What is the cognitive approach for children with chronic pain? - Chapter 12

What is this chapter about?

Children suffering from chronic pain experience continuous pain or recurrent pain for at least 3 months, which can fluctuate in severity, quality, regularity and predictability. Often they have had many consultations with other professionals. Many chronic pain syndromes involve back pain, abdominal pain and headaches. This chapter focuses on the last two. Chronic pain is a complex problem which, and according to the biopsychosocial model, it consists of three components that cause and maintain the pain experience: a biological component (the physical, the genes, the age, the sex, the temperament), a psychological component (anxiety, former pain experiences, learned pain behavior) and a social component (cultural influences, pain behaviors of others around you, reactions of parents and/or peers).

What does the psychological analysis of chronic pain mean?

In analysing chronic pain, many things need to be mapped:

• Symptom description (where, how long, how intense, how frequent?).
• The triggers (what exacerbates the pain?).
• Its course (when did it start, and how did it go from that point?).
• Behavioural aspects (learning factors?).
• Pain processing (what are the cognitions, emotions and behaviours in pain situations?).
• The role of stress and personality (how does the pain relate to these two factors?).
• Clinical trials and diagnoses (medical background, medication?).
• "Self-therapy" (what has already been tried to treat the pain?).
• Pain in family members (are there other family members with chronic pain?).
• Environment (what is the role and perspective of people in the environment?).

Keeping a pain diary is essential. Other self-report tools (such as assessment scales) can also provide insight into the subjective pain experience. In addition, there are also self-reporting tools for the child that are used for analysing the psychopathological symptoms, the impact on their social life, and the quality of their life. Since sleep disorders are also often part of chronic pain syndromes (Palermo et al., 2011), this should also be mapped. Therapists should focus not only on the child's pain experience, but also on the perspectives of the parents by looking at their assessments. The therapist should also determine what the behaviour of the parents is, so how do they behave when their child is in pain? What does this mean for ‘operant learning’? Operant learning means that if a child is sick and gets a lot of attention when he or she is sick compared to when he or she is happy, he or she might start to feel like that its good to be sick.

How does CBT work for children and adolescents with chronic pain?

Common CBT intervention techniques used to treat chronic pain are relaxation techniques or hypnosis, cognitive or behavioural interventions, biofeedback, acquiring pain management techniques in a situation with acute pain (e.g. in case of a migraine attack), and cognitive-behavioural strategies.

These techniques focus on self-management skills and the development of active coping strategies. The age of the child also determines the specific intervention and the degree of parental involvement. If there is parental involvement, their behaviour (in pain situations) also needs to be determined. The purpose of CBT is:

• To identify and then modify factors that trigger, aggravate and maintain the pain (in both the child and the parent).
• To develop adequate pain management techniques.
• To increase the child's self-efficacy.

In addition, each intervention contains psycho-education about chronic pain and a unique model of the specific pain syndrome is developed from a biopsychosocial perspective.

How is CBT used to manage chronic headaches and abdominal pain?

The prevalence of chronic headaches increases with age, and more girls than boys suffer from it. The most frequent types of (primary) headaches in children and adolescents are migraines (with and without aura, i.e.: focal neurological symptoms) and tension headaches. A typical feature of migraine (besides vomiting) is the pulsating quality of the medium to severe headache on only one side of the head. A migraine attack lasts between 4 and 72 hours. Tension headache is mild to moderate, lasts from minutes to days and is just bilateral (and without vomiting). It is important to pay attention to preventive pain management techniques and pain management techniques in situations of acute pain, as the negative consequences of headaches on the quality of life and the healthy psyche are often underestimated. There are also gender differences in chronic abdominal pain as more girls than boys suffer from this, especially between the ages of 13 and 15. If there is no underlying cause (which is often the case), this is called functional abdominal pain (this includes irritable bowel syndrome). Sometimes children and parents are very frustrated because no organic cause can be found. This frustration needs to be taken into account for further treatment. There is empirical support (based on three meta-analyses) for the effectiveness of CBT in treating chronic headaches and abdominal pains.

What is the role of computer-based CBT for chronic pain?

There is increasing attention to self-help programs for effective and preventive CBT. While this is an innovative, efficient and cost-effective alternative to face-to-face sessions (especially in rural areas), it also has drawbacks.

For example, it is more difficult for the therapist to notice alarming symptoms (such as indications of suicidal behavior), and technical defects can make communication more difficult. Since parental involvement may be necessary, they must also be willing and able to use such technologies.

Children suffering from chronic pain experience continuous pain or recurrent pain for at least 3 months, which can fluctuate in severity, quality, regularity and predictability. Often they have had many consultations with other professionals. Many chronic pain syndromes involve back pain, abdominal pain and headaches. This chapter focuses on the last two. Chronic pain is a complex problem which, and according to the biopsychosocial model, it consists of three components that cause and maintain the pain experience: a biological component (the physical, the genes, the age, the sex, the temperament), a psychological component (anxiety, former pain experiences, learned pain behavior) and a social component (cultural influences, pain behaviors of others around you, reactions of parents and/or peers).