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Behavior Modification
DOI: 10.1177/0145445505282164
2006; 30; 93Behav Modif
Frank Andrasik and Mark S. SchwartzBehavioral Assessment and Treatment of Pediatric Headache
http://bmo.sagepub.com/cgi/content/abstract/30/1/93 The online version of this article can be found at:
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10.1177/0145445505282164BEHAVIOR MODIFICATION/ January 2006Andrasik, Schwartz / PEDIATRIC HEADACHE
Behavioral Assessment and Treatment of
Pediatric Headache
FRANK ANDRASIK
University of West Florida, Pensacola
MARK S. SCHWARTZ
Mayo Clinic, Jacksonville, FL
Headaches are quite common in children and adolescents, and they appear to persist into adult-
hood in a sizable number of individuals. Assessment approaches (interview, pain diaries, andgeneral and specific questionnaires) and behavioral treatment interventions (contingency man-
agement, relaxation, biofeedback, and cognitive behavior therapy) are reviewed, as is the evi-
dencebase for their use. The article concludes with practical suggestions for headache manage-
ment.
Keywords: headache; assessment; treatment; contingency management;
biofeedback; relaxation; cognitive behavior therapy
EPIDEMIOLOGY AND SCOPE OF THE
DISORDER AND/OR PROBLEM
Headachesaresurprisinglycommonin children. Even at theyoung
age of 3 years, headaches are present in 3% to 8% of children. This
increases to about 20% at age 5 years, 37% to 52% at age 7 years, and
57% to 82% from age 7 to 15 years (see Lipton, Maytal, & Winner,
2001, fora review).A U.S. study that included 3,158 children,ages 12
to 17 years, found that 56% of the males and 74% of the females
reported a headache in the past 4 weeks, 27% of the males and 41.4%
of the females reported two or more headaches, and 4.5% of the males
93
AUTHORS’ NOTE: Direct correspondence to Frank Andrasik, Ph.D., Department of Psychol-
ogy, University of West Florida, 11000 University Parkway, Pensacola, FL 32514; e-mail:
BEHAVIOR MODIFICATION, Vol. 30 No. 1, January 2006 93-113DOI: 10.1177/0145445505282164
© 2006 Sage Publications
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and 9.4% of the females reported four or more headaches in the
past month (Linet, Stewart,Celentano, Ziegler,& Sprecher, 1989).On
a 1- to 10-point scale, the average intensity was moderate (4.5 males,
4.7 females), and the mean duration was 5 to 6 hours.
Many continue to believe that pediatric headache does not need to
be taken seriouslybecause it will be outgrown with time. Regrettably,
this does nothold true formany childrensoaffected, as revealedby the
longitudinal work of the Swedish pediatrician Bo Bille and others.
Nearly five decades ago (mid-1950s), Bille (1962) began a landmark
studyof about 9,000 Swedish schoolchildren, ranging inagefrom 7 to
15 years, and his first publication told us much about headache occur-
rence across gender and age. Bille was able to follow a subset of thesechildren, all of whom were diagnosed with migraine at a very young
age, for 40 years. The majority continued to be troubled by headaches
at this final follow-up assessment (Bille, 1997). Subsequent work has
confirmed the resilient nature of childhood headaches (e.g., Larsson,
2002; Sillanpää, 1994; Waldie, 2001) and reinforced the importance
of early intervention for ameliorating current symptoms and prevent-
ing adult symptoms (including headaches because of chronic overuse
of medication; Diener & Wilkinson, 1988). Furthermore, there are
indications that headaches have increased in prevalence over the past
decades (Sillanpää & Anttila, 1996).
The pain and suffering children experience can have a significant
impact on every aspect of their daily lives (Bandell-Hoekstra, Abu-Saadm, Passchier, & Knipschild, 2000; Hershey, 2005; Powers,
Patton, Hommel, & Hershey, 2003). Bille’s (1962) initial investiga-
tion, for example, found that sufferers of child headache missed sig-
nificantly more school time than other children. Egermark-Eriksson
(1982) found that approximately 70% of a sample of more than 400
children who missed 4 or more days of school suffered from recurrent
headaches.Finally, childrenwhoconsult a physicianhave beenshown
to incur more school absences (and more nausea) than those who do
not consult (Metsähonkala, Sillanpää, & Tuominen, 1997b). See
Allen, Mathews, and Shriver (1999) for further discussion of the
impact of headache on school performance and achievement.
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REFERRAL PROCESS/PROCEDURES/PROBLEMS
AND PROSPECTS
Although most headaches in childhood are not because of perma-
nent structural defects or diagnosable physical conditions other than a
primary headache disorder (Rothner, 2001), the prudent nonmedical
practitioner is wise to require a thorough medical evaluation from a
physician experienced with headache prior to accepting a patient for
treatment. It is equally prudent to remember that just because medical
factors are ruled out at the time of initial referral this does not mean
that organic factors cannot come into play at a later date. The practi-
tioner needs to observe for marked changes in presentation and aworsening of symptoms and consider these as indications of a need to
return to a physician. Also, many children will be receiving medica-
tion in addition to behavioral treatment. These concerns argue for a
close and sustained collaboration with medical colleagues when
treating patients with pediatric headache.
Diagnosis and medical evaluation for pediatric headache proceeds
much as it does for adult patients (Holden, Levy, Deichmann, &
Gladstein,1998; Rothner, 2001). Pediatric practitioners and research-
ers note that it can be more difficult to make specific diagnoses for
children because many features depart from those typically seen in
adults (e.g., migraine in children can be more frequent but briefer in
duration, it can be experienced as all encompassing instead of uni-lateral in location, etc.; Silberstein, 1990; Winner, Wasiewski,
Gladstein, & Linder, 1997). Lack of an agreed-onsystemforclassify-
ing and diagnosing headache in children complicates matters. Revi-
sions have been proposed to the system now widely in use with adult
headache patients (Gladstein & Holden, 1996; Winner et al., 1997).
These systems seek to distinguish migraine (with and without aura),
tension-type headache, and migraine-tension headaches combined,
the types most commonly seen by behavioral practitioners, from a
host of other headaches that typically do not come to the attention of
behavioral practitioners because they are more organic and less func-
tional in nature. These determinations are quite important for guiding
appropriate pharmacological treatment; however, they are less useful
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for planning behavioral treatment, where factors revealed during a
functional analysis are of greater benefit. A second approach classi-
fies headaches according to temporal patterns and severity, resulting
in five categories: acute, acute recurrent (usually migraine), chronic
progressive (organic), chronic nonprogresssive (usually tension), and
mixed (migraine and tension; Rothner, 1978).
STANDARDIZED APPROACHES TO ASSESSMENT
The major assessment approaches concern the clinical interview,
pain diary and/or log, general psychological measures, andheadache-specific measures (Andrasik, 2001a, 2001b; Andrasik, Lipchik,
McCrory, & Wittrock, 2005; King, Murphy, Ollendick, & Tonge,
1997; McGrath & Koster, 2001; Powers & Andrasik, 2005).
The interview serves two basic purposes, the first of which is to
assist in arriving at a classification. Here the focus is on headache
symptomatology and characteristic presentation (e.g., location, fre-
quency, duration, onset, accompanying symptoms, etc.). This is fol-
lowedby a careful functional analysis, focusing on headache anteced-
ents and consequences (Lake, 1981) that may potentially be altered
during treatment. It is helpful to interview parents, school personnel,
and sometimes friends and/or siblings.
To minimize recording bias, daily headache diaries or logs are rec-ommended (Andrasik, 2001a; Andrasik, Lipchik, et al., 2005). The
types of pain scales advocated vary as a function of age and interven-
tion intent. For example, McGrath and Koster (2001) listed nearly a
dozen different pain measures. If attempts are made to alter anteced-
ents and consequences as a part of treatment, then these aspects are
typicallymonitoredas well in thediary on a daily basis.These diaries,
thus, canbe used tohelp guide treatmentand assessoutcome,andthey
mayadditionallybe useful for tracking specific headache characteris-
tics when diagnoses are complicated and unclear (Metsähonkala,
Sillanpää, & Tuominen, 1997a).
Committees drafting guidelines for conducting controlled trials
recommend that the following serve as the primary measures of out-come: (a) number of days headache is present in a 4-week period; (b)
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severity of attack, rated on either (1) a 4-point scale, where 0 = no
headache, 1 = mild headache (allowing normal activity), 2 = moder-
ate headache (disturbing but not prohibiting normal activity, bed rest
is not necessary), and 3 = severe headache (normal activity has to be
discontinued, bed rest may be necessary) or (2) a visual analogue
scale, wherein one end is anchored as none and the other as very
severe; (c) headache duration in hours; and (d) responder rate, or the
number or percentage of patients achieving a reduction in headache
days or headache duration per day that is equal to or greater than 50%
(see Andrasik,2001a;Andrasik,Lipchik, et al., 2005, fora more com-
plete discussion; Andrasik, Burke, Attanasio, & Rosenblum, 1985;
Labbé, Williamson, & Southard, 1985; Richardson, McGrath,Cunningham, & Humphreys, 1983, for sample diary approaches and
comparisons of various approaches). These guidelines were devel-
oped largely with adult patients in mind; however, they should be
applicable with pediatric headache patients as well.
A number of general measures may be useful depending on the
presence ofcomorbid conditions (suchas anxiety anddepression) and
the goals of treatment (Powers & Andrasik, 2005).
Finally, headache-specific scales are increasingly being developed
for the purposes of assisting in the diagnosis of headache (e.g., Labbé
et al., 1985; McGrath & Koster, 2001; Mindell & Andrasik, 1987),
identifying environmental variables associated with headache (Budd,
Workman, Lemsky, & Quick, 1994), and assessing impact of head-ache on various important life domains (quality of life) and extent of
disability (Andrasik, 2001b; D’Amico et al., 2003; Hershey et al.,
2004; Powers & Andrasik, 2005; Powers, Patton, Hommel, &
Hershey, 2004).
STANDARDIZED TREATMENT PROTOCOLS
When organic causes have been ruled out and assessment informa-
tion has been gathered, Silberstein (1990) suggested reassuring the
familyabout thebenignnatureof theconditionandencouraging regu-
larization of routine activities (consistent bedtime, awake time, andmealtime, avoidance of activity overload). Indeed, interviews con-
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ductedwith patients with pediatricheadache at the initial consultation
revealed they most wanted information about the cause of their head-
aches and what would bring relief and reassurance they did not havea
life-threatening illness (Lewis et al., 1996). Treatment begins with
identification and modification of obvious trigger and contributing
factors, such as physical exertion, hunger, noise, traveling, light glare
(Andrasik, Blake, & McCarran, 1986; McGrath & Hillier, 2001), and
diet (Rossi, Bardare, & Brunelli, 2002).
The utility of contingency management alone has been demon-
strated in several case studies. In the first, Yen and McIntire (1971)
successfully reduced the constant headaches in a 14-year-old female
by applying a mild “red tape” response cost contingency (the childwas required to record various parameters about headache and list
activities that might be completed if headache was notpresent prior to
complaining to others or requesting medication). Ramsden, Fried-
man, and Williamson (1983) reduced reports of head pain in a 6-year-
oldby reinforcing well behaviorandpunishingpain behavior. Punish-
ment isunlikely tobeemployedin this era,because of the potential for
abuse and unpleasant emotional side effects and the availability of
many alternative,positivelyorientedprocedures. Finally, Lake(1981)
described an interesting indirect treatment approach that was used
with an 11-year-old migraineur whose headaches resulted in an
exceedinglyhigh rate of schoolabsences (the boyhad attended only ½
dayin theprior month). Treatment involved implementationof a writ-ten contract that provided reinforcement for increasingly sustained
school attendance. As school attendance increased, headache activity
markedlydecreased, andthis improvementwas maintained at a 1-year
follow-up evaluation.
The most common treatments reported in the literature employ
self-regulation strategies, chief among these being relaxation, bio-
feedback, and cognitive-behavioral therapies. Larsson and Andrasik
(2002) found more than 10 investigations of varied forms of relax-
ation, applied in varied settings (clinics and schools, the locations
where many headaches occur) and by varied personnel (therapists,
teachers, nurses, etc.). Generally positive effects have been obtained
with migraine and tension-type headache, pointing to the robustnessof this approach. These treatments have typically involved the follow-
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ing components: discrimination training focusing on identificationof
tense and relaxed larger muscle groups; differential relaxation (some
muscle groups are tensed while other muscles are relaxed); cued
relaxation (pairing breathing to a relaxing word, such as calm, peace,
or relax ); minirelaxation focused on a limited number of muscles in
the head, neck, or shoulder and applied regularly throughout the day
(whenever the watch is looked at, the school bell rings, etc.); and
application of techniques in everyday life (when headaches and feel-
ings of stress tend to occur). Relaxation treatment is typically
delivered over 8 to 10 sessions, administered either individually or in
groups.
Biofeedback constitutes another common approach for pediatricheadache (and this approach is well studied foradultsas well).Histor-
ically, thermal biofeedback has been used most often for migraine
headache and electromyogram (EMG) biofeedback for tension-type
headache (Andrasik, Larsson, & Grazzi, 2002; see Figure 1). See
Andrasik et al. (2002) for details regarding biofeedback treatment.
When used with patients with headache, these procedures likelywork
in a similar manner, by promoting generalized relaxation, and thus
they may be interchangeable (Andrasik & Flor, 2003). Work is only
now beginning to evaluate specific types of biofeedback that directly
target physiology presumed to underlie headaches. This includes
electroencephalogram (EEG) biofeedback (Siniatchkin et al., 2000)
and blood volume pulse biofeedback (Sartory, Müller, Metsch, &Pothmann, 1998).
Cognitive therapy or cognitive stress coping training has been
much less investigated; however, it too has promise. With one excep-
tion (Richter et al., 1986), cognitive approaches have been combined
with other major treatment modalities, and the experimental designs
employedhavenotmade itpossible topartial outthe sourceofeffects.
Researchers have begun to experiment with delivering self-regula-
tory treatments in more economical ways, by limiting individual ther-
apist contact or administering treatments to groups of patients. Pre-
liminary investigations with child migraineurs suggest that
biofeedback may work equally well when delivered in this manner,
with either the child or the parent serving as the main treatment agentfor the home instruction (Allen & McKeen, 1991; Burke & Andrasik,
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1989; Guarnieri & Blanchard, 1990; Hermann, Blanchard, & Flor,
1997; see Haddock et al., 1997, for a quantitative review). This
approach increasesthe need forfamilyinvolvement andsupport, lead-
100 BEHAVIOR MODIFICATION / January 2006
Figure 1. Childreceiving thermal and electromyogram(EMG) biofeedback. (Top Panel)The therapist is explaining the feedback modalities to the child. The verticalbarson either sideof thecomputermonitordisplay EMGactivity from thefore-head and forearm. The circle in the middle and the bar on the bottom of themonitor provide temperature (relative) feedback. Actual temperature valuesare provided digitallyin the middle of the circle. (Bottom Left Panel) A typicalthermistor placement formonitoring surface skin temperature. (Bottom RightPanel) A typical EMG electrode array placement for treatment of tension-typeheadache and generalized relaxation.
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ing Guarnieri and Blanchard (1990) to speculate that environmental
factors may be particularly important when employing such limited-
contact treatments (e.g., effects may be lessened when the home is
somewhat chaotic or nonsupportive). This makes sense fora pediatric
population but requires further study. Cautious practitioners will
check thehome environment beforedeciding on this approach in clin-
ical practice (Aromaa, Sillanpää, Rautava, & Helenius, 2000). Data
bearing on this point come from the investigation of Allen and
McKeen (1991). Several of the children who were treated complied
with relaxation; however, their parents did not follow the guidelines
for behavior management that were a part of the treatment package.
These children then gradually worsened over treatment and, subse-quently, did not do as well as the others. At a later follow-up, though,
the initial responders had regressed, and differences were no longer
apparent (Kuhn & Allen, 1993). Most recently, the effectiveness of
single-session behavioral treatmenthasbeen examined (Powers et al.,
2001). Although statistical significance was obtained, percentage
symptom reductions were only 10%, 25%, and 25% for headache
severity, frequency, and duration, respectively, at a modest follow-up
(average of 21 weeks). Thus, more intensive therapeutic effort is
needed.
Another approach to cost containment concerns group administra-
tion. This approach has been used regularly by Larsson and col-
leagues with relaxation approaches administered in school settings(see Larsson & Andrasik, 2002). Preliminary evidence supports the
utility of a brief group behavioral treatment that is designed to be eas-
ily administered by a neurologist and place minimal demands on pro-
vider and patient, such that it could be applied in various day-to-day
medical practice settings. In this investigation (Andrasiket al., 2003),
34 children (from age 9 to 16 years) with episodic tension-type head-
ache were seen in small groups (three to five individuals, based on
similar ages), once per week for 8 weeks, with sessions limited to a
maximum of 30 minutes. Each session followed the same format:
practice of progressive muscle relaxation training with eight muscle
groups (lower arms, upper arms, legs, abdomen, chest, shoulders,
eyes,andforehead)anddiscussion ofways to apply relaxation to copewith headache and headache-related distress. A tape recording of the
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first session was provided to guide home practice. Patients were
instructed to practice with the tape once per day during treatment and
twice perweek thereafter. A neurologist, whoconferredwith a behav-
ioralpsychologist,provided treatment. Statistically significant effects
were found for several variables (except analgesic tablets), and most
of these changes were clinically meaningful as well (≥ 50%). The
improvements noted at the end of treatment held throughout the 1-
year of follow-up. Although the reduction in analgesic tablet con-
sumption was not statistically significant, it was sizable from a clini-
cal perspective (exceeded 50%). Even though this investigation was
uncontrolled, the magnitude of effects rivaled those of typical, more
effort-intensive behavioral treatments and surpassed those that aretypical for placebo effects (Hermann, Kim, & Blanchard, 1995).
Further research on this type of approach, with larger samples,
appears warranted.
Prudent practitioners will consider medications based partlyon the
frequency of the headaches, the severity and durations of the head-
aches, and the effectiveness of simple analgesics for the child. Pro-
phylacticmedications areuseful forsome children with chronic head-
aches, especially those who have “severe, frequent attacks” and those
“complicated by neurological symptoms” (Silberstein, 1990). See
Damen,Bruijn, Verhagen, et al. (2005), Levin (2001), Lewis, Yonker,
Winner, and Sowell (2005), Pothmann (2002), and Winner (2001) for
a more complete discussion of medication approaches.
SUMMARY OF TREATMENT EFFICACY
Several major literature reviews have been conducted since the
mid-1990s. The first (Hermann et al., 1995) culled all available drug
andnondrug studies forchildhoodmigraine that hadappeared prior to
early 1993. A meta-analysis was then conducted on the 17 behavioral
and 24 pharmacological studies that met explicit design criteria to
ensure that adequate designs and sample sizes were employed, dupli-
cation of participants, and repetition of findings were avoided,
and samples were not specially selected. The results from that meta-analysis are presented graphically in Figure 2, which lists the results
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in decreasing order of obtained effects sizes (outliers excluded).
These findings provide support for various behavioral approaches,
reveal similar levels of effectiveness for these approaches when com-
pared to medication, and indicate that effects are larger than those
obtained for variousplacebo conditions. An updated meta-analysis bythese same authors revealed essentially the same findings (Hermann
& Blanchard,2002). A meta-analysiscompletedby another investiga-
tive team found similar support forbehavioral approaches (Eccleston,
Morley, Williams, Yorke, & Mastroyannopoulou, 2002).
The second major investigation (Holden, Deichmann, & Levy,
1999) examined 31 behavioral studies and determined the extent to
which they met what have become fairly standard criteria for deter-
mining efficacy of psychologically based interventions, based on the
seminal work by the Task Force on Promotion and Dissemination of
Psychological Procedures launched by Division 12 of the American
Psychological Association, the Society of Clinical Psychology. On
completion of their review, Holdenet al. (1999)rated theefficacy baseas follows: Evidence for relaxation and/or self-hypnosis was “well-
established”; thermal biofeedback was “probably efficacious”; and
Andrasik, Schwartz / PEDIATRIC HEADACHE 103
0
0.5
1
1.5
2
2.5
3
3.5
Treatment Condition
Thermal Biofeedback
Thermal BFB+Relaxation
Propranolol
Ergotamine
Clonidine
Relaxation
Dopaminergic
Multicomponent
Serotonergic
Calcium Blocker
Medication Placebo
Psychological Placebo
WaitList Control
Figure 2 Within-group effect size values for behavioral and pharmacological treatmentforchildhood migraine. (Data derivedfrom Hermannet al.,1995).Forthis typeof effect size, values greater than 1 reflect medium to large effects.
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cognitive behavior therapy was “promising” interventions. It was a
lack of available research rather than thepresence of negative findings
that resulted in the later two treatments’ not receiving higher status
ratings.
Another exhaustive efficacy review of treatments for pediatric
headache included a number of complementary and alternative medi-
cine approaches as well (McGrath, Stewart, & Koster, 2001). Seven
different electronic databases were searched; Internet sites and study
registries (Cochrane, National Institutes of Health [NIH],andDARE)
were examined; manual searches were conducted for recent books,
journals, conference proceedings, retried bibliographies, and so on;
and pertinent associations were contacted. Studies were rated withrespect to type andconsistency of evidence. Table 1 lists thecognitive
and behavioral treatments that employed randomized trials and
yielded consistent evidence, while Table 2 summarizes findings for
physical and complementary treatments. Obviously, work is just
beginning to scratch thesurface for these latter approaches. Andrasik,
Powers, and McGrath (2005) provided helpful guidelines for
improving clinical trials conductedwithpediatricheadachepatients.
Several investigations have revealed reasonable maintenance
effects over time (Grazzi et al., 2001; see studies reviewed in Larsson
& Andrasik, 2002), whereas at least one has been less positive (Kuhn
& Allen, 1993). It is unfortunate to note, minimal attention has been
devoted to identifying predictors of initial and enduring responses totreatment. A meta-analysis revealed that thermal and EMG biofeed-
back treatments led to greater clinical outcomes when used with chil-
dren than when applied with adults (for thermal biofeedback, child
headache sufferers improved by 62.3% whereas adult headache suf-
ferers improved by 33.9%; for EMG biofeedback, improvement rates
were 80.8% for children and 50.0% for adults), although no differ-
ences occurred for abilities to regulate physiology (Sarafino &
Goehring,2000).This supported thenotion that children maybe espe-
cially good candidates for biofeedback and related self-regulatory
treatments (Attanasio et al., 1985). Children appear to display a
greater placebo response (Bussone, Grazzi, D’Amico, Leone, &
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PRACTICE RECOMMENDATIONS
On working with a number of children and adolescents, ranging
from age 6 to 17 years, Attanasio et al. (1985) identified a number of advantages in working with younger individuals, which may help
account for their enhanced treatment response (see Table 3). Certain
difficulties were encountered as well (see Table 3); however, these
potentialproblems areeasilyaddressedby tailoring language andtak-
ing the time to ensureoptimal understanding, decreasing the lengthof
treatment trials, adding rest periods, and employing contingency
managementstrategies to sustainperformance whenmotivation lags.
Green (1983) provided a number of very helpful suggestions and
verbatim scripts to use when teaching self-regulatory skills to very
young children. She recommended inviting the family unit to the ini-
tial session to prevent the child from being singled out as the problem
or “sick one.” When employing biofeedback, she recommended thatthe therapist be introduced as a “biofeedback teacher,” someone who
teaches ideas and skills, who likes to be asked questions, and who in
106 BEHAVIOR MODIFICATION / January 2006
TABLE 3
Advantages and Disadvantages When Treating Children by Biofeed-back (from Attanasio et al., 1985)
Advantages
• Increased enthusiasm
• Quicker rate of learning
• Less skeptical about self-control procedures
• Greater confidence in special abilities
• Increased psychophysiological lability
• Few previous failure experiences with treatment
• Increased enjoyment when practicing
• Increased reliability of symptom monitoring
Disadvantages
• Briefer attention span
• Off-task behaviors during session• Fear and apprehension about equipment
• Intolerant of minor discomfort in removing sensors
• Emotional and psychological problems can complicate treatment
• Reduced ability to comprehend treatment rationale and procedures
• Scheduling can be complicated
• Lack of standardized electrode placements
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turn likes to askquestions. Shesuggested that a demonstration be pro-
videdwith a response that iseasilycontrolled or produces a quick,dis-
cernible response (EMG from the forearm, electrodermal response
while playing a guessing game).Shemakes frequent useof adjunctive
techniques, such as belly or diaphragmatic breathing, body scanning,
and imagery involving a “limp rag doll.”
Although fairly straightforward translations of biofeedback and
related treatments, developed with adult patients,havemetwith much
success, it is likely that addinga developmental perspective to evalua-
tion and treatment could enhance effects further, as this is rarely
reported as being done in theliterature. MarconandLabbé (1990)dis-
cussed cognitive, self-regulation, psychosocial factors, and issues thatarise at various stages of development. Some of the examples
reviewed concern conceptualizationsof pain; differences in language,
time perception, and approaches to tasks; and varied abilities to com-
prehend the notion of severity. They also pointed to the importance of
considering environmental influences on headache, specifically
attention from family members and teachers.
AllenandShriver (1998)provideda concrete illustrationof this last
point. They randomly assigned child and adolescent migraineurs,
ages 7 to 18 years, to either standard thermal biofeedback or biofeed-
back combined with “pain behavior management” training for par-
ents. Parents assigned to the latter condition were instructed to mini-
mize reactions to pain behavior displays, insist on participation innormal, planned activities to the extent possible, and praise and sup-
port biofeedback practice (see Table 4). Thermal biofeedback led to
significant improvement, as expected; however, the addition of parent
training added a further significant increment to treatment. The com-
binedtreatmentgroupobtained greater overall reductions in headache
frequency, had a larger percentage of patients displaying clinically
significant improvements (reductions greater than50%), and revealed
better adaptive functioning (i.e., pain led to less interference in daily
activities). Benefits from theaddition of parent behaviormanagement
training have not met with uniform success, however (Kröner-
Herwig, Mohn, & Pothmann, 1998).
A reduced contact approach appears to work well with pediatricpatients.This approach increases theneed forfamily involvement and
Andrasik, Schwartz / PEDIATRIC HEADACHE 107
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support. The home environment needs careful consideration before
deciding on this approach.
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108 BEHAVIOR MODIFICATION / January 2006
TABLE 4
Pain Behavior Management Guidelines for Parents (re-printed from Allen & Shriver, 1998, with permission of the Associa-
tion for Advancement of Behavior Therapy)
1. Encourage independent management of pain: Praise and publicly ac-knowledge practice of self-regulation skills during pain-free episodes.If pain is reported, issue a single prompt to practice self-regulationskills. Praise and reward normal activity when report of pain has beenmade.
2. Encourage normal activity during pain episodes: Insist on attendanceat school, maintenance of daily chores and responsibilities, participa-tion in regular activities (lessons, practices, clubs).
3. Eliminate status checks: No questions about whether there is pain or
how much it hurts.4. Reduce response to pain behavior : No effort should be made to assist
the child in coping. Do not offer assistance or suggestions for coping.Do not offer medications.
5. Reduce pharmacological dependence: If medication is requested,deliver only as prescribed (i.e., follow directed time table).
6. Recruit others to follow same guidelines: School personnel should notsend child home; child shouldbe encouraged andpermitted to practiceself-regulation skills in the classroom, workload should not bemodified.
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FrankAndrasik is a professor in theDepartment of Psychology at the Universityof West Florida and a senior research scientist at the Florida Institute for Human and Machine
Cognition in Pensacola. He has a long-standing interest in biofeedback and behavioral
assessment and treatment of recurrent pain and stress disorders, with most of this work
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concentrating on headache. He received the Distinguished Scientist Award from the
Association for Applied Psychophysiologyand Biofeedback in 2002 for his researchwith
headache disorders.He presentlyserves as editor-in-chiefof AppliedPsychophysiology
and Biofeedback and held this same position for Behavior Therapy in the past.
Mark S. Schwartz has been on the staff of Mayo Clinics since 1967, including 21 years in
Rochester, MN, and 15 years at the Mayo Clinic in Jacksonville, FL, where he remains at
present. He has a long-standing interest in biofeedback and related procedures, having
served as chair of the Biofeedback Certification Institute of America Board for 2 years
from its inception in 1981 and as president of the Biofeedback Society of America from
March1987 to March1988 just beforethis organizationchanged its name to the Associa-
tion for Applied Psychophysiologyand Biofeedback. His publicationsinclude Biofeed-
back 4: Theory and Practice (with M. Shark, 2002) and Biofeedback: A Practitioner’s
Guide (with F. Andrasik, 2003).
Andrasik, Schwartz / PEDIATRIC HEADACHE 113