Relaxation techniques in procedural pain In the brief context of procedural pain experience s, deep breathing is perhaps the most commonly used relaxation tool. Oft en props such as b ubbles or party blowers are employed, particularly with younger children; these tools incor porate a component of distrac- tion that can augment the benefi ts of deep breathing. Recor ded instructions for progressive muscle relaxation and guided imagery procedures are availa ble and can be used in procedural settings when there is less preparation time available. Relaxation techniques for chronic pain Relaxation is widely used in chronic pain (e.g. Pale rmo et al., 2010 ). Learning to employ relaxation strategies in a self-directed manner prov ides children a greater sense of control over their physiologi- cal processes, which may he lp counteract feelings of helplessness induced by chronic pain. Sometimes these techniques are taught using computer-based biofeedback (see Zeltzer, Chapter 60, this volume), providi ng concrete visual and/or audio feedback to help the child gain increased awareness over pr eviously involuntary physiological processes. Many therapists provide children with audio-r ecordings to practice techniques between sessions. Desensitization in procedural pain Desensitization is a time-intensive strategy that requir es a number of sessions with a trained clinician prior to the procedure. Th erefore, in the procedural pain context it is typically used with children who are known to have high leve ls of pain-related anxiety in response to medical procedures such as injections. Prior to a procedure, children can work with a CBT therapist to develop and undergo a systematic proc ess of pairing successive exposures to the feared stimulus (e.g. needle) with relaxation an d use of other adaptive coping skills. Over time, the previously feared situation (e.g. the needle stick) ceases to produce signifi cant pain-related anxiety. In addition to using guided imagery to develop relaxing images, this technique can also foc us on pain-reducing imagery. For example, a child might be guided to imagine the \200\230p ain control center \200\231 in the brain and then locate specifi c controls that can help t o turn down pain mes- sages traveling to a specifi c body area. Th ese techniques are typic ally more eff ective when the child has been guided into a general state of relaxation prio r to engaging in imagery exercises (Kuttner, 1991 ). Desensitization in chronic pain Expectancy eff ects have a strong infl uence on pain percep tion (e.g. Logan and Rose, 2005 ). Many children with chronic pain develop a pattern of avo iding activities they believe will trigger or increase pain (Martin et al., 2007 ). Desensi tization can be used to reduce this pain-avoidance pattern, unlink the association between activi- ties and fear of pain, and help children to re-engage in activities, which can in t urn help to reduce pain. Evidence base for relaxation strategies Relaxation strategies have a good base of evidence supporting their use with pediatric patients in procedural pain contexts (Dahlquist, CHAPTER 50 cognitive-behavioral interventions 523 et al., 1985 ; French et al., 1994 ). Breathing exercises have been shown to be eff ective in reducing children \200\231s self-reported pain, observer rated distress, and nurse repor ted distress during routine immunization procedures (Chambers et al., 2009 ). In a meta-ana ly- sis published in 2010, Palermo and colleagues (Palermo et al., 2010 ) concluded that re laxation as a stand-alone cognitive-behavioral treatment was eff ective in reducing pain ac ross studies of children and adolescents with a variety of chronic pain conditions includin g headache, abdominal pain, and fi bromyalgia. Typically, however, these strategies along w ith most others described earlier, are incor- porated into multicomponent CBT packages. biofeedback engaging and benefi t from the concrete, visual aspects of this technique. In f act, studies have shown that children with headaches derive greater benefi t from biofeedba ck compared to adults (Sarafi no and Goehring, 2000 ). Evidence base for biofeedback Th e most established evidence exists for the use of thermal bio- feedback to treat migraine headache and for surface EMG bio- feedback in the treatment of tension-type headaches (Herman and Blanchard, 2002 ). Several studies have demonstrated support for combining biofeedback training with interventions targeting parental responses to pain (Allen and Shriver, 1998 ; Kroner-Herwig et al., 1998), with results suggesting th at this combined approach yields modestly better long-term outcomes than biofeedback treat- ment alone. In a meta-analytic review, Hermann et al. (1995) found evidence showing greate r eff ectiveness of biofeedback compared to placebo or prophylactic drugs for the treatment of headache. Biofeedback/biofeedback-assisted relaxation training Biofeedback is a therapeutic procedure that measures and \200\230feeds back \200\231 information about an individual \200\231s p hysiological activity (typi- cally indicators of autonomic arousal) to increase awareness o f and voluntary control over those physiological processes (Arena and Blanchard, 1996 ; Ols on and Schwartz, 2003 ). In the treatment of pediatric pain, biofeedback is oft en taught i n conjunction with other relaxation strategies. As biofeedback is only one component of thi s approach, it is oft en referred to as biofeedback-assisted relax- ation therapy. Because of the need for trained practitioners (most oft en psychologists), specialized equipment, a nd the need for prac- tice to become skilled with these techniques, biofeedback is most com monly used for chronic and recurrent pain conditions. Studies have also begun to demonstrate the effi cacy of bio- feedback with pediatric patien ts with chronic abdominal pain (Schurman et al., 2010 ; Weidert et al., 2003 ). Several stu dies pro- vide support for the use of biofeedback in the treatment of fi bro- myalgia sympt oms (Buckelew et al., 1998 ; van Santen et al., 2002 ), although none of these studies is s pecifi c to the pediatric popu- lation. In their recent meta-analysis of psychological ther apies for pediatric chronic pain, Palermo and colleagues ( 2010 ) concluded that biofeedbac k was eff ective in reducing pain, with an odds ratio of 23.34. However, additional well-de signed studies of specifi c bio- feedback modalities and biofeedback assisted relaxation ap proaches are needed, particularly studies that examine pain conditions other than headache and that include outcomes beyond pain reduction, such as improvements in physical and psych ological functioning. Additionally, research is needed to compare biofeedback train- ing to placebo conditions to elucidate its specifi c and non-specifi c eff ects. Th is is an impo rtant design consideration given the poten- tial infl uence of the novelty of this treatmen t approach. Patients and families may have a negative bias towards psychological therapy fo r chronic pain, but may have a positive bias towards expectations for improvement when rela xation or pain management is taught via biofeedback. Teasing apart whether biofeedback-assi sted relaxation is more benefi cial for chronic pain management as compared to relaxation t aught without biofeedback is an ongoing eff ort in the study of psychological interventions for chronic pain. Biofeedback for chronic pain Biofeedback uses electrical sensors to measure and receive inf or- mation (feedback) about a patient \200\231s body. Th e biofeedback sensors are connecte d to a computer interface and provide real-time infor- mation about physiological processes such as muscle tension. Th is information provides concrete evidence to patients, demonstr at- ing when they are successful in making positive changes in their body, such as relaxing certain muscles, to achieve pain reduction. Biofeedback for pain management typically inco rporates a focus on one or more of the following physiological processes: respiration (pace and depth of breathing), muscle electromyography, periph- eral skin temperature, and blood fl ow or heart rate variability. Th e \200\230feedback \200\231 can be visual and/or audi tory. Visual information can be displayed in graphic or numeric form, such as readout of sk in temperature, or it can be transformed into other interactive dis- plays. For example, a child engaging in thermal biofeedback might watch an image of a hot air balloon that gradua lly rises as the child increases their peripheral skin temperature, or sinks back down if t he child \200\231s temperature drops. Similarly, relaxing music and images might play as lo ng as the child maintains muscle relaxation below a specifi ed surface electromyograph (EMG ) level, but stop if the child surpasses the muscle tension threshold. Multicomponent approaches Th e techniques described earlier in this chapter are frequently combined into multicomponent cognitive-behavioral treatment packages. Such packages typical ly combine one or more behav- iourally-oriented strategies, such as distraction, breathing, mus- cle relaxation, modeling/rehearsal, or desensitization, with one or more cognitively- focused strategies, such as imagery/hypno- sis, education, cognitive reframing, or positive coping statements (Uman et al., 2008 ). Each biofeedback modality has a diff erent mechanism that accounts for its benefi ts for pa in management; for example, EMG biofeedback promotes muscle relaxation, whereas skin-temper - ature biofeedback produces changes in peripheral and cranial blood fl ow. Th ese physical changes can be directly benefi cial to certain pain conditions, particularly migraine and tension head- aches. Biofeedback can also help to foster mind \200\223body connections, dec rease overall sympathetic arousal, promote general relaxation, and enhance a child \200\231 s sense of self control. Children oft en fi nd Multicomponent CBT for procedural pain When using multicomponent CBT in the context of a pa inful pro- cedure, techniques can be delivered all at once during the proce- dure itself, o r in stages (e.g. with some pre-procedural preparation, some intervention during the proced ure, and some post-procedural intervention). Parent or staff coaching in the use of the str ategies is SECTION 7 psychosocial interventions 524 also a common component of these treatment packages in the pro- cedural pain context, parti cularly for younger children (e.g. under age 8). Although combined approaches may be more t ime intensive to deliver, which is sometimes a challenge in the procedural set- ting, child ren are likely to benefi t more from this comprehensive approach. children with other pain conditions including musculoskeletal pain and recurrent abdominal pain, but the number of RCTs for these pain conditions was low. In a meta-analysis, Palermo and colleagues (Palermo, et al., 2010 ) addressed some of the l imitations of previous reviews by including more recently published trials (focused on head ache, abdominal pain, and fi bromyalgia) and examining outcomes of functional dis- ability and emotional distress in addition to pain. Th ey analyzed 25 RCTs of psychological treatme nts for pediatric chronic pain, with a total of 1247 participants. Th e meta-analysis found that multi- component CBT (along with relaxation therapy and biofeedback training as stand -alone approaches) led to signifi cant reductions in pain, but data were inconclusive regar ding eff ects on functional dis- ability and emotional functioning. Comparing studies on di ff erent pain populations, the greatest eff ects of CBT on reducing functional disability e merged for children with abdominal pain, although it is not clear whether fi ndings related to the type of pain condition or diff erences among specifi c interventions. Overall, the evidence in support of CBT for pediatric chronic pain is strong, with the growing body of R CTs demonstrating generally positive eff ects for a variety of cognitive and behavioral tre atment strategies for chil- dren with a range of pain conditions. See Table 50.3 for descri ptions of sample multicomponent CBT packages for chronic pain. Multicomponent CBT for chronic pain For children with chronic pain conditions, psychologist s typically teach a broad complement of CBT strategies, oft en in the context of multidisci plinary treatments that might also incorporate physical therapy and medication use. Patient s are encouraged to develop a \200\230toolbox \200\231 of diverse strategies for coping wi th pain and to adopt a self-management approach to their use outside of therapy sessions. T h e literature includes many reports of eff ective multicomponent CBT for treatment of pedi atric chronic pain. For example, Sanders and colleagues ( 1994 ) developed a comprehensive cognitive-behav- ioural family intervention for children with recurrent abdominal pain that included psychoeducation, muscle relaxation, breathing, positive self-talk, distraction an d imagery techniques along with some operant strategies. Biofeedback and relaxation strateg ies have frequently been delivered in combination in the treatment of pae- diatric headache (Holden et al., 1999 ). Logan and Simons ( 2010 ) developed a CBT package consisting of ps ychoeducation, relaxa- tion, and cognitive reframing skills for children with a range of ch ronic pain conditions and associated school impairment. Key considerations in the application of CBT to pediatric pain Preparing patients for CBT I t is important for families to have accurate expectations for CBT prior to commencing treat ment. For example, it is crucial to dispel the myth that psychological pain management stra tegies are only eff ective if there is a psychological cause for the pain. McGrath and coll eagues (2003) suggest off ering the analogy that morphine is oft en useful in reducing post operative pain, but this does not mean that postoperative pain is caused by a lack of morph ine. CBT is eff ective for pain management for several reasons. First, children with chroni c or acute pain oft en fi nd direct symptom relief from behavioral pain management strategi es. Second, chronic or recur- rent pain is oft en associated with functional impairment (e. g. poor adherence to medical procedures, inability to attend school, activ- ity limitations ), and CBT strategies can be eff ective in improving function even if there is not a reduct ion in pain. Th ird, pain and suff ering are oft en linked to feelings of hopelessness, hel plessness, frustration, fear, and anxiety. Th ese feelings can exacerbate pain, interfere w ith medical care, increase disability, and contribute to long-standing mental health diffi culties. Th us, CBT has tremen- dous value for the management of pediatric pain because it has demonstrated eff ectiveness for: (1) the direct modifi cation of pain sensation, (2) im proving maladaptive behavioral responses to pain (e.g. emotional distress, avoidance of act ivity), and (3) modifi cation of the negative thoughts that can lead to feelings of depress ion and anxiety (Turk et al., 2008 ). Evidence base for multicomponent CBT A number of well-validated CBT treatment packages have been cre- ated for pediatric procedural pain. Table 50.2 provides examples of empirically tested intervention packages. Many of these packages have been found eff ective in reducing emotional/behavioral dis- tress both by self-report and observation. Some studies have com - bined CBT with medications and found the combined approach to improve upon benefi ts from medication alone (Jay et al., 1991 ; Kazak et al., 1996 ). Reviewing empirically supported treatments for pro- cedure-related pain, Powers ( 1999 ) concluded that CBT treatment pack ages were a \200\230well-established treatment \200\231 for procedural pain in children an d adolescents. In a Cochrane review, Uman and col- leagues ( 2008 ) studied psychosocial in terventions for 2-to 19-year- olds undergoing needle procedures. Th ey found strong eff ect s on observer reports of pain and behavioral measures of distress for multicomponent CBT in terventions. Th e review by Chambers and colleagues (Chambers, et al., 2009 ) on interventi ons to reduce pain during immunization also found combined cognitive-behavioral interventio ns to be eff ective for reducing children \200\231s self-reported pain and observer-rated d istress. In a series of reviews of cognitive-behavioral treatment for vari- ous pediatric chronic pa in conditions published in 1999, CBT was found benefi cial for children with headaches (Hol den et al., 1999 ), recurrent abdominal pain (Janicke and Finney, 1999 ), and disease- rela ted pain (Walco et al., 1999 ). Most evidence was in support of combined treatment packages , although some evidence existed to support relaxation alone and thermal biofeedback alone (Holden et al., 1999 ; Palermo et al. 2010 ). In a systematic Cochrane review, Eccleston an d colleagues ( 2009 ) concluded that cognitive-behav- ioural treatments were eff ective in reducing pain in children with headache, with benefi ts lasting into follow-up assessment p oints. Th e authors concluded that these treatments may also benefi t It is helpful to explain to children and families that even an empirically eff ective treat ment such as CBT may not eliminate pain immediately or entirely. Over time and with adheren ce to treat- ment, however, CBT can oft en alter a child \200\231s experience of pain and t hus change their long-term trajectory (Kendall, 2012 ). Aft er treatment with CBT, it is co mmon for children with chronic pain CHAPTER 50 cognitive-behavioral interventions 525 Table 50.2 Sample CBT interventions for pediatric procedural pain Study Pain condition(s) Sample Study aims CBT components and Tx dose Outcomes (pain, function, distress) Boivin et al. (2008). Scheduled vaccination N = 239, healthy 4 \200\22312-year-olds Compare pharmacological + psychological approaches during vaccination to standard medical c are (SMC), including pharmacological pain management Treatment group received: parent + child education, anesthetic medication, parents providin g reassuring statements, and child distraction by blowing bubbles Compared to SMC, those in the multifactorial treatment group self-reported less pain on a v isual analog scale and facial pain scale. Parents \200\231 reports of child \200\231s pain were also less for children in the treatment condition vs SMC Cohen et al. (2002) Routine immunization N = 61, 3 \200\2236- year-olds To examine the e \203 cacy of children \200\231s use of coping skills training without tra ined parent/ nurse coaches Treatment included: video instruction in deep breathing; positive self-statements; video mo deling; practice Treatment group did not report using skills during the procedure, perhaps due to lack of pa rental/ nurse coaching. More child training and/or coach involvement might be necessary for e \200 ective child coping. Nurses encouraged child coping, whereas parents tended to res pond to child distress Schi \200 et al. (2001). Repeated blood draws N = 43, 4 \200\22312- year-olds with HIV Single group, repeated measures design to evaluate multicomponent pain management intervent ion for children with HIV under-going repeated venepuncture. Treatment included: preparation, relaxation, distraction, reinforcement, parent involvement , local anesthetic cream; no CBT or anesthetic cream used at baseline Children reported signi \201 cant reductions in distress and pain by the second post-inter vention procedure and maintained them at the third; parent anxiety was signi \201 cantly r educed by the second post- intervention procedure Blount et al. (1992). Routine immunization N = 60, healthy 3 \200\2237-year-olds To determine if combined CBT package result in less pain and distress by patient and parent report vs. no-treatment control group Treatment group received distraction, coping skills training, + use of a party blower for d eep breathing; Control group received standard care Trained parents prompted their child to use the blower more than untrained parents. Trained children engaged in more blower usage than untrained children. Child and parent reported d istress lower than both comparison groups to report that some pain persists, but that the pain is less noticeable and doesn \200\231t interfere with everyday life (Rogers, 2008 ). Children who use CBT strategies to manage pr ocedural pain might report that the procedure was not pain-free, but that it hurt less and they did not feel as anxious or distressed about it. child \200\231s discomfort. Th is high level of concern may inadvertently reinforce poor ad aptation in children with acute or chronic pain presentations. One important CBT goal for p arents is to learn to emphasize their child \200\231s use of coping skills rather than focu sing on the pain itself; decreasing parents \200\231 focus on the pain and has been shown t o lead to reduced child pain and distress for both procedural and chronic pain (Chambers et al., 2002 ; McMurtry et al., 2006 ; Walker et al., 2006 ). Additionally, research suggests that the association between pain and depression in children is signifi cantly reduced whe n parents use active pain coping strate- gies (Williamson et al., 2002 ). Parent involvement Parents play an integral role in CBT for children with chronic or acute pain, and there are multiple ways to incorporate parents into treatment. Kendall ( 2012 ) s uggests that parents can be \200\230con- sultants, collaborators, or co-clients \200\231 i n treatment. Parents serve as \200\230consultants \200\231 when they provide information a bout the social, developmental, or cultural contextual factors that may contribute to their child \200\231s pain. Th is information is crucial for establishing treatment goals and id entifying barriers to treatment. Parents are \200\230collaborators \200\231 when they help to oversee the implementa- tion of their child \200\231s newly learned cognitive behaviora l skills (Kendall, 2012 ). For example, parents can be taught how to use distraction techni ques during their child \200\231s painful procedure or taught how to eff ectively help impl ement long-term behavioral goals for a child with chronic pain. Lastly, parents can be dire ctly incorporated into CBT treatment with children as \200\230co-clients \200\231 if they are viewed as contributing to the child \200\231s presenting prob- lem. For example, many p arents become highly focused on their Developmental considerations CBT interventions are most eff ective when they conceptual- iz e presenting problems within the context of the child \200\231s current developmental tasks and milestones. Over the past 10 years there has been a signifi cant increase in research that examines devel- opmental factors as moderators of treatment outcomes, with the goal of improving our understanding of the relationship between the developmental level of a child and specifi c components of CBT (Holmbeck, 2012 ). Because CBT necessitates the acquisition of new or modifi ed behavioral and cognitive skill s, attention to a child \200\231s development is an important consideration in treatment pl anning. Although SECTION 7 psychosocial interventions 526 Table 50.3 Sample CBT interventions for pediatric chronic pain Study Pain conditions Sample Study aims CBT components and Tx dose Outcomes (pain, function, distress) Kashikar-Zuck et al. (2012). Juvenile \201 bro-myalgia syndrome (FMS) N = 114, 11 \200\22318- year-olds RCT to compare CBT vs education in reducing functional disability, pain, and symptoms of de pression in juvenile FMS Ten individual sessions in both conditions; CBT included: psychoeducation, muscle relaxatio n, activity pacing, distraction, problem solving, calming statements, relapse prevention st rategies; FM education condition included: education and discussion about FM, pain medicati ons, diet, sleep, exercise, and lifestyle CBT superior to FM education in reducing functional disability; both groups had decreases i n pain and depressive symptoms. Reduction in pain statistically but not clinically signi \201 cant Palermo et al. (2009). Chronic headache, abdominal, or musculoskeletal pain N = 48, 11 \200\22317- year-olds RCT to compare internet- delivered CBT vs. no treatment on reducing pain intensity and acti vity limitations Treatment group vs. waitlist control. Internet treatment consisted of 8 weeks of online mod ules including relaxation training, cognitive strategies, parent operant techniques, commun ication strategies, sleep, and activity interventions Internet treatment group had less activity limitations and pain intensity at post- treatmen t and 3-month follow-up vs. waitlist group. No di \200 erences in parental protectiveness or child depression Connelly et al. (2006). Recurrent headaches N = 37, 7 \200\22312- RCT to compare CBT via a CD-ROM (+ some therapist contact) vs wait-list control on headache management Six 1-h CD modules included relaxation, guided imagery, deep breathing, muscle relaxation, coping thoughts, and behavior management CD-ROM group had signi \201 cantly greater improvements in self- reported headache frequen cy, duration, and intensity vs wait-list controls. Gains maintained at 3-month follow-up year-olds Robins et al. (2005). Recurrent abdominal pain (RAP) N = 69, 6 \200\22316- year-olds RCT to compare combination of standard medical care (SMC) + CBT family groups vs SMC alone Five child \200\223parent CBT sessions included breathing, imagery, relaxation techniques; positive self-talk strategies; minimizing catastrophizing; distraction; parent reframing (i .e. encouraging coping, limiting secondary gains) Treatment group had signi \201 cantly less child- and parent-reported pain vs SMC group im mediately post-intervention. Group di \200 erences maintained at 1 year. Treatment group h ad signi \201 cantly fewer school absences vs SMC. No di \200 erences in functional disab ility or somatization some behavioral strategies such as simple distraction techniques can be eff ective even amo ng infants undergoing routine immuni- zations (Cohen et al., 2006 ), other skills may be le ss appropriate for younger children (e.g. understanding how changes in thinking impact futu re experiences). In general, behavioral strategies may be best suited to younger children a nd more verbal or cognitive strategies may work best for older children. However, given tha t age is only a proxy for development and that cognitive development impacts the rate and p rocessing of information, executive function- ing, meta-cognition, and self-regulation, a t horough understanding of a child \200\231s cognitive development is a critical factor in es tablishing CBT goals and tailoring interventions. eff ectiveness of CBT across a wide array of pain-related diffi culties, long-term maintena nce of treatment gains is less well demonstrated. Symptom relapse is most likely to occur w hen: (1) pain symptoms change or intensify, (2) a patient \200\231s perceived ability to ma nage the symptoms declines, and (3) there is an increase in psychological distress (Keefe a nd Van Horn, 1993 ). Relapse prevention strate- gies typically include anticipation of mino r setbacks, identifi cation of the early signs that distress is increasing, rehearsal of co gnitive and behavioral coping skills, and self-reinforcement for adaptive responses to rela pse (Keefe and Van Horn, 1993 ). Additionally, some patients may benefi t from intermittent \200\230tune-ups \200\231 with a therapist. Th is has been conceptualized as the \200 \230dental model \200\231 of care (Kazdin, 1997 ). Meeting every 3 to 6 months aft er treat ment may help to reinforce newly learned skills, identify new onset symptoms before they be come problematic, and help children develop more advanced skills to meet their evolving psy chological, psychosocial, and environmental demands (Kazdin, 1997 ). Relapse prevention For children with chronic pain or those who undergo repeated painful pro cedures, CBT interventions should incorporate strat- egies for relapse prevention. While em pirical studies support the CHAPTER 50 cognitive-behavioral interventions 527 Alternative delivery approaches and emerging directions in CBT for pediatric pain Group the rapy for chronic pain Group-based CBT interventions have been shown to be cost- and time-ef fi cient and as eff ective as individual treatment in numerous studies (Morrison, 2001 ; Se ars et al., 2007 ). Th e group format also promotes psychosocial support, a particularly sa lient important factor for children with chronic pain who oft en feel alienated by their co ndition. Group therapy programs can also incorporate other family members in treatment sess ions to help modify pain responses within the family environment (e.g. Coakley and Barber 2 012 ; Logan and Simons 2010 ). In the pediatric literature, group CBT has already demonstra ted eff ectiveness for a variety of pain- related problems such as irritable bowel syndrome (Hayutin et al., 2009 ), headache (Kroener-Herwig and Denecke, 2002 ) and pain- related sc hool absenteeism (Logan and Simons, 2010 ). (Hayes 2004). ACT and CCBT both blend many of the major tents of CBT with a functional, con textual philosophy of science or rational frame theory (Hayes and Smith, 2005 ; Hayes et al ., 1999 ). Rather than focusing on controlling or changing unpleasant expe- riences (e.g. p ain), these approaches incorporate acceptance and mindfulness techniques and promote the pa tient identifying their core values and fi ndings ways to live consistently with these val- ues in spite of pain. Th ese treatments oft en include exposure-based therapy aimed at inc reasing psychological fl exibility and restoring functioning. ACT and CCBT for chronic pain management have gained atten- tion in the clinical and resear ch literature given that some individu- als with chronic pain need to learn to function in the context of ongoing pain. As opposed to traditional CBT approaches where the goal is to change unwanted phenomena (e.g. reduce or elimi- nate pain), ACT and CCBT focus on reducing the distressing and disabling infl uences of pain, pain-related thoughts, and avoidance of potentially painful activities. Th ese approaches assist patients in identifying how to in crease functioning and quality of life in accordance with their personal values by shift in g away from recur- rent struggles with pain (Hayes and Smith, 2005 ; Hayes et al., 1999 ; M cCracken et al., 2007 ). Web-based treatment Th ere has been a recent emergence of Internet-based CBT inter- vention s for pediatric pain. Internet-delivered CBT for chronic pain has a number of advantages to traditional treatment deliv- ery models. It reduces waiting lists and scheduling confl ict s, can be self-paced, and minimizes stigma (Baer et al., 2007 ; Cuijpers et al., 2008 ). Bo th therapist-guided and unguided models exist. Limitations to this delivery method include the automated aspects of this approach, requirement of access to and comfort with appro- pr iate technology, and in the case of unguided approaches, a lack of immediate response to in dividual needs (Baer et al., 2007 ; Cuijpers et al., 2008 ). One meta-analysis (Cuijpers et al., 2008 ) found that since 2000, six randomized studies have examined interventions deli vered over the Internet for pediatric pain. Eff ect sizes for Internet-delivered CBT for pa in were promising (ranging from 0.19 to 0.79), but overall below those found for Internet-d elivered CBT for anxiety and depression in children (Cuijpers et al., 2008 ; Spek et al., 2 007 ). At present, Web-based interventions for pain appear promising but require additional research to determine effi cacy (Bender et al., 2011 ; Cuijpers et al., 2008 ; Macea et al ., 2010 ). 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.