Book Review

Redefining comfort

When your child hurts: effective strategies to increase comfort, reduce stress, and break the cycle of chronic pain

Coakley R (2016). New Haven, CT: Yale University Press, 360 pp. ISBN 978-0-3002-0465-0 (Paperback: $22.00 USD). Link

Reviewed by Maggie Stoeckel and Anna C. Wilson

printable version (PDF)

Chronic pain can be incredibly disruptive and challenging for young children and teens. As with other chronic health conditions, chronic pain does not exist in a vacuum; rather, the entire family system is faced with many potential obstacles posed by pain. Intuitive parenting practices are unfortunately not always effective for parenting a child or teen with chronic pain, as these youth have unique needs. Therefore, the parents of children with chronic pain can often feel at a loss when their natural, go-to parenting practices do not seem to fit the needs of their children. In her recently published book, When your child hurts, Dr. Rachael Coakley provides parents with a tangible and accessible resource full of effective strategies to increase comfort, reduce stress, and break the cycle of chronic pain.

The idea of redefining comfort is at the heart of Dr. Coakley’s book, as she pushes readers to think outside the “rest on the couch with hot cocoa until you feel better” box towards a more comprehensive, functional, and long-term definition of feeling comfortable. As Dr. Coakley points out, many parental responses to pain are helpful in the short-term but less helpful in the long-term, and this book provides parents with long-term strategies and solutions. This correction is gently offered to parents within the frame of acknowledging that the things we know to be helpful for parenting a child with chronic pain are not necessarily intuitive parenting practices. At the core of the book is the message that behavioral strategies can help children cope with and recover from chronic pain regardless of the etiology of pain, and that parents play a key role in facilitating change for their children. This resource is family-friendly and full of practical tips that parents can implement in their daily interactions with their children.

Dr. Coakley is the associate director of psychological services at the Pain Treatment Service in the Department of Anesthesiology, Perioperative and Pain Medicine at Boston Children’s Hospital. The preface of When your child hurts introduces Dr. Coakley as a pediatric pain psychologist. She describes a typical day seeing new patients in the pain clinic and tells the stories of four kids who are dealing with a variety of chronic pain problems and who present with varying levels of disability and different areas of impaired functioning. Most parents will find that one or more of these stories captures some aspects of their own experience, leading to an immediate recognition that this book is written for them. However, the reader’s real introduction to Dr. Coakley comes in Chapter 1, which is titled Beyond intuition: helping a child suffering from chronic pain. Here, Dr. Coakley introduces herself to the reader with an incredibly personal story about her experience taking her young son to the emergency room when he was having repeated seizures. She describes her own experience of being helpless as a parent, and not being able to see what her son needed from her in a moment of extreme stress. The emotional core of this story is likely to resonate with parent readers, who may also be feeling overwhelmed and helpless as they witness their child experiencing pain over and over again. Highlighting her own experience helps Dr. Coakley strike a careful balance in the tone used throughout the book; readers will feel that they are being spoken to by an experienced professional in the field of pediatric pain, and by a mother who is naturally compassionate. This serves to pull the reader closer to the author as a clinician, and the wonderful tone of informed caring is carried throughout the book.

The body of the book is broken into five sections, with sections one to four cleverly titled On your mark, Get ready, Reset, and Go. A fifth section provides a wealth of additional recommended resources, including apps, books, websites, and videos. This structure provides a frame for chapters that address a variety of topics. Each chapter also ends with take home points for parents. These How to help sections at the end of each chapter help to summarize the information and give parents concrete steps to take, even if the step is just understanding something about chronic pain, or considering new or alternative treatment options.

The first section, On your mark: understanding what pain is (and is not) includes five chapters dedicated to psychoeducation about chronic pain states, the mind-body connection, the stress-pain connection, and emotions in the context of pain. The very first chapter introduces parents to the idea that their first intuition about how to help their child may not be useful in the case of chronic pain. It provides specific examples of parenting practices and beliefs that need to be addressed if the child is to recover. Examples include, “My child’s pain and medical difficulties are real, so psychological strategies won’t help,” and “It’s not fair to expect my child to resume normal activities until his pain is gone.” Each statement is followed by evidence for why these parenting practices are not helpful in the case of chronic pain, and guides parents toward an alternative that is likely to be more helpful. Chapters addressing the science of pain, mind-body connection, stress, and negative emotions provide brief but effective psychoeducation. Throughout these chapters parents are encouraged to consider their own role in how they communicate or model these things for their children. In fact, the chapter on managing negativity, frustration, and doubt provides useful information about socioemotional development, but also gives very specific instructions for how parents can keep from over-identifying with their child’s negative emotions and help their child shift toward positive thinking and problem solving through modeling and coaching.

One of the most powerful chapters in the first section is titled Redefining comfort. This chapter defines comfort as being more than simply a lack of pain, and invites parents to think about activities and sensations that provide comfort to their child in different environments. It also provides a list of possibilities that includes a number of active items and highlights the idea that developing comfort, self-efficacy, and resilience can happen regardless of the presence of pain or stress. The author sets a gentle and collaborative tone, thereby increasing parents’ readiness for making changes to their existing pain management frameworks by embracing self-management approaches to pain. By the time parents have finished the first section of the book, they are likely well prepared to consider non-medication approaches to treatment for their child or adolescent.

The second section of the book, Get ready: selecting evidence-based treatments includes four chapters that outline the roles of behavioral medicine, physical and occupational therapy, medications and supplements, and other interventions. The chapter on behavioral medicine provides tips for identifying appropriate providers, and is a great resource for families who may be walking into the world of behavioral medicine for the first time, or may simply not know how to navigate the often confusing path to getting appropriate treatment. This chapter also summarizes cognitive behavioral therapy and related approaches, with descriptions of thought-based and behavioral strategies that might be used in a particular case. Chapters on physical and occupational therapy and medications and herbal supplements outline commonly used treatments, emphasizing the importance of using these treatments as part of a comprehensive pain management plan. Practical tips focus on finding providers and making the most out of these interventions. The final chapter in this section provides family-friendly descriptions of additional pain interventions, organized by tier. Top tier interventions including acupuncture, psychiatry, nutrition and sleep-medicine are described as tried and true. Second tier interventions (e.g. yoga, aromatherapy) are safe to try, while third tier interventions such as craniosacral therapy, chiropractic, and homeopathy are described as having less evidence in children and having the potential to be harmful. Taken together, the information presented in this section gives a comprehensive overview of effective treatment approaches for pediatric chronic pain. Of note, the author appears to have made a deliberate decision to include not only effective treatments, but also those which have been shown to be ineffective in the treatment of pain due to lack of empirical evidence. By including this information, the author reduces the likelihood that parents will feel that alternative treatments have been withheld from them or intentionally excluded from the book. The slight downside of this decision is that there will always be additional unsupported therapies available to patients, and some will find treatments that are not covered here. The range of recommended and safe treatments included also serves to highlight the complexity of chronic pain, and the fact that a multidisciplinary comprehensive plan is needed to address it. Importantly, practical steps a parent can take are included throughout, which helps translate the high volume of information into actionable items.

Section three, titled Reset: moving forward with relaxation and mindfulness provides an introduction to the important role that these strategies can play in reducing pain sensations, engaging the parasympathetic nervous system, and changing the brain. Chapters on breathing, guided imagery, muscle relaxation, mindfulness practice, and biofeedback provide concrete tools for parents and children to try at home. Parents are encouraged to try these strategies themselves before suggesting them to their child, and to try them first when their child’s pain is not extremely high and give opportunities for practice when the child is not in crisis. An illustration of diaphragmatic breathing accompanies the breathing chapter, the biofeedback chapter includes a list of apps and systems available for home use, and each chapter has specific scripts and exercises for families to try.

The fourth section, Go: getting kids going again describes behavioral approaches for supporting children in returning to physical activities, extracurricular activities, and school. The concept of scaffolding is used to frame these suggestions, and parents are asked to set small goals that they and their child are about 80% confident they can meet. The scaffolding chapter is full of illustrative case examples that highlight a variety of rewards and consequences parents might use. A full chapter is devoted to addressing concerns about social functioning and peer relationships, and provides concrete examples of ways to respond to peers’ questions, which will be helpful for many families. The final chapter of this section takes a step back to emphasize the importance of the family system as a whole, including parent self-care, marital relationship problems, and sibling needs.

One of the great strengths of this book is that it gently but consistently pushes the reader toward flexibility in thinking around pain, its origins, and its treatment. For instance, the tips from Chapter 1 invite parents to examine their own parenting and stay open to new ideas. The chapter on redefining comfort asks parents to reconsider things that will contribute to their child’s resilience and independence in the long run. Invitations to think flexibly like this are offered to parents throughout the book, effectively encouraging cognitive flexibility. There are also a number of family-friendly analogies about chronic pain throughout the book (e.g. pain as an overly sensitive alarm clock, software problem versus hardware problem), which Dr. Coakley and colleagues have previously written about (Coakley & Schechter, 2013). These also serve to disrupt rigid thinking around pain that the reader may have held and encourage new ways of conceptualizing the problem that they are facing with their child. Stories of hope are also interwoven throughout the book, as Dr. Coakley describes children and parents who are facing challenges but who are seeking help for their child and making progress toward recovery.

One minor shortcoming of the book is that there are sections that are quite dense in terms of the use of behavioral and medical language and concepts. These sections (e.g. portions of the chapter on pain and stress) may be difficult for some readers to understand completely or accurately. However, for most readers these sections will serve to highlight that chronic pain is not a simple medical condition, but rather a complex condition that requires multifaceted solutions to make long-term change.

Overall, this book is artfully crafted, authentic, and full of evidence-based advice for parents who find themselves in the incredibly difficult situation of having a child with chronic pain. Parents dealing with chronic pain in a child or adolescent are likely to find it a compelling read, regardless of the source of the child’s pain. Professionals can feel confident that parents will be engaged and receive excellent advice. The book may also serve as a helpful primer for psychologists who are engaged in clinical training to work with youth with chronic pain and their families. Pediatric psychologists and other pain providers are going to have When your child hurts on their recommended reading lists for years to come.

Cite as: Stoeckel M, Wilson AC. Redefining comfort. Book review: When your child hurts: effective strategies to increase comfort, reduce stress, and break the cycle of chronic pain. Pediatric Pain Letter 2016;18(2):14-17. www.childpain.org/ppl 

Reference

Coakley R, Schechter N. Chronic pain is like… the clinical use of analogy and metaphor in the treatment of chronic pain in children. Pediatr Pain Lett 2013;15:1-8. Link