The need and impact of a brief educational seminar on pediatric pain-focused CBT for school providers

Abstract

Objectives:

Pediatric chronic pain is common and can be detrimental to children’s social, emotional, and school functioning. Non-pharmacological approaches to chronic pain, like cognitive behavioral therapy (CBT) can be effective. Schools could provide children with chronic pain access to these interventions. However, school professionals (i.e. nurses and mental health providers) are seldom trained in CBT, creating a barrier to accessing such help. A seminar was created to introduce CBT strategies for chronic pediatric pain to school professionals. Feasibility, acceptability, and self-reported knowledge gain from the seminar were examined.

Methods:

Two introductory seminars (~2.5 hours each) were held separately for the Michigan Association of School Nurses and the Health Department of Northwest Michigan (n=71 total). The seminar provided an understanding of pain and pain-focused CBT strategies (e.g. activity pacing, positive self-statements, psychoeducation). Fifty-two school nurses, 16 mental health professionals, and three participants (unidentified title) rated program acceptability and self-reported knowledge of CBT before and after training (1=strongly disagree, 5=strongly agree).

Results:

89.6% of respondents agreed the training was helpful, and 87.5% were interested in additional training. For all questions relating to knowledge of CBT, a mixed model interaction showed a meaningful, increase of at least one point (on a five-point Likert-scale), F(2, 69.83) = 3.93, p = 0.024.

Discussion:

This study underscores the feasibility and acceptability of training school health providers in CBT for pediatric chronic pain. This project also established key partnerships in Michigan to expand future work in this realm with more comprehensive training and assessment of outcomes.

Introduction

Chronic pain affects 8%−38% of children and adolescents^1,2. Pain experienced by children can result in functional impairment^3,4 that can persist over time, including social⁵ and emotional difficulties³, mental health problems⁶ and poorer academic performance². There can be additional long-term effects of pediatric pain including potential substance use disorders or opioid misuse in adulthood⁷.

Pediatric chronic pain complaints, such as stomachaches or headaches, are frequent occurrences in school settings and are the most common reason for school nurse visits, accounting for about one third of all visits⁸. This makes school an important setting for addressing pediatric chronic pain. Strikingly, children with chronic pain are absent for more than one in five (22%) school days⁴. This is alarming because persistent school absences are a strong risk factor for school dropout², which in and of itself is associated with a lower likelihood of additional educational attainment, lower wages, and substance misuse^2,3. Addressing pediatric chronic pain early-on in the school setting could off-set these adverse outcomes. Effective nonpharmacological strategies for managing pain and preventing related adverse impacts are available,⁹ but have limited accessibility as providers are often specialized pain psychologists.

Cognitive Behavioral Therapy (CBT) for pain has been shown to be effective in managing pediatric chronic pain^10,9. CBT includes cognitive (e.g. problem solving) and behavioral (e.g. deep breathing, guided imagery, and activity pacing)^11–13 strategies to enhance coping and restore functioning^10,9. Unfortunately, however, few professionals become trained in CBT-based pain treatments, and there is a general lack of behavioral health providers across the US, particularly in rural or other underserved communities^1,14. In Michigan for example, a recent report indicates a major gap in behavioral health care particularly in rural and underserved areas¹⁵. These findings indicate that the behavioral health workforce is insufficient to meet the needs of children with chronic pain. Therefore, teaching other professionals who interface children, such as school providers, pain-focused CBT may be an effective method for increasing access to care.

Trained school providers (e.g., school nurses and mental health professionals) may serve as a potential access point in reaching children who experience chronic pain. Efforts to train school providers (e.g., mental health specialists) in CBT for pediatric mental health concerns has already been undertaken with promising results¹⁶. However, despite how common chronic pain issues are for youth, education and support for use of pediatric pain-focused CBT among non-mental health specialists such as school nurses (who are the most likely to interface with children with pain symptoms) and other school professionals is extremely limited.

The goal of the current project was to provide an introductory educational seminar on CBT for pediatric pain to two provider groups that serve Michigan schools: the Michigan Association of School Nurses (MASN), which includes school nurse members serving schools across the state, and the Health Department of Northwest Michigan (HDNW), which includes both school nurses and mental health specialists serving school districts in rural northwest Michigan, a region of the state with limited access to pediatric behavioral healthcare. Our aim was to assess whether the seminar was feasible and acceptable to participants, and whether it led to increases in self-reported provider knowledge of using CBT for pediatric chronic pain.

Materials and Methods

Participants

Participants included professional members of 1) the HDNW, a district health department serving four counties (Charlevoix, Emmet, Antrim, and Otsego) in the northwest region of the lower peninsula of Michigan, and employs nurses and mental health professionals serving schools in that region, and 2) the Michigan Association of School Nurses, a professional organization serving school nurses across the state of Michigan. Recruitment for participants was through partnership with these two organizations. All school nurses and school-based social workers from HDNW participated in the training. All nurses from the MASN fall conference with interest in our topic attended the session.

The sample comprised of 71 total participants (Table 1). Most participants were either school nurses (n = 52; 73.2%) or school mental health professionals (n= 16; 22.5%), who mostly self-identified as social workers (n=13). The participants primarily identified as female sex (n=62; 87.3%) and White (n=61; 85.9%) with a median age of 45.6 years.

Table 1:

Introductory Seminar Details

Focus	Detail
Introduction	Definition and prevalence of chronic pain Pain and impact on psychosocial functioning The biopsychosocial model of pain Chronic pain vs acute pain
Screening	Pain assessment Functional impairment Assessing related aspects of functioning (i.e. school outcomes, mental health) Creating a care plan with PCP or school personnel
CBT strategies for Addressing Pediatric Pain	Psychoeducation   Gate Control theory   Parent/Caregiver Guidelines Behavioral Strategies   Activity pacing   Relaxation strategies (i.e. mindfulness, biofeedback, activity pacing) Cognitive Strategies   Identifying negative thoughts   Positive self-statements Problem solving/ future planning Toolkit for participants   Handouts and educational videos11

^*Introductory seminar content was identical for the two groups, MASN and HDNW. Seminars were scheduled to be 2.5 and 3 hours respectively. For the latter group, additional case examples were provided to augment practice of the skills (activity pacing and identifying negative thoughts). In addition to sharing our own self-management tools, we also provided a list of freely available self-management tools and resources to support pediatric pain as part of the seminar.

Procedures

The introductory seminar discussed pain assessment and strategies for managing pediatric chronic pain. There were three objectives: (1) increase knowledge of biopsychosocial factors impacting pain in youth, (2) increase knowledge of strategies for assessing pain and co-occurring mental health concerns in youth, and (3) increase comfort level for considering use of CBT skills to manage pediatric pain concerns. These objectives were achieved through providing 1) a basic introduction of pediatric chronic pain through the biopsychosocial model of pain, 2) strategies for how to screen for pain (e.g., frequency, intensity, duration, location), use of pain intensity rating scales (such as the visual analogue scale or numerical rating scale), screening for disability due to pain (e.g. functional disability inventory¹⁷, PROMIS pain interference), and other related psychological aspects of functioning (e.g., assessment of anxiety via the Screen for Anxiety and Related Disorders¹⁸), and 3) an introduction to managing pediatric pain using CBT. These tools were discussed with the goal of improving functioning and coping with pain rather than or prior to improvement in pain. The specific CBT strategies taught included psychoeducation (e.g. gate control theory of pain), behavioral strategies (e.g. activity pacing, relaxation strategies), and cognitive strategies (e.g. identifying negative thoughts about pain, positive self-statements, and future planning). Case examples were provided throughout the seminar. See Table 1 for more details.

A licensed pediatric pain psychologist and researcher with a postdoctoral fellowship in pediatric pain and over 13 years of experience in the psychological assessment and treatment of pediatric chronic pain (NRC) led the introductory seminars. The seminars were conducted on-line through virtual attendance of the participants. One seminar was 2.5 hours and the other was 3 hours (Table 1). These differences in timing were based upon scheduling availability from the two separate groups from which the participants were pulled. The seminars were held separately for each group, though the content was virtually identical. School provider attendees received up to 3 professional pain-focused Continued Education credits for completing these seminars. This study was determined exempt by Michigan State University’s institutional review board.

Measures

Baseline and post-seminar surveys (approximately 10 minutes each to complete) were administered via Qualtrics. Demographics were also obtained (e.g., age, sex, race, ethnicity; see Table 2). The post-seminar survey was administered directly after the end of the seminar. The surveys assess two components of the seminar: (1) the feasibility and acceptability of the seminars, and (2) self-reported provider knowledge of pain-focused CBT for pediatric chronic pain.

Table 2:

Demographics

Demographic Factor	Combined (n=71)	MASN (n=50)	HDNW (n=21)
Age, M ± SD	45.6 (±10.8)	47.65 (±11.66)	41.85 (±8.08)
No Response	19.7 (14)	26.0 (13)	4.8 (1)
Sex, % (n)
Female	87.3 (62)	84.0 (42)	95.2 (20)
Male	1.4 (1)	0 (0)	4.8 (1)
No Response	11.3 (8)	16.0 (8)	0 (0)
Race, %, (n)
African-American/Black	2.8 (2)	4.0 (2)	0 (0)
Caucasian/White	85.9 (61)	82.0 (41)	95.2 (20)
Native Hawaiians/Other Pacific Islanders	1.4 (1)	2.0 (1)	0 (0)
No Response	9.9 (7)	12.0 (6)	4.8 (1)
Ethnicity, % (n)
Hispanic	4.2 (3)	6.0 (3)	0 (0)
Non-Hispanic	83.1 (59)	76.0 (38)	100 (21)
No Response	12.7 (9)	18.0 (9)	0 (0)
Employment Title, % (n)
School Nurse	73.2 (52)	94.0 (47)	23.8 (5)
Mental Health Professional	22.5 (16)	0 (0)	76.2 (16)
No Response	4.2 (3)	6.0 (3)	0 (0)
Degree Date (year), M ± SD	2002 (±11.0)	1999 (±10.9)	2007 (±9.5)
No Response	12.7 (9)	18.0 (9)	0 (0)
Employment Date (year), M ± SD	2015 (± 8.5)	2013 (± 9.9)	2018 (± 3.0)
No Response	15.5 (11)	22.0 (11)	0 (0)
Limited access to behavioral health providers?
Yes	69.0 (49)	72.0 (36)	61.9 (13)
No	26.8 (19)	22.0 (11)	38.1 (8)
No Response	4.2 (3)	6.0 (3)	0 (0)
Population served, % (n)
Rural		12.0 (6)
Rural/Suburban		4.0 (2)
Suburban		36.0 (18)
Rural/Suburban/Urban		6.0 (3)
Urban		26.0 (13)
No Response		16.0 (8)

Participants were also asked specific questions during the baseline survey to gauge current perceptions relating to pediatric chronic pain and access to resources. All participants were asked (yes, no) if the area they served had limited access to pediatric behavioral health providers.

Participants from the HDNW served a rural area. Thus, for the MASN group only, we queried about whether the setting served was rural, urban and/or suburban. The HDNW seminar was held after the MASN group so additional questions were added such as what percentage of children served have pain or related issues. This same group was also asked to rate two following questions during the presentation on a Likert scale from strongly disagree (1) to strongly agree (5): “Pediatric pain has increased as a result of the COVID-19 pandemic,” and, “Pediatric pain is a common problem impacting the children you serve.”

Feasibility and Acceptability of Seminar.

Participants were asked to rate the following two statements on a five-point Likert scale of strongly disagree (1) to strongly agree (5): “I have received helpful training/education on cognitive behavioral therapy for pain today”; “I would like additional training and support on using cognitive behavioral therapy approaches”. Participants also responded yes or no to the question “I am interested in future training opportunities”. These three questions were integrated into the post-seminar survey.

Knowledge of pain-focused CBT.

All participants were asked to rate the following three questions on a five-point Likert scale of strongly disagree (1) to strongly agree (5): “I understand the biopsychosocial risk factors associated with chronic pain in children”; “I understand the evidence for using cognitive behavioral therapy for pediatric pain management”; “I feel comfortable discussing cognitive behavioral theory strategies for students with pain symptoms.” Differences in self-reported provider knowledge of CBT strategies for pediatric pain management were compared between the pre seminar and post seminar. These items were refined based on a prior study¹⁹.

Data Analysis

Data analysis was conducted via SPSS version 28. Demographics were recorded using descriptive (age, degree date, employment date) and frequency measures (e.g. sex, employment title). To compare differences between seminar groups, means and frequencies of demographics for the two seminars were compared using chi-squared tests for categorical variables (e.g. sex, race, ethnicity, employment title, and access to behavioral health providers) and an independent t-test for continuous variables (e.g. age, degree date, degree year).

There were seventy-one participants who completed the pre-survey and fifty-six participants who completed the post-survey. Participants were matched between pre- and post-survey through IP addresses. Forty-seven (84%) out of the 56 participants who completed the post-survey were matched reliably using these means.

In the case of missing data (e.g., some participants did not complete post assessment or elected not to answer certain items such as sociodemographic questions) we retained available data for analysis. To check for bias in reporting, those without demographic data were compared to those with demographic data by the outcome of provider knowledge (all questions collapsed together). This was done by a chi-squared test where those missing the demographic sex were grouped versus those who reported the demographic sex (sex was used as a stand-in for completing demographic data). Missing data was then also grouped by those who responded on the post-seminar survey questions. These groups were also compared by chi-squared tests on sex, race, ethnicity, and employment title and were also compared via t-tests on age, degree date, and employment year.

Feasibility and Acceptability of Seminar

Participant satisfaction was analyzed using frequency of measures with the dataset in wide, multivariate form (one row per participant). Overall mean for acceptability and feasibility was used when the question response was in a Likert scale. The frequency of those who said yes to interest in future training opportunities was noted.

Knowledge of pain-focused CBT

Differences in self-reported provider knowledge of CBT strategies for pediatric pain management were compared between the pre-seminar and post-seminar. The data were organized in long, univariate format for repeated measures data (3 questions x 2 time points = 6 rows per participant) then analyzed using a linear mixed effects model with fixed effects for Seminar (between-subjects: HDNW vs. MASN), Question (repeated measure, 3 levels), Time (repeated measure: baseline vs. post-seminar), and all possible two and three-way interaction effects were explored. The model used a random intercept for participants. The linear mixed model used Type III sums of squares to test fixed effects with an F-statistic and p-value given for each effect. Values were considered significant if p<0.05.

We examined the Question*Time*Seminar interaction and other terms involving Seminar first because a lack of any seminar effects would support pooling data across seminars to answer the research questions. Next, we examined the Question*Time interaction to consider whether there were differences among specific objectives with respect to the amount of change over time (i.e., learning). Pairwise comparisons of the simple main effect of Time for each question were used to interpret the two-way interaction results because such an interaction suggests that the overall main effect of time is not stable across questions. We report the means and mean differences along with 95% confidence intervals and p-values with a Type I error rate set at 0.05.

Results

Missing data were acceptable in this study of school providers as 78.9% (n=56 of 71) of study participants completed the post-seminar survey and 47 of those (83.9%) were matched on the pre-seminar and post-seminar surveys. Nine participants could not be matched to a pre-seminar survey due to an inability to match IP addresses, likely due to connection errors on the participants’ end. However, all data for these participants were still retained since a linear mixed model method was used for analysis. Only one person did not complete any demographics at all. Excluding age as a missing demographic, 83.0% (n=59) of participants completed all demographic data in the pre-survey. For some items (e.g., age) there was a lower response rate (80.3%, n=57) on the pre-seminar survey and data were assumed missing not at random in that case. In comparing outcomes for those who reported demographics versus those who did not report demographics, results were non-significant.

Demographics

Table 2 presents demographics of the participants. The demographics varies slightly between seminar dates and are presented by seminar subgroup. Differences between means and frequencies for the two seminars were compared using chi-squared tests for categorical variables (e.g. sex, race, ethnicity, employment title, and response on access to behavioral health providers) and independent t-tests (unequal variances assumed) for continuous variables (e.g. age, degree date, degree year). With a Type I error rate of 0.05, age (p=0.032), ethnicity (p=0.048), employment title (p<0.001), degree date (p=0.005), and employment date (p=0.003) differed between the two seminar groups. The difference in employment title distribution was expected because MASN is made up of only school nurses and the HDNW has both school nurses and school mental health professionals. The MASN group was also on average older (which corresponds to holding a degree and being employed for longer) and had a larger percentage of Hispanic participants than the HDNW seminar group. The distributions of sex, race and behavioral health provider access did not differ between the two groups.

Only the HDNW group was asked a few additional questions about perceptions around pediatric pain during the seminar (which occurred subsequent to the MASN seminar). These participants generally agreed or strongly agreed (47.6%) that pediatric pain was a common problem impacting the children served. The other participants sampled neither agreed nor disagreed (28.6%) or disagreed (23.8%) with the statement with no participants strongly disagreeing. Approximately half (53.4%) of the participants also agreed (or strongly agreed) that pediatric pain increased as a result of the COVID-19 pandemic. Participants were further asked about the percentage of students they see who present with pain or pain-related issues with the majority (57.1%) identifying that between 10–49% of the students they serve present with pain. The other participants in this subgroup reported that more than 50% of their children have pain (14.3%) or less than 10% (28.6%).

Feasibility and Acceptability

Table 3 demonstrates the acceptability and feasibility of the seminar (using a 5-point Likert scale) and interest in future training (via yes/no). On average, 98.2% (n=55/56) of the respondents either agreed or strongly agreed they received helpful training/education. Of those who completed the post-seminar survey, the vast majority, 87.5% (n=49/56), were interested in future training.

Table 3:

Agreement with Feasibility and Acceptability

Item	Strongly Disagree % (n)	Disagree % (n)	Neither Agree nor Disagree % (n)	Agree % (n)	Strongly Agree % (n)
I received helpful training/education on CBT for pain today	0	0	1.3 (1)	36.3 (29)	32.5 (26)
I would like additional training and support on using CBT approaches for pain	0	0	11.3 (9)	35 (28)	23.8 (19)

Knowledge of Pain Focused CBT

A Type III test of fixed effects using a mixed linear model showed little evidence for interactions between seminar and other predictors of knowledge: Time*Question*Seminar, F(2, 69.83) = 2.455, p = 0.093; Time*Seminar, F(1, 60.31) = 1.367, p = 0.247; and Question*Seminar, F (2, 72.29) = 2.007, p = 0.142. With no interaction with seminar, focus shifted to interpreting other effects in the model. The outcome measured in each model was the 5-point Likert scale; the mean answer (1=strongly disagree – 5=strongly agree) was compared in the pre-seminar to the post-seminar with a 95% confidence interval (Figure 1).

Figure 1:

Following the introductory seminar on pediatric pain management, there were statically significant increases in understanding of biopsychosocial risk factors associated with chronic pain. From left to right, the mean increase in agreement were 1.005 (p<0.001), 1.325 (p<0.001), and 1.059 (p<0.001).

* indicates statistical significance <0.001

There was a modest Question*Time effect , F(2, 69.83) = 3.933, p = 0.024) showing that the magnitude of improvement over time varied somewhat based on the question. Interpreting the main effects of Question, F(2, 72.285) = 2.528, p = 0.087, and Time, F(1, 60.313) = 87.884, p < .001, is less important because the Question*Time interaction means the effect of each of those variables depends on which level of the other variable one examines. Therefore, the estimated marginal means for the longitudinal differences in means (post-seminar minus pre-seminar) were examined separately for each question (Table 4).

Table 4:

Mean agreement post-seminar vs pre-seminar

Question	Mean difference	SE	P	lower bound	upper bound
All questions	1.13	0.12	<.001	0.889	1.371
I understand the biopsychosocial risk factors associated with chronic pain in children	1.005	0.16	<.001	0.687	1.322
I understand the evidence for using cognitive behavioral therapy for pediatric pain management	1.325	0.162	<.001	1.002	1.649
I feel comfortable discussing cognitive behavioral therapy strategies for students with pain symptoms	1.059	0.112	<.001	0.834	1.283

Note. Mean agreement to the questions was recorded on a Likert scale and the pre and post seminar rating were compared and were statistically significance for each question individually and when examined together.

All three questions led to mean improvements of least one point after the seminars, but the largest improvement occurred with respect to participants’ ratings of understanding the evidence for using CBT. The smallest was for understanding risk factors associated with chronic pain in children (where participants generally reported a higher baseline level of understanding compared to the other items; Figure 1 & Table 4).

Discussion

It is important for these groups to address pediatric pain given how common^1,2 and potentially debilitating it can be for impacted youth, with adverse impacts noted in psychological, social and academic domains^3–6. Further, access to specialized care for pediatric chronic pain, particularly in rural and underserved communities such as Northern Michigan where a portion of this research took place, is extremely limited¹. This study explored the feasibility and acceptability of an introductory educational seminar on identifying, addressing, and managing pediatric chronic pain in school settings. The participants included school nurses and mental health professionals. In the current project, we partnered with two intermediary organizations to offer an introductory seminar to school providers serving Michigan students. MASN includes school nurses across the state and the HDNW employs both school nurses and mental health workers in Northern Michigan schools to offer focused support in rural and underserved communities with limited access to behavioral healthcare. This allowed us to reach a diverse group of professionals.

Providers across both organizations generally found the introductory seminar to be helpful as evidenced by self-reported increased knowledge, and importantly, the majority (87.5%) requested additional training and support. This data allowed us to establish that support for pediatric pain management in school settings is a community-driven need versus a solely investigator-imposed research idea. This initial groundwork has set the stage for developing critical partnerships with community stakeholders to foster further collaboration and support towards addressing pediatric chronic pain symptoms in Michigan school settings via a comprehensive educational approach.

Indeed, this work is complementary to ongoing work increasing access to evidence-based strategies for management of child mental health concerns in partnership with Michigan school providers²¹. Specifically, Michigan school providers (specifically mental health professionals) have been trained in CBT for management of mental health (anxiety, depression) in Michigan schoolchildren²¹. However, pain management has not been addressed. This is important because pain management is unique and both health and mental health professionals would benefit from targeted seminars on both unique pain management skills and how to apply their extant knowledge of CBT for mental health to pain management. However, our data supports that key providers (e.g., school nurses) tasked with addressing student pain lack this extant CBT knowledge, indicating a need for training in such strategies. Furthermore, participants themselves indicated the commonality of chronic pain impacting the pediatric population. Therefore, the current project is both timely and critically needed to address the common and debilitating problem of pediatric chronic pain.

Strengths/limitations:

This study was an important first step in establishing key partnerships with school providers throughout the state of Michigan and within northern Michigan communities which are traditionally rural and underserved. Specifically, the four counties served by the HDNW (Charlevoix, Emmet, Antrim, and Otsego) have an average of 1,095 residents to one mental health provider²². Another strength of this study is that our group engaged a heterogenous group of both school nurses and mental health specialists in addressing the challenges of pediatric chronic pain in school settings, which is important as both types of providers may be tasked with addressing student pain, yet not all schools have access to healthcare and/or mental health professionals. Therefore, a flexible approach reaching both healthcare and mental health professionals is critical. Although the majority of the providers (73.2%) were school nurses and presumably less familiar with cognitive behavioral approaches for managing pain symptoms, all provider types reported comparable levels of program feasibility, acceptability and knowledge increases. Both groups of professionals desired additional training and support.

We do note a limitation of this study is lack of nationally representative population. The majority of school providers were White, non-Hispanic, and female. Other limitations include lack of a control, a relatively small-scale investigation, and the inability to accurately match all pre/post data due to relying upon IP addresses. However, these findings lay the groundwork for future research in this area. Due to the relatively brief nature of the seminars, there was not adequate time to explicitly address the stigma associated with chronic pain which could be seen as a limitation in education of chronic pain management.

Future directions

Given the engagement of the providers from our partner organizations, we applied for and received grant funding (from the Blue Cross Blue Shield Foundation of Michigan and the Michigan Health Endowment Fund) to support more extensive education and evaluation of provider use of pediatric pain management strategies with these partner organizations. This program, called Helping Educators Learn Pediatric Pain Assessment and Intervention Needs (HELP PAIN), will include a comprehensive seminar program co-developed with key community stakeholders and then delivering the program to school nurses and mental health specialists from MASN and HDNW. We will evaluate program feasibility and will track provider use of strategies and student outcomes, in addition to evaluation of program sustainability and reach. This project is the next step to build upon the relationships and findings established from the current investigation and may also warrant a future clinical trial.

In summary, this work highlights the importance of engaging with key community stakeholders to establish the need, determine interest, and ultimately work together to address the problem of chronic pain impacting children.