Pain Neuroscience Education for Children

Original Editor - Robin Tacchetti based on the course by Tracy Prowse
Top Contributors - Robin Tacchetti, Jess Bell, Kim Jackson and Ewa Jaraczewska

Pain[edit | edit source]

Pain is a sensation and an emotional response to multiple stimuli created by the conscious brain which is then perceived as threatening.[1] Pain is not a measure of tissue damage, but rather the brain's response to the threat. Therefore, pain is not only physical but an emotional event for the person.[2] Pain is always an unpleasant body sensation, but it can be a challenge to define because it is subjective and ranges in quality, intensity and duration.[3]

See the following videos by Joshua Pate on the science of pain and phantom limb pain:

Chronic Pain in Children[edit | edit source]

It is estimated that thirty percent of children experience chronic pain, with a higher incidence in girls.[6] Chronic pain is defined as intermittent or continuous pain that has lasted for more than three months.[7] The quality of life of children who have chronic pain is often affected, and they may experience emotional distress, increased school absences, lower reading scores and will be more likely to have chronic pain as an adult. The most common chronic pain complaints from children are headache, musculoskeletal pain and abdominal pain.[6]

Signs of Pain in Children[edit | edit source]

Children in pain can exhibit different signs of pain based on their age, previous experiences, beliefs and expectations.[2] The following chart by Children's Minnesota[8] lists clues of pain by various ages of childhood and adolescents:

Children aged 1-3 years (toddlers) may:

  • Be able to describe the pain
  • Cry / whine
  • Grimace
  • Hold their body rigid, refuse to crawl or walk
  • Become frustrated more quickly
  • Display aggressive behaviour
  • Appear restless or be unable to sleep
  • Have a poor appetite[8]

Children aged 4-5 years (preschool) may:

  • Be able to describe the pain
  • Grimace
  • Hold their body rigid / refuse to move
  • Not like the painful area to be touched
  • Cry / whine
  • Appear restless or irritable
  • Have nightmares
  • Have a poor appetite
  • Not mention their pain if they believe they are being punished, or are fearful of treatment[8]

Children aged 6-12 years (school-age) are able to talk more directly about pain, including the cause of pain, type, and amount. Common behaviours might include:

  • Keeping still / guarding the painful area
  • Grimacing / crying
  • Withdrawing emotionally
  • Irritability
  • Restlessness / thrashing around
  • Disrupted sleep
  • Poor appetite
  • Having nightmares
  • Not mentioning pain if they are fearful of treatment[8]

Children aged 13-18 years (teenagers) may demonstrate both adult and childlike behaviour. There may be:

  • An alteration in activity level
  • Decreased cooperation / participation
  • Changes in eating / sleeping patterns
  • Irritability / restlessness
  • Change in ability to focus / concentrate
  • Anger / withdrawal[8]
The video below by Live Active Chiropractic provides a good summary of pain and strategies to help with pain[edit | edit source]

Pain Education[edit | edit source]

It is estimated that chronic pain in paediatric populations reaches 46%. [9] When working with children who have chronic pain, it is important to educate them and their parents on the concept of pain: how they understand pain, what function it serves and what biological processes are thought to increase it.[6] [10] Practitioners explaining these concepts should use easy to understand terminology for children and more in-depth language for parents[2] Having the child learn and understand pain concepts provides an opportunity for them to become an active participant in managing and treating their pain while the therapist acts as a coach.[11] [2] Thus, the therapist works more as a coach while the child leads. Encouraging the child to be an involved team member can alleviate barriers to treatment and result in more positive outcomes.[11]

Pain Education for Parents[edit | edit source]

Parents who have a child with chronic pain will often experience increased stress themselves. Being conscious of how they manage their stress is important because their coping skills are commonly modelled and emulated by their children. Parents who adopt self-care techniques can handle chronic stress with less negative outcomes and are better able to assist with family needs. Alternatively, parents who catastrophise, and have increased stress, and anxiety are less able to support their children. Studies show that 50 percent of parents of children with chronic pain have pain themselves. [12] Parents with chronic pain themselves may bring in their own biases regarding pain and the support they can provide for their child.[13]

The Ted Talk video below by Lorimer Moseley explains Why Things Hurt:[edit | edit source]

How to Help a Child in Pain[edit | edit source]

The following list from UC Davis Health[14] offers suggestions for how parents can help their child in pain:

  • Provide children with as many reasonable choices as possible and give them some control over treatment
  • Provide children with honest, accurate, and age-appropriate information about hospital experiences - this can help to alleviate fear and anxiety in children
  • Allow children the opportunity to ask any questions they may have and express their feelings
  • Ask children about any fears they have and clear up any misconceptions
    • If a child's fear is related to a past experience, it is important to discuss this experience and explore ways to work together to ensure the next experience (i.e. treatment / hospital stay) goes better
  • It is important to reduce any extra stimulation and anxiety in the room
    • Because children can pick up on their parents and other adults' emotions, it is beneficial to create a calm environment "with those people that can remain relaxed and supportive"
  • Encourage children to practise deep breathing to help with relaxation
    • Tools to assist can include bubbles and pinwheels
  • Provide children with items to distract them - re-focus their attention on something they enjoy (e.g. a game, activity)
  • Encourage children to use their imagination and focus their attention on telling a story
  • Provide opportunities for comforting touch (e.g. holding, cuddling)
  • Encourage parents to remain close to their child as this can help a child feel more secure[14]

Resources[edit | edit source]

References[edit | edit source]

  1. Li W, Liu P, Hu Y, Meng J. Pain Modulates Responses to Emotional Stimuli. Front Psychol. 2020 Nov 9;11:595987.
  2. 2.0 2.1 2.2 2.3 Prowse, T. Pain Neuroscience Education Course. Plus.. 2022
  3. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, Keefe F, Mogil JS, Ringkamp M, Sluka KA, Song XJ. The revised IASP definition of pain: Concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976.
  4. TED-Ed. The mysterious science of pain - Joshua W. Pate. Available from: [last accessed 9/5/2022]
  5. TED-Ed. The fascinating science behind phantom limbs - Joshua W. Pate. Available from: [last accessed 9/5/2022]
  6. 6.0 6.1 6.2 Pate JW, Hush JM, Hancock MJ, Moseley GL, Butler DS, Simons LE, Pacey V. A child’s concept of pain: an international survey of pediatric pain experts. Children. 2018 Jan;5(1):12.
  7. Koechlin H, Coakley R, Schechter N, Werner C, Kossowsky J. The role of emotion regulation in chronic pain: A systematic literature review. Journal of psychosomatic research. 2018 Apr 1;107:38-45.
  8. 8.0 8.1 8.2 8.3 8.4 Children's Minnesota. Pain in children and teens. Available from: (accessed 15 November 2022).
  9. Miró J, Roman-Juan J, Sánchez-Rodríguez E, Solé E, Castarlenas E, Jensen MP. Chronic pain and high impact chronic pain in children and adolescents: a cross-sectional study. The Journal of Pain. 2022 Dec 25.
  10. Koechlin H, Locher C, Prchal A. Talking to Children and Families about Chronic Pain: The Importance of Pain Education—An Introduction for Pediatricians and Other Health Care Providers. Children. 2020 Oct 12;7(10):179.
  11. 11.0 11.1 Hogans BB, Watt-Watson J, Wilkinson P, Carr EC, Gordon DB. Perspective: update on pain education. Pain. 2018 Sep;159(9):1681.
  12. Skarstein S, Bergem AK, Helseth S. How do mothers of adolescents with chronic pain experience their own quality of life? BMC Psychol. 2020 Jun 16;8(1):64.
  13. Guite JW, Russell BS, Homan KJ, Tepe RM, Williams SE. Parenting in the context of children’s chronic pain: balancing care and burden. Children. 2018 Dec;5(12):161.
  14. 14.0 14.1