Clinical Review: Focused

The Role of Cognitive Behavioral Therapy for ChronicPain in AdolescentsTamara K. Zagustin, MD

Chronic pain is frequently experienced in adolescents; it affects functionality and requiresinterventions to decrease the impairments caused by pain. Cognitive behavioral therapy(CBT) has been analyzed in numerous studies that evaluated its effects on reducing thedifferent types of chronic pain in children and adolescents. Interestingly, the outcome ofCBT was initially focused on pain intensity, but, because there is no correspondence between children’s pain intensity and level of disability, the ability to participate in school andsocial and recreational activities have been the primary focus of recent studies. There areinnovative methods of CBT (such as the third generation of CBT) with and without the useof technology that facilitates the availability of this psychological treatment to adolescentswith chronic pain, optimizing its accessibility and comprehensiveness, and maintaining itseffectiveness. In the future, specific types of CBT could be specific to the diagnosis ofchronic pain in the adolescent, sociodemographics, and other unique features. Parents ofchildren with chronic pain are usually included in these programs, either as coaches in theintervention or as recipients of psychological therapies (including CBT) to optimize benefits. CBT has no adverse effect on chronic pain in adolescents, and there is no literaturethat makes reference to the effectiveness of CBT in preventing chronic pain in adolescents.A review of the role of CBT in chronic pain in adolescents via a PubMed database searchwas performed to identify the role of CBT in the management of chronic pain inadolescents.

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T.K.Z. Pediatric Rehabilitation Medicine, Children’ Healthcare of Atlanta, 1001 JohnsonFerry Road NE, Atlanta, GA 30342. Addresscorrespondence to: T.K.Z.; e mail: tamara.zagustin@choa.orgDisclosure: nothing to disclose

Submitted for publication May 17, 2013;accepted May 17, 2013.

INTRODUCTION

Cognitive behavioral therapy (CBT) is a well established psychotherapy that was firstintroduced more than 40 years ago for the management of pain, stress, and disability inadults [1]. It is a goal oriented technique that emphasizes changes in thought patterns andbehaviors within a short time frame (usually 10 20 sessions) [2]. CBT was later introducedto the pediatric and adolescent populations to facilitate improvement in pain control, andto effect a more positive influence on the consequences of pain and suffering by modifyingsituational, emotional, familial, and behavioral factors [3]. CBT is a strategy that empowerschildren and adolescents to assume control over symptom management and is consideredto be a cost effective intervention that enables children and adolescents with chronicdysfunctional pain to return to a productive life.

The integrated interventions in CBT include relaxation training, biofeedback, stressmanagement, guided coping imagery, cognitive coping skills, and behavioral managementaimed at reducing or extinguishing the influences of factors that maintain maladaptivebehaviors, beliefs, and thought patterns [4]. CBT can be performed on a one to one basis(individualized) and/or within a therapeutic group setting, with family (ie, parents), or withother patients with similar diagnoses or problems.

CBT has been shown to be effective in children and adolescents with chronic and/orrecurrent pain, including headaches and abdominal, musculoskeletal, and systemicdisease related pain [5]. CBT has also been effectively useful in addressingco occurring depression [6], anxiety [7], chronic fatigue syndrome (CFS) [8 10], andposttraumatic stress disorder [11]. Treating these associated diagnoses can have a directimpact on reduction of pain severity [12,13], and therefore improves outcomes with

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the additional benefit of limiting recurrent medical consultations, minimizing costly diagnostic procedures, andlimiting the use of medications that do not afford symptom relief [13].

Chronic pain in adolescents is a multidimensional, biopsychosocial disorder with an unpleasant sensory andemotional experience that persists or recurs over time andcan be associated with or without tissue damage. Themanagement of chronic pain requires an interdisciplinary,comprehensive approach that includes CBT as a primarypsychological intervention [14]. The specialty of physicalmedicine and rehabilitation is appropriately linked to themanagement of chronic pain in both the pediatric and theadult populations. This article will review the medical literature about the role of CBT in the management of chronicpain in adolescents. Articles included in this review wereidentified through the PubMed database with the use of thefollowing search terms: chronic pain, adolescents, and CBT.Additional articles were obtained via cross reference of theprimary search.

BENEFITS OF CBT IN ADOLESCENTS WITHCHRONIC PAIN SYNDROMES

One in 4 children and adolescents frequently experiencesome type of chronic pain, and 8% present with severedysfunctional pain that requires intervention to decreasethe impairments caused by the pain [15]. Frequent diagnoses associated with chronic and/or recurrent pain inadolescents include the following: chronic headaches, irritable bowel syndrome, functional abdominal pain syndrome,juvenile fibromyalgia, complex regional pain syndrome,chronic nonspecific musculoskeletal pain, hypermobilityand/or Ehlers Danlos syndrome, juvenile idiopathic arthritis,neuromuscular diseases, sickle cell disease, and cancer.Prevalence rates for chronic pain in children and adolescentsvary substantially: headache, 8% 83%; abdominal pain, 4%53%; back pain, 14% 24%; musculoskeletal pain, 4% 40%;multiple pains, 4% 49%; other pains, 5% 88% [16]. Painprevalence rates are generally higher in girls and increasedwith age for most pain types. Lower socioeconomic statushas been associated with higher pain prevalence, especiallyfor headache [17].

Eccleston et al [18] identified that an interdisciplinaryprogram for adolescents with disabling chronic musculoskeletal pain, which includes CBT, physical and occupational therapies, and parent involvement was effectivein increasing physical performance, reducing emotionaldistress, increasing attendance in educational programs,and returning adolescents to school [18]. This study waslimited by not having a comparison group to controlfor any nonspecific effects of the treatment setting,staff patient relationships, or changes from a normalenvironment.

EFFECTIVENESS OF CBT IN ADOLESCENTSBASED ON TYPES OF CHRONIC PAINSYNDROMES

It is relevant to point out that research has highlighted thatthere is no correspondence between children’s pain intensityand level of disability [11]; therefore, when evaluating theoutcomes of CBT, it is important to monitor its impact onthe child’s ability to participate in activities of daily living,such as school attendance and social and recreationalactivities.

Merlijn et al [19] reported that adolescents with chronicpain who received a cognitive behavioral program werereported to have more control of their pain through trainingthat was considered feasible in daily life, and it showed animprovement in pain and quality of life. Parents in thisprogram valued the support that they experienced in helpingtheir child to master the pain through CBT.

Most studies that evaluate CBT in children and adolescentswith chronic pain are specific to chronic headaches, withgood effectiveness in pain control and benefits maintainedover time [5]. Palermo et al [2] performed a meta analyticreview to quantify the effects of psychological therapies forthe management of chronic pain in youth (headaches andabdominal, musculoskeletal, and disease related pain). Theyupdated the previous systematic review of randomizedcontrolled trials (RCT) [14] by including new trials and, at thesame time, included disability and emotional functioningwith pain as treatment outcomes. Psychological therapiesreduced pain intensity by at least 50% in significantly morechildren and adolescents compared with control conditionsafter treatment. At a 3 month follow up, these effects of painreductions persisted. Psychological therapies had a small effect that was not significant on reduction of disability whencompared with control conditions after treatment, and thepsychological therapies did not improve emotional functioning in youth (such as limitations in school work and dailyactivities) when compared with no treatment or placebo aftertreatment; yet the interventions delivered to children withabdominal pain produced greater changes and improvementin disability outcomes compared with interventions deliveredto children with headache and fibromyalgia. This small andnonsignificant effect of the psychological therapies ondisability and emotional functioning outcomes was probablydue to the small number of studies, the different measurements used, and the limited available measures.

Psychological treatments such as CBT, relaxation, andbiofeedback have been shown to significantly reduce painintensity in children and adolescents with headache,abdominal pain, and fibromyalgia when compared with notreatment control conditions in the systemic review byPalermo; yet there were too few studies that directlycompared the different psychological therapies, and, therefore, no conclusion could be made about superiority of 1intervention over the others.

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In a Cochrane Review [5] performed in 2009 on psychological therapies for the management of chronic andrecurrent pain in children and adolescents, 29 studies wereincluded, and it was found that CBT was an effective treatment in childhood chronic headache and chronic non headpain (predominantly abdominal pain). Due to the smallnumber of studies with available data, there were insufficientdata showing that these psychological interventions improved disability or mood in any chronic or recurrent paincondition as previously identified by Palermo et al [2]. Someadditional important limitations were identified: few studiesused an active treatment comparison (lack of placebocomparisons); most studies concluded with the immediateposttreatment period, without data on maintenance oftreatment effects; most studies focused on headaches andabdominal pain, although there was the intent to focus onmore heterogeneous sources of pain in this population; andnone of the studies included sociodemographic characteristics of the children and adolescents.

Additional studies have evaluated the intervention ofpsychological treatments with CBT to improve pain controlsafely and effectively in children and adolescents withcomplex regional pain syndrome [20], functional and/orrecurrent abdominal pain [21 23], and musculoskeletal pain[14]. Through a small, prospective, longitudinal, non RCTreported by Walco et al [24], cognitive behavioral interventions for pain in patients with juvenile rheumatoidarthritis were found to be an effective adjunct to standardpharmacologic interventions for pain, with significantreduction in pain intensity immediately after treatment aswell as pain reduction and improvement in function at 6and 12 month follow ups. In a non RCT of adolescents withjuvenile fibromyalgia, CBT was shown to be effective inreducing pain, somatic symptoms, anxiety, and fatigue, andin improving sleep quality, functional ability, and schoolabsences [25].

CBT AND FATIGUE

An RCT study evaluated CFS in adolescents in which the adolescents underwent a Fatigue In Teenagers on the interNET(FITNET), Internet based CBT intervention compared withthe usual care for adolescents with CFS (which includedtraditional face to face CBT), and both groups showed animprovement in school attendance, severity of fatigue, andphysical functioning at 6 months; yet, the intervention in theFITNET group was shown to be much more effective (by33%), compared with the control group [26]. It is importantto point out that this Internet intervention was comprehensive: it involved both the adolescent with the problem and atleast 1 parent who also received an Internet based program,which was separate yet similar and involved less detail; therewas a school mentor available who could be consulted toenhance school attendance; and the program was guided bya cognitive behavioral psychotherapist through e consults

on a weekly base, with availability through e mails at anystage during the intervention [26]. Even though it was astudy on CFS, this study is probably relevant for chronicpain, given that successful treatment with CBT in CFSin adults and adolescents can also lead to reduction ofpain [12].

CBT AND SCHOOL ABSENTEEISM

A large observational study involved adolescents with schoolabsenteeism and a mixture of emotional and disruptivesymptoms; this study showed the benefits of inpatienttherapy that included CBT and access to a special schoolwith expertise in teaching children and adolescents withpsychiatric disorders [27]. Overall, analysis of the resultsshowed a considerable decline in school absenteeism andmental health problems during treatment and subsequentfollow up. Continuous school attendance improved significantly at the end of inpatient treatment and at the 2 monthfollow up. Comorbid symptoms of anxiety, depression, anddisruptive and insufficient learning behavior were significantly reduced from pretreatment to follow up. There wasno control group, and therefore these data should beinterpreted conservatively. This study is relevant, given thatmany adolescents with chronic pain experience primaryand/or secondary depression, anxiety, and disruptive andinsufficient learning behaviors in addition to schoolabsenteeism.

CHRONIC ILLNESS IN ADULTHOOD

Interestingly, childhood adversities and early onset mentalhealth disorders such as depression and anxiety have independent, broad spectrum effects that increase the risk ofdiverse chronic physical conditions (ie, heart disease, asthma,diabetes mellitus, arthritis, chronic spinal pain, and chronicheadache) later in life as an adult [28]. Therefore, CBT interventions during youth to address chronic pain and/oranxiety and depression could have a positive impact onchronic health conditions in adulthood, in addition to theimmediate impact during adolescence. Future studies areneeded to evaluate this aspect of CBT over time.

FOLLOW-UP PROGRAMS FOR CBT

The RCT of psychological therapies used in adolescents withchronic pain conditions have shown improvement in totalquality, trial quality, and design quality reporting over thepast 10 years [2], yet there was very limited informationavailable on extended follow up to evaluate the treatmenteffects over time. Recommendations have been made toconduct follow up assessments for pain intervention studiesat a minimum of 6 months after the completion of treatment,as well as long term, to capture the immediate impact duringthe adolescent years and, subsequently, into adulthood.

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Most studies that evaluated CBT for chronic pain in adolescents have mostly examined immediate posttreatmenteffects, some up to 3 months after treatment, and very few at6 and/or 12 months after treatment.

The inclusion of a follow up program with additionalsessions of CBT led by skilled professionals, such as nursingstaff, at 6 and 12 months after initial treatment, has beenreported to prevent drop out and relapse [29]. This component of treatment is important, given the understandingthat chronic pain can be a lifelong condition, and that,depending on the underlying disease process, the health ofsome patients could decline over time. It is unrealistic toexpect that most participants will be able to manage theirpain effectively long term after a brief pain managementprogram (10 20 sessions) with no follow up sessions throughout a lifetime. This was the only study that includedfollow up sessions. Further studies are needed to determinehow many follow up sessions are necessary and within whattime span from the original intervention with CBT.

TOOLS TO EVALUATE THE IMPACT OF CBT ONCHRONIC PAIN AND QUALITY OF LIFE INADOLESCENTS

Managing chronic pain in adolescents can be challengingfor the adolescents, family members, and health care providers because there are no readily available biomarkers todefine presence, absence, remission, or exacerbations otherthan patients’ symptom reporting and the impact of painon their quality of life and activities of daily living. Thislack of an objective biomarker also challenges the evaluation of outcomes after implementing CBT in chronic painmanagement.

Measuring health related quality of life could facilitateunderstanding the impact that CBT has on chronic painin adolescents. The Child Health and Illness Profile, ChildHealth Questionnaire, KINDL (the German Generic Qualityof Life Instrument for Children), and Pediatric Quality ofLife Inventory are 4 measures of health related quality oflife that warrant consideration in pediatric chronic painmedicine, given that they are reliable, valid, and availableboth as patients’ self report and as a parental proxy reportform [30].

It is important that all future studies that evaluate theimpact of CBT in children and adolescents with chronic paindo so by following the Pediatric Initiative on Methods,Measurement, and Pain Assessment in Clinical Trials recommendations, in which core domains and measures forclinical trials to treat pain in children and adolescents aredefined [31]. This will assist in comparison and pooling ofdata and will promote evidence based treatment, encouragecomplete reporting of outcomes, simplify the review ofproposals and manuscripts, and facilitate clinicians makinginformed decisions regarding treatment.

METHODS OF DELIVERING CBT FORADOLESCENTS WITH CHRONIC PAIN

Traditionally, CBT has been available to adolescents withchronic pain at specialized pediatric centers, where a face toface interaction with a knowledgeable psychologist in CBTwould be able to provide this intervention in the management of chronic pain. However, the distance to majortreatment centers, the limited human resources available forthis population, and the expense of this service have beensignificant barriers. The alternative of initiating and sustaining a greater number of CBT programs for adolescents inlocal health centers can be very challenging; this was notedin a study that evaluated a multifaceted implementationstrategy to implement CBT for depressed adolescents into 2publicly funded mental health care centers [32]. One optionto overcome these barriers is through information technology systems that are universal and available to the generalpublic: computers with Internet capacity (Web based CBT),teleconferencing, and smartphone applications. The Internetmay be critical in reaching the large population of childrenand adolescents with chronic pain who are not able toreceive behavioral treatment in their local communities.

In general, there is an updated review of recent controlledtrials of Internet interventions for health conditions and howthe Internet is used to promote health [33]. The majority ofthe trials were small and underpowered, in particular, thestudies on children and adolescents; yet there was significantimprovement in the treatment of irritable bowel syndrome,headache, and chronic pain. None of these studies thatdemonstrated significant improvement included peer support in an online environment, so it is not clear whatadditional benefits would be realized if this component wereincorporated into the intervention.

Self administered CBT treatment at home, performedsimilarly to therapist administered treatment in a clinicalsetting, suggested an equivalent positive effect on painreduction; this included novel computer based applications.An RCT Internet delivered family CBT intervention forchildren and adolescents with chronic pain was consideredan acceptable method of delivering CBT by parents andchildren, and demonstrated significantly greater reduction inactivity limitations and pain intensity after treatment and at a3 month follow up when compared with the wait list control group [34]. The participation rate in this study wassimilar to rates of participation of face to face CBT, whichsuggests acceptability.

Using a Web based intervention that is able to deliverinteractive and personalized CBT to adolescents with chronicpain and to their parents, with the goal of reducing pain andassociated functional limitations, is important; Web MAP is1 of the interventions that has been studied [35]. The content for Web MAP was developed from existing, evidencedbased, outpatient CBTs for chronic pain; it includedchild pain management skills and parent interventions

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(eg, reinforcement of positive coping and activity participation). There was a moderate to strong acceptability of theprogram that could track patterns of user activity andWeb siteusage. In addition, the program was dynamic, which allowedfeedback in the design of the Internet intervention withappropriate adjustments; it was user friendly and feasible.

A review and meta analysis of computerized CBT (cCBT)[36] examines 4 studies that met inclusion criteria. Therewas significant improvement in frequency, duration, andintensity of the pain, by at least 50% from baseline toposttreatment assessment, that was maintained at the 3 and6 month follow ups. The reduction was significant betweenthe cCBT group and the control groups in all 4 studies. Twoof the studies showed an improvement in disability. Thesestudies provide tentative support for the use of cCBT for thetreatment of pain in children and adolescents, and cCBTcompared favorably with face to face CBT. From thesestudies, it was also pointed out that cCBT could be a moreaccessible and cost effective intervention [37]; yet furtherresearch is needed. The RCTs mentioned above [26,38] thatevaluated the effect of a Web based CBT versus usual carehighlights the value, efficiency, and success of Web basedprograms that incorporate CBT to manage chronic conditions in adolescents.

The use of videoconferencing has also facilitated theimplementation of CBT, with improvement on anxiety andquality of life in a non RCT, small pilot study (N ¼ 25),which evaluated the utility of this innovative delivery ofpsychological treatment for rural adult cancer patients [37].It would be of interest to explore the implementation of CBTin adolescents with chronic pain in an RCT that comparesface to face intervention versus videoconferencing.

Smartphone applications (apps) are becoming increasingly popular. The lack of regulation or guidance for healthrelated apps means that the validity and reliability of theircontent is unknown. A great number of apps (at least 111apps) have been released and identified with the focus onpain education, management, and/or relief, with a low levelof stated health care professional involvement in the development and content of these apps; therefore, the effectiveness, validity, adverse events, and limitations of theseproducts in facilitating pain relief is not clear [39].

In the future, different interventions of CBT could bespecific to the diagnosis of chronic pain in adolescents,including sociodemographics and other unique features.Having the option of an effective, specific, feasible, andacceptable Web based specialized program could optimizeaccessibility, management, cost, and care of adolescents withchronic pain. These Web based programs could be madecomprehensive by involving not only adolescents withchronic pain but also the parents and schools, and shouldpreferably be guided by professionals with experience inCBT (ie, cognitive behavioral psychotherapists or others)who are accessible during the program. More studies areneeded to compare the types of self administered CBT

performed and to evaluate the impact that they have in themanagement of chronic pain in youth.

IMPACT OF CBT ON FAMILY MEMBERS OFADOLESCENTS WITH CHRONIC PAIN

Family based CBT is of great importance when addressingchronic pain in adolescents, because it has been describedthat gathering information from parents about their ownpain histories allows health care providers to be able toidentify children at risk for developing maladaptive copingstrategies for pain and for higher levels of disease relatedpain and disability [40]; these would include interventionprograms that focus specifically on reducing children’s use ofa catastrophizing attitude to cope with their pain by activelyincorporating parents’ participation in the CBT program.There is some limited evidence that Internet delivered CBTcould cause changes in parental behavior; however, giventhe absence of a report on outcomes related to parentalbehavior and family CBT, future research is necessary toevaluate strategies to encourage parental participation withtreatment as well as to measure additional relevant parentaloutcomes such as parenting stress, parental emotionalfunctioning, parent child communication, and even theimpact on parents’ own chronic pain management. This isrelevant when considering that more than 90% of parents ofchildren with chronic rheumatic disease reported having atleast 1 chronic pain condition [40].

Family involvement in CBT as a coaching intervention foradolescents with chronic pain is beneficial and important[18]; yet there are some factors that need to be consideredwhen developing family CBT to optimize outcomes. Thereare differences between mothers’ and fathers’ catastrophizingtheir child’s chronic pain [41], in that mothers reportedhigher levels of catastrophizing compared with fathers. The 2genders did not differ in magnification and sense of helplessness. Maternal catastrophizing contributed significantlyin explaining the child’s pain intensity, whereas neithermothers’ nor fathers’ catastrophizing was significantly relatedto the child’s disability. These findings and differences areboth relevant for treatment conceptualization, and shouldbe included when developing family CBT to optimizeoutcomes.

The receptiveness of anxious mothers to the diagnosisand medical management of chronic abdominal pain in theirchild was better when a functional diagnosis was deliveredby a physician with a biopsychosocial rather than abiomedical orientation, because, in addition to medicaltreatment, psychosocial interventions such as CBT andcoping strategies for pain were incorporated to help alleviatethe pain [42].

When parents have a child with a long standing illness,including chronic pain, the parents’ balance in life is challenged, and therefore they may experience more stress, sadfeelings, and worries that can have a negative impact on their

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child’s well being and adjustment to the illness. Psychological therapies for parents of children with chronic illnesswere found to significantly improve child symptoms forpainful conditions immediately after treatment. Across allmedical conditions, CBT for parents significantly improvedchildren’s medical symptoms, whereas problem solvingtherapy for parents significantly improved parents’ behaviorand mental health by decreasing stress levels and improvingparents’ ability to solve problems [43].

ROLE OF PEER GROUPS IN CBT FORADOLESCENTS WITH CHRONIC PAIN

To our knowledge, there are no data that establish theadherence rate of children and parents in recommendedtreatments for chronic pain; yet the opportunity to interactwith peers who model and reinforce adherent behaviors(for both child and parent) could enhance interventions suchas CBT. Facilitating this intervention through an onlineenvironment might advance this interaction even more.Further research is needed. In addition, a challenge to thechild and families is that they might be seeking treatment forphysical rather than psychological symptoms and mightview the impairment as related to a medical condition.Validating the child’s pain and providing objective data toaddress the chronic pain in combination with peer andfamily support groups might help families to engage in, and toenhance the acceptability of, psychological intervention [13].

Currently there is a study protocol underway that is anRCT designed to develop and test a new peer mentorshipprogram that will provide modeling and reinforcement bypeers to other adolescents with chronic pain [44]. The studywill examine the feasibility of this intervention and willassess preliminary effectiveness of this program on mentoredparticipants’ pain and functional disability. CBT is incorporated into this study.

NEW INNOVATIONS WITHIN CBT

CBT research performed in adults and children with chronicdisease, including chronic pain, has largely contributed in thepast decades by identifying and programming interventionssuch as social and family support, coping abilities, locus ofcontrol, and self efficacy. More recently, there is a thirdgeneration of CBTs, such as dialectical behavioral therapy,mindfulness based cognitive therapy, functional analyticpsychotherapy, and acceptance and commitment therapy.These therapies are focused on developing interventionmodels that target the needs of patients with chronic disease[45] and have gained support for their use in the adultpopulation; yet the literature on the adaptation of this thirdgeneration of CBTs for youth populations is still nascent [46].

In a non RCT pilot study of 14 adolescents referred tothe pain treatment service due to chronic debilitating pain,the adolescents were treated by using an acceptance and

commitment therapy based approach (development of CBTthat emphasizes exposure and acceptance). After treatment,and at 3 and 6 month follow ups, there were improvementsin functional ability, school attendance, catastrophizing, andpain (ie, intensity and interference). The outcome of thispilot study indicated that exposure and acceptance can beuseful in the rehabilitation of adolescents with chronicdebilitating pain. RCTs are needed to empirically evaluatethe effectiveness, applicability, and impact of the new interventions available within CBT in adolescents with chronicpain [47].

No literature was identified in regard to the use in CBTfor the prevention of chronic pain syndromes in adolescents.None of the studies reviewed in the role of CBT for chronicpain in adolescents described the direct and indirect costbenefit of this intervention, either short term or long term,which would be of interest in the future.

ADVERSE EFFECTS RELATED TO CBT

One study reviewed the data from 3 RCTs on CBT for CFS,which were pooled and reanalyzed to look at possibledetrimental effects of CBT. One study concerned adolescents, and the other 2 studies were concerned with adults.Symptom deterioration during the trial was rated by patientsand measured as deterioration in fatigue, pain, functionalimpairment, and psychological distress. Both the frequencyand severity of deterioration in these domains werecompared between the patients receiving CBT and those inthe control group (those on the waiting list). The resultsshowed that patients who received CBT did not experiencemore frequent or severe symptom deterioration thanthe untreated patients, and that any deterioration duringCBT is a natural variation in symptoms. The investigatorsconcluded that CBT was helpful and safe for the treatment ofCFS, with no adverse effects related to CBT [48]. None of theother studies included in this review documented anyadverse events related to the intervention of CBT.

SUMMARY

CBT has been analyzed in a great number of studies thatevaluated its effect on reducing pain in adolescents withchronic headaches, followed by a lesser number of studiesthat evaluated chronic non headache pain. Pain intensitywas the most common treatment outcome assessed in mostof these studies. New treatments within CBT are beingdeveloped, and the method by which the treatment is beingdelivered is moving rapidly, with the accessibility of newtechnology available to the adolescents and general public.

Further development and evaluation of these innovativeCBT interventions need to be performed with high quality,large, multi site RCTs that evaluate the risk, benefits, cost,and accessibility of CBT as an isolated or interdisciplinaryintervention in adolescents with chronic pain. Emphasis

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should be on measuring functional outcomes based ondisability, quality of life, role functioning, and regular activity participation in the adolescents with chronic pain andnot only on pain intensity. Some validated tools are identified and available that are well defined for the purpose ofmeasuring outcomes and quality of life in adolescents withchronic pain, and these should be used in future studies.Across all medical conditions, family involvement in CBT foradolescents and children with chronic pain can be beneficial:the parents assist in providing the adolescents with betterproblem solving skills, which improves the children’s medical symptoms, which simultaneously improves parentalbehavior and mental health by decreasing the parents’ stresslevels. CBT does have a role in the management of chronicpain in adolescents. More studies are needed to assess theshort and long term impacts of CBT on the complexityof chronic pain in this very dynamic and heterogeneouspopulation.

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