Psychological therapies for the management of chronic and recurrent pain in children and adolescents.
BACKGROUND
An increasing number of children suffer with pain that lasts for six months or longer. Traditional treatment for such pain has been pharmacological and/or physical. Increasingly, following developments in the field of adult chronic pain management, psychological therapies are being employed to treat children with chronic or recurrent pain.


OBJECTIVE
To assess the effectiveness of psychological therapies in treating chronic or recurrent pain in children and adolescents, and to test the null hypothesis that psychological therapies are no more effective than placebo, waiting list control or standard medical care.


METHODS
Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE (1966-1999), Social Sciences Citation Index (1981-1999) and PsycLit (1974-1999) were made. RCTs were also sought in references of all identified studies, meta-analyses and reviews, and first authors and experts within the field were contacted. Date of the most recent search: December 1999.


METHODS
RCTs with at least five participants in each study arm which compared psychological therapies with placebo, waiting list or standard medical care for children or adolescents with chronic or recurrent pain were eligible for inclusion.


METHODS
Data were inspected for heterogeneity. For homogeneous dichotomous data the odds ratio with 95% confidence interval were calculated on an intention to treat basis.


RESULTS
Thirty papers were recovered, representing 28 RCTs. Of these, 18 were analysable and included a total of 808 patients, 438 of whom entered treatment conditions. Fifteen were trials of chronic or recurrent headache; two for recurrent abdominal pain; and one for sickle cell pain. Only pain experience data from 13 trials were meta-analysable. Two meta-analyses were conducted. The first analysis of single treatments versus controls gave a pooled odds ratio of 8.83 (95% CI 4.33 to 18.03; z=5.98, P < 0.00001, df = 12 ). The second analysis (combined treatment versus control) produced a similar estimate: pooled odds ratio = 8.64 ( 95% CI = 4.13 to 18.07; z-5.73, P < 0.00001, df = 9 ). Both analyses indicate that psychological treatment is effective when compared with a pooled group of control conditions. From the pooled data set the NNT was 2.32 (95%CI 1.96 to 2.88).


CONCLUSIONS
There is very good evidence that psychological treatments, principally relaxation and cognitive behavioural therapy, are effective in reducing the severity and frequency of chronic headache in children and adolescents. There is at present no evidence for the effectiveness of psychological therapies in attenuating pain in conditions other than headache, and little evidence for the effectiveness of psychological therapies in improving non-pain outcomes.
Eccleston
C
C
Pain Management Unit, University of Bath and Royal National Hospital for Rheumatic Diseases, University of Bath, Claverton Down Road, Bath, UK, BS16 6PJ. C.Eccleston@bath.ac.uk
Yorke
L
L
Morley
S
S
Williams
A C
AC
Mastroyannopoulou
K
K
D015746:Abdominal Pain / Q000628:therapy; D000293:Adolescent; D002648:Child; D002908:Chronic Disease; D015928:Cognitive Behavioral Therapy; D006261:Headache / Q000628:therapy; D006450:Hemoglobin SC Disease / Q000150:complications; D006801:Humans; D059408:Pain Management; D011613:Psychotherapy / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence