It is common for adolescents and children to experience chronic pain (Perquin et al., 2000). There are many negative implications associated with chronic pain such as limited social contact, lost days from school, and higher levels of anxiety and depression (Hunfeld et al., 2002; Logan, Simons, Stein, & Chastain, 2008; Walker, Guite, Duke, Barnard, & Greene, 1998). Psychological therapies are used to provide children and adolescents with skills to manage their pain. Our review assessed the efficacy of psychological therapies for children and adolescents with chronic pain on five outcomes; pain, disability, depression, anxiety, and sleep.
We searched the literature using CENTRAL, MEDLINE, EMBASE, and PsycINFO for randomised controlled trials of psychological therapies that were delivered to children and adolescents (0-18 years) with a primary chronic pain condition. We split the pain conditions into headache, musculoskeletal, abdominal, and neuropathic pain. We did not discriminate between how the therapy was delivered, however, each psychological therapy had to include recognisable therapeutic components.
Our search produced 35 studies. The majority of studies investigated children with headache pain (21 studies), followed by children with abdominal pain (8 studies), musculoskeletal pain (3 studies), and three studies included children with multiple pain conditions. The mean age of children was 9.40 years and 1,005 children completed treatment.
We analysed the outcomes twice. The first analysis combined all chronic pain conditions (apart from headache) and investigated the overall effect of therapies for children with pain. Second, subgroup analyses considered the pain conditions independently to determine whether specific pain conditions were benefitted by certain therapies. Our aim was to complement the findings of previous reviews (e.g. Eccleston, et al., 2014) that combine headache pain and non-headache pain to present the overall effectiveness of therapies.
We found that when chronic pain conditions were combined, a beneficial effect of therapy was found for reducing pain intensity and disability post-treatment, but these effects were not maintained at follow-up. No beneficial effects were determined for depression and anxiety, and no data could be extracted for the outcome sleep. When analysing the l pain conditions independently, six effects of therapy were found post-treatment and two effects were found at follow-up. For children with headache pain, pain intensity/frequency was reduced by 50% post-treatment and at follow-up, indicating a clinically significant improvement. The number needed to treat to benefit was 3 post-treatment and 2 at follow-up. For children with abdominal pain, pain and disability were reduced post-treatment, but no effects were found at follow-up. For children with musculoskeletal pain, pain intensity, disability, and depression were reduced post-treatment, and effects of disability were maintained at follow-up. No other effects were found for any specific pain condition. No data could be extracted for sleep outcomes and we were unable to analyse neuropathic pain as only one study was identified.
GRADE assessments were used to determine the quality of the evidence. When pain conditions were combined, the evidence was judged to be moderate. However, this rating dropped when assessing the evidence of specific pain conditions due to lower number of participants contributing to outcomes, risk of bias of studies contributing to outcomes, and increased heterogeneity of measures used for most outcomes. Therefore, more evidence is very likely to change our confidence in the estimate of effect for each condition.
Further, we were able to analyse whether the dose of treatment (duration of treatment) had an effect on the reduction of pain for headache and non-headache conditions. We found that for children with headache pain, higher doses led to greater reduction of pain. However, when conducting the same analysis on non-headache pain, no pattern was identified which suggests that more treatment may not uniformly lead to better pain outcomes.
The field of psychological therapies for paediatric pain is still relatively small, but it is growing. The findings of this review are promising, yet more work is needed in order to have confidence in the effects. Specifically, no trials measured sleep outcomes and only six trials presented extractable data on anxiety outcomes. This means caution should be exercised when interpreting anxiety findings. More trials that recruit children who have neuropathic pain are needed as the evidence to date is scant and we were unable to meta-analyse any outcomes for that condition.
We identified several areas where improvements should still be made. First, the heterogeneity of measures used within and across conditions means that pooling data is hard. Second, the factors that pose a risk of bias in the current studies should be identified and addressed in subsequent research, particularly the reporting of data. Third, trials should be registered online identifying a priori hypotheses and outcomes, to aid transparency of research.
Looking to the future, clinicians and trialists may benefit by being be more innovative in their approach to treating paediatric chronic pain. Cognitive behavioural or behavioural therapies were the only therapies used in the studies in this review. We remain uncertain as to whether other therapies could be beneficial for children and adolescent with chronic pain. Key outcomes need to be identified and measured homogenously across conditions. Finally, to date we are unable to identify the key variable of psychological therapies (if there is one) that produces beneficial outcomes. Treatments are described in scant detail in manuscripts making it difficult to analyse any intervention component systematically.
About Emma Fisher
Emma Fisher completed her undergraduate degree in Psychology from the University of Reading in 2007 and moved to the University of Bath to work as a Research Assistant in the Centre for Pain Research. During her time as a Research Assistant, she conducted a Cochrane Review investigating the efficacy of psychological therapies for parents of children with a chronic illness and updated a further review investigating the efficacy of psychological therapies for children with chronic pain. In 2012, Emma was awarded the University Research Studentship Graduate School Award to study anxiety in children with chronic pain as a PhD and is currently in her third year of study. Her research interests include the effect of anxiety on children with pain, catastrophising in children, and efficacy of psychological treatments.
Eccleston C, Palermo TM, Williams AC, Lewandowski Holley A, Morley S, Fisher E, & Law E (2014). Psychological therapies for the management of chronic and recurrent pain in children and adolescents. The Cochrane database of systematic reviews, 5 PMID: 24796681
Fisher, E., Heathcote, L., Palermo, T., de C Williams, A., Lau, J., & Eccleston, C. (2014). Systematic Review and Meta-Analysis of Psychological Therapies for Children With Chronic Pain Journal of Pediatric Psychology, 39 (8), 763-782 DOI: 10.1093/jpepsy/jsu008
Hunfeld JA, Perquin CW, Hazebroek-Kampschreur AA, Passchier J, van Suijlekom-Smit LW, & van der Wouden JC (2002). Physically unexplained chronic pain and its impact on children and their families: the mother’s perception. Psychology and psychotherapy, 75 (Pt 3), 251-60 PMID: 12396752
Logan, D., Simons, L., Stein, M., & Chastain, L. (2008). School Impairment in Adolescents With Chronic Pain The Journal of Pain, 9 (5), 407-416 DOI: 10.1016/j.jpain.2007.12.003
Perquin, C., Hazebroek-Kampschreur, A., Hunfeld, J., Bohnen, A., van Suijlekom-Smit, L., Passchier, J., & van der Wouden, J. (2000). Pain in children and adolescents: a common experience Pain, 87 (1), 51-58 DOI: 10.1016/S0304-3959(00)00269-4
Walker, L., Guite, J., Duke, M., Barnard, J., & Greene, J. (1998). Recurrent abdominal pain: A potential precursor of irritable bowel syndrome in adolescents and young adults The Journal of Pediatrics, 132 (6), 1010-1015 DOI: 10.1016/S0022-3476(98)70400-7