Anna C. Wilson, Ph.D. Pediatric Psychologist Assistant Professor, Department of Pediatrics Child Development & Rehabilitation Center Oregon Health & Science University
No Dislosures
Overview Definitions, chronic pain prevalence and impact in pediatric populations Developmental issues Models of chronic pain and disability in children Research on family and psychological issues in pediatric patients experiencing chronic pain Research on cognitive behavioral therapy (CBT) for chronic pain in youth What are the ideal treatments for pediatric chronic pain and the goals of psychological treatments in practice?
Types of Pain Acute: < 3 months, often much shorter with steady decline Recurrent: < 3 months of varying intensity, typically w/ pain-free periods Chronic: > 3 months of same pain problem, without apparent biological value (IASP, 2003)
Prevalence of Pain in Children with Serious Conditions Arthritis 30% moderate-severe Cancer 37% moderate-severe Chemotherapy 41% moderate-severe Crohn’s/IBD 85% mild-moderate
Prevalence of Weekly Pain in Children Without Serious Conditions Approximate % of children ages 6-17 report having pain about weekly: Headaches – 30% Migraine – 10% Abdominal pain – 12% Limb pain – 15% Back pain – 30% Other musculoskeletal – 30% (Perquin et al., 2000)
Chronic and Recurrent Pain is a Significant Pediatric Health Problem 20-40% of children and adolescents in community samples experience persistent pain (Perquin et al., 2000; Stanford et al., 2008) More severe persistent pain in 8% Pain accompanied by moderate to severe disability in 5% (Huguet & Miro, 2008) Most common locations: head, abdomen, limbs Multiple pains are common Girls > boys Peak incidence: ages 14-15 years (Stanford et al., 2008)
Why Treat Pediatric Chronic Pain? ⇩ Pain, suffering, and disability ⇧ QOL for child and family ⇩ Risk of ongoing disability related to chronic pain ⇩ Health care utilization
Common Diagnoses in Pediatric Pain Clinics Functional abdominal pain Chronic daily headache Myofascial pain (neck, shoulders, back) Fibromyalgia Complex Regional Pain Syndrome Combinations of diagnoses and locations
Case Examples 17 year old girl with back pain. Been enrolled in online school for 2 years. High depressive symptoms. Negative MRI. Completely withdrawn from physical activities and reports fear of movement. 13 year old boy with headache and fatigue, onset following viral infection. Failed a number of medication trials for headache. Resisting school attendance and refusing to go on long trips. Parents struggling with how much to push him. Some peer rejection at school.
Psychological Aspects of Pain Emotional: Distress and fear, sometimes sadness or irritability/anger, desire for comfort Behavioral: Withdrawal from activities and protective behaviors Cognitive: Thoughts that may or may not be helpful
Psychological Aspects of Pain: Parent Experiences Emotional: Distress and worry, frustration, sadness/loss, irritability/anger Behavioral: Allows or provides different consequences for child, changes in family schedule or activities Cognitive: Thoughts that may or may not be helpful
Consequences of Chronic Pain Child problems: school attendance and performance, sleep disturbances, emotional impact, peer relationships, physical activity Parent and family: burden (medical and lost work costs, time), emotional impact, family cohesiveness, changes in family roles
Children with Chronic Pain: Activity Limitations Child Parent Sports Running Gym Schoolwork Going to school Playing w/ friends 0 10 20 30 40 50 60 70 80 Participants (% ) Palermo, et al., 2004
Developmental Considerations Age/ developmental level Gender Child temperament Previous pain experiences, including hospitalizations and medical procedures
Age and Sex Increase in prevalence of pain problems post-puberty Sex-specific differences in pain emerge during adolescence (girls > boys) Sex-specific differences in depression emerge during adolescence (girls > boys) Complex changes occur with developmental, family, and hormonal factors during this transition
From Hakala et al., BMJ, 2002
Onset of chronic pain for young women: Weekly or more frequent headaches Rhee, 2005; J of Ped Health Care
Developmental Factors, cont. Child factors and temperament: Infants who were more fearful and high in reactivity more likely to have pain and somatic complaints at ages 5-8 Generally anxious kids are more likely to be anxious about pain situations, which can increase pain intensity Higher somatization relates to increased pain and disability Previous pain experiences: Painful NICU procedures shown to change pain pathways, sensitivity, etc. Some children develop anticipatory anxiety
Chronic Pain Development Pain may persist for biological reasons: Secondary to complications arising from chronic disease (e.g., arthritis, sickle cell disease) Persistent or abnormal excitability in the peripheral or central nervous system in the absence of ongoing tissue injury or illness (i.e., neuropathic pain). AND/OR psychosocial reasons: Behavioral factors Family factors Emotional factors Social factors (e.g., peer, school)
Why Study Psychological Factors? Disease/ Functioning Pain • Changes in disease/pain do not necessarily result in changes in functional outcomes (Palermo, 2000; Logan & Scharff, 2005) • The pathway from pain to impairment is likely impacted by many risk factors, including psychological risks (Eccleston, Morley et al., 2002)
Why Study Psychological Factors? Disease Functioning/ Status/ Chronic Pain Acute Pain Depression Family Factors Parent Behaviors Emotions, Avoidance Behavior Thoughts, and Withdrawal Behaviors! Stress Sleep Catastrophizing
Depressive Symptoms Negative mood Irritability Lack of pleasure Low motivation Decreased socialization Increased solitary behavior/withdrawal Sleep disturbances
Depression and the Course of Chronic Pain Associated with . . . pain perception functional disability Predictor of musculoskeletal pain recurrence at 4 year follow-up Associated with the generalization of pain at a 1 year follow-up among children
Psychological Models of Pain and Disability 1) Fear-avoidance cognitions and behaviors 2) Family/parent models: Parental modeling and inadvertent reinforcement
The Fear-Avoidance Model Vlaeyen & Linton, 2000
Fear-avoidance beliefs Cognitions (thoughts and beliefs) about pain being linked to physical activity or movement “Physical activity makes my pain worse” or “I cannot do movements that make my pain worse” Fear-avoidance beliefs are related to higher levels of pain and disability: Well-supported in adults with chronic low back pain (e.g., Jensen et al., 2001; Poiraudeau et al., 2006) Few measures of fear-avoidance beliefs that have been used in children and adolescents
Fear-avoidance in children and adolescents Cognitions and avoidance behaviors develop within a family context Parental responses to child pain may influence cognitions about pain, including fear-avoidance Children and parents play a role in appraising or judging pain to be more or less threatening
Parental Responses to Pain Specific parent responses to child pain behaviors may serve to inadvertently reinforce or encourage pain behaviors Protective or solicitous responses to child pain associated with higher pain intensity and disability (Claar et al., Pain , 2008; Chambers et al., J Ped Psych , 2002) Behaviors include: Frequent attending to pain symptoms Allowing activity withdrawal from less preferred activities (e.g., chores, school attendance) Giving special privileges or rewards
Summary: Fear-avoidance research As in adult chronic pain populations, fear-avoidance beliefs play an important role in adolescent disability Fear-avoidance beliefs seem to be important for adolescents with a variety of pain problems Fear-avoidance beliefs may be less tied to depressive symptoms and pain intensity in adolescents than in adults Parental behaviors in response to adolescent pain may influence adolescent cognitions and fears which in turn increase activity limitations Wilson, A ., Lewandowski, A., & Palermo, T. (2011). Fear-avoidance beliefs and parental responses to pain in adolescents with chronic pain. Pain Research & Management .
Family Models: Parental and Social Factors Parent behaviors, e.g., solicitous responses or inadvertent reinforcement of pain Parent-child interaction Parental modeling/pain history Parenting style Family functioning
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