not included here) that the team must also consider. Of note, when aiming for improved independent functioning, often offering the fewest accommodations possible (or weaning accommodations over time) is the best way to strike a balance between promoting independent functioning and unintentionally extending the student’s disability status.

Medical accommodations. From a medical standpoint, it is important to ensure that school officials understand aspects of the patient’s medical care. This involves a basic understanding of the chronic pain condition. For other comorbid symptoms or additional medical diagnoses, it is important that school teachers and nursing staff be knowledgeable of the student’s medication regimen so as to ensure medication adherence throughout the school day (Timmerman et al., 2016). There may be preventative medications to take on a regular basis. There may also be acute medical interventions that could safely be performed in the school setting. School nurses should provide a place for students to store their medication and other medical equipment, and should help monitor response to, or side effect from, medications. Finally, school officials need assurance that the child is medically stable and capable of attending school.

Children with chronic pain may also have special dietary needs (Brown, 2006). Depending on the age of the child, it may also be important for school staff to encourage appropriate nutrition (e.g. snacks during the day). It is a common recommendation to prevent dehydration as this will influence chronic pain. Children are often recommended to drink eight or more glasses of water per day. This involves carrying a water bottle throughout the school day (Shah et al., 2004). This also involves providing unrestricted access to restrooms given the increased fluid intake. A final recommendation for medical care involves providing any appropriate medical precautions the school staff should be aware of (including ‘no precautions’). It is very helpful for school staff to understand whether aspects of a student’s chronic pain condition or medication could influence his/her school performance.

Physical functioning accommodations. Due to pain avoidance and deconditioning (Simons & Kaczynski, 2012), students with chronic pain often develop improper posture and body mechanics (i.e. use of body in movement). Students with chronic pain are encouraged to carry supplies in a lightweight backpack. It is often helpful to receive an additional set of books at home to reduce carrying weight throughout the day. In addition, students with chronic pain often struggle with managing efficient levels of energy throughout the day. To promote stamina and improved pacing throughout the day, students are recommended to periodically leave their seat, stretch, and use relaxation skills throughout the school day. These brief exercises may be particularly helpful to manage pain or discomfort during sedentary activities in a classroom. Scheduled breaks throughout the school day allow time for students to take their medications or adhere to other medical or emotional/behavioral needs. During these breaks, having trained school counselors designated to facilitate a student’s use of coping strategies may further benefit the student’s increased school attendance (Brown, 2006). It is important that school personnel understand any assistive devices or physical accommodations that the child will need throughout the day. School staff are often surprised that there are few assistive devices a child with chronic pain may actually need. Although the child may not need visible assistive devices, other accommodations may be necessary to transfer effectively between classes, such as extended transitions between classes or transferring at a separate time than a majority of students. Particularly during school activities that require more strenuous physical exertion, some students may need additional assistance with stairs and modified gym activities.

Psychological accommodations. Managing pain requires psychological intervention as much as physical intervention. Students need to feel validated about their current level of distress. It is important that staff do not question the students’ pain or expect the student to justify the extent of his/her suffering. Rather, staff should encourage the child to engage in normal activities and support the student’s gradual return to class and increased participation in classroom activities. It is important not to ask about the pain often, because students do much better with distraction (i.e. when their attention is diverted to topics other than pain). This is one reason school attendance and classroom activities can be so helpful to these children—active distraction from pain. These children also require significant praise for getting through the day. Chronic pain is considered an invisible illness—although students do not present with physical symptoms easily observed visually by others, they continually struggle to make it through classroom activities. It is incredibly beneficial when teachers acknowledge the progress the student is making, provide hope that they can reach their goals, and provide support to go one step further each week—again, recovery from chronic pain is a long term process.

Children often learn a number of cognitive and behavioral strategies to mitigate pain, increase functioning despite pain, and maintain a positive attitude to progress in daily activities. It is often helpful for students to share their skills with teachers, as teachers or counselors can support the use of the skills within the classroom and often provide some creative modifications of how to apply these in the classroom. Further, teachers should allow moments during the class period for the student to use relaxation skills or other coping skills to modify fatigue or stress, being especially sensitive to not draw attention to him/her when it is clear s/he is actively coping with pain while trying to remain in the classroom.

In addition, the student will benefit from a specific plan to manage stress and pain in school. A rescue protocol to manage urgent flairs in pain or stress helps the student feel supported and helps teachers understand the student’s immediate needs. However, it is necessary that this plan note how the child will successfully return to class following an acute episode.

Additionally, chronic pain often presents with comorbid anxiety and depression (Dorn et al., 2003; Wager et al., 2015; Eliacik et al., 2017). It is important that these diagnoses are clarified with school personnel and additional supports are provided (e.g. school counseling). Even if these comorbid conditions are not present, it is highly recommended that the student follow-up regularly with the school counselor/psychologist to revisit their accommodations and any related psychosocial concerns. Through active monitoring of accommodations and supports in place, as well as the student’s response, everyone involved can make any necessary modifications as well as praise the student for his or her progress to date.

Related to the student’s psychosocial functioning, other factors related to school avoidance or declining participation in class should be carefully reviewed. A recent study suggests students with chronic pain may present with undiagnosed ADHD, autism, or nonverbal learning disorders more often than peers (Low Kapalu et al., 2018)—and this can go unnoticed when teachers and medical providers alike focus on chronic pain. Bullying or social aggression is also a common daily hassle for students with chronic pain (Fales et al., 2018). If needed, the school should provide the necessary academic or social supports.

Academic accommodations. Children and adolescents with chronic pain often worry about make-up work due to decreased attendance from chronic pain episodes (Walker, 2004). To alleviate these worries, a timeline and schedule for making up schoolwork should be established during the child’s school re-entry process (Brown, 2006). If the child enrolls in a rehabilitation program that would interfere with regular school attendance, the school should be informed and plan for how best to support academic progress during intensive rehabilitation. Until the child can demonstrate physical participation in a full day of school, consider a modified school day. Afterwards, a child may still benefit from a late start (miss first period) to facilitate improved sleep hygiene and transition to school. Other accommodations may include preventing cognitive fatigue by scheduling a study hall or less demanding class after a cognitively demanding class, or allowing a rest period during class after 30 minutes. Students may also benefit from study periods during the school day to receive additional tutoring/instruction from the primary teacher to ensure comprehension of the material and the expectations for work.

Students may also benefit from environmental accommodations to ease school stress and facilitate pain management in school. Students can reduce sensitivity to the environment with preferential seating, reduced/modified screen time, or quieter places for lunch and study hall. Receiving copies of class notes can reduce visual, physical and cognitive fatigue from transcribing notes in class. If additional time is provided to transition between classes, this may be an ideal time for the student and teacher to consult on any missed or misunderstood instruction

Finally, teachers can make several accommodations to support academic promotion. It is best to have a direct conversation about what tasks need to be performed so the student can clearly graduate to the next grade level. This will reduce a lot of anticipatory academic stress. It is very helpful in the short term to eliminate any past due academic work which is not necessary to demonstrate comprehension/competency in an academic area and is not essential to earn course credit. Some programs have considered offering course credit for learning about pain and pain management (Reid et al., 2016). Other necessary coursework may be modified to reduce cognitive burden. This may include reducing number of items on homework, providing reports in oral discussion instead of written format, providing copies of classroom notes, and using scribes. Teachers should avoid penalizing the student for work turned in late due to prior assessment and management of chronic pain; however it is acceptable to create a new plan for accountability with the student. Importantly, to the best of everyone’s ability, it helps to set an expected date for academic recovery, such that the student can be caught up in a reasonable amount of time. Prolonged periods of feeling behind in school add stress and interfere with performance and physical/emotional functioning.

Monitor the plan

Students returning to school after prolonged absence often benefit from administrative check-ins at scheduled intervals during the first one to two months of returning to school. These brief check-ins may take 10-15 minutes, but can ensure the student understands the accommodations provided, utilizes supports in the school, and is making adequate progress in academics. As students progress, some accommodations may be removed to reinforce independent functioning and prevent inadvertently maintaining a sense of disability. One or two follow-ups with the rehabilitation or medical team can be a successful way to validate the student’s progress and reinforce further independent functioning at school.

For students needing formal accommodations, a Section 504 Plan or Individualized Educational Program (IEP) may be helpful to provide structure for the medical, physical, and academic accommodations that the student needs (https://kidshealth.org/en/parents/504-plans.html). More specifically, a Section 504 Plan refers to written plans for specific students with disabilities (i.e. chronic pain conditions) containing educational accommodations to assist them within an academic setting. An IEP on the other hand is fitting for students who require further customized instruction in their curriculum to accommodate their needs. These formal accommodations ensure the student with chronic pain is systematically receiving necessary support in school, and allows these accommodations to be monitored and assessed as the student continues to progress in school.


While schools dedicate their efforts to providing a supportive environment for every student’s learning, supporting students with chronic pain can be challenging due to significant school absences, an incomplete understanding of chronic pain, and a lack of team support for the student. Given the complexities involved, collaboration among all parties involved in the student’s care is essential for optimizing a successful school re-entry. Understanding all perspectives, practicing the shared philosophy of pain rehabilitation, and careful planning are necessary components for a successful school re-entry. School personnel may benefit from collaborating with the rehabilitation team and family and following these guidelines to decide which specific accommodations may benefit the student’s medical, physical, psychological, and academic functioning upon his/her school re-entry. The primary goals should be to increase the student’s school attendance, active participation, and academic recovery. This increased functioning is likely to subsequently influence positive improvements in pain reduction, mood, engagement with peers, and eventual academic success.

Ethan Benore, PhD
Center for Pediatric Behavioral Health, Cleveland Clinic Children’s, Cleveland, OH, USA
email: benoree[at]ccf.org

Amy Fahrenkamp, PhD
Department of Psychology and Psychiatry, Mayo Clinic College of Medicine & Science, Rochester, MN

Oleh Zhakunets, MEd
Providence Academy, Parma, OH, USA

Gerard A. Banez, PhD
Center for Pediatric Behavioral Health, Cleveland Clinic Children’s, Cleveland, OH, USA

Cite as: Benore E, Fahrenkamp A, Zhakunets O, Banez G. School re-entry following chronic pain and disability: A pathway to success. Pediatric Pain Letter 2020;22(1):2-15. ppl.childpain.org

Appendix A: A philosophy for chronic pain and the role of the school staff

All Pain Is Real:
Pain is caused by complex interactions between the brain and the rest of the body. If the body has been in pain for a long time, the nervous system can continue sending pain signals even if there is no longer any tissue damage. This is why many patients are told “there is nothing medically wrong,” or “it must be psychological.” In fact, chronic pain is a neurological condition.

Don’t Ask If Your Student/Child Is In Pain:
Although pain in real, frequently talking about chronic pain draws your attention to it and enhances pain signals. If you ask your child if he/she is in pain, they will scan their body looking for the pain and find it. If he/she happens to be distracted from the pain at that moment, we want that moment to be continued. It is perfectly fine for him/her to complain if he/she feels pain, however prolonged discussion is unhelpful.

Improvement Is First Measured By Increased Functioning:
For most patients, the pain goes away after the child is functioning normally. Your child is improving when you see an improvement in his/her day-to-day functioning. Pay attention and reinforce the child each day he/she is demonstrating better daily functioning.

Focus on Independence, But Use Supports
Children with chronic pain do better when they focus on what they can do independently. Avoid hovering over the child or rescuing the child when they struggle. Their personal gains will increase their confidence and reduce distress during daily tasks. That being said, children should be encouraged to use the appropriate level of supports that help them complete daily tasks independently.

Healthy Habits For Life
Many of the lifestyle recommendations for improved health are also true for chronic pain. This involves regular physical activity, adequate nutrition, sufficient water intake, and good sleep hygiene. Specific recommendations should be in their health plan. Children with chronic pain can benefit from working with others who are following these same recommendations for their own personal health.

Pain Is Not The Only Problem
Chronic pain is often linked with several other issues that children must cope with. Due to pain signals and loss of activities, anxiety and depressed mood are common. Due to miscommunication or misunderstanding, bullying and socialization are common. Due to the long-term struggle of pain and changes in family life, parent stress and sibling rivalry are common. Other children’s struggle in school is more related to cognitive or social deficits rather than pain. It is important to treat the whole child by acknowledging these problems associated with pain. Often, reduction in these problems can instill hope and motivation for the overall pain management program.

A Long-Term Problem Requires A Long-Term Solution:
Quick solutions do not work for chronic pain problems. Children who do best over time make slow and steady progress in functioning first. Identifying short-term wins can help maintain motivation for the long-term goals.

**Adapted in part from Zeltzer & Schlank, 2005

Appendix B: Checklist for school re-entry planning meeting

School Staff                                                        

  • Clarification of class placement
  • Clarification of current accommodations/supports
  • Clarification of individualized educational goals
  • Clarification of current progress toward set goals and anticipated date of completion


  • Ensure school officials understand aspects of diagnosis, prognosis and treatment plan
  • Ensure student is medically stable and safe to attend school
  • Address any potential warning signs requiring further medical care (typically none)
  • Provide direction (i.e. time, place, method) for medication regimen so as to ensure medication adherence. Include prescription and prn medications
  • Address any side effects of medication/conditions that will influence behavior in class or academic performance (e.g. memory, attention, fatigue)
  • Address other medical needs (e.g. fluid intake, need for snacks)


  • Expectations to physically participate in school day
  • Any exceptions to typically participation (e.g. gym class, school trips)
  • Expectations for proper posture and body mechanics
  • Modifications to school day to reduce fatigue or strain (e.g. pace breaks, change in schedule)
  • Modifications to materials to reduce fatigue or strain (e.g. light backpack, extra set of books at home, copies of class notes)
  • Explanation of any assistive devices the child is supported in using (what is it and how should they use it?)
  • Clarification of any assistive devices they should not be using (e.g. wheelchair)


  • Review the emotional and social impact of chronic pain
  • Review interpersonal factors that may influence behavior at school (bullying, isolation)
  • Explanation of any coping skills the child will use in school (what is it and how should they use it?)
  • Staff-specific behaviors to help the student cope with pain in school
    • Avoid questions about pain
    • Validate student rather than challenge them
    • Encourage and praise normal/modified activities and participation in classroom activities
    • Understand and encourage use of coping skills; do not draw attention to student for using coping skills
    • Encourage student to advocate for their needs, even if school cannot directly meet those needs
    • Problem-solve solutions to frequent academic/social concerns
  • Create plan for ongoing follow-up with liaison at school to support implementing accommodations

Appendix C: Checklist for possible accommodations and supports

School environment

  • School placement (typically in school building, full-time)

Daily schedule

  • Allow late start only if needed to improve sleep hygiene and transition to school
  • Prevent cognitive fatigue with scheduled breaks throughout the day. This may be structuring a study hall after a cognitively/physically demanding class, or allowing a rest period during class after 30 minutes
  • Provide study periods during the school day to provide additional tutoring/instruction so that student understands the material and the expectations for work
  • Allow extended time during testing days

Education on chronic pain

  • Staff meeting to discuss student condition and accommodations
  • Student meeting  with classroom to discuss chronic pain
  • Student meeting with few key students who can provide limited physical and necessary emotional support

Academic recovery

  • Eliminate any past due academic work which is not necessary to demonstrate comprehension/competency in an academic area and is not essential to earn course credit
  • Prior to adequate assessment and management of chronic pain, student should not be penalized for work turned in late
  • Modify any necessary coursework to reduce cognitive burden. This may include reducing number of items on homework, providing reports in oral discussion instead of written format, providing copies of classroom notes, and using scribes
  • To the best of everyone’s ability, work towards a set date for academic recovery, such that student can be caught up in a reasonable amount of time. Prolonged periods of feeling behind in school add stress and interfere with performance and physical/emotional functioning

Medical Care

  • Provide specific recommendations for prescription medications (i.e. storage location, method and supervision of administration)
  • Provide specific recommendations for non-prescription medications (i.e. storage location, method and supervision of administration)
  • Ensure any notable change in functioning is appropriately assessed and child is returned to classroom


  • Allow preferential seating close to natural light to prevent sensitivity to fluorescent lighting
  • Limit working on a computer or tablet to reduce photosensitivity. This may include reading from a smart board
  • Provide copies of class notes to reduce visual and cognitive fatigue transcribing notes in class. Consider notes on colored paper to reduce glare
  • Allow work periods in a separate room to reduce sensitivity to noise
  • Allow lunch periods in a separate room to reduce sensitivity to noise
  • Allow student to transfer later between classes (3 minutes) due to speed or noise. This time between classes could be used to touch base with a teacher and then leave for the next class
  • Allow use of water bottle in school to prevent dehydration
  • Allow free access to bathroom given fluid intake
  • Allow snack in morning and/or afternoon to prevent low blood sugar
  • Allow distraction tools in classroom, provided student is still able to attend to class activities
  • Allow relaxation skills in classroom
  • Allow movement/stretching in classroom


  • Additional time with classroom teacher for missed instruction
  • Tutoring for academic recovery or missed instruction while managing pain during the school day
  • Counseling in school
  • Regular meetings with school personnel to monitor and modify accommodations

Appendix D: FAQs for school re-entry

Should the family consider homeschooling?
First, there is a difference between home schooling and home instruction. Home schooling is when the parent(s)/guardian(s) utilize a district-directed curriculum to educate the child. Home instruction is where the students’ home school district provides a state-licensed educator to come into the home to educate the child. For many reasons, we do not often encourage either homeschooling or extended home instruction for children with chronic pain. Children with chronic pain benefit from interacting with teachers, working alongside peers, following a consistent daily structure throughout the week, and being exposed to a range of different activities and location for distraction purposes. While homeschooling/home instruction allows flexibility, often this flexibility can lead to further avoidance of school activities and withdrawal from other physical and social activities. In very rare circumstances, if the child has significantly fallen behind in school, or school staff is not supporting accommodations necessary to ensure a positive progress in the classroom setting, alternative placements may be pursued. However, in these cases it is vital that the child maintain a structured routine, access individuals outside, and a variety of activities throughout the day and week.

Should the school utilize an IEP or Section 504 Plan?
For many students, a 504 Plan can support the appropriate recommendations. The 504 Plan is a federal civil rights law which protects the rights of individuals with disabilities in any agency, school or institution receiving federal funds to provide persons with disabilities to the greatest extent possible, an opportunity to fully participate with their peers. The 504 Plan requires schools to eliminate barriers that would prevent the student from participating fully in the programs and services offered in the general curriculum. This often includes those accommodations necessary to manage chronic pain while attending school. However, if additional academic concerns are noted (e.g. academic decline, poor attention, comprehension), the family may benefit from further clarification and understanding of the student’s academic needs.

Should the child attend summer school?
Summer school is a viable option to ensure the student has not missed important educational stages that may impede learning as s/he progresses to the next grade level. As noted above, the teacher interaction and consistent daily structure may further strengthen overall pain management skills and prepare them for the fall.

Should the student access tutoring to help with academic recovery?
Tutoring, in most cases, is a very appropriate and important option to make sure the student is receiving the individualized attention needed for additional, special, or basic instruction to compensate for any pain-related school absences. However it is important that the tutor be knowledgeable in the field of study to help appropriately modify the workload, such that the student can efficiently move forward.

Can the medical team excuse past absences or future absences?
Creating blanket excuses for past or future absences related to chronic pain is a slippery slope. The treatment team and the school should carefully consider the purpose for any absences related to pain and the potential risk to the student’s overall functioning by allowing absences. As a general rule, after treatment begins, we do not provide excused absences from school for symptoms associated with chronic pain, but do support excuses for medical care or unrelated illness (e.g. infection, flu).

Should the school send the child home when s/he is experiencing pain at school?
Again, following the general advice of providing structure and support throughout the day, we generally do not recommend sending a child home for symptoms associated with chronic pain. Creating a detailed plan for pain management in advance should help school staff manage any pain symptoms or exacerbations during the school day, avoiding the sense of urgency.


Agoston AM, Gray LS, Logan DE. Pain in school: patterns of pain-related school impairment among adolescents with primary pain conditions, juvenile idiopathic arthritis pain, and pain-free peers. Children (Basel) 2016; 3:E39. PubMed Abstract

Banez GA, Frazier TW, Wojtowicz AA, Buchannan K, Henry DE, Benore E. Chronic pain in children and adolescents: 24-42 month outcomes of an inpatient/day hospital interdisciplinary pain rehabilitation program. J Pediatr Rehabil Med 2014;7:197-206. PubMed Abstract

Benore E, Webster EE, Wang L, Banez G. Longitudinal analysis of patient-reported outcomes from an interdisciplinary pediatric pain rehabilitation program for children With chronic migraine and headache. Headache 2018;58:1556-1567. PubMed Abstract

Boutilier J, King S. Missed opportunities: school as an undervalued site for effective pain management. Pediatr Pain Lett 2013;15:9-15. Link

Brown RT. Managing pediatric pain in school. In: Finley GA, McGrath PJ, Chambers CT, editors. Bringing pain relief to children: treatment approaches. Totowa, NJ: Humana Press, 2006. pp. 113-130. Link

Dick BD, Pillai Riddell R. Cognitive and school functioning in children and adolescents with chronic pain: a critical review. Pain Res Manag 2010;15:238-244. PubMed Abstract

Dorn LD, Campo JC, Thato S, Dahl RE, Lewin D, Chandra R, et al. Psychological comorbidity and stress reactivity in children and adolescents with recurrent abdominal pain and anxiety disorders. J Am Acad Child Adolesc Psychiatry 2003;42:66-75. PubMed Abstract

Eliacik K, Kanik A, Bolat N, Mertek H, Guven B, Karadas U, et al. Anxiety, depression, suicidal ideation, and stressful life events in non-cardiac adolescent chest pain: a comparative study about the hidden part of the iceberg. Cardiol Young 2017;27:1098-1103. PubMed Abstract

Fales JL, Rice S, Aaron RV, Palermo TM. Traditional and cyber-victimization among adolescents with and without chronic pain. Health Psychol 2018;37:291-300. PubMed Abstract

Hechler T, Kanstrup M, Holley AL, Simons LE, Wicksell R, Hirschfeld G, et al. Systematic review on intensive interdisciplinary pain treatment of children with chronic pain. Pediatrics 2015;136:115-127. PubMed Abstract

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

Jones KM, King S, MacLaren Chorney JE. Supporting children with chronic pain in their return to school. Pediatr Pain Lett 2014;16:8-14. Link

Kashikar-Zuck S, Johnston M, Ting TV, Graham BT, Lynch-Jordan AM, Verkamp E, et al. Relationship between school absenteeism and depressive symptoms among adolescents with juvenile fibromyalgia. J Pediatr Psychol 2010;35:996-1004. PubMed Abstract

Katz ER, Varni JW, Rubenstein CL, Blew A, Hubert N. Teacher, parent, and child evaluative ratings of a school reintegration intervention for children with newly diagnosed cancer. Child Health Care 1992;21:69-75. PubMed Abstract

Kempert H, Benore E, Heines R. Physical and occupational therapy outcomes: adolescents' change in functional abilities using objective measures and self-report. Scand J Pain 2017;14:60-66. PubMed Abstract

King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain 2011;152:2729-2738. PubMed Abstract

Kliebenstein MA, Broome ME. School re-entry for the child with chronic illness: parent and school personnel perceptions. Pediatr Nurs 2000;26:579-582. PubMed Abstract

Larsson B, Carlsson J. A school-based, nurse-administered relaxation training for children with chronic tension-type headache. J Pediatr Psychol 1996;21:603-614. PubMed Abstract

Logan DE, Catanese SP, Coakley RM, Scharff L. Chronic pain in the classroom: teachers' attributions about the causes of chronic pain. J Sch Health 2007a;77:248-256. PubMed Abstract

Logan DE, Coakley RM, Scharff L. Teachers' perceptions of and responses to adolescents with chronic pain syndromes. J Pediatr Psychol 2007b;32:139-149. PubMed Abstract

Logan DE, Curran JA. Adolescent chronic pain problems in the school setting: exploring the experiences and beliefs of selected school personnel through focus group methodology. J Adolesc Health 2005;37:281-288. PubMed Abstract

Logan DE, Gray LS, Iversen CN, Kim S. School self-concept in adolescents with chronic pain. J Pediatr Psychol 2017;42:892-901. PubMed Abstract

Logan DE, Simons LE. Development of a group intervention to improve school functioning in adolescents with chronic pain and depressive symptoms: a study of feasibility and preliminary efficacy. J Pediatr Psychol 2010;35:823-836. PubMed Abstract

Logan DE, Simons LE, Carpino EA. Too sick for school? Parent influences on school functioning among children with chronic pain. Pain 2012;153:437-443. PubMed Abstract

Logan DE, Simons LE, Stein MJ, Chastain L. School impairment in adolescents with chronic pain. J Pain 2008;9:407-416. PubMed Abstract

Low Kapalu CM, Hall JJ, Wallace DP. Neuropsychological functioning of youth receiving intensive interdisciplinary pain treatment. J Pediatr Psychol 2018;43:870-881. PubMed Abstract

Power TJ, Heathfield LT, McGoey KE, Blum NJ. Managing and preventing chronic health problems in children and youth: school psychology's expanded mission. Sch Psychol Rev 1999;28:251-263.

Prevatt FF, Heffer RW, Lowe PA. A review of school reintegration programs for children with cancer. J Sch Psychol 2000;38:447-467.

Reid K, Simmonds M, Verrier M, Dick B. Supporting teens with chronic pain to obtain high school credits: Chronic Pain 35 in Alberta. Children (Basel) 2016;3:E31. PubMed Abstract

Shah SI, Aurangzeb, Khan I, Bhatti AM, Khan AA. Dehydration related abdominal pain (DRAP). J Coll Physicians Surg Pak 2004;14:14-17. PubMed Abstract

Simons LE, Kaczynski KJ. The fear avoidance model of chronic pain: examination for pediatric application. J Pain 2012;13:827-835. PubMed Abstract

Solé E, Castarlenas E, Sánchez-Rodriguez E, Galán S, de la Vega R, Jensen MP, et al. Chronic pain in the school setting: the teachers’ point of view. J Sch Health 2018;88:65-73. 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

Timmerman L, Stronks DL, Groeneweg JG, Huygen FJ. Prevalence and determinants of medication non-adherence in chronic pain patients: a systematic review. Acta Anaesthesiol Scand 2016;60:416-431. PubMed Abstract

Wager J, Brehmer H, Hirschfeld G, Zernikow B. Psychological distress and stressful life events in pediatric complex regional pain syndrome. Pain Res Manag 2015;20:189-194. PubMed Abstract

Walker LS. Helping the child with recurrent abdominal pain return to school. Pediatr Ann 2004;33:128-136.

Walker LS, Beck J, Anderson J. Functional abdominal pain and separation anxiety: helping the child return to school. Pediatr Ann 2009;38:267-271. PubMed Abstract

Zeltzer LK, Schlank CB. Conquering your child's chronic pain: a pediatrician's guide for reclaiming a normal childhood. New York: Harper Collins, 2005. Link