Management of chronic pain in children and young people: summary
A summary of the available evidence, combined with a consensus group agreement on key recommendations and suggested patient pathways.
6. Psychological Therapies
There is a range of psychological interventions available for children and young people with chronic pain. Most studies identified focussed on cognitive behavioural approaches, which include Behavioural Therapy [70] , Cognitive Behavioural Therapy ( CBT) [71] , Acceptance and Commitment Therapy ( ACT) [72] and Mindfulness-Based Interventions [73].
Typical treatments focus on the child/young person and family being actively involved in treatment, which often consists of psycho-education, behavioural strategies for engagement with normal daily activities, an increased awareness of the role of cognition in the exacerbation of suffering, self-regulation of emotion, techniques for reducing aversive arousal and skills training to parents and children/young people. This is delivered within a psychoeducational frame [74].
“The Matrix: A Guide to Delivering Evidence Based Psychological Therapies in Scotland” [75] gives further details on specific psychological interventions with strong evidence bases, together with intensity of intervention required. Most psychological interventions are high intensity and require commitment from the patient and family, and suitably trained and supervised psychological practitioners. The Matrix ( Table 2, key overleaf in Table 3) suggests that psychological interventions generalise across various chronic pain conditions in the paediatric population.
Table 2: The Matrix (2015) - A Guide to Delivering Evidence Based Psychological Therapies in Scotland
| Level of Pain Severity | Service Tier | Intensity of Intervention 2 | Type of Intervention | Recommendation | |
|---|---|---|---|---|---|
| |
|
|
|
Child | Adolescent |
| Moderate/Severe | 3 | High | Cognitive Behavioural Therapy | A [74, 76-78] | A [74, 76-78] |
| 3 | High | Relaxation | A [74, 76-78] | A [74, 76-78] | |
| 3 | High | Biofeedback | A [74, 76-78] | A [74, 76-78] | |
| Mild/Moderate | 2/3 | Low | Computer CBT (7+) | B [79] | B [79] |
| Moderate/Severe | 3 | High | Acceptance and Commitment Therapy | C [80] | C [80] |
| Mild/Moderate | 2/3 | Low | Internet-delivered Family CBT (11+) | C [81] | C [81] |
| Headache Pain |
|||||
| Mild/Moderate | 1/2 | Medium | Computer CBT (7+) | B [79] | B [79] |
| Tier 2-3 | Medium | Internet-delivered Family CBT (11+) | C [81] | C [81] | |
| Moderate/Severe | 3 | High | Biofeedback | A [74, 76-78, 82] | A [74, 76-78, 82] |
| 3 | High | Relaxation | A [74, 76-78] | A [74, 76-78] | |
| 3 | High | Cognitive Behavioural Therapy | A [74, 76-78] | A [74, 76-78] | |
| Tier 3 | High | Acceptance and Commitment Therapy | C [80] | C [80] | |
2 Tier 1 = Universal services consisting of all primary care agencies including general medical practice, school nursing, health visiting
Tier 2 = Combination of specialist CAMHS services and community-based services including primary mental health workers
Tier 3 = Specialist multi-disciplinary outpatient CAMHS teams
Tier 4 = Highly specialist CAMHS inpatient unit and community treatment services
2 Low Intensity Intervention = standardised interventions aimed at transient or mild mental health problems with limited effect on functioning.
High Intensity Intervention = formal psychological therapy delivered by a relatively specialist psychological therapist, aimed at common
mental health problems with more significant effect on functioning
Table 3: The Matrix- Key for Level of Evidence
| Matrix: Level of Evidence | Recommendation | |
|---|---|---|
| At least one meta-analysis/systematic review with medium-large effect sizes; or more than one RCT of high quality and consistency, aimed at target population, showing medium-large effect sizes | A | Highly Recommended |
| One RCT with medium-large effect size; or meta-analysis/systematic review or multiple RCTs showing small-moderate effect sizes, and demonstrating overall consistency of results | B | Recommended |
| One RCT with small effect size and/or multiple non- RCT studies with small effect sizes. There may be inconsistency in findings across studies but a general trend towards a positive effect should be noted | C | Limited/ developing evidence to date, no indication against use |
There is evidence from a high quality Cochrane review, in which 37 studies were identified across a range of chronic pain conditions (including headache, abdominal pain, and fibromyalgia). A reduction in pain and improvement in disability was found, with maintenance of effect at follow-up, although some limitations in the evidence were identified, particularly in relation to the interaction between mood, pain and disability identified [83].
1+
A systematic review and meta-analysis of psychological interventions for children and young people with chronic pain found effective reductions in pain intensity in a range of pain conditions, and improvement in functional ability. For chronic headache, there was some evidence for a dose response, with better outcomes from higher treatment doses [74].
1+
There is more limited evidence for the effectiveness of computer or internet based psychological interventions in children and young people [25]. Children and young people with long term conditions/chronic pain experience isolation through reduced school attendance and inability to take part in group activities like their peers. Provision of computer based CBT intervention may well exacerbate this situation. Online or computerised delivery of CBT interventions should therefore only be used if face to face therapy is not available or best used together with face to face support.
One of the limitations of the literature on psychological interventions is the target of intervention. While reduction in pain intensity is assumed to be the desired outcome, psychological approaches are often directed at improving daily functioning despite pain and/or addressing mood issues (which may affect how pain is processed).
2++
Recommendations
- Psychological interventions should be part of a multi-disciplinary approach to managing chronic pain in children and young people.
- Face-to-face psychological interventions should be delivered by suitably trained and supervised practitioners.
- Online or computerised delivery of CBT interventions should be considered if face-to-face therapy is not suitable or not available.
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