Unpacking: Pediatric Pain

Megan: 00:00:00

Can we inoculate children against chronic pain?

And we're not talking vaccine inoculation, so, yeah, okay, nobody has to get worried, but we're talking about, could I teach you about what pain means before you experience it?

So they've gone into middle schools and I think even elementary schools, maybe fifth grade somewhere around there, and taught kids about pain and their pain. Literacy increases tremendously. And so we'll know in a few years if that has an impact on the prevalence of pain in adults.

Intro: 00:00:43

Welcome to Unpacking Pain, a podcast dedicated to understanding the complexities of chronic pain, what causes it, how it affects our lives, and what we can do do about it.

Join doctor of physical therapy and pain science researcher Dr. Megan Steele and me, Holly Osborne, a chronic pain sufferer, as together we explore the biological, psychological and social aspects of chronic pain and create community and understanding in the process.

Holly: 00:01:19

Hi, everyone. Welcome back to the Unpacking Pain podcast. It's great to have you here. Hey, Megan.

Megan: 00:01:25

Hi, happy to be here. Excited for today's topic?

Holly: 00:01:28

Yeah, me too. I think this is going to be really interesting. I have a bunch of questions brewing for you. We're going to dive into.

We were talking about adults, and we've talked about gender differences and we've talked about, you know, the introspection and mindfulness and all these things that are quite grown up. But we've got probably a whole population of. Of chronic pain sufferers who are considered child childhood age. And that is really curious thing.

I would love to actually inspect this with you today and kind of understand what we're missing in terms of, like, so much of the research and everything that we see is around the adult body and the adult mind. And I think, you know, you tell me if I'm wrong, but kids aren't just like little adults. Right.

They're like, they're on a kind of a really different system when it comes to hormones and everything else.

Megan: 00:02:19

Very true. Yeah. They're not just smaller versions of us. They have different areas of brain development that are coming online at different times.

And their brains are even more plastic than ours.

And so they're constantly changing and very much affected by their external environment as well as their internal environment, what's going on inside their bodies. So really interesting.

Holly: 00:02:45

Yeah, I'm. I have to ask kind of a silly question at first, which, because you've already helped us learn the difference between acute pain and chronic pain.

And really what defines chronic pain? Is that definition any different for a child or do we look at the same kind of time Horizon.

Megan: 00:03:03

We do look at the same kind of time horizon, and that's really for definition purposes. And so it is still a three month period, period for the definition of chronic or persistent pain, which again, is not the best way to define it.

But because we don't really have a better option, we use a timeline.

Holly: 00:03:23

Okay, then can I ask, this is sort of a dumb question. How does a child, I mean, I understand, you know, they bonk around, they're rambunctious, maybe they're snow skiing.

Of course, you know, they can fall down and break their arm or get injured, but they're so resilient at that age. What creates the conditions for chronic pain in a kid?

Megan: 00:03:45

The full answer is we don't know a hundred percent right now, but we know there are some things that contribute. So we used to think babies and infants and even toddlers up to about 2 years old, you didn't have any memories.

So if you ask somebody about what's your earliest memory? They'll usually tell you something about four, five or six years old.

And so your hippocampus part, some parts of your brain and your memory system are not really as developed until you're two years old. And so the joke was, well, you have two years to mess up, and if you drop them, you know, at least they don't until they're too.

And really what we've learned over the past few years is that you do have a memory before too, but you don't have a way oftentimes to verbalize it.

Holly: 00:04:36

Hmm.

Megan: 00:04:36

And that's most often the way that we communicate about our pain to healthcare providers and our family members and things like that.

So sometimes people have maybe a subconscious awareness or a subconscious memory of something that happened before too, but because they don't have a way to verbalize it can sometimes be a little bit more challenging.

Holly: 00:04:56

Could that even include a difficult birth?

Megan: 00:05:00

Sometimes, yeah. There is some research around birth trauma and things like that.

There are some people that the evidence isn't very clear in that right now, but things like early adverse childhood experiences are being investigated more, I would say. And typically they'll use animal models initially. So what they'll do is induce a trauma to an animal like a mouse or a rat.

And so they'll take the pups away from their mom as inducing like a trauma of neglect or separation. And then they do behavioral testing on the pups, like give them a small cut on their hind paw and things like that.

Or feed them a high fat, high sugar diet to simulate a lower socioeconomic status, diet that they might eat and see how they do there.

Holly: 00:06:02

So we see that they. That even from early on, there's some response, there's some indication that they're clocking that trauma.

So can pain in a child actually appear even outside of injury?

If there is, I mean, just kind of sticking on that idea of a traumatic childhood experience, if a child witnesses or is involved in something highly traumatic, do we ever see pain show up as a way of them being able to express it, since they're not really fully formed with words, you know, at such a young age, could it ever sort of manifest and come out as pain?

Megan: 00:06:45

And that's not really clear either. There is definitely the potential for that. And you see that with these animal models, certainly.

And then you also see that kids who have four or more adverse childhood experiences on this ACEs scale have more health problems, they have more mental health problems, they have more physical health problems, and they have more pain.

And so what we've thought historically, or at least in the recent past, is that trauma doesn't cause pain necessarily, but it can definitely amplify pain. And so that's why they do these, maybe minor, like a little laceration on a hind paw, and they see who gets better and who doesn't. Right.

And so we've talked in the past about, like, 30% of people with an acute injury will shift over to chronic pain. And that number is more like 25, 20, 25% in kids.

Holly: 00:07:43

Hmm.

Megan: 00:07:44

Okay.

Holly: 00:07:45

This is so interesting to. To imagine how the brain is working at that time, because, like you said, there's so much more neuroplastic than we are as adults.

Is it possible to do different kinds of interventions when, let's say that you, you know, you're now dealing with, You're. You're treating a child who's expressing chronic pain issues, but they're, you know, we're not seeing evidence of continued tissue damage.

Are the protocols different with children than adults because their brains are so neuroplastic? And can they actually maybe even get over it faster than adults could?

Megan: 00:08:23

Sometimes, yes. And of course, because pain is so individualized, it matters a lot about the kid and the parents and. Or the caregivers and what's going on there.

But in terms of neuroplasticity, you know, you'd think that they would be able to recover faster or learn faster because they're doing so much changing in their brains.

And it turns out there are two really critical periods for areas of your brain that are involved in threat detection and memory and Emotion formation. So those areas tend to be your amygdala and your hippocampus, those deep subconscious areas in your, your limbic system.

And so around two to three, that is one critical period. And so you need like support and love and caring and safety signaling from most often your caregiver, your primary caregiver of your parents.

And then there's another critical period around 12 to 13 where you also need that kind of love support, safety signaling. You're seeing a lot of activation and growth in the amygdala. And so those tend to be two critical periods.

The problem with the second one, or at least as the mother of a toddler that I see potentially is your influences are primarily your friend group in the 12 to 13 time slot.

And so kids who had difficulty during both of those periods when that threat detection system was coming online can have changes in the way they process sensory information and other information in terms of a threat detection response.

Holly: 00:10:07

Do are hormones playing a role, particularly in that second phase, the 12 to 13, if they're going through, you know, a lot of hormone changes and experiencing puberty, does will that kind of ratchet things up?

Megan: 00:10:23

It seems likely.

There again, we don't have like a solid answer, but we do know that 70% of the people that suffer with chronic pain are female at birth and they have the same or very similar pain thresholds as their male, male at birth counterparts.

Until 13, until those hormone shifts start to happen, it's not the hormone levels themselves, it's the swings, it's the shifts in hormones that contribute to some of the pain, some of the injury risk and some of the inflammation issues. And so like you say, when you're 13, 12 or 13, your hormones are gone wild. That can be a contributing factor.

My research, I would really like to look into this once funding fingies crossed comes back. So there, there are, there's ways that our nervous system is primed, right? Externally we're primed for a response.

Like you say, if I witness a traumatic event that puts my nervous system on high alert, and if I witness a traumatic event and get a paper cut, I might sense that paper cut as like a huge painful laceration. Whereas if I were in the park sitting, having a lovely picnic and I got a paper cut, it might be a non issue.

So there's external primes and then there's internal primes. And what I really would love to look at are the internal primes being things like your hormone levels or the swings in your hormone levels.

And, and does that prime your nervous system to say, oh, we know what this means. Get ready. Get ready for that pain response where I'm a little more sensitized.

Get ready for that fight or flight response where again, my nervous system is a little more sensitized. So that is a really cool emerging area of research and a lot of interoception, interoceptive researchers are looking into that.

Not a lot, I would say, because it's very hard research to do. But that, that, that's my ultimate goal is to, is to look into that kind of the call is coming from inside the house type of, of study.

Holly: 00:12:45

Yeah, that's I, that is definitely worthy. Especially because we are learning so much more about the teenage ups. And you know, that fluctuation doesn't seem to be static and over time. Right.

It's like the fact that girls are getting their periods years earlier than they did a couple generations ago. You know, and this is the unscientific part of the, you know, half of the podcast saying this.

So you know, don't hold me to these numbers, but I think on average it used to be around, you know, 13 or so kind of give or take in Western cultures would be common to start one's period. And now we're seeing girls of 9, 10, you know, even as young as 8.

So yeah, there's, there's a lot going on there and it'd be really, I'm sure, helpful to understand how the changing hormone landscape is impacting them.

Megan: 00:13:40

Also a very multifactorial problem. You know, there's so many reasons why girls are developing sooner that research is looking into. But yeah, that's a really interesting piece of it.

And there was an interesting study as well about starting of menstrual cycles. And they were looking at can we predict who will develop widespread pain?

This is a research group at a University of Chicago who are doing really interesting studies.

So they did a longitudinal study where they looked at adolescents over multiple years, 207 of them actually females, and what they found was that 25% already had widespread pain before they developed their menstrual cycles and then 29% developed it afterwards. And those with widespread pain also reported worse menstrual pain.

Holly: 00:14:49

Mm, okay, that kind of makes sense that they follow each other, but to understand why and how it's become chronic in the first place.

Megan: 00:15:00

Yeah, they found a surprising link. So typically you'll see depression and anxiety or pain severity be predictors of widespread pain later on, but they did not find that in this study.

What they found was sensory sensitivity being A predictor of widespread pain later on.

Holly: 00:15:23

Could that be related to the autism spectrum and neurodivergence when we're talking about sensory differences?

Megan: 00:15:32

Yeah.

So a lot of times people associate sensory sensitivity with the autism spectrum, and there are a lot of people on the autism spectrum that also have sensory sensitivity, but they're not one and the same. They're not interchangeable. And so I think that's important.

But what they found in this study is that heightened sensitivity to loud noises, flashing lights, were then interpreted as painful. And so they termed these people as having multimodal hypersensitivity.

And so one way that we can help these people is to detect them early on to find out who they are and how to help them early on. And one way is to improve interoceptive awareness, which I think we talked about briefly.

One of the most widely studied ways to improve your interoceptive awareness is to count your heartbeats to see if you can tune into your body and count your heart rate. Other things are like. Things like somatic tracking, where you observe and follow sensations as they go through your body.

You observe neutral sensations or positive sensations, and then you start to work into the less pleasant sensations, always coming back into that safety of observing something positive or neutral. So I think that's a really exciting, interesting line of research that I think we're going to see expand in the near future.

Holly: 00:17:06

Yeah, I certainly. I hope so. There, like you said, there's a lot of. It's a big intersection. Right. Of a lot of things kind of meeting there. So it's not simple to unpack.

But I think this is so important to talk about. And so you're mentioning things like interoception and things that. That even little kids can do, like kind of counting their heartbeat.

What are some of the other curious. Other modalities?

Is there kind of a bag of tricks for a physical therapist or for a provider that is wholly different than that they might bring to an adult patient or do. Can we follow some of the same. Some of the same routines to get successful outcomes?

Megan: 00:17:51

Yes and no.

So I always joke that the reason I don't do peds is because you not only have to be a great physical therapist, you also have to figure out how to make everything fun. And I'm like, but you're fun.

Holly: 00:18:05

Megan, what are you saying about yourself?

Megan: 00:18:08

I'm not fun. I don't have time for fun.

Holly: 00:18:10

Yes. No, I'm kidding.

Megan: 00:18:13

Yeah, it's hard, you know, and sometimes you think like, oh, this is going to be great. Like, they're going to love this. And they look at you like you're so old and weird.

Holly: 00:18:22

You're dumb.

Megan: 00:18:22

Why are you doing that?

Holly: 00:18:25

Is it because I have a side part? I'm like, tell me the truth. Yeah.

Megan: 00:18:29

They're like, why are you looking at me, Millennial? I can't even. Yeah, I can't relate. So, yeah, that's challenging. But the people who do it, do it and they're fantastic at it.

There's another great joke about pediatric physical therapists that always have like a sheet of stickers on their person at all times. Like, you just have, they have tools that they know how to use and they, they use them well. But that's not gonna work for a 12 year old boy. Right?

They, they're gonna need a different incentive. And so what we find in terms of exercise is that the mindful exercise works better for adults. And just cardiovascular, general exercise works great.

Holly: 00:19:12

For kids, like get them, get their heart pumping. Like.

Megan: 00:19:16

Yeah, yeah, just moving. Just general exercise. Like not mindful, mindfulness based exercise.

And then you can do things like, you know, I'm not going to do breath work, but I could blow through a straw and make this feather go across this line on a navel, tennis kind of a situation or those types of things. So there's all different kinds of tools like that where you can use some of the mindfulness work, but make it kid appropriate.

There's a really great researcher and a great line of research out of Australia by a researcher named Joshua Pate. And he looks specifically at pediatric persistent pain.

And he's written books on it to help kids understand it and understand things like surgeries and just things that, like, kids would have a really hard time understanding and what they're doing. And another researcher named Adrian Lowe's group are looking at, can we inoculate children against chronic pain?

And we're not talking vaccine inoculations. Yeah.

Holly: 00:20:28

Okay.

Megan: 00:20:29

Nobody has to get worried. But we're talking about, could I teach you about what pain means before you experience it?

So they've gone into middle schools and I think even elementary schools, maybe fifth grade somewhere around there and taught kids about pain and their pain literacy increases tremendously. And so we'll know in a few years if that has an impact on the prevalence of pain in adults.

Holly: 00:21:03

Man, that's, that is going to be really interesting is the idea that if you have more fluency around pain, that as a child you won't get stuck in that pain. You'll have the ability to express yourself.

You'll be Able to, you know, make your needs known in a way that's, you know, that's relatable to an adult instead of, you know, I think we're all guilty as parents and step parents at some point of, you know, kind of like, quit whining. Right. It's like.

Megan: 00:21:33

And not throw up and you feel like the worst that ever lived. Like you're just going to go crawl in a hole.

Holly: 00:21:40

Yeah, exactly.

Megan: 00:21:42

But I'm.

Holly: 00:21:43

I'm imagining. Yeah. That there is this challenging age for kids where it's, you know, just saying it hurts doesn't get us far enough. And they.

If they had the tools to express with more dimensions, more dimensionality around what they were feeling, then it would also help the adults in their lives to, you know, not just take it seriously. I don't mean take it seriously that we don't, but to understand that this isn't just.

This isn't moaning or whinging about something, but that, you know, there's. There's something at play here that my child is putting words to. Now it's time to follow up.

Megan: 00:22:17

Absolutely. Yeah. So it can be one way that the child can express and also reduce a lot of the fear around pain.

Because as we've talked about, pain is not just a physical experience. And fear has a lot to do with chronicity and pain.

And if I have a pain experience, and this has to do with why maybe sometimes athletes and people who perform with their bodies at a very high level, like dancers and things like that, tend to ignore pain because they've normalized it. It's part of their daily life. It's a normal experience. I'm not afraid of it.

Holly: 00:22:58

Right.

Megan: 00:22:59

And part of that, you know, sometimes that goes too far. Right. Where I'm going to choose to dance on a broken ankle.

If you just throw some tape around me, which I have treated that dancer, and it was challenging.

Holly: 00:23:14

Oh, it's like. Sounds brutal. Yeah.

Megan: 00:23:16

But there's somewhere in the middle. Right. Of like, I'm terrified to move because I got a paper cut and I'm going to dance on my broken ankle.

There's a lot of area here in the middle where I have a healthy relationship to pain.

I recognize that pain is a normal human experience, and I'm not going to let something serious go on for too long, but I'm not also going to have a tremendous reaction to every sensation that goes on in my body.

Holly: 00:23:45

That sounds like such a gift to give kids who are already burdened with so much in the process of growing up and Becoming adolescents and young adults and so forth. I mean, it's like we need to give them more tools to not get stuck in the fear. And kids are so incredibly resilient if they're given the tools. Right.

But they're not going to get themselves out of it on their own. So I think that sounds really incredible.

Megan: 00:24:13

There is hope for kids who have pain and who have had traumatic experiences, much like adults. Social support has positive buffering effect on things like trauma and pain in children.

So research has, has demonstrated that having two people who aren't your parents care about you is enough to have a secure attachment, to have validation of what's going on with your symptoms. And it serves as a, as a buffer, as a community, social support buffer so that these people don't end up with chronic pain in their future.

Holly: 00:24:58

That just gives me a whole nother.

I mean, I almost kind of shudder to think of a child who's experiencing loneliness in, in a social, through social lens and what an adverse effect that may have on them just being able to heal from something that should be straightforward like a broken arm from a drop off the monkey bars. You know, we see it not infrequently, something happens on the soccer field, okay. You know, we, we cast it up, they get well, we move on.

But that's when the kid is, you know, kind of in this, you know, more normalized western setting, right. They're surrounded by friends.

Have you seen, you know, when you're an adult and you have an office job or a corporate job, at least once a year your employer might send out a survey that asks you how you feel about your boss and the company's mission and all that. And one of the questions that I started seeing over the last probably eight to 10 years is do you have a best friend here at work?

Oh, and it's something I'm wondering if they're asking kids now because we just assume that kids have friends, that it's gaggle of children, you know, gaggle of kids running around, they're all buddies together.

But the, the research has shown us that childhood lone loneliness, particularly among young boys and adolescent boys, is just getting worse and worse. How are we checking in on that?

I mean, I know this doesn't necessarily exactly to do with chronic pain, but since we're on the topic, are we checking on kids and that social, that, that social kind of happiness and that social hygiene? How do we.

Megan: 00:26:35

Yeah, I think that is absolutely necessary. And I think that show that four part series adolescence was a really big eye opener.

Holly: 00:26:44

For a lot of parents, that was so intense, wasn't it?

Megan: 00:26:49

So intense. And I have a toddler girl and I was like, how do we prevent this? You know, but riveted, right? It was riveting.

And I think it, it really started a conversation with a lot of people around, you know. Yes, my child has these computer friends. Maybe they're like playing games together in the evenings on the computer. But is that a social support?

Is that what we're looking for during that critical period of development in their brain or do they need something else?

So I think absolutely we need to be thinking about the community, the social support and what that looks like, whether that's a boys and girls club or a sport or an activity like art or painting. And where can I find my tribe? I think that's really, really important. Especially when we're talking about that transition into puberty.

Holly: 00:27:46

Yes.

Megan: 00:27:46

Kids are already dealing with so much during that time.

Holly: 00:27:50

Oh, it's gotta be. It's so confusing now with social media. I mean, I can't Even imagine being 11, you know, with TikTok and Instagram and all of that.

It's just, it's just so much.

And I'm imagining that if we have a child who's not necessarily plugged in to at least those two friends like you mentioned, that being at least, you know, a healthy baseline, then who are they exchanging their experiences with and who's helping normalize their experiences? Like if they have a difficult dentist appointment and have to have two, three teeth removed, you know, who are they telling? What's, who's there?

Are they going to. Able to go to school the next day and say to Jimmy, you know, about my teeth? And Jimmy says, me too. Or my little sister had that too. Right.

We're now normalizing it. You're part of that tribe. Your experience is a shared one. Ima, you know, for.

I'm imagining the absence of that and how isolating and difficult that might be even for something as banal as a tooth, you know, getting a tooth removed. Right?

Megan: 00:28:51

Yeah.

And things that are sort of non traditional adverse childhood experiences or non traditional traumas like having scoliosis and having to wear a scoliosis brace. So the prevalence of chronic pain in people who had scoliosis as children is significantly higher at somewhere like 66%.

And part of that may have to do with things like bullying and isolation and lack of social interaction at school because I feel like I'm othered, I'm different.

Holly: 00:29:33

So would it be fair to say that parents who are Seeing their kids experience pain that, you know, certainly there's nothing to indicate or warn us that it could become chronic, but we just want to head it off at the pass and do the right. Do as many things as we can. And should we be encouraging our kids to talk about what they've experienced? Let's say that, you know, very.

Unfortunately we were in a car accident and there were some injuries, and that was really scary. Should. How should parents really be encouraging their kids to, you know, and should we say you, you.

We want them to find a way to talk to their friends about it? You know, is, do we need to kind of probe and make sure that they're planning on doing that? Or how do you kind of do that intervention as a parent?

Megan: 00:30:22

Yeah, it's hard because, you know, you're walking a fine line of not wanting to dismiss something, wanting to normalize it, but also not wanting to medicalize or pathologize something that may not really be an issue.

Holly: 00:30:38

Right.

Megan: 00:30:39

And so I think again, it's always. And it's. And it depends answer of what is the kid experiencing? What are they going through, how are they expressing or not what's happening?

And then also how is the parent's experience influencing the child?

So what you find in children who have chronic pain is they often have a parent who either has a mental health condition or is in chronic pain themselves.

Holly: 00:31:10

And wow, okay, wow, that's big. Can you say that? Like, let's even repeat that. So parent has chronic pain, therefore the kid might be more likely right. To experience.

Megan: 00:31:22

Well, sort of the opposite. So, so when what they, they looked at the kids and they said, well, where is this chronic pain coming from?

And then we looked at or, or researchers looked at their caregivers, their primary caregivers. And so more often than not, when you have a child with chronic pain, there will be one or more primary caregiver with chronic pain.

And this again, is always multifactorial. It has to do with the fact that kids are constantly observing.

And so they're observing how you're dealing with your physical sensations, they're observing how you're reacting to their physical injuries. And, and so there, there are a lot of layers to it.

There is potentially some genetic component to chronic pain, but it's, you know, it's One of those 59 or 49, 51. Nature versus nurture. Right.

Issues where there's, there's so many factors to, to contribute that you can't say it's all just the genetics, and you can't say it's all just the experience. Yeah.

Holly: 00:32:35

It's really all knotted up together. And I wonder. There's also sort of an inverse effect that I have a friend whose mother was in chronic pain throughout her childhood.

And this was something that my friend was. The whole household was quite aware of. And to this day, this friend of mine absolutely hates to admit if she's in pain.

She won't tell you when she's in pain because she has this memory of just being completely sort of beholden to this pain.

This pain kind of ruled everything in the household, and depending on mom's pain level, we were either going to have a good day or we were going to have a bad day.

Um, and I don't know whether my friend is actually more inured to chronic pain, you know, than the average person, but she certainly ain't going to talk about it.

Megan: 00:33:29

You're not going to get it out of her. Right.

Holly: 00:33:33

Is there a way that people can almost kind of, through childhood, build up a resistance to pain, even if it's just psychological?

Megan: 00:33:43

Sure.

I mean, and like I was talking about with some of the dancers or athletes, you know, people can develop a different type of relationship with pain where they say, I know what this is. I'm choosing not to address it. I'm, you know, I'm not afraid of it. And also, I'm not going to acknowledge it. And.

And some of that is healthy, some of it is not. And when we talk about primary caregivers, too, we also. There's also some evidence to suggest that if your baby.

If the child is an infant and there's a lot of stress and trauma, that if the mother is supported, the child is less likely to experience chronic pain. Hmm. Oh, okay.

Holly: 00:34:36

So that even is being in an environment and being raised by someone who is supported, who is not hitting a brick wall, so to speak, in their own needs and their own pain, which probably gives that person, that mother, much.

Megan: 00:34:52

More bandwidth and ability to attune to her child. Yeah. The researchers described it in such a beautiful way. They described it as wrapping mothers in social support, which I thought, oh, lovely.

Holly: 00:35:06

Could we please. Yeah. Can we just do that? Can we, you know. Right. Prioritize that for a minute. I'd love to see, you know, with all the. Never.

I won't get political here, but there's lots of, you know, picketing and protesting about all kinds of things around reproduction. How about we just get really fierce about supporting wrapping moms in this support? I'd love to see people fight as hard for that as for other things.

Megan: 00:35:30

But, you know, really nice. Yeah. And. And what you see in countries that do that is the children have better outcomes.

Holly: 00:35:39

Yeah, I, I believe that totally.

I mean, the science backs it up, like you're saying, but just from a layman's perspective, it's like, yeah, of course there's a positive correlation there. Okay, what.

What if the mom's love or dad's love or, you know, auntie the caretaker, what if that love and that TLC is almost kind of giving the kid encouragement to have an owie? And, you know, and, and certain there's total credibility and, you know, truth associated with kids and their chronic pain.

But what about the cases where we think maybe there's.

I think you use the phrase secondary benefit or second, you know, there the kid is getting something out of the support and attention that they're getting, and they might continue reporting pain because that feels good to have the spotlight on you and all the care that comes with that. How do we sort of parse that out? Dr. Megan. And can we tell when that's happening?

Megan: 00:36:44

That's really challenging.

And yeah, secondary gain is, is defined as, as benefits, whether conscious or unconscious, that someone might receive from experiencing pain or illness beyond the immediate relief of symptoms.

And so for kids that aren't getting their needs met when they're healthy, they could potentially get their needs met when they are ill. And that can contribute to things later on in life.

A while ago, someone that was found out to have had been falsifying a cancer diagnosis and treatment, in part because of the way that she was treated by her coworkers during that time. And so it's not. It doesn't only affect kids, it affects adults, too.

And I don't know what the percentage is there, but I know that there's a likelihood that there's some percentage of kids who are doing that, because this is a way that I get my needs met when they're not being met otherwise. And I think finding out what the needs are outside of that can be one way to avoid that.

So that I can try to meet your needs, you know, to the extent that we can all meet every child needs in every moment is like, dare to dream.

Holly: 00:38:10

Yeah.

Megan: 00:38:12

Or not. Because I can't imagine how fun those kids would be later in life.

But, you know, if we can meet their basic needs and their safety needs and their security needs and their attachment needs. You know, I don't. I don't need to meet your cookie quota every day. Right, right.

But I think a lot of times kids Have a higher motivation to get back to play. And if I'm ill or I'm sick or I'm hurting, then I can't play. Then, you know, is that really. Am I really winning here?

Holly: 00:38:53

Yeah. They figure out pretty quickly that, you know, actually kind of a funny, but maybe. Maybe not so funny in light of what.

What could have been going on there underneath the. Underneath it all. But when I was in little softball player, I want to say maybe fifth grade or something.

I was no good, by the way, but neither was I. I had other. Other gifts maybe. But anyway, we had a girl on our team whose arm was in a cast, and she got a lot of attention for it. We were all signing the cast.

And honestly, it was kind of cool a little bit at the time to either show up with crutches or show up with a cast.

Well, the very next practice that our softball team had, there was a girl on our team whose name shell remained nameless in case someday, somewhere, she listens.

Megan: 00:39:38

To this good idea.

Holly: 00:39:39

She showed up with a finger splint, one of those, like, metallic that you see foam and then there's a metallic finger splint.

Megan: 00:39:46

Yeah.

Holly: 00:39:47

And I remember so distinctly because I walked to school with this girl and the finger splint wasn't on, but she busted it out of her backpack and threw the thing on for softball practice. And now suddenly was getting attention, just like the girl with the.

You know, so the coach and the assistant coach and others of us were like, what happened? What happened? Oh, my gosh, you. You hurt your finger. And it.

Then when she found out she was going to have to sit out that practice in the next couple of games, it came out that she had put it on herself that it actually belonged to her brother. So I. And so it is kind of funny. It's a giggle story. We're hilarious as kids.

I'm sure she could probably laugh about that story now, but just in case there was anything else going on there, I don't want to be too, you know, flip about it in case, you know, she was really feeling some neglect and really needed some attention, you know, as possible in that moment. But.

But anyway, just a funny anecdote to prove the point that you'd said about there's a strong pole toward being in that social circle toward playing. You know, kid won't bench themselves longer necessarily than they have to for the most part, if everything is, you know, going well.

Megan: 00:40:56

Exactly, exactly. So, yeah, I mean, that's the good and the bad of it, right?

Is sometimes they'll say they're feeling better before they're feeling better so that they can get back to play. And. But more often than not, they're not gonna bench themselves like you say.

Holly: 00:41:13

Yeah. So, no. What about being a parent of a child and you, you are in chronic pain and, God, we don't want to mess them up.

Like we, you know, it's just we, we do not want our chronic pain to cause any more trouble than it already has for ourselves and for those who love us. What would you offer, Dr. Megan, as a way for a parent? And it's going to depend, of course, on family dynamics, on the age of the child.

But are there any kind of good tips for how we as chronic pain sufferers might, in a healthy way, express what we're going through to a child?

Megan: 00:41:52

Yeah, I think, like you say, the age appropriate level of explanation of mom or dad or step parent is feeling this today and therefore cannot do XYZ or, you know, I think being open about your pain journey is a great way to help a child understand what's going on in their physical body and help them understand that their body is not the same as your body. And if they have a similar injury that you had, that it's not necessarily going to have the same path to recovery that you had.

Holly: 00:42:33

And I think, number one, yeah, just.

Megan: 00:42:37

Being open and normalizing situations is really important. And then also that social support outside the house.

So if they have two positive, consistent people outside of their house that do not have chronic pain, that can be one way that they can get more experience, understanding, attachment validation, that they're. They're less likely to develop chronic pain later on in life. Yeah, that.

Holly: 00:43:11

That makes sense. Like, we were talking earlier about sort of normalizing. I had three teeth pulled. So did my sister.

You know, you might find out from Wendy at school, my dad was a grumpy because he has a bad back or he can't take us to Six Flags on Saturday because his back. I was well aware of my dad's back problems when I was a kid.

And, you know, and I think one of the things that can be confusing to a child is when mood shifts in an adult. And sometimes we as the adult aren't aware that that mood shift maybe has occurred or is happening because of pain. And I don't necessarily.

I'm not saying we should tell kids that mood and pain ride together.

That might be, you know, a lot for them to try to understand, but I think it's also fair to say, you know, I'm sorry if I'm, you know, if Mom's a little, you know, less patient today than usual, you know, I'm. I'm experiencing. So, you know, I'm having some pain in my lower back. So, you know, bear with mom today. Okay.

Megan: 00:44:10

Would you?

Holly: 00:44:11

And, yeah, you know, so I. I think that kind of thing is healthy.

Megan: 00:44:14

Both people, you know, absolutely has to get it out. Right? Yes.

And kids internalize so much of what their parents are going through, and so if mom's in a bad mood, it's because of me until I'm told otherwise.

Holly: 00:44:31

Right.

Megan: 00:44:32

And so that's a really big, important piece of. I'm in pain. I'm not upset with you. I'm just not feeling good.

And so I need either a break or I need you to be quiet or I need whatever it is, because I don't want you to be under the impression that this is about you.

Holly: 00:44:54

Yeah, Yeah. I think that's an important one.

And it's easy to forget, too, because we just kind of fly through our days and, you know, we just go from one to the one thing to the other. Yep. When we started the conversation, we were talking a little bit about the fact that children are. The research isn't always transferable.

I mean, sometimes you're going to see some parallels, but we should never make assumptions that what's true for adults is going to be true for children. We know that there are all kinds of breakthroughs that are happening all the time in terms of surgical advances and body parts.

I. I've got the latest and greatest prosthesis in my. I feel like I have, like, the Tesla of. Not that I'm a Tesla Fiat, but I feel like I have the Tesla. The Tesla of shoulders.

Are we making as many strides where kids are concerned? Because I. Just. Because we've come up with, for example, a fantastic. A shoulder prosthesis for adults. Does that mean we have the same for kids?

God forbid. I mean, I. Again, I can't imagine a child needing a shoulder replacement at age seven. But you. You get where I'm going with this. Like, are we.

Are we pushing things forward here for kids as much as we are for grownups?

Megan: 00:46:06

Yes. I don't know if it's as much as we are for grownups, because kids, like you say, do tend to be a bit more resilient and things like that. Um, yeah.

You know, I recently saw the new casts that are coming out that are, like, open. It's like a hard shell, but it's like an open weave. And so it allows the Skin to breathe underneath.

Holly: 00:46:28

Ooh, no way. I've not seen that.

Megan: 00:46:30

Yeah, I had somebody come in with.

Holly: 00:46:32

Can you still sign that cast?

Megan: 00:46:34

You cannot. Well, maybe with a Sharpie, actually, but. Okay.

Holly: 00:46:37

Because that is a critical. That's a critical.

Megan: 00:46:40

Right. Child, childhood moment, milestone. Yes, totally.

Holly: 00:46:45

Okay, so that's really interesting. Can you actually see through to the skin and it lets them move a little bit differently, too.

Megan: 00:46:53

Well, ideally not, because if there's a fracture, you want to stabilize it. Right. But I think part of the discomfort of having a cast on is like the smell and, you know, if it would get sweaty under there and the.

Yeah, exactly. And then in terms of, like, surgical interventions, like scoliosis surgery has come a long way.

They have a lot of new interventions in that direction.

Certainly kids don't need joint replacements because most of our joints have about a 80 year expiration date, which is good, good news for most of us.

And, and yeah, some of the research I think, going into the pain prevention, I think is going to be really powerful over the next few years just to keep kids from even going, having to go through those experiences.

Holly: 00:47:44

Sometimes, you know, it wouldn't be a bad time to talk about it, it occurs to me, is when, for the most part, at least, public school kids are going to get the birds and the beads talk. Right. At some point. And even if it's not really about sex and reproduction per se, there's at least going to be a talk about the changing body.

Megan: 00:48:04

Yeah.

Holly: 00:48:05

And about the onset of menstruation. Right. And I am remembering back. I don't know if you remember that conversation, Dr. Megan, but we were never.

The word cramps and pain was never mentioned. Same. And so we knew there would be a period. We knew, you know, that there it was going to be a monthly task to take care of.

Even the boys are sitting in the room going, okay, I get it. But nobody said anything about menstrual cramps.

And that would actually be a really sensical moment to also not say, we're going to take a, you know, detour here and talk about all about chronic pain. But. But just, you know, from the fact that they're taking all this information in. Yep.

Let's pause there and, and explain, you know, that there can be some mild discomfort. We don't want to scare kids, but there can be some discomfort that comes along with this.

And hey, while we're on the subject, you know, discomfort and pain is something that we want to be able to talk to each other about.

You know, if you're going through that, make sure that not only are you sharing that with mom and dad at home, but that you're also telling each other about it. You want to, you know, make sure that your friends are part of your communication cycle when you're experiencing something. So I don't know.

I don't have all the answers, but I'm just thinking, why do we skip over that part?

Megan: 00:49:20

Yeah, I think that's a really important piece, and I think that would be a fantastic time to reinforce that message that maybe you heard about in second grade and then maybe get in fourth grade.

And even in the doctor of physical therapy program where I teach, the recommendation for pain science is that it be sprinkled out throughout the curriculum and then you also have a standalone course, because how many times have you heard something once and thought, I'm going to forget that as soon as I walk out the door here. Right.

And so not only hearing that message, but having it reinforced over and over and over again can be really powerful, especially because sometimes kids are going to get the opposite message from a provider potentially where they're going to hear things like pain equals damage, or we better get an MRI on that because it's something's wrong and that type of thing. So to be able to counter that with your knowledge of, oh, I know this, this is pain, and this is a normal human experience, and I'm going to be okay.

I think can be really powerful.

Holly: 00:50:28

I agree.

And I'm going to be so interested to see when that study starts coming back with findings, the one you mentioned about giving them language and some fluency around pain. And then we track them.

Megan: 00:50:38

Yes.

Holly: 00:50:39

Later on to see. I mean, I just.

I can imagine that that not only would help you around chronic pain, but maybe even expand expressing difficulty, things like heartbreak. Things like. Which by the way, that could be a whole nother topic for us. Dr. Megan. Because I have read.

BTW, just quick little non sequitur here, that heartbreak actually has a physical component to it and that it can actually make your chest, not your heart, but your chest ache. Yep. And that this is not imagined. And um, so maybe we might have to unpack.

Megan: 00:51:16

But.

Holly: 00:51:16

But if that turns chronic, then I'm really sorry because that someone means that. That means they're not getting over it.

Megan: 00:51:22

So maybe. Or maybe social isolation also has. Has been shown to have a physical component to it. So.

Holly: 00:51:31

Absolutely. Oh, for sure. It. It does ache to feel lonely. I have experienced that.

Megan: 00:51:35

And it is.

Holly: 00:51:36

It's an ache. I can. I can attest to that.

But um, you know, I think that this is all the more that we open these things up, normalize them for kids, give them a language that no matter what they're experiencing, they are likely to do better. We're likely to do better as their parents as well. Yeah. As their teachers, as their practitioners, so.

Megan: 00:51:56

Right.

Holly: 00:51:58

Yeah. Still a lot to learn, but a lot that we could be applying right now that, you know, and it's like, catch it before it falls. Right.

Have that conversation before it's overwhelming, before we're in acute pain. Absolutely. Yeah.

Megan: 00:52:11

If we've learned anything from adolescence, it's get the kid out of their bedroom and have a conversation.

Holly: 00:52:18

Right. I know. And get them off their phone.

Megan: 00:52:21

Yes. You know, and have.

Holly: 00:52:23

And have that conversation.

Megan: 00:52:25

Yes.

Holly: 00:52:26

Well, this has been an awesome conversation.

Megan: 00:52:29

Speaking of. I agree.

Holly: 00:52:31

Thank you for shedding your light on this. And this isn't the last time we'll talk about kids, I'm sure. You know, kind of like you said with the sprinkling.

I'm sure this will come up in future topics.

You know, as we're talking about family dynamics and about the stress of life and all that, parenthood, you know, can certainly play a big role in all of that. So, you know, and if.

Megan: 00:52:50

If.

Holly: 00:52:51

If any of our listeners have any questions, you know, feel free to reach out to us. We always make sure at the end of these episodes that you have a way to get a hold of Dr. Megan and me and fire away.

Megan: 00:53:02

Yes.

Holly: 00:53:03

If you are questions.

Megan: 00:53:05

So we love it. Maybe we'll do just a full episode of answering questions.

Holly: 00:53:11

Oh, yeah. Can we?

Megan: 00:53:12

That would be really fun.

Holly: 00:53:14

I love that we should even take callers like that. Like, I think I told you silly kind of slash embarrassing. Fun fact is that I was on QVC.

Megan: 00:53:22

Oh, yes.

Holly: 00:53:23

Selling makeup for, like, 10 months. I had no idea what I was doing. And the. The best part was taking a caller. Yeah. And getting a live question on air. And. Yeah, we got to do that. So. Okay.

So write your questions down, y'. All.

Megan: 00:53:38

Yes. Send tomorrow.

Holly: 00:53:39

And I will. Yeah, exactly. We want to hear from you. Well, thanks again for a really enlightening conversation again today, as always.

And although we were talking mostly about kids, we're turning it back to you for a minute because we want you to know, as we always like to sign off and say, on your pain journey, you're going to have setbacks or have frustration, but if your brain is still functioning, if you are still breathing, then what?

Megan: 00:54:02

Dr. Megan, you can change your brain, and therefore, you can change your pain. Yes.

Holly: 00:54:10

You heard it here.

Megan: 00:54:12

Not first, but hopefully more than once.

Holly: 00:54:15

But it will happen. Yep, I can attest to that and Dr. Megan knows it. So anyway, thanks again and and take care of yourselves and each other.

We appreciate you being here and we'll see you next time.

Outro: 00:54:29

Thank you so much for listening to this episode. We appreciate your tuning in and being part of the Unpacking Pain experience.

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You can get in touch at unpackingpain@gmail.com and we'd love to hear your thoughts or questions, your stories, even topics that you'd like us to cover in a future episode. Together, we're all fostering community as we shed light on the realities of living with chronic pain and discover new ways forward.