It takes two: Parent functioning within the pediatric chronic pain experience and interdisciplinary rehabilitation treatment.

OBJECTIVES: The present study aims to examine relationships between parental behavior and cognition and treatment outcomes in children enrolled in an intensive interdisciplinary pain rehabilitation program. RESEARCH METHOD: 670 consecutive referrals of children with chronic pain were enrolled in a clinical database registry from 2009 to 2014. Participants and their parents completed measures of physical and psychosocial functioning, and pain-related severity ratings. Data were taken at three time points: admission (N = 670), discharge (N = 504), and 6-month posttreatment (N = 110), although only complete data from 82 participants was used for final analyses. RESULTS: Both children and parents alike reported significant improvement in functioning, both at discharge and 6 months posttreatment. Parent functioning showed weak to moderate associations with child functioning, with stronger correlations at 6 months posttreatment. Regression analyses demonstrated that changes in parent functioning predicted child functioning and report of pain at 6 months. CONCLUSIONS: Parents are an integral part of a child's pain experience and associated disability. An improvement in parent functioning in the course of chronic pain rehabilitation is linked with functional gains in the child. Future research and clinical programming should target the role of parents in pediatric chronic pain interventions in order to optimize both child and family functioning. (PsycINFO Database Record

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here?

Pediatric chronic pain is a significant problem associated with substantial functional impairment. A variety of risk factors have been found to be associated with chronic pain in youth. The greatest amount of evidence appears to support that temperament, anxiety, depression, subjective experience of stress, passive coping strategies, sleep problems, other somatic-related problems, and parent and/or family factors are important variables. However, a great deal of this research focuses on a single risk factor or on multiple risk factors in isolation. Much of the literature utilizes older diagnostic criteria and would benefit from replication, larger sample sizes, and comparison across pain disorders. Problems also exist with disagreement across definitions, resulting in inconsistency or unclear use of terms. Furthermore, recent consideration has suggested that outcome measures should include functional disability in addition to pain. A second generation of research is needed to shed light on the complex interactions that likely play a role in the transition from acute to chronic pain. Building on recent calls for changes in research in this area, we propose the next steps for this research, which involve consideration of both biopsychosocial and developmental contexts.

The Cost-Effectiveness of Intensive Interdisciplinary Pediatric Chronic Pain Rehabilitation.

OBJECTIVE: Examine the cost-effectiveness of a 3-week interdisciplinary pediatric chronic pain rehabilitation program. METHODS: Self-reported health care utilization and parent missed work of youth with chronic pain (n = 127) at admission and 1-year follow-up were compared. Financials were calculated from program revenue and established national costs for health care and wages. RESULTS: Data indicate significant reductions in days hospitalized, physician office visits, physical/occupational therapy services, psychotherapy visits, and parental missed work. Estimated health care expenses were $61,988 in the year before admission and $14,189 in the year after admission (-$58,839). Estimated cost of missed work was $12,229 in the year prior and $1,189 in the year after (-$11,039). CONCLUSIONS: Comparing estimated expenses before ($74,217) and after ($15,378) minus program costs ($31,720), yielded estimated savings of $27,119 per family in the year following admission. These findings extend the benefit of the program beyond clinical improvement, to outcomes important to both families and insurers.

Adolescents with chronic pain and associated functional disability: A descriptive analysis.

The purpose of this research was to describe the biopsychosocial characteristics of adolescents with chronic pain and functional disability. Data were obtained from a registry of 100 adolescents (mean age = 15.84, SD = 2.72; 21 males) admitted to an interdisciplinary pain rehabilitation program. Clinician ratings were used to categorize coping and personality styles. The most common chief complaint at admission was limb pain (n = 44), followed by headache (n = 21) and abdominal pain (n = 17). Eighteen patients presented with other types of pain. The most frequent triggers to pain were physical trauma, medical condition or disability, and surgery or another medical procedure. Sleep problems, mental health difficulties, and high academic performance were common. Seven previously identified pain-associated disability factors, including passive or dependent coping style, chronic illness in a parent, personality consistent with alexithymia, unresolved family problems, early pain experiences, learning/developmental difficulties, and perfectionistic personality, were common. Ninety-eight adolescents presented with two or more of these contributing factors. Fifty-six adolescents had four or more of the factors. Adolescents with chronic pain and associated disability presented with numerous biopsychosocial factors that relate to their impairment. The understanding and attention to these factors will be important for successful rehabilitation.

The influence of anxiety reduction on clinical response to pediatric chronic pain rehabilitation.

OBJECTIVES: This study investigates the relationship between anxiety reduction and functional outcomes in children and adolescents receiving intensive interdisciplinary rehabilitation services for chronic pain (CP). Specifically, we evaluated whether: (1) anxiety changes over the course of treatment; (2) anxiety covaries with functional outcomes to rehabilitation; and (3) change in anxiety predicts change in functional outcomes from rehabilitation for CP. Using 3 separate measures assessing anxiety-related constructs, we hypothesized that anxiety would be associated with functioning, both before and following intensive rehabilitation for CP. Further, we hypothesized that a decrease in anxiety-related symptoms following rehabilitation would predict a positive change in functional outcomes. MATERIALS AND METHODS: Our sample consisted of 119 children and adolescents treated for CP in an interdisciplinary rehabilitation program between 2007 and 2012. Children completed 3 measures related to anxiety (general anxiety, pain-specific anxiety, pain catastrophizing) and 2 functional outcome measures (eg, Bath Adolescent Pain Questionnaire, PedsQL) as part of clinical care. RESULTS: Measures of anxiety-related constructs were significantly correlated with measures of impairment and functioning, both at admission and at 1-month postdischarge. Regression analyses demonstrated that, after controlling for age, sex, and pain level at admission, a decrease in anxiety significantly predicted between 14% and 40% unique variance in functional outcomes. DISCUSSION: The findings of this study support existing research on anxiety and CP, specifically the relationship between anxiety and pain-related disability. This study also supports the benefit of intensive interdisciplinary rehabilitation for both reducing anxiety and increasing functional outcomes, suggesting a possible link in children's response to intervention. Study limitations and future directions for related research are discussed.

Chronic pain in children and adolescents: 24-42 month outcomes of an inpatient/day hospital interdisciplinary pain rehabilitation program.

PURPOSE: The purpose of this research was to describe 24-42 month outcomes of a combined inpatient/day hospital interdisciplinary pain rehabilitation program for children and adolescents with chronic pain and functional disability. METHODS: One-hundred-seventy-three children and adolescents (mean age=15.1 years, SD=2.5) were treated in the three-week program. Mixed effects regression models (MERM) examined changes over time in pain ratings (0-10), school days missed by children and work days missed by parents in the preceding week, and the number of days hospitalized in the preceding month. RESULTS: Participants reported a significant decline in pain from admission to 24-42 month follow-up. The largest declines in pain occurred from discharge to 1-month follow-up (6.20 vs. 4.81 on a 0-10 numerical rating scale) and from 12 months to 24-42 month follow-up (4.90 vs. 3.56). Two distinct trajectories of treatment response were identified using growth mixture modeling: children with initially high pain ratings exhibited large reductions in pain ratings, while those with lower pain ratings at admission showed minimal reductions. Treatment resulted in significant reductions in school and work days missed and the number of days hospitalized (all p's < 0.001), with reductions evident at 1-month follow-up and maintained through 24-42 month follow-up. CONCLUSIONS: These results suggest that interdisciplinary pain rehabilitation is a promising approach to chronic pain and associated disability in children, with enduring improvements found 24-42 months following program completion. Distinct trajectories of treatment response were identified.

Noninvasive treatments for pediatric complex regional pain syndrome: a focused review.

This is a review of current literature of noninvasive treatments for pediatric complex regional pain syndrome (CRPS). There are a variety of noninvasive approaches to the treatment of pain, but few pediatric-focused studies have been published in regard to CRPS. In comparison with adult CRPS, there is a greater need for behavioral approaches in children to enable coping with difficult symptoms. Current gaps in knowledge include mechanisms triggering CRPS, pediatric-focused diagnostic criteria, validated tests that are diagnostically specific, definitive treatment protocols, age-based medication recommendations, and validation of specific noninvasive treatments in pediatric populations. Intensive multidisciplinary treatment is supported by high recovery rates and a family-centered approach that allows continuation of goals into the community environment.

Chronic constipation, atypical eating pattern, weight loss, and anxiety in a 19-year old youth.

CASE: A 19-year-old female was admitted to a children's hospital weighing 75 pounds. She lost 75 pounds over 2 years and did not menstruate for a year. Despite her dissatisfaction with her thin appearance and desire to weigh more, her inpatient treatment focused on "disordered eating." Adolescent medicine, nutrition, and gastroenterology specialists were consulted. A pediatric psychology consultation was initiated to address anxiety associated with eating as well as abnormal toileting behaviors. The patient reported that she had chronic constipation since the age 3 years with a large, hard, and painful bowel movement once every 1-3 weeks. She had numerous medical and nutritional interventions to improve her bowel functioning, including extensive laxative use and a diet high in fiber (mostly fruits and vegetables). Additionally, an extensive medical evaluation to look for physiological causes for chronic constipation, including Hirschsprung's disease, was not diagnostic. The patient described purposeful stool withholding due to her concern over painful bowel movements. She also avoided peer activities because she did not want to use toilets outside her home. The patient acknowledged that her disordered eating stemmed largely from her toileting difficulties. She described altering her eating habits to avoid bowel movements (e.g., eating small meals, not eating at school) and anxious thoughts while defecating. Defecation anxiety was now affecting other areas of her life. For example, she frequently used copious amounts of toilet paper to ensure thorough cleaning. The patient's parents confirmed her need to thoroughly clean after toilet use, using "almost half a roll of toilet paper." They described other concerning "routines," including refusing to use towels after showering. She dried herself with a fan because of fear that her towel may be dirty. They indicated that during early adolescence, she frequently washed her face to prevent acne breakouts. According to parents, the patient followed doctors' instructions "as though they (were) gospel," deviating from suggestions only with extreme resistance.

A meta-systems approach to evidence-based practice for children and adolescents.

Improving outcomes for children and adolescents with mental health needs demands a broad meta-systemic orientation to overcome persistent problems in current service systems. Improving outcomes necessitates inclusion of current and emerging evidence about effective practices for the diverse population of youth and their families. Key components of the meta-system for children with emotional or behavioral needs include families, cultural norms and values, and service sectors such as schools, pediatric health centers, specialty mental health systems, juvenile justice systems, child protection services, and substance use treatment systems. We describe each component of the meta-system, noting challenges to the provision of evidence-based practice (EBP) and highlighting ways to optimize outcomes. Our focus is on the inclusion of evidence-based assessment and interventions, including prevention, within a developmentally driven and culturally responsive contextual model. Recommendations for addressing disparities in research funding and essential steps to foster communication and coordination of EBP across settings are provided.

Chronic abdominal pain in children: what to do following the medical evaluation.

PURPOSE OF REVIEW: The purpose of this article is to provide an empirically informed but clinically oriented review of conventional, alternative, and rehabilitation therapies for chronic or recurrent abdominal pain in children. RECENT FINDINGS: Cognitive-behavioral procedures, including contingency management training for parents and self-regulation training for children, emerge as a probably efficacious treatment. Symptom-based pharmacological therapies can be helpful, but may be best reserved for children with severe symptoms that have not responded to simple management. Biofeedback therapy, hypnotherapy, and peppermint oil are among the most promising alternative therapies. For patients with severe functional disability, an interdisciplinary rehabilitation approach may be warranted. SUMMARY: As more is learned about different therapies for recurrent abdominal pain, an integrative approach that blends these interventions may become increasingly common.

Integrative approaches to childhood constipation and encopresis.

Constipation and encopresis (fecal soiling) are common childhood disorders that may lead to significant functional impairment. The etiology and course of constipation and encopresis are increasingly conceptualized from a broad biopsychosocial perspective, and therefore a holistic approach to assessment and treatment is indicated. Many children experience symptoms of chronic constipation and/or encopresis that are only partially responsive to conventional medical therapy. Complementary/alternative therapies can often help in the treatment of constipation/encopresis and are well accepted by patients and families.

Recurrent abdominal pain.

The purpose of this article is to provide an empirically informed but clinically oriented overview of behavioral treatment of recurrent abdominal pain. The epidemiology and scope of recurrent abdominal pain are presented. Referral process and procedures are discussed, and standardized approaches to assessment are summarized. Treatment protocols developed by Sanders and colleagues and by Finney and colleagues are described, followed by a review of treatment efficacy. The article concludes with practice recommendations that emphasize the importance of reassurance and education, appropriate and realistic treatment goals, the child's daily functional status, and treatment plans tailored to match the child and family's presentation.