Emily F. Law

Psychological therapies for the management of chronic and recurrent pain in children and adolescents

BACKGROUNDnThis is an update of the original Cochrane review first published in Issue 1, 2003, and previously updated in 2009 and 2012. Chronic pain affects many children, who report severe pain, disability, and distressed mood. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update focuses specifically on psychological therapies delivered face-to-face, adds new randomised controlled trials (RCTs), and additional data from previously included trials.nnnOBJECTIVESnThere were three objectives to this review. First, to determine the effectiveness on clinical outcomes of pain severity, disability, depression, and anxiety of psychological therapy delivered face-to-face for chronic and recurrent pain in children and adolescents compared with active treatment, waiting-list, or standard medical care. Second, to evaluate the impact of psychological therapies on depression and anxiety, which were previously combined as mood. Third, we assessed the risk of bias of the included studies and the quality of outcomes using the GRADE criteria.nnnSEARCH METHODSnSearches were undertaken of CENTRAL, MEDLINE, EMBASE, and PsycINFO. We searched for further RCTs in the references of all identified studies, meta-analyses, and reviews. Trial registry databases were also searched. The date of most recent search was January 2014.nnnSELECTION CRITERIAnRCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment, standard medical care, or waiting-list control for children or adolescents with episodic, recurrent or persistent pain were eligible for inclusion. Only trials conducted in person (face-to-face) were considered. Studies that delivered treatment remotely were excluded from this update.nnnDATA COLLECTION AND ANALYSISnAll included studies were analysed and the quality of outcomes were assessed. All treatments were combined into one class, psychological treatments. Pain conditions were split into headache and non-headache. Both conditions were assessed on four outcomes: pain, disability, depression, and anxiety. Data were extracted at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (between three and 12 months post-treatment).nnnMAIN RESULTSnSeven papers were identified in the updated search. Of these papers, five presented new trials and two presented follow-up data for previously included trials. Five studies that were previously included in this review were excluded as therapy was delivered remotely. The review thus included a total of 37 studies. The total number of participants completing treatments was 2111. Twenty studies addressed treatments for headache (including migraine); nine for abdominal pain; two for mixed pain conditions including headache pain, two for fibromyalgia, two for recurrent abdominal pain or irritable bowel syndrome, and two for pain associated with sickle cell disease.Analyses revealed psychological therapies to be beneficial for children with chronic pain on seven outcomes. For headache pain, psychological therapies reduced pain post-treatment and at follow-up respectively (risk ratio (RR) 2.47, 95% confidence interval (CI) 1.97 to 3.09, z = 7.87, p < 0.01, number needed to treat to benefit (NNTB) = 2.94; RR 2.89, 95% CI 1.03 to 8.07, z = 2.02, p < 0.05, NNTB = 3.67). Psychological therapies also had a small beneficial effect at reducing disability in headache conditions post-treatment and at follow-up respectively (standardised mean difference (SMD) -0.49, 95% CI -0.74 to -0.24, z = 3.90, p < 0.01; SMD -0.46, 95% CI -0.78 to -0.13, z = 2.72, p < 0.01). No beneficial effect was found on depression post-treatment (SMD -0.18, 95% CI -0.49 to 0.14, z = 1.11, p > 0.05). At follow-up, only one study was eligible, therefore no analysis was possible and no conclusions can be drawn. Analyses revealed a small beneficial effect for anxiety post-treatment (SMD -0.33, 95% CI -0.61 to -0.04, z = 2.25, p < 0.05). However, this was not maintained at follow-up (SMD -0.28, 95% CI -1.00 to 0.45; z = 0.75, p > 0.05).Analyses revealed two beneficial effects of psychological treatment for children with non-headache pain. Pain was found to improve post-treatment (SMD -0.57, 95% CI -0.86 to -0.27, z = 3.74, p < 0.01), but not at follow-up (SMD -0.11, 95% CI -0.41 to 0.19, z = 0.73, p > 0.05). Psychological therapies also had a beneficial effect for disability post-treatment (SMD -0.45, 95% CI -0.71 to -0.19, z = 3.40, p < 0.01), but this was not maintained at follow-up (SMD -0.35, 95% CI -0.71 to 0.02, z = 1.87, p > 0.05). No effect was found for depression or anxiety post-treatment (SMD -0.07, 95% CI -0.30 to 0.17, z = 0.54, p > 0.05; SMD -0.15, 95% CI -0.36 to 0.07, z = 1.33, p > 0.05) or at follow-up (SMD 0.06, 95% CI -0.16 to 0.28, z = 0.53, p > 0.05; SMD 0.05, 95% CI -0.24 to 0.33, z = 0.32, p > 0.05).nnnAUTHORS CONCLUSIONSnPsychological treatments delivered face-to-face are effective in reducing pain intensity and disability for children and adolescents (<18 years) with headache, and therapeutic gains appear to be maintained, although this should be treated with caution for the disability outcome as only two studies could be included in the follow-up analysis. Psychological therapies are also beneficial at reducing anxiety post-treatment for headache. For non-headache conditions, psychological treatments were found to be beneficial for pain and disability post-treatment but these effects were not maintained at follow-up. There is limited evidence available to estimate the effects of psychological therapies on depression and anxiety for children and adolescents with headache and non-headache pain. The conclusions of this update replicate and add to those of the previous review which found that psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up for children with headache conditions.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUNDnPsychological therapies have been developed for parents of children and adolescents with a chronic illness. Such therapies include interventions directed at the parent only or at parent and child/adolescent, and are designed to improve parent, child, and family outcomes. This is an updated version of the original Cochrane review published in Issue 8, 2012, (Psychological interventions for parents of children and adolescents with chronic illness).nnnOBJECTIVESnTo evaluate the efficacy of psychological therapies that include parents of children and adolescents with chronic illnesses including painful conditions, cancer, diabetes mellitus, asthma, traumatic brain injury (TBI), inflammatory bowel diseases (IBD), skin diseases, or gynaecological disorders. We also aimed to evaluate the adverse events related to implementation of psychological therapies for this population. Secondly, we aimed to evaluate the risk of bias of included studies and the quality of outcomes using the GRADE assessment.nnnSEARCH METHODSnWe searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO for randomised controlled trials (RCTs) of psychological interventions that included parents of children and adolescents with a chronic illness. Databases were searched to July 2014.nnnSELECTION CRITERIAnIncluded studies were RCTs of psychological interventions that delivered treatment to parents of children and adolescents with a chronic illness compared to an active control, waiting list, or treatment as usual control group.nnnDATA COLLECTION AND ANALYSISnStudy characteristics and outcomes were extracted from included studies. We analysed data using two categories. First, we analysed data by each individual medical condition collapsing across all treatment classes at two time points. Second, we analysed data by each individual treatment class; cognitive behavioural therapy (CBT), family therapy (FT), problem solving therapy (PST) and multisystemic therapy (MST) collapsing across all medical conditions. For both sets of analyses we looked immediately post-treatment and at the first available follow-up. We assessed treatment effectiveness for two primary outcomes: parent behaviour and parent mental health. Five secondary outcomes were extracted; child behaviour/disability, child mental health, child symptoms, family functioning, and adverse events. Risk of bias and quality of evidence were assessed.nnnMAIN RESULTSnThirteen studies were added in this update, giving a total of 47 RCTs. The total number of participants included in the data analyses was 2985, 804 of whom were added to the analyses in the update. The mean age of the children was 14.6 years. Of the 47 RCTs, the studies focused on the following paediatric conditions: n = 14 painful conditions, n = 13 diabetes, n =10 cancer, n = 5 asthma, n = 4 TBI, and n = 1 atopic eczema. We did not identify any studies treating parents of children with gynaecological disorders or IBD. Risk of bias assessments of included studies were predominantly unclear. Evidence quality, assessed using the GRADE criteria, was judged to be of low or very low quality.Analyses of separate medical conditions, across all treatment types, revealed two beneficial effects of psychological therapies for our primary outcomes. First, psychological therapies led to improved adaptive parenting behaviour in parents of children with cancer post-treatment (standardised mean difference (SMD) -0.20, 95% confidence interval (CI) -0.36 to -0.04, Z = 2.44, p = 0.01). In addition, therapies also improved parent mental health at follow-up in this group (SMD = -0.18, 95% CI -0.32 to -0.04, Z = 2.58, p = 0.01). We did not find any effect of therapies for parent behaviour for parents of children with a painful condition post-treatment or at follow-up, or for parent mental health for parents of children with cancer, diabetes, asthma, or TBI post-treatment. For all other primary outcomes, no analysis could be conducted due to lack of data.Across all medical conditions, three effects were found for the primary outcomes of psychological therapies. PST had a beneficial effect on parent adaptive behaviour (SMD = -0.25, 95% CI -0.39 to -0.11, Z = 3.59, p < 0.01) and parent mental health (SMD= -0.24, 95% CI -0.42 to -0.05, Z = 2.50, p = 0.01) immediately post-treatment and this effect was maintained at follow-up for parent mental health (SMD= -0.19, 95% CI -0.34 to -0.04, Z = 2.55, p = 0.01). The remaining analysis for PST on parent behaviour found no effect. No effects were found for CBT post-treatment or at follow-up for either parent outcome. For FT, only one analysis could be run on parent mental health and no effect was found. Due to lack of data, the remaining analyses of primary outcomes could not be run. For MST, no parent outcomes could be analysed due to lack of data.Secondary outcome analyses are presented in the Results section. Five studies reported that there were no adverse events during the trial. The remaining 42 studies did not report adverse events.nnnAUTHORS CONCLUSIONSnThis update includes 13 additional studies, although our conclusions have not changed from the original version. There is little evidence for the efficacy of psychological therapies that include parents on most outcome domains of functioning, for a large number of common chronic illnesses in children. However, psychological therapies are efficacious for some outcomes. CBT that includes parents is beneficial for reducing childrens primary symptoms, and PST that includes parents improved parent adaptive behaviour and parent mental health. There is evidence that the beneficial effects can be maintained at follow-up for diabetes-related symptoms in children, and for the mental health of parents of children with cancer and parents who received PST.

Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents

BACKGROUNDnChronic pain is common during childhood and adolescence and is associated with negative outcomes such as increased severity of pain, reduced function (e.g. missing school), and low mood (e.g. high levels of depression and anxiety). Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. However, new and innovative technology is being used to deliver these psychological therapies remotely, meaning barriers to access to treatment such as distance and cost can be removed or reduced. Therapies delivered with technological devices, such as the Internet, computer-based programmes, smartphone applications, or via the telephone, can be used to deliver treatment to children and adolescents with chronic pain.nnnOBJECTIVESnTo determine the efficacy of psychological therapies delivered remotely compared to waiting-list, treatment-as-usual, or active control treatments, for the management of chronic pain in children and adolescents.nnnSEARCH METHODSnWe searched four databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) from inception to June 2014 for randomised controlled trials of remotely delivered psychological interventions for children and adolescents (0 to 18 years of age) with chronic pain. We searched for chronic pain conditions including, but not exclusive to, headache, recurrent abdominal pain, musculoskeletal pain, and neuropathic pain. We also searched online trial registries for potential trials. A citation and reference search for all included studies was conducted.nnnSELECTION CRITERIAnAll included studies were randomised controlled trials that investigated the efficacy of a psychological therapy delivered remotely via the Internet, smartphone device, computer-based programme, audiotapes, or over the phone in comparison to an active, treatment-as-usual, or waiting-list control. We considered blended treatments, which used a combination of technology and face-to-face interaction. We excluded interventions solely delivered face-to-face between therapist and patient from this review. Children and adolescents (0 to 18 years of age) with a primary chronic pain condition were the target of the interventions. Each comparator arm, at each extraction point had to include 10 or more participants.nnnDATA COLLECTION AND ANALYSISnFor the analyses, we combined all psychological therapies. We split pain conditions into headache and mixed (non-headache) pain and analysed them separately. Pain, disability, depression, anxiety, and adverse events were extracted as primary outcomes. We also extracted satisfaction with treatment as a secondary outcome. We considered outcomes at two time points: first immediately following the end of treatment (known as post-treatment), and second, any follow-up time point post-treatment between 3 and 12 months (known as follow-up). We assessed all included studies for risk of bias.nnnMAIN RESULTSnEight studies (N = 371) that delivered treatment remotely were identified from our search; five studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, and two studies included mixed samples of children with headache and mixed (i.e. recurrent abdominal pain, musculoskeletal pain) chronic pain conditions. The average age of children receiving treatment was 12.57 years.For headache pain conditions, we found one beneficial effect of remotely delivered psychological therapy. Headache severity was reduced post-treatment (risk ratio (RR) = 2.65, 95% confidence interval (CI) 1.56 to 4.50, z = 3.62,p < 0.01, number needed to treat to benefit (NNTB) = 2.88). For mixed pain conditions, we found only one beneficial effect: psychological therapies reduced pain intensity post-treatment (standardised mean difference (SMD) = -0.61, 95% CI -0.96 to -0.25, z = 3.38, p < 0.01). No effects were found for reducing pain at follow-up in either analysis. For headache and mixed conditions, there were no beneficial effects of psychological therapies delivered remotely for disability post-treatment and a lack of data at follow-up meant no analyses could be run. Only one analysis could be conducted for depression outcomes. We found no beneficial effect of psychological therapies in reducing depression post-treatment for headache conditions. Only one study presented data in children with mixed pain conditions for depressive outcomes and no data were available for either condition at follow-up. Only one study presented anxiety data post-treatment and no studies reported follow-up data, therefore no analyses could be run. Further, there were no data available for adverse events, meaning that we are unsure whether psychological therapies are harmful to children who receive them. Satisfaction with treatment is described qualitatively.Risk of bias assessments were low or unclear. We judged selection, detection, and reporting biases to be mostly low risk for included studies. However, judgements made on performance and attrition biases were mostly unclear.nnnAUTHORS CONCLUSIONSnPsychological therapies delivered remotely, primarily via the Internet, confer benefit in reducing the intensity or severity of pain after treatment across conditions. There is considerable uncertainty around these estimates of effect and only eight studies with 371 children contribute to the conclusions. Future studies are likely to change the conclusions reported here. All included trials used either behavioural or cognitive behavioural therapies for children with chronic pain, therefore we cannot generalise our findings to other therapies. However, satisfaction with these treatments was generally positive. Larger trials are needed to increase our confidence in all conclusions regarding the efficacy of remotely delivered psychological therapies. Implications for practice and research are discussed.

Systematic Review and Meta-Analysis of Parent and Family-Based Interventions for Children and Adolescents With Chronic Medical Conditions

OBJECTIVEnTo quantify the effects of parent- and family-based psychological therapies for youth with common chronic medical conditions on parent and family outcomes (primary aim) and child outcomes (secondary aim).nnnMETHODSnMEDLINE, EMBASE, and PsycINFO were searched from inception to April 2013. 37 randomized controlled trials were included. Quality of the evidence was evaluated using GRADE criteria. Data were extracted on parent, family, and child outcomes.nnnRESULTSnPooled psychological therapies had a positive effect on parent behavior at posttreatment and follow-up; no significant improvement was observed for other outcome domains. Problem-solving therapy (PST) improved parent mental health and parent behavior at posttreatment and follow-up. There was insufficient evidence to evaluate cognitive-behavioral and systems therapies for many outcome domains.nnnCONCLUSIONSnParent- and family-based psychological therapies can improve parent outcomes, with PST emerging as particularly promising. Future research should incorporate consensus statements for outcomes assessment, multisite recruitment, and active comparator conditions.

Internet-delivered cognitive-behavioral treatment for adolescents with chronic pain and their parents: a randomized controlled multicenter trial.

Abstract Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included were 273 adolescents (205 females and 68 males), aged 11 to 17 years with mixed chronic pain conditions and their parents, who were randomly assigned in a parallel-group design to Internet-delivered CBT (n = 138) or Internet-delivered Education (n = 135). Assessments were completed before treatment, immediately after treatment, and at 6-month follow-up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to 6-month follow-up for Internet CBT compared with Internet education (b = −1.13, P = 0.03). On secondary outcomes, significant beneficial effects of Internet CBT were found on sleep quality (b = 0.14, P = 0.04), on reducing parent miscarried helping (b = −2.66, P = 0.007) and protective behaviors (b = −0.19, P = 0.001), and on treatment satisfaction (P values < 0.05). On exploratory outcomes, benefits of Internet CBT were found for parent-perceived impact (ie, reductions in depression, anxiety, self-blame about their adolescents pain, and improvement in parent behavioral responses to pain). In conclusion, our Internet-delivered CBT intervention produced a number of beneficial effects on adolescent and parent outcomes, and could ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families.

Daytime and nighttime sleep patterns in adolescents with and without chronic pain.

OBJECTIVEnThe aims of the current study were to characterize daytime and nighttime sleep patterns of adolescents with chronic pain, and to compare their sleep patterns to a healthy age- and sex-matched cohort.nnnMETHODSnSixty-one adolescents from a pain clinic and 60 age- and sex-matched youth from the community (mean age = 15.07; 69% female) participated. Participants underwent 10 days of actigraphic sleep monitoring to assess total sleep time (minutes of estimated sleep at night), wake minutes after initial sleep onset, sleep efficiency, and occurrence of sleep during the day.nnnRESULTSnAdolescents with chronic pain and healthy youth had similar nighttime sleep patterns (total sleep time, wake minutes after initial sleep onset, and sleep efficiency). However, adolescents with chronic pain spent more time sleeping during the day than their healthy peers. Longer daytime sleep was associated with more activity limitations in youth with chronic pain.nnnCONCLUSIONSnAlthough previous research using self-report methodology has indicated that adolescents with chronic pain commonly endorse poor sleep, findings from the current study suggest that these complaints may not be explained by differences in nighttime sleep patterns as measured by actigraphy. Use of multidimensional sleep assessment may help to understand the potential impact of sleep on chronic pain in adolescents.

Evaluating Treatment Participation in an Internet-Based Behavioral Intervention for Pediatric Chronic Pain

OBJECTIVEnLittle is known about how participation in internet-based behavioral interventions influences outcomes in youth with health conditions. This study describes participation in an online behavioral pain management intervention for families of adolescents with chronic pain.nnnMETHODSn26 adolescent-parent dyads were randomized to the intervention arm of a controlled trial evaluating a cognitive-behavioral pain intervention. Participation was measured by the number of logins, messages, completion of interactive fields, and behavioral assignments. Associations between content of messages from participants and treatment outcomes were evaluated.nnnRESULTSnMost participants (92.3%) logged in and completed assignments. Over half of participants initiated messages to the online coach. A greater number of messages sent by adolescents containing rapport or treatment content predicted positive treatment outcomes.nnnCONCLUSIONSnMost families actively participated in the intervention. Interaction with an online coach may increase the benefit of this Internet behavioral pain management treatment program for adolescents.

Sleep Outcomes in Youth With Chronic Pain Participating in a Randomized Controlled Trial of Online Cognitive-Behavioral Therapy for Pain Management

Sleep disturbances are commonly reported in youth with chronic pain. We examined whether online cognitive-behavioral therapy (CBT) for pain management would impact youths sleep. Subjective sleep quality and actigraphic sleep were evaluated in 33 youth (M = 14.8 years; 70% female) with chronic pain participating in a larger randomized controlled trial of online-CBT. The Internet treatment condition (n = 17) received 8–10 weeks of online-CBT + standard care, and the wait-list control condition (n = 16) continued with standard care. Although pain improved with online-CBT, no changes were observed in sleep outcomes. Shorter pretreatment sleep duration was associated with less improvement in posttreatment functioning. Findings underscore the need for further development in psychological therapies to more intensively target sleep loss in youth with chronic pain.

Current Smoking as a Predictor of Chronic Musculoskeletal Pain in Young Adult Twins

UNLABELLEDnChronic pain is common during adolescence and young adulthood and is associated with poor quality of life, depression, and functional disability. Recognizing that chronic pain has significant consequences, it is important to identify modifiable health behaviors that may place young adults at risk for chronic pain. This study examines associations between chronic musculoskeletal pain and smoking in young adult twins (n = 1,588, ages 18-30) participating in a statewide twin registry. Twins completed questionnaires assessing smoking, mood (anxiety, depressive symptoms, and stress), and chronic musculoskeletal pain. Analyses examined associations between chronic pain and smoking, particularly the role of genetics/shared familial factors and psychological symptoms. As predicted, results revealed a near-2-fold increased risk for chronic musculoskeletal pain in twins who currently smoked compared to nonsmokers, even when accounting for psychological factors. Results of within-pair analyses were only minimally attenuated, suggesting that associations between smoking and chronic musculoskeletal pain are better accounted for by nonshared factors than by shared familial factors/genetic effects. Future twin research is needed to identify what nonshared factors (eg, attitudes, direct effects of smoking on pain) contribute to these associations to further understand comorbidity. Longitudinal studies and recruitment of participants prior to smoking initiation and chronic pain onset will better identify causal associations.nnnPERSPECTIVEnThis article describes associations between musculoskeletal pain and smoking in young adult twins, taking into account psychological symptoms. Findings highlight the importance of nonshared factors in associations between pain and smoking and the need to explore the roles of lifestyle, individual attitudes, and direct effects of smoking on pain.

Pilot Randomized Controlled Trial of Internet‐Delivered Cognitive‐Behavioral Treatment for Pediatric Headache

To evaluate the feasibility and preliminary effectiveness of an Internet‐delivered cognitive‐behavioral therapy (CBT) intervention for adolescents with chronic headache.