Risk and Resilience in Pediatric Intensive Interdisciplinary Pain Treatment

By Anya Griffin, PhD
Director, Stanford Children’s Health Pediatric Rehabilitation Program (PReP)
Pain Rehabilitation Program
Stanford Children’s Health Pediatric Pain Management Clinic
Clinical Associate Professor
Department of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, California

Many researchers have identified the impact of risk and resilience factors on treatment outcomes for youth with chronic pain.  Risk factors contribute to decreased physical and psychological functioning and fosters maladaptive pain coping. Specifically, factors such as pain catastrophizing and avoidance may create a vicious cycle of pain exacerbation and crippling fears of movement. Clinically, providers are all too familiar with the complexities of helping to support families to shift beyond psychological inflexibility about pain, coping, and treatment. So how do pediatric pain rehabilitation programs combat these risks?  Research on adaptive resilience factors such as acceptance, self-efficacy, optimism, and psychological flexibility, has demonstrated improved outcomes for youth with chronic pain. Resilience is a key ingredient necessary for success.

In thinking about risk and resilience, I asked my retired-educator mother how we teach children to become more resilient. She was a kindergarten teacher in South Central Los Angeles for 50 years in a neighborhood tormented by poverty, neglect, violence, and few opportunities. This was an American war zone, where she taught resilience every day. As an African American woman from the segregated South, she knew how to combat adversity; thus, she was the perfect person for such a challenge. She used one word to describe teaching children resilience, “grit!” She went on to explain that it is nearly impossible to prevent falling down. It is all about what you think and do to pick yourself back up. She noted that many children were not taught optimism at home, so it should be reinforced and encouraged to sustain persistent effort towards goals. She shared that she always told her young students that they were “the smartest children (she) ever taught.” She noted how their little faces lit up as they eagerly snuggled closely for her daily lessons.  She pointed out how this helped them to believe in their own ability to succeed, by carefully seeking out even the tiniest achievements. She spoke of the need to shower children with positive affirmations to believe that “they can do it,” even when it does not yet seem possible. She infused optimism within her teaching style to help young minds believe in themselves. In addition, she reminded me that many school districts are now even adding mindfulness as part of their daily curriculum to build resilience and enhance coping with adverse childhood events. Resilience is a learned behavior.

The critical work conducted within Intensive Interdisciplinary Pain Treatment (IIPT) programs invites young people with chronic pain into a school of resilience. Since resilience is a teachable trait, it should be a top priority within pediatric IIPT. Resilience is a critical factor for treatment across occupational therapy, physical therapy, pain psychology, and pain medicine interventions in pediatric IIPT. Youth with chronic pain benefit from developing resilience by increasing acceptance, self-efficacy, and optimism about their futures, particularly when in treatment. Treatment can be a long, arduous process down a challenging path (e.g. increased pain during exercise, pain flares following desense, emotional distress, etc.). It is easy for pessimistic thoughts to permeate into one’s mind when the treatment seems to exacerbate the very symptom being treated.  It is difficult to comprehend how functional restoration will eventually lead to improvements in pain.  Confidence in treatment may begin to dwindle if families are not properly educated about this process. In addition, parents may also worry about their child’s progress in IIPT when pain levels elevate, which may inadvertently result in increased catastrophic thoughts.

Throughout the pandemic, pain providers have been in the trenches problem solving the challenges facing pediatric pain treatment. Healthcare provider burnout has been at an all-time high over the past twelve months. No matter how optimistic one is, there are some real concrete barriers (i.e. insurance coverage, increased unemployment rates, lack of financial and social resources, etc.) that many families now face, which creates higher risk factors. For instance, caregivers may be at higher risk of losing employment if required to take off work to participate in their child’s care or relocate for treatment. Single caregiver households may find it impossible to care for other children with online education demands, resulting in an unanticipated lack of focus on critical IIPT parental training and family interventions. The pandemic has temporarily influenced our way of practicing, particularly in states like California with the highest percentage of cases. Telehealth has created options for continued participation, despite the shelter in place restrictions. This has helped families to participate in IIPT programs when they may have otherwise been unable to receive this level of specialized care. Although vaccinations may help IIPTs to fully reopen, perhaps there is a benefit to continuing hybrid programs as a method of reducing health disparities and other access to care risk factors.

Researchers point to low readiness to change as a strong predictor of non-responders in pain treatment. By the time families have been referred for intensive pain treatment, many report feeling they have been given the impression “there is nothing more that can be done to help the pain.” Statements like these may unintentionally hinder potential progress in IIPT.  Building resilience should be an initial pain treatment goal, prior to the IIPT referral. Providers may begin to recognize that their own optimism is a necessary component of treatment success. Providers have an opportunity to create an environment that cultivates acceptance, self-efficacy, and optimism for their patients. It takes patience to infuse optimism within families that have experienced the trauma of pediatric chronic pain. The language utilized by all pain providers can help to promote cognitive flexibility and readiness for IIPT care. Language is a powerful clinical tool to foster resilience.

It is important to take resilience beyond the rich body of research knowledge and put it directly into daily pain treatment. Increasing resilience in youth with chronic pain means helping them to accept that somedays will be a success and some will not, guiding them towards the utilization of adaptive coping methods, and changing negative thoughts about their experience of pain. This involves teaching children how to pick themselves back up and never give up. It also means supporting families to understand the importance of reducing the impact of pain catastrophizing through effective coaching strategies.

As a pediatric pain psychologist and director of an IIPT, I lead an incredibly talented team of interdisciplinary pain rehabilitation providers striving to foster resilience in youth with chronic pain. This goes beyond educating our families; it begins with refining our team’s perspectives. Nurturing our own optimism, acceptance, and reducing catastrophizing facilitates a healing environment in IIPT programs. Pediatric IIPT can be a place of miraculous transformation for a child in chronic pain. Success begins from the moment our patients first arrive to the pain clinic, which is when their resilience training starts. As healthcare providers, it is critical to not only promote resilience, but to also be resilient in every moment of care we provide our patients. You never know just how far the power your own optimism may take families living with pediatric chronic pain, as they work towards building their own resilience. Perhaps we can all think like a kindergarten teacher as we create resilient youth who can begin to thrive, with and without chronic pain.

References

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• Cousins, L. A., Cohen, L. L., & Venable, C. (2015). Risk and resilience in pediatric chronic pain: Exploring the protective role of optimism. Journal of Pediatric Psychology, 40(9), 934-942.
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