Aromatherapy. Acupuncture. Biofeedback. Karate. Massage therapy. At Boston Medical Center’s (BMC) Pediatric Pain Clinic, patients take part in every one of these treatments to help empower them to take control of their chronic pain.
“Most of these kids are coming to see us after visiting multiple specialists, going through tons of expensive procedures including MRIs, endoscopies and surgeries, and trying many different pain medications, and they’re still experiencing debilitating headaches, stomachaches or some other kind of unexplained pain,” says child psychologist Laura Goldstein, PsyD, who co-founded the clinic in 2015 with pediatrician Caitlin Neri, MD, MPH.
Given that chronic pain is generally not caused by just one factor, the clinic’s philosophy is that one treatment alone won’t help in abating it, Neri says. That’s why the team offers a range of treatments, even if they seem unusual to patients.
“Many of the families we work with have no experience with integrative therapies before coming to us, but we really encourage patients to keep an open mind and try different things,” she says.
The approach appears to be working. Data collected by the clinic show that within three months of their first appointment at the clinic, patients experience enhanced quality of life and a significant reduction in the feelings of helplessness triggered by their pain.
“In essence, they are graduating from the clinic with a much greater ability to manage their pain,” says Goldstein, who is also an assistant professor of psychiatry at Boston University School of Medicine.
A focus on functioning
Goldstein and Neri originally created the pain clinic to support the medical center’s large population of children with sickle cell disease, for whom pain is a common problem. Word of the clinic quickly grew, and referrals started coming in from all kinds of pediatric specialties, particularly gastroenterology and neurology, as well as from primary care and other specialty clinics outside the hospital.
While Boston Children’s Hospital also offers its own integrated-care pediatric pain clinic, BMC is the medical home for low-income patients and was ripe for its own pain center. Having a pediatric pain clinic within the safety net hospital has made the service much more accessible for BMC’s patient population.
“For many of our patients, transportation is a huge barrier, or their parents hold multiple jobs, making the time needed for appointments a big factor,” Goldstein says. “What makes our program particularly unique is that patients can come in and get the majority of, if not all, their treatments in one visit.” They also don’t need to travel far within the hospital. All of the interventions—from acupuncture to karate to nutrition services—take place at the clinic, she says.
When the clinic opened, the integrated-care team included only Neri, Goldstein and a social worker. Today, the team includes a physical therapist, nurse educator, psychiatrist, massage therapist, acupuncturist, aromatherapist, karate instructor and nutritionist.
The multidisciplinary team schedules all new patient appointments on Mondays, when the practitioners meet with the family to discuss the child’s medical history and when his or her pain started, as well as the child’s sleep, diet and educational history. More than 60 percent of new patients report missing at least six days of school over the previous school year, with 37 percent missing 10 days or more, according to clinic data. Goldstein then meets privately with each patient and family to get a better sense of the child’s mental health history, previous trauma and whether he or she is experiencing anxiety or mood issues. She also asks how the families are coping with the child’s chronic pain.
“Before coming to us, most of these families have never gone through counseling, so having Dr. Goldstein as part of the integrated-care team really helps to take away the resistance some families have toward mental health care,” Neri says.
After assessing each new patient, Goldstein often starts by educating the parents about the best way they can help their children, she says.
“For most parents, their initial reaction if their child is in pain is to coddle them and do anything they can to help alleviate the pain,” Goldstein says. “We help them understand that what often works the best in chronic pain situations is to really just help the child focus on functioning. It can be a mindset shift for most parents.”
For example, she encourages parents never to ask their child about his or her pain, since it can make the child focus on the pain. Instead, she advises parents to support the child in independently using the pain-management strategies she teaches them, including deep breathing and meditation. She also suggests that her patients try yoga.
“Focusing on what the child can do to help himself or herself empowers the child to get control over the pain instead of allowing the pain to take control,” she says.
Goldstein will often perform evidence-based biofeedback interventions with patients to help them better understand the mind-body connection and teach them deep-breathing and relaxation techniques to help them calm down when they are feeling anxious or stressed or are in pain. She also works to educate schools on how staff can help children and adolescents with chronic pain miss fewer days of school. For example, she’ll speak with the nurse at a patient’s school about his or her treatment plan and encourage the nurse to allow the patient to take short breaks as needed for pain.
“We want the school nurses to understand that sending students with chronic pain home right away just reinforces this idea that they are too sick to be in school, which is the opposite message that we want to send,” she says.
Integrated and integrative
After each patient’s initial meeting, the clinic’s integrated-care team meets to discuss the patient’s case and to develop an individualized treatment plan, Goldstein says. Sometimes the plan will include physical therapy, behavioral therapy, sleep recommendations, the addition or subtraction of medications and/or nutrition services. At the patient’s follow-up appointment, typically about one to two weeks later, they’ll get to start sampling the integrative therapies the clinic offers, including acupuncture, aromatherapy, massage therapy and instruction in karate. The goal is to teach patients how to integrate these interventions into their daily lives as much as possible, says Christine Naoum-Heffernan, CPNP, the clinic’s nurse educator. When patients meet with the aromatherapist, for example, they work with her to develop a custom blend of scents that they can take with them and use as needed. With the acupuncturist, patients and parents are taught about certain acupressure points to focus on at home when the child is experiencing pain or stress.
“It’s not about magically sprinkling fairy dust and making these kids better,” Naoum-Heffernan says. “It’s about showing them tools they can then use to start making themselves feel better. It’s empowering them rather than telling them what to do, because when you empower them, they own it.”
Take 15-year-old Michael.* In the fall of 2017, he missed more school days than he attended, spending multiple days a week at home due to nonepileptic seizures and general body pain. He was referred to the pain clinic by his pediatric neurologist, who had already ruled out neurological issues. Goldstein educated Michael and his family on how the body reacts to stress and trained him on breathing exercises and other coping mechanisms he could use when he gets anxious or stressed. He also worked with the clinic’s karate instructor to learn how to use the power of his mind and body to “fight his opponent, pain” and started learning how to kickbox. Several months later, he reported a dramatic decrease in his pain, greater confidence and increased social outings with friends, and he’d greatly reduced his school absences.
“It’s just always so exciting to see these kids take their lives back,” Naoum-Heffernan says.
*Name changed to protect patient privacy.
The Monitor’s “Adventures in Integrated Care” series explores the work psychologists are doing as members of interdisciplinary teams. If you have a story to share, contact editor Sara Martin at smartin@apa.org.
