Study determines that Pain Buddy app may aid in reduction of pain severity

A child, resting in bed, fires up her 7-inch tablet and opens an app.

She selects from a variety of cartoon avatars — such as a panda or penguin — and backgrounds that include a colorful ocean floor with fish and other sea creatures.

Game on.

But this isn’t a typical game. It’s a kid-friendly tool that allows the child, who is being treated for cancer, to report the severity and type of pain she’s experiencing from her home — information her doctor can access in real time.

Playing their way to pain reduction

The app, named Pain Buddy, may aid in the reduction of pain severity in children during cancer treatment, according to results of a pilot study recently published in the online journal Pediatric Blood & Cancer.

The study found that Pain Buddy may be especially beneficial in helping children who have high levels of pain.

Pain Buddy app
Pain Buddy app

Pain Buddy is the brainchild of Michelle A. Fortier, a CHOC Children’s pediatric psychologist who is also a faculty member of the UC Irvine Sue & Bill Gross School of Nursing.

Fortier, who specializes in pain management in children, was principal investigator of the recently published pilot study. that was based on clinical studies of CHOC patients monitored by pediatric oncologist Dr. Lilibeth Torno and pediatric oncology nurse practitioner Christine Yun.

“Pain management is an important part of cancer survivorship, and I think Pain Buddy’s potential for use is very broad,” Dr. Torno says.

Most of the 48 children participating in the eight-week study had been diagnosed with leukemia. All were between the ages of 8 and 18. Results of this particular study come amid ongoing studies on the Pain Buddy app at other sites., Results of the comprehensive research effort, which will track 206 children, are expected in three years, Fortier says.

Pain Buddy app
The Pain Buddy app allows users to identify their pain through various games, like sorting balls into baskets.

The gap in children’s pain management

Pain Buddy, Fortier explained, was developed a few years ago to address a gap in pain management of kids at home compared to kids in the hospital, where it’s easier for doctors and nurses to stay on top of patients’ needs. The 48 children who participated in the pilot study spent a lot of time at home.

Tapping the expertise of professional app developers and researchers at UCI in the California Institute for Telecommunication and Information Technology (Calit2), Fortier and several other colleagues came up with a way for children to rate their pain as they were feeling it from home.

“Most kids experience pretty moderate to severe pain throughout their cancer treatment, and this pain just wasn’t sufficiently being addressed when the patients were at home,” Fortier says. “And when we think about pain assessment, we’re really terrible retrospective reporters of our pain experience.”

But with Pain Buddy, users can say how much they’re hurting, and where, as it’s happening.

“Pain can come from the cancer itself, such as a solid tumor, and it can come from treatment procedures,” Fortier says. “For example, lots of skin-breaking procedures occur during cancer treatment. And treatments like chemotherapy can cause nerve pain, inflammation of the gastrointestinal tract and mouth sores.”

Pain Buddy app
The Pain Buddy app allows users to describe their pain with word bubbles, and can alert the care team.

In addition to completing a pain and symptom diary twice daily, the app automatically alerted the participants’ medical teams about such symptoms as nausea, itching, sadness and redness.

With a touch of a finger, the patients could select word bubbles to indicate descriptions — such as bad, annoying, or and terrible — to describe their pain.

Clinicians, in turn, could promptly address any symptoms that warranted intervention.

Learning skills to cope with pain

A key component of the Pain Buddy app, which for now only has been used by the pilot study participants, is the incorporation of coping skills shown to be effective in the management of pain, such as deep breathing, progressive muscle relaxation and guided imagery.

During these skills training exercises, patients could accumulate coins and, visiting a virtual store, customize their personal avatar and buy additional background themes.

Pain Buddy app
The Pain Buddy app can help patients learn coping skills.

Pain Buddy represents an effective partnership between parents, young cancer patients and the health care institutions that treat them, Dr. Torno says.

“Our focus on cancer survivorship begins on the day of diagnosis,” Torno says.

CHOC’s After Cancer Treatment Survivorship (ACTS) program features a multidisciplinary team of clinical experts who monitor the late effects of cancer and develop a plan for long-term surveillance to ensure the best possible outcomes. Every child at CHOC who has gone through cancer therapy eventually lands in the ACTS program.

Fortier said the ultimate goal is to further refine Pain Buddy and license the app to hospitals for widespread use.

“The goal is to have every kid undergoing cancer treatment — from sarcoma patients to those with bone and other cancers — to have the ability to use Pain Buddy.”

Understanding the role of cultural stigma on seeking mental health services

By Dr. Sheila Modir, pediatric psychologist; Baleska Alfaro, licensed marriage and family therapist; and Dr. Ava Casados and Dr. Sarah Ruiz, post-doctoral fellows at CHOC Children’s

For some people, making an appointment with a mental health provider may be a personal and independent decision. For others, the decision to seek therapy services may be influenced by their culture or community, as each culture has its own understanding, interpretation and beliefs around mental health symptoms.

Our own culture also teaches us ways to cope with distress and whom to rely on for support during difficult times. This may impact whether a person seeks mental health services and treatment, or their decision not to seek care at all.

In many cultures, negative stigma about mental health symptoms or therapy services is a major obstacle to getting professional help. Research shows that people in racial and ethnic minority groups in the U.S. are less likely than White people to seek outpatient therapy services. Many ethnic minority groups are more comfortable going to their primary care physicians or family members for assistance with mental health symptoms as opposed to speaking with a mental health provider. We all want to be accepted by our communities, and sometimes fear of shame or embarrassment prevents people from seeking mental health treatment.

For instance, Black families may be understandably reluctant to seek mental health therapy due to the longstanding history of discrimination, racism and mistreatment the Black community has experienced at the hands of providers in the U.S. Instead, they tend to take an active approach in handling adversities independently and directly. They also tend to rely more on spiritual resources for emotional support. While these beliefs and approaches are valid, overly negative views of therapy can keep children who do need a higher level of care from getting that help.

Studies show that Latinx (a gender neutral reference to a person of Latin American cultural or ethnic identity in the U.S.) families are also less likely to trust mental health providers compared to White families and are more likely to rely on social support from extended family and other community members. When Latinx individuals do tell others about their experiences with stress or emotional difficulties, they often focus on physical symptoms such as trouble sleeping or loss of appetite and are less likely to discuss the thoughts or feelings that are bothering them.

For Asian American and Middle Eastern American communities, cultural beliefs that seeking mental health treatment will bring shame and dishonor to the family leads some people to internalize their symptoms instead of seeking therapy. Many Asian American children have described feeling pressured to appear perfect and successful, and therefore keep their symptoms secret. For Middle Eastern American adolescents, research has found that they tend to seek support from other family and religious community members.

While these beliefs and approaches are valid, overly negative views of therapy can keep children who do need a higher level of care from getting that help.

These examples are broad, but they illustrate just a few of the reasons why ethnic minority children are much less likely to receive therapy when they need it. Ultimately, it is the responsibility of the mental and medical health system to make services more accessible to under-served families, and to spark change to counteract myths about the stigma of mental health symptoms and mental health treatment. Parents can also play an important role in examining their family’s own cultural beliefs about treatment and identifying ways to advocate for their children to get expert help whenever they need it.

How our community can end mental health stigma

So, how do we, as parents, healthcare professionals and the community begin to work on eliminating the stigma surrounding mental health disorders and accessing mental health services? After all, one in five children experiences a mental health disorder.

Here are some tips that can help our children and families feel more comfortable with identifying, discussing, managing and accessing services for mental health.

1. Seek reliable information — A first step that we can take to end mental health stigma is to seek out reliable and accurate information about mental health disorders, treatment options and resources in our community. Trusted sources can include, but are not limited to:

When speaking to children about mental health, use resources that are age-appropriate and engaging. A young child may find books helpful, while an older child may prefer to get information online. Look over resources with your child to help them find reputable sources of information and avoid popular social media platforms as your only source of information. Not sure how to start? Here are a few resources for kids:

2. Use appropriate language — The resources listed above can help you understand how to talk to your children about mental health issues, as well as how to dispel mental health myths they might have heard about conditions and treatment. Using correct language can reduce any shame or guilt you or your family and friends may have about mental health and can create a space that makes it easier for children and teens to speak openly about their own struggles and seek help.

3. Celebrities normalizing mental health conditions — Because so many people live with and manage symptoms related to a mental health condition, it isn’t hard to find a celebrity or well-known public figure your child admires who has a mental health condition. We can use celebrity or public figure examples to help normalize mental health conditions and access to mental health treatment. Our children will be more open to discussing their mental health condition and to trying out mental health services if they know that their favorite singer, actor or athlete also lives with a mental health condition.

4. Learn to explain your child’s mental health condition to your support system and community — Once we have accurate information about our child’s mental health condition and treatment plan, it could help to share this information. If we share information about mental health with our families, schools or places of worship, as well as other members of our support system, they can each better understand the child’s mental health and how they manage symptoms. Sharing information can also help increase empathy and support for the child’s well-being.

5. Seek support in your community — Children and teens with mental health conditions may not know anyone else with a similar diagnosis, which can impact their self-esteem. For teens especially, finding support from an online community may be a helpful way to openly speak about their mental health condition. Parents may also benefit from knowing other parents with children who have mental health conditions, as this can allow families to find a sense of community or support. Your local National Alliance on Mental Illness chapter offers peer support groups for parents and individuals with mental health conditions.

6. Advocacy — Engaging in advocacy is another way that parents and community members can help break down mental health stigma. Organizations like National Alliance on Mental Illness engage in advocacy and policy change using individual’s stories. Advocacy can help raise awareness about important mental health issues and help dispel myths and break down stigma. It could also have positive impacts for those who are engaging in advocacy, helping to develop a sense of solidarity and common purpose.

Learn more about mental health services at CHOC.

CHOC awarded ACEs Aware grant funding to provide trauma-informed care training

CHOC Children’s has received $180,000 in grant funds from the Office of the California Surgeon General and the Department of Health Care Services to participate in the state’s ACEs Aware initiative.

The initiative seeks to change and save lives by helping Medi-Cal providers understand the importance of screening for Adverse Childhood Experiences (ACEs) and training them to respond with trauma-informed care.

CHOC will use its grant funds to conduct supplemental training to promote the ACEs Aware initiative among the Medi-Cal provider community in Orange County. Through this training, providers will learn the importance of incorporating ACE screenings into their clinical practice, as well as how to administer screenings, use clinical protocols to determine evidence-based treatment plans, and provide trauma-informed care. Trainings will also include mental health providers and school professionals to encourage communication and coordination between important systems in children’s lives.

“At CHOC, trauma-informed care is embedded into our treatment and interactions with our patients and families,” said Dr. Heather Huszti, CHOC’s chief psychologist. “The COVID-19 emergency underscores the critical need of using trauma-informed care to treat the whole child. We are so grateful to have received this funding to help teach providers throughout Orange County about the importance and practice of trauma-informed care.”s

CHOC was among 100 organizations throughout the state to receive a total of $14.3 million to extend the reach and impact of the ACEs Aware initiative. These grants will provide funding to organizations to design and implement training, provider engagement, and education activities for providers and organizations that serve Medi-Cal beneficiaries.

“We are looking forward to working in partnership with this amazing group of community leaders to further our efforts to help health care providers become ACEs Aware,” said California Surgeon General Dr. Nadine Burke Harris. “This work is critical, now more than ever, given the stress so many Californians are experiencing as a result of COVID-19 and the role of racial injustice as a risk factor for toxic stress. A trauma-informed health care workforce is vital for helping our state heal.”

The grant funding will provide critical support to community organizations serving Medi-Cal providers and beneficiaries, which have been experiencing increased stress during the COVID-19 emergency. Grant activities will augment California’s efforts, underway since the summer of 2019, to develop provider training and engage providers, including the promotion of payments to Medi-Cal providers for screening their patients for ACEs.

Added Dr. Karen Mark, DHCS medical director: “DHCS is committed to preserving and improving the overall health and well-being of all Californians. The ACEs Aware initiative is a vital part of the Medi-Cal program’s response to the COVID-19 emergency. These grants will help us reach Medi-Cal providers who serve diverse and often at-risk populations throughout the state, and will help to ensure that Medi-Cal members receive the high-quality, integrated care that every Californian deserves.”

Funding for the ACEs Aware grants was previously authorized in the 2019-20 budget using Proposition 56 funds for provider training on how to conduct ACE screening in the Medi-Cal population. In light of the COVID-19 emergency, the grant funding will provide critical support to the community organizations serving Medi-Cal providers and beneficiaries.

View the full list of ACEs Aware grantees.

Meet Dr. Micaela Thordarson

CHOC Children’s wants its referring physicians to get to know its specialists. Today, meet Dr. Micaela Thordarson, lead psychologist, Intensive Outpatient Program (IOP) at CHOC Children’s. 

Q: What is your education and training?

A: I earned my bachelor’s degree in psychobiology from UCLA with a minor in Spanish. I earned my PhD and master’s degree in clinical psychology from Palo Alto University with a specialization in children, adolescents and families. I completed my pre-doctoral internship with Nationwide Children’s Hospital in Columbus, Ohio, and my post-doctoral fellowship with Geisinger Health Systems in Pennsylvania.

Q: What are your special clinical interests?

A: I am particularly passionate about working with high-risk pediatric patients. I have done a great deal of work with suicidal and self-harming youth and their families. As a bilingual clinician in Spanish and English, I am also very interested in the interactions between mental health and cultural identities, for example, race/ethnicity, gender, religion and age.

Q: How long have you been on staff at CHOC?

A: I joined CHOC in October 2017.

Q: What are your most common diagnoses?

A: Depression, anxiety, and major life stressors are the most common difficulties our patients face.

Q: What would you most like community/referring providers to know about the Intensive Outpatient Program at CHOC Children’s?

A: Our eight-week intensive outpatient mental health treatment program – the only pediatric-dedicated one of its kind in Orange County — is designed to serve a broad range of emotional and behavioral difficulties for high-school aged teens 13-18. It includes individual and family sessions, and crisis support as needed. If the teens and families you serve could possibly benefit from an intensive program, please don’t hesitate to reach out to me. Additionally, we aim to collaborate closely with all the important stakeholders in our patients’ lives. This includes primary care physicians, psychiatrists, therapists, educators and coaches.

Q: What would you most like patients and families to know about the IOP?

A: While our program is hard work, it’s pretty fun to be a part of! The daily after-school programming for teens and their families is all interactive, including art and other expressive therapies, and designed to teach and practice new skills in fun ways.

Q: What excites you most about the IOP?

A: I am so excited to be able to offer a very important service to teens and families who are in crisis and need extra support. The program we offer is guided by research and has been carefully constructed to generate the best outcomes possible.

Q: What inspires you most about the care being delivered at CHOC?

A: I have worked with a number of different organizations and teams since I began my career in the mental health field. The team at CHOC is unparalleled in its enthusiastic dedication to innovation and excellence in the care of children.

Q: Why did you decide to become a psychologist?

A: I fell in love with the field of psychology immediately after taking my first job at a crisis shelter for teens. Getting to witness, and even participate in, the incredible changes these youths made in their lives in a few short weeks was inspirational. I knew that was work I wanted to be a part of for the rest of my career.

Q: If you weren’t a psychologist, what would you be and why?

A: Either a zookeeper, so I could spend time with cool animals every day, or a Disney princess at one of the theme parks so I could wear awesome costumes and play with kids all day.

Q: What are your hobbies/interests outside of work?

A: I love spending time with my family, hiking with my dog, and eating delicious food. I have a huge family and we have a lot of fun together!

To contact Dr. Thordarson, or to refer a patient, please call 714-509-8481.

CHOC Launches Mental Health Intensive Outpatient Program

A new intensive outpatient program at CHOC Children’s will offer solutions to teenagers and their families seeking hope and intervention for emerging mental health problems.

The Intensive Outpatient Program (IOP) at CHOC Children’s is designed for teens who show moderate to severe symptoms of anxiety, depression or other mental health problems.

Participants ages 13 to 18 attend after-school programming for three hours a day, four days a week in sessions that span eight weeks total.

Run by experienced, licensed clinicians who specialize in working with teens, the IOP incorporates therapy, mindfulness exercises, coping and problem-solving skills, art therapy and other expressive therapies to help teens develop and practice healthy behaviors and how to manage their feelings, emotions and personal interactions.

Parents or guardians also participate in family counseling and skills groups two days a week in the late afternoon and early evening.

A board-certified adolescent psychiatrist is also available for consultation and medication management, as is case coordination with other medical providers and the teen’s school, and crisis support.

Teens who could benefit from the program may exhibit a range of behaviors:

  • Moderate to severe symptoms of anxiety and depression
  • Extreme emotional outbursts
  • Significant conflict with family or friends
  • Suicidal thoughts
  • Decreases in functioning at home or school
  • Self-harming behaviors, such as cutting, burning, pulling out hair, excessive picking and scratching the body to cause bleeding

Time in the IOP is spent on identifying interventions that can aid participants in a variety of ways:

  • Improve symptoms of depression and anxiety
  • Improve functioning at home, school, and with friends
  • Develop new skills to cope with stress.
  • Establish new and healthy behaviors to learn how to manage feelings, emotions, and personal interactions.

The program is a component of CHOC’s landmark pediatric mental health system of care launched in spring 2015 to ensure children, adolescents and young adults with mental illness get the services and support they need.

The system of care also includes outpatient support for patients whose physical conditions are complicated by mental health challenges; mental health screenings for all 12-year-olds at their well child visits with CHOC pediatricians; and an increased presence of psychologists and social workers in the Julia & George Argyros Emergency Department at CHOC Children’s Hospital.

The cornerstone of the wide-ranging effort is the CHOC Children’s Mental Health Inpatient Center, set to open this spring at CHOC Children’s Hospital. With 18 beds, it will be the first unit in Orange County to accommodate children younger than 12.

Call 714-509-8481 to refer a patient to the Intensive Outpatient Program at CHOC Children’s.