Recurrent and intense headache pain is a grim fact of life for one out of every 10 children. During an episode of blinding headache pain, life is placed on hold. A new program at Western Psychiatric Institute and Clinic in Pittsburgh is using biofeedback and other nonpharmacological techniques to teach afflicted children how to conquer their pain and prevent future episodes. Boasting a 90 percent success rate, it has helped the children get back to school and play.

To help children and adolescents get their pain under control, experts at the program use biofeedback, relaxation training, coping skills, cognitive-behavioral therapy, patient and family education, and individual and family counseling.

According to Linda J. Ewing, Ph.D., R.N., director of the program, as many as 10 percent of children have some type of chronic pain, with recurrent headache being the most prevalent.

Ewing told Psychiatric News that the program arose out of mounting empirical evidence that biofeedback is an effective way of alleviating pain. Sometimes, she said, it has been proven to be more effective than medication for pain management. Studies by Edward Blanchard, M.D., and colleagues from the State University of New York at Albany’s Center for Stress and Anxiety Disorders showed that treatment of headache with biofeedback cut the number of headaches in half.

Biofeedback is a nonpharmacological technique in which people are trained to improve their health by using signals from their bodies. One commonly used type of machine picks up electrical signals from the muscles. It may then activate a beeping sound every time the muscles grow tense. Patients try to slow down the beeping by relaxing their muscles. Biofeedback seeks to change a person’s natural reactions to stress—which may often cause pain or disease—by training them to relax.

Who are the patients that seek pain relief at the program? "Our primary patient is an adolescent female with either migraine or tension headache," said Ewing. "We also have younger children with similar problems and another group of patients with sickle cell disease for whom biofeedback is also very effective."

The program has also helped children with cancer and functional abdominal pain.

Psychotherapy and counseling are often integral components of the pain management process, and the staff includes two psychologists and a psychiatrist. Nonetheless, Ewing emphasized, the treatment is not about the underlying psychological factors of pain, nor is it exclusive of them.

"Pain is real pain. It is not an imaginary phenomenon, even though there may be no underlying medical causes for it." According to a study by British pediatric researcher John Apley, M.D., more than 90 percent of recurrent pain cases have no clear organic cause.

In addition, behavioral reinforcements can inadvertently play a part in the child’s experience of pain if there is some kind of positive feedback for the child such as extra parental attention and concern or reduced expectations from teachers at school. "Intervention may then be focused on altering these reinforcers," said Ewing.

Participation in the program begins with a comprehensive assessment of the child and his or her family, and a thorough consideration of the factors that might be contributing to the pain. Children are given a pain diary to track and rate their pain, and treatment plans usually involve some combination of biofeedback, family therapy, cognitive-behavioral therapy, and psychoeducation. Environmental management may also be part of the treatment—certain aspects of the child’s lifestyle may need to be changed, such as sleep or homework habits.

"We might also find out that there is a real clinical depression that needs to be addressed," said Ewing.

In such cases, the program consults its child and adolescent psychiatrist, Maria C. La Via, M.D., an assistant professor of psychiatry at Western Psychiatric Institute and Clinic. "I evaluate children for any possible comorbidity, particularly depression and anxiety, because those often occur in children with chronic and recurring pain," La Via told Psychiatric News.

"If you adequately treat the comorbid condition with psychotropic medications, they are much better able to utilize the other modes of treatment that the team uses," said La Via. Treating the child for anxiety or depression then helps the child focus on relaxation and biofeedback, she added.

"Both anxiety and depression can intensify how a child perceives pain," emphasized La Via, who described a scenario in which a child in the program without comorbid anxiety or depression may score 3 on a pain rating scale of 1 to 10. With the comorbidity, the child may feel overwhelmed with anxiety or depression, and that score of 3 may increase to 6 or 7, for example.

There are a few challenges to getting the children and adolescents the help that they need, acknowledged Ewing. Because the program is located in a psychiatric hospital, sometimes people become defensive. "Their immediate response might be, ‘The pain is real,’ which, of course, it is," she commented.

Another barrier is getting people to believe that biofeedback and relaxation training will help alleviate the pain, when in a quick-fix society many people would rather take a pill and make it go away, she added.

"Once we get the families and patients into the program, we usually make very good progress," she said.