Acceptance and Commitment Therapy for children and adolescents with physical health concerns
Introduction
Despite continuous advances in health care, a large number of children and adolescents suffer from physical health concerns, such as chronic pain or fatigue, that significantly interfere with everyday life [1]. For a subgroup of individuals, behavioral strategies characterized by avoidance of negative psychological experiences result in, for example, social withdrawal, school absence, or poor treatment compliance (as seen among patients with medical conditions such as diabetes or cystic fibrosis). Although followed by short-term symptom relief such behaviors tend to, over time, result in lower levels of physical, social and emotional functioning (Holmström L, Kanstrup M, Kemani M, et al.: Exploring the debilitating effects of pediatric chronic pain: evaluation of the Pain Interference Index and analyses of the relation between demographic variables, pain and functioning, submitted for publication) [2], and thus, represent a major threat to future health and life quality.
Chronic physical health concerns in youths also have a significant impact on parental stress and family functioning [3] and commonly implies a substantial economic burden for the families [4], as shown in studies on pediatric chronic pain.
Furthermore, the debilitating effects of symptoms may remain into adulthood [5], which illustrates the need for better treatments aimed at improving or retaining functioning, also in the presence of longstanding symptoms and related distress.
From a contextual behavioral perspective, avoidance of, for example, pain and distress is considered a central target for treatment. In Acceptance and Commitment Therapy (ACT), the objective is to increase functioning and quality of life by improving the individual's ability to act effectively in alignment with life values and long term goals also in the presence of interfering thoughts, emotions and bodily symptoms (denoted as psychological, or behavioral, flexibility). Exposure to previously avoided situations (that elicit discomfort) is considered the core intervention, and conducted to facilitate acquisition of new behavioral responses while engaging in personally important activities. These ideas are supported in a large number of studies. For example, it has been shown that greater acceptance of chronic pain is associated with less avoidance of important activities, better emotional well being, and less health care utilization [6]. In line with these correlational findings, the empirical support ACT has increased rapidly during the past decade, particularly in the area of chronic pain [7, 8].
ACT represents a set of principles that should be applied functionally, that is, the topographical form may vary considerably due to the context. In working with children and adolescents it is of particular importance to carefully consider contextual factors related to the family, to maximize the feasibility and effects of treatment. For example, when medical treatments are ineffective the continuation of symptoms may elicit fear, frustration and hopelessness in the patient as well his or her family and beliefs such as ‘something must be wrong’ or ‘to reduce pain is the first priority’ should be expected. In this situation, parents may model and reinforce maladaptive behaviors such as using analgesics, seeking treatment or avoiding activities associated with symptoms and distress. Thus, it may be critical to address not just the child's pain and distress but also try to increase parental psychological flexibility, that is the parent's ability to effectively support the child in the presence of significant personal distress.
Importantly, developmental aspects should be considered in the assessment and treatment of pediatric patients. For example, a child may have rather different thoughts concerning their symptoms as compared with adults. Also, a relatively more explicit discussion of pain behaviors may be warranted to assist the child in discriminating between private experiences (thoughts, emotions and bodily sensation) and behaviors, as well as to clarify the function of those behaviors. Due to developmental aspects, the therapist should also be aware of possible problems with generalizing from one context to another. For example, strategies effectively used to deal with pain may not be utilized in relation to fatigue or anxiety unless specifically addressed. On a related note, difficulties with abstract reasoning have implications for discussions and exercises related to for example self-observation and perspective taking. For similar reasons, identification of personal life values may benefit from a discussion that initially concerns concrete goals relatively close in time.
Given the unique contextual and developmental aspects, results from studies on adults can only partially be generalized to pediatric samples. Only a few papers have yet addressed the utility of ACT, and ACT-constructs, in relation to children, adolescents, and families [9]. The critical need for more research is clearly illustrated in a recent systematic review and meta-analysis of randomized controlled trials (RCT) of ACT, which included only two RCT's with pediatric patients (depression and chronic pain) [10].
Thus, based on the growing empirical support for acceptance oriented interventions, the aim of the present paper is to present an overview of research on ACT for youths with physical concerns.
Section snippets
Findings
For the present review, relevant papers were either drawn from an ongoing systematic review concerning ACT and pain or identified through complementary searches in PubMed and PsychInfo using search terms such as ‘Acceptance and Commitment Therapy’ or ‘ACT’ in combination with ‘adolescents’, ‘children’ and ‘parents.’ Although research on ACT for children and adolescents with physical concerns is limited, several studies of importance for the field exist. The vast majority of ACT-studies are
Summary
Results from existing studies indicate the utility of an ACT approach in the treatment of youths with physical concerns. However, more research, including studies on specific conditions, is clearly needed to evaluate this approach. Also, there is an urgent need to clarify change processes, identify predictors of treatment outcome, evaluate the cost-effectiveness, and investigate the utility of different treatment formats (e.g. internet-delivered treatment).
References and recommended reading
Papers of particular interest, published within the period of review, have been highlighted as:
• of special interest
•• of outstanding interest
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Cited by (20)
Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission
2021, The Lancet Child and Adolescent HealthCitation Excerpt :Psychological interventions with robust evidence for procedural pain include distraction, hypnosis, combined CBT, and breathing exercises.297 There are many primary studies and evidence syntheses of psychological therapies delivered to children and adolescents with pain, including hypnosis,297 problem-solving therapy,300 acceptance commitment therapy,301 mindfulness,302 and memory reframing,303 among others. However, data for the possible harms from these approaches is rarely collected and is largely unavailable.304
Chronic pain
2020, Adherence and Self-Management in Pediatric PopulationsFurther validation of the Chronic Pain Acceptance Questionnaire for Adolescents in a broader paediatric context
2019, Journal of Contextual Behavioral ScienceCitation Excerpt :Young people experiencing chronic pain are significantly more likely to experience anxiety or depression (Zernikow et al., 2012), and to consider themselves as less independent than their peers (Eccleston, Wastell, Crombez, & Jordan, 2008). Importantly, evidence suggests that chronic pain and its consequences are likely to persist into adulthood (Walker, Guite, Duke, Barnard, & Greene, 1998; Wicksell, Kanstrup, Kemani, Holmström, & Olsson, 2015). This is reflected, for example, in the annual cost of PCP in the UK, previously estimated to be £ 3840 million (Sleed, Eccleston, Knapp & Jordan, 2005).
Improving flexible parenting with Acceptance and Commitment Therapy: A case study
2018, Journal of Contextual Behavioral ScienceCitation Excerpt :The treatment established a flexible behavioral repertoire not only in the mother, who received direct intervention, but was also generalized to the family context. This case study provides additional evidence in the same direction as other research in contextual therapy for parents (Ben-Porath, 2010; Biglan, 1989; Blackledge & Hayes, 2006; Coyne & Wilson, 2004; Gauntlett-Gilbert, Connell, Clinch, & McCracken, 2013; Gómez et al., 2012; Simon & Verboon, 2016; Wicksell, Kanstrup, Kemani, Holmström, & Olsson, 2015) Funding: This study was not funded.
Editorial overview: Third wave behavior therapies
2015, Current Opinion in PsychologyClinical Considerations for Behavioral Pain Management in Co-Occurring Acute and Chronic Pain Presentations
2022, Clinical Practice in Pediatric Psychology