Paediatric pain: Overview

Abstract
Objectives: Attrition from pediatric chronic pain clinics limits patients from receiving maximum benefit from evidence-based interventions, with likely persistence of chronic pain, functional and psychosocial impairments. We aimed to determine attrition prevalence from interdisciplinary pediatric outpatient chronic pain clinics and identify any associated patient and caregiver factors.

Methods: A retrospective analysis was performed of longitudinal data from patients and caregivers attending 10 interdisciplinary pediatric outpatient chronic pain clinics in Australia or New Zealand contributing to the Paediatric electronic Persistent Pain Outcomes Collaboration (PaedePPOC) database. Data was retrieved for patient attrition, patient and caregiver factors at treatment commencement and subsequent documentation of the episode end for treatment completers and non-completers. Statistical associations with patient attrition were assessed using logistic regression analyses.

Results: The prevalence of patient attrition was 19.3% in the PaedePPOC cohort (N=1051), occurring steadily over 11 months. Patients ending their treatment prematurely presented with longer pain duration (>12 mos) (χ2(1, n=879)=8.23, P=0.004) than treatment completers. In the regression model, only older patient age (P=0.010) and higher caregiver psychosocial burden (P=0.025) at treatment commencement were associated with attrition. While pain intensity, patient physical and psychosocial functioning scores and caregiver partner status were not.

Discussion: One in five patients commencing an interdisciplinary pediatric outpatient chronic pain clinic intervention did not complete it. Identifying patients at pre-intervention screening with longer pain duration, older in age and from families with greater reported caregiver burden and providing tailored supports may minimize attrition, therefore optimizing efficiency of service provision.

Abstract
Pain and mental health symptoms frequently co-occur in adolescents, often posing physical, social, and emotional challenges. While previous research has focused on clinician perspectives on chronic pain in isolation, limited knowledge exists on the potential unique challenges these co-occurring symptoms' present to clinicians in providing appropriate support to adolescents. This study examined clinician perspectives on the challenges and barriers to treating adolescents who experience co-occurring pain and mental health symptoms. Using a cross-sectional qualitative online vignette survey, responses were collected from 40 clinicians, including psychologists, physiotherapists, and doctors involved in treating adolescents (11-19 years) who experience co-occurring chronic pain and mental health symptoms. Participants, recruited from several countries, were asked about their perceived challenges to treating adolescents with co-occurring chronic pain and mental health symptoms. Vignettes were analyzed using reflexive thematic analysis. The analysis generated two themes. The first, 'tangled threads', describes how clinicians perceive mistrust from the adolescents based on previous negative clinician encounters and a perceived need to 'undo' this anticipated harm. The second theme 'the difficult-to-pursue integrated approach' depicts how fragmentation and siloed services for pain and mental health hinder effective treatment for adolescents who experience both symptoms. Co-occurring pain and mental health symptoms in adolescents are often initially mismanaged because they do not fit the mould of the services available to treat them, resulting in a more complex presentation to clinicians. The development of a more integrated clinical approach to treating adolescents with co-occurring pain and mental health symptoms is needed. PERSPECTIVE: This study identifies that clinicians perceive they face challenges treating adolescents with co-occurring pain and mental health symptoms, often due to the adolescent's prior clinical experiences and the limited comprehensive treatment options available to them. An integrated approach is urgently needed to tailor care and reduce harm.