1. Psychological Approaches to SCD Pain Management
Soumitri Sil, PhD
Assistant Professor of Pediatrics
Clinical Pediatric Psychologist
April 29, 2017

2. Objectives Discuss psychosocial aspects of pain
Describe empirically-validated treatment approaches to pediatric chronic pain

3. Psychosocial Aspects of Pain

4. What patients think I do.

5. The psychology of pain SCD pain can result in:
Irritability
Frustration (with lack of answers or relief)
Depression (the emotional toll of chronic pain)
Stress (due to functional limitations, changed lifestyle, lack of independence, feeling poorly)
Fear (of movement or worsening symptoms)
Hypervigilance (to potential environmental triggers or exacerbations)
Suicidal ideation or self-harm (cutting; hopelessness of finding relief)
Normalize these emotional reactions for patients

6. The social aspect of pain
Pain and pain behaviors (guarding, rubbing, wincing) communicate information to others
Chronic pain occurs in a communal context
Peer reactions
Special attention vs. “suck it up”
Family reactions
Pain tends to run in families
Adaptive response (modify and monitor)
Maladaptive response (catastrophizing and solicitous)
Models of coping in the family
Healthy vs. disability-oriented

7. Pain Affects Many Domains
Interference with functioning (at home, daily activities)
Sleep disruption
School attendance and performance
Decreased social interaction (hobbies, friends)
Reduced sports participation or physical activities
Anxiety and depression
About 15-20% of children with chronic pain present with clinically significant depressive symptoms.
Family impact (missed work, child care)
High health care utilization
Left untreated, the effect on family and psychological factors remain constant for up to 3 years
Hunfeld et al, 2002; Sil, Cohen, Dampier Clinical Journal of Pain 2016

8. Thinking about Pain How a person thinks about pain influences
Coping
Physical functioning
Overall well-being
Negative thinking and catastrophizing are associated with:
Increased functional disability
Increased activity reduction
Increased anxiety & depression
Sil et al, 2016; Gil et al., 1991; Eccleston et al., 2004

9. Catastrophic Thinking about Pain
Sil, Cohen, Dampier Clinical Journal of Pain 2016

10. Parents’ Catastrophizing Increases Child Risk of Disability
Sil, Dampier, Cohen Journal of Pain 2016

11. Talking to patients about pain
All pain is real to the patient, regardless of whether or not there is a clear origin
Stress (good and bad) typically worsens any medical problems including pain
The relationship between anxiety, depression, and pain is bi-directional.
Result in biological changes
that amplify the pain experience.

12. Multidisciplinary Treatment Approaches to Pain
Multimodal approach often more effective
Education
Psychological Treatments and Family Intervention
Cognitive-behavioral therapy
Acceptance and Commitment Therapy
Mindfulness-based Stress Reduction
Physical intervention
Massage, Physical or aquatics therapy
Complementary and Integrative Therapies
Acupuncture, Yoga, Tai-Chi
Systemic and regional pharmacological intervention
oral medications, injections, nerve blocks
American Pain Society Recommendations 2001

13. Empirically-validated treatment for chronic pain

14. Psychological Treatments for Pain
Evidence-based treatment for chronic or recurrent pain in children (Cochrane review, Eccleston et al., 2013)
Cognitive behavioral therapy
Headache, abdominal pain, mixed pain conditions, fibromyalgia, sickle cell disease, juvenile idiopathic arthritis
Pain improves at post-treatment
Disability improves at post-treatment (non-headache)
Mood improves at follow-up (3-12 months after treatment for headache)
Promising but limited for SCD only (Cochrane review, Anie & Green, 2015)
Mix of acute and chronic pain
Chronic pain is not well-understood
Well-designed, adequately-powered, large multi-site trials

15. Cognitive-behavioral therapy (CBT)
CBT effective treatment for pediatric chronic pain
Modify thoughts and behaviors that maintain pain and disability
Give patients strategies to help manage pain
Training in use of specific cognitive
and behavioral strategies
Improve daily functioning
Reduce depressed mood
Decrease pain intensity
Specifically, it involves training….otherwise termed pain coping skills training, to improve…
Eccleston et al., 2012; Palermo et al., 2010; Kashikar-Zuck et al., 2012

16. Central Components of CBT
Pain Education
Coping Skills
Behavioral
Cognitive
Parent Training and Guidelines
Lifestyle Modification
Pain Education
Coping Skills
Behavioral
Cognitive
Parent Training and Guidelines
Lifestyle Modification
Some of the central components of CBT for pain management include psychoeducation, parent training for managing pain, behavioral and cognitive coping, and self-monitoring. I’ll briefly touch on each of these.

17. Pain Education: Gate Control Theory
Pain signals travel from body to brain’s “pain center”
Pain perception affected by multiple factors
Medication
Relaxation
Attention and distraction
Thoughts and feelings
Pain Center
There are multiple factors that can help keep the nerve gates closed and also calm the nerves so fewer signals are being sent to the brain, such as relaxation, distracting one’s thoughts away from pain, and also positive thoughts and feelings.
Spinal Cord

18. Pain Education: Treatment goals and expectations
Functioning typically improves before pain intensity
One can’t “wait until I feel better” to resume life
Goals of treatment are improved functioning and coping, not pain reduction per se
Pain heals slowly, modifications may be necessary during recovery
Pain acceptance does not mean “giving up” just “moving on”
School is not “optional”; home schooling is discouraged
As pain reduces, risk for over-doing activity increases. Resuming activity too quickly with de-conditioned bodies can result in even worse problems

19. Parent Training and Guidelines
Encourage child’s independent coping
Support child’s use of coping skills
Decrease reinforcement of pain behaviors
Encourage normal activities
Minimize opportunities for secondary gain
Eliminate status checks (repeated questions about pain)
Follow doctor’s medication guidelines
Training parents in behavior management strategies is also important because chronic pain often is not only affecting the child, but the family as well. Parent training often includes problem-solving around how to reduce attention for negative pain behaviors, support the child’s use of coping skills in daily life, and also encourage independent coping.

20. Pain Coping Skills and Strategies
Behavioral Skills
Activities
Distraction techniques
Activity Pacing
Behavioral Activation
Socialization
School Attendance
Gradual re-entry
Accommodations
Homework
Extracurricular activities
Relaxation Skills (with Biofeedback)
Imagery
Diaphragmatic breathing
Progressive muscle relaxation
Autogenic relaxation
Mindfulness meditation
Both behavioral and cognitive coping strategies help provide kids with additional tools to use to better manage their pain. For example, activity pacing teaches kids why it is important to get up and use their muscles so they don’t become weak (underdo), but also being careful not to do too much activity at once and overdo it as both of these extremes can exacerbate pain.

21. What is biofeedback?
Information—or feedback—about biological functions, such as muscle tension, surface skin temperature, and breathing. 
Helps retrain how the body and brain respond to pain, builds self-awareness of the signs of stress, and increases sense of control

22. Pain Coping Skills and Strategies
Cognitive Skills
Cognitive restructuring
Positive or calm self-statements
Problem-Solving
Generalizing skills to daily life
Acceptance
Values-based living
Additionally, the cognitive coping skills helps train kids in how to identify and change negative thoughts and helpless feelings associated with pain, such as “I can’t handle this pain, the pain is terrible, it’s never going to get better.”

23. Pain Coping Skills and Strategies
Lifestyle Modification
Stress Management
Internal (fear-driven activity avoidance)
Environmental (stress, overdoing activity)
Sleep
Sleep hygiene (electronics in bed)
Stimulus control (using bed for sleep only)
Minimize daytime naps
Hydration
Water bottle at school
Flavored water
Scheduled water intake around meals
Eating
Integration of regular meals and snacks
Exercise
Paced and modified activity
Participation without over-exertion

24. Typical course of treatment
Average length of treatment 5-7 sessions, weekly or biweekly
Pain focused
Consider need to address other comorbid conditions first
Patient is primary participant, parent is involved to the extent necessary
More for younger children (< 11 years)
Less for adolescents
All patients/parents receive education and family guidelines
Therapy focuses on:
Teaching specific skills
Application and problem solving around use of these skills in daily life

25. Summary Pain is a complex and subjective experience
All pain is REAL regardless of physical versus emotional contributions
Treatment of chronic pain should be multidisciplinary
There is good evidence for the effectiveness of behavioral treatment for pediatric chronic pain
The focus is on improved function and pain reduction is likely to follow

26. Implementation of Behavioral Strategies
When to refer a family to a psychologist
How to explain to the family why a referral might be helpful
Training in behavioral strategies is required to implement CBT
Select a psychologist who is familiar with treating chronic pain in children

27. Acknowledgments
Mentors and Collaborators - Carlton Dampier, MD - Lindsey Cohen, PhD
Funding Sources
Emory + Children’s Pediatric Seed Grant
Emory University Committee and Atlanta Clinical and Translational Science Institute (UL1TR000454)
- Clinical Research Team
Patients, Families, and
Staff