Findings support the efficacy of Internet-delivered family CBT in significantly reducing pain intensity and improving function for children and adolescents with chronic pain. This study extends previous work on distance treatment in youth with chronic pain[3
] by demonstrating the efficacy of a self-guided Internet intervention with minimal therapist time. Similar to recent findings of Internet delivered treatment in adults with health conditions including chronic pain and headache[4
], this mode of treatment delivery can also be successfully used with children and their parents.
Advances in the mode of treatment delivery of CBT in pediatric chronic pain are critically needed as most children and adolescents do not have access to specialized treatment. In many parts of the world, when referred for specialty evaluation and care, children with chronic pain encounter significant difficulties accessing care due to a shortage of dedicated pain treatment facilities for children. For example, in a recent survey of Canadian pediatric pain treatment facilities, only five centers were available with sufficient expertise to treat children and these were all located in major urban cities[24
]. These authors concluded that a significant proportion of children with chronic pain in Canada, particularly those living in rural areas, did not have adequate access to care[24
]. A similar scenario exists in the United States and other parts of the world. Use of the Internet to deliver psychological treatment to children with chronic pain may be critical to providing access to a large number of patients at a low cost.
Our findings also extend previous work on family CBT[29
] demonstrating its efficacy among children with mixed chronic pain conditions. Parents received equal treatment time as their child with our Internet treatment. This dose of treatment directed toward the parent is more intensive than that reported in previous research in which interventions conducted with parents have primarily relied on brief educational sessions[13
]. In addition to education and operant strategies, we incorporated content directed toward parent-child communication, modeling, and parental stress management. It is possible that these parental strategies contributed to the positive child outcomes. Future studies are needed to compare child focused treatment to parent focused treatment and their combination to better understand the contribution of each to treatment success.
We also extend knowledge of parent outcomes in the present study. Specific hypothesized effects of family CBT have not previously been evaluated in parents despite the inclusion of parents in treatment. We measured changes in parental behaviors (i.e., parental protectiveness) that were targeted in treatment. However, unexpectedly, we did not demonstrate any significant group differences on this specific parental behavior, although in within- subjects analyses, we found that parental protectiveness diminished over time in parents in the Internet treatment condition. Because outcomes related to parental behaviors have not previously been reported in family CBT studies, it is not possible to compare our findings to similar studies. Perhaps our multicomponent parent treatment was not specific to addressing parental protectiveness, and/or that the assessment tool used is not stable enough over time to adequately measure treatment-related changes. Test-retest reliability of the Adult Responses to Children’s Symptoms measure has not yet been examined[34
]. In addition, we found that parents were less compliant than children in completing treatment modules and this may have affected their exposure to intervention content. Future studies should evaluate strategies to encourage parental participation with treatment as well as measure additional relevant parental outcomes such as parenting stress, parental emotional functioning, and parent-child communication.
Within the Internet treatment group, effects of treatment appear to be maintained over time and, for some outcomes, continued improvements were demonstrated at the three month follow-up. However, these results should be interpreted with caution as due to the wait-list control design, we did not have available comparison data from the control group at 3-month follow-up. Therefore, we cannot determine that continued improvements in children in the treatment condition were due specifically to the Internet intervention. In future studies, it will be important to use study designs that allow for examination of maintenance of treatment effects. In a recent systematic review of psychological therapies for chronic pain in children, in the few studies that have examined maintenance of treatment effects[6
], CBT was found to produce enduring changes in pain intensity.
A strength of the present study is that the outcome assessment plan included relevant multidimensional outcomes. Although pain intensity has been the most frequently reported outcome from chronic pain trials, it is critical that research on pediatric chronic pain also incorporate measurement of functional outcomes related to pain[22
]. Recently, recommendations have been made by the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (Ped-IMMPACT) concerning outcome domains that are important to assess in clinical trials with children and adolescents who have chronic or recurrent pain[18
]. Eight domains were recommended: pain intensity, physical functioning, symptoms and adverse events, global satisfaction with treatment, emotional functioning, role functioning, sleep, and economic factors. In this study, in addition to pain intensity, we evaluated treatment effects on children’s physical and emotional functioning.
Our study is one of the first to demonstrate changes in children’s physical functioning with psychological treatment. Treatment content directed toward both children and parents emphasized a return to usual physical activities. Children received instruction in activity pacing and goal-setting around physical activities. The involvement of parents in treatment may have also contributed to these improvements. Our findings are unique in that there is little evidence from RCTs that children’s physical or role functioning is changed by psychological treatments[6
] . One exception is a recent RCT of acceptance and exposure strategies in which a significant improvement on one measure of function, pain interference, was found for the treatment group in comparison to a usual care group[36
Group differences in children’s emotional functioning, specifically in their depressive symptoms, from pre to post treatment were not found. Overall, depressive symptoms were in the subclinical range both before and after treatment. However, at three month follow-up depressive symptoms were significantly decreased in the Internet treatment group. It is unclear whether a lengthier period of time was necessary for changes to occur in children’s emotional functioning or whether measurement issues contributed to this finding. Somewhat surprisingly, depressive symptoms have also been unchanged in other RCTs of psychological treatments for chronic pain[6
Because of the novel method of treatment delivery, we were interested in documenting treatment acceptability, satisfaction, and compliance with treatment. The participation rate in this study (74%) was similar to rates of participation in studies of face-to-face CBT[13
], suggesting acceptability. In our exploratory analyses, we also found that almost all children and parents rated the Internet treatment as acceptable and satisfactory. Moreover, the attrition rate was very low with only 8% of children dropping out of the trial. Overall, child and parent compliance with the program was good, with the majority of participants completing the entire program. As noted, child compliance was higher than parental compliance. However, treatment compliance was not related to treatment outcomes. Although Internet interventions present unique opportunities to measure real-time usage of an intervention, tracking the amount of time spent on web sites is challenging due to factors such as variations in individual user habits (e.g., not logging out or closing browser windows) and internet connectivity issues. In other Internet intervention studies, user characteristics such as comfort with the Internet have predicted treatment success[1
], and may be important to assess in future studies.
Our findings should be interpreted in light of several limitations. Because we did not include a measure of treatment expectancy or an attention comparison condition, we are unable to know the influence of expectancies nor are we able to separate treatment from placebo effects. Future studies with a placebo attention condition would help to answer this question. We were also unable to examine moderators of treatment outcome. This is a critical area of future investigation, as to date, there is virtually no available information on individual differences in treatment response in pediatric chronic pain trials[6
]. In addition, generalizability is not addressed as our sample included a relatively homogenous group of patients (mostly Caucasian and middle class) recruited from one treatment center. Last, our design would have been strengthened by inclusion of all data collection online. It is unknown if there might be differences in how children responded to the written questionnaire measures versus to the online questionnaire measures; however data from other studies suggest high levels of correspondence between written and computer-based administration of measures of domains such as pain and quality of life (e.g., [11
Randomized controlled trials of psychological therapies for chronic pain in children remain limited, particularly for children with pain conditions other than headache[6
]. This study contributes to this growing knowledge base of psychological therapies for pediatric chronic pain. As yet, the majority of studies of Internet interventions are limited to feasibility and efficacy trials[28
], and have not involved large-scale dissemination. However, if future research continues to find results that support this treatment modality, Internet interventions such as ours may have the potential for broad dissemination.