Although most research and attention focus on adults, children and adolescents suffer from chronic pain and mental health disorders in numbers as high as adults. A study published in JAMA Pediatrics last month showed that a third of children younger than age 18 who have chronic pain also meet the criteria for anxiety disorder, while 1 in 8 meet the criteria for a depressive disorder, triple what is seen in a community setting. Twenty percent of children and adolescents suffer from chronic pain, and studies repeatedly show that they are often inadequately treated.
The implications of untreated chronic pain are profound. It is a leading cause of loss in classroom time and social connection and of mental health disorders such as anxiety and depression. Conversely, anxiety and depression are also increasingly common and are shown to be significantly linked to chronic pain. Alarmingly, children (and adults) with both mood and pain disorders demonstrate higher levels of disability and a poorer quality of life than if they experienced only one of those conditions.
The problem doesn’t go away if we ignore children; in a study of adult patients with chronic pain, 17% reported that their pain originated in childhood or adolescence.
Pain and poor mental health are directly linked to the opioid crisis in children. A 2022 report by the Centers for Disease Control and Prevention showed that 1 in 7 high school students reported misusing opioids at least once, and it has also been reported that children and adolescents who use opioids are likely to have pain and anxiety or depression. The links between pain and mood are thus profound and, in many, a treatment conundrum.
As a pediatric gastroenterologist, I have spent almost 20 years caring for children with gastrointestinal disorders, many of whom have significant abdominal pain and related mental health issues. When treatments are not successful, I bear witness to the severe medical and social consequences that ravage their lives. As director of the Pain Research Center at New York University, I envision a future world in which children no longer suffer from the heartbreaking impact of inadequately treated pain and mental health disorders. I ask myself on a daily basis: How can we help these children?
The data increasingly support a role for bringing mood and pain together to the forefront of education, diagnosis and treatment for children with pain.
However, due to a dearth of research in children, broad guidelines in management of chronic pediatric pain, outside a few specific conditions and recent guidelines for acute opioid prescribing, are lacking. Yet, there are noninvasive, medication-free ways of “treating the brain” that have shown some success.
Mindfulness meditation techniques that involve fostering an awareness of feelings or sensation have shown preliminary success in kids and have more recently been found to induce brain activity patterns associated with potential improvements in pain and negative emotions in adults. Cognitive behavioral therapy, which teaches children ways they can reshape their thoughts around pain and anxiety; hypnosis; and virtual reality have shown success in some trials for pediatric abdominal pain and/or anxiety. Yet, the conclusion of many of these studies is that more studies are needed for confirmation.
Despite CDC guidelines emphasizing maximal use of therapies that don’t involve medication, there has not been a definable increase in use of these and other drug-free techniques. The reasons are multifold.
Many clinicians don’t know what is available. A study published in 2018 of 383 medical schools showed that 96% of schools in the United Kingdom and United States don’t require dedicated teaching on pain medicine. Although rates are improving, multiple generations of clinicians lack education in pain management. Educational programs that align management strategies with CDC guidelines, including the use of medication-free therapies in care, can effectively be used. Widespread education about these options for pain management is key for all health care students and workers because pain spans virtually every medical field.
Similar educational programs could be created for children and their families. Educational strategies, such as those put forth by the CDC to promote mental health, such as mindfulness and connectedness, could be recommended as a standard of care. Campaigns directed toward children and families are crucial.
The dearth of providers, particularly in rural or underserved areas, remains a key obstacle to accessing medication-free therapies. Increased access is of critical importance for public health. Several recent adult studies have revealed relatively low-resource options that could be done virtually, including mindfulness by telehealth or through an app and remotely delivered cognitive behavioral therapy.
On a policymaker level, insurance coverage for these services may not only increase access but also research to provide further documentation of which therapies work and which patients they work for.
In the meantime, families with children in pain should connect with an empathic, knowledgeable physician. Pain studies show that involvement of a health care provider who is empathic and attentive helps heal patients’ pain. Knowledgeable physicians will also be aware of medication alternatives to opioids. And optimal exercise, sleep hygiene and stress control have all been shown to improve outcomes in pain and mental health disorders.
A pain-free world should be a goal for humanity, especially for the sake of our youngest members.
Dr. Kara Margolis is director of the NYU Pain Research Center and an associate professor in the Department of Molecular Pathobiology at the NYU College of Dentistry and in the Departments of Cell Biology and Pediatrics at the NYU Grossman School of Medicine. She is also a public voices fellow at New York University.
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