Book Review

How to be a pediatric pain psychologist

Cognitive-Behavioral Therapy for chronic pain in children and adolescents

Palermo TM (2012). New York: Oxford University Press, 240 pp. ISBN 978-0199763979 (Paperback: $45.00 USD).

Reviewed by Deirdre E. Logan and Shannon Odell

printable version (PDF)

As clinical supervisors we have worked with many new pediatric psychology interns who are eager to get their first case assignment, only to have their enthusiasm plummet when they learn that this first case is an adolescent with chronic pain with severe pain-associated disability for whom nothing has helped. Many new trainees, and no shortage of more advanced practitioners, feel at a loss with such patients. They are unsure how to tackle the challenges these patients present or how to reduce the resistance such patients often express toward psychological treatment out of fear that engaging in such treatment somehow indicates that the pain is all in their heads. Now there is an excellent new resource for navigating these challenges, one that walks the practitioner step by step through the treatment process from the moment of meeting the patient through successful intervention.

Cognitive-Behavioral Therapy (CBT), a structured psychological approach that attempts to modify unhelpful thoughts and behaviors, has become a frontline treatment for pediatric chronic pain, with a strong and growing evidence base supporting its effectiveness. Tonya Palermo, PhD, a renowned pediatric pain psychologist, has recently published Cognitive-Behavioral Therapy for chronic pain in children and adolescents, a book that serves as a practical guide to implementing CBT with this population. Within the scope of this brief and accessible text, Palermo outlines the applications of CBT for pediatric chronic pain, addresses common challenges faced in delivering psychological interventions to this clinical population, and provides concrete resources to use in the psychological assessment and treatment of children and adolescents suffering from chronic pain and associated disability.

Cognitive-Behavioral Therapy for chronic pain in children and adolescents consists of three sections of text plus appendices. The first section includes an introduction and overview of CBT for pediatric chronic pain. Common pediatric chronic pain problems are described, and the biopsychosocial model of pain is presented as an explanatory framework for understanding these experiences and developing appropriate interventions. Palermo carefully distinguishes between incorporating psychologically-informed principles and education – something that all clinicians working with children with chronic pain can and should do – and delivering CBT, which she explains requires intensive training and specific qualifications.

This opening chapter is followed by a brief history of the uses of CBT in pediatric pain along with recent advances and variations, including brief treatment approaches and technology-based delivery methods. Palermo presumes the reader has a basic background and familiarity with CBT, although a concise primer is outlined in Chapter 2. There is a passing mention of more recently developed treatment approaches such as contextual CBT and acceptance and commitment therapy. Proponents of these newer approaches may find the attention to these treatment variations somewhat cursory, but references are provided to guide interested readers to more comprehensive sources for learning about these models and techniques. Palermo clearly and concisely lays out the evidence base supporting the use of CBT for pediatric chronic pain. Her extensive knowledge of research in the field is obvious and allows her to synthesize this information for the reader in ways that are both accessible and informative. This section also briefly describes the typical settings in which psychologists and other mental health professionals may assess and treat pediatric chronic pain, including outpatient practice, inpatient consultation-liaison, and intensive interdisciplinary rehabilitation settings.

The book’s second section focuses on chronic pain assessment, education, and treatment planning. Palermo provides the details of a comprehensive approach to assessment of pain in children and adolescents. This section could have been further enhanced with attention to how these assessment approaches can be modified for special populations such as very young children or those with developmental delays or communication deficits. In the chapter on education and treatment planning, which focuses on the initial treatment session, Palermo offers a clear framework for explaining to families the role of CBT in pediatric chronic pain treatment, incorporating language that can aid the clinician in decreasing resistance and facilitating buy-in to the psychological approach to pain management. She provides a useful list of questions to facilitate the assessment of each domain of the patient and family’s functioning. Overall, this section provides thorough guidance for conducting an initial assessment of a child and family presenting with chronic pain and using the information obtained to develop an effective treatment plan. The sections devoted to providing pain education give the reader some very useful language to employ when explaining pain to children and families. Overall, the assessment and treatment planning approaches outlined in the text are most easily applied in the outpatient setting. Palermo does offer some additional guidance on how to adapt the approaches into the pace and structure of inpatient consultation-liaison work and interdisciplinary rehabilitation settings. More discussion of these alternative treatment contexts could have strengthened this section but may have been beyond the scope of a brief text.

The final section of the text, Chapters 6 through 12, describes a variety of specific cognitive-behavioral interventions for pediatric chronic pain. Each chapter addresses a specific clinical technique (including relaxation, imagery, biofeedback training, parental interventions, and cognitive skills training) or an area of function that is a common target of cognitive-behavioral chronic pain treatment (including interventions to improve school functioning, sleep, and lifestyle and physical activity habits). Each of these chapters begins with a brief review of the literature and proceeds to describe the intervention approaches in detail. Specific techniques are described with understandable, easy to follow recommendations and enhanced with relevant clinical case examples. For example, in her chapter on cognitive skills training, she defines and describes exposure, an intervention commonly used for anxiety and fear-reduction. She provides a case example involving a patient who required an exposure-based school reentry plan, describing how it was implemented and the methods in which they addressed barriers. A relative newcomer to the field of pediatric pain with some background in CBT should find enough information within this text to feel confident working with a child or an adolescent presenting with chronic pain.

The chapters dedicated to specific techniques offer straightforward explanations of the basic principles of behavioral and cognitive strategies for coping with chronic pain. The chapter on cognitive skills is quite brief given the complexity that cognitive interventions can sometimes require, but the essential starting points of such approaches are addressed. Within this third section of the text, a particular strength of the book is the attention Palermo pays to interventions that target parental influences on the pediatric chronic pain experience. As there are currently no empirically-validated interventions for parents in the pediatric chronic pain population, Palermo provides much needed guidance, tools, and techniques for approaching, supporting, and working with parents to help them respond to their child’s pain in ways that facilitate adaptive functioning. For instance, she offers suggestions for interventions that enhance communication by eliminating status checks (i.e. asking the child about his/her pain) and promoting age-appropriate interactions. Also of note is her attention to the issue of health professionals’ perceptions about parents. Palermo acknowledges that some healthcare providers can have strong reactions or opinions about how parents respond to their child and encourages pain psychologists to assist other members of the child’s health care team to understand and manage those reactions.

The chapters devoted to addressing school functioning, sleep, and lifestyle issues offer useful guidance for intervening in these important but often underaddressed areas in pediatric pain management. Reducing school impairment can be one of the most important interventions in functional restoration for pediatric chronic pain. Palermo describes briefly the impact that pain can have on school functioning and offers several helpful suggestions for educating school personnel and helping parents who may have developed a contentious relationship with the school. Palermo includes a sample school letter in the appendix, offering providers a model format for educating school personnel about the nature of chronic pain and providing specific recommendations for appropriate modifications in the school setting. Although the topic of school functioning and related issues such as the impact of pain on peer relationships could have been expanded further, given the importance of this component of treatment and the variety of ways it can be addressed, there is an admirable amount of information and practical guidance provided in a relatively small number of pages. Chapter 10, Palermo’s chapter on sleep interventions, is a welcome addition to any provider’s library. She very aptly describes both the importance and challenges in addressing sleep. Her specific expertise in this area is evident. Again, helpful strategies and an outline of sleep interventions are provided as a useful tool for the reader to implement patients experiencing pain-related sleep disruptions.

The book is enhanced by numerous resources for interested providers, including web-based relaxation resources and a set of appendices replete with scripts and handouts for patients and families, providing valuable tools that will be particularly appreciated by clinicians in training or otherwise new to the field of pediatric pain treatment.

Overall, Palermo’s book is an approachable guide with a balance of empirical research, case examples, and concrete clinical tools that serve to demonstrate the implementation of strategies presented. Along with other hands-on resources such as Roslyn Rogers’ Managing persistent pain in adolescents: a handbook for therapists (2008; reviewed in Pediatric Pain Letter, 2009, Vol. 11, No. 1), this book will undoubtedly become a vital training tool and practical resource for psychology trainees and other newcomers to the field of pediatric pain psychology. More advanced practitioners will also find some useful new ways of framing specific cognitive-behavioral strategies or addressing specific aspects of the pediatric chronic pain experience that can enhance their clinical care of children and adolescents with chronic pain.

Cite as: Logan DE, Odell S. How to be a pediatric pain psychologist. Book review: Cognitive-Behavioral Therapy for chronic pain in children and adolescents. Pediatric Pain Letter 2012;14:25-27. www.childpain.org/ppl