damage or irritation. Interventions that may reduce pain percep- tion include medication, n erve blocks, cognitive-behavioral cop- ing strategies (distraction, hypnosis, controlled de ep breathing, progressive muscle relaxation, visual imagery), acceptance and commitment int erventions, and other physical interventions (heat, cold, massage, acupuncture, electroderm al stimulation). In situa- tions in which environmental and psychosocial stressors are the antecedent events that set the occasion for pain behaviors, and these behaviors are positiv ely reinforced by special social atten- tion or ministering behavior from others, and/or ar e negatively reinforced by physical, social, educational or work activity avoid- ance, thes e maintaining variables must be addressed or pain treat- ment will not be eff ective. Following the logic and model just presented, Flor et al. ( 2002 ) conducted a study of the role of operant conditioning in the devel- opment and maintenance of chronic pain. Th e st udy compared 30 adult patients with chronic back pain to 30 healthy matched con- trol parti cipants on their verbal and neurophysiological respond- ing to an operant conditioning para digm. Th e results showed that both groups \200\231 verbal reports were able to be conditio ned, but the patients with chronic low back pain showed diff erent cortical and electromyog raphic responses. Specifi cally, the patients with chronic pain were more easily aff ected by operant conditioning factors at both the verbal and neurophysiological level. Flor and c olleagues hypothesized that individuals with greater susceptibility to condi- tioning eff e cts may be more likely to develop chronic pain condi- tions. In support of this hypothesis, there is recent evidence that aft er experiencing painful stimulation in an experiment, ch ronic pain patients evidenced decreased diff use noxious inhibitory con- trol (DNIC) in the brain when exposed to subsequent painful stimulation, while healthy control participants ( Meeus et al., 2008 ) and individuals with major depressive disorder did not show this dimin ution of DNIC (Normand et al., 2011 ). Sander \200\231s ( 1985 , 2003 ) conceptual model distinguishes between acute and chronic p ain states. In acute pain, neurophysiological and gross motor pain responses are dominant a nd the most prevalent controlling consequent stimuli are those associated with the reduc- t ion of pain perception arising directly from tissue damage or irri- tation. When pain becom es chronic, pain responses may become more predominantly cognitive and subjective (anticipa tion, fear and avoidance of pain sensation). In chronic pain conditions, the most prevalent consequent stimuli maintaining pain behaviors involve escape or avoidance of anticipated p ain. Indeed, the patient now may be avoiding aversive environmental stressors associated wi th pain (e.g. physical contact or exertion, social interactions) or confused with subjectiv e pain perception (e.g. symptoms of anxiety, depression perceived as pain). In chronic pain states, this avoidance of physical activity and social interaction is maintained even aft er the original tissue damage or irritation is greatly diminished or no longer present. In addition, positive consequences such as social attention may play a greater role in chronic pain. Positive reinforcement of wellness behavior and the combination of operant and cognitive-be havioral interventions for clinical pain It is important to note that operant interventions for pain also include modifi cation of antecedent and consequent stimuli in order to stren gthen wellness-oriented behaviors that are alternatives to, or incompatible with, maladapti ve pain behavior. Examples of positive alternative behaviors include participation in thera py, use of pain coping strategies (distraction, muscle relaxation, positive self-statements ), increased physical and social activity, reduced use of narcotic pain medications, and re turn to role functioning (i.e. school or work). Given that the antecedent and consequent stimuli that maintain pain behavior may have shift ed when pain has become chronic, it is necessary to consider, and when possible, to modify these main- taining variables. As indicated by Sanders ( 2003 ), the eff ectiveness of any pain intervention is a function of the extent to which it sig- nifi cantly alters the prim ary antecedent and consequent stimuli initiating and maintaining the pain responses. For ex ample, if a patient is actually experiencing tissue damage or irritation (an antecedent con dition) then interventions that do not change the perception of this stimulus will not be e ff ective. Rather, escape- avoidance motivated pain behavior (e.g. avoiding physical activ- ity) will be maintained to the extent that the behavior reduces or eliminates perception o f pain resulting directly from the tissue In his excellent review article on operant therapy with patients with chronic pain, Sanders ( 2003 ) discussed the evidence base supporting the eff ectiveness of these operant interv entions, and emphasized that although operant conditioning can play a major role in modifyi ng pain behavior, it is not considered a complete or comprehensive treatment for clinical p ain. Th at is, medical, physi- cal and cognitive-behavioral interventions also should be us ed, when appropriate, in addition to operant behavioral treatment strategies. In clinical p ractice, operant procedures are rarely, if ever, used in isolation, and research evidence s upports the benefi ts of CHAPTER 51 operant treatment 537 combining these strategies with cognitive-behavioral techniques such as distraction, relaxa tion training and cognitive coping skills training. Th e evidence indicates that the additi on of cognitive- behavioral techniques to operant conditioning may signifi cantly enhance t he treatment eff ects accomplished with operant condi- tioning alone (Compas et al., 1998 ; Keefe et al., 1992 ; Lindstrom et al., 1992 ; Moraley et al., 1999 ; Sanders, 2003 ; Van T ulder et al., 2000 ). Based on his literature review and similar previous reviews by others , Sanders ( 2003 ) concluded that there is strong and sub- stantial evidence for the eff ec tiveness of operant conditioning inter- ventions demonstrated primarily with adult patients with low back pain. Th e evidence supports that operant conditioning alone or in combinati on with other treatment (e.g. cognitive-behavioral) strategies can produce signifi cant and sustained improvements in general activity level, work behavior, use of pain medication, a nd to a lesser degree subjective pain intensity ratings of patients with chronic pain when applied in either inpatient or outpatient settings. Th e evidence base is strong for adults with low back pain, but there are fewer methodologically rigorous data on the effi cacy of operant conditioning-based interventions on other pain conditions such as complex regional pain syndrome (CRPS), fi bromyalgia, and head- ache. Th e research evidence on operant con ditioning intervention eff ects with children, adolescents, and geriatric populations with diagnoses other than low back pain (either acute or chronic) were found to be less well dev eloped when Sanders conducted his 2003 review. this theory are studies indicating a signifi cant relationship between a family history of chronic pain and the occurrence of RAP. Th is relationship may be due to greater emphasis o n bodily sensations throughout the family or modeling of illness behavior by family members . A few intervention studies based on operant and social learning theories have been conducte d, and this literature was reviewed by Janicke and Finney ( 1999 ) to search for empirical support for treat- ments for RAP. Janicke and Finney ( 1999 ) found that based on the avail able studies and their methodological quality, operant proce- dures alone did not meet even the more lenient criteria for a \200\230prom- ising \200\231 intervention. Dietary fi bre treatments for RAP associated with constipation meet the criteria for a \200\230promising \200\231 intervention, and cognitive-behavioral interventions for RAP meet the criteria fo r a \200\230probably effi cacious \200\231 intervention. While the two case stud- ies usin g operant treatment alone reviewed by Janicke and Finney ( 1999 ) did not meet even the lea st stringent criteria for empirically supported \200\230promising \200\231 interventions, these early preliminary stud- ies demonstrated preliminary evidence that operant conditioni ng principles have some infl uence on the symptoms that are reported by children with RAP, and they set the stage for pursuing alterna- tives to medical treatment for RAP, including cognitive-behav- ioural interventions that utilize operant procedures as part of their trea tment strategies. From the time of Janicke and Finney \200\231s ( 1999 ) review to the pres ent day, operant interventions alone rarely have been recommended for RAP or other chronic pain conditions, but have been frequently combined with cognitive-behavioral tech- niques ( Banez and Gallagher, 2006 ; Blanchard and Scharf, 2002 ; Finney et al., 1989 ; Humphreys an d Gevirtz, 2000 ; Linton, 1986 a, 1986 b; Sanders et al., 1989 , 1994 ; Vervoort et al., 20 11 ). Empirically supported psychological treatments for recurrent abdominal pain Functional abdo minal pain is one of the more frequently researched types of chronic pain. In these studies a number of factors associated with the exacerbation and regulation of pain behavior have been identifi ed (e.g. regulation of aff erent input by the CNS, the patient \200\231s capa city for sustained attention to bodily sensations and painful stimuli, the amount of caregi ver attention paid to pain behavior, the child \200\231s emotional responding to pain, and the amount of eff ort devoted to using active coping strategies) (Hyams and Hyman, 1998 ; L ipani and Walker, 2006 ; Zeltzer et al., 1997 , 2006 ). Robins et al. ( 2005 ) conducted a randomized controlled trial of a cognitive-behavioral fa mily intervention for pediatric RAP. Th e intervention employed a social learning theory co nceptualization of RAP, emphasizing the interactive eff ects of skill defi cits in the chil d and maintenance of symptoms within the context of fam- ily interactions. Intervention str ategies included presenting this conceptual model to both child and parents, instructing ch ildren on active pain management techniques (deep breathing, imagery, relaxation, positive self-statements) using modeling and behav- ioural rehearsal, and teaching parents more appr opriate ways to respond to their child \200\231s pain behavior (reinforcement of behav- iou r incompatible with pain behavior, minimizing discussion of pain, refraining from allowing the child to gain special privileges or avoid age-appropriate responsibilities due to pain behavior). Children and parents receiving the cognitive-behavioral inter- vention reported less abdominal pain and fewer school absences (Robins et al., 2005 ). With respect to operant behavioral conceptualizations of chronic functional pain in childre n, operant principles have been hypothesized to be a possible factor in the development of recur- rent abdominal pain (RAP). Th e specifi c reasoning is that caregiv- ers or others i n the child \200\231s social environment may inadvertently reinforce illness behavior and m aladaptive coping strategies in the child. Children may receive increased parental attentio n and expe- rience other reinforcing consequences for their pain complaints (e.g. being exc used from school or household chores, or being allowed to avoid stressful social situations with peers; Janicke and Finney, 1999 ). Hicks et al. ( 2006 ) conducted an intervention study with 47 children and youth (ages 9 \200\22316 years) with recurrent headache or abdominal pain. Th e 47 participating youth we re randomly assigned to an Internet-based intervention group (n = 25) or a standard medical care waitlist control group (n = 22). Th e main components of the cognitive-behavioral int ervention were relaxa- tion skills training (deep breathing, visualization/imagery) and cog nitive strategies (self-talk). Clinically signifi cant improvement was defi ned a priori as a 50% or greater reduction in pain diary scores. Using this defi nition, 71% of the treatm ent group improved compared to 19% of the control group at 1-month follow-up, and 72% compa red to 14% improved at 3-month follow-up. Other investigators have adopted a social learning (aka. obser- vational learning or modeli ng) theory to explain the development of RAP (see Oster, 1972 ; Robinson et al., 1990 ; Sto ne and Barbero, 1970 ; Walker et al., 1991 , 1993 , 1994 , 1995 ; Walker & Zeman, 1992 ; as cited in Janicke and Finney, 1999 ). According to social learning theory the child observe s the pain complaints and corresponding reinforcement contingencies experienced by another person in his or her environment (usually a close family member) and adopts the same behavi or to deal with personal stressors. In support of SECTION 7 psychosocial interventions 538 Parent \200\223child interactions As can be discerned from the various operant and cognitiv e-behav- ioural and social learning-based studies described earlier, conduct- ing parent tr aining to change the ways in which parents respond to their children \200\231s pain versus wellness and coping behavior is a com- mon component of many of these intervention studies. Th e asso- ciated hypotheses are that parents or caregivers of children with chronic pain place too few demands on their children, attend exces- sively to pain symptoms, allow their children to escape or avoid activities and responsibilities because of pain behavior, and allow their children to assume a developmentally inappropriate level of dependence on the p arent or caregiver. Th ey may try to protect the child from symptoms by decreasing activiti es and demands. Th ey may increase the child \200\231s distress by overt expression of thei r own distress, and poor regulation of their own anxiety and frustration (Garber et al., 19 90 ; Liakopoulou-Kairis et al., 2002 ). juvenile idiopathic arthritis, sickle cell disease) and their parents in order to examine h ow children \200\231s distress, parent indulgence and child functional disability are inter related. Hierarchical linear regression analyzes indicated that solicitous parental respond ing to child pain behavior signifi cantly predicted functional disabil- ity aft er controll ing statistically for pain intensity. Furthermore, for children with greater distress (depr ession or anxiety symptoms), parental solicitous responses to the child \200\231s pain repo rts were more strongly associated with increased functional disability than for children wi th fewer symptoms of anxiety or depression (Peterson and Palermo, 2004 ). Th e interdisciplinary behavioral rehabilitation model for treating chronic pediatric pain Some clinicians and investigators have advocated using an inter- disciplinary rehabilitatio n approach to the treatment of pain-as- sociated disability syndrome (PADS) in children and adolescents (Bursch et al., 1998 , 2003 ; Hyman et al., 2002 ). PADS is charac- terized by severe disability that continues for 2 months or greater (Bursch et al., 2003 ). PADS desc ribes a chronic pain condition with frequent and severe diffi culties in functioning, regar dless of the location or cause of the pain (Bursch et al., 1998 ; Zeltzer et al., 1997 ). I n PADS the actual tissue damage sustained by the patient, the perceived severity of the con dition, and the degree of disabil- ity exhibited are oft en widely discrepant. PADS occurs with many variations in the etiology and source of the original pain. It may begin with ill ness, injury, viral infection, or developmental or psy- chological challenge. In many cases the original trigger may not be identifi ed. Th ere also is wide variation in the time cou rse of the development of the disability. Bursch and colleagues hypothesized that PADS deve lops when a physical trauma, illness, or other life circumstance becomes overwhelming to a vulnerable child who has poor coping skills and cannot regulate his/her own distress. Th e physical symptoms may allow the child to avoid or escape the stres- sor, associated discomf ort, and negative emotions. Consequently, the child may fail to develop positive coping str ategies and a behav- iour pattern in which avoidance of stressful or painful stimulation oc curs along with increasing dependence on others, social with- drawal, avoidance of school a nd physical activity, and progression of functional disability. In support of this conceptualization, Walker et al. ( 1995 ) stud- ied parents \200\231 rea ctions to somatic complaints associated with unex- plained illness and documented that pare nts oft en modify their interactions with their children in the presence of pain complaints or illness behavior. Other studies by Walker and colleagues have reported similar fi nding s that parents tend to encourage children to adopt the sick role for gastrointestinal sympt oms (Walker and Zeman, 1992 ), and children with RAP oft en have families in which there is greater parental attention to abdominal pain (Walker et al., 1993 ). Furthermore, a labora tory study by Walker and colleagues ( 2006 ), experimentally induced visceral discomfort as an analog of abdominal pain, and demonstrated that when social attention is provided conti ngent on gastrointestinal symptom complaints, these complaints nearly doubled in both child ren with a history of abdominal pain and controls without a history of abdominal pain. Pare nts also may model pain behavior (Schanberg et al., 2001 ). Parents \200\231 expressions of sympathy, attention to symptoms, emo- tional reactions, modeling of symptoms, and reinforc ement of pain behavior by allowing escape/avoidance of responsibilities, all have been asso ciated with greater pain and disability in their chil- dren (Fordyce, 1976 ; Payne and Norf l eet, 1986 ; Philips, 1987 ). A number of studies support that in at least some families, the child \200\231s pain symptoms play a functional role within family interaction patterns and relationships. In these families, functional disability may be more a function of thes e interaction patterns than of the subjective experience of pain (Covelman et al., 1990 ; K opp et al., 1995 ; Logan and Scharff , 2005 ; Naidoo and Pillay, 1994 ; Palermo, 2000 ; Sch arff et al., 2005 ). Other studies have examined the social consequences of chronic pain in children (Van Slyke and Walker, 2006 ; Walker and Zeman, 1992 ; Walker et al., 1993 , 2002 ). Parental responses studied have included minimizing (shift ing focus away from pain beh aviors, or reacting in a negative or punishing man- ner), solicitous responses (encourageme nt, reinforcement, frequent attending to pain), and protecting (excusing child from regular activities, allowing child to miss school and to stay in bed, etc.) (Van Slyke and Walker, 2006 ; Walker et al., 1993 ). More solicitous paren- tal responses have been associated wi th greater sick role behavior and greater functional disability independent of stress level or pain intensity (Gidron et al., 1995 ; Walker et al., 2002 ; Whitehead et al., 1994 ). In the interdisciplinary behavioral rehabilitation model, children and families are encoura ged to accept pain as a symptom that may or may not go away. Th ey are encouraged to move t heir focus away from total elimination of pain as their sole objective. When under- lying p ain mechanisms can be identifi ed, they are treated medically to the extent possible. Howev er, central emphasis is placed on rein- forcing more independent child functioning in activ ities of daily living, academics, social and physical activities. Interdisciplinary rehabil itation therapies are provided to treat specifi c symptoms of anxiety, depression, avoidanc e behavior, diminished muscle strength, limited range of motion, and academic defi cits, an d to teach active coping skills to the child and family. Finally, adaptive functioning inst ead of pain severity is used to measure progress. An inpatient interdisciplinary rehabilitation setting may be ideal for implementing systema tic behavioral interventions to shape functional behavior and reinforce its generalization across settings Peterson and Palermo ( 2004 ) studied 215 children between 8 and 16 years of age with chron ic or recurrent pain conditions (headache, CHAPTER 51 operant treatment 539 and situations (Amari et al., 1998 ; Palermo and Scher, 2001 ). However, there are few publ ished data on inpatient interdisciplinary rehabilitation programs that employ behavioral an d cognitive- behavioral interventions in a comprehensive and systematic man- ner to treat c hronic pain associated disability. In one case example, Palermo and Scher ( 2001 ) describe d improvements in the physical and psychosocial functioning of an adolescent with a severe pain disorder following an inpatient rehabilitation admission. Eccleston et al. ( 2003 ) st udied the eff ects of a 3-week interdisciplinary resi- dential program that emphasized cogn itive-behavioral and physical therapy interventions on 57 adolescents with chronic pain and their caregivers. Th eir results showed that the intervention eff ectively decreased distr ess and improved overall functioning and school attendance. Hechler et al. (2009) studied t he eff ectiveness of a 3-week multimodal inpatient pain treatment for 167 adolescents with various pain disorders. Patients were evaluated at baseline and 3 months post-treatment. Re sults suggest that 72% and 45% of the patients demonstrated clinically signifi cant changes in pain-related disability and pain intensity respectively. PADS. Th e investigators hypothesized that the group would exhibit signifi cant improvement across measures of functioning aft er com- pleting the inpatient intervention protocol as compared to their pre-admission functioning. As a group, the participating patients showed clinically and statistically signifi cant improvements in daily functioning and physical mo bility aft er receiving the interdiscipli- nary behavioral rehabilitation intervention. Cli nical signifi cance was determined by comparing patient \200\231s admission and discharge f unctioning and physical mobility scores. Upon admission patients typically had signifi cant diffi culties with self-care, cognition and mobility. At discharge, the patients functione d more autonomously. Th e patients also showed improvement in school participation, sleep, and medication use. Th e patients were responsive to diff er- ential positive reinforcement of coping behavior and compliance with task demands of gradually increasing diffi culty wi thin the rehabilitation context. For those with available follow-up information, physical function- ing was maintained or co ntinued to improve aft er discharge. Th e investigators speculated that the protocol was fe asible across devel- opment because of individualized shaping procedures and cognitive- beh avioral interventions that could be modifi ed for diff erent ages. Th e use of shaping allo wed the children to experience their fi rst suc- cesses in small steps, which may have help ed to promote coping, motivation and perception of self-effi cacy. Th e rehabilitation hosp ital setting provided an environment in which multiple staff members prompted and diff eren tially reinforced functional gains and cop- ing behavior while not reinforcing pain or illn ess behavior. Th is More recently Maynard et al. ( 2010 ) conducted a study to assess the outcome of an inpatie nt interdisciplinary behavioral reha- bilitation protocol to treat children and adolescents with pain- associated disability and distress. Th e conceptualization and the intervention approach were based on the prior work of Zeltzer et al. ( 2006 ). Maynard et al. ( 2010 ) conducted a retrospective review of the clinical outcomes from a sample of children and ado lescents admitted to an inpatient rehabilitation program for treatment of Escape Extinction (EE) Verbal Feedback and Distraction Break Cards + EE + Verbal Feedback 200 3 180 2.5 160 140 s s e r t s i D 2 s e t u n M n I n o i t a r u D 120 l a r o i v a h e B f o g n i t a R i 100 1.5 80 1 60 40 0.5 20 0 0 8/9/2007 8/7/2007 8/8/2007 8/4/2007 8/24/2007 8/23/2007 8/22/2007 8/21/2007 8/20/2007 8/19/ 2007 8/18/2007 8/11/2007 8/10/2007 8/6/2007 8/5/2007 8/2/2007 8/3/2007 8/1/2007 8/17/2007 8 /16/2007 8/15/2007 8/14/2007 8/13/2007 8/12/2007 Date Distress and Delay Bx Duration of Procedure Figure 51.1 Observer ratings of Mark \200\231s distress and delay behavior (squares) and th e duration of the procedure in minutes (diamonds) across escape extinction, verbal feedback and distraction, and verbal feedback + distraction + escape extinction + break cards condi tions. Reproduced with permission of the author from Kim, F., Slifer, K., Amari, A., Herman , L., and DeMore, M., Th e Utility of Operant Choice Using Patient-Controlled Break Cards d uring an Invasive Medical Procedure , May, 2009 which was previously presented as a poster at the Annual Convention of the Association for Behavior Analysis International, Phoenix, A Z. SECTION 7 psychosocial interventions 540 approach involving both fading of activity demands and shaping of increased eff ort and dur ation of physical functioning is consistent with the results of a randomized prospective cl inical trial conducted with adults with low back pain, which combined graded activity goals and operant conditioning to signifi cantly increase the patients \200\231 probability of r eturning to work and reducing their long-term use of sick leave (Lindstrom et al., 1992 ). Prior to psychology consultation, when nursing staff imple- mented an escape extinction pro tocol (i.e. simply proceeded with the necessary task) and Mark \200\231s distress and delay behaviors did not result in a break, high levels of distress were observed ( Figure 51.1 ; Phase 1). During initial treatment ( Figure 51.1 ; Phase 2), the introduction of verbal fe edback and distraction (conversation and access to a TV show) were provided by behav- ioura l psychology and child life staff . Th is intervention decreased distress behaviors; howeve r, delay behaviors, in the form of asking for frequent breaks and attempting to extend coun ting during each step increased. Th erefore, the next phase of treat- ment involved use of a patient-controlled break card in combi- nation with verbal feedback and escape extinction . Specifi cally, Mark was provided with a card before beginning the procedure, and was info rmed that he could exchange this card to request a 1 min break. Apart from natural breaks ( e.g. between steps, while staff cut the foam), Mark was only provided breaks when he approp riately used his break card. He was prompted to use his break card (if still available) if he verbally requested a break or exhibited anxious behaviors (e.g. \200\230stop \200\231 o r \200\230I \200\231m scared \200\231). Th e emphasis on functional measures rather than subjective pain ratings was an important p art of the behavioral rehabilitation approach in this study. Patients oft en showed little variability in their pain ratings during inpatient rehabilitation, continuing to give high ratings despite showing positive aff ect during participation in therapy and leisure activi ties. Th e Maynard et al. ( 2010 ) study was not a controlled experiment, and therefore cou ld not claim a causal relationship or dismantle the relative contributions of the multiple therapeutic components included in the rehabilitation protocol. Th erefore, the authors rec ommended that prospective randomized controlled clinical trials are needed involving multip le centers implementing the same protocol. Providing Mark with a choice of when to exercise limited con- trol over aversive stimulatio n and extinguishing delay behaviors resulted in markedly decreased distress and enabled sta ff to com- plete the change in a timely manner (Phase 3, Figure 51.1 ). Case example \200\230Mark \200\231 was a 12-year-old African American male with obesity and spinal musc ular dystrophy admitted to an inpatient rehabili- tation unit following orthopedic surgery. Postoperative com- plications included wound dehiscence (premature rupture of a wound alon g surgical suture) which required use of a wound vacuum-assisted closure (VAC) procedure to expedite heal- ing. Th is case study was previously presented as a poster at the Annual Co nvention of the Association for Behavior Analysis (Kim et al., 2009 ). 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