Book Review

A helpful manual for novice and seasoned psychologists providing care to adolescents with a variety of physical illnesses, including chronic pain

Children’s Health and Illness Recovery Program (CHIRP): Clinician Guide & Teen and Family Workbook

Clinical Guide: Carter BD, Kronenberger WG, Scott EL, Brady C (2020). New York: Oxford University Press, 126 pp. ISBN 978-0190070267 (Paperback: $53.00 USD). Link

Teen and Family Workbook: Carter BD, Kronenberger WG, Scott EL (2020). New York: Oxford University Press, 192 pp. ISBN 978-0190070472 (Paperback: $41.95 USD). Link

Reviewed by Ana B. Goya Arce

printable version (PDF)

Families face many challenges as they embark on the treatment of adolescent chronic illness including transitioning from seeking a unitary cure for symptoms to viewing the adolescent’s illness as chronic and manageable. Learning how to manage chronic illnesses requires a team consisting of healthcare providers across multiple disciplines, teachers and school officials, family members, and the adolescent. The multifaceted and multidisciplinary nature of chronic illness management in adolescents requires communication between all members of the treatment team, a flexible approach to manage symptoms and functional challenges as they emerge, cohesive messaging across providers and settings, and a shared understanding of the goal to support functioning and improve quality of life. Furthermore, management of chronic illnesses in adolescence presents unique challenges given debilitating symptoms associated with chronic illnesses can lead to decreased independence and thus complicate achievement of developmentally appropriate milestones needed to support a successful transition into adulthood. The Children’s Health and Illness Recovery Program (CHIRP) provides a framework and protocol specifically designed to treat adolescents with chronic physical illnesses. CHIRP is grounded in evidence and recognizes the complexities of chronic illness management within the developmental context of adolescence. The program focuses on improving quality of life through gradually improving adolescent functioning and independence, optimizing family support, and facilitating communication between treatment providers.

CHIRP materials consist of a Clinician Guide and an accompanying Teen and Family Workbook. The Clinician Guide begins with an introduction section which outlines the theoretical framework underlying the manualized treatment and provides research evidence supporting the individual treatment component and the treatment as a whole. The authors draw both from the scientific literature and from their combined clinical experience to explain the program’s foundations of (a) physical functioning, (b) academic functioning, (c) interpersonal functioning, and (d) skills development, coping and lifestyle management. Additionally, the authors provide a helpful review of the treatment components which are drawn primarily from cognitive behavioral therapy (CBT), behavioral family systems therapy (BFST), and an acceptance-based approach to coping. The thorough conceptual framing provides the clinician with a working understanding of each treatment component, thus supporting clinician agility in the delivery of the program. The authors highlight the importance of flexibility within fidelity, underscoring the importance of sound clinical judgment in the presentation and delivery of the various treatment components. The introduction to the treatment includes a Prep Session where the treatment model is introduced, commitment to the treatment is established, the need for school accommodations is explored, and a weekly physical activity program is developed. The introduction section in the Teen and Family Workbook similarly provides adolescents and their families with education about the importance of acquiring coping strategies to improve functioning and grounds the use of these skills with past clinical experiences and scientific evidence.

Following the Prep Session, CHIRP consists of 12 sessions covering a broad range of individual and family skills needed to successfully manage chronic illnesses and support increased functioning including: stress identification and management, problem-solving, relaxation skills, cognitive reframing skills, time management, assertiveness, delineation of family roles, family and peer communication skills, and family support. The program also includes sessions focusing on skill reinforcement and relapse prevention and includes the option to add a supplemental session if chronic pain is present. Throughout the Clinician Guide and the Teen and Family Workbook the authors utilize non-judgmental and patient-centered language, frequently acknowledging that the roadblocks families face in their path to improved illness management are understandable and relatable. The order in which the skills are presented is well thought out and each session transitions seamlessly into the next thanks to the use of homework, skills review, and ongoing refinement of previously used strategies, creating a cohesive and comprehensive program. For example, the weekly physical activity program developed during the Prep Session is reviewed and refined throughout all subsequent sessions, in line with the program’s core foundation of physical functioning. Similarly, tracking sleep routines and relaxation practices is assigned and reviewed throughout the program. The use of homework assignments focusing on the ongoing use of skills allows the team (clinician, adolescent, and caregivers) to monitor progress and address barriers to engagement promptly.

The Clinician Guide breaks down each session’s content into various elements including session format (teen-only, joint session with teen and parents), goals of the session, subheadings for content areas (which include additional information about the skills being taught and tips for delivering session content), additional clinician activities in selected sessions (e.g. recommendations for formalized interdisciplinary communication), and homework assignments. Similarly, the Teen and Family Workbook organizes session content by utilizing subheadings for each of the topics covered. Session content in the Teen and Family Workbook combines informational paragraphs, vignettes, figures, and worksheets. Each session introduces coping skills, explains how and when to use the skill, and provides instructions on how to utilize the included worksheets. The language, figures, and worksheets are age appropriate, well-designed, and work together to support a deep understanding of why these coping skills work and how they can be applied in the teen’s daily life.

One strength of CHIRP, which makes it uniquely suited to the treatment of chronic illness in adolescence, is the inclusion of family sessions aimed at examining how the adolescent’s chronic illness has impacted family dynamics, teaching family communication strategies to improve parent-child relationships, and fostering developmentally appropriate independence in the adolescent. Through teaching families the concept of misguided support, CHIRP provides parental education on how behaviors initially aimed at supporting the adolescent (e.g. reducing household chores) may inadvertently result in decreased confidence, self-efficacy and independence. Throughout CHIRP, parents and teens work together on identifying developmentally appropriate tasks and responsibilities in order to gradually normalize adolescent functioning across domains. Additionally, CHIRP helps optimize family support through assisting families in developing a framework for positive interactions, through delineating parental and teen roles within the family, and through teaching the principles of positive communication.

CHIRP’s Clinician Guide includes a wealth of empirical and practical knowledge. The introduction includes sample scripts that explain each treatment guideline, which provides the clinician with helpful language to explain the treatment rationale and support decreased anxiety in teens and their families as they shift from an acute-curable to a chronic-manageable view of the illness. Guidelines on who may not be a good candidate for CHIRP are provided, supporting clinicians with identifying patients for whom engagement in the program may be difficult and highlighting the importance of making judicious referrals. The inclusion of a sidebar at the end of each session facilitates delivery by providing case examples of how adolescents with chronic illnesses engaged in each session and highlighting clinician strategies that supported this engagement. The Clinician Guide provides sample standardized forms to facilitate referrals, interdisciplinary communication, and feedback; the inclusion of these forms and the availability of additional copies of these forms for download supports their recommended repeated use throughout the program. Furthermore, the Clinician Guide presents a series of validated measures and encourages their use to assess treatment progress and program outcomes. The Clinician Guide also acknowledges organizational and time barriers to the administration of CHIRP as an individual treatment and, in recognition of the frequent social isolation adolescents with chronic illnesses experience, provides guidelines and tips to support the implementation of CHIRP in a group format. Additional evidence-based practices on supporting group cohesion and managing group dynamics are also discussed. While CHIRP provides a wealth of practical tips and resources for clinicians, its biggest strength is its acknowledgment of the important role that acceptance, adolescent values, and family dynamics play in an adolescent’s illness management, resulting in a program that seamlessly weaves components of CBT, BSFT, and acceptance-based coping and thus provides a multidimensional yet cohesive treatment.

The one potential limitation of CHIRP is in the ease of initial implementation. The session content in the Clinician Guide is often presented in lengthy paragraphs requiring the clinician to parse out content to be presented in session from general clinician guidelines, tips for delivery, and information about common barriers faced by adolescents and their families. The use of worksheets is similarly embedded within these paragraphs without being highlighted through bolded, underlined, or italicized text, which may require clinicians to highlight, annotate, or separately outline which worksheets and figures correspond to each of the skills covered in session, especially as they work on becoming familiarized and comfortable with treatment delivery.

Overall, CHIRP provides a comprehensive approach to functional recovery and long-term illness management in adolescence. It is solidly grounded in evidence and combines behavior change, cognitive skills, acceptance, and behavioral family systems interventions. The combined experience of the authors shines through as they provide a wealth of recommendations for the delivery of the program, useful practical resources, and thoughtful anticipatory guidance around common sources of treatment resistance. After reviewing this program, it is my belief that CHIRP is a valuable evidence-based manualized treatment protocol that can benefit both novice and seasoned psychologists seeking to provide quality care to adolescents with a variety of physical illnesses, including those with chronic pain.

Cite as: Goya Arce AB. A helpful manual for novice and seasoned psychologists providing care to adolescents with a variety of physical illnesses, including chronic pain. Book review: Children’s Health and Illness Recovery Program (CHIRP): Clinician Guide & Teen and Family Workbook. Pediatric Pain Letter 2021;23(3):50-52. ppl.childpain.org