Research on ACT and CCBT demonstrates their eff ectiveness in adult chronic pain population s (McCracken and Eccleston, 2003 ; Ruiz, 2010 ; Vowles and McCracken, 2008 ). At this time, there is a limited but growing body of literature supporting the application of CCBT and A CT in children with chronic pain (Gauntlett-Gilbert and Eccleston 2007 ; Wicksell et al. 20 09 ). Th ere is also modest emerging evidence that acceptance and values-based parenting be haviors are associated with improved adolescent functioning in the context of chronic pain (McCracken and Gauntlett-Gilbert, 2011 ). One RCT comparing CBT to ACT for adult chronic pa in found similar outcomes across the two treatments; both approaches led to reductions in p ain interference and emotional distress (Wetherell et al., 2011 ). ACT and CCBT off er prom ising evidence that the acceptance of pain may be an important component of cognitive-behav ioral psychotherapeutic treatment for patients with chronic pain. Palermo and colleagues developed one such program to deliver Web-based family CBT to adoles cents with chronic pain (Long and Palermo, 2009 ). Adolescents received pain education, rel axation training, and other CBT skills and parents receive training on rein- forcement of p ositive coping, reward systems, communication, and modeling positive coping (Long et al. 20 09 ). Findings of a small RCT found signifi cant reductions in pain and activity limitation s post-treatment for the Internet CBT group compared to wait- list control group, with gain s maintained at a 3-month follow-up (Palermo et al., 2009 ). Several Internet-based CBT int erventions for children with headaches have also demonstrated reductions in pain and in pai n-related negative thinking (Hicks et al., 2006 ; Trautmann and Kroner-Herwig, 2010 ). Case example: Th e Comfort Ability program \200\224a brief multicomponent CBT group interve ntion Megan is a 14-year-old girl with complex regional pain syndrome in her right lower extremit y. Her pain led to signifi cant functional limitations; she struggled to attend school and withdrew from peer and extracurricular activities, spending most of her day at home on the couch. She was referred to physical therapy, but was so fearful of using her foot she was u nable to fully engage in treat- ment. Megan was referred for CBT, but she and her parents w ere resistant because they felt that Megan did not have a psychologi- cal problem. Th ey ar gued that because her pain was \200\230real \200\231, there would be no benefi t in \200 \230just talking about the problem \200\231. Variations on CBT for chronic pain: acceptance and commitment therapy and contextual cognit ive behavioral therapy Acceptance and commitment therapy (ACT) and contextual cogni- tive-b ehavioral therapy (CCBT) are relatively new models of psy- chotherapy commonly referred to as \200\230third wave \200\231 CBT approaches Megan and her parents attended \200\230Th e Comfort Ability \200\231, a 1-day pain managem ent workshop designed to provide children and parents with a non-stigmatizing, cost-, and t ime-eff ective intro- duction to the principles of CBT (Coakley and Barber, 2012 ). By addr essing the stigma and resource barriers that oft en pre- vent families from engaging in psy chological services for pain SECTION 7 psychosocial interventions 528 Baer , L. , Greist , J. , and Marks , I. M. ( 2007 ). Computer-aided cognitive management, an intervention such as this can provide the three important components of CBT including: (1) psychoeducation to help elicit motivation for pain self-management, (2) cogn itive and behavioral skill acquisition, and (3) brief skill rehearsal. Other advantages of a group treatment include the benefi t of peer-based psychosocial support. behavior therapy . Psychother Psychosom , 76 (4), 193 \200\223195. Bailey , K. M. , Carleton , R. N. , Vlaeyen , J. W. , and Asmundson , G. J. ( 2010 ). Treat ments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pai n: a preliminary review . Cogn Behav Th er , 39 (1), 46 \200\22363. Bantick , S. J. , Wise , R. G. , Ploghaus , A. , Clare , S. , Smith , S. M. , and Tracey , I. ( 2002 ). Imaging how attention modulates pain in humans using functional MRI . Brain , 125 (Pt 2), 310 \200\223319. Within the adolescent group, Megan expressed anxiety about whether her pain would get bette r, frustration over missed activities, social isolation, school absences, and friction at h ome. Megan engaged in a goal-setting activity to identify her individual goals for improved functioning, developmentally targeted psy- choeducation about how pain functions in the bo dy, interactive discussions and worksheets to learn how to identify and modify negative tho ughts and maladaptive behaviors, problem solving skills, and an art activity that promoted self-effi cacy. Additionally, she practiced behavioral skills such as diaphragmatic breathi ng, guided imagery, and progressive muscle relaxation. She learned how to use these strateg ies to manage the discomfort and stress associated with physical therapy and returning to s chool. Finally, she created a personalized pain management plan, highlighting the individua l cognitive and behavioral strategies she thought would work best for her. She left with a manual and a pain man- agement tool kit inclusive of a relaxation CD. Barakat , L. P. , Gonzalez , E. R. , and Weinberger , B. S. ( 2007 ). Using cognitive- beha vior group therapy with chronic medical illness . In R. W. Christner , J. L. Stewart , and A. Freeman , (eds) Handbook of cognitive-behavior group therapy with children and adolescen ts: specifi c settings and presenting problems , pp. 427 \200\223446. New York : Routledge /Taylor & Francis Group . Barlow , J. H. , and Ellard , D. R. ( 2004 ). Psycho-educational interventions for children with chronic disease, parents and siblings: an overview of the r esearch evidence base . Child Care Health Dev , 30 (6), 637 \200\223645. Beck , A. T. ( 1979 ). Cognitive therapy and the emotional disorders . New York : Meridian . Bender , J. L. , Radhakrishnan , A. , Diorio , C. , Englesakis , M. , and Jadad , A. R. ( 2 011 ). Can pain be managed through the Internet? A systematic review of randomized controll ed trials . Pain , 152 (8), 1740 \200\2231750. Blount , R. L. , Landolf-Fritsche , B. , Powers , S. W. , and Sturges , J. W. ( 1991 ). Dif f erences between high and low coping children and between parent and staff behaviors durin g painful medical procedures . J Pediatr Psychol , 16 (6), 795 \200\223809. Boivin , J. M. , Poupon-Lemarquis , L. , Iraqi , W. , Fay , R. , Schmitt , C. , and Rossign ol , P. ( 2008 ). A multifactorial strategy of pain management is associated with less pain in scheduled vaccination of children. A study realized by family practitioners in 239 chil dren aged 4 \200\22312 years old . Fam Pract , 25 (6), 423 \200\223429. Megan \200\231s mother and father attended the parent workshop. Th ey expressed feeling sad , anxious, and overwhelmed by Megan \200\231s sit- uation. Th ey shared openly with other p arents who had similar experiences. With guidance, Megan \200\231s parents were able to ide ntify that Megan \200\231s chronic pain was exacerbated by factors such as her transition t o a new school, the recent loss of her grandmother, her sensitive temperament, and her perf ectionistic personality. Th ey were taught how to minimize their responses to her pain (e.g . refraining from asking her to \200\230rate \200\231 her pain, encouraging her to be func tional) and how to support her in using her cop- ing skills. Importantly, they were also pr ovided with guidance for how to advocate for Megan at school so that Megan would be well su pported with a school re-entry plan. Buckelew , S. P. , Conway , R. , Parker , J. , Deuser , W. E. , Read , J. , Witty , T. E. , et al . ( 1998 ). Biofeedback/relaxation training and exercise interventions for fi bromya lgia: a prospective trial . Arthritis Care Res , 11 , 196 \200\223209. Chambers , C. T. , Kenneth , D. , and Bennett , S. M. ( 2002 ). Th e impact of maternal behavior on children \200\231s pain experiences: an experimental analysis . J Pediatr Psychol , 27 (3), 293 \200\223301. Chambers , C. T. , Taddio , A. , Uman , L. S. , and McMurtry , C. M. ( 2009 ). Psychologica l interventions for reducing pain and distress during routine childhood immunizations: a sy stematic review . Clin Th er , 31 (Suppl 2), S77 \200\223S103. Chen , E. , Zeltzer , L. K. , Craske , M. G. , and Katz , E. R. ( 1999 ). Alteration of mem ory in the reduction of children \200\231s distress during repeated aversive medical proced ures . J Consult Clin Psychol , 67 (4), 481 \200\223490. Th ree weeks aft er attending the workshop Megan \200\231s parents reported signifi cant ch anges in their approach to Megan \200\231s care, with observable benefi ts. Th ey noted tha t Megan was regularly attending shortened days at school. She was participating in physical therapy and had set a motivating goal of getting her ears pierced when she \200\230gradua ted \200\231 from her treatment. Her parents noted that she still struggled with \200\230b ad days \200\231 but that her mood and function were steadily improving. Megan \200\231s pa rents observed a shift in Megan \200\231s thinking and in her approach to pain manage- ment . Th ey planned to initiate treatment with a local psycholo- gist to provide ongoing CBT to Megan in order to further her initial gains. Coakley , R. M. , and Barber , B. N. ( 2012 ). Overcoming common barriers to engagement in psychological services for chronic pain: a one-day pediatric pain management workshop for y outh and parents . Pediatr Pain Lett , 14 (1), 10 \200\22315. Cohen , L. L. , Bernard , R. S. , Greco , L. A. , and McClellan , C. B. ( 2002 ). A child-f ocused intervention for coping with procedural pain: are parent and nurse coaches necessary ? 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H. , and van Bon , W. H. ( 2006 ). Pain- and distress-reducing interventions for v enepuncture in children . Child Care Health Dev , 32 (3), 257 \200\223268. Th orndike , E. L. ( 1913 ). Th e psychology of learning . New York : Teachers Woods , M. P. , and Asmundson , G. J. ( 2008 ). Evaluating the effi cacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: a randomized control led clinical trial . Pain , 136 (3), 271 \200\223280. Zabin , A. M. ( 1982 ). The modifica tion of children \200\231s behavior during blood work procedures. Doctoral dissertation, We st Virginia University, WV. College Press . Trautmann , E. and Kroner-Herwig , B. ( 2010 ). A randomized controlled trial of Internet-b ased self-help training for recurrent headache in childhood and adolescence . Behav Res Th er , 48 (1), 28 \200\22337. CHAPTER 51 Operant treatment Keith J. Slifer , Adrianna Amari and Cynthia Maynard Ward Introduction Operant conditioning interventions for clinical pain involve the modifi cation of environmental and social stimuli that are (1) ante- cedents (discriminative stimuli or setting events) to maladaptive pain behavior or (2) consequent stimuli that maintain the ma la- daptive pain behavior through positive reinforcement (social atten- tion or assistance from others) or negative reinforcement (escape or avoidance of uncomfortable, eff ortful ac tivity, or of social, aca- demic, or work responsibilities). While aspects of operant condi - tioning theory have been included in the design of interventions to manage acute pediatri c medical procedure-related pain (see Slifer et al., 1995 , 2002 , 2011 ), this chapter wil l not include these studies but will focus on operant conditioning based interventions for ill- ness- and injury-related chronic or recurrent pain. variables are manipulated the occurrence of target behavior can be reliably increased or de creased. In this type of research, rather than obtaining a single or a few observations of a large sample of partici- pants, the investigator obtains many observations of only one or a few participants. One important advantage of this type of research is that variability w ithin subjects is considered important informa- tion to be studied rather than error varian ce to be controlled by averaging across a large group of subjects or by other statistical m ethods. In single-subject experimental design research an empha- sis is placed on replicati on of demonstrated functional control both within a given subject on diff erent occasions a nd across settings and replication of the same or similar results for a given interven- tio n across repeated applications with a relatively small series of participants. Th is is par ticularly useful when developing and test- ing new intervention approaches based on cumulat ive individual subject evidence. Th is approach is also preferred by behavior ana- lysts be cause it allows for more individualization of intervention procedures while basing them on a consistent rationale and set of learning and conditioning principles. Th is is especially important for working with children whose behavior patterns are develop- ing based on thei r ongoing learning experiences. Th is individual- ized approach to intervention is a hallma rk of Applied Behavior Analysis, and it is especially useful for demonstrating the eff ecti ve- ness of novel interventions. Th ese interventions may later become the focus of more co nventional randomized clinical trials that assess for generalizability of eff ects across l arger samples of participants. In light of this research philosophy many of the studies dis cussed in this chapter employed single-subject experimental design and the strength of the evidence derives from replication across studies demonstrating the same or similar behavior al phenomena. Th is evidence base is supplemented by the few relevant group design studies and systematic reviews across studies that are available in the literature. Before reviewing the history and empirical support for oper- ant conditioning based interve ntions for pain, in general, and pediatric pain, in particular, it will be useful to note t hat much of the work in this area has been conducted by psychologists and behavior analysts who have been trained in the research methods and conventions of the Experimental Analysis of Behavior and Applied Behavior Analysis (see Iversen, 2013 ; Cooper et al., 1987 for mor e background on these disciplines). Th ese fi elds employ single-subject experimental desig ns in which each subject serves as his or her own control and careful, repeated observation s are conducted on the same individual across time (referred to as a time series). Th e ind ividual \200\231s behavior is measured during these obser- vations by recording the occurre nce or not of operationally defi ned behavioral responses, features of the physical and soc ial environ- ment, and sometimes physiological responses of the participant (e.g. blood pre ssure, heart rate, body temperature, etc.). Th e prefer- ence for single-subject methods an d research designs arose from the philosophical perspective that information about what con trols behavior can be learned from studying its variability across envi- ronmental conditio ns within a single participant. Observations of the antecedents and consequences of target behavior lead to hypotheses about controlling variables. Single-subject research involves s ystematic control and manipulation of antecedent or con- sequent variables in order to demo nstrate and confi rm the hypoth- esized functional control over the behavior being studied. Th e investigator \200\231s aim is to show that when hypothesized controlling Origins of operant treatment for chronic pain Although the focus of this book and, therefor e, this chapter is on methods for understanding and treating pain in infants, children, and youth, it will be helpful to consider the origins of the operant SECTION 7 psychosocial interventions 532 conceptualization of pain behavior in the adult clinical pain man- agement literature. Wilb ert Fordyce and colleagues conducted some of the earliest work applying operant behavioral concepts to understanding and treating patients \200\231 pain (Fordyce, 1976 ). He and his colleagues proposed that a signifi cant part of clinical pain is the patient \200\231s over t behavior that can be infl uenced by myriad social and environmental factors in addition t o being infl uenced by actual tissue damage or irritation (see Fordyce and colleagues \200 \231 work sum- marized in Sanders, 2003 ). the environment may come to sustain the pain behavior even aft er the condition that caused the pain has resolved. \200\230Environment \200\231 in this context refers primarily to t he social environment. Th at is, overt expressions or demonstrations of pain behavior may f requently be followed by attention and attempts by family members and/or medical personnel to provide comfort (Fordyce et al., 1968 ). Th e patient in this case had complained of low back pain for 18 years and had decreased ab ility to function in the physical activ- ities of daily living. She could maintain a maximu m of 20 min of continuous activity without reclining to rest. When a pain episode occurred, she ceased all activity, laid down, took pain medication, and cried until the pain subside d. At these times she received a lot of solicitous and ministering attention from her husba nd and son. She had undergone surgical interventions to remove a herni- ated disk (the sour ce of nerve root irritation) and a lumbosacral spine fusion to stabilize her spine. Aft er a careful medical evalu- ation revealed no evidence of remaining neurological disorder, the investigators reasoned that this patient \200\231s behavior was main- tained by contingent attention, medication, and rest. Th erefore, the fi rst intervention based on operant cond itioning theory was to remove the contingent relationships between pain complaints and medi cation administration. Instead of being provided on an \200\230as needed \200\231 basis in response to pain complaints, the medication was provided according to a standard medicatio n schedule and gradually faded in dosage until completely discontinued. At the same time, t he medical and rehabilitation staff were instructed to be as neutral and socially unrespons ive as possible to the patient \200\231s complaints of pain or discomfort. Instead, wheneve r the patient was engaged in an out of bed activity and not speaking of her pain the staff provided positive social attention including praise for any observed increase in physical a ctivity. In this way, pain behavior was placed on operant extinction and physical functioni ng was diff erentially positively reinforced. Using these modifi ed contin- gencies, a prog ram of occupational and physical therapy was developed that used rest and attention as the positive reinforcer for increasing participation in activities (e.g. weaving) and walk- ing . As a result, the patient showed a marked increase in her activ- ity level and her pain co mplaints nearly disappeared in a period of about 8 weeks. Th e operant conceptual framework for understanding chronic pain is that consequences that immediately follow pain behaviors may have a powerful infl uence on the probability of the pain behav- iours occurring again in the future. As a result of this behavior- consequence association, pain behaviors that originated because of body damage or tissue irritation may come under control of consequences and conditioning that occur in the patient \200\231s so cial environment. According to Fordyce, the two general processes that are responsible for this operant conditioning are positive rein- forcement and avoidance learning. Positive rei nforcement suggests that the occurrence of pain behaviors will increase in frequency if fol lowed by positive consequences. By defi nition, if a behavior increases in frequency aft er a specifi c consequence consistently follows it, then whatever the consequence was is hypo thesized to be a positive reinforcer. Positive reinforcers of pain behavior may include con tingent social attention in the form of attempts to com- fort and console, eff orts by othe rs to soothe the pain, and providing contingent pain medication (pro re nata, prn, or \200 \230take when needed \200\231 medication). Avoidance learning of pain behavior occurs when the frequency of a behavior increases aft er that behavior allowed the patient to escape or avoid aversive stimulation. In this process, pain behaviors such as limping, bracing, or activ- ity avoidance become as sociated with decreased or no pain sensa- tion, and as a result these behaviors are negativ ely reinforced and are maintained or increase in frequency. In chronic pain patients this p rocess may become elaborated to the point that the anticipa- tion of suff ering becomes a c onditioned aversive stimulus. Th us, in the context of anticipated pain, if the patient dis plays protective pain behaviors and pain perception or its exacerbation does not occur, the n the same protective behaviors are more likely to be emitted in the future. During the 1970s and 1980s, a few similar case studies of chil- dren were published using t he same type of operant behavioral contingencies as those fi rst described by Fordyce and c olleagues ( 1968 ). For example, Sank and Biglan ( 1974 ) used operant pro- cedures within a controlled case study to treat a 10-year-old boy with severe stomach pains. Th e investig ators developed a token economy in which tokens were awarded to positively reinforce non-pa in behaviors while attention was withheld from the boy \200\231s pain complaints. Th is tre atment was reported to decrease the fre- quency of pain attacks, the magnitude of the boy \200\231s pain ratings, and to increase his school attendance. Furthermore, Fordyce noted that once such avoidance learning occurs, it requires little ong oing reinforcement to maintain it. In this context reinforcement refers to the avoidance of nociception. If a behavior occurs due to anticipation of pain and motivation to avoid both the aversive experience of the anticipation (anxiety, physiological arousal) and the nocic eptive stimulus, the patient will maintain the avoidance behavior even if the nociceptive s timula- tion is never again experienced. In this situation the goal of operant treatment is to prompt and reinforce normative physical activity and arrange the environment such that the patient attempts typical physical activity without the self-protective pain behaviors, and does not experience pain or experiences it at much lower intensity or magnitude. Miller and Kratochwill ( 1979 ) published another controlled case study in which time out w as used to treat a 10-year-old girl with complaints of severe stomach pain that were hypoth esized to be maintained by parental attention. Th e behavioral treatment in this case invol ved removing adult attention and social activities contin- gent on pain complaints. With th is intervention, pain complaints in the home decreased from two per day during baseline obs ervation to approximately one per week aft er treatment, and this improve- ment was maintai ned at 1-year follow-up. A similar decrease in