Review of Managing your child’s chronic pain
Palermo TM, Law EF (2015). Oxford: Oxford University Press, 240 pp. ISBN 978-0-1993-3004-1 (Paperback: $19.95 USD). Link
Reviewed by Ethan Benore
Parenting is hard, but we manage. Parents may find themselves applying idioms like “kids don’t come with an instruction manual” as a rationale to help cope with the daunting task of raising children. This challenge is all the more arduous when the normal trajectory of childhood is upset by chronic pain. Parents may hover, coddle, excuse, resent, berate, or avoid their child in need. They often express feeling overwhelmed and out of their league. However, with this new book by Drs. Palermo and Law, Managing your child's chronic pain, parents do have instructions. This book places sound evidence-based practice into the hands of parents, guiding them in managing the myriad of problems faced by chronic pain. Not a step-by-step approach, Palermo and Law teach parents the knowledge and tools necessary to best support their children.
The book is elegantly simplistic in design. Each chapter begins with a brief explanation, followed by thorough detail, then a summary of major points. Testimonials are inserted to engage parents and validate their struggle. At the end of each chapter, a parent should feel comfortable with applying the concept through practice assignments. Following the guidelines in the preface and introduction, parents are encouraged to progress through the chapters slowly (e.g. 1-2 weeks per chapter) to allow for multiple practice opportunities and a sense of mastery on each skill before building a new skill. This repetitive style of presentation, successfully used in speeches, is framed between an effective preface and conclusion. Parents should not overlook the preface—it is an excellent pep talk for the work ahead and may help those reluctant readers gain motivation and hope. At the end of the book, Drs. Palermo and Law smartly conclude with a summary of the entire book, helping parents get the big picture and commit to a long-term plan for success. This book is not meant as a one and done type intervention, but a lifestyle change for the whole family!
In the introduction, Drs. Palermo and Law present the background for their approach. They present basic information on pain perception and chronic pain differentiated from acute pain, as well as specific conditions related to chronic pain. This information is both preceded and followed by a description of cognitive behavioral therapy (CBT). While concise and informative, the medical and psychological jargon may be difficult for families new to the field of chronic pain. Based on my clinical work, many parents need significant help understanding the link between a physical pain condition and a psychological understanding of pain perception and regulation. Hopefully, this introduction will serve as a catalyst for a more detailed conversation between parents and the treatment team, helping parents gain mastery of relevant medical and psychological terms needed to support their child.
Strategically, Palermo and Law then focus on the parenting role. The foundation for raising a child with chronic pain is clear: 1) Understand chronic pain; 2) Understand the impact of pain on your child as well as the whole family; 3) Commit to improving your child and your family’s life—and it starts by taking care of yourself! Most people accept the metaphor of applying the oxygen mask on yourself before helping your child, as this message is reflected in Chapter 1. When the parent is ready, Chapter 2 leads them to ask, “What do I want?”. Now informed, parents are prepared to identify resources and clarify realistic goals for the child and family. The practice assignment helps parents make an intentional commitment to develop and apply new skills.
What follows is the feasible and pragmatic instruction on six core skills professionals know as empirically-supported cognitive behavioral treatments, for which the authors have previously demonstrated expert understanding (Palermo, 2000, 2012; Palermo et al., 2010; Eccleston et al., 2014). Chapter 3 beautifully summarizes relaxation skills and empowers parents to be a source of comfort by teaching or guiding these skills—the Appendices and online resources are especially helpful, as the plethora of relaxation scripts/apps/CDs are overwhelming. Having led relaxation in my own children, this chapter reminds me what a wonderful experience it is for parent and child alike. Chapter 4 targets behavior modification—affirming that “it is safe…to participate in normal activities even when not feeling well” (p. 59). Too often parents consider the basics of behavioral expectations and rewards as something for disruptive toddlers, excusing their own child from activities of daily living. Palermo and Law explain how behavioral principles are foundational to successful pain management. They provide ample demonstrations of what it looks like in this population and practical instructions parents can readily apply. I can hear the voices of my own patients when reading case examples. Again, the Appendices provide a useful place for parents to start their own program.
Chapter 5 targets realistic expectations for lifestyle factors ensuring that activity, nutrition and fluid intake are monitored and managed, prescribed to children with the same serious tenor as medications or procedures. As is often the case clinically, sleep (Chapter 6) may require greater attention and education for parents to feel they are successfully managing these important hours. In Chapter 7, the goal is applying previously learned skills to reintegrating in school and social activities. Chapter 8 gives parents an empirically-based method they can teach to the child to reduce varied pain-related stressors through problem-solving and cognitive coping skills. Chapter 9 succinctly addresses the varied hurdles parents may face that inadvertently take center stage when trying to apply cognitive behavioral skills. I was particularly impressed with the attention paid to parent-child communication, a common stumbling block I encounter for families who want the same thing but struggle working as a team. Finally, all skills are reviewed in Chapter 10 with a mindset of reflection, self-reinforcement, and continued progress—a wonderful capstone to the efforts parents have put forth over the previous several weeks applying CBT skills.
My only reservation about this book is that it straddles the line between a psychoeducational book and a treatment workbook (without a formal treatment program). These are well-established treatment strategies, but some families will continue to struggle. There is a potential risk for families applying the knowledge in this book without support. Parents may feel frustrated or defeated if the skills as written do not work immediately or as expected. I have witnessed this in children who try relaxation apps/CDs before visiting—they are now reluctant to relax because, as they report, “That breathing stuff doesn’t work!”. While the authors wisely recommend evaluation and treatment for comorbid anxiety and depression, I would add that, if the chronic pain situation does not improve, professional consultation with a psychologist could greatly enhance the parent’s application of these CBT skills.
I see this book being read and re-read by parents as they apply the skills and strengthen their parenting effectiveness—either as a full program or an extension of their current pain management program. In addition, chapters in this book may be applicable to relatives who wish to support the family and child, as they may need to modify their own behaviors within the family. Finally, I would recommend this book for clinicians familiar with CBT but nervous about independently applying it to a child with chronic pain—Drs. Palermo and Law successfully model how to address this topic with families and guide them through a treatment program.
Perhaps the best take home point of this book is in the title—MANAGING. This word has multiple meanings and all are achieved through this book. By developing the skills to direct and lead the child’s independent functioning, parents will cope with this challenging time and achieve their goal to be a successful parent. Parenting a child with chronic pain is hard—but we manage.
Cite as: Benore E. Book review: Managing your child's chronic pain. Pediatric Pain Letter 2015;17(3):47-49. www.childpain.org/ppl
Eccleston C, Palermo TM, Williams AC, Lewandowski Holley A, Morley S, Fisher E, Law E. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2014 May 5;(5):CD003968. PubMed Abstract
Palermo TM. Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature. J Dev Behav Pediatr 2000;21:58-69. PubMed Abstract
Palermo TM. Cognitive-behavioral therapy for chronic pain in children and adolescents. Oxford: Oxford University Press, 2012. Link
Palermo TM, Eccleston C, Lewandowski AS, Williams AC, Morley S. Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review. Pain 2010;148:387-397. PubMed Abstract