Some children, like some adults, have chronic, unexplainable pain. They have backaches every day or their legs and feet hurt every day or their necks throb constantly — and no one is sure why. Doctors call this pain idiopathic, a medical term for "we have no clue." Idiopathic pain arises spontaneously and without a known cause.
How best to treat idiopathic pain is one of medicine's great mysteries. You can anesthetize patients with painkillers, but that's not a great long-term solution, since patients become habituated (and in some cases addicted) to pain meds. In children, the situation is even more dire, since they may face decades of swallowing drugs. (See nine kid foods to avoid.)
That's why a study just published in the journal Pain is so encouraging. According to the study, clinicians who used a particular form of behavior therapy called acceptance and commitment therapy (ACT) with a group of 16 chronic-pain patients ages 10 to 18 saw remarkable results: after just 10 weeks of ACT sessions, during which patients were taught strategies for accepting chronic pain so they could pursue important goals, those kids suffered less intensely and functioned significantly better day to day than did a control group of 16 chronic-pain kids who had been treated the way kids with persistent aches are normally treated — with drugs and standard talk therapy. Both groups improved, but the children in the ACT group, who got no drugs, improved more than those who took pills.
What exactly is ACT? Where standard psychotherapy often tries to change negative thoughts by asking probing questions (does everyone at the office really hate you, or are you just indulging in your own self-doubt?), ACT therapists take the position that trying really hard to change your thoughts tends to be counterproductive. Negative thoughts have a way of coming back again and again — have you ever tried to stop obsessing about pizza when you're on a diet? (See pictures of what makes you eat more food.)
Rather, ACT promotes the acceptance of negative thoughts, emotions and bodily sensations (like chronic pain) that a patient may have struggled with for a long time. The goal is to observe and be mindful of your crummy thoughts and feelings without getting mired in them — and to be able to act in accordance with your values (like, say, going to work every day or not drinking too much) despite them. In short, ACT therapists encourage engagement with life even when it hurts. (Learn about how ACT works and the fascinating psychologist who created it.)
ACT has proved effective for a variety of conditions — from depression to drug abuse to schizophrenia — but this is the first time it has been used to treat kids with pain. Here's how the study worked.
The research team — four Swedish investigators at the Karolinska Institute and Uppsala University — recruited kids who had truly suffered. The children had headaches, backaches and neck problems; many had widespread musculoskeletal pain; a couple had internal, visceral pain. They had high depression scores; 11 of the 32 had been to the emergency room with pain symptoms; 20 had had MRIs to try to find the source of their pain (without success); 21 had had physiotherapy. In short, the kids' parents had tried everything, and nothing had worked.
Half the kids were randomly assigned to participate in 10 weekly one-hour ACT sessions (along with an extra one or two ACT sessions with their parents present). During the sessions, the therapists emphasized that the kids should go out and do what they truly loved even if they were hurting that day — in other words, that they should accept rather than try to avoid their chronic pain. To shift kids away from focusing only on alleviating their symptoms, therapists discussed how their pain was not caused by a harmful disease or injury and how previous strategies (such as taking painkillers) had not worked. Kids were encouraged instead to notice and accept discomfort and to get back into activities they had abandoned. Therapists and kids talked about what the kids really wanted out of life and how they could achieve it. (See the top 10 medical breakthroughs of 2008.)
The control group of kids was treated for far longer than 10 weeks; in fact, they had an average of 23 weekly sessions, although those sessions were divided among physicians, physical therapists and a psychologist or psychiatrist. Each day, these kids were also given up to 100 mg of amitriptyline, a sedating drug that used to be prescribed as an antidepressant but is now used more often as a treatment for chronic pain.
ACT proved to be the better approach by far. Even when the ACT kids were interviewed 18 weeks after their last session, they reported less discomfort than did the control group, as well as less fear of injury and greater capacity to do things like go to school regularly. The authors conclude that drugs, while they can help in the short term, don't stimulate long-term behavior change. By contrast, with ACT, "the target in treatment is to clarify and reduce avoidance behaviors that prevent the patient from living a vital life," the study says. (Read "On the Couch Online: Does Tele-Therapy Work?")
How this succeeds isn't entirely clear, but the researchers used a simplified version of ACT with the kids. Typical ACT sessions with adults require difficult meditation strategies, but psychologist Rikard Wicksell, who led the Swedish team, says the researchers wanted to make sure their strategy was age-appropriate, so they didn't require meditation and instead focused on behavioral activation: getting the kids moving.
"Most of the things they want to do in life are associated with having to experience pain," says Wicksell. The kids want to play soccer or basketball, they want to go to movies, they want to be able to tell friends they can spend a whole Saturday with them. But for many of these kids, just standing up from a sofa can hurt a little. "So we discuss pros and cons — the short- and long-term consequences of not doing things with friends," says Wicksell. The kids eventually learn how to take their pain along with them to social outings — how to hold it close rather than dragging it at a heavy distance. (See the most common hospital mishaps.)
Parents also must be educated. According to Lynnda Dahlquist, a professor at the University of Maryland, Baltimore County, and co-author of the chronic-pain chapter in the Handbook of Pediatric Psychology (2003), many parents reinforce avoidance behavior in kids with chronic pain by doing something that comes naturally to parents: being kind to their kids. "Let's say Johnny's back pain flares up during math class," says Dahlquist. "He feels terrible, so he says, 'I can't do my math.' Mom comes, takes him home, puts the TV on and gives him a back rub. Well, math isn't fun. And who wouldn't like a back rub?" Instead of being indulged, kids with chronic pain often need a push.
ACT can provide that push — but one that comes from within. The new study suggests a less sentimental approach for kids with chronic pain: sympathy but never pity.