Current estimates suggest that up to one in four children will have an episode of chronic pain lasting three months or longer [1]. This type of persistent pain is linked to significant physical, psychosocial, and psychological burdens for children and families [2,3]. Chronic pediatric pain also places a significant burden on our healthcare system, ranking among the most expensive pediatric health problems in the United States and costing an estimated $19.5 billion dollars per year [4]. Psychological interventions for pain and pain-related functional deficits (i.e., school impairment, sleep disruption, peer-based challenges, etc.) have been considered an integral part of treatment for the recovery from chronic pain for almost twenty years [5,6]. Taken as a whole, psychological skills and strategies such as cognitive reframing, biobehavioral relaxation, graded in vivo exposure, and mindfulness are demonstrated to decrease pain, improve functioning, increase self-efficacy, and reduce the daily stress that commonly co-occurs in children and adolescents with persistent pain. Moreover, parent-based interventions that reduce maladaptive responses to child pain are demonstrated to further promote a child’s recovery [7].

Presently, most psychological interventions for pain are designed with a multi-component structure and are often concerned with evaluating the value-add to standard biomedical approaches to care, the “dose” needed to effect change, the effectiveness of novel delivery methods that can increase access to care, and in many cases assessing how the direct involvement of systems such as parents or families may enhance outcomes. However, the treatment of chronic pain is not a one-size fits all solution and it is unlikely that a single intervention strategy will systematically work for all children with pain. Psychological comorbidities, family-based influences, school environments, developmental factors, functional disability, and underlying pathophysiology of pain all vary by individual. As such, we need to develop various intervention strategies, with the goal of understanding how we can maximally apply these skills and strategies to enhance recovery or coping with pain and to reduce the stress and psychosocial burden for children and parents.

Despite the proven effectiveness of psychologically based strategies for pain, too few pediatric patients referred to psychological services for pain management obtain services due to a lack of available providers, scheduling conflicts, inadequate knowledge of efficacy, and financial or insurance constraints [8,9]. These logistical barriers highlight the need to create models of care that can be flexible in meeting the time, cost, and limited resource barriers that interfere with service acquisition [9]. Additionally, psychological interventions for pediatric pain must also be packaged and administered in a format that is acceptable, attending closely to the common biomedical biases that may inhibit initial engagement in services. For example, when parents perceive their child to have a solely physical problem, they may dismiss or minimize the need for psychological intervention [8,10,11]. Fortunately, gaining a foundational understanding of the biopsychosocial model of pain helps to illuminate how psychological interventions can effectively foster recovery and may increase the likelihood of obtaining targeted psychological services for pain [12].

Helping children and families to effectively manage pain may ultimately be similar to how we help our children succeed in school; all children need to be taught the academic material as well as the skills and strategies that help cement the learning process. How well any individual child succeeds in school, however, is due to a variety of factors such as attentional capacity, intelligence quotient (IQ), motivation, family reinforcement, etc. Children who have poor attention or low motivation, may ultimately be identified as needing additional services such as individual tutoring, small group instruction, or a more structured learning environment to obtain success. Similarly, one of our primary goals in pediatric pain is to identify patient characteristics that may signal the need for more intensive or focused intervention efforts that can help foster recovery [13]. As a corollary, considering that our patients with pain are akin to students in school highlights how first line education and intervention may be necessary, even if not sufficient to produce change for all children. Interventions that provide the building blocks for effective pain management early in a child’s experience of pain—for example, before functional deficits occur—may help to change a child’s long term trajectory in the same way that obtaining a short course of tutoring before a child fails a class may ultimately help a child to stay on pace with peers. Thus, in our current line of research and clinical practice we need to think about generating evidence-based first line interventions, such as targeted pain education and cognitive behavioral coping skills, while at the same time devising specialized or more intensive psychological treatments for those with more entrenched difficulties.

This review includes an overview of pediatric chronic pain intervention research in the past 10 years. Our search terms and findings are presented in Table 1. This is not intended to be an exhaustive list of all interventions tested for all chronic pain conditions, but rather to represent a broad overview of what is being developed and tested for “chronic pediatric pain.” Based on a review of this literature, we will present an overview of current theoretical frameworks that are currently guiding the development of interventions in this field and highlight specific ways in which these frameworks map onto pain-management skills and strategies. We will further evaluate current barriers and challenges in clinical application, and discuss future directions for more seamlessly integrating psychological interventions into the clinical management of pediatric pain.

Pediatric pain interventions are based on the understanding that pain is a complex biopsychosocial experience shaped not only by underlying pathophysiology but also by individuals’ thoughts, feelings, and behaviors [43]. Interventions based in the foundational theories of cognitive behavioral, biobehavioral, and acceptance-based models of care currently encompass the majority of psychological interventions for children and adolescents with pain. However, these theoretical approaches are not necessarily mutually exclusive, as many of the current interventions for pediatric pain contain elements of two or more theoretical orientations. Collectively, these theoretical approaches demonstrate promising improvements in self-efficacy, self-management, family functioning, psychosocial well-being, pain severity, school attendance, anxiety, depression and feelings of hopefulness [7,44,45]. The vast majority of evidenced-based interventions for pediatric pain are designed as brief, goal-oriented treatments incorporating learning experiences that help to modify negative cognitions about pain and eliminating dysfunctional behavioral patterns that occur as a result of the pain. Psychological interventions for pain are also commonly designed to help un-link the association between the sensory experience of pain and the cognitive affective evaluation of the pain that triggers a fight or flight response, often referred to as a “pain alarm” [46]. Specifically, most psychological treatments for pain are designed to address the negative or fearful thoughts about pain (e.g., ‘it’s going to hurt too much’, ‘I can’t do this’) that produce physiological changes (e.g., racing heart, shortness of breath, increased discomfort) and resultant behavioral changes (e.g., withdrawal from activity, poor sleep). Interventions may also use strategies such as graded exposure to anxiety producing stimuli and reinforcement for adaptive behaviors.

As pediatric pain is conceptualized as a biopsychosocial process, intervention efforts are ideally targeted towards a systems framework inclusive of parents, families and schools. It has been well documented that the way parents respond to their child’s pain is associated with pain severity, functional disability and other somatic complaints [3,7,47]. Moreover, without targeted parent support at home and school, it is more challenging for children and adolescents to make steady gains. Parents can be collaborators in treatment when they are involved in the planning and reinforcement of their child’s psychological intervention plan [48]. For example, parents may be taught how to use relaxation techniques to help reinforce the use of these strategies at home, or may collaborate by consistent provision of rewards or consequences for a child’s established behavior plan [17]. But perhaps more importantly, parents can be co-treated along with their child. For example, it’s common for parents to become highly focused on their child’s pain. This attention to pain is known to inadvertently reinforce a child’s focus on his or her own pain increasing disability [49,50]. In contrast, when parents are taught how to reduce their focus on a child’s pain, a child’s pain and function may improve [27]. Research also suggests that parent-focused treatments such as Problem Solving Therapy (PST) may directly improve parent behaviour and parent psychological functioning [51], an important outcome given that parents are known to experience significant stress in the context of their child’s pain [52].

School performance has also been an identified target for intervention because functional impairment in schools—including poor grades, absenteeism, and peer victimization—is a well-documented problem for children with pain [53,54,55]. It’s easy to understand why pain can reduce a child’s ability to cope with school demands and contribute to poorer grades. However, for some children school pressures and peer victimization may also be a contributory factor to the onset of pain, thus requiring intervention to reduce the underlying psychosocial stress.

Psychologists typically teach a broad complement of cognitive, behavioral, and biobehavioral strategies, often in the context of multidisciplinary treatments that might also incorporate physical therapy and non-opioid medications. The literature includes many reports of effective multicomponent Cognitive Behavioral Therapy (CBT) treatments for pediatric chronic pain (see Table 1). However, with some notable exceptions for conditions such as headache pain, [5] there is little conclusive evidence about which component parts of psychological intervention are most effective for which population of children with pain. Many investigations have tried narrowing down this area of research by investigating interventions via defined primary pain (e.g., abdominal, musculoskeletal, neuropathic), developmental level (children vs. adolescents), pain severity, psychological comorbidities (e.g., anxiety, depression) and other factors. Yet, in clinical practice, where the majority of children with chronic pain have more than one pain condition and an array of psychological and psychosocial stressors [1], these research-defined classifications may be less salient.

While randomized controlled trials (RCTs), both individually and collectively evaluated in meta analyses, provide our best evidence that psychological strategies offer benefit to pediatric patients with pain, a broader examination of the current research in this field may help us to better conceptualize new directions in this field. Specifically, we can learn how evidenced-based psychological interventions are being implemented across pediatric pain conditions, in various settings, using novel delivery methods and unique combinations of skills and strategies.

Below we briefly review the most common outpatient intervention frameworks cited in the last ten years (2005–2015), highlighting how a variety of skills and strategies may be applied in helping children, adolescents, and parents in the management of pediatric pain.

Over the last ten years, our increased knowledge of the neurobiology of pain in combination with a promising research foundation demonstrating that evidenced-based psychological intervention can offer immediate and long-term benefit to children with chronic pain, has led to more nuanced questions regarding the dose, application and dissemination of these interventions. For example, the majority of interventions have been designed as brief models of care (<8 h), increasing our confidence that positive outcomes are possible within a relatively short duration and enhancing opportunities to treat more patients. Effective group treatments similarly enhance opportunities to treat larger numbers of patients while simultaneously providing social support. Moreover, new models of care including internet and telehealth assisted delivery, suggest that our current technology affords opportunities to bring these evidence-based skills and strategies into patients’ homes, eliminating many of the logistical barriers to treatment.

Even with these advances, intervention research for pediatric chronic pain is still in its relative infancy and there remain several gaps in our intervention research. For example, our review finds that many interventions did not clearly specify the duration of treatment, leaving out important details such as the number of sessions or the length of each session. Without this “dose” information, it can be difficult to compare efficacy across interventions and challenging to determine how much treatment might be needed for any particular child or family. The use of a tiered care approach to treatment, whereby various levels of intervention intensity are recommended based on a child’s particular profile, may emerge as a useful way to direct care. Thus, the availability of various “doses” of intervention is highly relevant. In some cases, patients may first be directed through lower levels of intervention with non-responders proceeding to more intensive interventions, though the use of rapid screening tools (e.g., Pediatric Pain Screening Tool [86]) may also allow providers to identify patients who, according to identified risk factors (i.e., functional disability, depression) need to be fast-tracked to higher levels of intervention (e.g., Intensive Interdisciplinary Rehabilitation Therapy).

Within the current model of care there still remain too many patients who do not seek or attain any psychological interventions for pain due to biomedical biases [8]. Continuing efforts to disseminate basic neuro-science education and to arm children and parents with the necessary skills and strategies early in a child’s experience of chronic pain, or even preventively, remains a goal for intervention research. Interventions that use non-diagnostic titles such as “The Comfort Ability” [80], “Web-Map” [76], “Teens Taking Charge” [77] or “Headstrong” [16] may help to reduce patient bias [87,88]. Additionally, including psychological interventions as an integrated part of an interdisciplinary treatment program can enhance acceptability. Recent success with social media efforts to shift public opinion about the management of acute pain in children [89] suggests that beyond our focus on patient bias, pediatric psychologists may also have a role to play in shifting general public awareness towards a broader understanding of psychological intervention for managing pediatric chronic pain.

When patients do demonstrate a willingness to engage in psychological intervention for chronic pain, we still have too few options available for clinical use. To date, even with the proliferation of research-based internet programs, there are no web-based protocols available for public use. Moreover, only a handful of the interventions reviewed over the past ten years are maintained outside the research arena as ongoing clinical services. Thus, we need to continue to focus efforts on how to effectively share our knowledge and integrate evidence-based interventions into our current healthcare systems. Programs such as The Comfort Ability, a one-day CBT workshop for children with pain and their parents, is one such example. This program, inclusive of leaders’ manuals and patient and parents’ workbooks, is designed as a first-line intervention for pediatric pain. Now actively running at eight healthcare institutions, it has demonstrated feasibility for transfer to other sites.

While evidence in the field suggests that many patients and parents benefit from first-line education and intervention, there is also a need to become more specialized in our approach to intervention for those who have high levels of disability or complex comorbidities. There is a need to more fully establish a personalized medicine approach, enabling the identification of patient-specific mood, cognitive, developmental and behavioral patterns that may map onto specialized or tailored interventions leading to improved long-term pain-related outcomes. Without such efforts, patients may become frustrated with trial and error approach or even become treatment resistant [71]. One such example of a specialized approach to care is the “GET Living” intervention, designed to target pain-related fear [90]. With past research demonstrating that patients with high pain-related fear may only partially respond to general CBT [91], more tailored or specialized treatment is warranted for this patient subgroup. Graded in vivo exposure, a specific cognitive–behavioral technique that is effective at improving function for individuals with pain-related fear is being evaluated as the hallmark treatment of GET Living. Though this more intensive treatment is not needed for all pediatric patients with pain, the specialization of this intervention may provide an important path forward for patients with pain and high levels of associated fear.

In conclusion, pediatric chronic pain intervention research in the past ten years has made tremendous gains. Collectively there is compelling research demonstrating meaningful gains in reducing pain severity and improving functional outcomes for many brief, outpatient interventions. Nevertheless, there remains a continued need to develop interventions that help to diminish biomedical biases and reduce logistical barriers to care. Moreover, we need sustained efforts in identifying and developing first-line interventions that have wide-scale applicability as well as more nuanced and targeted treatment for patients with more psychophysiological complexities. Psychologists must also consider how to translate our current research initiatives into routine practice for children with chronic pain. Beyond developing interventions, we must continue to educate patients, providers and the general public toward a comprehensive understanding of how and why these interventions can foster adaptive recovery. As our knowledge of the neurobiology of pain continues to expand and we continue to gain confidence in our intervention research, it will be increasingly possible to effectively implement and facilitate the adoption of our evidence-based research.