Child Youth Care Forum (2012) 41:579–598

DOI 10.1007/s10566-012-9174-x

ORIGINAL PAPER

Family-Based Cognitive-Behavioral Treatment

of Chronic Pediatric Headache and Anxiety Disorders:
A Case Study

Kelly L. Drake • Golda S. Ginsburg

Published online: 19 February 2012

 Springer Science+Business Media, LLC 2012

Abstract
Background Chronic pediatric headache disorders are pervasive, debilitating, and
associated with high rates of comorbid anxiety disorders. The combination of headaches
and anxiety presents unique challenges for clinicians. Cognitive behavioral therapy (CBT)
is a promising treatment for pediatric headache, however, available treatments fail to
adequately address comorbid psychopathology resulting in less than optimal response
rates.
Objective This case study illustrates the use of a family-based CBT for treating
comorbid pediatric headache and anxiety disorders.
Methods A 10 year old boy with chronic daily headache was evaluated and treated as
part of the Children’s Headache and Anxiety Management Program (CHAMP). The patient
and his parents were evaluated by an independent evaluator (IE) at pre- and post-treatment
and one-month follow-up. Evaluations consisted of structured interviews as well as parent
and child self-report measures of headache and anxiety symptoms and impairment. At
baseline the child met diagnostic criteria for chronic headache disorder, separation (SAD),
and generalized anxiety disorders (GAD), and had significant symptoms of obsessive–
compulsive disorder (OCD). Treatment included 8 conjoint sessions of CBT.
Results Post-treatment evaluation revealed a significant reduction in headache-related
severity and disability (but not frequency), and loss of initial GAD (but not SAD) diag-
nosis. By the one-month follow-up, the child no longer met criteria for any anxiety disorder
and was no longer disabled by headaches. The case highlights how CHAMP may be
effective in reducing headache and anxiety symptoms and associated impairment.
Conclusions This case illustrates the challenges in treating this population and suggests
specific interventions that might enhance treatment outcome.

Keywords Children
Headaches
Anxiety
Cognitive behavioral therapy
Parenting

K. L. Drake (&)
G. S. Ginsburg

Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences,
The Johns Hopkins University School of Medicine, 550 N. Broadway/Suite 202, Baltimore,
MD 21205, USA
e-mail: [email protected]

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Introduction

Chronic pediatric headache disorders are pervasive and debilitating. An estimated 10% to
30% of youth experience weekly headaches that account for several hundred school
absences each month and are associated with lower academic performance (Egger et al.
1998; Stang and Osterhaus 1993). Chronic headaches are associated with higher rates of
sleep disturbance, excessive daytime sleepiness (Bursztein et al. 2006; Miller et al. 2003),
social withdrawal, and higher levels of family conflict (Abu-Arefeh and Russell 1994;
Breuner et al. 2004; Frare et al. 2002; White and Farrell 2006). Furthermore, pediatric
headaches pose a heavy burden on the healthcare system. Each year, over 10 million
children are seen in primary care and emergency departments because of headaches, and
headaches are the third most common reason for referral to emergency departments
(Bulloch and Tenebein 2000; Kabbouche et al. 2008). If ineffectively treated, chronic
pediatric headaches can persist into adulthood (Bille 1997; Brna et al. 2005). Given the
high prevalence and economic, societal, and personal costs of headaches, effective treat-
ments are needed.
Behavioral treatments, such as relaxation training and biofeedback have demonstrated
efficacy in reducing headache frequency and severity (Holden et al. 1999), however, there
is room for improvement given that many youth remain symptomatic after these treatments
(Allen et al. 2002; Andrasik et al. 2003; Bussone et al. 1998; Powers et al. 2001; Smith
et al. 1991). Cognitive-behavioral therapy (CBT) has demonstrated efficacy with a wide
range of pediatric medical and psychiatric conditions and has been successfully applied to
pediatric headaches (Kroener-Herwig and Denecke 2002; Palermo et al. 2009, 2010;
Trautmann and Kroner-Herwig 2010). The empirical literature examining CBT for pedi-
atric headache disorder is growing and results are promising. Across studies, the majority
of children treated with CBT report significant improvement in headache frequency and
severity. However, many youth continued to have clinically significant headaches and
treatment has not been consistently associated with a reduction in medication usage
(Griffiths and Martin 1996). One reason for less than optimal response rates may be that
key factors that maintain headaches (i.e., psychiatric comorbidity and parental accom-
modation) are not adequately addressed in treatment.
It is well documented that youth with chronic headaches have high rates of comor-
bid psychopathology (Larsson and Sund 2005; Pakalnis et al. 2005; Seshia 2004;
Vulic-Prtoric and Macuka 2006). One study found that 84% of youth with chronic
headaches had a comorbid psychiatric disorder, most commonly anxiety (35%) and
depressive (23%) disorders (Liakopoulous-Kairis et al. 2002). Treatment of children with
headache disorders and comorbid psychopathology is complex but necessary to achieve
optimal outcomes. Indeed, evidence suggests that untreated psychiatric comorbidity is
associated with poor treatment outcome in children with chronic headache (Guidetti et al.
1998). In addition, evidence suggests that children’s pain-related disability is exacerbated
by parental reinforcement of sick-role behavior (Peterson and Palermo 2004) and that
parental involvement in treatment may enhance outcomes for youth with chronic head-
aches (Allen and Shriver 1998). Parent pain behavior management training may enhance
treatment outcome by enlisting the support of parents and working with them to adjust
environmental contingencies that maintain illness behavior. Unfortunately, most behav-
ioral treatments for headaches do not adequately train parents on how to eliminate sick-
role behaviors.
Taken together, current behavioral treatments for pediatric headache disorders have two
shortcomings which may explain why many youth remain symptomatic and few achieve

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full remission. First, the majority of behavioral treatments fail to adequately address the
etiological, maintaining, and exacerbating role of psychiatric comorbidity (primarily
anxiety symptoms/disorders). Second, most behavioral treatments do not adequately
incorporate the parents as agents of change in the therapeutic process. To address the real
world needs of children with chronic headache disorders and comorbid psychiatric
symptoms and improve outcomes, a broader treatment model is needed to provide a
framework for refining existing behavioral treatments and informing clinicians on how best
to intervene with these children.
The purpose of the present case study is to present and illustrate an intervention model
that draws on the existing literature and provides a framework for incorporating a
comprehensive set of treatment strategies designed to reduce comorbid headache and
psychopathology in youth. While the intervention strategies are not new, they are applied
to a case that represents the real-world presentation of youth with headache disorders in a
way that will assist clinicians in determining how to manage these common clinical
challenges. The paper concludes with a discussion of clinical implications as well as
recommendations for practitioners who work with children afflicted with headaches and
anxiety.

The Intervention Model

Current understanding of the co-occurrence of pediatric headache and psychiatric symp-

toms is informed by the biopsychosocial model of chronic pain (Gatchel et al. 2007).
Within this framework, children’s headache pain is viewed as multidetermined and
influenced by a combination of biological, psychological (anxiety), and social/environ-
mental factors (parenting behaviors). This model guided the development of the Children’s
Headache and Anxiety Management Program (CHAMP) which is a family-based inter-
vention grounded in cognitive-behavioral and operant conditioning theories. This theo-
retical framework and supporting empirical literature were used to guide the selection of
intervention strategies. CBT skills target the core symptoms of headaches and anxiety
(cognitive, somatic, and behavioral) and include: cognitive strategies (i.e., cognitive
restructuring to reduce maladaptive cognitions related to pain and anxiety), somatic
strategies (i.e., relaxation training), and behavioral strategies (e.g., having children engage
in activities despite pain, facing anxiety provoking situations). Using a family-based
approach, these skills are taught to both parent and child and parents also learn operant
learning strategies to encourage adaptive coping during headache and anxiety-provoking
episodes. Specifically, parents learn pain behavior management skills (i.e., to eliminate
reinforcement of sick-role and avoidant behavior) and contingency management (i.e., to
eliminate parental accommodation by rewarding healthy and brave behavior). In addition,
parents are provided with psychoeducation to address other parenting behaviors that may
maintain pain and anxiety (e.g., overprotection). Compared to a traditional medical model,
this model emphasizes the reciprocal relationships among pain, affect, and parenting and
includes a set of therapeutic strategies that can be tailored to meet the specific needs of
pediatric headache patients who (more commonly than not) present with untreated psy-
chopathology. The intervention, applied to a case, is described in greater detail following a
brief description of the assessment procedures and the patient’s background and diagnostic
profile.

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Methods

After several failed therapies, Brian and his mother were referred to the CHAMP study by
a neurologist in a regional headache treatment center. They presented for treatment in the
CHAMP research study in the spring of 2010. The study was supported by a grant from the
Migraine Research Foundation and the study protocol was approved by the institutional
review board. Prior to the initial evaluation, Brian and his parents provided informed
consent/assent. The initial evaluation consisted of a semi-structured diagnostic interview,
clinician administered measures, and several parent and child self-report measures of
headache and anxiety symptoms and impairment. Measures were selected based on their
ability to assess symptoms and disorders to determine eligibility, identify treatment targets
based on hypothesized treatment mediators (i.e., parenting behaviors), and monitor treat-
ment progress in terms of functional impairment.

Measures of Symptoms and Disorders

Anxiety Disorders Interview Schedule: Child and Parent Versions (ADIS-IV-C, ADIS-IV-
P; Silverman and Albano 1996). The ADIS-IV assesses a broad range of disorders in youth
and possesses the best psychometric profile for diagnosing childhood anxiety disorders of
available diagnostic measures (Rapee et al. 1994; Silverman et al. 2001). ADIS interviews
were conducted by doctoral and master’s level independent evaluators (IEs) who received
rigorous training as part of a larger clinical trial.
Clinical Global Impression-Severity (CGI-S) and Improvement (CGI-I) Scales (Guy
1976). The CGI scales are IE-rated measures of global anxiety severity and improvement
for the past week and are commonly used in clinical trials. Parallel measures were con-
structed to evaluate overall severity and improvement of headaches for the past week.
Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al. 1997,
1999). The SCARED is a widely used self-report measure of pediatric anxiety symptoms
with parallel child and parent versions. The SCARED has solid psychometric properties
(Birmaher et al. 1997, 1999; Muris et al. 1998) and is sensitive to treatment response
(Birmaher et al. 2003).
Daily Headache and Anxiety Diary. A daily diary was used to track the frequency,
severity, and duration of headache episodes and anxiety symptoms, as well as medication
use and missed school/activities. Daily headache diaries are reliable and valid measures of
pediatric pain perception (Allen and Mathews 1998; McGrath 1987). Severity ratings range
from 0 (no pain/no anxiety) to 10 (the most severe pain/anxiety).

Measures of Functional Impairment

Pediatric Migraine Disability Assessment (PedMIDAS; Hershey et al. 2001, 2004). The
PedMIDAS is the most commonly used IE-administered measure of pediatric migraine
disability/impairment and includes four ‘‘disability grades:’’ 0–10 = little to no disability,
11–30 = mild disability, 31–50 = moderate disability, and [50 = severe disability. The
measure has sound psychometric properties and is sensitive to treatment response (Hershey
et al. 2001, 2004).
Global Assessment Scale for Children (CGAS; Shaffer et al. 1983). The CGAS is a
widely used clinician-rated measure of global functioning with sound psychometric

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properties (Green et al. 1994). The scale ranges from 1 to 100 with values indicating the
degree to which symptoms interfere with overall functioning. Higher scores indicate better
functioning.

Measure of Parenting Behaviors

Adult’s Responses to Children’s Symptoms (ARCS; Van Slyke and Walker 2006). The
ARCS is a measure of parenting behavior in response to child illness and includes parallel
parent and child versions. Only the Protect subscale was used because it assesses parenting
behaviors most associated with reinforcement of illness-related behavior and this was a
primary treatment target. The scale consists of items that assess the extent to which parents,
as a result of the child’s headaches, limit the child’s activities (e.g., let child sleep late or
stay home from school), grant special privileges (e.g., bring the child special treats or
gifts), and relinquish the child from responsibilities (e.g., doing the child’s chores for him/
her). Internal consistency for this scale is adequate (alpha = .87) (Van Slyke and Walker
2006).

Patient Presentation

At the time of the initial evaluation, Brian (name and identifying information changed to
protect confidentiality) was a 10 year old, Caucasian boy who lived with his biological
parents and older sister. His developmental history was normal and his medical history was
unremarkable with the exception of headaches. Brian was enrolled in the 4th grade and his
academic performance was above average. Prior to his illness, he was outgoing, had
several good friends, and was active in the local children’s theater, swimming, and soccer.
Based on information obtained from the initial evaluation, Brian met diagnostic criteria for
chronic daily headache (CDH), generalized anxiety disorder (GAD), separation anxiety
disorder (SAD), and had significant but subclinical obsessive compulsive (OC) symptoms.
A brief description of his core headache and anxiety symptoms and associated impairment
is presented below.

Headache History

Brian reported new onset of daily headaches beginning in the fall of 2009 with headache
severity fluctuating from mild to severe throughout the day. Neurological disease was ruled
out with imaging. Within several weeks of the onset of CDH, Brian was leaving school
early every day due to worsening of headaches. Shortly thereafter, his mother withdrew
him from school and began home-schooling him. Brian wanted to return to school but was
worried that his headaches would get worse. His mother quit her job in order to stay home
with him and devote all of her time to monitoring and managing his headaches. Around
this time, Brian also stopped engaging in most social and recreational activities and began
sleeping approximately 15 hr/day. In addition, he avoided many situations (e.g., crowded
places, birthday parties, soccer practice) for fear that the noise or commotion might trigger
or worsen a headache. His parents tried to eliminate potential headache triggers by con-
trolling the lighting and noise level in their home, limiting his time outside in the heat,
permitting him to sleep late, withdrawing him from school and allowing him to have a
shortened home-school day with frequent breaks. Brian’s parents acknowledged that they

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reinforced his illness behaviors by giving him special attention, doing his chores for him,
and reducing expectations for completing school work. Past treatments included various
over-the-counter analgesics (Tylenol, Advil, Ibuprophen) and allergy medications
(Claritin) as well as prescription agents including Pamelor (nortriptyline) and Topamax
(topiramate). These latter medications were quickly discontinued after 1 week due to side-
effects including increased anxiety and skin rashes. In addition, Brian’s mother sought out
nontraditional therapies including chiropractics, acupuncture, and liver and parasite
cleanses. None of these interventions were successful in reducing the frequency or severity
of headaches. At time of evaluation, Brian was taking ‘‘as needed’’ (PRN) administrations
of Midrin (isometheptene, dichloralphenazone and acetaminophen) or Dolgic (acetami-
nophen and butalbital). He reportedly used these medications 5/7 days per week on
average. These medications were somewhat effective in reducing headache pain but the
effects were temporary and Brian complained of sedating side effects. During the trial,
Brian’s medication use was carefully monitored.

Anxiety History

Brian had a history of anxiety since early childhood though prior to the current evaluation
he was never diagnosed or treated for anxiety. In terms of GAD symptoms, he worried
extensively about his school performance (e.g., getting good grades, making mistakes,
upsetting his teachers), making others proud of him, and never getting in trouble at home or
school. Brian also worried about how well he was doing in recreational activities including
sports, drama, and choir. He worried about being injured or killed in a number of situations
including riding in elevators and being in tall buildings. Due to excessive worry, he was
easily fatigued, unable to concentrate, emotionally labile, and complained of chronic
muscle aches and difficulty sleeping. Prior to the evaluation, neither Brian nor his parents
recognized the extent of his worry and the detrimental impact it was having on his emo-
tional and physical health.
In terms of SAD symptoms, Brian described having a strong feeling that ‘‘something
bad will happen’’ to him or his family when they were not together. He avoided sleeping
alone and in the dark for fear that ghosts, monsters, or kidnappers would hurt him or take
him away from his family. Brian explained that, when he is not with his family, he ‘‘feels
miserable’’ because he cannot sleep, relax, or have fun due to worries that he might not see
them again. He cried when he spoke about his sister’s plans to attend a sleep-away camp
for several weeks during the upcoming summer and stated that he worried about something
bad happening to her. To prevent distress, there was a great deal of accommodation. He
was allowed to miss sports practices and games, social activities, and choir if a family
member was not able to accompany him. His parents made special arrangements with their
church for him to be in the same Bible study class with his sister even though the class was
intended for older children. His mother had a tendency to under-estimate the negative
impact of his anxiety stating that she thought it was ‘‘sweet’’ that he wanted to be with his
family all the time.
Finally, in terms of OC symptoms, Brian regularly experienced distress when his hands
were soiled. He requested hand sanitizer several times a day and his mother kept bottles of
sanitizer in the car, throughout their home, in her purse, and in his classroom. His mother
stated that she accommodated his compulsive hand washing/sanitizing because she thought
it was ‘‘cute’’ that a little boy would be so concerned about having clean hands. Brian and
his mother denied that these symptoms produced any distress for him because his com-
pulsive behaviors were always accommodated by having hand sanitizer available.

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The CHAMP Treatment

Therapists

The authors developed the treatment manual, child workbook, and served as co-therapists
for Brian and his family. The workbook included handouts that were used in session, out-
of-session assignments, and daily headache and anxiety diaries.

Course of Treatment

A total of 8 conjoint sessions were completed. Each session after the first began with a
symptom check-in and review of out-of-session assignments, including the daily headache
and anxiety diary and parenting behavior diary (which are assigned at the end of each
session) and each session (except the first) included an in-session behavioral exposure. The
out-of-session practice tasks (after the first session) included new behavioral exposures and
continued practice of the exposures completed in previous sessions. Below is a brief
description of the content covered in each session.

Session 1

Session Objectives

To establish rapport and instill hope, provide psychoeducation about headaches and anx-
iety, and identify healthy lifestyle habits that may reduce headaches.

Session Skills

The therapists provided psychoeducation about headaches and anxiety, taught the family
how to identify key signs of headaches/anxiety, and presented an overview of the CHAMP
model and intervention strategies. To illustrate, we explained that anxiety and headaches
show up in three ways: negative thoughts about danger/threat (‘‘I might get hurt’’) and/or
inability to tolerate pain (‘‘I can’t go to the party, I might get a headache and it will never
go away’’), bodily reactions (e.g., heart beating faster, stomachaches, trembling), and
behaviors (e.g., fidgeting, crying, and avoidance). We emphasized that avoidance increases
and maintains anxiety as well as headache-related disability and will therefore be a primary
treatment target. Next, the importance of healthy habits was reviewed and potential health-
related headache triggers (e.g., sleep, hydration, exercise, nutrition) were identified as
targets for change. During the session, Brian complained of a moderately severe headache
and stated that he was tired. In response, his parents rubbed his back, gave him sunglasses
to wear, gave him a caffeinated drink, and suggested that he put his head down and rest.
Based on these observations and data from the initial evaluation, it was clear that unin-
tentional parental reinforcement of illness behavior would be a target of treatment. Finally,
Brian’s parents conveyed their reluctance to accept our conceptualization of his illness
(i.e., that there is a reciprocal relationship between anxiety and headaches and that
avoidance maintains anxiety and illness behavior) and minimized the role of anxiety in the
course of his illness. To address their concerns, we provided empathy and reassurance that
we understood parents were doing what they believed was best for their child and that

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anxiety is very common and sometimes difficult to identify. We discussed how traditional
medical interventions had not provided symptom relief and that, since chronic illness-
related behaviors and disability are reinforced by environmental factors, we were opti-
mistic that a behavioral approach could provide some symptom relief.

Out-of-Session Assignments

Increase water intake to 8 glasses a day and reduce sleep to 10 h/day. To improve his mood
and level of physical activity, Brian was asked to engage in one pleasurable activity each
day and complete the headache and anxiety diaries.

Session 2

Session Objectives

Review CHAMP model, begin plan for reducing avoidance, and teach contingency man-
agement skills to parents.

Brian’s Progress

Brian’s diaries indicated no change in the frequency or severity of headache or anxiety

episodes during the past week. He reported daily headaches and an average severity rating
of 8 for headaches and 7 for anxiety (on a 0–10 scale where ‘‘0’’ indicates no pain/no
anxiety and ‘‘10’’ indicates the most severe pain/anxiety). He used his PRN medications
five times during the past week. Brian reported that he increased his daily intake of water to
8 glasses but continued to sleep 12–15 hr/day. He attempted to engage in pleasurable
activities but reported that he never really enjoyed them because he always had a headache
and was worried about something bad happening.

Session Skills

After reviewing the model, the therapists provided a rationale for reducing avoidance
related to headache episodes and anxiety-provoking situations. Specifically, we described
how ‘‘Running away from things that make you feel scared or nervous reduces your anxiety
and makes you feel better in the short term, but in the long term, running away actually
increases anxiety because you never have a chance to learn that you can handle the anxiety
and that all of those terrible things that anxiety tricks you into believing are often not true.
So, if you want to shrink your anxiety, you have to face your fears. The same is true for
headaches. When you avoid doing things because of headaches, you teach yourself that you
are incapable of doing things because you’re ill and you begin to see yourself as ‘‘sick and
helpless.’’ The therapists worked with Brian and his parents to develop a hierarchy (i.e., a
list of situations, in order from least to most difficult, that are avoided due to headaches
and/or anxiety) for behavioral exposures. The therapists explained that, in order to reach a
goal—like facing a big fear or functioning in spite of headaches, it helps to break it down
into small, manageable steps. Brian’s hierarchy items are listed in Table 1. Next, Brian’s
parents were taught contingency management skills which included a discussion of
how parents can help children make behavioral changes by using positive reinforcement

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(e.g., attention, praise, rewards) to increase the frequency of well and brave behaviors
while withdrawing parental attention/reinforcement to reduce pain and anxiety related
behaviors (e.g., avoidance). Finally, parenting behaviors that can maintain child illness and
anxiety symptoms were described. Specifically, it was explained that: (a) parental over-
control (i.e., behaviors that are restrictive, overprotective, and lacking in autonomy
granting) minimizes children’s opportunities to develop autonomy and a sense of mastery
and this can exacerbate anxiety and dependence. Thus, parents were asked to monitor these
behaviors using the parenting diary and begin to allow Brian greater autonomy by
encouraging him to complete his morning and evening routines independently; and that
(b) parental accommodation and reinforcement of sick-role behavior maintain child
symptoms. It was explained that ‘‘When children are chronically ill and receive special
rewards or are permitted to miss out on responsibilities or activities, they may come to
believe that they cannot function during headache episodes. Overtime, it becomes more
rewarding to be sick than to be healthy. On the other hand, when parents encourage
children to function in spite of headaches, they will reinforce coping behavior as opposed
to illness-related behavior- and that will reduce disability. We are going to shift the focus
toward healthy behavior and make that more rewarding.’’ Brian’s parents were asked to

Table 1 Goals for behavioral exposures: Brian’s hierarchy

Target symptom Situation Level of difficulty
(0–8)

Headache Complete 30 min blocks of school work 3

Attend soccer practice (with a parent) 3
Play in soccer games 3
Attend birthday parties 4
Attend school for half days 5
Spend time in crowded places 6
Attend school for a full day 7
Return to school full time 8
Anxiety Ride in elevator with family 2
Rub flour on hands and refrain from washing for 5 min 3
Attend soccer practice/game without a family member present 4
Rub dirt on hands and refrain from washing for 5 min 4
Practice being assertive with family 4
Limit use of hand sanitizer 5
Ride elevator alone 5
Attend play date without a family member present 6
Practice being assertive with friends 6
Sleep upstairs, in the dark, alone 7
Attend Bible study class without a family member present 7
Refrain from asking questions before going to a new place 7
Spend weekend with grandparents 8
Attend sleepovers 8

Level of difficulty ranges from 0 to 8 where 0 is not at all challenging and an 8 is extremely challenging

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use the parenting diary to monitor these behaviors so they could receive specific instruc-
tions during upcoming sessions on ways to eliminate these behaviors.

Out-of-Session Assignments

Complete 30 minute blocks of schoolwork and attend soccer practice (with parents) for at
least 30 minutes.

Session 3

Session Objectives

Teach relaxation exercises and parent pain behavior management strategies.

Brian’s Progress

Brian and his parents reported having ‘‘a good week’’ with a mild reduction in anxiety
(average severity rating = 7) and headache severity (average severity rating = 6) but no
change in headache frequency. Despite having pain, Brian did not use any medication
(OTC or prescription) and explained that he wanted to try to ‘‘live with the pain and not
feel like I’m in a fog.’’ Behaviorally, Brian increased his level of daily activity by attending
one soccer practice, singing in a church concert, and completing his daily schoolwork
assignments. During the discussion about anxiety-provoking situations, his parents indi-
cated that they were able to see how anxiety was playing a role in his daily life and might
be making his headaches worse. Nonetheless, they had difficulty allowing him to complete
his morning and evening routines independently explaining that if they do them, they will
get done correctly and more efficiently. In response, the therapists explained, ‘‘We
understand that parents sometimes exercise more control because they want things to go
smoothly for their children and think it’s easier if they do everything themselves. However,
in the end it may inadvertently teach children that they are incapable of doing things for
themselves and it prevents them from mastering skills, like independent self-care, that
parents find important and want their children to learn.’’

Session Skills

The concept of physiological tension and its association with headaches and anxiety was
provided. The therapists explained that ‘‘Having too much anxiety can lead to a build-up of
tension in the body. However, you can control the tension in your muscles and your whole
body. Learning how to relax your body can help you lower your heart rate and blood
pressure; slow down your breathing; reduce stress and negative feelings like anxiety,
anger, and irritability; reduce headaches and stomachaches; and can even help you sleep
better.’’ The therapists taught Brian and his parents deep diaphragmatic breathing exercises
and progressive muscle relaxation (PMR) which consisted of gently tensing and relaxing
all the muscle groups from head to toe. Next, Brian’s parents were taught specific parent
pain behavior management strategies (see Allen and Shriver 1998) which consisted of:
encouraging activity during headaches; expecting Brian to attend school, do chores, par-
ticipate in activities (e.g., practices, clubs); not permitting a reduced work load; praising
and rewarding activity such as attending soccer and doing homework; limiting status

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checks (i.e., asking whether he has a headache and how he is feeling); recognizing and
rewarding his independent coping behavior; and shifting attention away from illness
behavior and toward wellness behavior. Finally, Brian completed an in-session exposure
consisting of riding the elevator several times until his self-reported level of anxiety
decreased to a minimal level.

Out-of-Session Assignments

Practice relaxation and attend soccer practice (without parents), play in soccer game (with
family present), attend a birthday party for at least 30 minutes, and rub flour over hands and
refrain from washing for 5 minutes. Brian’s mother was assigned the task of contacting the
school to arrange for him to be gradually reintegrated into his classroom.

Session 4

Session Objectives

Teach cognitive restructuring.

Brian’s Progress

Brian’s diaries indicated slight but continued improvement in average anxiety (sever-
ity = 5) and headache (severity = 5) symptoms. Although there was no change in head-
ache frequency, the family was very enthusiastic about Brian’s progress and attributed his
reduction in symptoms to the parents giving him more attention when he is ‘‘powering
through his headaches,’’ their insistence that he function in spite of headaches, and the
behavioral exposures which have helped to reduce some of his anxiety and make him feel
more confident. He used medication on two occasions during the preceding week and
explained that he took the medication to ensure that his headache would not stop him from
enjoying a friend’s birthday party or catching up on his schoolwork.

Session Skills

The clinicians introduced the concept of negative ‘‘self-talk’’ related to headaches and
anxiety. Brian and his family were taught to identify negative thoughts (‘‘I can’t go to the
party because it will be too noisy and my headache will get even worse and I’ll feel
terrible’’), challenge distorted thoughts using Socratic questioning and examining evidence
to support or dispute the thoughts (e.g., what is the evidence for and against that thought?
What might happen instead? Even if your headache gets worse, could you survive it?), and
generate coping thoughts (‘‘I’m going to try to stay at the party as long as I can. Even if it’s
loud and I get a headache, I’ll still get to see my friends and I might have a good time’’).
They were instructed to ask the following types of questions in order to examine the
validity or helpfulness of thoughts: what’s the worst thing that could happen? Is it really
that bad? Is it likely to happen? Would I feel bad forever? Is it going to matter a week, a
month, or a year from now? Is this thought helpful? What could be positive about the
situation? What’s another way to think about it? The answers to these questions can help
increase doubt about scary thoughts and generate more realistic, coping thoughts. During
the session, Brian, like many children his age, had some difficulty identifying his negative

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thoughts about headaches and anxiety-provoking situations. When asked what was scary
about a particular situation (e.g., returning to school), he responded by stating: ‘‘I don’t
know. I’m not thinking about anything. I just know that I feel scared.’’ The therapists
explained that it can be difficult to identify thoughts and that it is a skill that requires a lot
of practice. Sometimes, it is easier to identify scary thoughts in the moment when facing a
fear or feeling nervous. To help him practice, his parents were taught how to use Socratic-
type questioning to help elicit the nature of his fears during the behavioral exposures and
any other times when he was feeling anxious. Finally, the in-session exposures included
riding the elevator to the top floor of our 9 story building several times until he reported no
anxiety and rubbing dirt over his hands for several minutes and refraining from washing or
using hand sanitizer. The goal was for Brian to refrain from washing his hands for 5
minutes or until his level of anxiety reduced to a minimal level. However, he seemed to
have forgotten about the dirt on his hands and only washed them after using the restroom
an hour later.

Out-of-Session Assignments

Get hands dirty and delay washing for longer intervals, reduce the use of hand sanitizer to
once a day, role play being assertive with family members, attend a play date without a
family member, and attend school for one-half day. During these exposures, Brian was
asked to identify and challenge negative self-talk.

Session 5

Session Objectives

Teach problem-solving skills.

Brian’s Progress

Diaries indicated a continued reduction in average anxiety (severity = 4) and headache

(severity = 4) symptoms and impairment. Furthermore, for the first time since the onset of
his CDH, Brian reported 1 day with no headache and only used pain medication one time
during the past week because the overall severity of headaches was ‘‘more manageable.’’
Brian was praised for getting caught up with his schoolwork and successfully attending
school for one-half day. Despite his success, Brian was reluctant to return to school for
longer periods of time. The therapists reviewed CHAMP skills and focused on helping him
identify and challenge his distorted beliefs. Brian acknowledged that he was worried that
‘‘Everyone is going to be looking at me and wondering where I’ve been…they’re going to
think there’s something wrong with me.’’ We examined the likelihood of his fear (‘‘since
you haven’t been in school for 5 months, there’s a good chance that they will look at you
and notice that you’re back’’) and used Socratic-questioning to facilitate alternative
explanations/outcomes (‘‘How do you know that people will be thinking bad things about
you when they look at you?’’ ‘‘What are some other things that they may think when they
see you?’’ ‘‘Will anyone be happy to see you back in school?’’). By the end of this process,
Brian determined that there was little evidence to support his fear that people will think
poorly of him and that many of his peers may react to him in a positive way. He was able to
develop helpful/coping thoughts about returning to school (‘‘It will be fun to see my friends

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again. If people look at me, it’s probably just because they’re curious about where I’ve
been, and that’s normal’’). The therapists recommended that he write a list of coping
thoughts (e.g., ‘‘Even if I get a headache, I can handle it,’’ ‘‘Maybe my friends and teachers
will be happy to see me’’) on a note card so that he could carry it with him throughout the
day and refer to it whenever he started to feel anxious. In addition, his parents were making
progress in terms of rewarding coping behavior and removing reinforcers for illness/
avoidant behavior. As one example, Brian’s mother explained how she did not pay
attention (or give in) to Brian’s attempts to delay his return to school. Instead, she told him
how proud she was that he was being so courageous and that she was excited for him to
earn a ‘‘family game night’’ as a reward for his effort. In addition, his parents were
encouraging him to complete morning and evening routines independently, engage in more
daily activities, and were no longer asking for status checks.

Session Skills

To teach problem-solving it was explained that higher levels of stress can come from
having too many problems (e.g., conflict with parents, siblings, and peers), letting problems
build up, and not having a good method for solving problems. Becoming a better problem-
solver can reduce conflicts and stress/anxiety which can, in turn, reduce headaches. Next,
the family was taught problem-solving skills by using the SOLVE method where
S = Settle down (it is better to try to solve problems when you are calm), O = Own the
problem (identify the part of the problem that is under your control), L = List solutions (be
creative and brainstorm solutions without judging them), V = Vote for one solution based
on the pros and cons of each one, E = Engage in the best solution and evaluate the
outcome. If the problem is not solved, go back to the list and choose another solution. After
practicing the SOLVE method in session, Brian engaged in his in-session exposures which
included riding the elevator alone (which no longer elicited any anxiety) and role-playing
being assertive with friends. He stated that the role-play was helpful because it gave him a
chance to practice what he wanted to say and that made him feel more confident.

Out-of-Session Assignments

Sleep upstairs alone, sleep in dark room, practice being assertive with friends, attend Bible
study class alone, spend at least 20 minutes in a crowded place, attend school for a half
day three times, and ask no more than 2 questions when facing an ‘‘unknown’’ situation
(to reduce reassurance-seeking behaviors).

Sessions 6–8

Session Objectives

Review skills and discuss relapse prevention strategies.

Brian’s Progress

Brian and his parents reported a steady reduction in average anxiety (severity = 2) and
headache (severity = 3) symptoms over the last few sessions. He also reported several
days with no headache, less pain medication use (an average of one OTC pain pill per week

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for each of the 3 weeks), increased level of physical activity (playing soccer and/or
swimming daily), and improved sleep patterns (averaging 9–10 hours of sleep each night).
In terms of school attendance, he successfully attended three half-days of school during
week 6, 4 out of 5 full days during week 7, and attended the full week during week 8. He
reported no anxiety when riding elevators, and only minimal anxiety with sleeping alone in
the dark, entering new situations, or when his hands were dirty. He was no longer using
hand sanitizer. Brian also reported a positive experience when he confronted his friends
and had to be assertive. His progress throughout treatment was reviewed and the family
expressed satisfaction with Brian’s accomplishments.

Session Skills

All CHAMP skills and parenting strategies were reviewed and the therapists discussed the
importance of continued practice and relapse prevention. The goal of relapse prevention is
to teach parents to anticipate recurrences of symptoms and to be proactive by continuing
to practice coping skills in order to minimize the likelihood of a full relapse. It was
explained that ‘‘Sometimes when we learn something new, it’s easy to fall back into old
habits—we call this a ‘slip.’ Occasional slips are normal and common. Slips do not mean
that all you learned has been forgotten or was not helpful. So, if you have a slip, you
should keep it in perspective and not let it get you upset. Then, you should get back on
track and continue using your CHAMP skills. Face your fears when they are still small.
Engage in activities in spite of headaches. If you want to prevent these slips from hap-
pening in the first place, you have to practice. The more you practice, the better you will
get’’ (adapted from Silverman et al.1999). Next, we generated a list of situations that may
happen in the future that could lead to a slip and developed a plan to cope with them
before they happen. For example, Brian said he was worried about his sister going to
sleep away camp during the upcoming summer. We discussed how he could apply
CHAMP skills to develop a coping plan. His final plan consisted of challenging anxious
thoughts, generating coping thoughts, relaxing his body when he feels tense, and using
problem-solving skills to cope with missing her (e.g., he can call her once a day, write her
letters, talk to his parents about missing her, engage in fun activities with friends). During
the in-session exposure, Brian practiced being assertive by engaging in several role-plays
in which he had to confront his friends whom he felt were taking advantage of him by
using his toys without permission and ignoring his requests to clean up after themselves
when they came to his house to play. Each role-play became increasingly more difficult as
we became more confrontational to help him face his fears of being rejected by his friends
for standing up for himself.
As termination approached, it was clear that Brian still had difficulty with separation
events and his mother continued to engage in overprotective behaviors such as imposing
limits on the amount of time he spent away from her, arranging to have his play dates at
their home (as opposed to allowing him to play at a friend’s house), and attending his
soccer practice even after he demonstrated that he was able to go alone. This pattern
and the potential consequence of reinforcing his separation anxiety were gently raised
with his parents. She stated that she was aware of this but felt ‘‘lost’’ since she had quit
her job and was devoting nearly all of her time to caring for him and home-schooling
him. Her sacrifices were acknowledged and we used problem-solving skills to help
her generate a plan for returning to work and granting Brian more autonomy and
independence.

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Out-of-Session Assignments

Continue practicing all CHAMP skills and behavioral exposures including attending
school, separating from his family, attending sleepovers, visiting grandparents for the
weekend, etc.

Results

Treatment Outcome and One-Month Follow-Up

Changes in Child Symptoms and Diagnoses

After 8 sessions, Brian no longer met diagnostic criteria for GAD, however, he continued
to have clinically significant SAD as well as daily (but less severe) headaches. His OCD
symptoms persisted at the subclinical level but were less bothersome. At the one-month
follow-up evaluation, he reported only minimal symptoms, no longer met criteria for any
anxiety disorder diagnosis, and was considered very much improved by the independent
evaluator (IE). Figures 1, 2, and 3 display changes in IE determined diagnoses, child and
parent report of anxiety symptoms, and severity ratings for headaches and anxiety across
the three assessments. The pattern of findings indicating reductions in headache and
anxiety symptoms and impairment was consistent across all IE-administered measures
(ADIS, CGI-I) as well as parent and child reports (SCARED, Daily Headache and Anxiety
Diary).

Changes in Child Functional Impairment

Headache-related disability according to the PedMIDAS decreased from 270 (severe

disability) at pre-treatment, to 39 (moderate disability) at post-treatment, to 3 (no dis-
ability) at the one-month follow-up. IE-rated assessment of global functioning (CGAS)
improved at each assessment and indicated minimal interference in functioning by the end
of treatment and follow-up. Finally, by post-treatment, Brian was no longer taking any
prescription medication for his headaches and was back in school full time just before the
end of the school year. These functional improvements were maintained at the one-month
follow-up. Anecdotally, Brian’s mother was contacted 6 months post-treatment to discuss
this case study and she reported that he was going to school full time with no hesitation,
had minimal anxiety, infrequent headaches, was not taking any pain medication, and that
she was able to return to work.

Changes in Parent Behavior

Both Brian and his mother reported a decline in the frequency of parenting behaviors that
serve to accommodate his headaches and reinforce his illness-related behavior via sec-
ondary gain (Fig. 4). Specifically, she was no longer relinquishing him from chores,
permitting him to sleep late or miss school, engaging in status checks, or giving special
attention during pain episodes.

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Fig. 1 Clinician severity ratings 8

(CSRs) for anxiety disorders Pre-treatment
based on the Anxiety Disorders 7

Clinician Severity Rating

Post-treatment
Interview Schedule (ADIS).
CSRs of 4–8 indicate a clinically 6 1 month follow-up
significant anxiety disorder,
CSRs of 1–3 indicate subclinical 5
levels of anxiety symptoms, and
a CSR of 0 indicates normative 4
anxiety
3

0
SAD GAD OCD
Anxiety Disorder

Fig. 2 Changes in child and

SCARED-
parent report of total anxiety Child report
symptoms as measured by the
Screen for Anxiety Related SCARED-
Parent report
Emotional Disorders (SCARED).
A SCARED total score C 25
indicates clinically significant
anxiety

Pre-treatment Post-treatment 1 month follow-up

7
CGI-Severity
CGI-Severity Score

Headaches
6
CGI-Severity
Anxiety
5

1
Pre-treatment Post-treatment 1 month follow-up
Time Point

Fig. 3 Changes in independent evaluator (IE) rated severity of anxiety and headache symptoms as
measured by the Clinician Global Impression—Severity scale (CGI-S) where 1 Normal, 2 Borderline ill, 3
Mildly ill, 4 Moderately ill, 5 Markedly ill, 6 Severely ill, 7 Extremely ill

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3
Maternal report
2.5 Child report

ARCS Score
2

1.5

0.5

0
Pre-treatment Post-treatment 1 month follow-up
Time Point

Fig. 4 Changes in maternal accommodation/reinforcement of child headache-related behavior based on the

Protect subscale of the Adult Responses to Children’s Symptoms (ARCS). The scale ranges from 0 to 3 with
higher mean ratings indicating more maternal accommodation and reinforcement of the child’s illness-
related behavior

Discussion

The case presented highlights the issues involved in identifying and treating comorbid
headaches and anxiety. This case was selected for its relevance to the real world presen-
tation of children with chronic headaches for whom the contributory role of anxiety is often
overlooked. Of relevance for the pediatric clinician is the lack of awareness (on the part of
the parents, child, and previous medical providers) regarding the extent, severity, and
impairment associated with anxiety symptoms. This may be due to a tendency for many
parents to focus exclusively on physical symptoms while ignoring psychological symp-
toms. Perhaps due to stigma, some families are resistant to suggestions that psychological
dysfunction may be related to physical symptoms. As a result, parents may not commu-
nicate mental health concerns to their pediatric medical providers. Pediatric practitioners
would be well served to be on the lookout for anxiety when children complain of chronic
headaches. Indeed, there is some evidence that anxiety may precipitate headache episodes
(Seshia 2004), however, the relationship between anxiety and headaches is most likely
reciprocal in nature. Thus, pediatric medical providers should routinely screen for psy-
chological dysfunction and make appropriate referrals when warranted.
From this case, many lessons were learned. First, anxiety reduction skills were par-
ticularly effective in reducing Brian’s overall functional impairment. Although he con-
tinued to have daily, but less severe, headaches, he ‘‘got his life back’’ and was able to go
to school, play with other kids, attend birthday parties, play in soccer games, etc. Second,
this case also highlights the tremendous burden of the child’s illnesses and the role of
parental accommodation in maintaining the child’s symptoms and illness-related behavior.
Parental involvement was a critical component of treatment. Brian’s parents were unin-
tentionally reinforcing his illness behavior and accommodating his headaches and anxiety.
Shifting the environmental contingencies was necessary so that healthy and brave
behaviors were rewarded (reinforced), while illness and avoidant behaviors were extin-
guished (not reinforced). Although parental involvement in behavioral treatments is not
widely practiced for CDH, the benefits have been demonstrated in the treatment of pedi-
atric headache (Allen and Shriver 1998) and anxiety (see Barrett et al. 1996; Suveg et al.
2006 for review).

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A goal of this case study was to describe the application of a family-based CBT for
children with comorbid headaches and anxiety. The findings presented are very pre-
liminary, based on a single case with a short one-month follow-up, and subject to threats to
validity. Changes in functional impairment as measured by the PedMIDAS are unusually
extreme. Brian’s pre-treatment PedMIDAS score was especially elevated because Brian
had not attended school, engaged in school work at home, or participated in any social or
recreational activities for several months prior to enrolling in the CHAMP study. Such a
high score suggests severe disability, which was accurate for this case; however such an
extreme score may not generalize to the majority of children with chronic headaches.
Furthermore, Brian continued to make additional treatment gains during the interim
between the post-treatment evaluation and the one-month follow-up. It is possible that
these gains can be attributed to his continued practice of the CBT skills, positive changes in
parenting behaviors, and our emphasis during the last two sessions on relapse prevention
and preparing for future challenges. However, it cannot be ruled out that Brian’s reduction
in headaches, anxiety, and functional impairment may have been due to other factors such
as spontaneous remission, reduction in medication usage (some medications may exac-
erbate headaches with overuse), or alleviation of stress associated with going to multiple
doctor visits each week and not feeling satisfied with the treatments offered. In addition,
the follow-up evaluation was conducted during the summer when there tends to be fewer
stressors for school-aged children and children tend to spend more time engaging in
recreational activities. A longer follow-up is needed to determine the durability of his
treatment response.
Nonetheless, this case highlights the importance of evaluating the mental health of
children with physical complaints and enhancing outcomes by targeting psychological and
familial factors. Although medication management of chronic headaches and anxiety can
be effective, many children and families may be dissatisfied with medications or reluctant
to try them and prefer a behavioral treatment. Our CHAMP treatment protocol offers these
families and their treatment providers a viable adjunctive (or alternative) behavioral
approach which may lessen the need for medication. The CHAMP intervention yielded a
positive outcome for this case and is currently being evaluated on a larger scale.

Acknowledgments This work was supported by a grant from the Migraine Research Foundation (grant
number 90040570) awarded to Golda S. Ginsburg and Kelly L. Drake.

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