AREAS OF FOCUS
Pediatric Chronic Pain
Chronic pain is pain that persists long after an injury or illness should have healed, and in children it is far more common than most people realize. A 2024 analysis published in PAIN found that one in five children and adolescents worldwide live with chronic pain. It often follows an injury, an illness, or a period of stress, and it can affect school, sleep, friendships, and family life. For a child living with chronic pain, the search for answers can be long and confusing, especially when the tests come back normal, but the symptoms are real. The pain is real, and with the right approach, most children improve.
Why the tests often come back normal
Standard tests such as X-rays, MRIs, and bloodwork assess the body’s structure: bones, joints, tissues, and inflammation. In many children with chronic pain, that structure is normal because the problem lies in how the nervous system processes and interprets pain signals, which these tests cannot detect. Families are often told that nothing is wrong, even though their child is clearly in pain. Normal results do not mean there is nothing wrong. They mean the cause lies in signaling rather than in structure.
The forms it takes
Chronic pain in children takes several forms. Some children develop pain amplification syndrome, in which the nervous system turns up the volume on pain, so that even a light touch or normal activity can hurt. Others develop complex regional pain syndrome, a localized form of amplified pain that usually centers on one limb and causes visible changes such as swelling and shifts in color and temperature. Pain also accompanies dysautonomia and POTS, as well as inflammatory diseases such as juvenile arthritis, in which the immune system drives the pain. Because these conditions overlap and can resemble one another, identifying which one a child has is the first step toward the right treatment.
How it affects a child's life
Chronic pain in young people affects school, sports, friendships, family life, and mental health. It is often accompanied by poor sleep, fatigue, and the anxiety that naturally follows pain no one can explain. A child may miss school or pull back from activities they love, even when they look well on the outside. Being believed matters a great deal here, because a child who is treated as if the pain were imagined can become more isolated, which can make recovery harder.
What helps
Treatment depends on what is driving the pain. For amplified pain, the instinct is to rest and protect the painful area, but that often makes things worse. The most effective treatments retrain the nervous system toward more normal functioning through steady, graded physical activity, attention to sleep and stress, and sometimes support from a psychologist who understands pain. When an inflammatory disease is causing the pain, treating that disease comes first. Recovery is rarely quick or linear, but most children improve, especially when the condition is recognized early and treated in a coordinated way.
How Dr. Shulman approaches it
Dr. Shulman is a pediatric rheumatologist who cares for children and teens with chronic pain, including pain amplification syndromes, complex regional pain syndrome, and pain associated with dysautonomia and inflammatory disease. Colleagues refer patients whose pain does not fit a pattern. He knows chronic pain from both sides of the exam table, as a physician and as a patient who has lived with its challenges, and he writes about it in his forthcoming book, Cramp: A Doctor’s Notes on Pain. His starting point is that a child in this much pain deserves to be believed while the work of getting better continues.
Frequently Asked Questions
What counts as chronic pain in a child?
Chronic pain is pain that persists long after an injury or illness should have healed, or pain that keeps returning over weeks or months. It can be constant or intermittent, and it can remain in one area or move around the body. What makes it chronic is how long it lasts and how much it disrupts a child’s daily life.
Is my child’s pain real if the tests are normal?
Yes. Standard tests assess the body’s structure, but in many forms of chronic pain, the problem lies in how the nervous system processes pain signals, which these tests cannot detect. The pain a child experiences is exactly as reported. A child who is treated as if they were making it up can get worse, so being believed is part of getting better.
What causes chronic pain in children?
Chronic pain can follow a minor injury, an illness, or a period of stress, and it often outlasts the original cause. In some children, the nervous system becomes oversensitive and continues to signal pain even after the original cause has healed. In others, an ongoing condition such as juvenile arthritis drives the pain through inflammation. Identifying which process is at work guides treatment.
Can children recover from chronic pain?
Yes. Most children improve, and many recover fully. For amplified pain, recovery usually involves retraining the nervous system through steady, graded activity, attention to sleep and stress, and sometimes support from a pain psychologist. The process takes time and is rarely linear, but the outlook is genuinely hopeful, especially when the condition is recognized early and treated in a coordinated way.
What should I do if my child has ongoing pain?
A helpful first step is to describe the pattern clearly to a doctor, including how long the pain has lasted, what seems to trigger it, and how it affects school, sleep, and activity. From there, families often work with a clinician experienced in pediatric pain. The most important early steps are obtaining the right diagnosis, avoiding a cycle of increasingly extensive testing that yields no findings, and starting treatment that addresses the cause.
Does chronic pain look different in adults than in children?
Chronic pain is common in adults as well, and the CDC reports that one in four American adults lives with it. In adults, it more often presents as widespread pain, overlaps with conditions such as fibromyalgia, and tends to occur alongside other chronic health issues and a longer history of unexplained symptoms. Adults are also more likely to have spent years being told their tests are normal, which makes recognition and being believed all the more important.
Dr. Shulman specializes in treating children and adolescents. Adults who recognize this pattern in themselves can discuss it with their physician or request a referral to a specialist in adult chronic pain.
For appointments or clinical questions, please contact Rady Children’s Health Orange County (formerly CHOC).