A RANDOMIZED EVALUATION
Carrie L. Hicks, Carl L. von
Baeyer and Patrick J. McGrath
Journal of Pediatric Psychology 2006; 31(7): 724-736. Link to abstract.
Contact: carl.vonbaeyer [at] usask.ca
Headaches and stomach aches are among the most common childhood complaints dealt with by physicians (Farrell, 1984; Rappaport, 1989). Although these types of pains are often considered to be relatively benign, for some children who suffer with repeated episodes, the severity of pain and the frequency of recurrence can be debilitating and can significantly affect functioning. For most children with recurrent pain, current models of health care delivery are not sufficient. Often these children are subjected to expensive and unpleasant medical procedures (e.g., barium x-rays) which result in unremarkable findings; even more commonly these children are not treated at all.
Psychological treatment approaches have been used to effectively treat chronic and recurrent pain (Eccleston, Morley, Williams, Yorke, & Mastroyannopoulou, 2002); however, they are not always readily accessible. With the advent of more advanced technologies, new methods of health care delivery are being developed, such as distance treatments (Nickelson, 1996; Stamm, 1998). Distance treatments have many advantages over traditional therapies including increased access to treatment, savings in time and money, and reduced feelings of shame (Kirby, Hardesty, & Nickelson 1998; McGrath et al., 1992; Springer & Stahmann, 1998; Stamm, 1998).
The above-titled study examined the clinical efficacy of an Internet-based cognitive-behavioral treatment program for children with recurrent pain. The scientific findings are described in a 2006 article in the Journal of Pediatric Psychology. Below is a more detailed summary of the treatment program than is presented in the article. As well, links to sample pages from the original treatment website are provided below.
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The content of the ‘Help Yourself Online’ program (Hicks, von Baeyer, & P. J. McGrath, 2001) was largely based on information adapted from a draft of the Pain Module (P. J. McGrath, 2000) for the Family Help project at Dalhousie University. The main therapeutic elements of the cognitive-behavioral treatment were relaxation techniques (i.e., deep breathing, relaxation, visualization/imagery) and cognitive strategies (e.g., self-talk). As well, background information was presented on headaches and stomach aches to promote self-understanding and to help children recognize that some of their peers deal with similar problems. Positive lifestyle choices such as diet, exercise, social activity and active coping were also emphasized. Each chapter or weekly component presents a new topic (see the link to the Treatment Guide webpage below). At the end of each chapter, participants answered between three and five questions regarding the material presented and then submitted their responses by way of an online form. The end of chapter questions had several purposes including maintaining regular contact with participants, promoting treatment adherence and ensuring that the participants understood the information presented.
The same treatment materials were used for both younger and older children. Parents were encouraged to assist younger children or children with reading difficulties with the more challenging material. In addition to the information provided to children, there were two chapters specifically for parents, which discussed ways of encouraging healthy behavior.
The ‘Help Yourself Online’ website (Hicks, von Baeyer, & P. J. McGrath, 2001) was designed and built by the first author with essential input provided by the second and third authors, using Dreamweaver® 4 software. In designing the website, the main goal was to make it informative, yet appealing and interesting to children and adolescents. To that end, the pages of the website were designed like pages in a book to minimize the need for scrolling through large amounts of text. Colourful animations and characters were included on each page and a joke was included at the end of each chapter.
Access to the treatment website was given to participants only after randomization. Consideration was given to making the treatment site password-protected; however, it was viewed as a potential barrier (i.e., lost or forgotten passwords slowing down participation). Therefore, access to the website was direct via a web address, which was e-mailed to participants. To provide some degree of privacy, participants were asked to use only first names for any forms submitted online.
As a part of the treatment package, each participant also received a personalized relaxation tape. Each tape contained a number of relaxation and imagery techniques including full body relaxation, mini-relaxation, the three breaths technique, beach imagery and special place imagery. The special place imagery was based on information provided by the child during the intake process regarding a favorite place that helps them to feel relaxed. A thought journal was also included in the treatment package, to be used in conjunction with cognitive restructuring strategies.
Individuals in the 'Help Yourself Online' treatment group accessed the online manual which consisted of seven chapters, in addition to a welcome chapter. Participants were instructed to work through one chapter per week and to complete the online questions when they had finished each chapter. Upon completion of the online questions, participants would press the ‘Submit’ button and the responses would be automatically sent to the researcher in the text of an e-mail message. In several chapters, participants were assigned skills to practice during the week (e.g., deep breathing) and these skills were then subsequently discussed in an e-mail or a telephone call. Parents were also asked to review the Welcome chapter and the two parent chapters.
Over the 7-week treatment, the researcher regularly e-mailed and telephoned participants to check on their progress and to review materials. During treatment, participants were contacted by e-mail in weeks one, two, three, five, and seven and by telephone in weeks two, four and six. Parents were contacted by telephone in weeks two and six, and had the option of receiving copies of the messages sent to their children. Participants and parents were also given the e-mail address of the researcher/therapist and a contact telephone number in the event that they had any questions or problems. Some participants and/or their parents took the opportunity to initiate contact to ask for additional information or to talk about issues that arose. All contact between the participants and researcher/therapist was timed during treatment. At the end of treatment, each participant received a certificate in recognition of participation in the ‘Help Yourself Online’ program.
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Farrell, M. K. (1984). Abdominal pain. Pediatrics, 74(suppl), 955-957.
Hicks, C. L., von Baeyer, C. L., & McGrath, P. J. (2001). ‘Help Yourself Online.’ Sample pages available at http://www.usask.ca/childpain/research/hicks/index.html.
Kirby, K. M., Hardesty, P. H., & Nickelson, D. W. (1998). Telehealth and evolving health care system: Strategic opportunities for professional psychology. Professional Psychology: Research and Practice, 29, 527-535.
McGrath, P. J. (2000). Family Help: Pain Module. Unpublished manual, Dalhousie University, Halifax, NS.
McGrath, P. J., Humphreys, P., Keene, D., Goodman, J. T., Lascelles, M. A., Cunningham, S. J., et al. (1992). The efficacy and effectiveness of a self-administered treatment for adolescent migraine. Pain, 49, 321-324.
Nickelson, D. W. (1996). Behavioral telehealth: Emerging practice, research and policy opportunities. Behavioral Sciences and the Law, 14, 443-457.
Rappaport, L. (1989). Recurrent abdominal pain: Theories and pragmatics. Pediatrician, 16, 78-84.
Springer, A. K., & Stahmann, R. F. (1998). Parent perception of the value of telephone family therapy when adolescents are in residential treatment. The American Journal of Family Therapy, 26, 169-176.
Stamm, B. H. (1998). Clinical applications of telehealth in mental health care. Professional Psychology: Research and Practice, 29, 536-542.