Review of When Your Child Hurts:  Effective Strategies to Increase Comfort, Reduce Stress, and Break the Cycle of Chronic Pain.  By Rachael Coakley.  Yale University Press.  325 pp.  $22.

Chronic pain is a pervasive problem for children in the United States.  Each year about 1.7 million youngsters experience moderate to severe pain.  More than half of kids with pain have trouble keeping up in school and staying in touch with friends.  And the price tag of pediatric chronic pain is approaching $20 billion.

In When Your Child Hurts, Rachael Coakley, the associate director of psychological services at the Pain Treatment Center of the Department of Anesthesiology, Perioperative and Pain Medicine of Boston Children’s Hospital, offers a wide range of suggestions for managing children’s pain and pain-related problems. Her book is a valuable resource for parents in search of skills, strategies, and information that will reduce pain and foster adaptive growth.

Dr. Coakley reviews “the trifecta of services” – behavioral therapy, physical and/or occupational therapy, and medications – most relevant to the management of chronic pain.  And she identifies several “second and third tier” interventions, including acupuncture, sleep analysis, nutrition, yoga, aromatherapy, Reiki, chiropractic therapy, and homeopathy, that might be useful as well.

When Your Child Hurts is often refreshingly candid.  Parents, Coakley writes, should not be afraid to move their kids away from more passive behaviors (resting, watching television, snuggling on the couch) to more active pursuits (taking a walk, returning to school) even when they continue to complain that they are in pain.  The “self-efficacy” that often results, she indicates, will help children become more resilient.  Parents should set carefully calibrated goals that are not too easy to reach, and enforce them with carrots and sticks (such as limitations on screen time) that are consistently applied.  And since children rely on their parents for cues about how to respond to their situation, Coakley recommends that mom and dad remain calm and confident, even if at times they have to “fake it.”

Coakley reveals also that although Reiki, an alternative healing technique with Japanese roots, is a safe practice with no negative side effects, research trials indicate that it is no more effective than a placebo.  Despite mounting evidence that bio-feedback can play a positive role in pain management, Coakley writes, it is not covered by most behavioral health insurance policies (unless it is integrated into a broader practice of pain management and not offered as a stand-alone treatment).  And she informs parents with children who may need accommodations or services from schools for an extended period of time that they have a right to request formal arrangements (known as 504 plans and IEPs, individualized education plans) to ensure that there is an appropriate learning environment.  IEPs, she adds, are more comprehensive, include more services, are more difficult to qualify for, and take longer to put in place.

Throughout When Your Child Hurts, Coakley emphasizes the connection of the mind and the body and the indispensable role of psychologically based remedies in pain management.  Reflective listening, for example, can help a child release feelings of negativity, frustration, and fearMindfulness, a meditative practice that focuses attention on something that is going on now (and stimulated, for example, by playing the game “I never noticed”), can reduce physical discomfort and emotional distress.  Reading or telling guiding imagery stories (for which Coakley includes elaborate models) “can be used to trick the brain into modifying physical sensations that might be associated with pain or discomfort.”  And progressive muscle relaxation can activate “the parasympathetic nervous system” and thereby reduce blood pressure, slow the heart rate, improve digestion, and increase blood flow to the extremities.

Unlike the pain that follows a fall from a bicycle or a sliced finger, Coakley stresses, chronic pain does not alert our body to danger or protect it from harm.  Indeed, it is often difficult to pinpoint its underlying causes.  Over the counter and prescription medications (including anti-depressants, aspirin, vitamins, and a host of topical treatments) often can help, of course.  But When Your Child Hurts makes a compelling case that psychological and behaviorally based strategies should be integrated into a recovery plan.  And Coakley seems to be on target as well when she concludes that (for now, at least) managing pediatric pain, one of our nation’s most persistent and most invisible problems, is an art as well as a science.

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