Commentary

Preparing for return to in-person school instruction in pediatric chronic pain populations

Lauren E. Oddo and Laura S. Gray

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Summer typically provides a welcome reprieve from school-related stressors and functional demands that burden our patients. This summer will be different, given the need to prepare many patients for return to in-person instruction after prolonged disruptions in school attendance pursuant to the coronavirus pandemic. In the current report, we focus on select challenges associated with return to in-person instruction in pediatric pain populations. We draw from our ongoing clinical work within a multidisciplinary pediatric pain clinic in a large metropolitan area, and highlight clinical strategies designed to support patients’ adaptive coping and decrease functional disability during this time. It is our hope to contribute to an ongoing dialog surrounding optimal delivery of services for this vulnerable population.

Implementation of accommodations

Challenges

There is consensus that youth experiencing chronic pain should engage in school, as focusing on functioning decreases pain-related disability (Logan & Simons, 2010; Simons et al., 2010). Some patients require reasonable accommodations (i.e. formal or informal alterations of environment, curricula, and/or equipment to allow students with disabilities and/or functional limitations an equal opportunity to benefit from the educational process; e.g. Harrison et al., 2013; Conroy et al., 2020) to optimize functioning and decrease the likelihood of chronic boom and bust cycles leading to increased pain, deconditioning, and functional disability (Carter & Threlkeld, 2012). Barriers to implementing accommodations may exist within the school building itself due to pandemic safety precautions. For some students, in-person instruction requires remaining in a single classroom, limited/specified break times, wearing masks (requiring pull-down to hydrate and eat), and food restricted from classrooms. Schools may require students who report feeling unwell (e.g. headache) to return home. Several of our patients have been reluctant to deploy coping skills in the classroom (e.g. drinking water, taking movement breaks) for fear of breaking school rules. Certainly, the increasing availability of vaccine for some populations may continue to change the school landscape and decrease anxiety associated with return to school, whereas prolonged wait for vaccine approval for others, such as younger age groups, may lead to continued pandemic modifications in the schools. Our goal is to help patients use behavioral pain management strategies within the school building while maximizing health and safety.

Clinical strategies

Selecting appropriate accommodations. Implementing formal and/or informal accommodations in this context requires forethought, flexibility, and creativity among providers, families, and school personnel. Several clinical indicators can help guide decision making, including current level of functioning, physical deconditioning, anxiety symptoms, and history of school refusal. Sometimes the best option for reducing functional disability is not to offer too extensive a set of accommodations, or to ensure accommodations are only a temporary and scaffolded support. Certain accommodations can perpetuate a focus on pain and functional disability (see Clinical example 1).

Collaborating with third parties. We work with patients, their families, and schools to understand the rationale for certain accommodations versus others, to problem solve any barriers, and to effectively communicate. We often select discrete coping skills that students feel comfortable deploying within the classroom, which can maximize adherence. Common strategies include getting up from the desk to sharpen pencils or to throw something away, eating a peppermint (i.e. simulating mindful eating), and using deep breathing exercises. Coping cards depicting these options often encourage follow-through. We also help families to partner with schools by streamlining communication, identifying school advocates, and selecting top problems.

Partnering with schools is also an essential step in developing and implementing accom-modations to support student success. We establish open dialog with partners from patients’ schools who are abreast of school policies and capabilities. Written letters detailing accommodations help ensure that schools understand students’ needs. Early and ongoing communication helps to develop reasonable accommodations before students return to the building. See Table 1 for additional communication tips.

Table 1
Tips for successful partnerships with schools

Clinical example 1. One family asked school personnel to provide several breaks for their child (“Aaron”) out of the classroom. Aaron and his family presented to our clinic feeling frustrated that their efforts were ineffective. We soon learned that these breaks involved Aaron standing in the open hallway while others passed him by, as the school had limited space options due to physical distancing precautions. Aaron reported feeling spotlighted and quite uncomfortable in these breaks, resulting in increased stress, physiological arousal, and attention to pain. Additionally, Aaron frequently reported to the school nurse with requests to take exams during the mornings, in anticipation of headaches in the afternoons interfering with performance. It appeared that these accommodations were inadvertently reinforcing pain behaviors and functional disability. Indeed, an important step in developing reasonable school supports was first aligning with Aaron and his family to better understand their concerns.

Resistance to in-person instruction and anticipatory anxiety

Challenges

Patients with chronic pain often develop school avoidance cycles (Smith & Bryant, 2020) and anxiety predicts poorer school functioning in this population (Khan et al., 2015). Prolonged time in virtual schooling may exacerbate anticipatory fear and complicate return to school. Some students might experience intense fear of crowds, developed after prolonged social distancing. Others may struggle to adjust to new schedules, physical demands, and social expectations. Indeed, many patients with chronic pain are likely to prefer virtual learning, but key features of this context can interfere with their functional goals. The virtual environment generally limits social/physical demands, provides students with the ability to attend class from the comfort of their beds, and sleep in. Any change, perhaps especially during this time, is likely to be difficult for our patients and prompt fear, anxiety, and stress, which could exacerbate pain and symptoms.

Clinical strategies

Psychoeducation. We encourage clinicians to support patients and families in understanding the benefits of in-person instruction from a chronic pain perspective (Logan et al., 2008; Logan & Simons, 2010). For example, discussion that in-person instruction reduces self-regulation and executive functioning demands, in contrast to virtual format, which typically requires significant caregiver monitoring as youth are tasked with structuring days and self-regulating towards goals, often with limited school-based support. Our patients report that enhanced social interactions, changes in settings, and more engaging classes characteristic of in-person instruction provide them with distractions from pain. The in-person context can allow for easier access to extracurricular activities, socialization, and supports belongingness — encouraging school attendance on bad pain days. In-person instruction also provides natural limits on daytime sleeping and helps to regulate sleep schedules. Patients who are ambivalent about return to in-person instruction, despite clear need, may benefit from motivational interviewing using personalized feedback to support adaptive decision-making (Miller & Rollnick, 2009).

Exposure. Gradual exposures can help to address school-related anxiety. Clinicians will need to implement exposures as creatively and flexibly as possible, conditional on school protocol and safety precautions. For example, some families practice their school commute. Others meet teachers/counselors in person. If permitted, students can view their lockers and practice walking to classes. If these in-person exposures are not feasible, consider imaginal exposures or virtual options. Social skills practice via role plays and virtual and in-person conversations may be indicated. Non-school activities out of the home can support social exposure goals. Families often implement reward schedules and/or token economies to support motivation. Families also help with extensive problem solving, particularly with exposures involving younger children. As with any exposure, deploying relaxation and cognitive strategies may be useful (Southam-Gerow, 2019).

Structured return to in-person instruction. Developing a structured and time-bound gradual return to school plan can encourage approach behaviors and minimize school avoidance. These plans are quite prescriptive, and families are encouraged to share the plan with the school (see Text Box 1). In developing these plans, we emphasize the importance of not going backwards; for example, once a child participates in full days, they agree to not drop back to half days. Patients and their families often agree on no matter what criteria, which provide them with concrete circumstances permitting absence (e.g. profuse bleeding or fever). Clear, predictable, and mutually agreed upon expectations for patients and families can help to decrease parent-child conflict. Note that some schools may offer hybrid virtual options, which could be indicated in a return to school plan. Providers should carefully consider risks/benefits of virtual options within return to school plans, contingent on school, family, and patient factors (e.g. avoidance).

Clinical Example 2. A recent patient (“Jade”) presented to our clinic with a significant history of school refusal and generalized anxiety. She was advised by a primary care provider to return to in-person school, and she had attended a single in-person day. However, the school soon transitioned to a temporary virtual instruction due to a possible coronavirus case within the community. Following this disruption, Jade had not returned to in-person instruction and her parents reported being unable to motivate return. They experienced significant parent-child conflict. We implemented a time-bound gradual return to instruction plan, with a contingency management protocol (see Text Box). Jade and her parents contributed to and agreed upon the plan.

Sleep considerations

Challenges

Many children and families report sleep dysregulation and limited routines during the pandemic (Bates et al., 2020; Gilic et al., 2020; Yang et al., 2020; Becker et al., 2021). A challenge for our patients is deploying planning, organizational, and time management skills to structure and self-regulate a daily routine with intentional breaks from screens as well as opportunities for walking and physical movement. These circumstances increase risk for deconditioning in pediatric pain populations.

Clinical strategies

Given impending sleep and lifestyle adjustments associated with return to in-person instruction and the likelihood of deconditioning among our patients, we recommend starting sleep and lifestyle changes promptly. Standard CBT-insomnia protocols (Lewin & Huntley, 2017; Palermo et al., 2017) are well suited. We also coach patients and families to gradually move bedtime and waketime earlier over time by 15- to 30-minute increments (e.g. facilitated by use of phone reminders in the evening and an alarm in the morning) until the desired bedtime/waketime is reached. Indeed, a consistent bedtime routine can also help facilitate sleep onset during this gradual shift. Increased daytime activity is also useful in regulating sleep/wake patterns.

Clinical Example 3. One patient described wanting to maintain a better balance between their schoolwork and other enjoyable activities. Another patient created a non-negotiables list of must-do activities the night before in-person instruction days, including gathering school materials, laying out school clothes, and packing lunch, water bottle (extra water if fountains are turned off), and snacks. These activities were routinized prior to the pandemic, but likely require forethought and practice after more than a year of virtual instruction.

Cultural considerations

Patients and families express various beliefs about pain, privacy, and disclosure (Batista et al., 2012; Khin Hla et al., 2014; Sieberg et al., 2017). For example, some families may view clinicians and/or school personnel as experts, and appear reticent to express their concerns about treatment plans. Indeed, careful attention to these and other factors is essential in optimizing care, particularly with differing family concerns related to the pandemic and return to in-person school. Clinical frameworks, such as the multidimensional ecological comparative approach (MECA), can help to optimize care by supporting culturally attuned and empowering encounters between clinicians, patients, and schools (Falender et al., 2014).

Conclusion

Our patients will likely encounter novel challenges in the transition to in-person instruction after prolonged in-person absence and new opportunities to deploy coping skills and strategies. Many clinicians anticipate an uptick in school-related anxiety and refusal. In this brief review, we hope to contribute to an important dialog surrounding clinical care during this time. Please see Appendices for additional resources and clinician guides for return to school and managing anxiety.

Cite as: Oddo LE, Gray LS. Preparing for return to in-person school instruction in pediatric chronic pain populations. Pediatric Pain Letter 2021;23(2):17-26. ppl.childpain.org

References

Barkley RA, Robin AL. Your defiant teen: 10 steps to resolve conflict and rebuild your relationship. New York: Guilford Press, 2008. Link

Bates LC, Zieff G, Stanford K, Moore JB, Kerr ZY, Hanson ED, et al. COVID-19 impact on behaviors across the 24-hour day in children and adolescents: physical activity, sedentary behavior, and sleep. Children 2020;7:138. PubMed Abstract

Batista ML, Fortier MA, Maurer EL, Tan E, Huszti HC, Kain ZN. Exploring the impact of cultural background on parental perceptions of children’s pain. Child Health Care 2012;41:97-110.

Becker SP, Dvorsky MR, Breaux R, Cusick CN, Taylor KP, Langberg JM. Prospective examination of adolescent sleep patterns and behaviors before and during COVID-19. Sleep 2021;zsab054. PubMed Abstract

Carter BD, Threlkeld BM. Psychosocial perspectives in the treatment of pediatric chronic pain. Pediatr Rheumatol Online J 2012;10:15), 15. PubMed Abstract

Conroy K, Greif Green J, Phillips K, Poznanski B, Coxe S, Kendall PC, et al. School-based accommodations and supports for anxious youth: benchmarking reported practices against expert perspectives. J Clin Child Adolesc Psychol 2020;1-9. PubMed Abstract

Falender CA, Shafranske EP, Falicov CJ. Reflective practice: culture in self and other. In: Falender CA, Shafranske EP, Falicov CJ, editors. Multiculturalism and diversity in clinical supervision: a competency-based approach. Washington, DC: American Psychological Association. pp. 273-281. Link

Gilic B, Ostojic L, Corluka M, Volaric T, Sekulic D. Contextualizing parental/familial influence on physical activity in adolescents before and during COVID-19 pandemic: a prospective analysis. Children 2020;7:125. PubMed Abstract

Harrison JR, Bunford N, Evans SW, Owens JS. Educational accommodations for students with behavioral challenges: a systematic review of the literature. Rev Educ Res 2013;83:551-597.

Khan KA, Tran ST, Jastrowski Mano KE, Simpson PM, Cao Y, Hainsworth KR. Predicting multiple facets of school functioning in pediatric chronic pain. Clin J Pain 2015;31:867-875. PubMed Abstract

Khin Hla T, Hegarty M, Russell P, Drake-Brockman TF, Ramgolam A, von Ungern-Sternberg BS. Perception of pediatric pain: a comparison of postoperative pain assessments between child, parent, nurse, and independent observer. Paediatr Anaesth 2014;24:1127-1131. PubMed Abstract

Lewin DS, Huntley E. Insomnias of childhood: assessment and treatment. In Attarian HP, editor. Clinical handbook of insomnia. Cham, Switzerland: Springer, 2017. pp. 135-158. Link

Logan DE, Simons LE. Development of a group intervention to improve school functioning in adolescents with chronic pain and depressive symptoms: a study of feasibility and preliminary efficacy. J Pediatr Psychol 2010;35:823-836. PubMed Abstract

Logan DE, Simons LE, Stein MJ, Chastain L. School impairment in adolescents with chronic pain. J Pain 2008;9:407-416. PubMed Abstract

Miller WR, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother 2009;37:129-140. PubMed Abstract

Palermo TM, Beals-Erickson S, Bromberg, M, Law E, Chen, M. A single arm pilot trial of brief cognitive behavioral therapy for insomnia in adolescents with physical and psychiatric comorbidities. J Clin Sleep Med 2017;13:401-410. PubMed Abstract

Sieberg CB, Smith A, White M, Manganella J, Sethna N, Logan DE. Changes in maternal and paternal pain-related attitudes, behaviors, and perceptions across pediatric pain rehabilitation treatment: a multilevel modeling approach. J Pediatric Psychol 2017;42:52-64. PubMed Abstract

Simons LE, Logan DE, Chastain L, Cerullo M. Engagement in multidisciplinary interventions for pediatric chronic pain: parental expectations, barriers, and child outcomes. Clin J Pain 2010;26:291-299. PubMed Abstract

Smith AM, Bryant G. Have to’s before want to’s: an accessible framework for breaking the cycle of avoidance and reestablishing routine in youth with chronic pain. Pediatr Pain Lett 2020;22:(3),33-37. Link

Southam-Gerow MA. Exposure therapy with children and adolescents. New York: Guilford Publications, 2019.

Yang S, Guo B, Ao L, Yang C, Zhang L, Zhou J, et al. Obesity and activity patterns before and during COVID-19 lockdown among youths in China. Clin Obes 2020;10:e12416. PubMed Abstract