Cognitive-behavioral Therapy for Chronic Pain in Children and Adolescents

238 Pages·2012·0.93 MB·English

by  Tonya M. Palermo

Cognitive-Behavioral Therapy for Chronic
Pain in Children and Adolescents
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Cognitive-Behavioral Therapy
for Chronic Pain in Children
and Adolescents
TONYA M. PALERMO
1
1

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______________________________________________________________________________________
Library of Congress Cataloging-in-Publication Data
Palermo, Tonya M.
Cognitive-behavioral therapy for chronic pain in children and adolescents / Tonya M. Palermo.
p. cm.
ISBN 978-0-19-976397-9 (pb : alk. paper) 1. Pain in children—Treatment. 2. Cognitive therapy for children.
3. Cognitive therapy for teenagers. I. Title.
RJ365.P38 2012
618.92’0472—dc23 2011045317
ISBN: 9780199763979
______________________________________________________________________________________
9 8 7 6 5 4 3 2
Printed in the United States of America
on acid-free paper
CONTENTS
Foreword vii
Preface xi
Acknowledgments xiii
PART I Introduction to Cognitive-Behavioral Th erapy for
Chronic Pain in Children and Adolescents
1. Th e Problem of Chronic Pain in Children and Adolescents 5
2. A Brief History: Development of Cognitive-Behavioral Th erapy
in Pediatric Pain Management 17
3. Th e Evidence Base for Cognitive-Behavioral Th erapy for Pediatric
Chronic Pain 25
PART II Assessment, Education, and Treatment Planning
4. Assessment and Evaluation 41
5. Education and Treatment Planning 60
PART III Interventions
6. Relaxation, Imagery, and Biofeedback Training 75
7. Parental Intervention Strategies 92
8. Cognitive Skills Training 106
9. School Interventions 116
10. Sleep Interventions 128
11. Lifestyle and Physical Activity Interventions 141
12. Conclusions and Future Directions 152
APPENDICES
1. Pain Diary 163
2. Educational Resources for Parents 164
3. Basic Abdominal Breathing Instructions 166
4. Progressive Muscle Relaxation Script for Younger Children
(under 10 years) 167
5. Progressive Muscle Relaxation Script for Older Children
(ages 10 and above) 169
vi Contents
6. Favorite Pleasant Place 172
7. Muscle Relaxation with Imagery Script 173
8. Relaxation Practice Tips 175
9. Relaxation Practice Log and Diary 176
10. Parent Management Guidelines 187
11. Point System 179
12. Privilege System 181
13. Tips for Parents to Establish an Eff ective Reward System 182
14. Tips for Establishing Good Communication Habits 183
1 5. Positive Coping Self Statements Worksheet 184
16. Th ought Record 185
17. Th ought Continuum Exercise 186
18. Th ought-Stopping Instructions 188
19. Sample School Letter 189
20. Sleep Diary 191
21. Tips for Improving Your Sleep 192
22. Diffi culty Falling Asleep—Stimulus Control Instructions 194
23. Instructions for Activity Pacing 195
24. Pleasant Activities Chart 196
References 197
Index 215
FOREWORD
Across the world many children and young people suff er with persistent pain,
disability, and distress. Although this suff ering is an overwhelming tragedy for
individuals and their families, it is largely ignored by modern societies, perhaps
because the concept of “chronic pain” in children seems diffi cult for us to consider
and accept. Although this collective denial has been dented in recent years, it
remains stubbornly enduring. Young people report pain that reduces their ability
to function in normal society: their schooling is disturbed, friendships are dis-
turbed, family life is altered, emotional control is impaired, depression ensues,
and we suspect that their development is hindered as well. In short, the conse-
quences can be catastrophic for children.
M uch of the suff ering associated with pain is, however, treatable, even when
the pain itself proves stubbornly resistant to cure. In this volume, Dr. Tonya
Palermo, a leader in psychological pain management, brings together for the fi rst
time a full consideration of cognitive behavioral approaches to the management
of chronic pain in youths. Specifi cally, she captures current best practices in cog-
nitive and behavioral interventions, including relaxation training, biofeedback,
and coping skills training. Beyond this, her focus is on critically important areas
of functioning, in particular schooling, sleep, and physical activity. Too oft en psy-
chological therapies can be narrowly focussed on the cognitive, with too little
consideration of the behavioral. Refreshingly, this author grounds psychology in
action. Constantly at stake is how psychology can stimulate a return to more
normal behavior, or promote activity that fosters developmentally appropriate
behavior. Promulgated here is a psychology of doing.
Th is is an important book. Its publication will establish a landmark in the his-
tory of pediatric pain psychology. Just as the publication of Wilbert Fordyce intro-
duced a fi rst full consideration of a behavioral treatment for adults in pain
(Fordyce, 1976 ) and Turk, Meichenbaum, and Genest (1993) expanded it with
cognitive considerations, so Palermo in this volume, with her explicit and unapol-
ogetic focus on the clinical, will establish a standard for clinical practice for work-
ing with children and adolescents with chronic pain. Th is book has brought us up
to date, and drawn a line from which we cannot or should not retreat. Th e task of
viii Foreword
the pain community now is to take up the challenge of therapy-development. In
particular, there are three areas for us to focus on.
(1) First, in Chapter 7 we fi nd a whole chapter devoted to parents. Th e
adults in the child’s environment are, perhaps obviously, very
important. Here we fi nd excellent guidance on how to consider
working eff ectively with parents. We are, however, only at the very
beginning of this science. Let us be clear: it starts with us. Adults in a
child’s environment set the standards for behavior. We model how to be
in pain, how to communicate about that pain, and how to help those in
pain. Despite the importance of adult carers, there is very little research
work and clinical guidance on how to work with parents. First, parents
oft en present with mental health problems of their own, typically
depression, which if untreated may have an impact on their ability to
work rehabilitatively with their child. Second, optimum methods of
working with parents in supporting their child’s adoption of self-
management techniques are unknown. Work in the related fi elds of
spousal relationships has taught us that reassurance and uncritical
positive regard are not always helpful, and that sustaining a supportive
role as a carer can be challenging (e.g., Cano, Miller, & Loree, 2009 ;
Martire, Schulz , Keefe , Rudy , & Starz, 2008 ). Th ird, treatments designed
specifi cally for parents of young people in pain have yet to emerge,
although they have proven promising in the cognate fi eld of pediatric
cancer (e.g., Sahler, Fairclough , Phipps , Mulhern , Dolgin , & Noll , et al.
2005).
(2) Second, it is noteworthy that the author includes a chapter (Chapter 10)
on sleep and sleep disorders. Sleep disorders, including wakefulness,
night terrors, diffi culties falling asleep, and daytime lethargy are for
some a normal part of childhood and adolescence, but they can have
major eff ects on cognition, mood, and social relations. With pain as a
compounding factor, this toxic combination can be diffi cult to treat.
Th is chapter is therefore very welcome, and its inclusion is a notable
extension to previous treatment approaches. More research is needed
on optimal treatment strategies. Although standard sleep hygiene with
its focus on habits is important, we still know very little about the
relationship between cognition and sleep, or about how fear of sleep
(or lack of sleep) may aff ect a patient’s adjustment.
(3) Finally, the author makes us aware throughout the book of the develop-
mental context of young people experiencing pain and disability, or
learning to live with chronic pain in treatment. To some extent it is
perhaps normal pediatric clinical practice to adapt treatment material
and delivery to meet the developmental profi le (including cognitive,
social, and emotional) of the child with pain. However, there is almost
nothing written in guidance about either the eff ects of chronic pain on
childhood development or the important developmental variables to
Foreword ix
take account of in assessment and treatment. To compound this
defi ciency, little is also written about familial and parental development.
New research programs are needed to study the eff ects of pain on the
development of children, parents, and families.
In sum, this book off ers comprehensive guidance on assessment, evaluation,
and treatment of chronic pain. Th e addition of treatment materials in the appen-
dices is also an important feature that will prove helpful to many clinicians.
Pediatric chronic pain management is still a young fi eld, but this volume is an
important summary and punctuation in its development. Th ere is clearly work to
do, but in Cognitive-Behavioral Th erapy for Chronic Pain in Children and Adolescents ,
Palermo provides guidance for those working with children and adolescents with
chronic pain and their parents who are presenting for treatment now.
— Christopher Eccleston, Ph.D.
Professor of Psychology;
Director, Centre for Pain Research
Th e University of Bath, United Kingdom
REFERENCES
Cano , A. , Miller , L. R. , & Loree , A . ( 2009 ). Spouse beliefs about partner chronic pain .
Journal of Pain , 10 , 486 –4 92 .
Fordyce , W . ( 1976 ). B ehavioral Methods for Chronic Pain and Illness . St. Louis, IL :
Mosby .
Martire , L . M. , Schulz , R. , Keefe , F. J. , Rudy , T. E. , & Starz , T. W . ( 2008 ). Couple-oriented
education and support intervention for osteoarthritis: Eff ects on spouses’ support and
responses to patient pain . Family Systems & Health , 26 , 185 –1 95 .
Sahler , O. J. , Fairclough , D. L. , Phipps , S. , Mulhern , R. K. , Dolgin , M. J. , Noll , et al . ( 2005 ).
U sing problem-solving skills training to reduce negative aff ectivity in mothers of chil-
dren with newly diagnosed cancer: Report of a multi-site randomized trial. J ournal of
Consulting & Clinical Psychology , 73 , 268 –2 71 .
Turk , D . C. , Meichenbaum , D., & Genest , M . ( 1983 ). P ain and Behavioral Medicine:
A Cognitive Behavioral Perspective . New York : Guilford Press .