Book Review

A valuable resource for parents with children/adolescents with chronic pain

How to stop chronic pain in children: a practical guide

Dobe M, Zernikow B (2014). B. Stewart, Trans. Heidelberg, Germany: Carl Auer International, 190 pp. ISBN 978-3-8497-8005-0 (eBook: € 15.99). Link

Reviewed by Karen E. Weiss and Emily A. McTate

printable version (PDF)

It is now established that chronic pain affects many children and adolescents (up to 25%). Pediatric chronic pain can be quite debilitating, affecting functioning in areas of school, social, physical, sleep, eating, and mood. Recently, more research has been published examining the importance of family factors. In our intensive interdisciplinary chronic pain rehabilitation program at Mayo Clinic, parent participation is mandatory and is seen as a key aspect to adolescents’ successful rehabilitation and maintenance of progress when returning home. Parents are expected to participate in approximately 20 hours of programming per week focused on how to support their child’s pain management, with primary goals including taking the focus off of symptoms and re-establishing normal expectations at home (e.g. attend school, complete chores). Although recent studies (e.g. Lynch-Jordan et al., 2013; Palermo et al., 2014) have emphasized the importance of family and parent functioning/behaviors, there is little information available for parents regarding what they should or should not do when it comes to their child’s struggles with chronic pain.

Dobe and Zernikow’s book, How to stop chronic pain in children: a practical guide, is an easy to read text that we imagine most parents would find interesting and enjoyable to consume. It is evidence-based and written for the lay person. The book provides a comprehensive explanation of how chronic pain develops and is maintained, emphasizes the biopsychosocial nature of this condition, and provides straightforward and practical advice for families to break the cycle of chronic pain. The authors emphasize the biological and neurological components of chronic pain and how avoidance of activities can strengthen these networks, maintaining pain and disability. They also stress the importance of returning to functioning despite symptoms and explain that reduced pain often will not occur without increase in functioning. They provide case examples and summaries which are helpful in clarifying information.

This book consists of nine chapters. Chapter 1 provides an overview of pain; specifically, the differences between chronic and acute pain and how pain is processed in the brain. Chapter 2 focuses on three thought traps that are common for children, adolescents, and providers working with chronic pain that result in an inability to move forward in chronic pain management. The traps discussed include “the pain has a strictly psychological origin”, “the pain has a strictly physical origin”, and “pain must vanish — at all costs”. In Chapter 3, the authors review advantageous and disadvantageous behaviors in response to pain. This chapter details measures or guidelines for shifting the approach for management of chronic pain. Medications for chronic pain are the content area for Chapter 4. Dobe and Zernikow briefly discuss ways in which inappropriate use of pain medications can increase pain and opioid addiction. Chapter 5 describes things to consider for specific pain conditions including headaches, abdominal pain, and back pain. In Chapter 6, the authors provide answers to common questions asked by parents. Chapter 7 addresses how to collaborate productively with relatives, teachers, and doctors. Chapter 8 provides detailed strategies/techniques that parents can use to help their children actively cope with pain (e.g. progressive muscle relaxation, diaphragmatic breathing). Chapter 9 closes the book by describing physical and psychological indications that would warrant further assessment by a professional.

The first three chapters contain most of the meat of this book, delving into many of the factors that contribute to the development and maintenance of chronic pain and specific advice to parents regarding how to move in a different direction. The authors emphasize the biopsychosocial model, which will likely be new information to many parents. Perhaps the most beneficial portion of Chapter 1 is a description and diagram of the vicious cycle of pain. The description of the cycle clearly displays how thoughts are related to stress reactions, ongoing pain, and pain sensitization. Further, the chapter illustrates the relationships between fear of pain and experience of pain. The chapter concludes with a section highlighting the stress experienced by parents of children and adolescents with chronic pain and potential for developmentally inconsistent relationships between the child and parent to arise. This is done beautifully without blaming or shaming parents.

When discussing the thought traps in Chapter 2, the authors emphasize that chronic pain is never purely psychological or completely physical. In our work, we often see families who have fallen into the trap of believing the etiology of their pain is completely physical. For these patients and families, this trap has resulted in countless tests and procedures, significant expense, frustration with negative results, and perhaps worst of all, a delay in effective treatment of pain resulting in further functional impairment. The authors’ goal of helping parents identify if they are falling for a trap or preventing the fall entirely is certainly a worthwhile endeavor. Further, it will likely be difficult for families to engage fully in a biopsychosocial model of interventions without challenging these powerful thoughts. The chapter concludes by encouraging families to identify the biological, psychological, and social factors related to the child’s chronic pain and discuss these factors together with the goal of keeping all aspects of chronic pain in mind.

In Chapter 3, the authors begin by explaining how pain becomes associated with unpleasant activities and how pain may be lessened when children are involved in pleasant activities. The authors then launch into practical strategies including decreasing parent focus on pain (by having parents give the child $1 each time they ask about it!), using distraction, giving encouragement for engaging in active pain coping strategies, activity pacing, and using positive reinforcement for positive behavior change. This chapter emphasizes the importance of not using pain as an excuse or reason to engage in avoidance behavior and identifies hesitations parents commonly experience in sending their children to school in spite of pain. The authors urge parents to think about long-term and short-term outcomes of allowing avoidance. Examples from families who incorporated these concepts are used to help illustrate the point. This chapter also addresses the impact of a child’s chronic pain on his or her parents’ marital relationship and need for consistency and agreement between parents on management of pain. Finally, the authors suggest strategies to talk with siblings.

As with any book, in addition to several strengths, there are a few weaknesses that readers may want to be aware of if recommending this book to clients. First, although generally well written, there are parts of the book that are more difficult to understand due to wording/sentence structure. This is likely related to translation from German to English. Along similar lines, there is one section that reads a bit harshly. When Dobe and Zernikow discuss thought trap 3 in Chapter 2, they state that it is often difficult to “ascertain who’s at fault” — either parents or doctors for focusing on fixing the pain. Although we understand what they are trying to convey, we can imagine parents may become defensive when reading this section. However, these are small concerns that can be handled by discussing them before recommending this book.

In the section on self-talk (Chapter 8), the authors emphasize a cognitive behavioral therapy (CBT) approach (of changing negative thougths to positive thoughts) rather than other acceptance based strategies, which have also been shown to be effective for chronic pain. If we were recommending this book to parents, we would likely explain that some adolescents find changing their thoughts to be a powerful and effective strategy, whereas others find this task to result in additional stress and feelings of being ineffective. In those cases, an acceptance approach that allows youth to notice their negative thoughts, understand that these thoughts are there for a reason (based on our history), and choose to act according to what is important to them (values).

The second half of the book is not quite as rich as the first half. Although it provides some helpful advice, Chapter 6 has information that may be somewhat redundant. We also feel the section on parents who are maritally separated to be to somewhat narrow. The authors provide a short discussion regarding some of the difficulties that can arise when a child’s parents are separated. However, they don’t provide much guidance on how separated parents can support their child together (e.g. work together to be on the same page about expectations and consequences). Finally, readers who prefer a hard copy may be disappointed as the book is is only available as an e-book.

Despite these weaknesses, we believe many parents who have children who struggle with chronic pain would benefit from this book. Further, the book would likely be helpful as an adjunctive to ongoing therapy. Dobe and Zernikow clearly warn against treatments commonly attempted that are not supported by scientific evidence or clinical experience (e.g. special diets, homeopathic supplements). This message is crucial for parents as a means to prevent problems in the long run. If parents follow the advice put forth, they could substantially decrease the effect chronic pain has on their children’s lives.

Overall, the book provides information based on research and clinical experiences that parents and clinicians would likely find helpful. The authors cover a range of topics and provide clarifying summaries and case examples. Dobe and Zernikow do a lovely job of providing straightforward and practical advice while empathically acknowledging the path which often leads to parent behaviors that are not helpful. In particular, they emphasize why too much medical work-up and appointments can be detrimental, how avoidance of activities can strengthen the chronic pain cycle, and specific parent behaviors that can lead to decreased functioning. In addition, they provide an appendix with information on therapies such as biofeedback, Transcutaneous Electrical Nerve Stimulation (TENS), and self-hypnosis. They appropriately warn against passive treatments and note that when passive treatments fail to provide complete pain relief, children are left feeling hopeless, scared, and frustrated. At the end of the book, the authors provide websites for additional resources. We feel this book is a valuable resource for both parents with children with chronic pain and clinicians who work within the field of pediatric chronic pain. We will likely recommend this book to trainees and parents who attend our program.

Cite as: Weiss KE, McTate EA. A valuable resource for parents with children/adolescents with chronic pain. Book review: How to stop chronic pain in children: a practical guide. Pediatric Pain Letter 2015;17(1):13-15. www.childpain.org/ppl 

References

Lynch-Jordan AM, Kashikar-Zuck S, Szabova A, Goldschneider KR. The interplay of parent and adolescent catastrophizing and its impact on adolescents’ pain, functioning, and pain behavior. Clin J Pain 2013;29:681-688. PubMed Abstract

Palermo T, Valrie CR, Karlson CW. Family and parent influences on pediatric chronic pain: a developmental perspective. Am Psychol 2014;69:142-152. PubMed Abstract