children

Review
Acceptance and Commitment Therapy for Pediatric
Chronic Pain: Theory and Application
Melissa Pielech 1, *, Kevin E. Vowles 1, * and Rikard Wicksell 2
1 Department of Psychology, University of New Mexico, Albuquerque, NM 87131, USA
2 Department of Clinical Neuroscience, Karolinska Institutet, SE-171 76 Stockholm, Sweden;
[email protected]
* Correspondence: [email protected] (M.P.); [email protected] (K.E.V.);
Tel.: +1-505-277-1394 (K.E.V.)

Academic Editor: Lynn S. Walker

Received: 4 October 2016; Accepted: 25 January 2017; Published: 30 January 2017

Abstract: Acceptance and Commitment Therapy (ACT) is a third wave behavior therapy approach
which aims to increase engagement in activities that bring meaning, vitality, and value to the lives of
individuals experiencing persistent pain, discomfort, or distress. This goal is particularly relevant
when these aversive experiences cannot be effectively avoided or when avoidance efforts risk their
exacerbation, all of which may be common experiences in children and adolescents with chronic pain
conditions. The primary aim of the present paper is to review and summarize the extant literature
on the application, utility, and evidence for using ACT with pediatric chronic pain populations by:
(1) defining the theoretical assumptions of the ACT model; (2) summarizing research study findings
and relevant measures from the published literature; and (3) critically discussing the strengths,
limitations and areas in need of further development.

Keywords: Acceptance and Commitment Therapy; ACT; children; adolescents; pediatric; chronic
pain; pain acceptance

1. Introduction
A significant percentage of young people experience chronic pain, generally defined as pain that
persists for three months or longer [1]. A subset of these patients report marked deficits in healthy
functioning [2] and commonly experience comorbid mental health difficulties that can persist into
adulthood [3]. Treatment efforts for chronic pain often highlight the primacy of pain reduction or
elimination. Such efforts to minimize current pain and avoid it in the future are perfectly natural.
In acute cases, efficient pain escape and avoidance behaviors can have genuine adaptive value, as they
minimize risk of morbidity and mortality by allowing for efficient detection and response to painful or
potentially painful situations [4–6].
In the case of chronic pain, however, these perfectly natural responses may not be the most
adaptive. In fact, when persistent, avoidance behaviors can be reliably associated with significant
disruptions in physical, social, and emotional functioning across the lifespan, often without any
corresponding decrease in pain. A prime and well-established example of these findings is the
fear-avoidance model, which consistently indicates that more persistent and widespread efforts to
avoid pain are associated with worse current and future functioning in both pediatric and adult
settings [7–11]. In youth, the role of caregiver responses to pain is also highly relevant, as high
fear-avoidance in parents or responses to the child’s pain that reinforce avoidance are related to
greater levels of child distress and disability [12–14]. Thus, when pain avoidance is a primary goal in
youth and their caregivers, there appears to be a heightened risk that pain will be more disruptive in
important areas of physical and psychosocial functioning [15,16].

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Children 2017, 4, 10 2 of 12

Youth with chronic pain and their family systems are therefore likely in need of treatments that
emphasize effective responding to pain, with less reliance on pain control. It is possible that effective
responding to chronic pain requires somewhat paradoxical responses to pain. Such paradoxical
responses might include, for instance, decreasing pain avoidance attempts, particularly when they
are ineffective at avoiding pain over the longer term or when they negatively impact important
functioning. Further, effective responding to pain may actually include “approach” behaviors, such
as participation in meaningful activities even when pain is present. Importantly, adoption of such
strategies requires careful consideration regarding whether one is willing to experience pain in the
service of engagement in meaningful activities. Acceptance and Commitment Therapy [17] aims
to improve the ability to act in alignment with personal values while in the presence of potentially
interfering pain and distress, a response pattern defined as psychological (or behavioral) flexibility.
As part of this process, the individual is encouraged to explore and challenge the utility of avoidance,
as well as acceptance-oriented strategies, in managing chronic pain. The primary aim of the present
paper is to provide a narrative review and summary of the extant literature on the application
and utility of ACT specifically for pediatric chronic pain. First, we review the primary goals and
theoretical assumptions of the ACT model. Second, we summarize treatment outcomes and relevant
measures from the published literature. Finally, we discuss strengths, limitations, and areas in need
of development.

1.1. The ACT Model

While a full review of the theoretical and philosophical assumptions of the ACT model is beyond
the scope of the present review (see Hayes et al. [17] for more information), it is important to highlight
a few key points. The first is to emphasize the overarching goal of ACT, which is to increase successful
engagement in activities that bring meaning, vitality, and importance to the lives of individuals
experiencing persistent pain, discomfort, or distress. This goal is particularly relevant when these
aversive experiences cannot be effectively avoided or when avoidance efforts risk their exacerbation,
as is often the case with persistent pain. Each of the following conceptual assertions circle back to this
overarching goal.
ACT is based on the philosophical positions of both pragmatism and functional contextualism [18].
Its pragmatic goal is “effective action,” meaning it aims to facilitate the effectiveness of behavior in
achieving adaptive and functional goals over the longer term. At the level of actual clinical interaction,
this goal is described in terms of greater engagement in valued actions. The functional contextual
orientation of ACT allows one to define two primary aims: (1) accurate prediction and (2) useful
influence on behavior [19]. The pursuit of these aims requires one to attend to the relevant contextual
events in any analysis of behavior, including historical events giving rise to the behavior as well
as relevant ongoing events in the person’s environment. Practically, ACT seeks to undermine the
influence of key current and historical stimuli that contribute to ineffective responses to pain, such as
persistent avoidance, and bolster the influence of those that contribute to more effective responses,
such as the specification and pursuit of desired valued outcomes. These aims of “accurate prediction”
and “useful influence on behavior” are concordant with the operant behavioral roots of both ACT and
Cognitive-Behavioral Therapy (CBT; [18,19]).
Much discussion has occurred regarding the similarities and differences amongst ACT and other
forms of psychotherapy, principally Cognitive Behavioral Therapy (CBT; for information regarding
applications of CBT for pediatric chronic pain, please refer to [20,21]). We suggest that there are
two key differences between these approaches. The first is the central focus on the facilitation of
values-based actions in ACT. While such a focus is both fully compatible and at times apparent within
CBT (e.g., [18,19]), its centrality in ACT is distinctive. The second key difference pertains to working
with human language and cognition. In brief, ACT seeks not to directly alter the occurrence of certain
instances of human cognition (e.g., catastrophic thinking) and sensation (e.g., pain intensity), but to
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increase the repertoire of responses to these cognitions and sensations, as well as the flexible use of
them, to facilitate actions more in line with valued activities over the longer term.
The experimental pain literature provides several examples regarding the utility of altered
responding to human cognition and sensation in adults. One of the earliest experimental trials
of acceptance involved an acute pain induction task, where participants were asked to submerge a
hand into an ice water bath and were randomized to a pain control (e.g., keep your pain under control;
don’t let it increase) or pain acceptance (e.g., let your pain be; don’t let it control your responses) set
of instructions [22]. Results indicated that tolerance time for participants in the latter condition were
significantly longer than the former. Importantly, participants in the pain acceptance condition viewed
pain and thoughts about pain as less influential than those in the pain control condition. This pattern
of results has been replicated several times in studies with experimentally induced pain and healthy
controls [23–27], as well as in adults with low back pain [28]. Furthermore, laboratory studies suggest
that the inclusion of values in experimental pain settings is important. For example, when a pain task
is paired with a personally important reason for experiencing the pain, tolerance times tend to be
increase and the experience of pain is viewed as a less important determinant of behavior [27,29].
The clinical model of ACT specifies several related treatment processes, each of which is intended
to help facilitate more effective responding to difficult or aversive experiences. For example, the
central overarching process has been termed “psychological flexibility,” which can be simply defined
as effectively and flexibly responding to aversives such that engagement in important areas of living
is maintained at a level that is sufficient for the needs of the individual [17,30]. Thus, an instance of
psychological flexibility in an adolescent with chronic pain may be maintenance of social and scholastic
engagement even with the ongoing experience of chronic pain and including times when pain is low as
well as when it is high (see Wicksell et al. [31], summarized below, for description of a case example).
Underlying this overarching process of psychological flexibility are three pairs of “sub”
processes [17]. These three pairs include (1) acceptance and defusion; (2) moment-to-moment
awareness and a transcendent sense of self; and (3) clarity and committed action in pursuit of
valued activities (e.g., see [17] for details, as well as [32] for an empirical evaluation of this model
in chronic pain). Acceptance and defusion refer to patterns of responding to pain that involve
acknowledgement that pain and suffering are a normal part of life many times and choosing to work
with these experiences rather than try to avoid or control them [33–35]. Moment-to-moment awareness
and a transcendent sense of self refer to aspects of mindfulness that seek to increase consistent,
nonjudgmental attention to the present moment, less struggling with present experiences, and the
facilitation of a stable sense of self as a person having experiences, rather then an unstable sense of self
as a person who is defined by the experiences themselves (see [36,37]). Finally, clarity and committed
action in relation to values includes a definition of useful, valued directions to help guide behavior
while in the midst of difficult circumstances, as well as a flexible commitment to these values such that
behavior can be adjusted over time to facilitate consistent movement towards them [38].
Thus, treatment success in ACT for pediatric chronic pain could be defined as the occurrence of
effective responding to the natural variations in pain intensity that occur, such that personal needs and
goals are being met or progressed. Furthermore, the model assumes that such treatment success is
most likely to occur when one is (1) aware of pain when it is occurring, but is not consumed by that
experience to the exclusion of other things happening; (2) aware of present experiences as they are
occurring and able to let these experiences come and go; and (3) clear on valued areas and engaged in a
flexibly persistent pattern of behaviors to pursue these areas. Overall, the relevance of these processes
in adult chronic pain is reasonably well-established in that measures of these processes are reliably
and significantly related with pain-related distress, disability, and healthcare use [39–41].
In the case of pediatric pain treatment specifically, this model applies to both caregiver and child.
Much like caregiver responses are important in the fear-avoidance model, greater caregiver acceptance
of pain and discomfort is associated with less restricted functioning in children [42,43]. Thus, it can be
hypothesized that parental support of the child’s engagement in valued activities in the presence of
Children 2017, 4, 10 4 of 12

pain via operant approaches may be helpful to the child’s overall success in adapting effectively to a
chronic condition.

1.2. Developmental Considerations

ACT has been successfully adapted and implemented for use with a wide range of pediatric
populations including youth with chronic pain (e.g., [44]), cystic fibrosis [45], and anxiety disorders [46],
as well as medical conditions that involve pain as a primary symptom [47]. For a review of the
application of ACT more broadly with pediatric populations with physical health conditions, please
refer to [48]. Given the inherent level of abstraction in some ACT concepts, developmentally sensitive
modifications in the language and delivery of treatment may be necessary. Adaptations should
be made based on clinical judgment and awareness of the patient’s level of cognitive, social, and
psychological functioning, as well as abstraction abilities (refer to [49] for a discussion of adapting
ACT interventions for adolescent populations). Briefly, adaptations may include age-appropriate
simplification of language of complex concepts, such as referring to distressing, pain-related thoughts
as coming from a “pain monster” whose advice may serve to restrict functioning and effective
engagement in valued activities [31]. Concrete strategies can be used for teaching abstract concepts,
like facilitation of values identification by using a heart shaped box that is filled with slips of paper
describing patient values or teaching mindfulness via a walking exercise [50]. There are also numerous
ACT metaphors that are developmentally relevant for use with adolescents, though it is recommended
that use of metaphors be chosen with consideration to the patient’s social context and interests. It can
also be helpful to reiterate and repeat important topics to reinforce understanding. Additionally, the
importance of family factors and inclusion of parents/caregivers in pediatric pain treatment is of
clear importance [14,31,51]. From an ACT perspective, more traditional behavioral strategies such
as contingency management may favorably be combined with interventions aimed at improving the
parent’s ability to self-manage distress, which otherwise may interfere with effective coaching [33].

2. The Evidence-Base for ACT with Youth with Chronic Pain

2.1. Search Criteria

Relevant treatment outcome papers using ACT published through December 2016 were identified
through searches on PubMed and PsychInfo using search terms such as ‘Acceptance and Commitment
Therapy’ or ‘ACT’ and ‘children,’ ‘adolescents,’ ‘youth,’ or ‘pediatric’ and ‘chronic pain.’ The evidence
base for using ACT with youth for chronic pain is modest, and includes one case study, one case
series, two randomized controlled trials, and three prospective cohort studies. Each of these studies
is reviewed below. In addition, a fourth cohort study is also reviewed. While the study described a
CBT-based intervention, mediation analyses were done using a measure of pain acceptance, thus the
outcomes seem relevant to include.

2.2. Case Study and Case Series

The first study in the field of ACT for pediatric chronic pain is a case study by Wicksell et al. [33]
that facilitated development of ACT treatments for youth with chronic pain and was helpful in
distinguishing between ACT and CBT in the context of chronic pain rehabilitation. The patient was a
14-year-old female, who had been experiencing persistent pain for three years. Her array of symptoms
were conceptualized as “musculoskeletal pain syndrome” and included generalized joint and body
pain, persistent headaches, and features of panic attacks with subsequent school absence, social
isolation from friends, and withdrawal from valued activities. Treatment was rehabilitative in nature
and primarily consisted of exposure to stimuli related to pain and distress, including avoided activities
and places, as well as significant values clarification exercises. Treatment comprised a total of 13
sessions over a six-month period, with three of the 13 sessions including both patient and parents.
At discharge, improvements were noted in functional disability, engagement with valued activities,
Children 2017, 4, 10 5 of 12

scholastic involvement, and avoidance of emotions. Importantly, these improvements were sustained
during a six-month follow up period.
In 2007, a follow-up case series was published describing findings from an individual ACT-based
treatment approach used with 14 adolescents (11 females, mean age = 17 years, standard deviation
(SD = 2.1) with chronic pain and high levels of pain-related disability [52]. Primary outcome
variables were disability and school attendance. Treatment emphasized exposure to private events
and previously avoided activities, values clarification and use of values as guiding principles for
engagement in exposure, as well as acceptance of distressing and negative feelings. Treatment length
varied from 5–29 weekly sessions and included individual sessions with parents, as needed. Significant
improvements were observed in the primary outcomes variables, which were maintained through 3
and 6-month follow-ups. Significant improvements were also observed in levels of pain catastrophizing,
pain intensity, and pain interference.

2.3. Randomized Controlled Trials (RCT)

Following the case study and pilot case series, Wicksell et al. [44] published the first RCT
evaluating the effectiveness of an ACT-based treatment for children and adolescents with chronic pain.
ACT was compared to a multidisciplinary treatment (MDT) including amitriptyline medication. The
primary components of the 10-week ACT-oriented treatment group were acceptance strategies and
exposure, with sessions occurring weekly. A total of 32 youth participated (mean age = 14.8 years,
SD = 2.4) with 16 patients randomized to each condition. Patients in the ACT condition improved
significantly in multiple domains (e.g., functional disability, health related quality of life) and changes
were sustained through follow up, as evidenced by multiple large effect sizes. Patients in the
MDT group improved in many domains, as well, but across conditions, patients who received ACT
improved significantly more in levels of pain-related fear, overall quality of life, pain intensity, and pain
interference. A prolonged treatment period in the MDT condition complicated comparisons at follow
up, but results demonstrated the relative utility of ACT in comparison to a multidisciplinary treatment.
In a planned set of post-hoc analyses, Wicksell et al. used data from this same RCT to identify
mediators of treatment outcome [41]. Tested mediators were pain intensity, as well as both CBT- and
ACT-consistent variables, including self-efficacy, catastrophizing, kinesiophobia, pain-impairment
beliefs, and pain reactivity. Only these last two variables, which were argued to be representative of
a more flexible and willing pain response style, were shown to be significant mediators of change.
Furthermore, in subsequent analyses these same two mediators were independent predictors of
outcomes at follow-up for the ACT condition only. Although tentative, the pattern of results suggests
that variables consistent with psychological flexibility mediate the effects of ACT-based interventions
to improve functioning in patients with chronic debilitating pain.
In a more recent study, Ghomian and Shairi [53] compared an ACT based treatment (n = 10) with
a control condition (n = 10) in children ages 7 to 12 with chronic pain. Details regarding treatment
components or the control condition were not provided (Note. the study authors were emailed a
request asking for further details regarding treatment and control conditions and no response was
received). Data was collected at four time points: pre-treatment, discharge, and 3.5 and 6.5 months
post-treatment. Regarding results, patients in the ACT condition reportedly demonstrated significantly
greater improvements in functional disability at the end of treatment and through the follow up
time points.

2.4. Prospective Cohort Studies

Gauntlett-Gilbert et al. [54] evaluated outcomes from a 3-week residential, interdisciplinary
ACT-based program (~90 h of treatment) for adolescents (n = 98) with chronic pain. The program,
comprised of physical conditioning, activity management, and psychology, also included parent
involvement in most sessions, with the exception of a four-day period where parents received therapy
separately from their child. Data on self-reported functioning (e.g., depressive and anxious symptoms,
Children 2017, 4, 10 6 of 12

levels of pain acceptance) and objective physical ability was collected from child and parent across three
time points: baseline, three weeks after discharge from treatment, and at a three-month follow up time
point. Patients improved across all domains of functioning in a manner that was theoretically consistent
with ACT whereby improvements occurred without efforts to control pain or manipulate cognitions.
Additionally, improvements in pain-related acceptance were associated with better treatment outcomes,
suggesting a key role of acceptance in pediatric pain rehabilitation.
Martin et al. [55] published outcomes of a feasibility trail of ACT for adolescents with chronic
pain and Neurofibromatosis type 1 (NF1), an autosomal disorder. The sample included 10 adolescents,
who averaged 17 years of age and seven parents, who participated in a two day group intervention
provided in a “workshop” format. At a three-month follow-up, significant declines in pain interference
were reported by both patients and parents, while patients only reported decreased pain intensity.
The authors suggested that the obtained data supported the feasibility of ACT in young people
diagnosed with NF1.

Prospective Studies with Parents

Recently, Wallace et al. [56] published the first pilot study examining the application of an
eight-week, ACT-based group intervention with parents (n = 8; 6 completed the study) of youth
with chronic pain. The primary treatment target was to increase parental psychological flexibility,
specifically for parents to identify areas of ineffective action or stuckness within themselves and their
family unit, as well as develop strategies to support pursuit of values-based action. Sessions were
delivered once a week, on an outpatient basis, and were 75 min long (session by session content is
detailed by the authors in the manuscript [56]). Measures of parent psychological flexibility, responses
to child pain symptoms, and levels of pain interference were collected during treatment and at three
follow up time points, up to six months post treatment. Overall, parents were highly satisfied with the
intervention. Furthermore, parent levels of psychological flexibility increased during treatment, as well
as through follow up. During follow up, parent protective responses and adolescent-reported levels
of pain interference decreased significantly. The authors hypothesize that the delayed improvements
observed in parental responses may indicate a potential mediating effect of psychological flexibility on
parental responses.
A final study examined changes in pain-acceptance following CBT for chronic pain. While this
study was not strictly an application of ACT, the treatment description suggests that there were
some goals that were concordant. For example, the authors of the study noted that participants and
their parents were told that the goal of treatment was not decrease pain, but to “increase coping
skills, functioning, and quality of life” [34]. Thus, it seemed appropriate to include this study
within the present review, particularly because it examined how changes in acceptance over the
course of the treatment were related to changes in distress and disability. A total of 112 youth, aged
11–18, participated in the treatment program, which included daily relaxation training, physical
therapy, occupational therapy, recreation therapy, family therapy, and psychotherapy groups. Levels of
acceptance significantly increased during treatment, while levels of depression, pain catastrophizing,
and functional disability significantly decreased. Importantly, changes in acceptance significantly
predicted changes in all psychosocial variables and functional disability.

3. Measures of ACT Processes in Youth with Chronic Pain and Their Families
Table 1 describes self-report measures for youth and their caregivers that assess constructs relevant
to ACT processes and their relation with other psychosocial measures of pain-related functioning.
In brief, to date there are four measures that explicitly measure ACT processes in children and
adolescents, and three questionnaires developed for use with caregivers either as a proxy report (n = 1)
or a report of the caregiver’s own experience and behaviors (n = 3). Three measures not specifically
validated with pediatric chronic pain populations were included due to their utility in assessing ACT
processes [57–59]. Further research and evaluation on all of the measures is warranted, as the statistical
Children 2017, 4, 10 7 of 12

properties have only been preliminarily validated. Notably, however, findings from the published
cross-sectional studies with pediatric samples are consistent with similar studies in adults and illustrate
that ACT-relevant processes are related to functioning in a manner consistent with the underlying
theory of ACT (e.g., greater pain acceptance is associated with better emotional and physical status).

Table 1. Measures of Acceptance and Commitment Therapy (ACT) processes in pediatric chronic pain.

Measures Description Relations

Child Specific
Chronic Pain Acceptance 20 item self-report measure, Correlated with disability, depression,
Questionnaire: Adolescent version adapted from the adult version anxiety, self-efficacy. Not correlated
(CPAQ-A; [60,61]) [33]. Assesses two aspects of pain with pain-specific variables
acceptance: (1) Activity (e.g., pain duration).
Engagement and (2) Pain
Willingness. Response options
range from (0) never true to (4)
always true.
Child and Adolescent Mindfulness 10 item measure of mindfulness Correlated with quality of life, school
Measure (CAMM; [58]) * skills. Normed on four samples of and social functioning and
school age children and mindfulness-inconsistent processes
adolescents. Response options (e.g., externalizing behavior).
range from (0) never true to (4)
always true.
Avoidance and Fusion 17 item measure of psychological Scores for both versions correlated
Questionnaire for Youth inflexibility for youth. There is with child anxiety, somatic complaints,
(AFQ-Y; [57]) * also a validated eight-item short mindfulness, quality of life, and
form of the AFQ-Y. scholastic functioning.
Parent specific
Parent psychological flexibility 24 item measure to assess parental Scores correlated with child disability,
measure (PPFQ; [43,62]) levels of psychological flexibility depression, and pain acceptance, as
in responses to child’s pain well as with parental response
symptoms. Items range from (0) behaviors, as assessed by the Adult
never true to (6) always true. Responses to Child Symptoms (ARCS)
measure [63].
Chronic Pain Acceptance 16 item self-report measure of Scores correlated with child pain
Questionnaire: Parent report parent perceptions of child’s intensity and disability, as well as
(CPAQ-P; [64]) acceptance of pain, adapted from parent pain catastrophizing,
the adult CPAQ [33]. Same two pain-related fear, and maladaptive
subscales as the CPAQ-A. protective responses.
Response options range from (0)
never true to (6) always true.
Parent Pain Acceptance 15 item self-report measure of Scores correlated with child pain
Questionnaire (PPAQ; [42]) parent’s own levels of acceptance acceptance, pain-related fear, and pain
towards their child’s pain. catastrophizing, as well as parental
Adapted from the CPAQ-P [64]. maladaptive responses to pain and
Two sub-scales: (1) Activity pain catastrophizing
Engagement and (2) Pain-related
Thoughts and Feelings.
Parental Acceptance and Action 15 item self-report measure of In preliminary validation, the PAAQ
Questionnaire (PAAQ [59]) * experiential avoidance in relation correlated with symptoms of child
to parenting. Two subscales: (1) psychopathology and measures of
Inaction and (2) Unwillingness controlling parental behaviors and
affective expression. Predicted
significant amounts of variance in
parent and clinician ratings of child
anxiety symptoms.
* Not a pain specific ACT measure.
Children 2017, 4, 10 8 of 12

4. Strengths, Limitations, and Future Directions

ACT takes a pragmatic and flexible approach to the treatment of pediatric pain. The overarching
goal of ACT is to decrease ineffective struggles for control of pain or distressing emotions and increase
adaptive responses to pain and facilitate consistent re-engagement with valued activities. Theoretically,
the probability of this occurring is assumed to be more likely when one approaches aversive experiences
with more openness and fewer struggles for control, and when one is more aware of both one’s personal
values and currently available opportunities to engage in valued activities.
Although preliminary, the growing body of evidence regarding ACT for pediatric pain is
promising and results from existing studies are consistent, offering some support regarding validity
and utility. Notably, and unfortunately, the number of studies on ACT for pediatric pain patients
is considerably smaller than the body of research and strong evidence for using ACT for adult
chronic pain [65]. Furthermore, beyond a small number of studies, the literature on ACT for children
and adolescents suffers from either an absence of or poorly defined control conditions, and small
sample sizes. Thus, there is a need for more studies and those of higher quality in terms of study
design, evaluation across settings (e.g., outpatient, day hospital, individual vs. group), and further
identification and replication of the mechanisms by which improvements in functioning occur during
treatment. Formal inclusion of parents in treatment and assessment of parent pain-related functioning
is also needed to illuminate and optimize their role in their child’s pain rehabilitation.
At present, there is also a need for precise measurement of ACT treatment processes in youth
with chronic pain. The adult chronic pain literature boasts numerous measures of ACT constructs,
such as psychological flexibility [66,67], pain acceptance [33], engagement in valued activities [68–70],
and committed action [38], which could potentially be adapted for use with pediatric populations.
While there is one measure of pain acceptance for youth, it is curious that no measure of values or
assessments related to other aspects of the model have been developed yet for pediatric chronic pain
populations. Given the focus within ACT on improvements in values-based actions, the development
of a robust measurement method in young people with chronic pain appears highly important.
In particular, valued domains in adults may be different than in youth and these differences may
require a carefully considered assessment. Furthermore, clinical experience suggests that certain times
in one’s life, for example, adolescence, are a time of personal determination of what is of personal value.
For example, there can be consideration and weighing of socially-constructed values (e.g., be popular)
in relation to those that are more personal in nature (e.g., be kind to others). The adult literature on
values assessment offers little to no guidance on the assessment of “values formation” (for lack of
a better term) and this seems a distinct and important opportunity for those that work in pediatric
settings. In addition, further specification of the unique and interactive effects of caregiver and child
responses to pain within an ACT framework appears to present an important opportunity for further
work. Thus, while some aspects of the ACT model may be appropriate to assess via a process of
“downward” extension from adults to youth, there may be particular facets of the pediatric setting that
are deserving of careful consideration.
There are several additional considerations in relation to the use of ACT in the treatment of
pediatric chronic pain. First, there is little guidance on ages that are appropriate or inappropriate
for ACT; notably, only two of the ten studies reviewed explicitly made mention of developmental
adaptations or considerations taken into their protocol [31,55]. In particular, it is not currently known
if there is a minimum age, or minimum set of developmental milestones that must have been met,
for successful treatment participation. The authors’ clinical experience suggests somewhere in the
8–10 range may be a lower age limit, but this intuition is in need of empirical examination. Second,
there is little guidance on the selection of type of psychological treatment, for example, use of ACT
instead of CBT. Given the overlap between approaches, it may be that firm data-based rubrics are
unlikely in the near future. Furthermore, given the distinctions between ACT and CBT, as detailed in
the first major section of this paper, perhaps ACT is more relevant for use in individuals with significant
deficits in values clarity and pursuit of values-based directions, or in those who are so paralyzed by
Children 2017, 4, 10 9 of 12

pain and associated cognitions that cognitive methods are unlikely to work in an efficient manner.
Third, while caregiver involvement in treatment is important and there is evidence demonstrating
that caregiver responses and functioning impact child outcomes, the exact type or duration of such
involvement is not clear. For example, is it sufficient to simply have caregivers sit in on some or all
treatment sessions, or is it necessary for caregivers to receive treatment specific to their particular
needs? Again, clinical experience suggests that the latter is more likely to be of use, but, to our
knowledge, there are no data to use for guidance. It seems fair to note that these three issues are
important for psychological interventions for pediatric chronic pain writ large and seem necessary to
address for the field to move forward to firmer empirical ground.

5. Conclusions
To conclude, a primary goal of ACT for pediatric chronic pain is to support youth in healthy
functioning and aid them in the process of re-engagement in valued activities so that their focus may
shift back to age- appropriate activities, rather than predominantly on pain control or pain avoidance.
The theoretical principles of ACT provide a framework for the structure of such treatment. While the
extant data is promising, much more work needs to be done to augment the evidence base for the
application of ACT with pediatric pain populations and to ensure that clinical practice is consistent
with the hypothesized theoretical principles of ACT.

Acknowledgments: This work was supported by funding from the National Institutes of Health (R34AT008398;
PI: Kevin E. Vowles) and the National School of Research in Health Care Science (PI: Rikard Wicksell).
Author Contributions: M.P. and K.E.V. conceived of the idea for this topical review and outlined the paper. M.P.
performed the literature search, summarized findings for studies and measures, and put together an initial draft
of the paper. K.E.V. wrote and finalized the introduction, provided edits and feedback. R.W. contributed to the
conceptual organization of the paper, wrote up summaries on processes of change related studies, and provided
valuable edits and feedback to finalize the paper.
Conflicts of Interest: The authors declare no conflict of interest.

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