This is a focus review on pediatric pain and conversion disorder. My name is Erin Conley. I'm a pediatric physical medicine rehab provider for St. Luke. I have nothing to disclose. My hope today is that we'll be able to really define and understand chronic pain, and the multifactorial nature, and the assessment, and the counseling, and education that goes into that for patients and families. In the same way, we'll look to define conversion disorder. Then for both, looking into their risk factors, comorbidities, and then since there's such a multifactorial nature, really looking at the interdisciplinary approach to treatment. First, we'll be focusing on pediatric pain. Pain in itself is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Prevalence varies, but up to half of early adolescents may experience musculoskeletal pain at some point in their childhood. Again, that number can be between 20 and 46 from studies in 2009, 2011. For it to be chronic pain, it has to be present for greater than three months in a persistent or recurrent manner. That can lead to a process called sensorial sensitization, this maladaptive response. That can be really a complex interaction between the primary afferent nerves, dorsal horn neurons, spinal glia, neurotransmitters, and focusing into this dysregulated state of nocicepsin. It can be a result of direct injury, but can also occur after illness, traumatic psychological events, uncontrolled stress, and even physical inactivity. In terms of prevention of chronic pain, we first look at what are some of the risk factors that lead to the development of chronic pain, or situations where children may be likely to have an altered pain response. In NICU population, there's been work to say that early exposure to painful stimuli can be a risk factor and produce persistent changes to pain perception and response. We can also say this certainly is a risk factor for some of our kids with medical complexity and multiple comorbidities who undergo many painful procedures in their early lives. One study pointed out the highest risk of developing pain in individuals occurs when they are experiencing day-to-day fatigue, headache, or those participating in a vigorous activity as they're more likely to be injured dramatically. There has been a recent increase over the years and felt to be of many factors. Increased pain identification, there's perhaps higher stress and anxiety in children and young adults than in previous years, poor role modeling as their parents or communities may be sending them different messages on what pain is and how to deal with it, maladaptive pain behaviors, and then the attitude towards pain. I came across something interesting and I apologize that I don't know where it's from, but that we view pain now as naked pain, that it's not present, it's not a fact of life like many generations viewed it before, but now it belongs specifically in the realm of medical and hospital and clinic settings, and it shouldn't ever be experienced and that in itself can lead to certainly an altered pain response or can set a child up for poor coping behaviors. There's also this fact of diagnostic and uncertainty of just, they don't know what's wrong with me, they don't understand me, there must be something bad going on, it's still going on, I'm going to injure myself, and how that can continue to have a significant impact on the patient and families. Then if we're dealing with acute pain, certainly early recognition and a proper treatment of acute pain decreases the likelihood of developing a chronic pain state. Just briefly, a visual to look at different factors that go into the experience of pain that a child may undergo, and so there's certainly the initiation, whether that's an illness, an injury, a procedure, and then many times it's unknown. Certainly factors that can modulate pain starting with the individual, even from genetics, coping to strategy, past experiences, family, parental reaction to pain, whether a parent or a caregiver takes on a more enabling role, or often a punishing role for someone experiencing pain. Then the social and cultural, just with what schools like, they're removed from their friends, what support do they have, and then a piece of interventions as well. Outcome can be a vicious cycle of pain behavior, pain-associated debility, and then each of those can then interact with themselves, and people can perceive more pain in a setting of this approach that I am disabled, or my pain makes me disabled. Looking at rating pain, there are self-reported scales and then observational scales for the younger kids. Self-reported scales are probably ones that you're familiar with, numerical rating scale, please rate your pain on a scale of 0-10, visual analog scale, which places those numbers then on a line with marks. To the right would be more severe, to the left would be more mild, and then the faces pain scale or the color analog scale, which uses colors in that similar way of visual analog or numerical. There's certainly an overlay and you can see where there's the faces, above it is the visual analog scale, and that can too have a different color change to it as well. Felt to be useful in children and adolescents ages 6-17. Observational scales are used for the younger pre-verbal children, that's your FLAX score, or even a neonatal facial coding system. Specifically looking at musculoskeletal pain, one study looked at nearly 15 percent of children have persistent musculoskeletal pain of at least one week duration. I found one study that said as many as one-third experience, in some manner, weekly musculoskeletal pain. Then I think the PEDS rehab text says one in five pre-teens experience new onset musculoskeletal pain. The treatment for musculoskeletal pain can be physical therapy, cognitive behavioral therapy, and then pharmacotherapy as well. This is looking at proper treatment of acute pain, and then getting into how do we continue to treat chronic pain. In neuropathic pediatric pain, it's a little different avenue of treatment. The causes can vary from phantom limb pain, post-operative trauma, Fabry's disease, which has a neuropathy component, cancer, multiple sclerosis, post-traumatic neuralgia, radiculopathy, compression radiculopathies in children in the study of metabolic disorder or injury. The treatment is multimodal. There are oral IV and topical options. Often we'll think of the TCA or the tricyclic antidepressants, gabapentin, pregabalin, and then there's options for interventional procedures if needed, such as nerve blocks or steroid injections. But really that multimodal treatment is key. Complex regional pain syndrome perhaps is not as severe in children as in adults, and there's a potential for better outcome and better response to conservative measures. The definition or the associated symptoms we would see is localized pain, allodynia, swelling, range of motion limitations, bone demineralization, changes of skin, hair, and nail over the affected area. Medications should be facilitatory and rarely are the sole treatment options. Rehabilitation includes desensitization therapy, exposure within functional activities, stretching, and or weight-bearing. But also a key piece would be mental health too, and someone undergoing complex regional pain syndrome. Then there are two types of CRPS. Type 1 occurs or is defined when there's no identifiable damage to the nerves in the affected limb, whereas type 2 is that we have a history of nerve damage that we can point to and say, yes, it's developed in the setting of known nerve damage. Juvenile onset fibromyalgia, the identification remains controversial. There are guidelines by the American College of Rheumatology, which I will not go in today in our brief review, but it certainly has an overlap of central sensitization, functional limitation caused by pain, including a sedentary lifestyle, decreased school attendance, and key feature being widespread pain. One of the biggest things that we can offer is the counseling and education behind exercise and the benefits of exercise. Both of these syndromes, CRPS and pediatric fibromyalgia, can have many associated symptoms such as fatigue, or sleep disturbances, or maladaptive stress responses. Again, a lot of that that we can offer really involves or rotates around education as well. Overall, treatment of pain best managed in an interdisciplinary team approach. This can include a rehabilitation program, medical management of associated symptoms, and that could be headache, sleep, and then psychological treatment and support of the patient and family. This can occur in an outpatient clinic-based setting, an intense outpatient program, or even an intensive inpatient program. We're going to switch gears a little bit and talk about conversion disorder in pediatrics. Conversion disorder is also called functional movement disorder, functional gait disorder, used to find other qualifiers such as hysteria. The DSM-5 defines it as a functional neurologic symptom disorder and lists four criteria. It places it within the somatic symptoms and related disorder, and the criteria include that symptoms of altered voluntary motor or sensory function must be present. The workup and examination provides evidence of incompatibility between the symptom and any recognized neurologic or medical condition. The symptoms cannot be explained by another medical or mental disorder, and the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning, or they're so significant or severe that they warrant medical evaluation. Conversion disorder or functional movement disorder is not factitious disorder. Factitious disorder is when there's deliberate symptom production for psychological gain, and then there's malingering, which is deliberate symptom production for external or material gain. The estimated prevalence of conversion disorder in children and adolescents is two to four per 100,000 young people. Typical onset is between 10-15 years old, and it is rare for it to occur under the age of eight. But as we all know, the pressures on young kids and the society, and exposures to young kids seems to be changing, and so we may find that younger cases occur. Generally, the female-to-male ratio is two or three to one, though it's trending towards one-to-one. As we talked before with the criteria that there are symptoms among motor, sensory, and other would be a general category, and that could be vision. Often acute onset, meaning the child goes to bed that night and wakes up, and now has the sudden onset new gait disturbance, or inability to move their leg, or inability to feel on half their body. It can occur following minor illness or injury, especially in younger children. Classically, we all learned about, or many of us learned that patients experiencing conversion disorder have this indifference or this label indifference. But that's not always the case. Children can be very upset and very concerned about their symptoms and not indifferent. Then as defined in the categorizing or the definition of itself, the DSM, the exam is inconsistent with neuroanatomical function, meaning you have a flaccid limb, but preserved or normal reflexes, or they have that gait where they're attempting to walk the line, and they have tremendous excursions in their trunk control and balance, but yet they're able to stay on that line, and that can be known as a stasia abasia. Then or a non-dermatomor sensory distribution or double vision that persists despite closing one eye. These aren't areas where we're trying to trick kids with a physical exam, but certainly inconsistencies arise. Cincinnati Children's put out a great study when they reviewed the characteristics and outcomes from patients who had been admitted to their acute pediatric rehab with conversion disorder, and they found they really grouped them into eight categories, again, going from DSM-5. Those categories, as you can read, weakness paralysis, abnormal movement, swallow speech, attack seizures, anesthesia, special sensory symptoms, and then a mixed approach. They actually had fairly good outcomes in their study, which I'll talk about in a second. Risk factors for conversion disorder, one is this rigid personality trait or somewhat obsessive, mental health factors such as anxiety, state, or depression, history of previous sexual abuse, and then other environmental factors, risk factors, stress, parent-child relationship, stress, parental rejection, difficulty in school. But two, these children often are considered high achievers. One study said that children with somatization symptoms disorder, symptoms along these lines have been described as insecure or internalizing, very conscientious, and often perfectionist. Characteristics. One of the biggest factors in being able to move forward with treatment would be acceptance of the diagnosis. This can be very difficult because the symptoms can be quite alarming, and people, their friends, their neighbors, well, oh my goodness, are you having a stroke? I heard about someone or I read about on the Internet. A lot of these symptoms can be associated with a fear of something very severe or very scary in terms of medical health and prognosis. Being able to switch into a diagnosis of, okay, this is a functional movement disorder, and working with the patients to understand there's this incredible mind-body connection or using that computer analogy where your hardware is intact, meaning your brain, your nerves, your muscle, your joints, but yet the connections between there's some misfiring in your software, and we need to look at reprogramming through some of our treatment. So this includes both the psychiatric intervention, which can include hypnosis, psychotherapy, counseling, medication, biofeedback is huge I think too, and then the physical rehabilitation and a structured rehab aimed at systemic reacquisition of skills. There will often be significant resistance, or at least in my experience of patients to the psychiatric intervention saying, oh, I knew it, you think it's in my head, it's not in my head, you think I'm crazy, even when we're working on developing this rehab program or working on the functional and physical activities. One thing I communicate to patients is that the counselor or the mental well-being to go through an intensive program like this in the recovery, it isn't something that we're born knowing, and so if we can think of a counselor as like a coach, none of us are equipped really to go through something like this, so it's nice to have that external coach with you on this journey, and sometimes patients seem to accept that a little more than the understanding that they may feel or hear that you're saying is that, there's something wrong with my brain, I'm making it up and that needs to be fixed too. Certainly, there are many factors as we alluded to with conversion disorder and that you have to have buying of the patient, you have to have engagement of the family, and then through that support though by medical providers, it can be not helpful if this patient has a gait disorder where they fall all the time, or they're experiencing pseudo seizures and every time they go to the ED, they get admitted, or they get an MRI, or they get a CT, and or when they go to a specialist, then more tests, more invasive tests are ordered. Certainly, a team understanding or a unified approach can really help dispel some of that confusion that the patient may feel and support them in their path to recovery. Outcome is generally favorable. The pediatric rehab textbook lists 85-95 percent or 97 percent full recovery. A study in 2002 looked at 90 percent, and then specifically in Cincinnati study where they focused on their inpatients, all had improved WEFIM scores at discharge, and then they were all improved and maintained at three months. Eighty percent had no re-admissions, and almost half of the children and adolescents dismissed or discharged from rehab returned to school within one week. There's certainly unfavorable outcomes and factors, and longer duration of symptoms, high level of pain can really be a barrier as well. History of sexual abuse or the family and patient persistent belief that the symptoms are due to organic cause, and they just haven't found that yet. Then certainly a sick role reinforcer, or even though it's not a deliberate attempt to achieve external or material gain, there can be perceived or unperceived benefits to being in the sick role. I don't have to go to school because I'm sick and therefore I don't get picked on or bullied at school, or I started football and I don't really like it, but now I've had this injury and I'm unable to move my leg, and therefore I can't participate in football anymore, or my parents are divorced, but when I'm sick and I can't walk, my dad comes over to help me, and my parents are both in the same house, are some of the experiences that I've run into for children. Moving on to questions, I'll let you read this and then we'll talk about a little bit more on the next section. The answer is that the FACES scale is reliable for children over the age of six, and just for background or for additional references, in 2013, one group found that it was actually helpful down to age four, though I think the textbook answer is going to be six. Then a great recommendation came from a Canadian group in 2018 that looked at the visual analog scale, the FACES revised, and then the color scale, and then found again that six to 17 years of age, that it could be helpful. This one's a true or false regarding the diagnostic criteria for functional neurologic symptom disorder and factitious disorder. The answer is false, and then they don't overlap because that falsification of signs and symptoms with deception is applicable within factitious disorder, not conversion or functional neurologic symptom disorder. That's large of the presentation, the references are available, and I thank you for watching.

pediatric pain

conversion disorder

chronic pain

nociception

prevalence

psychiatric intervention