A sixteen-year-old adolescent girl presented with diffuse neurological symp- toms (e.g., jerks, numbness, and itches in lower extremities) resulting in severe difficulties with walking. She underwent extensive medical testing without any positive findings. Her mother was very concerned and called the hospital repeat- edly to discuss her daughter’s symptoms and to request additional assessment and intervention. The daughter was eventually referred to participate in outpatient ACT sessions. The mother agreed to participate in a single session, during which the goals of an ACT approach were described, with emphasis on shifting perspec- tive from symptom reduction to increased functioning, life vitality, and personal values. Although the mother expressed support for the treatment plan, she con- tinued to phone various members of the treatment team regarding her daugh- ter’s symptoms. Eight weeks into treatment, the adolescent girl was progressing extremely well but expressed concern that her mother continued to focus on pain management and was starting to interfere with her ability to engage in valued activities. At this point, a recruiting strategy was used to enlist the mother’s support. Together the therapist and adolescent outlined what needed to be said: 1. Ask Mom if we can talk; schedule a day and time to do so.
2. Tell Mom that she’s important to me and that I really need her support right now.
3. Explain that I’ve changed my goal from having as little pain as possible to doing all of the things I really want to do in life (my values).
4. Let her know that I think it’s okay and normal to have pain (both physical and emotional).
5. Let her know that I understand it is hard for her to see me in pain and that I know it is hard for her to push me to do things when I’m really down or in pain.
6. Tell her that it would mean a lot to me if she did this anyway—just like a coach.
7. Share with Mom that I will love her no matter what (even when I feel angry or sad or am in pain). Let her know that I really want to do the “important and cool stuff,” and she can really help me out with this.
8. Give an example, like the time she told me to skip swim practice because my leg hurt or the time she made me rest instead of going to the movies with my friends.
9. Ask her if she would be willing to support me in my values, even when it’s hard for me and for her. Let her know that even though this will probably be really hard, this is what I want for my life.
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Conclusion
Scientific advances in the understanding and treatment of pediatric chronic pain leave us with an impressive armamentarium of possible interventions to choose from. Nevertheless, a substantial number of pediatric patients continue to exhibit marked impairment and functional disability in response to chronic pain syndromes. Clinicians and researchers have long emphasized the usefulness of an integrated behavioral medi- cine approach to working with pediatric patients and their families, with emphasis on psychosocial functioning rather than focusing narrowly on symptoms. Despite widespread agreement on the insufficiency of disease models, there continues to be a strong focus in psychological research and practice on symptom reduction and cognitive- emotional reg- ulation. Such an approach may reinforce beliefs that physical and emotional pain should be managed or controlled, and must be substantially reduced for functioning and life quality to improve. An ACT approach, emphasizing values-based exposure and accep- tance of uncontrollable pain and distress, is clearly a decided departure from traditional pain management models.
We presented an ACT conceptualization of pediatric chronic pain and suggested ways of adapting ACT clinical methods for children and their families. Central to this model of chronic pain is a radical shift in perspective from managing symptoms to promoting acceptance and learning to live well in the presence of pain and distress. In medical settings, the successful implementation of ACT requires ongoing collaboration with physicians, other members of the treatment team, and important adults in the child’s life. As described in this chapter, a contextual shift from symptom alleviation to valued living in the presence of pain involves other people in the child’s life. The illustration of the patient’s dilemma (figure 1), along with discussions regarding accep- tance, defusion, and mindfulness, can be used with parents and health care profes- sionals to conceptualize the problem and treatment objectives. Empirical research with children and adults (e.g., Dahl et al., 2004; Greco et al., 2008; McCracken et al., 2007; McCracken, Vowles, & Eccleston, 2005; Wicksell et al., 2007) and our clinical experi- 2005; Wicksell et al., 2007) and our clinical experi- ence suggest that ACT may be a beneficial approach for chronic pain patients. In the coming years, it will be essential to conduct well-designed randomized controlled trials to identify long-term outcomes and mechanisms of change in pediatric populations.
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