directly. She reported that over a 3-month period, 21% of children who had one pain had at least one other. Subsequently, other inves- tigators found a co-occurrence rate that ranged from a low of 5% (Larsson and Sund, 2007 ) to a high of 50% (Kroner-Herwig et al., 2011 ) depending on defi nitions of chronic pain. Fichtel and Larsson ( 2002 ) found that almost 1 5% of their Scandinavian sample of chil- dren with chronic pain had four or more pain sites . Shared biological and clinical features Th e recognition that multiple pain sites are commo n in individ- uals who have chronic pain has prompted a more in-depth look for similarities between these entities. Th e fact of their frequent co-occurrence has signifi cant researc h implications as it requires an explanatory model that is broader than focus on a specifi c end organ (stomach, back, head, etc.). It is not only the frequency of overlap of these e ntities that is noteworthy, however, but also the co-occurrence of many other associated fe atures. Th ese include female predominance, association with psychological disorders, schoo l and sleep disruption, frequent fatigue and loss of mental clarity. Additionally, many of the same centrally acting non-specifi c treatments (exercise, stress reduction, acupuncture , neuromodulat- ing drugs such as antidepressants and anticonvulsants) are eff ective for t hese all of these syndromes. Th ese shared characteristics pro- vide further support for th e linkage of these entities and add to the critical importance of a multidisciplinary appro ach which allows the insights of researchers who had been narrowly exploring one type of pa in to infl uence the thinking of those exploring other pain problems. In this section, we w ill review the evidence that supports the existence of the numerous commonalities among the se entities. Because much of the work stems from adult research, we will use the schema dev ised by Mayer and Bushnell ( 2009 ) in the fi nal sec- tion of their seminal volume on func tional pain syndromes where they attempt to synthesize what we have learned about the inter -re- lationship of these common problems in adults and add pediatric data where it is avail able. Th is recognition has led a number of investigators to conclude that at their core, many of these entities have a similar etiology \200\224 a hypersensitivity to noxious and non-nox ious stimuli typically known as central sensitization (Woolf, 2011 ) which is multifacto- r ial in origin. In fact, Yunus ( 2007a , 2008 ) has recently clustered a number of these ent ities together under the rubric of \200\230central sensitivity disorders \200\231 implying the centrality of central sensitiza- tion in their etiology. He identifi ed research that demonstrated an altered response to pressure, heat, cold, and auditory sensations in adults with migraine, fi bromyalgia, and irritable bowel syndrome. Similarly, Von Baeyer and Cham pion ( 2011 ) conclude that these SECTION 4 pain in specific populations and diseases 230 Family history Th ere is strong evidence that chronic pain problems tend to run in families . Th is is most likely due to a number of factors including the genetics of nociception, ge netic inheritance of painful conditions, and parental modeling of pain behavior. problems are all manifestations of an underlying pain vulnerability which stems from multip le sources but yields similar outcomes. Th e origins for this increased susceptibility to pain are quite com- plex and not fully un derstood and likely vary from individual to individual. Mayer and Bushnell ( 2009 ) and Yun us ( 2007b ) have sug- gested that this alteration may emerge from multiple mechanisms, bot h biological and social. Th ese may include genetic predisposi- tion, anxiety or depression , increased psychosocial stressors, early life adversity, infections, and/or infl ammation. Microtrauma such as that stemming from hypermobility or overuse may also play a role. Th e se factors may impact on the central nervous system and cause the hyperexcitability that is called central sensitization which they feel is the core biological link and fi nal common pathway to the creation of functional pain disorders. Other models suggest while acknowled ging the centrality of central sensitization that psychological factors exert their infl ue nce independently and not necessarily through a hyperexcited central neurons. Studies have attempted to evaluate the relative contributions of genetics to variations in pain sensitivity, in both animals and humans (Foulkes and Wood, 2008 ). For example, Mogil and col- leagues compared the pain thresholds within and between 11 inbred laboratory mouse strains using multiple laboratory-induced pain modalities and identifi ed signifi cant gen etic contributions to nociception and a variety of candidate genes (Mogil et al., 1999 ). In addition to experimentally induced pain, several studies have investigated the genetic c ontribution to diff erences in severity of and susceptibility to certain chronic pain condi tions. A recent study by Kato and colleagues which included 15,950 pairs of twins, found a genetic contribution of about 50% to the likelihood of developing fi bromyalgia (Kato et al ., 2006 ). Th e inheritance of other chronic pain problems has been studied. Migraines (wit h and without aura) all have a substantial risk of familial recurrence. Concordance rates f or migraine are consistently higher among monozygotic than dizy- gotic twins (Montagna, 200 8 ). Th irty-three per cent of individu- als with irritable bowel syndrome have a family hi story (Whorwell et al., 1986 ). Th ere is similar data for other central sensitivity syndro mes. As should be evident from the preceding discussion, if one assumes that functional pain dis orders emerge from a composite of biological vulnerabilities and psychosocial factors which jointly create abnormalities of pain processing or the misperception of those signals, the n the notion that pain can be categorized as strictly physical or psychological is highly o utdated and in fact destructive. Unfortunately, however, many families may become frustrate d by the traditional approach to unexplained pain \200\224extensive laboratory investigatio n and imaging which if negative results in referral to a mental health professional. It is essential that the child and family understand that declaring the pain syndrome to be funct ional does not at all imply psychogenesis. Th e pain itself is the disease. Additionally, a number of environmental characteristics may play an important role. Parenta l modeling of pain behavior has been demonstrated to increase pain behavior in their childr en. Parents with pain are more likely to have children with pain and children are more like ly to have pain sites that are similar to their parents (Evans et al., 2007 ). Parents \200 \231 interactions with their chil- dren may have a role in infl uencing the likelihood that the pain will aff ect the child \200\231s functioning (Goodman and McGrath, 2003 ). Th e r elative contribution of genetics, modeling, and parental response to the pain experience pr obably varies from child to child but it is clear that chronic pain aggregates in families. Schanberg and col- leagues ( 2001 ) reviewed the family history of 100 patients seen in a pediatric rheumatology clinic and found that 90% of parents reported at least one chronic p ain condition, typically lower back pain, shoulder/neck pain, and migraine headache. On ave rage, par- ents reported a history of 3.5 chronic pain conditions. Ninety-three per cent of parents reported at least one relative with chronic pain in their immediate family. It is critical therefore that a detailed fam- ily history be obtained to further our understandin g of the factors contributing to the child \200\231s chronic pain. Shared clinical features Besides abnormalities of nociceptive processing, there are a numbe r of other clinical and epidemiological characteristics of functional pain syndromes that l ink them together \200\224 they occur predomi- nantly in females, there is oft en a family history of pain problems, there is an association with early life trauma, and they frequen tly occur in individuals with specifi c personality types and mental health disorders. Addi tionally, they oft en co-occur with other clini- cal conditions in which there is autonomic dysregulation such as postural orthostatic tachycardia syndrome. Finally, they all seem to respond, at least somewhat, to centrally acting interventions such as anticonvulsants and antidepressants, exercise, acupuncture, stress management, and cognitive-behavioral therapy . Greater prevalence in girls and women For reasons that are not entirely clear at this time, adolescent girls and women are much more likely to experience chronic pain than boys and m en. In community-based studies, girls are twice as likely as boys to report chronic pain (P erquin et al., 2001 ). A similar fi nding is reported in analyzes of pediatric chronic pain attend- ees where in one study, 73% were female (Vetter, 2008 ). Th e num- bers vary depen ding on the study but the incidence of abdominal pain, fi bromyalgia, and migraine headache is much higher in girls than in boys. Although there is much speculation as to the origin of these diff erences, the fi nding that girls report more chronic pain than boys is robust and consistent. Th ere is certainly precedent for sex diff erences in neurological phenome na. For example, the incidence of attention defi cit-hyperactivity disorder, enuresis, and learning disabilities is much higher in boys than girls. History of adverse life events Th ere is an emerging literature on the impact of early life events on the development of nociceptive pathways and on the devel- opment of chronic pain subsequently. Th e strongest work in this fi eld comes from the animal literature in which rodents are sub- jected to a variety of noxious experiences and the impact of those on sub sequent pain responsiveness is assessed. Rat pups subjected to daily foot shocks during the ir equivalent developmental phase to the human neonatal period demonstrated long-term eff e cts on sensitivity to pain and on their response to morphine subsequently (Shimada et al., 1990 ) . Likewise, rat pups subjected to infl amma- tory pain, skin wounding, and visceral stimulation such as colorec- tal distension demonstrated increased visceral sensitivity and other CHAPTER 23 chronic pain syndromes in childhood: one trunk, many branches 231 changes in sensory pathways long aft er the stimulation had ceased (Al-Chaer et al., 2000 ) . health concerns and pain. Regardless, whether anxiety and depres- sion stem from having chr onic pain and/or are precursors to it is less relevant to this discussion than the fact tha t these disorders require treatment as part of a comprehensive approach to pain. More subtle adverse experiences in animals have also been shown to impact pain sensitivity and pain thresholds as well. In a series of studies, rat pups subjected to maternal separat ion experienced both a dampening of their stress response as evidenced by decreased stress hormone output and a heightened sensitivity, depending on the timing of the separation. Int erestingly, in one study, pregnant rats were subjected to inescapable stress during the las t week of pregnancy. Stress appeared to cause cognitive delays, anxiety, and hypersensitivi ty of the adrenal stress response in their off spring. Together, this work suggests that no xious events early on, both sub- tle and pronounced, can impact on the subsequent pain expe rience of rodents (Al-Chaer and Weaver, 2009 ). Response to centrally acting, non-speci \201 c therapies Another intriguing overlap betwee n these disorders is their response to centrally acting and oft en non-specifi c treatments . It is clear, for example, that centrally acting drugs such as selective serotonin re-upta ke inhibitors and serotonin \200\223noradrenaline reuptake inhib- itors, tricyclic antidepr essants such as amitriptyline or nortriptyl- ine, and anticonvulsants such as gabapentin or pregabalin seem to decrease chronic pain symptoms in most functional pain syn- dromes. Add itionally, other non-pharmacological approaches such as exercise, stress reduction, cogniti ve-behavioral strategies, and acupuncture all have demonstrated effi cacy in diminishing pa in in individuals with many of these pain disorders. Th e literature in humans on the relationship of early adverse life events and pain is more tenuous although suggestive of a similar relationship to that found in animals. For exampl e, Hermann and colleagues ( 2006 ) compared the responses on quantitative nerve testing bet ween a group of 9- to 14-year-old children who had pro- longed time in the neonatal intensi ve care unit with those who did not. Th ey found that consistent with animal fi ndings, pai n expe- riences in the neonatal period were associated with alterations in thermal pain res ponsivity in school-aged children who had been born preterm suggesting that those experienc es created measurable diff erences in nociception many years aft er they had occurred. Th ere are numerous studies that support the effi cacy of non-spe- cifi c treatments in chr onic pain. For example, amitriptyline appears eff ective at reducing pain in functional abd ominal pain, tension and migraine headaches, and in fi bromyalgia (Goldenberg et al., 1996 ; Hershey et al., 2000 ; Rajagopalani et al., 1998 ). Likewise, there is evidence that both exercise and acupuncture is also eff ective for all three of these entities (Drossman, 199 9 ; K seoglu et al., 2003 ; Martin et al., 2006 ; Meiworm et al., 2000 ; Melchart et al. , 1999 ; Takahash, 2006 ). Finally, studies have identifi ed that cognitive- behavioral the rapies and stress reduction techniques diminish pain in chronic pain syndromes as well (Dro ssman, 1993 ; Nelson, 2006 ; Th orn et al., 2007 ). Th e fact that similar interventions ar e eff ective for many diff erent types of chronic pain in children adds further credence to the notion that they are fundamentally linked at some level. Additional literature to support the long term impact of early life events on pain emerges from the abuse literature. Chartier et al. ( 2007 ) identifi ed the fact that individuals w ho had been abused as children had statistically more physical complaints than those who we re not abused. In a community sample of women, individuals with chronic pain were far more likely to have an abuse history than those who did not have chronic pain (Walsh et al., 200 7 ). Together, this animal and human research strongly suggests that early life cir- cumsta nces can alter nociception. Temperament/personality A number of studies have investigated t he relationship of tempera- ment, generally assumed to be the innate biological underpinnin g of personality, in children and response to painful procedures. Schechter et al. ( 1991 ) in a prospective study identifi ed that chil- dren with a \200\230diffi cult temperament cluster \200\231 were more reactive to immunization than children other children. Chen et a l. ( 2000 ) con- structed a pain-sensitive temperament cluster and found that chil- dren wi th acute lymphocytic leukemia who rated more highly on that scale were more likely to repor t a higher level of distress during lumbar punctures than those who did not. Orthostatic intolerance It has become increasingly clear that chronic pain is oft en associ ated with autonomic dysregulation. Th is is oft en manifested through orthostatic intoleran ce, the prime example which is postural ortho- static tachycardia syndrome (POTS) which is oft en present in indi- viduals with chronic pain. POTS typically occurs following illness or injury. Ohja et al. ( 2011 ) identifi ed the fact that in patients with POTS, 75% had ga strointestinal pain, 40% had headache, and 98% had a sleep disorder. Kitzberger et al. ( 20 11 ) examined the relation- ship between chronic pain, autonomic function, physical disabil ity, and psychological function and found that heart rate changes of greater than 30 beats per minute associated with positional change (the traditional adult POTS criteria) in patie nts with chronic pain were associated with higher levels of disability, depression, and anx - iety. Although there is some debate as to whether a 30-beat increase is an appropriate th reshold for children (Singer et al., 2012 ), eval- uating the child for orthostatic intoler ance should be part of the physical examination of any child with chronic pain. Th e literature on the relation of personality and chronic pain is a bit more complex and f ar beyond the scope of this chapter but it is likely that personality may have a role in th e development of chronic pain and certainly on one \200\231s ability to cope with it. Comor bidity with disorders of mood and a \200 ect Research on comorbid psychiatric disorders in chronic pain reveals that patients with mental health disorders are signifi cantly over- r epresented in chronic pain clinics (Bair et al., 2008 ; Lynch et al., 2006 ; Varni et al., 1996 ; White and Farrell, 2006). Th e relationship between psychological factors and both a cute and chronic pain is extensively explored throughout this volume. Th ere is clearly the need for population-based prospective studies to examine this issue but few could disagree with the frequent co-occurrence of mental Hypermobility Th ere are a number of studies which suggest that joint hypermobil- ity is as sociated with chronic fatigue and fi bromyalgia (Castori et al., 2011 ; Voermans et al., 20 10 ). Rozen et al. ( 2006 ) has suggested that cervical hypermobility is more frequent in i ndividuals with head- ache disorders than in the general population. Sacheti et al. ( 1997 ) reported on the high incidence of abdominal pain in individuals with Ehlers \200\223Danlo s, hypermobile type. Th e mechanism may stem SECTION 4 pain in specific populations and diseases 232 from central sensitization due to a continuous aff erent stimulation from frequent microtra uma due to subluxations or dislocations or from other factors, but hypermobility is oft en identifi ed in indi- viduals with chronic pain. 6 months for pain) diff ered from the low absence group (less than 2 days) primarily on two variables. Th e high-absence group was more likely to have depressed mood and a lower acad emic per- formance than the low-absence group. School avoidance may be a signifi cant contr ibutory factor in a subgroup of these children. Sleep dysfunction Roth-Isigkeit et al. ( 2005 ) reported that the incidence of sleep dis- t urbance in a cadre of children with various chronic pains was 53%. Most clinicians who work with children with all types of persistent pain would agree that issues around sleep are a common occur- rence in their patients. Clearly, pain and sleep are inversely relat- ed \200\224 the more pain, the less sleep; the less sleep, the more pain. It appears that poor sleep increases pain perception and reduces one \200\231s ability to cope with pain thus i ncreasing pain and further decreas- ing sleep. Sleep diffi culties may present as delays in sleep initiation, multiple night awakenings, non-restorative sleep, or early morning awake ning. Palermo and Fonareva ( 2006 ) have reviewed this topic and suggest that although the adult literature is replete with studies which identify a relationship between chronic pain and poor sleep, there is a paucity of such studies in children. Th e few studies that have attempted to use theoretically objective measures to assess sleep (polysomnography and act igraphy) have yielded somewhat inconclusive results although the preponderance of evidence sug- gests that like in adults, sleep is oft en impaired in individuals with chronic pain a nd it should be addressed as part of comprehensive approach. It is clear, therefore, that school absence is a critical issue in the rehabilitation of ch ildren with chronic pain. Th e more school one misses, the greater the anxiety that surroun ds school re-entry which may potentiate the pain experience which will promote fur- ther sc hool absence. Th is cycle must be addressed as part of a com- prehensive approach to chroni c pain. Family distress Th e persistence of pain in a child, regardless of its etiology, oft en tak es a signifi cant toll on the family at multiple levels. Watching your child suff er with p ain that you cannot ameliorate is agonizing for many parents and frequently leads to emotio nal distress. In a study by Eccleston et al. ( 2004 ), 40% of parents of children with chro nic pain had depressive symptoms and 60% had a high level of general anxiety; 66% of parent s had high scores on parenting stress indices. Feelings of guilt and inadequacy are frequen t and parental confl ict commonly increases. Adding to family distress are the fi nancial burdens typically asso- ciated with pediatric chronic pain. Sleed et al. ( 2005 ) examined the economic impact of chronic pain in an adol escent rheumatol- ogy clinic in the UK. She found that the cost of adolescent chronic pain averaged about 8000 \200\224 approximately 14 000 for those with non-rheumatological d isorders and 4500 for those with rheumatic disease. In addition to the direct costs of me dical care (diagnostic testing, medical visits, hospitalizations, medications), the burden of which will vary depending on the specifi c health care system, there are many indirect c osts to families. She found that in the 52 families of children who had chronic pain that s he evaluated, family members missed on average 78 work days per year (20% of the working ye ar). In addition to time off from work, there were expenses associated with lost productivi ty, transportation, additional childcare expenses, non-prescription medications, special fo ods, plus a number of other out of pocket expenses which all add to the fi nancial pressure s on families. Coupled with the emotional stressors, these create a great weight on familie s who must grapple with these complexities. Impact on school and family life In addition to their similar biological and clinical featu res, these syndromes have a similar impact on children and their families. All chronic pain problems interfere with the child \200\231s schooling and enjoyment of daily life. Th ey h ave a direct impact on the family as well, causing both fi nancial and emotional distress. Impact on school It is intuitive that chronic pain would have an impact on school performan ce and numerous studies validate this assumption. Th e frequency of school absence has been formally studied in many of the functional pain disorders and is clearly increased compare d to the non-pain population (Sato et al., 2007 ). In fact, rates of school absence for chi ldren with chronic pain oft en exceed those with other chronic health conditions (Palmero, 2000 ). For a small group of children, that impact is so pronounced that they formally with - draw from school. Vetter found that 12% of children with a variety of chronic pain proble ms are home schooled and that those who are not miss on average 3 days of school per month (Vetter, 2008 ). Logan and colleagues ( 2008 ) reviewed the school performance of over 200 children attending a chronic pain clinic. Th ey examined data on the school performance usi ng a variety of sources including child and parent reports and school records and found sur prising concordance among informants. Th ey found that many adolescents with chronic pain m iss a signifi cant amount of school, experience a decline in grades, and perceive pain to i nterfere with their school success. Why do some children with chronic pain attend school an d others with similar conditions do not? Obviously the answer is complex and a number of fa ctors are probably at play. Breuner et al. ( 2004 ) studied almost 300 children with headac he and found that children with high absences (greater than 2 days in the last Treatment implications As should be clear from the previous discussion, the purpose of this chapter is to highlight the commonalities that exist among functional pain problems which may not be evident if one focuses solely on individual pain sites. Importantly, many of the similari- ties in etiology and impact between these entities have treatment implications. In fact, a number of the interventions that may be rec- ommended to address the abdominal p ain in Constance, the young woman in the case example presented in this chapter may be equa lly effi cacious for her headache and musculoskeletal pain as well. Th e fi rst goal of treatment is to evaluate the patient for red fl ags that would imply tr aditional organic disease. Even if these are identifi ed, however, symptom treatment is sti ll critical as merely treating the disease does not necessarily immediately eliminate distr essing symptoms. Th e following discussion, however, assumes that organic disease is not pr esent or has been well controlled yet pain persists. CHAPTER 23 chronic pain syndromes in childhood: one trunk, many branches 233 Feedback to families Goals of the feedback session Th e feedback session in which the natur e of the functional pain problem that the child is experiencing is explained is critical to the successful rehabilitation of it. Th e discussion is remarkably simi- lar regardless of the specifi c site of the pain or the number of sites involved. At its conclusion, the fam ily should be reassured that the doctor understands the child \200\231s problem, that he or she does not believe it is solely in their child \200\231s head, and that all are comforta ble with a functional diagnosis with minimal subsequent testing neces- sary. Lindley identi fi ed the factors associated with limited improve- ment aft er one year in children with fu nctional abdominal pain and reported that acceptance of the diagnosis by the child and fami ly was essential to recovery (Lindley et al., 2005 ). Th e feedback session should also emp hasize that improvement will be gradual, and that both parent and child participation in th e process are essential. emphasized. Th e key element is that a number of factors (infl am- mation, infection, genet ic predisposition, stress, depression, injury) may have altered the transmission of pain in formation in the child and that sensation is now the problem, making the child pain vul- ne rable. Use of key phrases ( \200\230the pain is hurting but not harming you \200\231; \200 \230the pain you are experiencing is not protective \200\231) as well as the use of analogi es is oft en helpful. Th ere are a number of analogies that are oft en used (Coakley and Sc hechter, 2013 ). Th e hardware/ soft ware discussion (the pain represents a soft ware probl em (the pain message) and not a hardware problem (the bowel, head, mus- cles, etc.)) is hel pful in computer-savvy families. Another frequently used analogy is the false alarm analogy \200\224 the continuous pain is like a false car alarm \200\224 annoying but not represe nting a genuine prob- lem. Most clinicians develop their own analogies and explanatory mode ls to help families understand this complex concept that does not follow the traditional me dical model. Typical treatment recommendations Specifi c treatment recommendations are available through out this volume in the sections that address each of the functional pain problems individua lly. In general, however, regardless of the site of the functional pain problem, a number o f elements should be addressed as part of the treatment. Setting the stage It is not uncommon for children with functional pain syndromes, especiall y those who have multiple pain sites, to have seen a number of clinicians and to have had e xtensive imaging and laboratory inves- tigation. Because functional problems oft en have no confi rmatory tests, if no traditional organic explanation is uncovered at the end of the investigative journey, families will sometimes urge clinicians to order additional tests in the hope that the answer lies in the results of the next investigation. It is therefore im portant to present a func- tional pain diagnosis not as one of exclusion but in a positive way. Merely stating what the diagnosis is not and what has been ruled out (not cancer, not arthritis, etc.), is far less satisfying to parents than stating that this pattern (the loc ation, the family history, the time course, the quality of the pain, the negative physical examination, the lack of red fl ags for organic disease) supports a functional pain diagnos is. Obviously, the clinician cannot be completely certain that there is not an organic diag nosis that has been missed and the ques- tion of how much testing is enough always arises. Th is is especially diffi cult when parents produce case reports from the internet or the n eighborhood in which a rare entity with similar symptoms has been missed by clinicians for years. If aft er a reasonable investiga- tion, the clinician states that a functional diagn osis is most likely but he or she will continue carefully monitoring the child ( \200\230wa tch- ful waiting \200\231; Herzog and Harper, 1981 ) and will pursue new symp- toms if they emerge, most parents will be satisfi ed. Additionally, it is important that the physician not imply that the lack of a clear organic diagnosis suggests a psychological explanation. Although psychological factors should not be dismissed, except in rare cases, the symptoms are the result of a complex interplay of a variety of factors and triggers; therefore, impl ying solely psychological origin not only distances the clinician from the family, but is i n fact incor- rect. If families feel that their child \200\231s suff ering is being trivial ized or dismissed, even if that is not the intent of the clinician, many fami- lies will th en continue their search for an organic explanation sub- jecting the child to additional of t en unnecessary testing and adding to their own and the health care system \200\231s fi na ncial burden. School reintegration As mentioned earlier, school absence is a frequent phenomenon in child ren with chronic pain. For children with frequent absences, the return to school may be hig hly stressful. Children may assert that they are not worried about returning to school aft er a prolonged absence, yet concern about missed work and academic perform- ance and promot ion, diffi culties with concentration due to pain, worries about discussion with peers rega rding the reasons for the absence and about being jostled in the hallway, fears of not bein g believed by other students and teachers along with a host of other considerations create an inevitable anxiety in the returning student who must deal with these issues while not fe eling that well. It is imperative therefore that school reintegration be carefully orchestrated and oft en g radual. Depending on the country, there may be legal protections available to the student ( a 504 plan in the US, for example) which may ease the return. Regardless of how the school re-entry plan is confi gured, it should be followed religiously. Decisions about school att endance should not be made in the morning when the child reports he or she is not feeling w ell enough to return to school. School attendance is expected unless the child has a fever or a contagious process. Accommodations can be made regarding the length of the school day and in the workload but the expectation must be that the child attends school every day. Sleep Addressing issues of sleep is imperative. As mentioned earlier, inadequate and oft en non-restorative sleep is extremely common in chronic pain. A detailed sleep history should be obtained and identifi ed issues should be addressed. Issues of sleep hygiene (get- ting into bed when tired, no television in the room, etc.) should be discussed. Relaxation stra tegies are also oft en helpful and can be taught by the clinician or by a colleague with ex perience in these techniques. If sleep remains an issue despite the introduction of psy- ch ological strategies, a number of pharmacological agents may be considered. In particular, s ome of the agents typically administered Speci \201 c content Th e nature of the discussion with the family about functional pain p roblems should be individualized based on the educational, social, and cultural characteris tics of the family. Regardless, the complex nature of pain and the biopsychosocial dimensio ns should be SECTION 4 pain in specific populations and diseases 234 Provider communication Because children with multiple pain problems typically see multi- pl e specialists (neurology for headache, rheumatology for joint and musculoskeletal pain, gas troenterology for abdominal pain, ortho- paedics for back pain, cardiologists for POTS) in addition to their primary care providers, it is imperative that a mechanism for com- munica tion among providers be developed. Specialists may not address or even ask about other pain sites which they perceive are out of their realm of expertise and assume those will be add ressed by others. Th ey may off er suggestions that they perceive are help- ful for the spe cifi c problem that they are asked to address but may in fact be detrimental to the whole c hild. Additionally, there is also oft en signifi cant variability of opinion among provider s as to the etiology, evaluation and treatment of chronic pain problems. Konenjiberg et al. ( 2004 ) gave 135 pediatricians a series of case scenarios involving chronic pain and aske d how clinicians would address them. Th ere was limited consensus on etiology, on spe- cifi c diagnostic testing, and on treatment. A similar situation likely occurs in clinical prac tice as these problems are oft en quite confus- ing and subject to multiple diagnostic opin ions. As a result, fami- lies may feel confused by the lack of clarity among their physicia ns and continue a futile search for the right answer. Tests may oft en be unnecessarily rep eated and agents prescribed that may interact negatively. It is imperative therefore in sit uations in which multiple pains exist that the clinical team be in communication and speak, as much as possible, in one voice. for pain or spasm oft en have a side eff ect of sedation which can be an added benefi t of their use if they are taken at bedtime. Physical activity It is not uncommon when one is in pain to limit physical activ- ity. Th i s may occur because of associated pain, anxiety about pain which may occur as a result, dep ression, or diminished interest in social activities but regardless, it oft en leads to dec onditioning which increases pain and disability. Decreased exercise and weight bearing can also promote osteopenia. It is oft en valuable to have a skilled physical therapist evaluate the child \200\231s mus culoskeletal system to determine whether formal physical therapy may be needed or whether a home exercise program will suffi ce. Th e therapist can also evaluate the need for desensi tization and can emphasize the importance of pacing and stretching. He or she can identify particularly tight or weak areas and if the child is hypermobile, can help with strengtheni ng specifi c muscles to com- pensate for ligamentous laxity and promote joint stability. If only core strengthening and building endurance are felt to be necessary, then physical the rapy may not be necessary and a graduated exercise pro- gramme may be substituted. Either w ay, increasing movement will promote a sense of well-being and an inevitable reduction of p ain. Addressing anxiety and depression As mentioned repeatedly, anxiety and depression are oft e n fellow travelers with chronic pain and may have a role in initiating it, maintaining it, or both. Clinicians should address this with families in the context of the numerous factor s involved with chronic pain, as opposed to the organic versus psychological paradigm. Th e re is an extensive literature on psychological strategies reducing the arousal in pain sens itive individuals and response to these strategies does not imply psychological causation ( Eccleston et al., 2009 ). Th e psycholo- gist can teach relaxation strategies, can address catastrophization, and explore the thoughts that might be promoting incapacitation from a n ociceptive stimulus. Most pediatric pain programs employ or are connected to pediatric psyc hologists and their evalu- ation should be a critical part of the assessment and treatment of pain in children. Many families may be resistant to this part of the evalu- ation and th ey oft en fear that they will be blamed for their child \200\231s pain. As a result, they m ay state (sometimes quite strongly) that that component of the evaluation is unnecessary as their child \200\231s pain is real. It is important to dispel the notion that the purpose of psycho- logical evaluation and treatment in chronic pain is to unearth subtle psychologi cal causation and blame parents for the child \200\231s problem. It is to identify every tr igger that may promote and maintain pain and to teach techniques to help ameliorate it. Occ asionally, psychophar- macological intervention may be necessary as well. Conclusion Th is chapter has attempted to review the commonalities and overlaps between the common pain problems that children experience, most of which are functional in nature. Th is area has had limited attention in the past, most likely due to the fact that pain proble ms are typically evaluated by experts in the specifi c organ system from which the pain see ms to stem and they may not have expertise in pain that stems from other areas. When one lo oks at these problems from a distance however, there are remarkable similarities in their t heoretical aetiolo- gies, in their impact on the child and family, in associated symptoms, and in their treatment. Th e adequate care of these problems demands an appreciation of the biopsychosocial model which looks at the child as a whole and on a multidisciplinary appro ach which allows for mul- tiple streams of information to impact on the child \200\231s car e. Case example Constance Payne is a 15-year-old young woman who was referred to the gastroenterology progr am by her primary care provider for longstanding abdominal pain which had recently escalate d in intensity. Constance has had periumbilical pain since the age of 12 but recently since high school entry her discomfort had increased. In the past, Constance had missed 1 to 2 d ays of school a month for her abdominal pain, but in the fall of ninth grade began missing at least one day per week. Attending to other symptoms Other symptoms may amplify the incapacitation associated with c hronic pain, regardless of site. Dizziness, nausea, and fatigue may result from pain but ma y also potentiate it. If at all possible, these symptoms should be addressed. Oft en POTS m ay be associated with these symptoms or with a general sensation of feeling unwell but it i s oft en not considered and orthostatic vital signs are not obtained. Because the treatment of POTS is oft en relatively straightforward and its amelioration can dramatically help th e child \200\231s pain and mood, obtaining blood pressure and heart rate measurements both lying down and then standing up should be a routine part of the evaluation of any type of c hronic pain. Th e gastroenterologist who evaluated her identifi ed no pat- tern to her symptoms and no o bvious triggers for it. Her physi- cal examination and subsequent laboratory investigation did not off er a specifi c pathological explanation for her pain nor did the endoscopy that was performed subsequently. A number CHAPTER 23 chronic pain syndromes in childhood: one trunk, many branches 235