Medical Evaluation

The most crucial component of chest pain evaluation is a thorough physical examination and comprehensive medical history. Patients and parents are likely to be queried about events leading up to, during, and following the episode or episodes of chest pain, as well as details regarding time of onset, frequency, duration, setting, exacerbating and relieving factors, and any other physical symptoms that accompany the chest pain. Any relationship between the pain and body positions, activity, meals, trauma, potential foreign body ingestion, menses, and psychological stress may be noted and explored. It is recommended that adolescents be asked privately about substance use, including illicit substance use. A typical physical examination of a child or adolescent with a chest pain complaint includes auscultation of the heart and lungs, vital signs, general appearance and state, examination of skin and extremities, range of motion and resistance testing of the upper extremities, and palpation of chest wall, musculature, breasts, sternum, and xiphoid. In many cases, a thorough history and physical examination are sufficient to determine the cause. However, some patients are referred for 1 or more specific cardiac, gastrointestinal, or respiratory tests ( Box 1 ) based on the presence of accompanying signs and symptoms ( Box 2 ).

The most serious potential causes of chest pain are cardiovascular and are often a primary concern of children and families seeking medical attention. Diseases of the heart represent a serious public health concern and are the fifth leading cause of death for children aged 1 to 19 years, although most chest pain complaints are not attributable to cardiac problems. Studies report that 1% to 5% of children seen at emergency departments for a primary complaint of chest pain are identified as having a causal heart problem. However, the association of chest pain in adults with cardiac disease and myocardial infarction is well known and patients’ caregivers are likely to perceive chest pain as heart pain. Between 50% and 56% of pediatric patients with chest pain attribute their pain to a heart problem and most report a specific fear of heart attack or heart disease. This fear may persist despite education regarding prevalence. Adolescents who report knowing that heart attacks are unlikely in their age group and that chest pain is generally benign nonetheless tend to attribute their own pain to a heart problem.

The fear and concern reported by patients with chest pain and their families reflects perception of chest pain as potentially dangerous. Public health education regarding hypertension and cardiovascular disease in adults may increase younger individuals’ awareness of cardiac risk factors and the most dangerous potential implications of chest pain. In addition, rare but tragic sudden deaths of local or high-profile young athletes from cardiac ailments are often well publicized. This may increase public estimation of catastrophic cardiac events during childhood and adolescence far beyond actual prevalence rates. It is therefore unsurprising that clinicians overwhelmingly report that both patients and their parents may be frightened by chest pain.

When pain persists following a negative medical evaluation, any psychological distress experienced by children and their families also has the potential to persist. According to follow-up questionnaires sent to patients with chest pain of mixed causes and their parents 1 to 2 years after an initial emergency department evaluation, 34 of the 35 cases who reported continuing chest pain also indicated ongoing worry and concern about that pain. Clinicians report that, in some cases, a parent’s anxiety regarding a child’s chest pain may be such that the child is restricted from participating in sports or strenuous physical activities even after undergoing a medical evaluation with negative results. In addition, medical care providers express concern that parental anxiety may drive a certain amount of health care use by pediatric patients with chest pain, and observe that such anxiety may potentially result in more testing than is diagnostically necessary.

Bidirectional Relationship Between Chest Pain and Emotional Distress

The emotional stress observed in patients with chest pain and their caregivers is particularly relevant given that there is the potential for a bidirectional relationship between chest pain and emotional experiences. In addition to experiencing pain related to organic disease, children may experience the bodily sensation of chest pain, tightness, or pressure as part of the physiological arousal that accompanies strong emotional experiences. As such, any emotional distress that a child might feel regarding their pain has the potential to increase the frequency and severity of that pain. Increased pain may in turn be accompanied by increased distress, and so on ( Fig. 1 ). For patients who experience intermittent episodes of chest pain that reoccur over an extended period of time, the pain has the potential to become preoccupying and may provoke increasingly high levels of persistent worry in patients and caregivers.

Cycle of chest pain, thoughts, and emotions.

Working with Emotionally Distressed Patients

Clinicians may be able to address this distress by acknowledging that chest pain can be a frightening physical symptom. Normalizing the distress about chest pain may encourage patients and their caregivers to be receptive to education about actual childhood prevalence rates of feared cardiac events, such as heart attacks or heart disease. Following the medical examination, diagnosis, and treatment recommendations, we suggest that clinicians check with the patient regarding their anxiety and their current attribution for their pain. If uncertainty is apparent, it may be helpful to suggest to the caregiver that some children need continued reassurance and review of the cause of their pain. Referral for psychological consultation is warranted if the child’s pain exceeds the level that would be expected based on organic causes.

Consultation and Liaison with Medical Treatment Team

It is wise for the referring clinician/and or treatment team to discuss the concerns about the patient with the consulting psychologist. This consultation facilitates ongoing protections of the child’s safety, health, and progress in assessment and treatment planning. Topics of such discussion may include any medical risks, psychological risks (such as suicidality and self-harm), predictors of treatment nonadherence, and any changes in physical symptoms. In addition, the psychologist may be able to discuss the need for other behavioral health–related interventions for problems that the referring physician may not have suggested during the original referral. Some physicians may be less familiar with the benefits of direct referrals to psychologists for the management of psychosocial and behavioral interventions for exercise, risk factor counseling, and risk reduction.

Assessment

The major goal of psychological assessment of a child with chest pain is to integrate medical symptoms and disease with affective, cognitive, behavioral, and familial functioning within the context of overall well-being. Assessment includes interviews with the child and caregiver and the administration of standardized measures of behavioral and psychological functioning. An initial joint conversation allows for rapport building, observation of child/caregiver interactions, and review of informed consent/assent. Because the child will likely have undergone multiple medical appointments, tests, and procedures related to chest pain, the psychologist should quickly orient the child to the purpose and procedures of the meeting. Younger children may need to be reassured that the psychologist is a doctor who will not be administering shots or other painful physical procedures. If the child has been brought to an outpatient setting, it is helpful to determine his or her understanding of the visit and provide orientation to assessment procedures.

For children with conditions that require adherence to effortful treatment regimens, the joint discussion is an appropriate time to determine the distribution of disease-related tasks (eg, what the child does to take care of the disease, what the caregiver does, what other family members do). It may be helpful to playfully ask the child and caregiver to each identify the hardest and easiest disease-related task. This process can offer insight into family dynamics as well as past or current barriers to treatment adherence. Separate interviews following the combined introduction may facilitate both gathering information and establishing relationships with the child and parent. With adolescents, an individual interview is often beneficial even during a brief consultation.

During interviews with the parent, it can be helpful to begin by assessing the child’s typical daily activities, likes, dislikes, and general personality traits. A review of the child’s medical history may then ease into discussion of its effect on the family’s lifestyle and coping methods. Reviewing caregivers’ knowledge about the child’s medical health and their perception of the treatment regimen may reveal additional adherence barriers. In some cases, identifying barriers to adherence may be a primary goal of the assessment. Given the myriad individual, familial, and environmental influences on children’s lives it is often helpful to conceptualize barriers systemically, while remaining mindful of the transactional relationships that may occur both within and across systems ( Fig. 2 ). Expressing empathic, genuine, and nonjudgmental concern for the family may facilitate open and sincere communication from the caregiver.

Possible barriers to adherence.

The form of the child interview will vary depending on the child’s chronologic age and developmental level. When the assessment occurs during multiple appointments, it is often beneficial to balance assessment across structured child and parent diagnostic assessment (ie, using structure or semi-structured diagnostic interview schedules for Diagnostic and statistical manual of mental disorders [DSM-IV]), behavioral assessment (ie, structured observations, parent-child interactions), and parent evaluation (ie, parent report instruments). It is also important to include age-appropriate activities that ensure the child has ample modes to express their pain, coping, and adjustment (eg, verbally, behaviorally, indirectly). For example, it may be helpful to ask children to describe their disease and treatment to assess knowledge and skill level. Asking children to identify a negative aspect of the disease (eg, what they dislike the most about it) may provide insight into both distress levels and adherence barriers. For children whose condition is of recent onset, a discussion of what has changed since their pain began can provide insight into coping and adjustment. Children who have lived with their condition for longer can be asked about what advice or information they would give to a child with a similar condition, and the child’s family. Asking a child whether any peers have been told about the child’s condition, and if so what their reaction has been, can also suggest information about adjustment. In general, the overall goals of assessment are to determine clinical diagnosis identify the target problem area(s) and conceptualize a treatment plan or recommendation.

Chest Pain Analysis

The child’s experience of chest pain is a central focus of assessment. A thorough and detailed understanding of the pain may be best accomplished by beginning with open-ended inquiries (ie, “Tell me a bit about how your chest pain affects your daily life?”), moving on to specific inquiries (ie, “What activities does your pain keep you from doing?”), and eventually progressing to closed-ended inquiries depending on response quality (ie, “Can you run when you have chest pain?”). Beginning with open-ended questions shows caregivers that they are being listened to and can allow children to use creatively descriptive idioms for pain. The form and specificity of subsequent questions are guided by the quality of previous responses. Younger children may need to move quickly into closed-ended questioning. Areas of inquiry can be broadly categorized as pain characteristics, antecedents, alleviating factors, response behaviors, and consequences (see Box 1 ).

Psychiatric Diagnosis

Psychiatric diagnosis is another possible reason for referral. Systematic evaluation of psychopathology can identify difficulties that are causal, exacerbating, or comorbid with chest pain. To this end, the caregiver’s concerns about the child should be elicited and the child should be queried about emotional and behavioral functioning. This questioning may be effectively and thoroughly accomplished by administering structured diagnostic interviews. Because some symptoms may be common to both medical and psychiatric diagnoses, queries should be used to differentiate disease symptoms and natural reactions to a medical diagnosis from clinically significant psychopathology. Box 2 summarizes a few possible child and parent report instruments that may be helpful in screening for and diagnosing psychological difficulties in patients with chest pain.

Intervention

With the exception of a few related medical conditions (eg, asthma), there is a paucity of research evaluating psychological interventions with pediatric patients with chest pain. It is therefore often necessary to adapt protocols developed with physically well children or children with other health conditions to meet the needs of the patient. It is crucial to maintain continuous assessment of patient health and safety as well as symptom improvements and declines. The diverse causes potentially associated with chest pain make it difficult to form generalizations about intervention guidelines. This article provides a few brief general suggestions for promoting positive health behaviors, followed by specific considerations for selected conditions. Clinicians are encouraged to use the references herein as a starting point from which to explore issues that are especially relevant to their own patients.

Promoting Positive Health Behaviors and Reducing Risk Factors

Patients with chest pain but with apparently significant coronary artery disease risk factors or other health compromising behaviors (eg, obesity, physical inactivity, nicotine use) should be referred to appropriate specialists for counseling and/or treatment. The urgency of lifestyle change may vary depending on current health and disease status. Health behaviors particularly relevant to patients with chest pain may include diet and physical activity level. Strategies for eliciting behavior change may include self-monitoring, stimulus control strategies, contingency planning, and breaking long-term treatment goals into discrete components. Older children and adolescents who are ambivalent or negative toward possible behavior change may benefit from motivational interviewing strategies to promote change readiness. In particular, interventions targeting changes in diet and physical activity level often include a familial component because these behaviors often reflect the lifestyle of the family as a whole. Patients with chest pain who are overweight may benefit from lifestyle interventions delivered in a group setting. Children and families who successfully complete health behavior interventions are likely to require some sort of follow-up service to maintain lifestyle changes and changes in health status.

Assessment

The major goal of psychological assessment of a child with chest pain is to integrate medical symptoms and disease with affective, cognitive, behavioral, and familial functioning within the context of overall well-being. Assessment includes interviews with the child and caregiver and the administration of standardized measures of behavioral and psychological functioning. An initial joint conversation allows for rapport building, observation of child/caregiver interactions, and review of informed consent/assent. Because the child will likely have undergone multiple medical appointments, tests, and procedures related to chest pain, the psychologist should quickly orient the child to the purpose and procedures of the meeting. Younger children may need to be reassured that the psychologist is a doctor who will not be administering shots or other painful physical procedures. If the child has been brought to an outpatient setting, it is helpful to determine his or her understanding of the visit and provide orientation to assessment procedures.

For children with conditions that require adherence to effortful treatment regimens, the joint discussion is an appropriate time to determine the distribution of disease-related tasks (eg, what the child does to take care of the disease, what the caregiver does, what other family members do). It may be helpful to playfully ask the child and caregiver to each identify the hardest and easiest disease-related task. This process can offer insight into family dynamics as well as past or current barriers to treatment adherence. Separate interviews following the combined introduction may facilitate both gathering information and establishing relationships with the child and parent. With adolescents, an individual interview is often beneficial even during a brief consultation.

During interviews with the parent, it can be helpful to begin by assessing the child’s typical daily activities, likes, dislikes, and general personality traits. A review of the child’s medical history may then ease into discussion of its effect on the family’s lifestyle and coping methods. Reviewing caregivers’ knowledge about the child’s medical health and their perception of the treatment regimen may reveal additional adherence barriers. In some cases, identifying barriers to adherence may be a primary goal of the assessment. Given the myriad individual, familial, and environmental influences on children’s lives it is often helpful to conceptualize barriers systemically, while remaining mindful of the transactional relationships that may occur both within and across systems ( Fig. 2 ). Expressing empathic, genuine, and nonjudgmental concern for the family may facilitate open and sincere communication from the caregiver.

Possible barriers to adherence.

The form of the child interview will vary depending on the child’s chronologic age and developmental level. When the assessment occurs during multiple appointments, it is often beneficial to balance assessment across structured child and parent diagnostic assessment (ie, using structure or semi-structured diagnostic interview schedules for Diagnostic and statistical manual of mental disorders [DSM-IV]), behavioral assessment (ie, structured observations, parent-child interactions), and parent evaluation (ie, parent report instruments). It is also important to include age-appropriate activities that ensure the child has ample modes to express their pain, coping, and adjustment (eg, verbally, behaviorally, indirectly). For example, it may be helpful to ask children to describe their disease and treatment to assess knowledge and skill level. Asking children to identify a negative aspect of the disease (eg, what they dislike the most about it) may provide insight into both distress levels and adherence barriers. For children whose condition is of recent onset, a discussion of what has changed since their pain began can provide insight into coping and adjustment. Children who have lived with their condition for longer can be asked about what advice or information they would give to a child with a similar condition, and the child’s family. Asking a child whether any peers have been told about the child’s condition, and if so what their reaction has been, can also suggest information about adjustment. In general, the overall goals of assessment are to determine clinical diagnosis identify the target problem area(s) and conceptualize a treatment plan or recommendation.

Chest Pain Analysis

The child’s experience of chest pain is a central focus of assessment. A thorough and detailed understanding of the pain may be best accomplished by beginning with open-ended inquiries (ie, “Tell me a bit about how your chest pain affects your daily life?”), moving on to specific inquiries (ie, “What activities does your pain keep you from doing?”), and eventually progressing to closed-ended inquiries depending on response quality (ie, “Can you run when you have chest pain?”). Beginning with open-ended questions shows caregivers that they are being listened to and can allow children to use creatively descriptive idioms for pain. The form and specificity of subsequent questions are guided by the quality of previous responses. Younger children may need to move quickly into closed-ended questioning. Areas of inquiry can be broadly categorized as pain characteristics, antecedents, alleviating factors, response behaviors, and consequences (see Box 1 ).

Psychiatric Diagnosis

Psychiatric diagnosis is another possible reason for referral. Systematic evaluation of psychopathology can identify difficulties that are causal, exacerbating, or comorbid with chest pain. To this end, the caregiver’s concerns about the child should be elicited and the child should be queried about emotional and behavioral functioning. This questioning may be effectively and thoroughly accomplished by administering structured diagnostic interviews. Because some symptoms may be common to both medical and psychiatric diagnoses, queries should be used to differentiate disease symptoms and natural reactions to a medical diagnosis from clinically significant psychopathology. Box 2 summarizes a few possible child and parent report instruments that may be helpful in screening for and diagnosing psychological difficulties in patients with chest pain.

Intervention

With the exception of a few related medical conditions (eg, asthma), there is a paucity of research evaluating psychological interventions with pediatric patients with chest pain. It is therefore often necessary to adapt protocols developed with physically well children or children with other health conditions to meet the needs of the patient. It is crucial to maintain continuous assessment of patient health and safety as well as symptom improvements and declines. The diverse causes potentially associated with chest pain make it difficult to form generalizations about intervention guidelines. This article provides a few brief general suggestions for promoting positive health behaviors, followed by specific considerations for selected conditions. Clinicians are encouraged to use the references herein as a starting point from which to explore issues that are especially relevant to their own patients.

Promoting Positive Health Behaviors and Reducing Risk Factors

Patients with chest pain but with apparently significant coronary artery disease risk factors or other health compromising behaviors (eg, obesity, physical inactivity, nicotine use) should be referred to appropriate specialists for counseling and/or treatment. The urgency of lifestyle change may vary depending on current health and disease status. Health behaviors particularly relevant to patients with chest pain may include diet and physical activity level. Strategies for eliciting behavior change may include self-monitoring, stimulus control strategies, contingency planning, and breaking long-term treatment goals into discrete components. Older children and adolescents who are ambivalent or negative toward possible behavior change may benefit from motivational interviewing strategies to promote change readiness. In particular, interventions targeting changes in diet and physical activity level often include a familial component because these behaviors often reflect the lifestyle of the family as a whole. Patients with chest pain who are overweight may benefit from lifestyle interventions delivered in a group setting. Children and families who successfully complete health behavior interventions are likely to require some sort of follow-up service to maintain lifestyle changes and changes in health status.

Cardiac Chest Pain

Because of the need to rule out cardiac causes in many cases, chest pain is the second most common reason, following heart murmur, for referral to a pediatric cardiologist. On the rare occasions when pediatric chest pain is associated with serious cardiac illness, prompt recognition, evaluation, and intervention are essential to protect against an adverse outcome; conversely, diagnostic error may lead to morbidity or morality. Undergoing an extensive medical evaluation for chest pain may be anxiety provoking for pediatric patients and their families. Patients referred for cardiac testing may experience significant chest pain–related concern during the interim between referral and testing, even if they are reassured that their pain is unlikely to be causally linked to a heart problem. Only 20% of adolescents who are referred from primary care for cardiac evaluation report feeling reassured by a primary care provider, with 30% reporting increased anxiety after their appointment. Therefore, short time intervals between referral and further tests are desirable not only medically but also from a psychological viewpoint.

Research indicates that 6% to 12% of patients with chest pain referred to a pediatric cardiologist for testing will receive a cardiac diagnosis. Some patients with cardiac diagnoses may benefit from psychological consultation. Cardiac disorders that are not associated with psychopathology per se may nonetheless have significant lifestyle implications that place patients at risk for adjustment difficulties. Patients may be required to refrain from activities such as organized sports or adhere to medication regimens. Patients and families may also need assistance in coping with the emotional ramifications of a heart condition that increases a child’s risk of morbidity. Even conditions that are objectively low risk nonetheless have the potential to provoke strong emotional reactions from parents and children.

Congenital Heart Disease

At times, chest pain may occur in patients with a history of congenital heart disease (CHD). CHD may function as an ongoing stressor for both the patient and their family. A meta-analysis of research regarding behavioral functioning in children with CHD suggests that children 10 years or older are rated by parents as having more internalizing and externalizing problem behaviors than healthy controls. The children themselves indicate increased depression. Overall, children with CHD seem especially at risk for internalizing problems during late childhood and early adolescence, such as mood and anxiety disorders, relative to externalizing behavior problems.

Children with more severe CHD may also be at greater risk for cognitive difficulties as well as mild motor deficits and language difficulties. Children with surgically corrected CHD may be particularly at risk for academic difficulties. However, little research has been conducted on psychological or academic interventions with this population specifically. These patients may nonetheless benefit from psychological and academic interventions. Overall, CHD is associated with an increased risk for emotional and cognitive difficulties. Emotional difficulties such as anxiety and depression may be especially relevant for older children and adolescents.

Clinical Considerations for Work with Patients with CHD

Mitral Valve Prolapse

Children with mitral valve prolapse (MVP) are often referred for psychological assessment and treatment, partly because of the similarity between the cardiovascular symptoms of the MVP and the manifestations of panic attacks, including palpitations, chest pain, fatigue, dizziness, and a sensation of fainting. Although medical treatment is not indicated for most patients with MVP, it is generally beneficial to collaborate with the cardiologist to help the child and the family to identify what physical symptoms merit calling the physician. This process includes identifying urgent and nonurgent symptoms of concern. Second, the autonomic symptoms associated with MVP can frighten children and their caregivers. In some cases, the symptoms are linked with the presence of anxiety disorders. Both children and their caregivers may benefit from education about MVP, psychoeducation about the physiology of emotions, especially anxiety and panic, and cognitive and behavioral skills in emotion regulation, particularly skills in managing the autonomic symptoms of hyperarousal. For the child with MVP, the intense physical symptoms and the fear and confusion can result in a panic attack. In some cases, children develop an enduring fear of having additional symptoms, and become hypervigilant to the slightest bodily sensation (eg, sensations of warmth, sweaty palms, slight heart rate changes). This fear may trigger the release of stress hormones (those that induce panic attacks), thus initiating and/or escalating a new panic attack. For children with chest pain who also meet diagnostic criteria for an anxiety disorder, the child and caregiver may benefit from a full course of evidence-based treatment of that disorder.