Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – A randomized controlled trial

Pilot Randomized Trial of Integrated Cognitive-Behavioral Therapy and Neuromuscular Training for Juvenile Fibromyalgia: The FIT Teens Program

Cognitive-behavioral therapy (CBT) improves coping and daily functioning in adolescents with juvenile fibromyalgia (JFM), but is less effective in reducing pain. This pilot trial evaluated the efficacy of a novel intervention (Fibromyalgia Integrative Training for Teens; FIT Teens) which integrates CBT with specialized neuromuscular exercise training to enhance the effect of treatment on reducing pain and disability. Forty adolescents with JFM (12-18 years) were randomized to CBT-only or FIT Teens. Treatment was conducted in group-based sessions over 8 weeks with assessments at baseline, post-treatment, and 3-month follow-up (primary end point). Primary outcomes were pain intensity and functional disability. Secondary outcomes were depressive symptoms, fear of movement, and pain catastrophizing. Thirty-six participants (mean age=15.33 years; 90% female) completed the program. Intent to treat analysis was conducted to evaluate differences between the FIT Teens and CBT groups from baseline to 3-month follow-up, controlling for baseline group differences. Participants in the FIT Teens group showed significantly greater decreases in pain than the CBT group. FIT Teens participants also showed significant improvements in disability, but did not differ from CBT-only at the 3-month end point. Results provide preliminary evidence that the FIT Teens intervention provides added benefits beyond CBT in the treatment of JFM, particularly in pain reduction.

PERSPECTIVE

Results from this pilot randomized controlled trial of a new combined CBT and specialized neuromuscular exercise intervention (FIT Teens), compared with CBT alone suggested that FIT Teens offers stronger treatment benefits than CBT alone at initial treatment follow-up, especially with respect to the outcome of pain reduction.

Measurement framework for the Environmental influences on Child Health Outcomes research program

PURPOSE OF REVIEW

Diverse methodological approaches pose significant challenges to assess environmental exposure effects on child health outcomes. Although transdisciplinary research efforts offer unique opportunities for understanding the complex and multidimensional facets of lifespan health and disease trajectories, a shared measurement strategy is necessary for ensuring cohesion and comprehensibility across disciplines and domains.

RECENT FINDINGS

Exposure science often focuses on one life stage, one primary outcome domain and/or one environmental context without regard for understanding the complexity of exposome pathways and outcomes across a developmental continuum. As part of the National Institutes of Health Environmental influences on Child Health Outcomes Program, the Person Reported Outcomes Core developed a unifying measurement framework that takes a lifespan development approach to assess physical, mental and social health outcomes within the complex matrix of environmental exposure pathways.

SUMMARY

The proposed framework offers a shared methodological approach to health outcome assessment, with a particular emphasis on person-reported outcomes. This framework will be instrumental for future large-scale consortia and transdisciplinary team science efforts by providing a common structure, measurement guidance and consistent terminology.

The management of young people who self-harm by New Zealand Infant, Child and Adolescent Mental Health Services: cutting-edge or cutting corners?

OBJECTIVES

Self-harm is common in New Zealand (NZ) young people and can have short-term and long-term consequences, including suicide. This study was undertaken to examine the extent to which evidence-based approaches for addressing self-harm are offered by Infant, Child and Adolescent Mental Health Services (ICAMHS).

METHODS

A national survey of ICAMHS practitioners working with young people who self-harm was undertaken between May and July 2016.

RESULTS

Responses from 23 out of 30 ICAMHS confirmed self-harm was a familiar presentation and most commonly associated with diagnoses of depression, anxiety and borderline personality disorder. Cognitive behavioural therapy (47.1%, n = 8), dialectical behaviour therapy (47.1%, n = 8) and acceptance and commitment therapy (5.9%, n = 1) were the treatments of choice, but variably delivered. There were significant training gaps for all types of therapy.

CONCLUSIONS

Although it is reassuring that many ICAMHS are using evidence-based approaches to address self-harm in young people, there is concerning variability in the way these therapies are delivered. Improvement in training in key modalities, further research into therapist performance and continuous evaluation of workforce development are needed to maximise the effectiveness of proven interventions and provide NZ young people with the state-of-the-art service they deserve.

Pain and its Impact on the Functional Ability in Children Treated at the Children's Cancer Center of Lebanon

PURPOSE

The purpose of this study was to describe the characteristics of pain in children under treatment at the Children Cancer Centre of Lebanon at the American University of Beirut Medical Centre. Design and Methods A cross-sectional correlational survey was used. The Adolescent Pediatric Pain Tool and the Functional Disability Inventory were used to examine the characteristics of pain experienced in a consecutive sample of children treated at the CCCL and its impact on their functional abilities.

RESULTS

The mean age of the 62 participants was 12.3 (SD 2.9). The overall mean pain intensity rating for the sample was 5.06 (SD 1.87) on a 10 cm Word Graphic Rating Scale. More than one-half of the children in the sample (57.4%) reported having pain "sometimes" with a median duration of two hours per pain episode. The most frequently reported locations of pain were the forehead, the abdomen, and the lower back. For the most part, the children used sensory words to describe their pain experience. The children reported moderate levels of functional disability (mean FDI score 25.04, SD 13.81). Multivariable linear regression analysis identified frequency, duration, location, use of affective descriptors, and treatments as statistically significant predictors of pain intensity.

CONCLUSION

Regrettably, the findings reported attest once again to unrelieved pain in a pediatric oncology population.

PRACTICE IMPLICATIONS

Policy makers can contribute to pain control by introducing legislation and national policies to ensure adequate pain management for children with cancer in Lebanon.

A meta-analysis of dropout rates in acceptance and commitment therapy

Many psychotherapies, including cognitive behavioral therapy and acceptance and commitment therapy (ACT), have been found to be effective interventions for a range of psychological and behavioral health concerns. Another aspect of treatment utility to consider is dropout, as interventions only work if clients are engaged in them. To date, no research has used meta-analytic methods to examine dropout in ACT. Thus, the objectives of the present meta-analysis were to (1) determine the aggregate dropout rate for ACT in randomized controlled trials, (2) compare dropout rates in ACT to those in other psychotherapies, and (3) identify potential moderators of dropout in ACT. Our literature search yielded 68 studies, representing 4,729 participants. The weighted mean dropout rates in ACT exclusive conditions and ACT inclusive conditions (i.e., those that included an ACT intervention) were 15.8% (95% CI: 11.9%, 20.1%) and 16.0% (95% CI: 12.5%, 19.8%), respectively. ACT dropout rates were not significantly different from those of established psychological treatments. In addition, dropout rates did not vary by client characteristics or study methodological quality. However, master's-level clinicians/therapists (weighted mean = 29.9%, CI: 17.6%, 43.8%) were associated with higher dropout than psychologists (weighted mean = 12.4%, 95% CI: 6.7%, 19.4%). More research on manipulable, process variables that influence dropout is needed.

Multi-Family Pediatric Pain Group Therapy: Capturing Acceptance and Cultivating Change

Behavioral health interventions for pediatric chronic pain include cognitive-behavioral (CBT), acceptance and commitment (ACT), and family-based therapies, though literature regarding multi-family therapy (MFT) is sparse. This investigation examined the utility and outcomes of the Courage to Act with Pain: Teens Identifying Values, Acceptance, and Treatment Effects (CAPTIVATE) program, which included all three modalities (CBT, ACT, MFT) for youth with chronic pain and their parents. Program utility, engagement, and satisfaction were evaluated via quantitative and qualitative feedback. Pain-specific psychological, behavioral, and interpersonal processes were examined along with outcomes related to disability, quality of life, pain interference, fatigue, anxiety, and depressive symptoms. Participants indicated that CAPTIVATE was constructive, engaging, and helpful for social and family systems. Clinical and statistical improvements with large effect sizes were captured for pain catastrophizing, acceptance, and protective parenting but not family functioning. Similar effects were found for functional disability, pain interference, fatigue, anxiety, and depression. Given the importance of targeting multiple systems in the management of pediatric chronic pain, preliminary findings suggest a potential new group-based treatment option for youth and families. Next steps involve evaluating the differential effect of the program over treatment as usual, as well as specific CBT, ACT, and MFT components and processes that may affect outcomes.

Pain Assessment Methods and Interventions Used by Pediatric Psychologists: A Survey by the Pain Special Interest Group of the Society of Pediatric Psychology

Although many valid pain-related assessment instruments and interventions exist, little is known about which are actually utilized in practice and the factors that contribute to pediatric psychologist's decisions about their use. The aim of this survey study was to present a summary of current clinical practice among pediatric psychologists in the area of pediatric pain and to identify the needs and possible resources that would enable practitioners to better implement evidence-based assessments and interventions. To accomplish this aim, the Pain Special Interest Group of the Society of Pediatric Psychology (SPP) constructed an online survey that was sent electronically to current members of the SPP list serve. Results indicated the majority of participants are guided by a theoretical model and are using evidence-based assessments and interventions, although they are not always familiar with the literature supporting their use. Providers noted evidence-based pain intervention is facilitated by assessment tools, intervention resources, and appreciation of pain interventions by multidisciplinary team members. Barriers are both logistical (clinic space and time constraints) and knowledge-based (lack of familiarity with assessments/interventions). Thus, while pediatric psychologists are progressing towards better translation of research to practice, continued educational efforts and communication among practitioners about available resources are warranted.

Pain Beliefs and Quality of Life in Young People With Disabilities and Bothersome Pain

OBJECTIVES

Pain beliefs have been hypothesized to play an important role in pediatric pain. However, research examining the associations between pain-related beliefs and measures of function in youths with disabilities is limited.

METHODS

In total, 84 youths (mean age, 14.26 y; SD, 3.27) with physical disabilities who indicated they also had bothersome pain were interviewed and asked to rate their average pain intensity in the past week and to complete measures of pain-related beliefs and health-related quality of life.

RESULTS

A number of pain beliefs were associated with different physical and psychosocial function domains, although different beliefs appeared to play different roles, depending on the function domain examined. Across all of the health-related quality-of-life domains studied, a belief that pain is influenced by one's emotions was associated with lower levels of function. No differences were found in pain beliefs related to age. In addition, a small difference in pain beliefs was found for sex; specifically, girls were more likely than boys to endorse the belief that pain is influenced by emotions.

DISCUSSION

The findings provide new information regarding the role that pain beliefs have in predicting function and have important clinical implications regarding how youth with physical disabilities and pain might be most effectively treated.

Interventions to Support Integrated Psychological Care and Holistic Health Outcomes in Paediatrics

There are strong calls from many national and international bodies for there to be a 'holistic' and integrated approach to the understanding and management of psychological and physical health needs. Such holistic approaches are characterized by the treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease. Holistic approaches can impact on mental and physical health and are cost-effective. Several psychological interventions have demonstrated efficacy in improving holistic health outcomes, for example Cognitive Behaviour Therapy, Behavioural Therapies and Problem Solving Therapies. They have shown to impact upon a wide range of outcomes, including psychological distress, pain, physical health, medication adherence, and family outcomes. There is increasing recognition that the holistic goals of the child and family should be prioritised, and that interventions and outcomes should reflect these goals. A focus on holistic goals in therapy can be achieved through a combination of personalised goal-based outcomes in addition to symptom-based measures.

Psychological Interventions for Children with Functional Somatic Symptoms: A Systematic Review and Meta-Analysis

OBJECTIVE

To analyze the effectiveness of psychological treatments on symptom load and associated disability in children with functional somatic symptoms, and to explore potential moderators of effects.

STUDY DESIGN

Cochrane, PubMed, PsycINFO, EMBASE, and CINAHL were searched for randomized controlled trials published in peer-reviewed journals. Randomized controlled trials studying the effect of a psychological treatment on symptom load and disability in children with functional somatic symptoms were selected. Data on symptom load, disability, and school absence directly post-treatment and at follow-up were extracted by 2 assessors. Studies were appraised with the Cochrane risk of bias tool. Standardized mean differences were pooled in a random-effects model. Heterogeneity in effect-sizes was explored by use of meta-regressions. PROSPERO Registration ID: CRD42015029667.

RESULTS

Out of 4098 identified records, 27 studies were included in this review of which 21 were included in meta-analyses. Psychological treatments reduced symptom load (Hedges g = -0.61), disability (Hedges g = -0.42), and school absence (Hedges g = -0.51) post-treatment in children suffering from various functional somatic symptoms. Effects were maintained at follow-up. Type and duration of symptoms, age, and treatment dose did not explain heterogeneity in effect-sizes between studies. Effect-sizes should be interpreted with caution because of the variety in outcome measures, unexplained heterogeneity in found effects and potential publication bias.

CONCLUSIONS

Psychological interventions reduce symptom load, disability, and school absence in children with functional somatic symptoms. Future research should clarify which patient and treatment characteristics modify outcomes.

Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: Preliminary outcomes from the Toronto General Hospital Transitional Pain Service

Background: Chronic postsurgical pain (CPSP) and associated long-term opioid use are major public health concerns. Aims: The Toronto General Hospital Transitional Pain Service (TPS) is a multidisciplinary, hospital-integrated program developed to prevent and manage CPSP and support opioid tapering. This clinical practice-based study reports on preliminary outcomes of the TPS psychology program, which provides acceptance and commitment therapy (ACT) to patients at risk for CPSP and persistent opioid use. Methods: Ninety-one patients received ACT, whereas 252 patients did not (no ACT group). Patient outcomes were compared for the two groups at first and last TPS visits. Pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety, depression, and opioid use were analyzed using two-way (Group [ACT, no ACT] × Time [first, last visit]) analyses of variance (ANOVAs). Results: Patients referred to ACT were more likely to report a mental health condition preoperatively (P < 0.001), had higher opioid use (P < 0.001) at the first postsurgical visit, and reported higher sensitivity to pain traumatization (P < 0.05) and anxiety (P < 0.05) than the no ACT group at both time points. Both groups showed reductions in pain, pain interference, pain catastrophizing, anxiety, and opioid use by the last TPS visit (P < 0.05). The ACT group demonstrated greater reductions in opioid use and pain interference and showed reductions in depressed mood (P = 0.001) by the end of treatment compared to the no ACT group. Conclusion: Preliminary outcomes suggest that ACT was effective in reducing opioid use while pain interference and mood improved.

Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement

Öst's (2014) systematic review and meta-analysis of Acceptance and Commitment Therapy (ACT) has received wide attention. On the basis of his review, Öst argued that ACT research was not increasing in its quality and that, in contradiction to the views of Division 12 of the American Psychological Association (APA), ACT is "not yet well-established for any disorder" (2014, p. 105). We conducted a careful examination of the methods, approach, and data used in the meta-analysis. Based in part on examinations by the authors of the studies involved, which were then independently checked, 91 factual or interpretive errors were documented, touching upon 80% of the studies reviewed. Comparisons of Öst's quality ratings with independent teams rating the same studies with the same scale suggest that Ost's ratings were unreliable. In all of these areas (factual errors; interpretive errors; quality ratings) mistakes and differences were not random: Ost's data were dominantly more negative toward ACT. The seriousness, range, and distribution of errors, and a wider pattern of misinterpreting the purpose of studies and ignoring positive results, suggest that Öst's review should be set aside in future considerations of the evidence base for ACT. We argue that future published reviews and meta-analyses should rely upon diverse groups of scholars rather than a single individual; that resulting raw data should be made available for inspection and independent analysis; that well-crafted committees rather than individuals should design, apply and interpret quality criteria; that the intent of transdiagnostic studies need to be more seriously considered as the field shifts away from a purely syndromal approach; and that data that demonstrate theoretically consistent mediating processes should be given greater weight in evaluating specific interventions. Finally, in order to examine substantive progress since Öst's review, recent outcome and process evidence was briefly examined.

Photographs of Daily Activities-Youth English: validating a targeted assessment of worry and anticipated pain

PHODA is an electronic measure that individualizes and guides treatment for individuals with chronic pain. Implicit in its design is recognition that pain-related fear is a driving force that impedes treatment progress. With this tool, patients visually rate their expectations about the harmful consequences of specific movements. This study aimed to (1) develop and validate PHODA-Youth English (PHODA-YE) and (2) evaluate the potential impact of PHODA-YE assessment on treatment outcomes. Participants were 195 youth, age 8 to 20 years, who presented to an outpatient pain clinic for evaluation (n = 99), or enrolled at the Pediatric Pain Rehabilitation Center (PPRC) intensive program (PPRC; n = 96). All patients completed the PHODA-YE along with measures of emotional functioning and disability. Patients in the PPRC completed the measure at both admission and discharge. After eliminating infrequently endorsed and poorly loading items, factor analytic procedures yielded a 4-subscale, 50-item measure with strong internal consistency (from 0.92 to 0.97 across subscales). Fear, avoidance, and functional disability were strongly associated with PHODA-YE scores, supporting construct validity. Within the PPRC sample, PHODA-YE was sensitive to changes over time in relation to functional improvements. Across the PPRC sample, patients found it helpful to complete the PHODA and target feared activities. Altogether, the PHODA-YE is a valid and concrete assessment tool that rapidly identifies specific activities and movements that elicit fearful responses from patients.

Coaching of patients with an isolated minimally displaced fracture of the radial head immediately increases range of motion

STUDY DESIGN

Prospective cohort.

INTRODUCTION

Elbow stiffness is the most common adverse event after isolated radial head fractures.

PURPOSE OF THE STUDY

To assess the effect of coaching on elbow motion during the same office visit in patients with such fractures.

METHODS

We enrolled 49 adult patients with minimally displaced radial head fractures, within 14 days of injury. After diagnosis, we measured demographics, catastrophic thinking, health anxiety, symptoms of depression, upper extremity-specific symptoms and disability, pain, and elbow and wrist motion. The patient was taught to apply an effective stretch in spite of the pain to limit stiffness, and elbow motion was measured again.

RESULTS

With the exception of radial deviation and pronation, motion measures improved slightly but significantly on average immediately after coaching. Elbow flexion improved from 79% (110° ± 22°) of the uninjured side to 88% (122° ± 18°) after coaching (P < .001); elbow extension improved from 71% (29° ± 14°) to 78% (22° ± 15°) (P = .0012).

DISCUSSION

Instruction that stretching exercises are healthy even when painful resulted in immediate improvements in motion. Prospective studies comparing different strategies for coaching patients regarding painful stretches might help clarify the optimal approach.

LEVEL OF EVIDENCE

Therapeutic level 4.

Importance of Pain Acceptance in Relation to Headache Disability and Pain Interference in Women With Migraine and Overweight/Obesity

BACKGROUND

Pain acceptance involves willingness to experience pain and engaging in valued activities while pain is present. Though pain acceptance could limit both headache-related disability and pain interference in individuals with migraine, few studies have addressed this issue. This study evaluated whether higher levels of total pain acceptance and its two subcomponents, pain willingness and activity engagement, were associated with lower levels of headache-related impairment in women who had both migraine and overweight/obesity.

METHODS

In this cross-sectional study, participants seeking weight loss and headache relief in the Women's Health and Migraine trial completed baseline measures of pain acceptance (Chronic Pain Acceptance Questionnaire [CPAQ]), headache-related disability (Headache Impact Test-6), and pain interference (Brief Pain Inventory). Migraine headache frequency and pain intensity were assessed daily via smartphone diary. Using CPAQ total and subcomponent (pain willingness and activity engagement) scores, headache frequency, pain intensity, and body mass index (BMI) as predictors in linear regression, headache-related disability, and pain interference were modeled as outcomes.

RESULTS

On average, participants (n = 126; age = 38.5 ± 8.2 years; BMI = 35.3 ± 6.6 kg/m² ) reported 8.4 ± 4.7 migraine days/month and pain intensity of 6.0 ± 1.5 on a 0-10 scale on headache days. After correcting for multiple comparisons (adjusted α = .008), pain willingness was independently associated with both lower headache-related disability (P < .001; β = -0.233) and pain interference (P < .001; β = -0.261). Activity engagement was not associated with headache-related disability (P = .128; β = -0.138) and pain interference (P = .042; β = -0.154). CPAQ total score was not associated with headache-related disability (P = .439; β = 0.066) and pain interference (P = .305; β = 0.074). Pain intensity was significantly associated with outcomes in all analyses (Ps < .001; βs 0.343-0.615).

CONCLUSIONS

Higher pain willingness, independent of degree of both migraine severity and overweight, is associated with lower headache-related disability and general pain interference in treatment-seeking women with migraine and overweight/obesity. Future studies are needed to clarify direction of causality and test whether strategies designed to help women increase pain willingness, or relinquish ineffective efforts to control pain, can improve functional outcomes in women who have migraine and overweight/obesity.

Evidence-Based Psychological Interventions for the Management of Pediatric Chronic Pain: New Directions in Research and Clinical Practice

Over the past 20 years our knowledge about evidence-based psychological interventions for pediatric chronic pain has dramatically increased. Overall, the evidence in support of psychological interventions for pediatric chronic pain is strong, demonstrating positive psychological and behavioral effects for a variety of children with a range of pain conditions. However, wide scale access to effective psychologically-based pain management treatments remains a challenge for many children who suffer with pain. Increasing access to care and reducing persistent biomedical biases that inhibit attainment of psychological services are a central focus of current pain treatment interventions. Additionally, as the number of evidence-based treatments increase, tailoring treatments to a child or family’s particular needs is increasingly possible. This article will (1) discuss the theoretical frameworks as well as the specific psychological skills and strategies that currently hold promise as effective agents of change; (2) review and summarize trends in the development of well-researched outpatient interventions over the past ten years; and (3) discuss future directions for intervention research on pediatric chronic pain.

Acceptance and Commitment Therapy for Pediatric Chronic Pain: Theory and Application

Acceptance and Commitment Therapy (ACT) is a third wave behavior therapy approach which aims to increase engagement in activities that bring meaning, vitality, and value to the lives of individuals experiencing persistent pain, discomfort, or distress. This goal is particularly relevant when these aversive experiences cannot be effectively avoided or when avoidance efforts risk their exacerbation, all of which may be common experiences in children and adolescents with chronic pain conditions. The primary aim of the present paper is to review and summarize the extant literature on the application, utility, and evidence for using ACT with pediatric chronic pain populations by: (1) defining the theoretical assumptions of the ACT model; (2) summarizing research study findings and relevant measures from the published literature; and (3) critically discussing the strengths, limitations and areas in need of further development.

Exploring Changes in Valued Action in the Presence of Chronic Debilitating Pain in Acceptance and Commitment Therapy for Youth - A Single-Subject Design Study

Objective: The objective of the study was to improve the understanding of processes of change in Acceptance and Commitment Therapy for youth with chronic debilitating pain by exploring the relation between individual change patterns in pain intensity and valued activities.

Method: A single-subject design across three adolescents suffering from longstanding debilitating pain was utilized. Pain intensity and participation in valued activities were rated daily. Visual analysis of the graphed data was performed to evaluate the effects of the intervention, and the relationship between pain intensity and values-based activity.

Results: The graphed data illustrated that pain levels did not decrease from the baseline period to the follow-up period. In contrast, compared to baseline ratings values oriented behaviors increased from the start of treatment to the follow-up period.

Conclusion: Results illustrate that increases in values-based behavior may occur without corresponding decreases in pain, and warrant further research on change processes in ACT for youth suffering from chronic pain.

Acceptance and Commitment Therapy and Selective Optimization with Compensation for Institutionalized Older People with Chronic Pain

OBJECTIVE

Recent studies support the efficacy of Acceptance and Commitment Therapy (ACT) with people with chronic pain. In addition, Selective Optimization with Compensation strategies (SOC) can help the elderly with chronic pain to accept their chronic condition and increase functional autonomy. Our aim was to analyze the efficacy of an ACT treatment program combined with training in SOC strategies for elderly people with chronic pain living in nursing homes.

METHODS

101 participants (mean age = 82.26; SD = 10.00; 78.6% female) were randomized to the intervention condition (ACT-SOC) or to a minimal support group (MS). Complete data are available for 53 participants (ACT-SOC: n = 27; MS: n = 26). Assessments of functional performance, pain intensity, pain acceptance, SOC strategies, emotional well being and catastrophizing beliefs were done preintervention and postintervention.

RESULTS

Significant time by intervention changes (P = 0.05) were found in acceptance, pain related anxiety, compensation strategies, and pain interference in walking ability. Simple effects changes were found in acceptance (P = 0.01), selection strategies (P = 0.05), catastrophizing beliefs (P = 0.03), depressive symptoms (P = 0.05), pain anxiety (P = 0.01) and pain interference in mood and walking ability (P = 0.03) in the ACT-SOC group. No significant changes were found in the MS group.

CONCLUSIONS

These results suggest that an ACT intervention combined with training in SOC strategies could help older people with pain to improve their emotional well being and their functional capability.

Pain Interference Mediates the Relationship between Pain and Functioning in Pediatric Chronic Pain

Pediatric chronic pain is a major health problem commonly associated with impaired functioning. There is a great need for more knowledge regarding the complex interplay between demographic variables such as age and gender, pain, and functioning in pediatric chronic pain. Objective: The objective of the study was to investigate if; (1) pediatric chronic pain patients with high and low levels of functioning differ in demographic variables, pain, and pain interference; (2) explore the mediating function of pain interference in the relationship between pain and functioning (i.e., depression and functional disability). Method: The study includes a consecutive sample of children and adolescents referred to a tertiary pain clinic due to chronic pain (n = 163). Cross-sectional data was analyzed to investigate the interrelationships between variables. Analyses of indirect effects were used to assess the impact of pain interference on the relation between pain and depression. Results: Findings illustrate high levels of depression, school absence and pain interference in this sample. Furthermore, pain interference mediated the relationship between pain and depression. Conclusion: Thus, this study adds to the growing support of findings suggesting that functioning and pain interference should be routinely assessed in pediatric chronic pain and a central target in treatment. Particularly, these findings imply a need for interventions specifically aimed at improved functioning for patients with chronic debilitating pain.

The Parent Psychological Flexibility Questionnaire (PPFQ): Item Reduction and Validation in a Clinical Sample of Swedish Parents of Children with Chronic Pain

In pediatric chronic pain, research indicates a positive relation between parental psychological flexibility (i.e., the parent’s willingness to experience distress related to the child’s pain in the service of valued behavior) and level of functioning in the child. This points to the utility of targeting parental psychological flexibility in pediatric chronic pain. The Parent Psychological Flexibility Questionnaire (PPFQ) is currently the only instrument developed for this purpose, and two previous studies have indicated its reliability and validity. The current study sought to validate the Swedish version of the 17-item PPFQ (PPFQ-17) in a sample of parents (n = 263) of children with chronic pain. Factor structure and internal reliability were evaluated by means of principal component analysis (PCA) and Cronbach’s alpha. Concurrent criterion validity was examined by hierarchical multiple regression analyses with parental anxiety and depression as outcomes. The PCA supported a three-factor solution with 10 items explaining 69.5% of the total variance. Cronbach’s alpha (0.86) indicated good internal consistency. The 10-item PPFQ (PPFQ-10) further explained a significant amount of variance in anxiety (29%), and depression (35.6%), confirming concurrent validity. In conclusion, results support the reliability and validity of the PPFQ-10, and suggest its usefulness in assessing psychological flexibility in parents of children with chronic pain.

A Clinical Pilot Study of Individual and Group Treatment for Adolescents with Chronic Pain and Their Parents: Effects of Acceptance and Commitment Therapy on Functioning

Pediatric chronic pain is common and can result in substantial long-term disability. Previous studies on acceptance and commitment therapy (ACT) have shown promising results in improving functioning in affected children, but more research is still urgently needed. In the current clinical pilot study, we evaluated an ACT-based interdisciplinary outpatient intervention (14 sessions), including a parent support program (four sessions). Adolescents were referred to the clinic if they experienced disabling chronic pain. They were then randomized, along with their parents, to receive group (n = 12) or individual (n = 18) treatment. Adolescent pain interference, pain reactivity, depression, functional disability, pain intensity and psychological flexibility, along with parent anxiety, depression, pain reactivity and psychological flexibility were assessed using self-reported questionnaires. There were no significant differences in outcomes between individual and group treatment. Analyses illustrated significant (p < 0.01) improvements (medium to large effects) in pain interference, depression, pain reactivity and psychological flexibility post-treatment. Additionally, analyses showed significant (p < 0.01) improvements (large effects) in parent pain reactivity and psychological flexibility post-treatment. On all significant outcomes, clinically-significant changes were observed for 21%–63% of the adolescents across the different outcome measures and in 54%–76% of the parents. These results support previous findings and thus warrant the need for larger, randomized clinical trials evaluating the relative utility of individual and group treatment and the effects of parental interventions.

Attachment and Chronic Pain in Children and Adolescents

Although attachment theory is not new, its theoretical implications for the pediatric chronic pain context have not been thoroughly considered, and the empirical implications and potential clinical applications are worth exploring. The attachment framework broadly focuses on interactions between a child’s developing self-regulatory systems and their caregiver’s responses. These interactions are believed to create a template for how individuals will relate to others in the future, and may help account for normative and pathological patterns of emotions and behavior throughout life. This review outlines relevant aspects of the attachment framework to the pediatric chronic pain context. The theoretical and empirical literature is reviewed regarding the potential role of attachment-based constructs such as vulnerability and maintaining factors of pediatric chronic pain. The nature and targets of attachment-based pediatric interventions are considered, with particular focus on relevance for the pediatric chronic pain context. The potential role of attachment style in the transition from acute to chronic pain is considered, with further research directions outlined.

Fear of pain in children and adolescents with neuropathic pain and complex regional pain syndrome

A significant proportion of children and adolescents with chronic pain endorse elevated pain-related fear. Pain-related fear is associated with high levels of disability, depressive symptoms, and school impairment. Because of faulty nerve signaling, individuals with neuropathic pain and complex regional pain syndrome may be more prone to develop pain-related fear as they avoid use of and neglect the affected body area(s), resulting in exacerbated symptoms, muscle atrophy, maintenance of pain signaling, and ongoing pain-related disability. Not surprisingly, effective treatments for elevated pain-related fears involve exposure to previously avoided activities to downregulate incorrect pain signaling. In the context of intensive interdisciplinary pain treatment of youth with neuropathic pain, decreasing pain-related fear is associated with improved physical and psychological functioning, whereas high initial pain-related fear is a risk factor for less treatment responsiveness. An innovative approach to targeting pain-related fear and evidence of a neural response to treatment involving decoupling of the amygdala with key fear circuits in youth with complex regional pain syndrome suggest breakthroughs in our ability to ameliorate these issues.

Comparing group-based acceptance and commitment therapy (ACT) with enhanced usual care for adolescents with functional somatic syndromes: a study protocol for a randomised trial

INTRODUCTION

Functional somatic syndromes (FSS) are common in adolescents, characterised by severe disability and reduced quality of life. Behavioural treatments such as acceptance and commitment therapy (ACT) has shown promising results in children and adolescents with FSS, but has focused on specific syndromes such as functional pain. The current study will compare the efficacy of group-based ACT with that of enhanced usual care (EUC) in adolescents with a range of FSS operationalised by the unifying construct of multiorgan bodily distress syndrome (BDS).

METHODS AND ANALYSIS

A total of 120 adolescents aged 15-19 and diagnosed with multiorgan BDS, of at least 12 months duration, will be assessed and randomised to either: (1) EUC: a manualised consultation with a child and adolescent psychiatrist and individualised treatment plan or (2) manualised ACT-based group therapy plus EUC. The ACT programme consists of 9 modules (ie, 27 hours) and 1 follow-up meeting (3 hours). The primary outcome is physical health, assessed by an Short Form Health Survey (SF-36) aggregate score 12 months after randomisation. Secondary outcomes include self-reported symptom severity, symptom interference, depression and anxiety, illness worry, perceived stress and global improvement; as well as objective physical activity and bodily stress response measured by heart rate variability, hair cortisol and inflammatory biomarkers. Process measures are illness perception, illness-related behaviour and psychological flexibility.

ETHICS AND DISSEMINATION

The study is conducted in accordance with Helsinki Declaration II. Approval has been obtained from the Science Ethics Committee of the Central Denmark Region and the Danish Data Protection. The results will be sought to be published according to the CONSORT statement in peer-reviewed journals.

DISCUSSION

This is one of the first larger randomised clinical trials evaluating the effect of a group-based intervention for adolescents with a range of severe FSS.

TRIAL REGISTRATION NUMBER

NCT02346071; Pre-results.

Nonpharmacologic Treatment of Pain

Pain is a complex biopsychosocial experience that is influenced by neurological processes and psychosocial factors. Systematic reviews and meta-analyses of randomized controlled trials of psychological interventions have demonstrated evidence for psychological approaches in treating procedural pain and multiple types of chronic pain, including headaches, abdominal pain, and musculoskeletal pain. This article is directed toward clinicians and would provide an overview of cognitive-behavioral therapy, including specific cognitive-behavioral techniques for pediatric pain. A review is provided of preparation and psychoeducation, distraction, exposure and psychological desensitization, relaxation techniques, additional cognitive and behavioral therapy, exercise and alternative options, use of technology, multicomponent approaches, and final considerations in treating acute and chronic pain. It is important to consider multiple characteristics of the child when selecting an intervention for chronic pain, which are reviewed in the article.

Circles of engagement: Childhood pain and parent brain

Social interaction can have a profound effect on individual behavior, perhaps most salient in interactions between sick suffering children and their parents. Chronic pain is a difficult condition that can produce considerable changes in children's behaviors that can secondarily have profound effects on their parents. It may create a functionally disabling negative feedback loop. Research supports the notion of alterations in the brain of individuals who observe and empathize with loved ones in acute pain. However, neural activity in relation to empathic responses in the context of chronic pain has not been examined. Ongoing suffering with chronic pain in a child can result in child's brain circuit alterations. Moreover, prolonged suffering jointly experienced by the parent may putatively produce maladaptive changes in their neural networks and consequently in parental behaviors. Here we put forth the conceptual framework for 'Chronic pain contagion' (CPC). We review the underlying processes in CPC and discuss implications for devising and implementing treatments for children in chronic pain and their parents.

Acceptance and commitment therapy in youth with neurofibromatosis type 1 (NF1) and chronic pain and their parents: A pilot study of feasibility and preliminary efficacy

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder affecting about 1 in 3,500 individuals. Chronic pain is commonly reported among individuals with NF1 and plexiform neurofibroma tumors (PNs). Acceptance and Commitment Therapy (ACT), an empirically supported method for addressing chronic pain, helps individuals re-focus on valued relationships and activities. This pilot study investigated the feasibility and preliminary efficacy of a brief ACT workshop in the NF1 population. Eligible participants included adolescents and young adults (AYA; 12-21 years) with NF1 and chronic pain that interfered with daily functioning and their parents. Patients and parents completed baseline measures of pain interference, pain intensity, functional disability, pain acceptance, depression, and anxiety. Then, AYA and parents participated separately in a 2-day small-group ACT workshop. A telephone booster session occurred 1 month post-intervention. Three-month post-treatment measures were completed by mail. Ten adolescents (4 males; M age = 16.9 years) and seven parents provided baseline and 3-month data. Mean satisfaction with the study was moderate to high (3.9 for patients and 4.6 for parents on a 1-5 scales). Patients and parents reported significant declines in patients' pain interference at 3 months post-treatment. Patient-reported pain intensity significantly declined from baseline to 3 months. Parents reported marginally greater acceptance of their child's pain. No changes emerged in functional ability or mood. Preliminary findings suggest that a brief ACT group intervention is feasible and may help AYA with NF1 and PNs cope with their chronic pain, although larger randomized studies are needed to confirm treatment efficacy. © 2016 Wiley Periodicals, Inc.

Pediatric complex regional pain syndrome: a review

Complex regional pain syndrome (CRPS) is a chronic, intensified localized pain condition that can affect children and adolescents as well as adults, but is more common among adolescent girls. Symptoms include limb pain; allodynia; hyperalgesia; swelling and/or changes in skin color of the affected limb; dry, mottled skin; hyperhidrosis and trophic changes of the nails and hair. The exact mechanism of CRPS is unknown, although several different mechanisms have been suggested. The diagnosis is clinical, with the aid of the adult criteria for CRPS. Standard care consists of a multidisciplinary approach with the implementation of intensive physical therapy in conjunction with psychological counseling. Pharmacological treatments may aid in reducing pain in order to allow the patient to participate fully in intensive physiotherapy. The prognosis in pediatric CRPS is favorable.

Customized CBT via internet for adolescents with pain and emotional distress: A pilot study

The aim of this pilot study was to explore the effects of an early and customized CBT intervention, mainly delivered via internet, for adolescents with coexisting recurrent pain and emotional distress (low mood, worry, and/or distress). The intervention was based on a transdiagnostic approach, to concurrently target pain and emotional distress. A single case experimental design (SCED) was employed with six participants, 17-21 years old, who were recruited via school health care professionals at the student health care team at an upper secondary school in a small town in Sweden. The intervention consisted of 5-9 modules of CBT, delivered via internet in combination with personal contacts and face to face sessions. The content and length of the program was customized depending on needs. The effects of the program were evaluated based on self-report inventories, which the participants filled out before and after the intervention and at a six month follow-up. They did also fill out a diary where they rated symptoms on a daily basis. The results were promising, at least when considering changes during the intervention as well as pre- and posttest ratings. However, the results were more modest when calculating the reliable change index (RCI), and most of the treatment effects were not sustained at the follow-up assessment, which raises questions about the durability of the effects. Taken together, this study indicates that this type of program is promising as an early intervention for adolescents with pain and concurrent emotional distress, although the outcomes need to be explored further, especially in terms of long-term effects.

Age moderates response to acceptance and commitment therapy vs. cognitive behavioral therapy for chronic pain

OBJECTIVE

The purpose of this study was to examine age differences in response to different forms of psychotherapy for chronic pain.

METHODS

We performed a secondary analysis of 114 adults (ages 18-89 years) with a variety of chronic, nonmalignant pain conditions randomly assigned to 8 weeks of group-administered acceptance and commitment therapy (ACT) or cognitive behavioral therapy (CBT). Treatment response was defined as a drop of at least three points on the Brief Pain Inventory-interference subscale.

RESULTS

Older adults were more likely to respond to ACT, and younger adults to CBT, both immediately following treatment and at 6-month follow-up. There were no significant differences in credibility, expectations of positive outcome, attrition, or satisfaction, although there was a trend for the youngest adults (ages 18-45 years) to complete fewer sessions.

CONCLUSIONS

These data suggest that ACT may be an effective and acceptable treatment for chronic pain in older adults.

Living Life With My Child's Pain: The Parent Pain Acceptance Questionnaire (PPAQ)

OBJECTIVE

Parents' emotional, cognitive, and behavioral responses are highly influential on children's pain and functional outcomes. One important response to pediatric pain is acceptance: the degree to which an individual participates in routine daily activities in the presence of pain and is willing to let pain be a part of their life without efforts to control or avoid it. However, no tool currently exists to assess parents' own acceptance of their child's pain. The aim of this study was to validate the Parent Pain Acceptance Questionnaire (PPAQ).

MATERIALS AND METHODS

The PPAQ was administered to 310 parents of youth with chronic pain in an outpatient pediatric headache program and a day hospital pain rehabilitation program. An exploratory factor analysis revealed 2 factors for the PPAQ: an 11-item Activity Engagement scale and a 4-item Acceptance of Pain-related Thoughts and Feelings scale.

RESULTS

The PPAQ total score and subscales demonstrated strong internal consistency. Greater parent pain acceptance was positively associated with child pain acceptance, and was negatively correlated with parent protective behaviors, parent minimizing behaviors, parent and child pain catastrophizing, and child fear of pain. Parent protective behaviors and child pain acceptance both served as mediators of the relationship between parent pain acceptance and child functional disability.

CONCLUSIONS

The PPAQ is a valid measure of parent pain acceptance and may provide valuable insights into parent responses to child pain and the ways in which parent acceptance influences child outcomes. Clinical implications and suggestions for future research are discussed.

Psychological Treatments and Psychotherapies in the Neurorehabilitation of Pain: Evidences and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

BACKGROUND

It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams.

OBJECTIVES

To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases.

METHODS

A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions.

RESULTS

The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache.

CONCLUSIONS

Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the paper.

A validation of the pain interference index in adults with long-standing pain

BACKGROUND

Chronic pain is a major health problem and more knowledge is needed regarding the interference of pain on behaviors in different life domains. Clinically useful and statistically sound pain interference measures are highly important. Studies on youths have shown that the Pain Interference Index (PII) is a reliable and valid instrument that is sensitive to change following behavioral treatment. This measure may also have utility for adults, but no study has so far evaluated the statistical properties of the PII for long-standing pain in adults.

METHODS

Data were collected from 239 consecutive adults with non-specific chronic pain referred to a tertiary pain clinic. We investigated the factor structure of items using a principal component analysis. Cronbach's alpha was calculated to assess internal consistency. The questionnaire's ability to predict levels of, e.g., disability was analyzed by means of regression analyses.

RESULTS

Analyses illustrated the adequacy of a one-factor solution with six items. Cronbach's alpha (0.85) suggested a satisfactory internal consistency among items. The PII explained significant amounts of variance in pain disability, physical, and mental health-related quality of life and depression, suggesting concurrent criteria validity.

CONCLUSION

The PII is a brief questionnaire with reliable and valid statistical properties to assess pain interference in adults. Other studies support the reliability and validity of PII for use with youths, and now the PII can be used to analyze the influence of pain on behaviors across age groups. Potentially, the PII can also be used as an outcome measure in clinical trials.

Acceptance and commitment therapy - Do we know enough? Cumulative and sequential meta-analyses of randomized controlled trials

Acceptance and Commitment Therapy (ACT) has accrued a substantial evidence base. Recent systematic and meta-analytic reviews suggest that ACT is effective compared to control conditions. However, these reviews appraise the efficacy of ACT across a broad range of presenting problems, rather than addressing specific common mental health difficulties. Focussing on depression and anxiety we performed a meta-analysis of trials of ACT. We incorporated sequential meta-analysis (SMA) techniques to critically appraise the sufficiency of the existing evidence base. Findings suggest that ACT demonstrates at least moderate group and pre-post effects for symptom reductions for both anxiety and depression. However using SMA findings are more qualified. There is currently insufficient evidence to confidently conclude that ACT for anxiety is efficacious when compared to active control conditions or as primary treatment for anxiety. Similarly, using SMA, there is currently insufficient evidence to suggest a moderate efficacy of ACT for depression compared to active control conditions. To stimulate further research we offer specific estimates of additional numbers of participants required to reach sufficiency to help inform future studies. We also discuss the appropriate strategies for future research into ACT for anxiety given the current evidence suggests no differential efficacy of ACT in the treatment of anxiety compared to active control conditions.

Processes of change in Acceptance and Commitment Therapy and Applied Relaxation for long-standing pain

BACKGROUND

The utility of cognitive behavioural (CB) interventions for chronic pain has been supported in numerous studies. This includes Acceptance and Commitment Therapy (ACT), which has gained increased empirical support. Previous research suggests that improvements in pain catastrophizing and psychological inflexibility are related to improvements in treatment outcome in this type of treatment. Although a few studies have evaluated processes of change in CB-interventions, there is a particular need for mediation analyses that use multiple assessments to model change in mediators and outcome over time, and that incorporate the specified timeline between mediator and outcome in the data analytic model.

METHODS

This study used session-to-session assessments to evaluate if psychological inflexibility, catastrophizing, and pain intensity mediated the effects of treatment on pain interference. Analyses were based on data from a previously conducted randomized controlled trial (n = 60) evaluating the efficacy of ACT and Applied Relaxation (AR). A moderated mediation model based on linear mixed models was used to analyse the data.

RESULTS

Neither catastrophizing nor pain intensity mediated changes in pain interference for any of the treatments. In contrast, psychological inflexibility mediated effects on outcome in ACT but not in AR.

CONCLUSIONS

Results add to previous findings illustrating the role of psychological inflexibility as a mediator in ACT.

State of the art in biobehavioral approaches to the management of chronic pain in childhood

Chronic pain in childhood is prevalent, persistent and significantly impactful on most domains of life. The chronic pain experience occurs within a complex biopsychosocial framework, with particular emphasis on the social context. Currently, psychological treatments involve a cognitive-behavioral therapy treatment plan, providing some combination of psychoeducation, self-regulation training, maladaptive cognition identification, behavioral exposure and parent involvement. New treatment areas are emerging, such as group- and internet-based cognitive-behavioral therapy, motivational interviewing, comorbid obesity intervention and intensive multidisciplinary rehabilitation. Preliminary studies of emerging treatments demonstrate encouraging results; however, treatment effectiveness hinges on accurate matching of patient to treatment modality. Overall, the current direction of the field promises many innovative breakthroughs to ameliorate suffering in youth with chronic pain.

Trajectories of change during a randomized controlled trial of internet-delivered psychological treatment for adolescent chronic pain: how does change in pain and function relate?

Although pain and function improve at immediate posttreatment for youth receiving cognitive behavioral therapy for chronic pain, limited data are available to understand changes that youth make during psychological treatment. We sought to characterize distinct trajectory patterns of change in pain and function to understand the temporal association of these changes during internet-delivered cognitive behavioral therapy (CBT). Weekly repeated assessments of pain and function were conducted during 8 weeks of treatment among 135 adolescents, aged 11 to 17 years, with chronic pain who were randomized to the cognitive behavioral intervention arm of an ongoing trial of internet-delivered CBT (Web-based management of adolescent pain; Web-MAP2). Using random-effects growth mixture models, we characterized pain and functional disability trajectories finding distinct trajectory groups indicating patterns of both linear and quadratic effects. Trajectories of change showed that some patients' pain and functional disability were improving, others worsened or changed minimally. Paired t tests compared the within-subject relative change rate in pain and function demonstrating similar change range for pain and function during the treatment period. There was no support for improvements in either pain or function to precede changes in the other domain. Findings may be useful in informing future studies of psychosocial treatments for pediatric chronic pain to consider how to target treatment strategies to distinct patient response profiles. This may lead to the development of intervention strategies that can both more effectively target children's pain and function during treatment and lead to sustained changes after treatment.

Review: Effectiveness of mindfulness in improving mental health symptoms of children and adolescents: a meta-analysis

BACKGROUND

Mindfulness-based interventions (MBIs) are increasingly used in the management of various mental health disorders in children and adolescents. However, there is limited evidence about the efficacy of various interventions used.

METHOD

A systematic review was performed to examine the effects of different MBIs on mental health symptoms and quality of life in both clinical and nonclinical samples of children and adolescents using data from only randomized control trials. The studies were also assessed for quality. Based on the type of MBI, study population, and control arm we had three comparisons for meta-analyses.

RESULTS

Fifteen studies were included in the qualitative analysis but only 11 trials with comparable interventions and controls were included for meta-analyses. Mindfulness-based stress reduction/mindfulness-based cognitive therapy arm was more effective than nonactive control in the nonclinical populations. Acceptance commitment therapy was comparable to active treatments in patients in the clinical range. Other MBIs were also effective improving anxiety and stress but not depression in nonclinical populations compared to nonactive control.

CONCLUSIONS

Mindfulness-based interventions can be effective in children and adolescents with mental health symptoms. As there were significant limitations these results must be interpreted with caution.

Pediatric Headaches

Pediatric headaches are common, and many may never require intervention by a health care provider. However, migraines can become more difficult to treat, especially if they become chronic daily headaches. Pediatric headache is a subjective and unique experience that requires attention to both psychological and physiologic components in diagnosis and treatment. A biopsychosocial, multidisciplinary approach, including both medication management and psychological treatment, is considered essential for effective management.