What does pain look like?

We probably know what it feels like. But if you had to express pain, what would it look like?

A group of Indigenous children and teenagers from four First Nations communities in the Maritimes were asked to paint their pain, to express their hurt through art. Researchers were hoping to tease out emotions from a population more inclined to show resilience to pain, and in that to better understand how their pain is experienced and interpreted.

John Sylliboy hangs one of 22 pieces of artwork by Indigenous children during an art exhibit at Toronto's Sick Kids hospital, while Sharon Rudderham, a health director at the Eskasoni Health Centre, watches. Both are with the Aboriginal Children's Hurt and Healing Initiative. (Ed Ou/CBC News)

"Aboriginal children feel and experience pain just like anyone else. It's just that they express their pain very differently," said John Sylliboy, community research co-ordinator with the Aboriginal Children's Hurt and Healing Initiative.

"They don't necessarily verbalize their pain, or they don't express it outwardly through crying or through pain grimaces," he told CBC News.

These children are socialized to be stoic about their pain, to hold in their pain. - Margot Latimer, Centre for Pediatric Pain Research, IWK Health Centre

"A lot of kids, they just suck it up," said Sylliboy. "That's what they say all the time. 'We just suck it up.'"

The genesis of this initiative started in 2008, when Margot Latimer, a clinical scientist at the Centre for Pediatric Pain Research at the IWK Health Centre in Halifax, made an observation.

"We noticed we weren't seeing any First Nations youth referred to our pain clinic at the IWK hospital and wondered why that was so."

Latimer is a co-principal investigator with the Aboriginal Children's Hurt and Healing Initiative.

This painting didn't come with a narrative. It was painted by an 11-year-old indigenous child. It shows a child crying and in some form of pain. (Aboriginal Children's Hurt and Healing Initiative)

It didn't make sense, she thought — especially since research shows that chronic illness in First Nations communities is almost three times higher than in the general population.

Aboriginal children are especially vulnerable, says Latimer, with higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis.

But they're less likely to be treated for what ails them.

And so Latimer wondered: "What was happening there? Do they conceptualize pain differently? Do they manage it themselves? Is there something that they're doing that maybe we can learn from?"

Children learn to be 'stoic'

Early findings in the study revealed there's no simple answer. Rather, say researchers, a "complex mix of factors have led to a cultural divide for First Nations children in pain, and non-Aboriginal health care providers."

"These children are socialized to be stoic about their pain, to hold in their pain," says Latimer. "We heard repeated stories about needing to be brave, [it's] a weakness to show pain."

The artist, 16, wrote: 'It's basically about emotional pain, … her loneliness, and how this represents how far away she's away from her happiness.' (Aboriginal Children's Hurt and Healing Initiative)

Latimer and Sylliboy agree cultural traditions, and lingering effects from the residential school system, are some of the reasons Indigenous kids pull on their suit of armour against pain and hurt.

The kids … they started drawing something else, which was emotional pain, something we didn't ask. - John Sylliboy, Aboriginal Children's Hurt and Healing Initiative

"These children live in houses with extended family," says Latimer. "They live with their grandparents, and some of their parents attended residential school. They hear the stories."

This is where the art workshop was an invaluable exercise.

The Indigenous children and teenagers transformed blank canvasses into sometimes dark, sometimes hopeful images of physical pain.

And then researchers noticed something surprising and unexpected.

"The kids … they started drawing something else, which was emotional pain, something we didn't ask. And they started expressing it in a way that was phenomenal," said Sylliboy.

The painter, 15, said: 'I did this painting on hope because pain does not last forever and it stands for hold on, pain ends. And the birds is the pain going away, like flying away. And pain takes place all around the world.' (Aboriginal Children's Hurt and Healing Initiative)

"These kids told us about loneliness, sadness, darkness, bullying, hopelessness. It's not the typical anxiety [or] depression. It is more complex than that."

The researchers believe this could be a valuable lesson in clinical settings.

"To these clinicians who are just asking about physical pain and not looking at emotional pain as well, it is important, because Aboriginal kids are showing us that there is no difference between emotional and physical pain", said Sylliboy. "It's just pain."

'I drew two sides of one story,' the 16-year-old artist wrote. 'It's about emotional pain. They can put on a smile throughout the day and pretend to laugh, and have a fake smile, but really on the inside they feel so lost and alone in the dark.' (Aboriginal Children's Hurt and Healing Initiative)

It's all about creating a safe space for the children when they come to the hospital, says Latimer. She says it's about learning a bit about them and gaining their trust.

"When they come to the health centre, or a physician or a nurse practitioner, they want to tell their story, but we do not train health professionals to assess pain that way." she says. "We train health professionals to assess pain based on zero to 10. We assign a number of intensity to it."

Dale Sheppard, of the Art Gallery of Nova Scotia, helps set up an art exhibit at Toronto's Sick Kids Hospital. Indigenous young people from the Maritimes expressed their pain through art. (Ed Ou/CBC News)

The Canadian Institutes of Health Research is committing part of a $25 million grant to the Aboriginal Children's Hurt and Healing Initiative. That is enough money, say researchers, to expand their research to six additional Indigenous communities.

The children's art meanwhile, was recently showcased at the Sick Kids Hospital in Toronto and is set to travel to other Canadian cities in the coming months.