Bottom line
Psychological therapies reduce pain frequency immediately following treatment for children and adolescents with chronic headache and reduce pain intensity for children and adolescents with mixed chronic pain conditions. Psychological therapies also reduce disability for children and adolescents with mixed chronic pain conditions immediately following treatment and up to 12 months later, and for children with headache conditions up to 12 months later.
Background
Chronic pain or pain that lasts for longer than three months is common in young people. Psychological therapies (e.g. relaxation, hypnosis, coping skills training, biofeedback, and cognitive behavioural therapy) may help people manage pain and its disabling consequences. Therapies can be delivered face-to-face by a therapist, via the Internet, by telephone call, or by computer programme. This review focused on treatments that are delivered face-to-face by a therapist, which includes therapies delivered by telephone or via a book with exercise instructions. For children and adolescents, there is evidence that relaxation by itself and cognitive behavioural therapy (treatment that helps people test and revise their thoughts and actions) are effective in reducing the intensity of pain in chronic headache, recurrent abdominal pain, fibromyalgia, and sickle cell disease immediately after treatment.
Study Characteristics
This review included 47 studies with 2884 participants. The average age of the children and adolescents was 12.6 years. Most studies included young people with headache (23 studies) or stomach pain (10 studies), The remaining studies investigated children with irritable bowel syndrome, fibromyalgia, temporomandibular disorders, sickle cell disease, inflammatory bowel disease, or included samples with various chronic pain conditions.
Key results
Psychological therapies reduced pain frequency immediately following treatment for children and adolescents with chronic headache, and pain intensity and anxiety for children and adolescents with other chronic pain conditions. Psychological therapies also reduced disability for children and adolescents with non-headache chronic pain conditions immediately following treatment and for children with headache and mixed chronic pain conditions up to 12 months later. We did not find any benefit of psychological treatments on reducing anxiety for children with headache or for depression in children with headache or mixed chronic pain conditions.
Quality of evidence
We judged all outcomes to be low or very low-quality, meaning our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect or we have very little confidence in the effect estimate; or the true effect is likely to be substantially different from the estimate of effect.
Psychological treatments delivered predominantly face-to-face might be effective for reducing pain outcomes for children and adolescents with headache or other chronic pain conditions post-treatment. However, there were no effects at follow-up. Psychological therapies were also beneficial for reducing disability in children with mixed chronic pain conditions at post-treatment and follow-up, and for children with headache at follow-up. We found no beneficial effect of therapies for improving depression or anxiety. The conclusions of this update replicate and add to those of a previous version of the review which found that psychological therapies were effective in reducing pain frequency/intensity for children with headache and mixed chronic pain conditions post-treatment.
This is an update of the original Cochrane review first published in Issue 1, 2003, and previously updated in 2009, 2012 and 2014. Chronic pain, defined as pain that recurs or persists for more than three months, is common in childhood. Chronic pain can affect nearly every aspect of daily life and is associated with disability, anxiety, and depressive symptoms.
The aim of this review was to update the published evidence on the efficacy of psychological treatments for chronic and recurrent pain in children and adolescents.
The primary objective of this updated review was to determine any effect of psychological therapy on the clinical outcomes of pain intensity and disability for chronic and recurrent pain in children and adolescents compared with active treatment, waiting-list, or treatment-as-usual care.
The secondary objective was to examine the impact of psychological therapies on children's depressive symptoms and anxiety symptoms, and determine adverse events.
Searches were undertaken of CENTRAL, MEDLINE, MEDLINE in Process, Embase, and PsycINFO databases. We searched for further RCTs in the references of all identified studies, meta-analyses, and reviews, and trial registry databases. The most recent search was conducted in May 2018.
RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment, treatment-as-usual, or waiting-list control for children or adolescents with recurrent or chronic pain were eligible for inclusion. We excluded trials conducted remotely via the Internet.
We analysed included studies and we assessed quality of outcomes. We combined all treatments into one class named 'psychological treatments'. We separated the trials by the number of participants that were included in each arm; trials with > 20 participants per arm versus trials with < 20 participants per arm. We split pain conditions into headache and mixed chronic pain conditions. We assessed the impact of both conditions on four outcomes: pain, disability, depression, and anxiety. We extracted data at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (between three and 12 months post-treatment).
We identified 10 new studies (an additional 869 participants) in the updated search. The review thus included a total of 47 studies, with 2884 children and adolescents completing treatment (mean age 12.65 years, SD 2.21 years). Twenty-three studies addressed treatments for headache (including migraine); 10 for abdominal pain; two studies treated participants with either a primary diagnosis of abdominal pain or irritable bowel syndrome, two studies treated adolescents with fibromyalgia, two studies included adolescents with temporomandibular disorders, three were for the treatment of pain associated with sickle cell disease, and two studies treated adolescents with inflammatory bowel disease. Finally, three studies included adolescents with mixed pain conditions. Overall, we judged the included studies to be at unclear or high risk of bias.
Children with headache pain
We found that psychological therapies reduced pain frequency post-treatment for children and adolescents with headaches (risk ratio (RR) 2.35, 95% confidence interval (CI) 1.67 to 3.30, P < 0.01, number needed to treat for an additional beneficial outcome (NNTB) = 2.86), but these effects were not maintained at follow-up. We did not find a beneficial effect of psychological therapies on reducing disability in young people post-treatment (SMD -0.26, 95% CI -0.56 to 0.03), but we did find a beneficial effect in a small number of studies at follow-up (SMD -0.34, 95% CI -0.54 to -0.15). We found no beneficial effect of psychological interventions on depression or anxiety symptoms.
Children with mixed pain conditions
We found that psychological therapies reduced pain intensity post-treatment for children and adolescents with mixed pain conditions (SMD -0.43, 95% CI -0.67 to -0.19, P < 0.01), but these effects were not maintained at follow-up. We did find beneficial effects of psychological therapies on reducing disability for young people with mixed pain conditions post-treatment (SMD -0.34, 95% CI -0.54 to -0.15) and at follow-up (SMD -0.27, 95% CI -0.49 to -0.06). We found no beneficial effect of psychological interventions on depression symptoms. In contrast, we found a beneficial effect on anxiety at post-treatment in children with mixed pain conditions (SMD -0.16, 95% CI -0.29 to -0.03), but this was not maintained at follow-up.
Across all pain conditions, we found that adverse events were reported in seven trials, of which two studies reported adverse events that were study-related.
Quality of evidence
We found the quality of evidence for all outcomes to be low or very low, mostly downgraded for unexplained heterogeneity, limitations in study design, imprecise and sparse data, or suspicion of publication bias. This means our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect, or we have very little confidence in the effect estimate; or the true effect is likely to be substantially different from the estimate of effect.