A cross-disciplinary resource for treating chronic pain in children and adolescents
Practical treatment options for chronic pain in children and adolescents: an interdisciplinary therapy manual
Dobe M, Zernikow B, editors (2013). Berlin: Springer, 248 pp. ISBN 978-3-642-37816-4
Reviewed by Edin Randall and Monique Ribeiro
As a pediatric psychologist and a pediatric psychiatrist with backgrounds in pain management and psychosomatic medicine, we are keenly aware of the complexities and challenges of assessing and treating patients and families with chronic pain conditions. Working with these youth on a daily basis, we recognize the necessity for multidisciplinary, intensive treatment for children and adolescents with severe functional impairments due to pain. Although 5% of all children suffer from chronic pain severe enough to impact their academic performance and psychosocial and emotional health (Huguet & Miró, 2008), few programs exist in the United States and internationally that are specifically tailored to effectively treat pediatric chronic pain.
As efforts are made to expand the number and quality of available resources, the field is in need of conceptual and practical guidance. After ten years of spearheading a successful inpatient treatment program (German Pediatric Pain Center: GPPC), Drs. Michael Dobe and Boris Zernikow offer an in-depth, comprehensive review of the epidemiology, etiology, diagnostics, and evidence-based assessment and treatment of pediatric chronic pain disorders. In their interdisciplinary therapy manual, Practical treatment options for chronic pain in children and adolescents, the authors provide readers from various disciplines with invaluable information and tools required for treating this challenging patient population.
The book consists of nine chapters. Chapters 1 through 3 review the epidemiology of pain disorders, the biopsychosocial conceptualization of pain, and medical/psychological diagnostic procedures of various chronic pain conditions. Chapter 4 broadly reviews the basics of pediatric pain treatment. Chapters 5 and 6 provide detailed specifics of the GPPC program; Chapter 5 covers the criteria for inpatient admission at the GPPC and Chapter 6, which represents the majority of the book’s content, provides an overview of the therapeutic milieu and techniques utilized at the GPPC. Chapter 7 explains how treatment can be modified for patients with concomitant psychiatric disorders, learning difficulties, and systemic stressors. Chapter 8 reviews the empirical evidence supporting the effectiveness of the GPPC, along with other existing pediatric pain (day and inpatient) programs. Finally, Chapter 9 consists of worksheets and diagnostic tools for the practicing clinician.
Overall, the book has many assets in its conception and execution. Given that providers from various fields work with this patient population, the authors’ efforts in making the content accessible and useful to a broad range of disciplines is commendable. The authors nicely combine many areas of education (i.e. biological, pharmacological, psychological conceptualization and treatment) that are integral and usually difficult to find in one respectable source. However, in making such an attempt to be all-inclusive, certain sections of the book may strike some readers as being overly detailed and others as oversimplified, depending on the reader’s background and level of expertise.
The authors’ review of differential medical diagnoses is easy to understand and of practical value for the nonmedical provider. Similarly coherent are the explanations of several psychological theories and approaches to pain. For instance, Chapter 4 provides basic information about the role of emotions and cognitions in pain, describes the therapeutic attitude required for successful treatment (e.g. avoiding the dichotomization of pain as being either organic or psychological, understanding the interplay between emotional difficulties and pain perception, and maintaining a positive attitude), and highlights the Three Thought Traps, which may be useful for general practitioners but quite familiar to pain specialists with a cognitive-behavioral orientation. Case examples and scripts which illustrate how different techniques can be implemented are provided throughout the book and will be most helpful to the provider with limited experience working with pediatric pain populations. There is also an in-depth description of biological aspects of chronic pain in Chapter 2, including neural processes involved in pain modulation. While we believe that an understanding of neurobiology is needed when working with chronic pain, the extensive detail provided in Chapter 2 may make this content rather inaccessible and hard to digest for readers with a nonmedical background.
There is also wealth of practical resources included in the text. For example, a table in Chapter 3 lists key psychological and multimodal assessment tools and provides the citations for the original sources. In Chapter 9, the authors helpfully provide diagnostic tools and worksheets to be used in treatment (along with instructions for administration). Of note, readers are encouraged to replicate the worksheets, as they are not formatted to be photocopied directly from the book.
Chapter 6 extensively describes various aspects of the GPPC treatment model and constitutes the majority of this treatment manual. It should be noted that this comprehensive, lengthy chapter could benefit from reorganization into several chapters. By doing so, the authors would assist the reader with absorbing and more efficiently accessing the information presented. The reader is first provided with a clear review of GPPC admission process, structure and organization of the inpatient program, as well as a prototypical daily schedule. The authors then present seven modules of treatment, which do not, however, reflect sequential phases of treatment. Module One reviews content for the initial phases of treatment including education about pain (e.g. the vicious cycle of pain, pain-related fears and anxiety sensitivity) and goal setting. Modules Two, Three and Four provide specific treatment interventions utilized with patients and families (e.g. mindfulness-based, imaginative and exposure techniques, cognitive and acceptance-based strategies, the pain provocation technique). Module Five covers optional interventions, which include physical therapy, art and musical therapies, and medication management. Finally, Module Six discusses discharge planning.
This chapter also reviews a variety of interventions and astutely specifies how to modify treatment when patients are also struggling with depression, anxiety, or trauma. For example, the authors recommend using stabilizing techniques for youth with a history of trauma, gradual exposure interventions for those with anxiety disorders, and cognitive restructuring for patients with depressive symptoms. Although the seasoned pain clinician is likely familiar with the interventions provided, we recognize that the general practitioner may find this information helpful. The chapter could be enhanced by addressing interventions associated with the school, community, and social domains. We also appreciate the review of pharmacological treatment of pain disorders. However, we feel that the book could have been strengthened by some balanced attention to psychopharmacological interventions, given the psychiatric comorbidities present in many patients. Similarly, more attention could have been devoted to describing the role of physical therapy and occupational therapy in this multidisciplinary treatment approach. The Stress Day, created by the authors and individually tailored to each patient’s needs exemplifies a creative intervention that encourages patients to practice skills while being challenged by activities of daily living. The Stress Day has significant therapeutic benefit and can be adapted to different treatment settings.
Overall, Dobe and Zernikow’s book is a thorough guide with empirical evidence, case examples, and practical clinical tools that help demonstrate the implementation of the strategies presented. The essential themes of the manual can be readily implemented in a range of health care systems including the United States managed care model, although certain aspects may require change and adaptation. Overall, this book will prove helpful across disciplines and levels of professional expertise: from the newcomers who are seeking education and tailored interventions for youth with chronic pain across a range of treatment settings to the seasoned pain specialist interested in starting an intensive multidisciplinary treatment program. By sharing their expertise and unique treatment model in this text, Dobe and Zernikow offer a valuable contribution to the field of pediatric chronic pain.
Cite as: Randall E, Ribeiro M. A cross-disciplinary resource for treating chronic pain in children and adolescents. Book review: Practical treatment options for chronic pain in children and adolescents: an interdisciplinary therapy manual. Pediatric Pain Letter 2014;16(1-2):29-31. www.childpain.org/ppl
Huguet A, Miró J. The severity of chronic pediatric pain: an epidemiological study. J Pain 2008;9:226-236. PubMed Abstract