Acute pain alerts the body. It serves to make us quickly realize potential threats and initiate action to eliminate the cause of pain and reduce the pain. Hence, pain is always accompanied by feelings of fear and threat. In a child, the degree of increased pain-related anxiety is determined by three processes. These are attention to the pain, the amount of pain-related catastrophizing, and pain-related behavior. The most important facts underlying the biopsychosocial model of chronic pain are summarized as follows:

The degree to which pain-related behavior predicts the pain perception of children or adolescents is explained by the “fear-avoidance model” of Vlaeyen and Linton (2000) which was recently hypothetically adapted to paediatric pain (Asmundson et al. 2012). Pain as a potential threat leads to increased anxiety and tension. Cognitive processes such as fear of pain may result in situations or movements being erroneously considered as threatening. Those appraisals make the patient avoid certain situations or body movements in order to evade the pain. Especially in patients with backache, such behavior will result in increasingly restricted mobility and even more pain in the long run. According to the theory of Vlaeyen and Linton (2000), the fear of pain has more impact on the patient’s life than indeed the perceived pain itself. The patient’s fear of pain is dependent on the extent to which he/she is able to fearfully perceive physical processes in his/her body (anxiety sensitivity). Increased anxiety sensitivity is closely associated with fear of pain. In a study of 21 children and adolescents suffering from chronic pain, Martin et al. (2007) were able to demonstrate that premorbid anxiety sensitivity is a predictor of fear of pain. Presumably, anxiety sensitivity is associated with maladaptive interoception. Thus, anxiety sensitivity modulates pain perception to a considerable degree and has a strong impact on pain-related behavior (see Sect. 6.4.6.1 for a detailed account of the theoretical background of fear of pain and anxiety sensitivity).

What are the practical consequences of all this theory for the education session?

It is important for children and parents with a somatic fixation that all their perceptions and fears are taken seriously. From a psychotherapist’s viewpoint, it is important to evaluate the somatic observations but at the same time refuse the underlying irrational assumptions. This may be a challenge since every child knows cases from the family, the newspaper, or TV – and even if it is just one case – in which a malignant disease was not recognized on time. Counteracting these fears by recognizing them as being normal may help to avoid any dysfunctional conflict about the “right” perception. Most patients will usually be ready to follow the pain education supplemented by the information above. Asking the child to explicitly scrutinize that information with respect to his/her own case will motivate him/her to continue work. As a next step, we discuss the child’s own biological concept of permanent pain. If he/she has a sense of humor, it is quite easy to quickly find a common basis, as the following example will illustrate:

Questions aiming at the cost/benefit ratio are easy to understand by the affected children.

Even if no question about the child’s physiologic processes and their interaction with body signals were left unanswered, we have to acknowledge that there will never be 100 % security in life, as some of the smart children will point out. In those cases it has always been helpful to ask the child to make a list of pros and cons with respect to a so-far undetected severe somatic disease being responsible for the pain. This task ends with a decision as to which way to go and which way is worth living. This decision should be taken solely by the child (or if too young, together with the family) taking all the facts into account – try to leave your personal opinion out. If the decision is not to give up the search for “the” one and only cause (the still undetected disease), pain therapy doesn’t make sense and should be stopped. The psychotherapist should never be hurt by such a decision. Instead, he should offer to start pain therapy when the child and the family are ready.

Body awareness may be reduced by focusing on sensory perceptions incompatible with pain perception. Focusing on sensory perceptions (external or internal stimuli) is also well suited to the regulation of emotions and for controlling stressful memories (e.g., for experiencing flashbacks of traumatic or critical life events; Sect. 6.5.2). Hence, those techniques are also used in trauma therapy.

One version of a mindfulness technique is the adapted version of the 5-4-3-2-1 ­technique and can be found in Chap. 9 (instructions included; Chap. 9, Worksheet #8).

In this technique the child focuses first on five different things he/she sees, then on five things he/she hears, and then finally on five different bodily perceptions (incompatible with pain) that he/she can feel. Then the child begins again, but concentrates each time on just four different things. In the next round, the child concentrates on only three things, and so on. The child’s ability to concentrate on that which he/she really perceives is crucial to the success of the exercise. Some children do better when they recite each of these perceptions out loud to themselves. Some children love to run through this exercise quickly; others take a lot of time with it and enjoy the quiet and relaxation it produces or use the technique to get to sleep at night. It often happens that a child will experience the bodily perceptions as rather unpleasant, as the increased attention to interoceptive stimulus results in stronger pain perception. In this case the child will be encouraged to focus on sight and hearing (possibly on smell). Finally, many children reject the given structure (5-4-3-2-1). But the exact structure of the technique is not significant to its success. This is rather determined by the extent to which the child is able to concentrate on the present sensory stimuli. Alternating between sight and hearing (1-1), for example, without focusing on feeling, can also work well, as can closing the eyes and concentrating exclusively on various noises that are perceptible in the moment. Increased practice will reveal which variant of the technique best suits the child, whether it be slowly concentrating exclusively on hearing and feeling, the 5-4-3-2-1 or another structure. In the instruction in the 5-4-3-2-1 technique, it is very important to portray the described structure as just one possibility which can be changed to suit the needs of the child. Children should therefore try out various variants in order to be able to decide which suits them best.

This technique is especially suitable for children aged 13 years and older. You should plan on 30 min for giving the instructions as well as teaching the technique and another 10–20 min in upcoming appointments to discuss with the patient what was good and what was difficult. In order to decide whether this technique is suitable for the child and which part of it is especially suitable, the child should practice it well – at least three times a day. He/she should make a table with three columns, i.e., the time, which variant was used, and how successful it was. The procedure is illustrated in the next case report.

Body awareness can be reduced by focusing on topics incompatible with pain ­perception. As often practiced in everyday life or in the treatment of acute pain, in its simplest form this technique may comprise remembering one’s birthday or great holidays or doing simple counting exercises. But, this is often not enough to reach an elevated distraction score as needed in the treatment of pain disorders.

Of course the exercise should be neither too demanding nor too simple so that its cognitive requirements don’t render it unsuitable to some children. The distraction-ABC exercise that we have developed has turned out to be especially beneficial to children from about the age of 8, as it can be adapted in endless variants in order to be suited to each child’s age and abilities. This technique involves searching for words beginning with each letter of the alphabet within certain preset themes. These could be, for instance, animals – or horse breeds – (much loved by female children), or car words-ABC, or sentences-ABC, in which each succeeding sentence begins with the next letter of the alphabet. At higher levels of complexity, some of the children’s favorite sensory channels are included. For example, some older adolescents love the juke box version, in which songs are played in their heads (for approximately 10–20 s), also in alphabetical order. Even more complex is music video in which a music video is played through along with its corresponding song. These more complex levels of the exercise require the patient to be able to imagine the relevant sensory channel, be it sight, hearing, or feeling. We usually get indications of the preferred sensory channels during the education sessions and evaluation of diagnostic resources (see Chap. 9, Worksheets #1–6). Of course, we can always simply ask the patient (“Do you know music well enough to be able to play it in your head?”).

The distraction-ABC may be roughly categorized into four degrees of complexity:

In Chap. 9 (Worksheet #7) you will find instructions for the technique and several examples. Adolescents especially love the numerous possibilities and are eager to develop their own distraction-ABC. The examples presented here represent only a fraction of the many variants that have so far been developed by the children themselves. Therefore, the distraction-ABC is one of the most powerful interventions for treating even children with severely chronified pain disorders.

The 5-4-3-2-1 technique and the distraction-ABC may well be combined. Such a combination is especially suited to children with general anxiety or hypervigilance due to trauma. An external focus increased by anxiety predisposes a child to the 5-4-3-2-1 technique, but the effect of this technique alone is sometimes not strong enough. In the combined version the child searches for visual or auditory clues (viewing, hearing, not feeling) in alphabetical sequence (A  =  hearing an automobile, B  =  seeing the beard of a therapist, C  =  seeing a computer, D  =  hearing the barking of a dog, E  =  …). Some children love to do this without an alphabetical sequence (i.e., S  =  snack, G  =  glasses, a  =  …).

The distraction techniques presented here are not ideal for children younger than 8 years or with a pronounced learning disability. Simpler versions of the distraction-ABC are better suited, e.g., variations of the game “I spy with my little eye” or the search of the surrounding area for a certain number of things with a certain color or shape (“Find 10 blue objects, then 10 red objects.”). Another technique is to imagine stories on a given subject, e.g., the favorite doll.

Depending on the degree of pain chronicity, body awareness and pain perception may initially only show a weak and brief modification (seconds). But with ongoing practice, the effect is less transient. This is the reason why the child has to practice several times daily apart from the therapeutic sessions.

The child is invited to imagine a place (a real place from the past or present or an imaginary place) with as many sensory qualities as possible (seeing, hearing, ­feeling, smelling, tasting). For the individual child this “Safe Place” should be associated with feelings of security and safety. Mediated by the evoked positive physiologic reaction of relaxation, the aim is to positively influence both mood and body awareness and possibly also negative memories, thoughts or perceptions.

Depending on the patient’s feeling of familiarity with imagination techniques and his/her ability to visualize, we need 2–4 single sessions lasting between 10 and 40 min to teach and discuss the respective techniques. The first session is used to explain the exercise and its goal. When the child fully understands all information, explore his/her ability to evoke vivid imagery (use questions like “Can you imagine things in pictures?” or “If you imagine your last holiday, do you see any ­pictures with your inner eyes?”). Most patients will react unambiguously (e.g., intense thinking with a frown vs. “Sure, everybody can do that.”). If children with a vivid imagination agree to do the technique, the next step is to find a suitable “Safe Place.” It could be a real place from the last holiday, the patient’s room, a fantasy, or a fantasy construct from the movies (e.g., Lord of the rings or Twilight). Any place is allowed as long as the child associates security and safety with it. Having identified a suitable place, the patient’s homework is to write down in short descriptions what precisely he/she is seeing, hearing, feeling, smelling, or tasting at his/her “Safe Place” (Chap. 9, Worksheet #12).

In most cases no real people should be present at the “Safe Place” (animals and fictitious people are allowed, i.e., from movies, games) in order to avoid transferring relationship problems with a real person to the “Safe Place” which would then make it unhelpful. Sometimes a child wishes to also have a beloved person in his/her “Safe Place.” If this person is associated with feelings of security and is not ill, it is worth a try. It is no obstacle if the child is unable to describe the “Safe Place” with all the mentioned sensory qualities. In case the child spontaneously names two “Safe Places,” he/she should try a detailed description using all sensory qualities for both places. Usually the child will know intuitively which one is better suited. In the next therapeutic session, only one “Safe Place” is practiced.

A special version of the “Safe Place” is described by Seemann et al. (2002) (“children with headache,” only available in German language). They name it “Pet on my Belly.” Instead of a place, an animal is conveying safety and security. This version is less dependent on the ability of abstract thinking and is thus well suited to younger patients. However, the child must be able to imagine emotions and touch. Since the exercise is meant to be a relaxation technique and the setting is predefined in the instructions, we modified this technique. Especially younger children who see their pet as a source of comfort are very susceptible to exercises involving their pet. Also children with a strong imagination who like animals but do not have a pet themselves often enjoy imagination exercises with animals as a central anchor. The pet involved should not be sick or very old such that its death is foreseeable, a point that should be determined explicitly. Especially younger children like to repress those facts. To maintain the positive features of animal imagination independent of the context, biography, and the child’s abilities, we recommend a procedure following that of the “Safe Place.” In younger children it is helpful if the psychotherapist collects the cues together with the child and the psychotherapist writes them down (Chap. 9, Worksheet #12). Often a numerical rating scale (NRS) is too abstract for children younger than 9 years. In this case you may substitute the numeric imagination score by verbal denotations such as “excellent,” “good,” “moderate,” and “bad.”

Imagining a Pain Fighter or a creature from fairy tales is supposed to reduce the child’s helplessness by supporting the child in his/her efforts to cope with the pain. In accordance with the previously presented imagination techniques, the child is instructed to imagine with as much detail as possible. Together with the child the psychotherapist should consider in which way the Pain Fighter could support pain coping. Please find below three examples:

This imagination technique is trained and practiced the same way as the “Safe Place” or “Pet on my Belly.” The technique especially suits children younger than 12 years. The Pain Fighter arises from a very infantile fantasy in which the pain is considered an opponent. This technique – at least as presented – is not recommended for children aged 13 years and older. In those patients it should not be the primary aim to fight the pain as an enemy. It is sometimes difficult to explain this to the younger child. For older patients we recommend the “internal helper” well-known from trauma therapy (Reddemann 2005; only available in German language).

Usually children are very quick to spot dysfunctional thoughts and change them with the appropriate support. As with adults, cognitive restructuring is a multistep approach:

In this chapter, we simply focus on describing the implementation of this ­cognitive restructuring in pain therapy. For a comprehensive presentation of approaches to cognitive restructuring in children, see Stallard (2005) or Schlarb and Stavemann (2011).

Some patients are not that happy with a purely cognitive approach. They don’t really like to extensively dispute their thoughts. These patients (of course this approach fits for the other patients as well) might be suited to writing down the “Three Letters” before deciding to learn more cognitive interventions or to learn a more acceptance-oriented approach.

This technique will work only if the child has the necessary cognitive ability (typically from 13 years and up) and is willing to take on the required homework.

The psychotherapist asks the child to write three letters (for a detailed instruction, see Chap. 9, Worksheet #17). The third letter should be written immediately after the second letter is finished (only a short break is allowed). Each letter should comprise about one written page. Some of the children will pack all necessary information into a letter of no longer than half a page; others will need 2 to 3 pages each:

These letters are well suited to gaining an overview of all relevant parts of the child’s life, his/her own perspectives of change, important resources, and critical (cognitive) factors relevant for therapy. It is then quite easy to filter all important negative cognitions out of the Three Letters together with the child. Often you will find those written down word by word. An invaluable benefit of that intervention is that it will help the child analyze his/her situation more clearly. Reaching this clarity by his/her own effort will make the child proud. Writing the Three Letters allows the child to ponder all relevant areas of life, presumably for the first time.

This intervention should be avoided with children with a current depressive episode. If suicide is the only solution given at the end of letter 2, the child should be complimented for his/her courage in writing down his/her worst fears. This information should then be made known to the psychotherapist for immediate attention. Any real current danger of a suicide attempt may reflect a depressive comorbidity which will require further action.

At the end of the last chapter, we explained a technique (“the Three Letters”) that allows for the elaboration of pain-related desires and goals. That intervention is also well suited as a preparation for the work with acceptance-based cognitive techniques that do not focus on the modification of thoughts. Research results offer preliminary support for the view that an acceptance-based approach is effective in both adults and children with severe chronic pain (Wicksell et al. 2009, 2011). In children with a pain disorder, the acceptance of pain may result in a better quality of life (Feinstein et al. 2011). Pain acceptance seems to have an inverse relationship to emotional impairment and pain intensity (Wallace et al. 2011).

What exactly is the difference between a cognitive and an acceptance-based approach? And how can the difference between acceptance and resignation be explained to the patient and his parents?

Contrary to the cognitive approach, the focus of an acceptance-based approach is not to teach alternative appraisals or lines of thought concerning pain but to reach the goals important to the patient in the intermediate or long-term future, irrespective of pain intensity. The focus of pain therapy shifts from pain reduction to a meaningful and happy life even if it is still painful (Wicksell et al. 2007). As mentioned before, the Three Letters can be the first step to identifying the long-term goals of the child.

The advantage of an acceptance-based approach is that pain is no longer regarded as an enemy that should be modified, reduced, or circumvented. Thus, the symptom distress of the whole family system arising from the pain-reduction battle can be eased. This approach is especially helpful if long-standing chronic pain makes quick pain reduction seem improbable. Because of their severe impairment in school, these children are at high risk of dropping out. Therefore, action is badly needed although options for change are minimal. The acceptance-based approach can be implemented in four steps.

Applying this technique, groups of muscles are tensed and then relaxed in a predefined sequence, always starting with the large muscles of the extremities and proceeding to the trunk muscles and finally to the small muscles of the face: