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Working With Children Who Have Chronic Painful Disabilities Using Acceptance and Commitment Therapy

Treatment of children suffering from chronic pain syndromes is the focus of this study. Diagnoses associated with severe disabling pain included problems such as headaches, back and/or neck pain, complex regional pain syndrome, arm or leg pain, and postherpetic (herpes) cheek pain. Past studies have looked at how pain relieving drugs can reduce pain. But other researchers have shown that decreased pain doesn't always result in increased function or a change in disability. That suggests the link between pain and disability is more complex than it seems on the surface.

The author of this study suggests it may be more helpful to focus on other factors than just alleviating pain. For example, a child's self-concept of being disabled or fear of re-injury during exercise could be a stumbling block to recovery. Adults have been found to demonstrate fear-avoidance behaviors (FABs). FAB refers to how people stop moving in ways that might recreate their pain or possibly cause a reinjury. It's possible that children experience the same pattern of FABs as adults do.

The approach used by these researchers was to compare multidisciplinary treatment (MDT) with a cognitive behavioral therapy called Acceptance and Commitment Therapy (ACT). MDT included physical therapy, psychologic counseling, and pain management with medications. Both the patient and the family were involved in discussing pain and disability. All efforts were made toward increasing the level of physical activity. Sometimes this approach is referred to as a biobehavioral treatment.

Acceptance and Commitment Therapy (ACT) is based on the idea that children severely disabled by pain think and act in ways that interfere with normal function. Their thoughts become inflexible and negative. In order to help these children accept their pain and to live well in spite of it, ACT strategies were given a try. ACT assumes everyone can live a full and satisfying life despite having chronic pain. The goal of ACT is to accept chronic pain rather than trying to reduce the pain.

Exposure and acceptance is the name of the ACT intervention used. Psychologists taught the children how to view their pain as inevitable. Since it's not going to go away, they might as well participate in activities they enjoy anyway. Therapy involved discussing negative thoughts and a tendency to avoid activities. The psychologist also helped the children find ways to value life, notice and accept unpleasant thoughts and emotions, and actually enjoy engaging in activities that could potentially cause pain.

Various tests and measures were used to compare the results of these two treatment approaches. In fact, 11 different primary (main) and secondary variables were considered. These included physical and mental health, quality of life, pain-related functioning, pain intensity, and avoidance of pain. Depression, pain avoidance, coping, and worry about pain or discomfort were also measured and compared.

Children in the ACT group showed major improvement in many areas. After treatment, the ACT group exhibited fewer pain behaviors, less fear of reinjury or movement, and better perceived quality of life. These improvements over time were much better than for the MDT group and the changes lasted. The authors suggested that ACT is the more favorable treatment approach to use with pediatric pain patients. However, they were very critical of their own study.

They pointed out many ways in which the methods used just weren't good enough. Although their work has made an important contribution in this area, future studies are needed to produce high-quality research. For example, a larger number of children involved (sample size) would allow analysis of the data not possible with this study. And along with self-report as a measure of results, it might be a good idea to find other, equally (if not more) reliable measures for this age group.

Future studies should take a look at costs associated with treatment approaches and conduct a cost-to-benefit ratio analysis. This would help identify cost-effective treatment approaches. For this study, it looked like the ACT approach cost much more than the MDT treatment. But, in actual fact, the MDT group had twice as many sessions as the ACT group. That was unintended but perhaps other studies are needed to see if more sessions are needed using one approach over another.

References: Rikard K. Wicksell, et al. Evaluating the Effectiveness of Exposure and Acceptance Strategies to Improve Functioning and Quality of Life in Longstanding Pediatric Pain. A Randomized Controlled Trial. In Pain. February 2009. Vol. 141. No. 3. Pp. 248-257.

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