Book Review

Truly practical and of interest to your whole team

Practical treatment options for chronic pain in children and adolescents: an interdisciplinary therapy manual (2nd edition)

Dobe M, Zernikow B, editors (2019). Cham, Switzerland: Springer, 299 pp. ISBN 978-3030192006 (Softcover: $99.99 USD; eBook: $79.99 USD). Link

Reviewed by Dustin P. Wallace

printable version (PDF)

Chronic pain remains stubbornly common in young people, and in many cases leads to considerable impairment. In recent decades, various lines of research have converged to show that chronic pain is better conceptualized as a response rather than a stimulus, and perhaps even as a behavior the brain (us!) engages in to protect the organism (also us!). As the brain’s responses are shaped by a myriad of biopsychosocial and historical factors, team-based treatment has long been recognized as critical for young people with chronic pain. But within the team-based treatment approach, there are various models and levels of intensity. Further, even with the advantages of an interdisciplinary team it can be daunting to consider translating the vast amounts of research into care for each specific young person in your clinic or program.

This manual seeks to bridge that chasm, and the authors draw on many combined years of experience in effectively treating young people with chronic pain as a functioning team. Practical treatment options… is truly a “pulling back of the curtain”, allowing the rest of us a close look at the workings of many members of a functioning team that has contributed to the recovery of many, many young people affected by chronic pain, as well as their families.

When writing this review, I’ll first admit that it was hard to improve upon the excellent forwards written by Dr. Chuck Berde and Dr. Leora Kuttner for the first edition of this book. Each of these eminent leaders in the field of pediatric pain specifically points out many key strengths of this book that earn it the label “practical” in its title, and they each go to great lengths to point out its patient- and family-centered language and approach. Further, both Dr. Berde, an anesthesiologist by training, and Dr. Kuttner, a clinical psychologist, point out the book’s interdisciplinary appeal, providing useful insight and setting a “standard of care” applicable to physical and occupational therapists, physicians, psychologists, child life specialists, nurses, and others who work with children and families affected by chronic pain. It should also be noted that Dr. Edin Randall and Dr. Monique Ribeiro provided an excellent review of the first edition of this manual for the Pediatric Pain Letter (Randall & Ribeiro, 2014). Their review calls this manual a “thorough guide with empirical evidence, case examples, and practical clinical tools that help demonstrate the implementation of the strategies presented” and points out its applicability in multiple clinical contexts internationally.

The strengths of the first edition clearly remain in this updated and revised second edition. In terms of changes, the book has been updated throughout, providing new information related to advances in our understanding of the background and pathophysiology of pediatric pain, as well as updated numbers and statistics regarding its prevalence and various forms. Even more, the book has been greatly expanded, adding 7 chapters with a significant expansion of the pragmatic details of intensive treatment. Indeed, by my calculation, what was covered in two chapters in the first edition has grown to encompass a full nine chapters of clinical and administrative details pertinent to an entire team.

To begin the book, the authors provide a concise review of epidemiology and impairment related to chronic pain in young people, and then quickly move into a thorough discussion of the biopsychosocial conceptualization of chronic pain. This discussion is scientifically based, interspersed with clinical guidance on many topics, and includes many examples of patient-friendly language. Within these chapters, the authors provide information on key physiological and psychological components such as pain transmission and modulation, peripheral and central sensitization, genetics, emotions and thoughts, and the role of conditioning and learning in the pain experience. The authors provide clear guidelines for assessing pain, ruling out other potential medical concerns (such as autoimmune causes), diagnosing primary chronic pain conditions, and evaluating psychological factors that might affect treatment.

The same level of attention is provided to the psychosocial aspects of pain, including learning history, thoughts, emotions, and social contributors to both pain itself and associated impairment. These biopsychosocial chapters set the stage for an in-depth discussion of approaching families with the diagnosis of chronic pain. Indeed, the section regarding talking with families about chronic pain contains many valuable examples of language to convey diagnosis and to help families avoid the “three thought traps” which can complicate response to treatment recommendations.

In the second part of the book, the authors open the doors wide to allow other interdisciplinary teams the valuable and rare opportunity to see their inner workings. This section of the book starts with basic and pragmatic details and shows the program from both the staff and patient perspective. Indeed, the authors are very forthcoming, even including such details as sample schedules, staffing levels, and wait times. The discussion moves to more nuanced details such as the content of educational groups and specific pain-coping training, again with sample language tips to help address concerns that can complicate response to treatment.

Later within the second part, the authors review additional interventions to help individuals who are also dealing with impairing depression, anxiety (including social anxiety and social skills deficits), or trauma. The authors integrate a description of their “stress day,” which includes aspects of exposure to pain and functioning, as well as other situations that cause stress for each individual child. There is also a chapter on integrating families, with specific attention to relevant concerns such as family dynamics, parents with their own pain or health concerns, and concerns of abuse. There is also an important discussion of discharge planning, work toward relapse prevention, and even tips around carefully considering a readmission.

Finally, the third part of this book begins with additional information pertinent to adapting treatment for kids with more severe psychological comorbidities, and following the pattern of the rest of the book this is handled in a practical manner, incorporating patient stories and specific language to use with families. This is followed by an entire chapter of clinical tools such as assessments, patient education handouts, and clinical worksheets. The book concludes with a chapter dedicated to reviewing the current empirical evidence and the group’s own research in many different ways, including clinical improvement, economic improvement, and even teasing out one specific component of the treatment with particular impact on outcomes (I won’t share which component; you’ll just have to get the book and find out!).

Overall, I clearly concur with prior descriptions of this book as practical. While the middle portions of the book are likely of greatest interest to those running or developing an intensive interdisciplinary program, the early chapters along with many of the clinical tips throughout are likely to be of great benefit to clinicians from any background. Indeed, the book as a whole is an accessible and helpful description of pain treatment, and would be useful to physicians and nurse practitioners, psychologists and other mental health providers, as well as team members such as physical and occupational therapists, art and music therapists, child life, nursing staff, and others involved in the outpatient or intensive treatment of young people with pain. In addition to the specific content within the book, its practical nature is further strengthened by the many examples of patient-friendly language included throughout. For example, not only do the authors caution the reader to watch for certain unhelpful thoughts or attributions regarding pain, they specifically include ideas for addressing family conceptualizations such as dualism (this is “all medical”, or “all psychological”) and attributing changes in symptoms to secondary gain. This is by no means an isolated example, as these kinds of tips are included throughout, and are also integrated within the clinical examples interspersed through each chapter. Overall, the book is thoughtful in addressing ways that psychological and environmental factors can be appropriately addressed, and the sections about working with parents who have their own medical and psychological challenges stands out as particularly nuanced.

The only potential limitations of the book are consequences of its focus on the work of one interdisciplinary team. As a result, there is limited discussion of the different roles that clinical staff can play, as in different hospitals and countries many roles filled by nurses or teachers might be instead addressed through intervention by physical or occupational therapy, or child life. Additionally, while the discussion of the overall approach is important to all team members, there were fewer specific examples of the role of music therapy, art therapy, and social work. Finally, the authors discuss an integration of mindfulness and acceptance within a CBT-based approach, but in these cases the cognitive-behavioral approach clearly remains the dominant mindset, leading mindfulness to be conceptualized more as relaxation and distraction, and acceptance as a tool primarily for unchangeable symptoms. This is likely a common manner in which these concepts are utilized within a CBT-based treatment, but certainly not the only way.

Overall, this book is an important contribution to the cause of interdisciplinary treatment of young people with chronic pain. It is written with an openness to international perspective, overflowing with clinical tips and practical strategies, and solidly rooted in the current state of the evidence for pediatric pain treatment. Personally, I will be immediately making it available to all members of our interdisciplinary pain teams, ranging from inpatient consultation through outpatient treatment, and on to intensive interdisciplinary treatment. In addition to being a valuable component of our onboarding process for new team members, I suspect that this book will spur many valuable clinical conversations, updated treatment ideas, and perhaps some academically fruitful discussions as well.

As we generate knowledge and share this information, we must continually adapt our approaches to suit those working on the front lines. In our experience working with pain in children with IDD, the delay in relevant knowledge generation and translation is unacceptable; we need to move forward in a coordinated and helpful way. The proactive consideration of the above recommendations by researchers and stakeholders in program development has potential to streamline the development of trainings and improve their impact in the field of pain and childhood disability. Furthermore, it is critical to think beyond goals of initial knowledge translation and towards the integration of interventions into direct care. For example, the training could be provided while resources like pain communication tools are simultaneously incorporated into child intake packages of an organization. Knowledge is only potential power. As researchers, it is our responsibility to ensure it is harnessed and used for the greater good of children with IDD and their families.

Cite as: Wallace DP. Truly practical and of interest to your whole team. Book review: Practical treatment options for chronic pain in children and adolescents: an interdisciplinary therapy manual (2nd edition). Pediatric Pain Letter 2020;22(2):25-27. ppl.childpain.org

References

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. Link