Chronic Pain in Children and Teenagers – PediaCast CME 098

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Description

  • Drs Megan Schaefer, Lindsey Vater, and Jackie Warner visit the studio as we consider chronic pain in children and teenagers. Long-lasting pain is common and results in lots of stress and anxiety. Tune in as we explore coping strategies that bring relief.

Instructions to obtain CME/CE Credit

  1. Read this information page.
  2. Listen to the podcast.
  3. Complete the post-test at Nationwide Children’s CloudCME.

Topic

  • Chronic Pain in Children and Teenagers

Presenters

Learning Objectives

At the end of this activity, participants should be able to:

  1. Define pediatric chronic pain and its impact on children’s quality of life and functioning.
  2. Describe the interdisciplinary nature of pediatric chronic pain treatment.
  3. Determine the appropriate level of care for each patient.
  4. Outline the roles of parents/caregivers and schools in supporting children with chronic pain.

Links

Disclosure Statement

  • No one in a position to control content has any relationships with commercial interests.

Commercial Support

  • Nationwide Children’s has not received any commercial support for this activity.

CME/CE Information

  • In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
  • Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
  • As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
  • Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Contact Us

  • CMEOffice@nationwidechildrens.org

 

Episode Transcript

Dr Mike Patrick: This episode of PediaCast CME is brought to you by Pediatric Psychology at Nationwide Children's Hospital.

Hello everyone. And welcome once again to PediaCast CME. It is a continuing medical education podcast for healthcare providers. This is Dr. Mike coming to you from Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 98. We're calling this one chronic pain in children and teenagers. I want to welcome all of you to the program.

So chronic pain is not fun. In fact, it's annoying and causes tons of stress and anxiety. For those impacted by it, and I'm saying that as an adult, you know, when children and teenagers suffer from chronic pain, it not only impacts the individual, and it really does impact the quality of their life, but it also causes stress and anxiety for siblings, parents, the entire family.

Really, there are lots of conditions that can cause chronic pain. Things like cancer and its treatment, migraine headaches, gastrointestinal disorders, juvenile arthritis, sickle cell anemia, sports injuries, just to name a few. So chronic pain does not only happen to adults. It happens to lots of kids as well, but there is hope for those coping with chronic pain.

It's a multidisciplinary effort with physicians, psychologists, physical therapists, teachers, coaches, and parents, all playing a role. And that is our topic today. Chronic pain in children and teenagers in our usual PDA cast CME fashion. We have a couple of great studio guests joining us today. Dr. Lindsey Vater and Dr.

Jackie Warner. They are both pediatric psychologists at Nationwide Children's Hospital. We also have a terrific guest host this week. Who's going to be leading the conversation. Dr. Megan Schaefer from Pediatric Psychology at Nationwide Children's. We will get to all those folks and introduce them momentarily.

But before we do that, I do want to remind you, you can claim free category one CME credit after listening to this episode. Really easy to do. Simply head over to the show notes at PediaCastCME. org. You'll find a link to the post test in the show notes. Follow that link to Cloud CME, click on the materials tab, take and pass the post-test and the category one credit is yours.

We offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the exact credits you need to fulfill your state's continuing medical education requirements.

Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at PediaCastCME. org. Also want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

Also, your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at PediaCastCME. org. So let's take a quick break. We'll get our expert panel settled into the studio and then we will be back to talk about chronic pain. In children and teenagers, it's coming up right after this.

Dr. Lindsay Vater is a pediatric psychologist at Nationwide Children's Hospital and an assistant professor of pediatrics at the Ohio State University College of Medicine. Dr. Jackie Warner is also a pediatric psychologist at Nationwide Children's and an assistant professor of pediatrics at Ohio State.

Both have a passion for supporting children, teenagers, and families impacted by chronic pain. Before we dive into that one, let's give a warm PediaCast welcome to our guests, Dr. Lindsay Vater and Dr. Jackie Warner. Thank you both so much for stopping by and visiting with us today.

Dr Lindsey Vater: Hi, thanks for having me.

Dr Jackie Warner: I'm excited to be here. Thanks for having me too. Also happy to be here.

Dr Mike Patrick: Yeah, we are also happy that both of you are here, and we have one more person to introduce. Our conversation today is going to be led by Dr. Megan Schaefer. She too is a pediatric psychologist at Nationwide Children's and an assistant professor of pediatrics at Ohio State.

She's also a member of our PediaCast CME planning committee. And I just want to welcome her to the program. Thanks so much, Megan, for putting our episode together this week.

Dr Megan Schaefer: Absolutely. I'm excited to talk about chronic pain with you all.

Dr Mike Patrick: Yes, I'm excited for it as well. And we'll go ahead, Megan, then I'll hand the reins over to you.

And let's dig into chronic pain in kids and teenagers.

Dr Megan Schaefer: All right, let's do it. To start off, we know that there can be a lot of misunderstanding regarding chronic pain, as well as confusion between the differences between chronic and acute pain. So, Dr. Vater, I'm wondering if you can start us off by describing chronic pain and how is it different than acute pain?

Dr Lindsey Vater: Of course. And I think, you know, Megan, I'm excited that you brought up the confusion because I think the world of pain medicine has changed a lot since the opioid epidemic, so our understanding of pain is only growing day by day. So, I think the simplest definition of Acute versus chronic pain is timing.

Acute pain is any type of pain that lasts less than three to six months. We're dealing with kids and teenagers, so we usually use that three-month marker in the younger population. And then chronic pain is pain that persists beyond three months. If we want to get a little bit more complicated with it, acute pain is usually triggered by some kind of illness or injury.

So, it would make sense that if we broke our ankle, that would hurt. It is our body's warning sign or our danger sign. And then typically that pain would go away once that injury or illness has healed. Now with chronic pain, this is where things get a little bit more difficult. Because sometimes we have an illness or injury where the pain has started, but most of the time we don't.

Chronic pain is a condition that can start early. Out of the blue, kids typically report maybe like pain in their head. It lasts a little bit, but it'll go away. And over time, the longer they have that pain, the greater the reports of intensity, duration, and we might even see the pain start to spread from like the headache to the shoulders to stomach aches.

And I think. Once we cross into the chronic pain territory, the ouch becomes just one of many symptoms. Chronic pain also is usually accompanied with tight, tense muscles, with physical deconditioning, lots of fatigue and sleep issues. So really, the difference between the two is not necessarily how bad the pain hurts or where the pain lives.

It is how long that pain has been around and then those outside symptoms. symptoms from the pain.

Dr Megan Schaefer: Thank you. That, that's a very helpful distinction to make between those differences. And I, I think as we highlighted with the question, there can be a lot of misunderstanding and misconceptions in society about the differences between those types of pain.

Dr. Warner, can you give us a little more information about how common chronic pain is in children and adolescents? And then what populations are most at risk for chronic pain?

Dr Jackie Warner: Sure. And, and I'm glad you asked about this too, because this is another surprise, I think, for people often, which is that chronic pain in young people is common.

It's not unusual to have an episode of chronic pain at some point during childhood or adolescence. Now, it doesn't always grow into a lifelong condition for everybody, but we know that 11 to 38 percent of kids and adolescents. We'll experience some episode of chronic pain and that's at varying degrees and severity and duration, but it happens and in the subpopulations of greatest risk.

Some of this is clear and some of this is emerging. So, we know that girls, especially adolescent girls, seem to be more at risk. For chronic pain than boys, we know that youth with certain medical conditions like sickle cell, rheumatologic disorders, neurological disorders, these kiddos tend to have higher rates of chronic pain episodes.

Certain psychological conditions seem to be associated with more risk for chronic pain. Condition. So, for example, if you have a child who has premorbid anxiety, depression, post-traumatic stress disorder, and accumulation of those adverse childhood events, or we sometimes describe them as ACEs, that can place a child more at risk.

There's a little emerging literature coming out now related to kids who have neurodivergent qualities. And I think anecdotally, I bet Dr. Vater will talk about this too, but we see this clinically all the time, but we know now that our kids who have autism spectrum disorder, our kids who have ADHD, they seem to be more at risk for chronic pain conditions too.

And then of course, a favorite refrain of ours is chronic pain runs up and down family trees. So, if you have a parent, a grandparent, family members with chronic pain, we expect that you also might be prone to that. The last thing to mention is that chronic pain, we'll talk about this, is biopsychosocial, and so one of the populations that we see often affected by chronic pain are those who have social circumstances that make chronic pain that make it fertile ground for chronic pain to grow.

So, kids who have lower socioeconomic backgrounds may be at more risk for chronic pain. And part of that is we expect they have limited access to health care, higher levels of social stress, sometimes minority related stress or exposure to adverse environmental conditions.

Dr Megan Schaefer: Thank you, Dr. Warner, and I really appreciate how you're talking about those populations that are more at risk, how much that solidifies that biopsychosocial model, right, with each of those being risk factors for, for certain situations, and then also sharing the incidence rates, because I think sometimes our patients and families are actually surprised at, at how often, like, people might have a chronic pain episode in, in childhood.

So, thank you for talking more about that. Dr. Vater, I'm wondering if you can talk a little bit more about how chronic pain impacts the quality of life in children and adolescents. I know there's lots of domains that you'll touch base on, and you were talking about a little bit before.

Dr Lindsey Vater: Yeah, I think, again, highlighting the difference between acute and chronic pain, this is really where a big difference between the two lies.

With chronic pain you know, or just pain in general, what we've historically been taught is if it hurts, let's rest, take it easy, wait it out, things will get better. And that is true for most acute pains, but what we see is that's the opposite of what we need to be doing for chronic pain. So, you know, we're, we're operating a little bit against kind of historically what we think we know and what we think makes things better.

And we're accidentally making things a little bit worse. So typically, when pain starts to set in, I don't know about most, but I know myself, if I hurt, it's a lot harder to find motivation to want to get up and do things. And again, it is our common knowledge and our first instinct to say, if I hurt, I'm going to take it easy today.

So, what we see is over time, these are kids who are hurting most of the day, every day, so they start missing out on going to school. They can't go to school because they're hurting too much. They're maybe not attending school because of lots of doctor's appointments. But then if you're missing out on school, you're also missing out on times with friends.

You're starting to feel socially isolated. Unfortunately, chronic pain is, you know, kind of considered an invisible diagnosis. So, our kids are often being labeled as making it up. Or there's nothing wrong with you or you look perfectly healthy because on the outside, these kids do look healthy, but on the inside, they are struggling with a significant debilitating condition.

We see kids start to just disengage from the things that brought them interest. They're not as interested in the things that they used to find fun or entertaining. You know, either due to personal choice to not participate or sometimes because of school attendance issues. They're not allowed to play on sports teams or be involved in the clubs that they were previously excited about.

And we do see along those lines, too, if they're not engaged in those things. Really, we start to see just kind of dulling of the personality. We hear a lot of brain fog, a lot of attention and concentration and memory issues. Really, chronic pain affects awesome kids. They're normally kids who are very interested, invested.

They have a lot of unique hobbies and interest. And when chronic pain starts to set in, I think, yes, they're hurting a lot, but I think more so than that, they're less engaged and parents describe it as they're losing their sparkle. They've lost their kid. It's just kind of a shell of a kid that they see these days.

And when that sets into it's not just a patient problem. We see parents are really at a loss of how do I interact with my child siblings report a loss of my Yeah. My sister and my brother are still here, but they don't want to do the things they used to do. So, I always say ouch is just the tip of the iceberg.

It's all the other things associated with that, that they really start to struggle with.

Dr Megan Schaefer: And you know, it seems like, as you said, there's so many vast, you know, changes to quality of life. And as you said, from a family system, noticing that their child doesn't feel the same, which can be really, difficult, which I think moves us into, we don't want these kids to lose their sparkle, right?

So how do we identify this and how do we treat that moving forward? So, Dr. Warner, to start with the assessment piece, what would you say are the big challenges in diagnosing pediatric chronic pain?

Dr Jackie Warner: Well, there are a lot of challenges in diagnosing chronic pain, and I think that is reflective of the complexity of the condition too.

So those two things run parallel. When I think about diagnosing chronic pain and why it's complicated, I think about it from child factors and provider factors. So, from a child's perspective, one of the big barriers is communication. We're just having a conversation about this as providers related to our kiddos who are nonverbal.

So, we have plenty of kids who are experiencing pain in their body and either they cannot communicate, their vocabulary is limited, their cognitive development is limited, and that can range within the child, but it's a complication. You must know that pain is existing to treat it. To call it chronic pain, we need to know it's on board.

Another complication that I think throws a lot of people for a loop is how a child expresses pain via their behavior, so not just their language. So, we all have assumptions that we bring to the table when we're making diagnoses and things that we're looking for. The reality is that kids express, display chronic pain or any kind of pain sensation in various ways.

Some kids will scream and cry and give you that traditional presentation that I think a lot of people expect. That is not the case for all kids, especially our kids with chronic pain. A lot of times we hear them say, you know, I'm getting kind of used to the sensation, not in a positive way, but they won't come screaming and crying.

Often, they present with more of a flat affect around chronic pain, or it'll appear as though nothing is wrong. Speaking to that invisibility element that Dr Vater mentioned before, parents. When really, they're having an aggressive flair. So even onto that, we have some kids who will laugh when they're having a pain episode.

So, you really cannot just look at a child's pain behaviors when you're trying to understand what's going on. And that complicates the diagnostic process too. The subjectivity of chronic pain also makes it complicated to diagnose because pain is highly subjective. It's susceptible to environmental influence, so cultural norms, expectations, your personal history with pain, your mood, all of this can inform how a child or how a family chooses or just naturally describes their pain experience.

That all those factors influence a child's inner experience too, which I'm sure we'll talk about more later when we talk about it being biopsychosocial. So, from a child's point of view, lots of factors that can muddy the water. And then from a provider perspective, you know, I kind of touched on this already, but there's this assumption that that chronic pain needs to be isolated.

I think sometimes that to diagnose this, to treat it, we need to excise these confounding variables, these things that interact. And we don't necessarily need to control or excise all these psychological factors to say what's going on. All pain is biopsychosocial, so we know that psychological and social factors will always and forever be interacting with every type of pain experience.

So, we don't need to Isolate that variable to begin multidisciplinary care or to be able to call it what it is. But I do think that sometimes leads people astray and makes them think, oh, we need to remove this variable first before we can treat the pain. It's, it's all part of one system.

Dr Megan Schaefer: Thank you.

And to build off on this, all of us who know when treating chronic pain, oftentimes we know that there can be an association with mental health, which can sometimes also make. The diagnosis and the treatment part a little bit more challenging. So, Dr Vater, what role does mental health play in pediatric chronic pain?

And how can it be addressed sensitively so that when Children are in those intakes, they're not hearing the message that the pain is all in their head.

Dr Lindsey Vater: I'm glad you asked this question because I would say by the time kids and families make their way to me for chronic pain treatment, a lot of them are saying, I've been told it's all in my head.

I've been told my child is making it up, or I've been told there's nothing wrong with my child, and I think we're missing something, and I think that, you know, there's a number of variables at play as to why a child or a family might feel that way, and I think the most important thing when you're working with a family with chronic pain is just to start with validation.

Explaining to them that no two pains are the same. Every chronic pain and every pain experience is unique to the person. And I believe you, the only measure we have right now in terms of chronic pain is self-report. So, I always say, if the child is telling us that the pain is a seven out of 10, then I take the pain as a seven out of 10 at face value, because that information is telling us something that serves a purpose.

And while all pain is regulated by the brain, it is a brain body connection, that does not mean that mental health caused pain. It's a correlation versus causation issue. So really, it gets a little tricky from the provider's standpoint, though, because we are trying to parse things out. And families oftentimes are looking for one easy answer, and chronic pain is not that.

Chronic pain is also Often and everything and diagnosis, so it gets tricky if you break it down to the symptoms. There's some research to show the most common symptoms of this population are insomnia or sleep difficulties, chronic fatigue. Increased irritability, decreased motivation, increased excessive worries, and then appetite changes.

So, if we think of just those symptoms alone and the silos that they live in, those can live in many different diagnoses, mental health and physical health wise. So, there's a lot of muddy water in terms of what they're presenting to you with. If we break it down to kids who meet criteria for a mental health diagnosis.

When it comes to the chronic pain population, around 15 percent of the chronic pain population needs criteria for a major depressive disorder or a generalized anxiety disorder. So, it's a relatively small amount of this population, given the high overlapping symptoms between those between mental health and physical health.

Like Dr. Warner mentioned earlier, there is growing research in the world of neurodiversity in patients with chronic pain, so we are seeing more ADHD, more autism presenting to our clinics, and this is a, a new emergence in the field, so we don't necessarily have statistics on this. And I think one of the things that confuses people or maybe surprises people a lot is only around 4 percent of this population meets criteria for PTSD or some kind of other trauma diagnosis.

A lot of the population has a misconception that chronic pain is associated with some kind of psychological trauma, and what we see is that's not true. And I think the tricky thing, too, is, you know, with the DSM 5 criteria right now, one of the most important things of the DSM criteria is if we're diagnosing a mental health diagnosis, we must be sure that there's not an underlying medical condition at play, too.

So, it gets a little trickier. It doesn't mean that because you have chronic pain, you can't have depression or because you have depression, you do have chronic pain. It's just a call for sensitivity when we're diagnosing these things, and I always talk to families about, you know, when I hurt, I'm not in a great mood, and when I hurt for a really long time, and I'm not in a great mood for a really long time, that's going to have changes, and to treat the whole human, we have to treat all areas of the human, which does make a call for the importance of a mental health provider being a part of the integral treatment of chronic pain.

Dr Megan Schaefer: Thank you. I think you're doing a great job highlighting all the factors that can contribute to chronic pain, which I think leads us to treatment and talking about all the different therapies and providers that are a part of treatment for chronic pain. So, Dr. Vater, can you please elaborate on the gold standard treatment for pediatric chronic pain?

Who is usually involved in treatment? This is one of my favorites

Dr Lindsey Vater: parts about working with chronic pain is it takes a village, and I think the cool thing about it taking a village is there's lots of eyes and ears, and with the right team, the family really gets a comprehensive, full service stop in terms of treatment for chronic pain.

As we've said time and time again, this is a biopsychosocial problem. So, the way I describe this to families is we, we all have four, four wheels on our car. And to treat chronic pain, each single one of those wheels is having some kind of issue. Whether it's flat, the axle's broken, who knows? We must make sure that we are focusing our interventions and our efforts on all sides of the car on all sides of the person.

So, when you think of gold standard treatment, there is no one quick, easy fix. Oftentimes, there are going to be multiple parties involved. The gold standard treatment typically involves some kind of medication or medical management. And this is a person who, you know, there are medications that can help with some chronic pain.

Not an opioid, but there's other medications kind of at play, but also the medical management person really stands as the organizing centerpiece because with chronic pain, it's normally not just a headache or a stomachache. It is all different types of medical specialties. So, this person serves as that center point and hopefully the organizer, the like center of the hub of communication for all the parties involved with this patient in this care.

Additionally, we have physical therapy involved, not necessarily in the traditional sense of the way we think of physical therapy. So, if a kid presents to us with chronic leg pain, they're not only doing leg exercises. Physical therapy is going to focus more on the day-to-day functioning. How do we get you back to doing the things you enjoy?

Making sure that we can build that tolerance and really get them back to the functioning they were used to before. We have pain psychology and there's a lot of things involved with pain psychology. So traditionally you're probably used to hearing cognitive behavioral therapy for chronic pain, some acceptance and commitment therapy for chronic pain, bio feedback, relaxation training.

All these things are focused on how do we think about the chronic pain? How do we drive values driven action versus not necessarily pain behavior action, and then just giving them control in what seems kind of uncontrollable. And then we also have complementary alternative medicines that we can tap in, so this would be acupuncture, massage, aromatherapy, other things that can help these kids calm that central nervous system and get back to that day-to-day life and enjoying the things that they want to enjoy more often.

Dr Megan Schaefer: Yes, you are certainly right that it takes a village, and that is the fun part about treating chronic pain is you get to work and collaborate with a lot of other providers. Dr. Warner, we also know that education is an important part of chronic pain treatment. I know Dr. Vater was mentioning that, of being able to provide education validation from the get-go.

Can you share with us maybe some of the more common metaphors that we use to help explain chronic pain in a way that can be digestible for kids and adolescents? And then also just give any recommendations or tips that you would give to healthcare providers when they're trying to explain chronic pain to families and patients.

Dr Jackie Warner: Yeah, of course. And I think Dr. Vater does such a beautiful job talking about this stuff and she, she already hit, I think, one of the, the most important points with respect to what is the most important thing to do educationally and that, that validation piece just takes you so far. I'll come back to that in a minute.

When, when it comes to metaphors, there are a few common ones that we really like to use that seem to resonate with a lot of families. I think wise to know your audience and wise to know if metaphors are going to be helpful or confusing as we become more aware of the number of kids who have autism, who are, who are also experiencing chronic pain and the number of kids who are just not neurotypical.

I think we need to be more sensitive to this possibility that metaphors can be helpful or, you know, confusing. For those who find it useful, we like to use a computer glitch metaphor to talk about the difference between acute pain and chronic pain, and that can be a nice base point to start. A lot of our kids have exposure to technology and understand this concept of what's hardware versus what's software, so we'll often say, you know, when we have chronic pain versus acute pain, we’re usually dealing with a software problem instead of a hardware problem, whereas if you have acute pain, it's kind of akin to kind of a smash screen or a keyboard that's missing a letter.

Something is not working that needs to be replaced or repaired versus when you have chronic pain, it's more like getting that blue screen of death that. The software just won't load, or you're just stuck with a virus. You need to upgrade the software, or you need to remedy the communication system within the computer, not necessarily the hardware of the computer.

So that's a lot of times where we begin metaphor wise. An extension of that metaphor that you can use to help under help kids understand how chronic pain gets going and how it's how it's being used as an alarm mechanism to try to get your attention is by talking about pain, chronic pain being similar to a car alarm that's too sensitive that will start to Blast the alarm when a gust of wind hits it instead of somebody trying to break in an overly sensitive system is the gist of what you're trying to get across there.

Also, a smoke detector that's continuing to go off even when the fire has been put out is a nice metaphor to use when you have a kiddo who started with an injury or an illness and the pain signals continue to ring in their bodies, but that. initial acute issue has already been remedied. So, I think metaphors from that perspective can be useful.

Dr. Vater, do you have any other favorite metaphors? I know you live in metaphor land too, just like me.

Dr Lindsey Vater: Yes, I do love metaphors. I think you hit most of them. I think the wheels on the car is another one I use. The gate control theory of pain is technically the theory that we all use and operate under in the world of pain medicine, but I think families sometimes resonate with that too, is like the open versus closed gates.

Yeah. Put simply with that one, so like, this is a good, you know, acute versus chronic pain explanation too, is For pain to exist in the body, the body has to send a signal up to the brain and there's a gatekeeper up there who decides is now the right time for this pain and is this pain serious enough that I need to drive this person to action or energy or they need to do something about it.

If the answer is yes to both of those questions, those gates will open, and the brain will send those pain signals to whatever part of the body sent the signal up to the brain. They'll close when the need is no longer there to experience that pain, but with chronic pain, for one reason or another, those gates are staying open.

I always say it's a friendly gatekeeper with chronic pain. They're just saying, yes, now's the right time, or this is a serious enough reason to send pain to the body. So those gates are staying open, and they're maybe being triggered by things that don't necessarily need to draw us to action.

Dr Jackie Warner: Yeah, the gate control theory is a classic.

And I think what's nice about that is it can help you bridge between kids who need a little more of a concrete explanation and kids who can live with metaphors a little bit easier. When I present gate control theory of pain, I usually draw it out on a person. Like I draw out a little. Sort of like not stick figure body.

I don't know gingerbread body. That's not quite anatomically correct but and I'll try to point out the peripheral nervous system and the central nervous system and Demonstrate how a pain signal can travel upward and then you move into metaphor land with the gatekeeper But it bridges a little bit more in the middle of that concrete abstract And then Megan, you also asked about important educational tips and just to come back to this.

I know that we said validation is where you start. It's where you drop down in the middle and it's where you end the conversation, and you just continue. There's no end point for validating because there's so many There's so many messages of, I'm not sure I believe you, this doesn't seem right, that hits a child from so many directions.

You just, you can't, you can't do that too much. I think the other educational tip is to make sure that parents and kids understand that we are using a multidisciplinary model because it's the gold standard of care, because this is how chronic pain works. And we're not sending you to multidisciplinary team members because we don't believe you or because we think it's just a mental health problem.

Parents, Dr. Vater mentioned this parents worry that we're missing something or that our attention to mental health signs and symptoms means that we're not believing what's going on or we're Not planning to treat the physiological experience, so making sure that they understand the brain and the body are working together to generate and maintain pain sensation that you understand how these worlds work together and that we're pulling in different providers to make sure that we're treating the entire problem more at the root instead of just throwing you a band aid and hoping that'll pacify you.

Those are important educational things to think about.

Dr Megan Schaefer: Those are all very helpful tips. I appreciate your sharing. And now to move on to more specific nationwide treatments here for chronic pain. We are very lucky at this institution to have a variety of supports for our patients with chronic pain.

Thanks to leaders like you all who have brought some phenomenal interventions. So, I'm wondering if we can start to talk a little bit about what those look like here, and we're going to start with comfortability. So, Dr. Warner, you want to take that away?

Dr Jackie Warner: Yeah, absolutely. Comfortability is one program that we have available for a lot of different kids and families here.

I think of it as a program that casts a very wide net. It's equity and access forward. It gets kids and caregivers the content. That they would access in pain and discomfort psychology over the course of six to eight separate visits in the span of one day of work shopping. So, we use comfort ability program to provide kids and families with the foundation so they can go further and faster and deeper with their tailored individual treatments.

We use it as a booster. We use it as a course corrector. We can use it for lots of different purposes. But it helps us access a lot of service and resource in a small amount of time and without a ton of disruption to a family's life in the comfort ability program, kids and families are learning pain neuroscience.

They're learning how to skills, the stuff that they would learn in pain psychology. They really get a road map to comfort and something that they can travel, take and travel with them to their next steps and care if they have next steps in care.

Dr Megan Schaefer: And then, Dr. Vater, can you talk about our other interventions, which include pain clinic and eye prep?

Dr Lindsey Vater: Absolutely. So, we are lucky, like Dr. Warner and Dr. Schaefer, like you have said, to have multiple layers and levels of chronic pain intervention here at Nationwide Children's. So, first, we'll talk about pain clinic. So, pain clinic is more hands on and, like Dr. Warner said, comfortability is great because it's a one day, kind of one stop shop.

Pain Clinic is great because it's also a one stop shop, but this is for the kids who require a little bit more time and more of those hands-on practice. So, typically with Pain Clinic, kids will present for about a four-hour session once every other week. And during that four-hour session, they're busy.

They're rotating through physical therapy. Pain psychology, usually acupuncture or massage, and then about every other visit, they're also meeting with a medical provider just to make sure they're still on track to see how progress is going and what they're doing in those sessions is they're learning the hands-on skills.

One at a time so that they can then go spend about a week, week and a half using those skills in the day-to-day environment, coming back, checking in, see how they do, learn a few more skills. So that one's really cool because it builds. There's also social work a part of that team because, again, we've talked about how pain management affects the whole family.

And a lot of time parents don't know what to do. We call it misguided support. They think what they're doing is really helping the child. They're doing the best with all the information they have, but sometimes accidentally reinforcing some of those pain behaviors as well as, you know, maintaining that pain relationship.

So social work is there to help navigate any school issues, any parenting issues. Sometimes we have siblings that need a little bit of extra support in TLC too. Now, the next step up is what we call iPrep. So, the long, the long name for that is the Intensive Pain Rehabilitation and Education Program. So, this is a day treatment model.

This is a 15-day Monday through Friday model where the kids are here from 8 a. m. until 4 p. m. every day. So, it's like pain clinic, everything pain clinic offers, and then we're adding to it. So, we have a school-teacher that is a part of the team. We have, um, therapeutic recreation, music therapy, occupational therapy.

We're really adding and treating that whole human, and we're trying to get them back to that normal day to day activity. We require daily parent participation in this program, so they're also learning all the skills that the kids are learning, but they're learning it in a way of, how do I support my child?

How do I get them to use these things? And then with I PREP, the kids are coming for a follow up model too, where they're being seen after the three weeks are over at 1-, 3-, 6-, and 12-months discharge, because we know that chronic pain comes with relapse. That's a typical part of a chronic pain recovery model, so having those regular check ins allows us to catch things ahead of time, make sure they're still using their skills, how's your stress management.

Once kids start feeling better, that's when they start, you know, having some injuries in gym class again, which can trigger maybe another chronic pain episode. So just trying to keep them on track and using the skills over time as they integrate these things into daily practice.

Dr Megan Schaefer: So, we've talked a lot about the different types of treatments.

Dr. Vater, can you talk about how we decide which type of treatment would be best for, for patients?

Dr Lindsey Vater: Absolutely. I think the easiest explanation is it comes down to functioning and or, you know, the lack of functioning that a child in a family is experiencing because of the pain. So, we have kids who have that mentality of like, I'm just going to suck it up and I'm going to go and I'm going to do, but I'm still really hurting.

And for a kid who is still out there attending school, doing the sports practice, but they're still struggling with that chronic pain, something like comfortability or maybe even just like an outpatient pain psychology referral would be appropriate for them. But once we start to see the kid in the family move towards dysfunction because of pain, when they really start missing out on things, that's when we start to escalate the level of care needed.

So, for kids who are maybe still attending school semi regularly, they're missing out on a thing here and there, we would probably recommend pain clinic. And then for the kids who make it to I PREP, these are kids who often haven't attended much of school at all. They're not involved in any activity.

Really parents describe it as like most of the day is spent in, in their bed, on their couch, not able to do or enjoy much. At all. But I think it also, you know, we were we live in a world of medicine, and we live in a world of insurance, too. So also, sometimes decision making comes down to what levels of intervention have they tried.

Dr Warner has done a great job explaining, you know how we talk about pain and education goes a long way. Sometimes a family just hasn't been given a good conceptualization. And a good, believable, like, this is what we think the diagnosis is. And that's powerful. So sometimes it just takes a quick, easy diagnosis and conceptualization, and then the kids and the families are off running with treatment.

And that can avoid the need for those, like, lengthier, more time intensive treatments like eye prep or pain clinic. We also just have like some logistical things. There's not a ton of pain treatment. We are lucky that we live in a state with a lot of chronic pain treatment. We might be the only, we might be the top state for chronic pain interventions, but logistics play a role in this too.

So, if a family is coming from six hours away and every other four hour, every other week, four-hour appointment might not be feasible. So, we could maybe make the argument of for the treatment they need, we need the three-week approach. And then sometimes just insurance will help, you know, just kind of guide us in which way it might be a little bit more appropriate, cost effective.

But at the end of the day, we're lucky to live in an institution that helps us navigate that piece of the puzzle as well.

Dr Megan Schaefer: Thank you. And we've talked a lot about when in your answers, you all have touched about the importance of systems and chronic pain treatment. So, Dr. Warner, I'm wondering if you can talk a little bit more from the parental involvement piece.

So, what role do parents and caregivers play in chronic pain treatment and how can they best support their child?

Dr Jackie Warner: Yeah, it. Caregivers are instrumental in a child's chronic pain navigation and how they experience their symptoms, really. And, you know, caregivers, it goes beyond parents. I mean, any central adult figure in your child's life can have an impact on their experience coping with, understanding, experiencing chronic pain.

A lot of times we'll instruct caregivers. And to join, to join as a team and operate as kind of like the unflappable flight attendants on a turbulent airplane ride, really emphasizing that you need to lead with a calm confidence, validating that people might be feeling fear and proceeding with this internal awareness and external presence of we're going to get through this.

We're going to make it safely to the ground. And that's sort of like the demeanor that I usually try to engender with families, with, with parents and caregivers. And then we usually give them some hard and fast guidelines to follow. I think Dr. Vater mentioned this, that I think you said misguided support.

And that's a nice way of putting it. We in Comfortability will often talk about first intuition parenting and second intuition parenting. And I think that That that framework helps parents understand the misguided component of it, which is that your first intuition is not bad, but it is first intuition and appropriate for certain circumstances.

Chronic pain requires these second intuition approaches, and those second intuition approaches include things like really refraining from status checks, which means we don't ask or talk about pain on a regular basis. We're not trying to light up. Any kind of attention around pain that would encourage pain signaling, pain promotion.

We encourage typical daily activities with time-based pacing instead of symptom-based pacing. Even on flare days, we want kids learning how to modulate their daily activity while still engaging. We call out and praise functioning. kiddo name their feelings, but we recognize and manage our own fears, which are natural to occur.

For In a separate non child facing space, so with your own therapist, with your friends, with your family. So those are, those are kind of the top pieces of parental guidance, but it's essential.

Dr Megan Schaefer: And school is another important system when we're thinking about chronic pain treatment. Dr. Vater, can you talk about how as healthcare providers we collaborate with the schools to best support students with chronic pain?

Dr Lindsey Vater: I would say as providers, this is the question or the ask we get most frequently from patients and families. Yes. There's been a change since COVID in terms of how schools are tracking attendance and requirements for attendance, and recent research studies suggest that kids with chronic pain are missing about 22 percent of school days.

That is over 40 academic school days a year. Which would land a family somewhere in the truancy range. So as a provider, we're probably getting asked for blanket excuses. And more recently, an issue that we've been running into in the chronic pain world is we're asking, we've been asked for very specific, what type of pain is it?

Exactly how many days should they be missing if they were to have a chronic pain episode? And what we know about chronic pain is it is unpredictable. The most reliable thing is it's unreliable. So those are questions that we literally don't have the answer to. And what we know in terms of school and school attendance with chronic pain is not only is it safe to go to school with chronic pain, but also recommended to go to school with chronic pain.

This population, if we, if we look at the kids who are still attending school, they're reporting Increased academic success, they're reporting better relationships with peers and positive adult relationships, and they're reporting better sleep habits. We know sleep is really entwined with how a body responds and heals from pain.

And we see less pain reports. So, the pain is reported to be less intense and they're having pain less days. So as providers, this is a tricky ask that we that we're being put in because we know the best thing is to send a kid to school when as a parent, the last thing you want to do is put your kid in a situation where things would be hard for them or seems like they can't perform.

So, I think in terms of schools and how we communicate with them and in terms of schools and how we communicate with families, our expectations, it is taking that patient approach. The listening approach and the gentle guidance and psychoeducation of why school attendance is important. And while we cannot provide a blanket excuse because attendance is important, what we can do is we can talk about 504 or IEP accommodations.

A lot of times this population would qualify for extended testing, breaks in quiet spaces. We would recommend the quiet space be as demedicalized as possible. So, a trusted teacher's room versus a nurse's office. And that kind of goes back to that gate control theory of pain, where if we're sending the kid to the nurse's office, every time they're having a pain episode, they're going to be reminded of the ouch.

They're going to be asked the ouch. That's a school nurse's job. But if we can send them to a trusted teacher, maybe a quiet space or a resource room that allows them that. Functional independence in terms of navigating and using skills. And then I think just in terms of talking to families, you know, we don't want to overdo it too fast so we can also write for gradual returns to school for our kids who have missed a lot of time.

We can provide education for staff. I know we here in I PREP have a lot of conversations with school nurses, with intervention specialists, and just teaching and coaching the teachers of what is appropriate, what is helpful, and what is not helpful in terms of the Helping the kids stay in school and be successful in school.

Dr Megan Schaefer: And it sounds like there's been a lot of amazing work going on here at Nationwide with our chronic pain treatment programs. I'm curious if you all could talk a little bit more about how research has been collected for these programs and what outcomes are we finding. Dr. Warner, if you want to talk a little bit about CAP and then we'll hand it over to Dr. Vater for iPrep.

Dr Jackie Warner: Yeah, I think we're, our research engine is really heating up around the pain space here, and I'm so excited about this part. Within CAP, we try to analyze our post day outcomes, quarterly basis, and we're seeing great outcomes so far. I think there's lots of different areas to explore still, so that we can get kids the best care at the right time, the right place, all those things.

But so far, 100 percent of our kids and teenagers and parents who do the program and who respond to our surveys say they would recommend it to another friend or family dealing with chronic discomfort. So, we have a lot of kind of overarching support from families that participate. And then some of the things that stand out to me are we see that in the 90th to 100th percentile of responses, Parents and caregivers are feeling more confident in managing their child's symptoms, they're planning to make changes in how to manage their child's symptoms, they feel ready to implement a functional restoration plan, which is that go back and do before you wait until your child is feeling better.

And then our children, our kids, are saying that they're ready to take an active role in managing their discomfort, they're ready to use their comfort plans that they create during the day, and they're gaining hope that things can get better. So, I think our outcomes are great, but there's a lot more to do.

Dr Lindsey Vater: Yeah, I would echo what Dr. Warner said. I think, you know, it's common for some of our iPrep and pain clinic kids to come from or to graduate back down to CAP. Yeah. So, the, the same results are being echoed in our programs here in, in Pain Clinic and I PREP. Additionally, we have some research to suggest that the quality-of-life scores, by the time the kids make their way to us, the quality of life, the PEDS QL scores are nor, normally in the statistically significant range for extreme dysfunction, low quality of life.

What we see is at graduation day, our kids have shown statistically significant improvements, and beyond that, every follow up visit, they're getting better and better to the point where around that 6 months to 12-month mark, we have kids who are falling in what we would consider a relatively normal score range for that.

The same goes for Functional Disability Index, by the time they get to us, we have kids who are reporting significant pain related functional disability in the extreme range, and again, by that 6 month to 12-month mark, we are having kids who are falling in what we would consider a normal range, even outside of the chronic pain population.

And then I think beyond self-report, we also have some objective functional testing that shows that their, like, physical strength is improving over time. And I think. Beyond the data and the scores, we also have kids who are reporting going to school, getting driver's license, going to prom. Like, I think those are the things that speak most importantly to me is it's, it's the kids that are back out there and living life and reporting that they wouldn't have been able to do it had they not received pain treatment.

Dr Megan Schaefer: That is excellent news. I'm so glad to hear, as you said, bringing the sparkle back to all the kids and living their lives out and doing things that are meaningful. Dr. Vater, can you share just one memorable story or experience that highlights the benefit of chronic pain treatment on a patient that you've cared for?

Dr Lindsey Vater: Absolutely. And I think this, I wouldn't say that this is based on any one particular patient. I would say that this is based on a cumulative, almost everyone who's gone through the I PREP program and that is the difference that you see in three weeks. Chronic pain treatment is not easy, and oftentimes families come for chronic pain treatment thinking the pain is going to get better, and unfortunately with the treatment, pain is typically the last thing to get better.

It's that overall functioning that improves first, and I think the, the most memorable stories for me are the kids who come on day one, they're exhausted, they're falling asleep in the 3-p. m. group. Cause they're just so exhausted from all the work that they're doing. And then you see them really working hard and embracing.

And we always say that there's almost this leap of faith of, of trust in the process and trust in themselves and building the confidence. And then honestly, by week three, I know Dr. Warner and Dr. Schaefer, you guys have also been here in the iPrep world. It's tiring as a provider because we have teenagers who are breaking rules.

We have teenagers who are running up and down the hallways. Our lunch ladies are just. Always smiling from ear to ear because we have kids who can't be contained in our little space because they're just so excited to get out and spread joy and do and achieve. So, I think overall that's my most memorable part and my favorite reason of working here is to see the hard work these kids are willing to put into their mental and physical health.

And to see how quickly they can absolutely turn dysfunction and to not only function but thriving.

Dr Megan Schaefer: Thank you. And as you said, it truly is a powerful transformation and is one of the most fun parts of our jobs watching them grow into themselves again and be the people that they were before chronic pain entered their lives.

So, to close us off, we're just going to talk a little bit more about advocacy. Dr. Warner, can you talk a little bit about how we can raise awareness about pediatric chronic pain to ensure that all children receive proper care and support?

Dr Jackie Warner: Sure. There is so much we can do. I think one of the most important things we can do is make space at the table for families and kids dealing with chronic pain.

I really think nothing in this space should be done without the influence and perspective of folks who are living with this. And that's going to help us understand where energy is most useful, where what's well resourced, what's not well resourced from the lived experience. I think we can be champions for implementation science in addition to bench science, you know, this is, this implementation science is kind of a new area or a new terminology, but it's devoted, it's a science devoted to population health, and it really studies how we can support the uptake of resources and care by the community rather than the continued creation of new resources.

We can be champions for one another within the system and outside the system. We really cannot have providers dismissing the value of a multidisciplinary approach, nor can we tolerate insurance companies or system factors that deny kids access to life saving programs like I PREP and intensive functional rehabilitation programs.

And then just in your daily life, I think providers can be active myth busters when it comes to chronic pain, and that's an invaluable advocacy service you can provide daily. So, the number one concern I get from kids and parents is that they think their doctors don't believe them. And maybe the number two is that things will never get better.

By educating our colleagues and reminding kids and their parents that their brains are plastic and capable of learning new patterns, we're really creating a different reality for providers and families. So, so in that vein, for those people who are not as devoted and excited about chronic pain as Dr.

Vater and I are. I understand it's not everybody's cup of tea, but we love it. I would recommend the Meg Foundation. That is a fabulous resource. They have been partnering with Society of Pediatric Pain Psychology to create more resources that are family facing, that are fun, that are engaging.

They have a pain myths and facts eBook that you can use and keep in your office so that kids and providers are able to see some of those things that are just sometimes not taught in medical school or not taught in the community. You can, you can consult the World Health Organization. They have guiding resources for kids who have chronic pain conditions and treating them.

The International Association for the Study of Pain has a long list of organizational resources. You can be an advocate by knowing those tools and knowing how to access them. And you can use us. We, we want to help be the mouthpiece for Excellent quality of life and care for kids with chronic pain conditions.

So let us know, consult us. We, we want to help.

Dr Mike Patrick: Great. Well, this was a fantastic conversation. You guys did an outstanding job. I really appreciate it so much. And I'm sure that all our listeners do as well. We are going to put links in the show notes to all the things that Dr. Warner had just mentioned.

So, we will have links to the Comprehensive Pain Management Clinic at Nationwide Children's Hospital, also Pediatric Psychology at Nationwide Children's, the Meg Foundation, the World Health Organization, all the things that she had mentioned, we'll make sure that those end up in the show notes. So, folks can find those easily.

There's also a great up to date article. If you have access to that called pain in children, approach to pain assessment and overview of management principles. Uh, so if you'd like to read more or want to share that with your colleagues, we'll put a link to that in the show notes as well. So once again, Dr.

Lindsay Vater and Dr. Jackie Warner, both with pediatric psychology at Nationwide Children's Hospital. Thank you both for stopping by today.

Dr Jackie Warner: Thank you. It was a lot of fun. You took the words right out of my mouth. I was going to say tons of fun. Love to do it.

Dr Mike Patrick: Yes. And, uh, not only fun and just so, um, informative and, uh, I'm sure our audience members appreciate you guys taking time out of your busy schedules to share your expertise with all of us.

And then also, uh, thanks to our host this week, Dr. Megan Schaefer with Pediatric Psychology. Uh, Megan, you did a fantastic job. Thank you so much for leading us today.

Dr Megan Schaefer: Thank you. This was a great conversation.

Dr Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Lindsay Vater and Dr. Jackie Warner, both pediatric psychologists at Nationwide Children's Hospital.

And of course, thanks again to our guest host this week, Dr. Megan Schaefer, also a pediatric psychologist. at Nationwide Children's don't forget you can find us wherever podcasts are found or in the apple and google podcast apps, iHeart radio, Spotify, SoundCloud, Amazon Music, YouTube, and most other podcast apps for iOS and android our landing site is PediaCastCME.

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