Research has shown that significant early pain experiences can have a big effect on the developing nervous system:
• It may cause children to become more sensitive to pain.
• It may contribute to the development of chronic pain later in life.
For these reasons, our goal at Whole Child LA is to treat pain, not only to reduce suffering and enhance our children's ability to go to school and carry out normal childhood activities, but also to reduce their risk for developing chronic pain as adults.
In most cases of chronic pain, treatment is aimed at helping the body’s natural pain control system to start working effectively again. We take a “systems” approach to understanding and treating childhood pain by offering many 'evidence-based' and different types of clinical services delivered via an integrated and coordinated care team.
Use of needles, pressure, or other stimulation modalities at specific points along the body to increase the body’s internal sense of balance. It is a wonderful way to balance the body and experience a fully relaxed state.
> Michael Waterhouse <
Acupuncture is the use of needles, pressure, or other stimulation modalities at specific points along the body to increase the body’s internal sense of balance. The points are like energy generators along energy tracts called meridians in Traditional Chinese Medicine and the concept behind treatment is that the acupuncturist determines where energy is blocked or in excess and stimulate specific points, based on the diagnosis, to help energy flow more evenly throughout the body. Thanks to advances in needle and laser technology, this ancient natural healing modality can be used safely and effectively on all ages of children and adolescents. Well known for the treatment of acute and chronic pain, it is also a wonderful way to balance the body and experience a fully relaxed state. Mike Waterhouse explains how acupuncture works.
Acupuncture is the insertion of fine needles into the body at specific points and has been shown effective in the treatment of specific health problems. These points have been mapped by the Chinese over a period of two thousand years. Recently, electromagnetic research has confirmed their locations. How deep the needles go depends upon the nature of the problem, the location of the points selected, the patient’s size, age, health, and upon the acupuncturist’s style or training. Usually, needles are inserted into the skin from ¼ to 1 inch deep. Acupuncturists should use sterilized, individually packaged, disposable needles. Needles should not be saved and reused for later treatments. The patient should feel some light cramping, heaviness, distention, tingling, or electric sensation either around the needle or traveling up or down the affected meridian, or energy pathway. Modern Western medicine cannot explain how acupuncture works. According to ancient theory, acupuncture allows Qi to flow to areas where it is deficient and away from where it is excessive. I n this way, acupuncture regulates and restores the harmonious energetic balance of the body. And, according to this practice, it is disharmony that is said to cause disease.
An interactive therapeutic process that uses art to help children with pain to take control, help foster separation and strengthen their sense of self. Through their pictures, sculptures, collages and paintings, children express and project their inner images and learn about themselves.
> Dr. Esther Dreifuss-Kattan <
Esther describes art therapy as used in pediatric chronic pain.
One of the primary goals of art therapy is to understand the internal world of children. We strive to make it accessible for exploration and then search for the meanings that will ameliorate physical and psychic pain and foster growth. If we are to communicate effectively with our patients, it is essential to discover a common language. Long before the development of language, the infant has his own world with self-created images and sensory experiences. Sigmund Freud has suggested that children at play behave like creative writers or artists, developing a world that pleases them. He indicates art’s curious ability to handle feelings and themes that in ordinary life are too painful to talk about directly. The picture is a bridge between the inner and the outer world of the child. Both worlds contribute to the creation of the picture. Through their pictures, children express and project their inner images. Once the picture is finished, the art therapist, together with the child, will look at the finished product and invite the child artist to share his feelings, thoughts and associations about it. However, if the patient is too young or is not interested in talking about the picture, that is fine, too. Often the act of creation is therapeutic in itself. However, if a discussion is established, the child may share with the therapist a possible title or story or explain the individual parts of the picture. The better the therapist knows the child and his or her medical, psychological, and family history, the easier it is for thr therapist to interpret some of the content of the picture. This can relieve fears, allow for exploration of trauma, and elucidate family dynamics. Art therapy allows for externalizing on the paper the internal world and conflicts of the child.
This therapy utilizes relaxation techniques with non-invasive equipment that provides feedback about the body to learn how to reduce tension and pain.
> Dr. Bruce Levine & Diane Poladian <
Biofeedback uses a computer or other feedback device to assist your child in managing symptoms by becoming aware of and learning to voluntarily control physiological changes associated with the stress response. These monitored changes may include muscle tension, skin temperature, sweat gland response, brain wave activity, or breathing rate. During a biofeedback session, a trained therapist applies electrodes or other sensors to various parts of your child’s body. The electrodes are attached to devices that monitor your child’s responses and give him visual and/or auditory feedback. For example, he might hear tones and see colorful graphs on a monitor that display changes in his muscle tension or skin temperature. With this feedback, he can learn how to produce voluntary changes in body functions, such as lowering muscle tension and sweat gland response or raising skin temperature. T hese are signs of relaxation. The biofeedback therapist also will teach your child different relaxation skills such as breathing, muscle relaxation techniques, or imagery. The point of using biofeedback for chronic pain management is to help children learn to be aware of how their body reacts to different experiences and also to gain physiologic control of the branch of the nervous system that is always activated by pain or stress. Everyone who has ever been in pain knows that the more pain you have, the more stress you feel. And the more stress you feel, the more pain you have. So, through biofeedback, we attempt to break the stress-pain cycle. Usually there are quick changes, but even if at first there is little change in the pain itself, as the child gains more control over his body, the pain experience also becomes more manageable.
Craniosacral therapy (CST) is a light-touch manual therapy that enhances the function of your child's central nervous system (CNS). The CNS oversees every other system in the body. By addressing it directly, craniosacral therapy improves overall function of the CNS to help bolster your child's natural, self-healing capabilities.
The craniosacral system comprises the bones of the skull and the membranes surrounding the brain and spinal cord. It is named for the cranium ("cranio-") and the sacrum ("-sacral"), that triangle-shaped bone in the low back where the bottom of the spinal cord attaches. Throughout this system - and bodywide - motion equates to good health and well-being. Everything vital to our existence - organs, nerves, bones, fluids, etc. - has a certain intrinsic motion or rhythm. In order for your child's body to remain strong and healthy, all structures must maintain their inherent rhythms. By releasing restrictions that impede these necessary movements, CST helps restore essential rhythm, circulation, and balance to improve the normal self-corrective mechanisms within your child's body. Because it affects the CNS directly, craniosacral therapy helps dissipate the negative effects of stress and reduces misguided pain signals. The end result is better regulation of central pain circuits, a greater sense of resiliency, and stronger resistance to disease. Because of the gentle nature of this work, craniosacral therapy is ideal for children and teens in fragile or acutely painful conditions.
This therapy helps patients learn how to use and enhance his/her own imagination so that central pain circuits become disrupted and reprogrammed to help reduce and turn off pain. The goal is to help the patient to heal and stay well.
> Dr. Kathryn de Planque <
Hypnotherapy teaches the utilization of mind-body techniques, including hypnotherapy and guided imagery. I help the patient learn how to use and enhance his/her own imagination and work on strengthening the part of the brain that experiences images or sensations. In this way central pain circuits become disrupted and reprogrammed to help reduce and turn off pain. The goal of this treatment is that the patient learns how to help him/herself to heal and stay well. Dr. de Planque describes what she tells parents when a child with chronic pain first comes to see her.
My treatment is based upon a mind-body approach to healing. Children with chronic pain generally require a calming of the nervous system. The use of hypnotherapy and guided imagery influences this process as well as provides support for strengthening the immune system, release of stress and pain, and other healing goals set by the child. Many of these goals are emotionally based, such as reducing sadness or worry. My goal is for the child to learn how to help him or herself to heal and stay well. I always begin with an explanation of how the mind influences the body, and I think it is vitally important that each child, no matter what age, has a clear understanding of WHY hypnotherapy works and HOW they can use it to help themselves. Establishing safety and trust, especially with teenagers, is most important. I also try to instill in the children I see a sense that they can influence change within their own body by using their mind. After 2 or 3 sessions, the child begins to make his own choices of "where to go", and we may agree on the goal for the day. Before 6 sessions, we will make a tape that is specific to the child’s needs that can be used at home.
This form of yoga trains patients in special therapeutic yoga postures and breathing practices to reduce pain and stress and promote optimal healing. The use of props allows students of all abilities and at every level to benefit without injury or fatigue.
> Beth Sternlieb <
There are many different forms of yoga being taught today. In our program, we use a type of yoga called Iyengar yoga because it is highly therapeutic and safe for people with medical conditions, including chronic pain. In therapeutic yoga, the yoga series is matched to the healthcare needs of the child and changes as the child progresses. The yoga poses are intended to correct health-related problems, both in body structure and in internal organ function. Iyengar yoga teachers must have a minimum of five years of training before they are certified. It is important that a yoga exercise program is developed by someone who knows human physiology and can tailor the yoga program to the needs of the child with chronic pain. For this reason, we suggest private lessons rather then group classes until the child is familiar with the poses and can easily do them on his own. Beth Sternlieb is the certified therapeutic Iyengar yoga teacher in our program. Beth talks about Iyengar yoga.
Iyengar Yoga is a traditional form of yoga based on the teaching of the Indian Master B.K.S Iyengar. His method of teaching is orderly and progressive, and the postures are adjusted to meet the physical conditions and needs of each student. B.K.S. Iyengar developed a method of teaching that enhances the therapeutic benefits of yoga and a way of doing yoga postures and breathing that could be adapted to students of all ages, levels of experience, and ability. His method brings awareness, circulation, strength, and flexibility to various parts of the body to maintain optimal health. Iyengar Yoga stresses precision and correct alignment in all postures and makes use of props, such as wooden blocks, belts, and blankets. With the aid of props, students who are stiff, weak, or unable to hold a yoga pose for the necessary amount of time can use physical support to get the desired result. A well-trained, experienced teacher can use props to address health problems. For example, lying in a backbend over a chair stimulates the adrenal glands, doing standing poses, like Trikonasana (Triangle Pose) against a wall, can teach correct alignment and relieve pressure on the lower back.
The goal of mindfulness meditation is to help you learn how to be “present” and “in the moment.” So many of us are worried about what we did, what happened, what we have to do, or what will happen, that we spend much of our lives not enjoying or appreciating the present moment, being alive, and being with people we love. Learning mindfulness meditation helps us do this.
> Beth Sternlieb & Susan Kaiser Greenland <
I began to practice mindfulness meditation when my daughter was 5 years old. It was so helpful to me that I never stopped, and I have been teaching mindfulness meditation to parents and kids ever since. Mindfulness is being present with what is happening, in a balanced and non-judgmental way. Mindfulness also helps us be with children, who are sensitive and vulnerable to acceptance or disapproval. When we parents cultivate mindful awareness, we develop more patience and acceptance when our child is in distress. This helps the whole family. Mindfulness helps us find the distance to be with a child in pain—if we get too close, too reactive, we are too involved—and this hurts rather than helps the child. If we seek to protect ourselves and pull too far back, our child can feel abandoned. The practice of mindfulness helps us connect with our child and stay with him. The way to do this is to return to the present moment, to the simple sensory awareness of what’s going on in that moment. Our children give us feedback when we slip out of attention, if we choose to listen; they have a kind of sonar for authentic presence. Our mindful presence helps our children tolerate their own painful experiences with more calm. Children find out that most experiences are not as bad or as scary as they think. They rediscover how to experience directly, simply, exactly what is, even if it’s unpleasant, without making a big fuss. Even when a child is going through an emotional or physical storm, a mindful parent can stay centered right in the midst of the storm. When we can reduce our own stress level and relax, our children can borrow from our strength and cope better with their own stress. By practicing mindfulness, we can learn to relax right in the midst of difficulties, without having to escape. We can stay empathically close to our child. Lots of times what gets in the way of parents being effective is the need to have things go well and the feelings of failure and frustration that come up when it doesn’t happen that way. And when our children are suffering, mindfulness can make the difference between offering a wise response or an emotional reaction that we may regret. We don’t have to make it all better or make it go away, but just be willing to be there, accepting, caring, and kind. Mindfulness meditation can decrease stress, increase our pleasure in parenting, and increase our capacity to live in the moment and to turn off the critical tapes that run in every parent’s mind. Learning to relax and breathe into the moment brings a sense of confidence; kids can also learn mindfulness meditation. Sometimes the best way is for the family to learn together and practice together.
Music therapy sessions emphasize learning breathing and vocalizing techniques for relaxation; improvisation, songwriting and music recording for self expression; and guided imagery with music. No music experience is necessary.
> VANYA GREEN <
PT involves the assessment/management of movement dysfunction. It is the physical therapist’s job to analyze the entire neurological, muscular and skeletal systems in order to provide the most effective treatment for movement dysfunction and pain.
> Sean Hampton, Diane Poladian, Celia deMayo <
Physical Therapy involves the assessment and management of movement dysfunction. It is the physical therapist's job to analyze the entire neurological, muscular and skeletal systems in order to provide the most effective treatment for movement dysfunction and pain. As physical therapists, our main goal is always to restore normal, pain-free movement and functioning.
The primary role of the physical therapist is to help your child’s physical structural body become normalized and in balance, including posture, tight or weak muscles, and muscle-nerve mechanics. Many physical therapists also use electrical stimulation units for treating pain. The most commonly used home device is the transcutaneous electrical nerve stimulation (TENS) unit. This is a gadget that your child can wear. It has electrodes that she can place on the part of the body that is in the most pain. The physical therapist can teach your child how to increase the frequency or amount of stimulation so that she/he can feel a comfortable “buzz” that doesn’t hurt but feels good. This stimulation is believed to block pain signals and can be very effective for some children. It also is typically covered by most health insurances. Sean Hampton, M.P.T, one of our longtime physical therapists, describes PT in children with chronic pain.
While electrical stimulation can be helpful in treating chronic pain, physical therapists employ many other treatments to help your child get back to an active life. The therapist may also use manual hands-on stretching and mobilization treatments to help stretch out muscles, joints, and nerves that have become tight over time and with decreased activity. The therapist must have the ability to make therapy fun and interesting for children.
Individual child, family, parent, or couples therapies help patients/couples/families create balance between attachment and freedom to explore possibilities and opportunities by teaching problem solving and relationship skills, mindfulness and relaxation, and help people clarify their goals and take the necessary steps to realize them. Patients are helped with any individual or family issues that either contribute to or exacerbate pain, and patients are helped to develop strategies to function again socially, at home and at school. Patients develop strategies and coping skills to decrease pain and increase a sense of control, improve function, manage psychological distress, improve quality of life, and integrate the mind-body connection within the context of our multidisciplinary pain team approach.
> Samantha Levy & Shelley L. Segal & Diana Taylor <
The goal of psychological therapies is to provide an individualized psychotherapy treatment plan to help develop strategies and coping skills to decrease pain and increase a sense of control. An important goal is to improve function, help the patient manage psychological distress such as anxiety and/or depression, improve quality of life, and integrate the mind-body connection while working with our multidisciplinary pain team. Our clinical psychologists also understand child, adolescent, and young adult developmental needs as well as those of couples trying to parent the child who has pain. They help children, teens, adults, couples and families create a balanced life between attachment (feeling connected within the family) and the freedom to explore opportunities involved in growth. In the context of the psychotherapeutic relationship, problem-solving and relationship skills are taught, patients are helped to engage in mindful awareness and relaxation, and goals are clarified so that individuals can take the necessary steps to realize them.
In cognitive behavioral therapy (CBT), children learn to identify situations that make them anxious, to change the way they think about situations (this is called “cognitive reframing”), and to reduce their feelings of anxiety at those times, through various relaxation and mental strategies. Behavior therapy helps children to identify and address different situations that cause them stress and pain and helps them to adopt new ways to react. It also teaches them how be calm so that they can feel better, think more clearly, and make better decisions. Often in CBT, children first practice being able to think about the things that make them anxious and then think or imagine themselves in the situation. Then little by little they practice actually doing the thing(s) that makes them anxious. This practice of accomplishing a task in small increments is called desensitization. Relaxation training, hypnotherapy, and mindfulness meditation (see below) can also be incorporated into cognitive behavioral therapy to help a children desensitize so that they can function well, worry less, and feel better overall.
When your child stays home from school, you or your spouse or partner may have to miss work or scramble for child-care arrangements. Parents often have different ways of dealing with a child who reports too much pain to be able to attend school. Marital stresses can develop, siblings can behave disruptively, and the family can become stressed. Through family (or sometime just couples) therapy, families can work together to help themselves function better as a cohesive and supportive unit and, in turn, help the child with pain to function and feel better. The goals of family therapy are to: 1) observe, identify, and alter family dynamics that may contribute to the child’s pain perception and difficulty coping; 2) participate in developing and implementing a behavioral plan; 3) address family stress and other problems; 4) improve family communication; and 5) provide support and improve family coping. There is often resistance to family therapy. It is easier to focus on the child with the pain problem then to examine factors that may be contributing to the problem. Parents often do not realize the inadvertent roles that they play in helping their child cross the line from experiencing a moderate pain problem to developing a pain-associated disability syndrome (PADS), a condition in which children with chronic pain quickly spiral out of control and become low- or non-functioning. Fortunately, parents can also help their child to become fully functional again.
When should you consider family therapy? Any family can benefit from family counseling, which in addition to redirecting behavior, will educate you about how pain works and what you can do to help your child become fully functioning again. However, I typically recommend family therapy when it appears that individual therapy is not helping, or when there is clearly a family dynamic that is inhibiting the child from getting better. The general rule of thumb is that if things don’t improve with adequate treatment of your child’s pain, you should be considering what family factors might be inadvertently contributing to the pain. For example, take a look at yourself and your spouse/partner and notice how you react to your child when he/she is complaining about pain.
Do you find that you get so anxious that you feel the need to “do something” immediately to make it stop?
Do you feel that you are suffering as much as your child, and is your suffering interfering with your life and causing you to lose sleep, or have you become irritable, depressed, or anxious?
Do you find it difficult to convince your child to do anything when she/he is in pain?
Do you have a hard time not asking your child how he/she is feeling?
Do you constantly monitor your child’s face for signs of pain? Are you and your spouse/partner constantly in conflict over the best way to deal with your child?
Are you sleeping with your child every night?
Do you identify too closely with your child because you have the same type of pain problem and is it interfering with your child’s ability to do things for him/herself?
Do you feel that you are the one shouldering all the responsibility for your child’s pain and that you are not getting the support you need from your spouse/partner?
Are your other children starting to show signs of neglect? Are they “acting out”?
If your answer is “yes” to several of these questions, then you are probably a candidate for family therapy. When family therapy is suggested as part of a child’s treatment plan, many parents feel that they are being told that they are failures as parents. They may say, “I think we are doing pretty well…Why would we need family therapy?” A recommendation for family therapy does not necessarily mean that your marriage is bad or your family is dysfunctional. Typically, the recommendation simply means that there are some behavioral patterns within the family that may be making it more difficult for the child with pain to function. Nobody is at fault, the system just needs “tweaking.” One thing is certain, whenever a family makes the commitment to therapy, changes happen. A family therapist may choose to work with the parents alone if the psychologist feels that this is where the primary problem is. F or example, marital/couples therapy may be the most effective treatment if parental discord is creating tensions at home and aggravating the child’s pain problem. The focus of marital therapy in this context is to help both parents examine their goals and expectations of their child, and to learn how to work together.
This service is conducted by a child and adolescent psychiatrist who fine-tunes the balance of neurotransmitters in the brain and nervous system, many of which are involved in pain systems. Planned medication early provides a buffer so that the body can heal.
> Dr. Ryan Davis <
Psychopharmacology is carried out by a board certified child and adolescent psychiatrist. Psychopharmacology addresses fine-tuning the balance of chemicals and neurotransmitters in the brain and body’s nervous system. Many of the same chemicals involved in emotional states like anxiety and depression are also involved in pain systems. The goal is to diagnose the specific excess or reduction in these brain chemicals through a careful history to learn about behavior, thinking, and emotions, as well as life experiences, in order to determine the specific medication that will help balance the system while more effortful coping strategies are being learned. Often planned medication early in treatment can provide a buffer so that the body is not so stress-reactive and can heal.
The first visit at the clinic is generally a 2-3 hour appointment for the child/teen and parents, with pediatric pain specialists: Dr. Lonnie K. Zeltzer and Dr. Paul Zeltzer. Here, the patient’s narrative about his or her experience takes center stage.
We welcome humor and employ empathy in understanding the pain story told by the patient and family. The essential messages of the first visit are (1) that the pain is real and makes biological sense, (2) the suffering is understandable and makes psychological sense, and (3) that suffering can and will improve first. Pain is not a mystery.
You may be asked to fill out a questionnaire for both parents and patients for clinic purposes.
Whole Child LA offers state-of-the-art medicine in combination with the regenerative power of complementary therapies to treat children suffering from chronic pain. Many of the children whom we see have complex problems that have not been helped adequately by the biomedical model of care.
The first visit at the clinic is generally a 2-3 hour appointment for the child/teen and parents, with a pediatric pain specialist. Here, the patient’s narrative about his or her experience takes center stage.
WCLA brings all its clinicians under one roof that will provide treatment for children nationally who have the most pain-related disability. Our staff works as a team to develop an individualized approach for each child that involves the active participation of the child and family in finding solutions to the problem.
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Whole Child LA is a low volume office. We do not double book patients - a practice common to most physicians' offices. Your booked appointment is reserved in advance for you so your personal physician can focus on your comprehensive care.
Insurance companies expect physicians to double book an average of 4 to 6 patients per hour. That is how their contractual agreements and reimbursements are structured. These expectations limit our ability to work with insurance companies' contractual requirements and to provide our patients with the comprehensive integrative care for which our clinic is known.
Therefore, our practitioners work as “out of network” providers. We do not overbook nor do we schedule more than two patients per hour, (initial visits vary from 1.5 to 3 hours). Thus, your missed appointment represents a loss for our physicians and to the clinic.
We require a 24 hour notice of cancellation for all appointments.
After payment is made to our office, the bills can be submitted to PPO insurance plans as “out of network” directly by you. You will be reimbursed dependent upon your individual insurance plan. Please contact your insurance company for information on your coverage for “out of network” providers.
Respectfully, we are not providers for any HMO insurance or Medicare.
PARTH R BHATT