Text extracts reproduced from Jennifer Verrill Schurman and Craig A Friesen, Integrative tr eatment approaches: family satisfaction with a multidisciplinary pediatric: Abdominal Pain Clinic, International Journal of Integrated Care , Volume 10, p 1 \200\2239, Copyright 2 010 (CC By 3.0). results in frustration. However, aft er the coordinated interdiscipli- nary assessment, and once treatment plans are developed, parents are oft en quite appreciative of the service p rovided in the MPC team, especially with holistic and multidisciplinary team approach (Tabl e 62.5 ) (Schurman and Friesen, 2010). Many pediatric pain facilities are structured to off er a variety of health care services on the same day as the fi rst visits. Th is is not on ly convenient for fami- lies but establishes early on that a comprehensive examination of t he child \200\231s needs is being completed. Initial evaluation Organization of the data gathering process is important. Cott has argued that the initial interview for a complex problem requires the simultanous presence of the most senior clinicians; in other programs initial data gathering may use standardized ques- tionnaires administered by relatively junior clinicians or non-spe- cialists (Cott, 1987). Th e child should obviously be involved in all decisions (Desparmet, 2009). Th e evaluatio n of the patient should involve family members and consider the entire history and fam- ily dynamic. Parents should be prepared for the possibility of an extended meeting. A checklis t of items that should be discussed during this initial evaluation is provided in Table 62. 6 (adapted from National Health and Medical Research Council, 2005). Th e length of this ex tended fi rst contact interview can be anywhere from an hour to the better part of a day (W eisman, 2008). Parents and siblings should be incorporated into the interview, which will i nclude social history, school performance and extracurricular activities changes. Results are not always positive, however, and it is important to recognize when MPCs do not get it right so that these situations can be planned against. If expectations are not met, mistrust and sensitivity to future advice can arise: this represents a continuation of exp erience of failure derived from previous visits to other single modality specialists (Weism an, 2008). Negative experiences with MPCs include the length of a visit (including time wai ted between meetings) waitlist times, scheduling confl icts, and complexity of the interpre tation of outcomes. Parents expect the MPC to off er coping solutions and stress management skills (Claar and S charff , 2007). Th ey also anticipate SECTION 9 special topics 650 Referral From General Practitioner, Family, Hospital inpatient or emergency service Question Is there a clear diagnosis which accounts for the pain complaint and is that diagn osis currently being optimally treated? Make Appointment with one provider or a modality clinic based on location /type of pain Yes N0 Schedule patient with at least three providers including: Psychologist, Physician (pain specialist), and a select specialist depending on diagnosis. Plus a child life counselor or nurse (depending on child age and sta \200 availability) Provider suggests MPC treatment First Meeting Questions Is further investigation required? Is there evidence of physiologic al process which would cause \200\230harm \200\231 if patient began to participate in an a ctive recovery program? Patient tested/ assessed: Counseling is recommended: Treatment Prot ocol established: Pharmacist is incorporated if needed Initiate recovery program while investigation process (if needed) continues N0 De \201ne limits of recovery program to be pursued Follow up visits with appropriate providers Child life specialist, pharmacist Reassessment Reevaluate treatment plan, diagnosis Question: Is pain relieved or eliminated? Pain relief may not be an achievable goal althoug h understanding and management of the problem may be No Yes Maintain the treatment for ___ weeks (determined in assessment) Consult with team about pha sing the patient out of treatment Treatment has been successful? (No Relapse) Yes Discharge from the clinic. Figure 62.3 Patient \202 ow for chronic care services. Table 62.6 Patient assessment checklist (conducted with child and family present) Pain history information of signi \201 cance for symptomatic treatment of pain Expectations of outcome Circumstances associated with pain onset Patient belief around cause(s) of pain Primary site of pain Family belief around cause(s) of pain Radiation of pain Expected reduction in pain and symptoms required to resume regular activities Character of pain (throbbing, sharp, aching etc.) Patient \200\231s typical coping response for stress or pain, Intensity of pain during movement, at rest, and at present, during last week Presence of anxiety or psychiatric disorders (e.g. depression or psychosis) Highest level of intensity Family expectations and beliefs about pain, stress and postoperative course Factors altering pain (what makes it worse/better?) Ways the patient describes or shows pain Associated symptoms Source: data from National Health and Medical Research Council, Acute pain management: scie nti \201 c evidence , Sydney, Australia, Copyright 2005 Commonwealth of Australia. Temporal factors (is pain present continuously or otherwise?) E \200 ect of pain on activities E \200 ect of pain on sleep Physical exam, diagnosis, and feedback Th e physical exam including neurological exam (Desp armet, 2009; Weisman, 2008) and the diagnosis and feedback all provide both diagnostic and communication opportunities. Ensure adequate time for understanding, and confi rm comprehen sion (Desparmet, Medications taken for pain Additional treatments used for pain Health professionals consulted for pain treatment CHAPTER 62 organizational systems in pediatric pain 651 References American Society of Anesthesiologists. (2010). Practice guidelines for chronic 2009). Th is is where trust between provider and patient can be rein- forced. All questions should be answered thoroughly. Th e plan will be multifaceted and complex, and determined by pain management. Anesthesiology , 112 (4), 1 \200\22324 . the team during evaluation of the patient \200\231s needs and capabilities. American Society of Anesthesiologists. (2012). Practice guidelines for acute pain managemen t in the perioperative setting: an updated report by the American Society of Anesthesiologi sts Task Force on Acute Pain Management. Anesthesiology , 116 (2), 248 \200\223273 . Outcome goals are established in the feedback session, such as reintegration into various a spects of daily routine (Weisman, 2008). Families may not always accept the diagnosis and p lan, follow up should be encouraged. If the family is unwilling to return then the importan ce of a discussion with their family doctor should be emphasized. Refer to the section on p arents \200\231 perceptions about how to increase their satisfaction which has a highly pos itive association with adherence and good outcomes. Berde, C. and Solodiuk, J. (2003). Multidisciplinary programs for management of acute and c hronic pain in children. In N. Schechter, C. Berde, and M. Yaster (eds), Pain in infants, c hildren and adolescents (2nd edn), pp. 471 \200\223488 . New York : Lippincott Williams & W ilkins . Bonica, J. (1974). Organization and function of a pain clinic. In J. Bonica (ed.) Advances in neurology: international symposium on pain , pp. 433 \200\223443 . New York : Raven . Conclusion Th is chapter provided guidance and described options for organi- zations that m ay adopt a new or modify an existing pediatric pain center. It focused on the importance of multidisciplinary treatment assessments and the incorporation of the entire health team th rough various times of the treatment plan. Th e information here will help identify the pro per staff for a MPC, and emphasize the need for team leaders to be explicit with members ab out procedures and expectations from the beginning. Using options presented, multi- discipl inary teams may develop such procedures; however each team may require certain customizatio n. Th e emphasis should be on team cohesion, which will translate to better patient care. T h e sections of parental expectation and patient fl ow may assist teams to communicate clea rly with the family about what the patient may expect from treatment and recovery options. Brislin, R. P. and Rose, J. B. (2005). Pediatric acute pain management. Anesthesiol Clin North Am , 23 (4), 789 \200\223814 . doi:10.1016/j.atc.2005.07.002. Claar, R. L. and Scharff , L. (2007). Parent and child perceptions of 285 \200\223301 . chronic pain treatments. doi:10.1080/02739610701377962. Child Health Care , 36 (3), Coleman, S. A. and Booker-Milburn, J. (1996). Audit of postoperative pain control. Infl uen ce of a dedicated acute pain nurse . Anesthesia , 51 (12), 1093 \200\2231096 . Available at : <http://www.ncbi.nlm.nih.gov/ pubmed/9038438>. Cott, A. (1987). Illness behavior: a multidisciplinary model. In S. McHugh and T. M. Vallis (eds) Th e disease-illness distinction: a model for eff ective and practical integration o f behavioral and medical sciences , pp. 87 \200\22399 . New York : Plenum Press . Cravero, J. P. and Blike, G. T. (2004). Review of pediatric sedation. Anesth Analg , 99 (5) , 1355 \200\2231364 . doi:10.1213/01.ANE.0000134810.60270.E8. Desparmet, J. (2009). Chronic pain management: organization, techniques and guidelines. In M. Astuto (ed.) Basics, anest hesia, intensive care and pain in neonates and children , pp. 241 \200\223253 . Milan : Spr inger-Verlag . Dowden, S., McCarthy, M., and Chalkiadis, G. (2008). Achieving organizationa l change in pediatric pain management. Pain Res Manage , 13 (4), 321 \200\223326 . Availabl e at: <http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid =2671318&tool=pmcentrez&re ndertype=abstract>. Case example MacKIDS is a moderate sized pediatric hospital, contained within a large hospital corporati on providing all pediatric services save solid organ transplant and cardiac surgery. It has had a robust postoperative pediatric pain service which functioned as part of the adult se rvice until the adult inpatient surgery relocated, leaving a small pediatric service with 2 h per day of nursing time assigned from amongst the Post-Anesthesia Care Unit nursing staf f . Gardea, M. A. and Gatchel, R. J. (2000). Interdisciplinary treatment of chronic pain. Curre nt Rev Pain , 4 (1), 18 \200\22323 . Available at: <http://www.ncbi.nlm. nih.gov/pubmed/109 98711>. Golianu, B., Krane, E. J., Galloway, K. S., and Yaster, M. (2000). Pediatric acute pain man agement. Pediatr Clini North Am , 47 (3), 559 \200\22387 . Available at: <http://www.ncbi.n lm.nih.gov/pubmed/20185654>. Harmer, M., and Davies, K. A. (1998). Th e eff ect of education, assessment and a standardi zed prescription on postoperative pain management. Th e value of clinical audit in the esta blishment of acute pain services. Anesthesia , 53 (5), 424 \200\223430 . Available at: <htt p://www.ncbi.nlm.nih. gov/pubmed/9659013>. Recently a community foundation has off ered fundraising sup- port directed to establishmen t of an interdisciplinary pain pro- gramme. Th e community foundation has coordinated a mee ting of Canadian pediatric pain experts to identify best practice in a chronic pain program for pediatrics. Th ey have created a \200\230made in Canada \200\231 approach to the prob lem intended to be a template for a knowledge translation eff ort into multiple juris- dict ions supporting best practice complex pain care for children, adolescents and young adults transitioning between pediatric and adult care systems. Th is information is providing a mo del to guide program development at MacKIDS. Howard, R. F. (2003). Current status of pain management in children. JAMA , 290 (18), 2464 \200\2232469 . doi:10.1001/jama.290.18.2464. Joseph, M. H. (2007). Selected topics in perioperative multimodal pediatric pain management . Semin Anesth Periop Med Pain , 26 (3), 141 \200\223148 . doi:10.1053/j.sane.2007.06.006. Kingsley, R. A. and Porfyris, S. (2011). Th e role of nurse practitioner in chronic pain ma nagement. In B. C. McClain and S. Suresh (eds) Handbook of pediatric chronic pain , pp. 375 \200\223408 . New York : Springer . doi:10.1007/978 \200\2231-4419 \200\2230350 \200\2231. Th e question of how to best provide pediatric chronic pain services, acute pain services a nd possibly also support palliative care services has arisen during a time of health care b udget con- traction. Awareness of the need for pediatric chronic pain care is growing. It i s becoming clear that although the volume might be small, there is a need for an organized institutional approach to pediatric chronic pain care. Kawamoto, K., Houlihan, C. A., Balas, E. A., and Lobach, D. F. (2005). Improving clinical p ractice using clinical decision support systems: a systematic review of trials to identify features critical to success. Br Med J , 330 (7494), 765 . Long, A. C. and Guite, J. W. (2008). Treatment-related expectations in pediatric chronic pain. Pain Child , 10 (3), 18 \200\22322 . McCLain, B. C. (2000). Organization of pain management services for children. In T. Benzon, J. Rathmell, C. Wu, D. Turk, and C. Argoff (eds) Practical management of pain (3rd edn), p p. 59 \200\22367 . New York : Mosby . Th e challenge is to identify those elements which can be pro- vided either through re-allo cation of existing resources or at the least possible incremental cost. SECTION 9 special topics 652 Rudin, N. J. (2001). Chronic pain rehabilitation: principles and practice. WMJ , 100 (5), 3 6 \200\22343 , 66 . Available at: <http://www.ncbi.nlm.nih.gov/ pubmed/11579799> Miaskowski, C., Crews, J., Ready, L. B., Paul, S. M., and Ginsberg, B. (1999). Anesthesia-b ased pain services improve the quality of postoperative pain management. Pain , 80 ( 1 \200 \2232 ), 23 \200\22329 . Available at: <http://www.ncbi.nlm. nih.gov/pubmed/10204714>. Rusy, L. M. and Weisman, S. J. (2000). Complementary therapies for acute pediatric pain man agement. Pediatr Clin North Am , 47 (3), 589 \200\22399 . Available at: <http://www.ncbi.nl m.nih.gov/pubmed/10835992>. National Health and Medical Research Council. (2005). Acute pain management: scientifi c ev idence . Sydney : National Health and Medical Research Council . Rycroft -Malone, J. (2004). Th e PARIHS framework \200\223 a framework for guiding the imp lementation of evidence-based practice. J Nurs Care Qual , 19 (4), 297 \200\223304 . Ospina, M. and Harstall, C. (2003). Multidisciplinary pain programs for chronic pain : evid ence from systematic reviews . Edmonton : Alberta Heritage Foundation for Medical Research . Schurman, J. V. and Friesen, C. A. (2010). Integrative treatment approaches: family satisfa ction with a multidisciplinary pediatric abdominal pain clinic. Int J Integr Care , 10, 1 \200\2239 . Available at: <http://www.pubmedcentral. nih.gov/articlerender.fcgi?artid=29486 77&tool=pmcentrez&rendertype =abstract> Palermo, T. M., Eccleston, C., Lewandowski, A. S., Williams, A. C., and Morley, S. (2010). Randomized controlled trials of psychological therapies for management of chronic pain in c hildren and adolescents: an updated meta-analytic review. Pain , 148 (3), 387 \200\223397 . doi:10.1016/j. pain.2009.10.004.Randomized. Susan, A. F., Eastman, M., Benjamin, K., and Horgan, M. J. (1998). Outcome measures aft er standardized pain management strategies in postoperative patients in the neonatal intensive care unit. J Perinat Neonatal Nurs , 12 (1), 58 \200\22369 . Peng, P., Stinson, J. N., Choiniere, M., Dion, D., Intrater, H., Lefort, S., Lynch, M., et al . (2007). Dedicated multidisciplinary pain management centers for children in Canada: th e current status. Can J Anaesth , 54 (12), 985 \200\22391 . doi:10.1007/BF03016632. Th e Royal Australasian College of Physicians. (2006). Management of procedure-related pain in children and adolescents. J Paediatr Child Health , 105 (2), 1 \200\22329 . Reid, K., Lander, J., Scott, S., and Dick, B. (2010). What do the parents of children who h ave chronic pain expect from their fi rst visit to a pediatric chronic pain clinic? Pain Re s Manag , 15 (3), 158 \200\223162 . Available at: <http://www.pubmedcentral.nih.gov/article render.fcgi?artid=2912615& tool=pmcentrez&rendertype=abstract>. Tsao, J. C. I., Meldrum, M., Bursch, B., Jacob, M. C., Kim, S. C., and Zeltzer, L. K. (2005 ). Treatment expectations for CAM interventions in pediatric chronic pain patients and thei r parents. Evid Based Complement Alternat Med , 2 (4), 521 \200\223527 . doi:10.1093/ecam/n eh132. Roshanov, P. S., Misra, S., Gerstein, H. C., Garg, A. X., Sebaldt, R. J., Mackay, J. A., et al . (2011). Computerized clinical decision support systems for chronic disease management : a decision-maker-researcher partnership systematic review. Implement Sci , 6 (1), 92 . Weisman, S. J. (2008). Multidisciplinary approaches to chronic pain. In G. A. Walco and K. R. Goldschneider (eds.), Pain in children: a practical guide for primary care , pp. 133 \200\223143 . Totowa, NJ : Humana Press . Roy, R. (2008). Multidisciplinary approach and chronic pain. In Pyschosocial interventions for chronic pain , pp. 147 \200\223164 . New York : Springer . doi:10.1007/ 978 \200\2230 - 387 \200\22376296 \200\223 8. CHAPTER 63 Education for pediatric pain Alison Twycross and Susan O \200\231Conner-Von Summary Th is chapter focuses on educating children, parents, and health care professionals about pain management. Th e fi rst half of the chapter examines issues related to children and parents while the second half concentrates on health care professionals. Th e current state of knowledge will be explored and strategies for educating each group discussed. Th e Promoting Action on Research Implementation in Health Services (PARiHS) model (see also Ya mada and Hutchinson, Chapter 61, this volume) is used to help explain why healthcare pro- f essionals do not always use their knowledge in practice. Implications for practice, educati on and future research are also outlined. cognitive-behavioral interventions were found to be the most eff ective in terms of decreas ing pain and distress (for further discussion see Cohen et al., Chapter 53; Liossi et al., Chapter 54; Logan et al., Chapter 50, this volume). Th ere is promising but lim- ited evide nce for the effi cacy of providing information and prepa- ration (Uman et al., 2010). Some studies have focused on developing techniques for prepar- ing preschool and school-age d children for surgery. Educational programs including a variety of coping models, sensory and procedural information, and structured medical play, have resulted in less situational anxiety and increased knowledge in children undergoing surgery in hospital settings (O \200 \231Conner-Von, 2000). A variety of interventions have been examined in terms of preparing children for surgery, such as individual and group preparation, vid- eotapes, websites, and stress point preparation. Pre-surgery prep- aration strategies for children have been show n to be eff ective in reducing situational anxiety and increasing knowledge (O \200\231Conn er- Von, 2000). However, there is a paucity of research addressing educational needs of chi ldren and families of diverse cultural back- grounds, those undergoing emergency procedures and families of infants. Moreover, most research was conducted with children receiving inp atient care, yet the number of outpatient and day case procedures continues to rise placing increased responsibility on parents for pain assessment and management at home. Children and parental knowledge about pediatric pain Children \200\231s knowledge about pai n It is well established that a child \200\231s cognitive development aff ects their percep tion of pain, behavioral response to pain, and abil- ity to communicate about pain (Harbeck and Peterson, 1992). A child \200\231s view of pain tends to follow a consistent developme ntal pat- tern (McGrath, 1990). Children learn about pain and how to cope with pain through their own and their family \200\231s experiences with pain. Moreover, the signifi cance of what children learn about pain is a direct result of their stage of cognitive development (Wood, 1993). For example, school-aged children in Piaget \200\231s concrete oper- ational stage are able to perform cognitive operations and apply new skills when thinking about eve nts. Th ese children can use their past experiences to understand the reasons for administr ation of an analgesic drug. Parents \200\231 knowledge about pain Regardless of culture or socioeconomic background, ch ildren fi nd parents are their greatest source of support during a painful pro- cedure (Jon es et al., 2005). Unfortunately, little is known about parental perceptions and understandi ng of the information they receive about managing their child \200\231s pain (Oakes, 2011). Studies exploring parents \200\231 management of children \200\231s postoperative pain at home have found that even if they recognize their child is in pain, they oft en give inadeq uate doses of pain medication (Finley et al., 1996; Fortier et al., 2009). Th is is perhaps attributable to parental attitudes towards pain medications. Indeed, two studies conducted in the US found parents fear the negative side eff ects of analgesic drugs; consider analg esics to be addictive; and believe children should receive as little pain medication as pos sible (Zisk et al., 2007, Most pediatric pain research exploring the educational needs of children has focused on pro cedural pain. Children oft en con- sider procedures to be worse than the health issue initi ating the need for the procedure (Finley and Schechter, 2003). Th e most commonly studied n eedle procedures are immunizations and injections. A systematic review of psychological int erventions for needle-related procedural pain in children (28 randomized con- trolled trial s with 1951 participants) included children aged 2 to 19 years (Uman et al., 2010). Distrac tion, hypnosis, and combined SECTION 9 special topics 654 2010). Further, studies in the UK and Canada have found parents are satisfi ed with pain ca re, even if their child experiences moder- ate to severe pain during the postoperative peri od (Twycross and Collis, 2012; Twycross and Finley, 2013). Parents may not be aware of the harmful consequences of unrelieved pain. Th ere is a need for health care professionals to educate parents about pain assessment and management. with Cansur by Jason Gaes (1987) and Th e Berenstain Bears Go to Th e Doctor (Berenstain, 1 981). For younger children, puppets and dolls can be eff ective in explaining procedures (C hild Life Council, 2007; Li et al., 2006). A variety of strategies have been used to edu- c ate children about pain, including print materials, therapeutic play, and cognitive-behavio ral methods (Idvall et al., 2005). For younger children, puppets and dolls can be eff ectiv e in explaining procedures, whereas older children and adolescents may prefer peer group or technology-based education (Child Life Council, 2007; Li et al., 2006). However, there is a lack of research addressing the importance of development in terms of designing education al interventions for children. In addition to cognitive development, the child \200\231s ps ychosocial development must be considered. For example, educational strategies for a younge r child should involve parents, whereas involving peer mentors may be more eff ective for a dolescents. Parents have indicated they would like more information about their child \200\231s pain ma nagement (Franck et al., 2005; Simons and Roberson, 2002; Simons et al., 2001). Th ere is e vidence of a wide variability in the amount of information, type of pain content, and clari ty of pain information given to parents regarding their child \200\231s postoperative pain management (Tait et al., 2008). In Tait \200\231s study, parents (n = 187) of children sche duled for surgery completed ques- tionnaires about their perceptions, understanding, and sa tisfaction with the information they received regarding their child \200\231s postop- erati ve pain management. Of note, parents whose child received patient-controlled analgesia were given signifi cantly more infor- mation than those receiving nurse controlled analgesia (p <0.025). However, approximately one-third of parents had no understanding of the risks of pain management postoperatively. Th is reinforces the importance of providing pain manageme nt education to parents. Web-based interventions Computers have changed the way we live, work, play, and learn (McGr ath et al., 2010). Many children use technology in their edu- cational and home settings us ing Web-based programs is an obvious choice when designing strategies to educate children a nd adolescents about pain. Web-based technology has many advan- tages over the use of print ed material. It is easy to individualize, update when new information is available, and can be interactive. Web-based education can provide information and guidance for patients with out geographic or time restrictions (Brillhart, 2007). Technology has been used to educate children dealing with chronic pain (Palermo and Valenzuela, 2003), functional abdominal pai n (Sato et al., 2009), cancer pain (O \200\231Conner-Von, 2009), and arthri- tis pain (Stin son et al., 2012). However, more research is needed to evaluate the eff ectiveness of these educational interventions in terms of decreased pain intensity scores, increased knowledge of pain management strategies and improved functioning (i.e. school attendance and peer in teraction). Th e relevant child population should be involved in the creation and critique of these programs (O \200\231Conner-Von, 2009). Several studies in North America have explored the eff ect of providing parents with an edu cational booklet about pain manage- ment following day surgery (Chambers et al., 1997), car diac surgery (Huth et al., 2003), and in the emergency department (LeMay et al., 2010). Th ere was some evidence parental knowledge increased fol- lowing the educational intervention but limited improvements in pain management were found. However, in LeMay et al. \200\231s study, the investigators found the use of an educational booklet was not eff ec- tive in r educing pain and unpleasantness related to pain, nor did it improve pain beliefs held by pa rents (n = 195). Th ese investigators suggested having parents actively participate in thei r child \200\231s pain management would be more eff ective than a passive educational inter vention such as a booklet. Similar results were noted in a study by Greenberg et al. (1999) using a videotape to increase parental (n = 100) knowledge. Providing parents with informa tion about pain is not suffi cient; there is also a need to empower parents to take a more active role in advocating and caring for their child in pain. For a further discussion of p ain and the family, see Birnie et al. (Chapter 12, this volume). Th e eff ectiveness of a Web-based program designed to educate adolescents (aged 10 \200 \22316 years) about tonsillectomy was tested by O \200\231Conner-Von (2008). Children (n = 66) were randomly assigned to a Web-based educational program or to attend the standard edu cational program at the hospital prior to the day of surgery. Th e Web-based program contai ned the same educational content as the standard hospital-based educational program. A scri pt was created in conversational format with early and middle adolescents teaching each oth er about the surgi- cal experience, pain assessment and management, and non-phar- macologic al ways to cope before and aft er surgery. To determine content accuracy and validity of th e information provided in the program, fi ve adult experts who care for patients in this ag e group reviewed the script. Next, 40 healthy adolescents read the script to determine read ability and age appropriateness. Lastly, two focus groups of six adolescents (n = 12) who h ad undergone a tonsillectomy within the past year reviewed the Web-based pro- gramme and co mpleted a questionnaire to rate the program on ease of navigation, clarity of content, and age appropriateness. Aft er completing the questionnaire, adolescents in the focus group se ssions discussed their health care experience of having a tonsil- lectomy and their pain ma nagement during hospitalization and Strategies for educating children and parents about pediatric pain Strategies for educating children about pain Nurses have an obligation to educate patients about their health and t o assess the patient and family \200\231s comprehension of the health care information (Ame rican Nurses Association, 2001, 2008; Association of Pediatric Hematology/Oncology Nurses, 2007; US Department of Health and Human Services, 1992). Nurses are usu- ally the health ca re professionals responsible for educating chil- dren about pain (American Nurses Associati on, 2005; Kotzer et al., 1998), yet these guidelines and standards do not provide specifi c strategies for educating children about pain. A variety of methods have been used to educate children about pain. Early educational strat egies for children consisted of provid- ing information through print materials, such as My Book for Kids CHAPTER 63 education for pediatric pain 655 at home. Th en participants discussed the program in terms of what was most helpful, not he lpful and how the program could be improved. text messaging with pain professionals. For example, the Arthritis Foundation website inclu des specifi c education on parenting a child with juvenile arthritis and interactive capabi lities with medical experts to answer questions about treatment, easing pain, and cop- ing strategies. Moreover, parents have noted that activities such as blogging to track their ch ild \200\231s pain can be an invaluable coping tool (Kuttner, 2010). Technology provides ne w opportunities to educate parents about their child \200\231s pain. However, much research is needed in the methodological development of these strategies and to test their eff ecti veness. (See also Stinson and Jibb, Chapter 55, this volume.) Seventy per cent (n = 46/66) of the patients had no prior surgi- cal experience. On enrolme nt to the study, 70% of the participants reported fears related to surgery, the most freque nt being fear of pain. Patients in the Web-based educational program showed a statistically signifi cant increase in knowledge acquisition (p = 0.0005) compared to those assigned to the standard pre-surgery educational program as well as increased satisfaction with the met hod of education (p = 0.004). Although not statistically signifi - cant, pain intensity sco res obtained 2-h and 24-h postoperatively were clinically signifi cant; pain scores for pat ients who did not use the Web-based program increased (mean score of 4.71 two hours aft er surgery, and a mean score of 6.09 twenty-four hours aft er surgery while at home). Patients using the Web-based pro- gramme reported advantages of this type of education such as the ability to view the program as oft en as needed, when it was con- venient, at their own pac e, and in private. Health care professionals \200\231 knowledge about pediatric pain Nurses \200\231 knowledge about pediatric pain Over the past 15 years, seven studies have examined nurses \200\231 k nowl- edge about pediatric pain (Table 63.1). Th e results of these studies suggest gaps re main in nurses \200\231 knowledge. Th ese studies have not all used the same questionnaire, thus precluding precise compari- sons. However, the results provide an indication of where gaps in knowledge are; there seem to be particular issues in relation to pain assessment, analgesic drugs, and non-pharmacological methods. Th e one study that took place in the dev eloping world (Ekim et al., in press) suggests there are greater gaps in knowledge than in other countries. Further research is needed to explore this in other devel- oping countries and to identify eff ective ways of providing required education. Strategies for educating parents about pain An essential component of educating children ab out pain is to educate their parents. Just as children require age-appropriate explanations of pain, it is critical to assess parents \200\231 cognitive abil- ity, understanding of p ain, experience with pain, and readiness to learn, in order to provide appropriate educatio n. Th e goals of educating parents about their child \200\231s pain are to improve knowl- e dge and awareness of pain, to decrease misconceptions about pain, to provide pain relief, a nd to facilitate eff ective communi- cation with the health care team (Curtiss, 2010; DiMag gio et al., 2010). Other health care professionals \200\231 knowledge about pediatric pain Little research has been carried out in relation to medical staff s \200\231 knowledge about pediatric pain. O ne study suggests pediatric residents (registrars) have gaps in knowledge similar to those iden- tifi ed with nurses (Saroyan et al., 2008). Th is pilot study tested the hypothesis t hat there are diff erences in residents \200\231 pediatric pain knowledge across diff erent specialities (pediatrics (n = 26), ortho- paedics (n = 19) and anaesthesiology (n = 15)). Pediatric residents had statistically signifi cantly higher knowledge than those working in orthopedics (p = 0.006) and anaesthesiology (p <0.001). Th e pediatric residents on averag e answered 60% or fewer questions correctly. Questions relating to pain assessment for prev erbal and cognitively impaired children were particularly poorly answered. Th ere were also gaps in knowledge about the maximum daily dose of paracetamol (acetaminophen) and equianal gesic doses of diff er- ent opioids. Over the past three decades, a variety of strategies to educate parents about pain have bee n used. Earliest materials consisted of providing information through print materials such as Children \200\231s Cancer Pain can be Relieved (Wisconsin Cancer Pain Initiative, 1989), Making Cancer Less Painful (McGrath et al., 1992) and Pain, Pain, Go Away: Helping Childre n with Pain (McGrath et al., 1994). A randomized trial (Chambers et al., 1997) evaluating t he eff ects of educating parents (n = 82) with the later booklet (a 15-page gen- eral guide to teach parents about assessment and management of pain) revealed that parents in the pai n education group had fewer concerns about the use of paracetamol (acetaminophen) for their child undergoing day surgery and expressed more positive attitudes toward children \200 \231s pain medications. However, there were no group diff erences in medication administrat ion or pain assessment on the fi rst 2 days aft er surgery. As a result of this study, the investigators concluded that simply providing print materials about pain is not enough to c hange parental behavior, more targeted educational strategies are needed to improve parenta l pain assessment and management. Kolarik and colleagues, in one US hospital, explored pediatric residents \200\231 (n = 49) perceptions about their educational needs in palliative care (Kolarik et al., 2006). Reside nts indicated they had little training, experience, or knowledge in most areas of pediatric palliative care and wanted more education regarding pain manage- ment. Similarly, a study amongst pediatric occupational therapists (n = 129) found only a moderate awareness of issu es relating to pain in children (Turnquist and Engel, 1994). Participants thought the educa tion received prior to qualifi cation was limited and their current knowledge was inadequat e. A recent exemplar of this type of targeted parental educational program is the Pediatric PR O-SELF Pain Control Program which includes a comprehensive teaching booklet to increase par - ent \200\231s knowledge, pain management diary to track analgesic dosing, a timer to insu re adherence with analgesic regimen, and interactive nurse coaching (Sutters et al., 2011). Further advances in technol- ogy provide pain education through real time telehealth (vide ocon- ferencing), social media (blogs), Web-based modules, and email or Th ere is a paucity of research in this area but from the studies carried out we can surmis e that knowledge defi cits exist across all professional groups. Recent reviews of curricul ums content in the SECTION 9 special topics 656 Table 63.1 Summary of studies examining nurses \200\231 knowledge Author Sample and questionnaire Gaps in knowledge and mean score Salantera et al. (1999) Pediatric nurses (n=265) in Finland Completed a knowledge and attitudes questionnaire. \227\206 Analgesic drugs \227\206 Non-pharmacological methods Mean score: 63% \227\206 Analgesic drugs \227\206 Non-pharmacological methods \227\206 Physiology of pai n \227\206 Psychology and sociology of pain Mean score: 78% Twycross (2004) Pediatric nurses (n=12) Used a modi \201 ed version of Salantera \200\231s questionnaire \227\206 Pain assessment \227\206 Pharmacology of analgesic drugs \227\206 Use of analge sic drugs \227\206 Non-pharmacological methods Mean score: 66% Manworren (2000) Pediatric nurses (n=274) Pediatric Nurses \200\231 Knowledge and Attitudes Regarding Pain S urvey \227\206 Non-pharmacological methods \227\206 Analgesic drugs \227\206 Incidence of resp iratory depression Mean score: 76% Vincent (2005) Pediatric nurses (n=67) Adapted version of the Nurses \200\231 Knowledge and Attitudes Rega rding Pain Survey \227\206 Pharmacology \227\206 Incidence of respiratory depression Mean score: 74% Rieman and Gordon (2007) Pediatric nurses (n=295) working in Shriner \200\231s Hospitals in the USA Revised version of the Pediatric Nurses \200\231 Knowledge and Attitudes Regarding Pain Survey. \227\206 Pharmacology (particularly opioids) \227\206 Pharmacokinetics \227\206 Non-phar macological methods Mean score: 62% Tierman (2009) Pediatric nurses (n=292) in Ireland Pediatric Nurses \200\231 Knowledge and Attitudes Regar ding Pain Survey \227\206 Pharmacology and the use of opioid analgesia \227\206 Addiction \227\206 Accura cy of child \200\231s self-report of pain Mean score: 38% Ekim et al. 2012 Pediatric nurses (n=224) from \201 ve pediatric hospitals in Turkey Pediatric Nurses \200 \231 Knowledge and Attitudes Regarding Pain Survey UK and Canada suggest limited input about pain within pre-qual- ifi cation curriculums (Bri ggs et al., 2011; Twycross and Roderique, 2011; Watt-Watson et al., 2009). Th is is despite the International Association for the Study of Pain (IASP) (2005) having published a Core Curriculum for Professional Education in Pain. Th e lack of pain content may impact on the quality of care provided to children and indicate a need for post-qualifi cation training.