Anna C. Wilson, Ph.D. Pediatric Psychologist Assistant Professor, - - PowerPoint PPT Presentation

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)

 Arthritis

30% moderate-severe

 Cancer

37% moderate-severe

 Chemotherapy

41% moderate-severe

 Crohn’s/IBD

85% mild-moderate

Prevalence of Pain in Children with Serious Conditions

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

• nline 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 Completely withdrawn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

10 20 30 40 50 60 70 80

Playing w/ friends Going to school Schoolwork Gym Running Sports Participants (% ) Child Parent

Palermo, et al., 2004

Developmental Considerations

Age/ developmental level Gender Child temperament Previous pain experiences, including

hospitalizations and medical procedures

 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

Age and Sex

 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/ Pain Functioning

• 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?

Emotions, Thoughts, and Behaviors!

Disease Status/ Acute Pain Functioning/ Chronic Pain

Depression Family Factors Parent Behaviors Avoidance Behavior Withdrawal Stress Sleep Catastrophizing

Negative mood Irritability Lack of pleasure Low motivation Decreased socialization Increased solitary behavior/withdrawal Sleep disturbances

Depressive Symptoms

 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

Depression and the Course of Chronic Pain

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.

Parent behaviors, e.g., solicitous responses or

inadvertent reinforcement of pain

Parent-child interaction Parental modeling/pain history Parenting style Family functioning

Family Models: Parental and Social Factors

 Theory 1: parent acts as a model

 Higher chronic pain risk for children who have a

mother with abdominal pain or headache

 Similar pain locations found in family members

(likely has a genetic component as well)

 Theory 2: Parent pain experiences change their

responses to child pain (be more attentive)

 Maternal modeling and responses to child pain

seem to be more critical than paternal behavior

 Some evidence that girls are more responsive to

maternal behaviors than boys

The Parent with Chronic Pain

Sensitivity to Maternal Interactions

0.5 1 1.5 2 2.5 3 3.5 4 4.5 Boys Girls Pain Promoting Pain Reducing Control Chambers, Craig, & Bennett, 2002 *

 Parent and Teen Health Study (PATHS; PI: Wilson)  Examine a group of adolescents who are at increased

risk for developing chronic pain: Children who have a parent with chronic pain

 Hope to learn more about the influence of parent

pain experiences on adolescent health and pain

• utcomes, as well as cognitions about pain

 Recruiting parents with and without pain and their

11-15 year old children

 Laboratory pain tasks to assess conditioned pain

modulation, as well as exercise tasks to assess general physical functioning

Ongoing Study: PATHS

 Majority do not consult a pain specialist  PCPs may be unsure of where to refer  Pharmacological agents effective with only a minority

• f children

 Psychological services focused on pain management

are often unavailable

Treatment of Chronic Pain

 Independent functioning  Effective problem-solving  Decrease pain behaviors and pain intensity  Restorative sleep & low-impact aerobic exercise  To meet rehab goals incrementally, with a focus on

returning to areas of core functioning first: school attendance, physical activity

 Gain self-management skills for coping  Reduce pain-related anxiety

Goals of Treatment

The Ideal Approach

Patient Pain Physician Psychologist Physical Therapist and/or Occupational Therapist Nurse

Psychological Therapies – Early Development

 Headache management: relaxation-based methods,

biofeedback training, and cognitive-behavioral treatment (CBT) packages (e.g., Labbe & Williamson, 1984;

Larsson et al., 1987)

 Development and testing of home self-management

with CBT strategies (e.g., Help Yourself: A Treatment for Migraine

Headaches, McGrath et al., 1990)

 Family CBT approaches, e.g., for abdominal pain

(Sanders, et al., 1989)

Later Developments

 New populations: e.g., juvenile fibromyalgia

(Kashikar-Zuck, et al., 2005)

 Interdisciplinary treatment programs

incorporating CBT (Eccleston, et al., 2003)

 Greater inclusion of parents in treatment

 Focus on teaching operant strategies (how to reinforce

adaptive behaviors)

 Education about chronic pain  Cognitive therapy methods: Changing thinking, reducing

catastrophizing and fearful thoughts

 Skills acquisition and rehearsal (e.g., relaxation training)  Behavioral change by operant methods  Parental and school involvement  Generalization and maintenance, relapse prevention

CBT for Pain Management

Educational Videos

 http://www.youtube.com/watch?v=4b8oB757DKc&featur

e=youtube_gdata_player

 http://www.ted.com/talks/elliot_krane_the_mystery_of_

chronic_pain.html

 May involve deep breathing, progressive muscle

relaxation, imagery, mindfulness, or biofeedback assisted relaxation

 Goals:

 Teach use of positive coping strategy that provides

distraction or reduces pain focus and reduces physiological arousal

 Produce physiological changes expected to help decrease

pain

 Most promising research is on pediatric headache

Relaxation Therapies

 Activity Pacing

 Avoid overexertion  Increase tolerance through gradual increase of activity time

 Exposure to reduce pain focus, catastrophizing, and

anticipatory anxiety

 Engage in activities despite pain

 Cognitive approaches to reduce pain focus,

catastrophizing, and anticipatory anxiety

 Mental distraction  Positive re-framing

 Re-identify life goals and what is important

Behavioral Skill Building

 Rewarding a child based on their participation in

activities, use of pain control strategies, or other specified goals

 Providing a consequence for failure to meet specified

goals

 e.g., child has all privileges (TV, normal bedtime, phone,

video games, etc.) when he attends school but all privileges are removed on days when school is missed

 Can be used to target a range of adaptive behaviors  Important to start small to ensure high likelihood of

success

 Point systems can also be used

Operant Methods: Contingent Reinforcement

How effective is CBT?

 Palermo, Eccleston, Lewandowski, de C Williams, &

Morley (2010). Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: An updated meta- analytic review. Pain, 148: 387-397.

Meta-analysis of randomized controlled trials of CBT: 25 studies

Pain Conditions # of studies Headache 19 Abdominal pain Abdominal pain or headache 4 1 Juvenile fibromyalgia 1

Treatments Studied

Treatments # of studies Biofeedback 4 Relaxation training 9 CBT 12 Treatment delivery # of studies Clinic vs. home 4 Computer 2 Individual treatment 14 Group treatment 8

• Parents included in treatment n = 7 studies
• M treatment duration in 20 studies = 6.4 hours

Findings from Overall Analysis: Pooled Treatment Conditions

 Psychological therapies reduced pain intensity

by at least 50% in significantly more youth, as compared to control conditions at post- treatment (OR 5.92; 95% CI 4.07 to 8.61, Z=9.31,

p<.0001)

 At 3-month follow-up, similar effects on pain

reduction were found (OR 9.88; 95% CI 5.25 to

18.58, Z=7.11, p< 0.0001)

 The number-needed-to-treat for benefit is 2.64

(CI 2.27 to 3.21) at post-treatment and 1.99 (CI 1.66 to 2.60) follow-up

Pre-Post Findings on Pain Reduction

Post-Treatment Data: Disability and Emotional Functioning

Outcome k Total N SMD Disability 6 220

• 0.24, p =.08

Emotional functioning 6 204

• 0.12, p =.42
• Limited data on disability and mood but it suggests

lack of effect with psychological treatment

Promising New Directions in CBT Treatments for Youth with Chronic Pain

Coping with Pain in School

 Uncontrolled trial of a group-based CBT intervention to improve

school functioning in youth with chronic pain and depressive symptoms

 N = 40 youth, with chronic pain and depressive symptoms (mild

to mod), ages 12 to 17 yrs

 8 hours of group treatment (4 two hour sessions or one-day

workshop format); conjoint and separate parent-adolescent content

 Treatment outcomes: depressive symptoms, pain, school

functioning

 Significant improvement in pain intensity and school attendance from

pre- to post-treatment

Logan & Simons (2010). Development of a group intervention to improve school functioning in adolescents with chronic pain and depressive symptoms: A study

• f feasibility and preliminary efficacy. Journal of Pediatric Psychology.

ACT-Oriented Interventions

 One of the newer developments in CBT includes acceptance

and commitment therapy (ACT)

 Treatment objective is to improve functioning by increasing

psychological flexibility

 32 youth randomized to ACT or Standard Care  10 weekly sessions (range 7-20); sessions with parents as well  Core interventions: exposure to previously avoided situations

and emotions; acceptance as an alternative to avoidance

 Treatment outcomes: function, depressive symptoms, pain

Wicksell, Melin, et al (2009). Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – a randomized controlled trial. Pain 141, 248-257.

ACT-Oriented Interventions

 Findings:

 Both groups improved at post-treatment on function, pain

interference, and quality of life

 The ACT group had significantly more improvement at post-

treatment in pain impairment beliefs, pain interference, and mental well-being compared to the MDT group

Wicksell, Melin, et al (2009). Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – a randomized controlled trial. Pain 141, 248-257.

Internet Intervention

 Web-based Management of

Adolescent Pain (Web-MAP): Internet delivered family CBT modules

 Education about chronic pain  Behavioral skills (e.g., deep breathing and relaxation)  Cognitive skills  Parent multi-component (communication, operant

strategies)

Palermo TM, Wilson AC, et al. Randomized controlled trial of an Internet delivered family cognitive behavioral therapy intervention for children and adolescents with chronic pain. Pain, 2009, 146, 205-213.

Post-treatment Results: Diary Reported Activity Limitations

1 2 3 4 5 6 7 Pre-tx Post-tx Internet treatment (n=26) Wait-list control (n=22) F (1, 45) = 9.25, p = .004, partial n2 = .17

Post-Treatment Results: Diary Reported Pain Intensity

1 2 3 4 5 6 Pre-tx Post-tx Internet treatment (n=26) Wait-list control (n=22) F (1, 45) = 5.28, p = .03, partial n2 = .11

Internet Intervention

 Significant reduction in activity limitations and in pain

intensity in youth receiving Internet CBT in comparison to the control condition

 Internet offers opportunities to extend reach of face to face

treatment and to provide access to care to those who can’t receive treatment in person

 Next phase: multisite study, currently enrolling

Palermo TM, Wilson AC, et al. Randomized controlled trial of an Internet delivered family cognitive behavioral therapy intervention for children and adolescents with chronic pain. Pain, 2009, 146, 205-213.

New Developments in Research

 Emerging focus on specific interventions to target

functional impairment

 Inclusion of functional outcome measures, not just

measures of pain

 Inclusion of parents in treatment studies

 CBT is appropriate for treating pain that IS and IS NOT

associated with serious disease

 A child does not need to be extremely depressed or

anxious to benefit from psychological treatment

 Wide range in child and family readiness to accept

psychological treatments

 CBT is not a replacement for medical care, and often

works best as part of a team approach

Referring a Child or Adolescent to CBT for Pain Management

 Patients and parents have often gotten the (usually

inaccurate) message from providers that pain is “all in your head” or is not real

 CBT can help reduce pain and improve functioning,

and can reduce distress related to pain for the child and family

 CBT can also help address depression and anxiety

symptoms related to pain, as well as sleep problems

 As with any treatment, not every child will benefit

Referring a Child or Adolescent to CBT for Pain Management

Summary

 Chronic pain affects a large number of children and

adolescents who are otherwise healthy, especially adolescent females

 Theory and research supports the role of psychological

factors, including emotions, behaviors, and cognitions, as being important contributors to pain intensity and pain persistence

 Effective treatment for chronic pain, regardless of

etiology, often requires a multidisciplinary approach: medication management, physical therapy, and psychological treatments

Acknowledgments

 Pediatric Health Pilot Project (PI: Wilson): Oregon Clinical and Translational

Research Institute (OCTRI), grant # UL1 RR024140 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research

 Patient-Oriented Career Development Award (PI: Wilson): Adolescents at

risk for chronic pain, NIH/NICHD, grant #K23HD064705

 Medical Research Foundation of Oregon (PI: Wilson): Neurobiological

characterization of familial history risk for chronic pain in adolescents

 Collaborators:  Tonya Palermo, PhD  Amy Lewandowski, PhD

OHSU/Doernbecher Services

 Pediatric Pain Management Clinic: Multidisciplinary team of

providers, includes anesthesiologists, physical therapists, nurses, and psychologists.

 Coping Clinic: CBT, relaxation training, and biofeedback

services for youth with chronic painful conditions.

 Referrals: (503) 418-5188

Ongoing Research Studies

 Parent and Teen Health Study (PATHS): Enrolling

adults with chronic pain and healthy adults and their 11-15 year old children

 Web-based management of adolescent pain (WEB-

MAP2): Internet intervention for 11-16 year olds with chronic pain

 Call: (503) 494-0333

Questions?

Email: longann@ohsu.edu