Complementary Medical Therapies for Pain Management

Behavioral Medicine in Pediatric Pain Management

By Rupa Gambhir, PsyD
Department of Anesthesiology, Critical Care and Pain Medicine
Boston Children’s Hospital
Department of Psychiatry
Harvard Medical School

Indications for Behavioral Medicine in Pediatric Chronic Pain Management

The significance of behavioral medicine in pediatric pain management stems directly from the most widely accepted definition of pain, that is, “an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage” (IASP). Many youth with chronic pain have seen numerous medical specialists, undergone expensive evaluations and treatments, and tried many different pain medications without resolution of their pain symptoms. The recognition that the biomedical model alone cannot explain or treat chronic pain has led to the understanding that pain is triggered, maintained, and amplified by a complex interplay of various biological, psychological, and social factors (Biopsychosocial Model). An individual’s genetics, mood and temperament, history with painful experiences, and social and environmental responses to pain are key determinants in the evolution of their pain experience and must all be considered to effectively address a patient’s pain, distress, and disability. Pain symptoms commonly result in anxiety, fear, and depression, which if unaddressed, make the pain more difficult to manage. Chronic pain develops and intensifies as a result of attentional processes and fear avoidance behaviors (Fear Avoidance Model). A prior history of emotional difficulties may increase youth’s vulnerability to catastrophizing, hypervigilance, and behavioral withdrawal that serve to maintain the pain-disability cycle.

Cognitive Behavior Therapy

Behavioral medicine approaches for youth with chronic pain fall under the umbrella term of cognitive behavior therapy (CBT). Cognitive behavior therapy is evidence based, goal-oriented psychological therapy that involves teaching coping skills to help modify maladaptive cognitive processes and physiological reactivity that serve to heighten pain responses.  CBT is individualized to address the various factors that trigger and exacerbate pain symptoms. A primary goal of CBT is to reduce pain related functional disability to improve school performance, sleep, and physical activity routines that are commonly compromised in relation to pain. Another important focus of psychological treatment is to reduce frequently co-occurring symptoms of anxiety and depression that make it harder for youth to deal with their pain. A variety of specific cognitive behavioral interventions are utilized including cognitive skills training, acceptance and commitment therapy (ACT), relaxation and biofeedback training, and parent centered interventions.

Psychoeducation is a crucial foundation to pediatric chronic pain intervention and often involves a reconceptualization of pain to help the patient and family move from a view of pain as purely sensory/biomedical to multidimensional.

Cognitive skills training addresses “automatic thoughts” or mental messages about pain that modulate the ensuing fear or comfort the patient experiences. Cognitive perceptions that the pain is horrible, will be unmanageable, or highly disruptive often serve to intensify the pain experience. Cognitive interventions center on promoting thought awareness and perspective taking to challenge and change negative self-talk, replace unhealthy behavior with more adaptive behavior, and recover control of their lives.  

Acceptance and Commitment Therapy (ACT) aims at changing the way people experience their thoughts, feelings, and sensations (rather than change them), to disconnect from the struggle with pain (even though the pain may still be there), and engage in behavior that is consistent with their values and goals.  Mindfulness based methods as well as other skills training may be used. 

Relaxation training aims at decreasing the sympathetic nervous system arousal (fight or flight response) that is generated by pain (in this case, the danger signal). In chronic pain, this system is activated repeatedly and goes from being adaptive to maladaptive (or stuck in a persistent state of high reactivity). This phenomenon, known as central sensitization affects brain structure and function as well as the developing immune and hormonal systems in ways that eventually serve to directly maintain the chronic pain irrespective of external factors. Relaxation techniques including diaphragmatic breathing (“belly breathing”), guided imagery (going to a “favorite place”), mindfulness, and progressive muscle relaxation (systematic tensing and relaxing of various muscle groups) serve to decrease the body’s stress response and reverse the physiological reactivity (such as elevated respiration and heart rate, muscle tension) that supports pain maintenance and exacerbation.  Biofeedback uses technology to visually display patient’s physical reactions to stress while teaching them physical and mental exercises to help them fine tune their relaxation response.

Parent training addresses unintentional parental reinforcement of pain (special attention, being excused from school or chores) and encourages positive family coping (reduced pain checks, modeling healthy behavior) in order to help scaffold their child’s improved function. 

Identifying a Behavioral Medicine Specialist for a Pediatric Pain Patient

Cognitive behavioral strategies, like any other new skills, require an appropriate framework and regular practice to be effective. Working with a qualified pediatric behavioral medicine specialist may greatly enhance patient’s ability to learn and employ effective pain coping skills. There are a few important considerations when referring pediatric pain patients for behavioral medicine. First, patients must understand that the referral is not because their pain is psychological or just in their mind but that it is real and influenced by behavioral, psychological and social factors. In addition, CBT is an important way for them to learn ways to cope more effectively with their pain and reduce its negative impact on their lives. CBT offers a variety of non-pharmacological approaches to address the patient’s particular challenges with pain. Specific ways to locate a qualified pediatric behavioral pain medicine specialist include:

1. Identify pediatric pain medicine programs in academic medical settings or specialty medical services that treat youth with pain since behavioral medicine providers are often employed as part of the multidisciplinary pain team.  The American Pain Society (APS) lists many comprehensive pediatric pain treatment programs across the county. 
2. Contact professional organizations that focus on pediatric psychology and CBT such as the American Psychological Association (APA) and Association of Behavior and Cognitive Therapists (ABCT). These can also be helpful resources to identify a pain psychologist.
3. Ask primary care physicians or insurance company member services about pediatric behavior health providers who specialize in CBT, chronic pain, or coping with chronic medical illness.

References:

1. Noel, M. Parker, JA, Petter, M., Chambers, CT. Cognitive Behavioral Therapy for Pediatric Chronic Pain: The Problem, Research, and Practice. Journal of Cognitive Psychotherapy. 2012 26(2):143-156
2. Palermo, T. (2012). Cognitive Behavior Therapy for Chronic Pain in Children and Adolescents. New York, NY: Oxford University Press
3. Turk, DC & Gatchel, RJ Ed. (2002), Psychological approaches to pain management: a practitioner’s handbook (2nd ed). New York, NY: Guilford Press
4. Gatchel, RJ, Peng, YB, Peters, ML, Fuchs, PN, Turk, DC. The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions. Psychological Bulletin. 2007. 133(4): 581-624
5. Simons LE, Kaczynski KJ. The Fear Avoidance model of chronic pain: examination for pediatric application. J Pain. 2012 Sep;13(9):827–35
6. Zagustin, TK. The Role of Cognitive Behavior Therapy for chronic pain in adolescents. PMRJ. 2013, Aug;5 (8), 697-704

Websites:

1. American Psychological Association. Division 54. www.societyofpediatricpsychology.org.
2. American Pain Society. www.ampainsoc.org.
3. Association for Behavioral and Cognitive Therapies. www.abct.org