Multimodal Rehabilitation: A Mind-Body, Family-Based Intervention for Children and Adolescents Impaired by Medically Unexplained Symptoms. Part 1: The Program

Abstract

We describe a mind-body, family-based, multimodal rehabilitation program for children physically impaired by medically unexplained symptoms. In collaboration with the family, a multidisciplinary team identifies what is typically a diverse range of interconnected problems, and implements targeted interventions whose aim is to improve the child's physical, psychological, and social functioning and the psychological, emotional, and relational well-being of the family as a whole. The program is run in an inpatient hospital context and involves multiple modules—physical therapy, pharmacotherapy, individual therapy, family therapy, and an educational component—delivered concurrently. A companion article will present case studies and outcome data.

Acknowledgments

The authors thank Dr. Ken Nunn for his role in setting up the inpatient rehabilitation program in the 1980's and for passing on his wisdom and Kannan Kallapiran and Stephen Scher for their input into earlier drafts of this article.

Notes

1. Children exposed to negative life events have better outcomes if their parents are functioning well, ensure cessation of stressful events, provide safety and comfort, and maintain structured routines (Kozlowska & Hanney, 2003).

2. Whereas a normal breathing rate at rest is 7–14 breaths per minute, the majority of our patients breath at 20–40 breaths per minute in the assessment interview. This is a nice marker of sympathetic arousal.

3. In parallel to sympathetic activation, activation of muscle motor units or muscle spindles can cause musculo-skeletal pain due to increased tension in motor units or pressure in the spindle. These changes can be induced by over use or by emotional stress (Flor & Turk, 2011; Hubbard, 1996).

4. Flor and Turk metaphorically refer to this phenomenon as activating the child's pain memory (Flor & Turk, 2011). We have found that many children, adolescents, and families find this metaphor very helpful.

5. We are unable to access alternate therapies such as massage, release of trigger points via physical pressure, and acupuncture within the hospital. Some children or parents find these interventions very helpful.

6. Reparative body processes occur when the parasympathetic system is activated (A. D. Craig, 2005; Porges, 2011). They also occur during sleep (Marano et al., 2011). This reparative state is incompatible with states of high arousal which are mediated by activation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic system (Chrousos, 1992).

7. We explain to parents that the human brain is programed to read the emotional state of others (de Gelder, 2006). Thus, if the parent is distressed and aroused, the child will also be distressed and aroused. Seen from this perspective many parents agree to a formal assessment (and treatment) of their own emotional functioning.

8. The therapeutic effect of medications is enhanced if the patient (and family) understand their function and expect a therapeutic response.

9. The visual aid is a biofeedback tool called mycalmbeat (www.mybrainsolutions.com/mycalm-beat). The picture depicts a set of lungs that the child can download onto an iPad and use to time their breathing. Auditory tools involve sounds which are used to pace breathing (e.g. Respire-1 CD uses a chime track and is available at www.coherence.com).