Sim, Leslie

ABSTRACT Background and Objective Despite growing interest in mindfulness‐based interventions for adolescents with chronic pain, the data have not been systematically summarized. We conducted a systematic review and meta‐analyses to estimate the effect of mindfulness‐based interventions on pain intensity, catastrophizing, acceptance and interference; functioning, quality of life, and anxiety and depression in youth with chronic pain. Databases and Data Treatment Electronic databases CINAHL, CCTR, Embase, Medline, PsycINFO, Scopus and Web of Science were systematically searched to January 2, 2025. Studies were included if they were in English, included > 5 patients, were not part of intensive interdisciplinary pain treatment and included pre‐post outcomes from mindfulness‐based interventions delivered to adolescents with chronic pain. Risk of bias was assessed with the Newcastle–Ottawa Scale. Results Fourteen studies including a total of 323 adolescents were identified. There were significant within group improvements in pain intensity, pain catastrophizing, pain acceptance, pain interference, functioning, depression, anxiety, and quality of life, with results maintained or increased at follow‐up effect sizes at follow‐up were moderate to large (e.g., quality of life SMD = 0.33; pain intensity SMD = −0.73; pain interference SMD = −1.44). Heterogeneity of results was generally moderate to high. Compared to standardized long interventions, variable length interventions showed greater pre‐post changes in functioning, pain intensity, and pain catastrophizing. The certainty in the estimates was generally low, due to risk of bias and pre‐post designs. Conclusions Although adolescents with chronic pain report improvements after participating in mindfulness‐based interventions, rigorous RCTs are needed to substantiate these results. Significance Statement Chronic pain in youth is common and difficult to treat. Previous interventions have largely been based on cognitive‐behavioural therapy and not successful for all. This is the first systematic review and meta‐analysis in paediatric chronic pain to focus on mindfulness‐based interventions, highlighting an alternative and potentially effective intervention approach. This study informs clinicians about an effective intervention approach and assists researchers in identifying gaps for further research.

Objectives To describe the incidence, presentation and long-term health outcomes of suicidal thoughts and behaviours (STBs) in children aged 12 years or under. Methods This population-based study included children identified through the Rochester Epidemiology Project who presented between 2005 and 2023 with STBs across primary, secondary and tertiary care centres in Olmsted County, Minnesota, USA. Information related to the patient and family characteristics, presentation, prior history and outcomes was manually extracted by two independent researchers. Patients were excluded if the index visit note could not be located, the patient had no suicidal ideation, attempts, intent or plan, was older than 12 years 11 months at the index date, less than 2 years old or was a duplicate entry. Results The average annual population was 28,035 children, of which 637 presented with STBs (mean (SD) age, 10.6 (1.7) years; 51.2% girls, 76.3% White, average follow-up 7 years). The majority of the cases presented to the emergency department (ED) 491 (77.1%). The annual incidence per 100,000 person-years tripled from 68.8 in 2005 to 208.6 in 2023. Overall, 105 patients (16.5%) presented with a suicidal attempt. There were no cases of death by suicide. A prior psychiatric diagnosis was present in 454 (71.3%). STB events were preceded by a precipitating event in 471 (73.9%), the most common of which was an argument with a parent, followed by a bullying event and family distress. A specific suicide plan was reported by 328 (51.5%) with laceration reported most frequently, followed by hanging and overdose. Significant predictors of a suicide attempt were previous use of mood stabilisers (OR 3.21; 95% CI 1.24 to 7.97) and having a specific plan (OR 2.73; 95% CI 1.72 to 4.41). Children who had suicidal attempts had more subsequent ED visits (3.50 vs 2.58; p=0.009) and hospitalisations for psychiatric reasons (1.90 vs 1.30; p=0.003) and psychiatric hospitalisation days (12.70 vs 9.04; p=0.048). Subsequent suicide attempts occurred in 31% of the cohort during follow-up. Conclusion STBs in preadolescent children are rare but are increasing in incidence. Such children have significant psychological diagnoses, use of mental health services, and subsequent suicide attempts. Novel age-appropriate interventions are needed.

Background/Objective: The COVID-19 pandemic led to a widespread transition to online learning. Yet, it is unclear how this shift in learning format impacted school attendance in adolescents with chronic pain, a group that struggles with school absenteeism. This study compared school attendance and format (e.g., in-person, online) in patients with chronic pain attending an Intensive Interdisciplinary Pain Treatment Program (IIPT) before the pandemic to an age- and gender-matched sample of youth attending the program after the pandemic. Methods: Participants were 226 school aged adolescents (13–18 years; M age = 15.89, SD = 1.46) enrolled in an IIPT before and after the COVID-19 pandemic. Patients admitted before March 2020 (pre-pandemic group; n = 113) were compared to an age- and gender-matched group of patients who were admitted to the IIPT from November 2021 to November 2023 (post-pandemic group = 113). Upon admission to the program, participants completed validated measures of internalizing symptoms and functional disability. They also completed structured questions related to pain and school history. Results: Significantly more patients in the post-pandemic group were attending school through online and home-schooling options (p < 0.01). Youth who attended the IIPT after the pandemic missed fewer school days (p < 0.05) than those who attended before the pandemic. The groups did not differ in functional disability or internalizing symptoms. However, participants in the post-pandemic group who attended online school missed more school days (p < 0.01) and experienced greater functional disability (p < 0.05) than those who attended in person. Conclusions: The findings highlight how the COVID-19 pandemic may lead to sustained changes in the way adolescents with chronic pain attend school, with implications for increased functional disability and school dropout among this vulnerable population.

Importance Suicide is a leading cause of death among young people and an escalating public health crisis. Objective To assess the effectiveness and harms of available treatments for suicidal thoughts and behaviors among youths at heightened risk for suicide. Evidence Review A systematic review was conducted searching databases including MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and various gray literature sources from January 1, 2000, to September 26, 2024. We included randomized clinical trials, comparative observational studies, and before-after studies of psychosocial interventions, pharmacologic interventions, neurotherapeutics, emerging therapies, and combination therapies. Eligible patients were youths (aged 5-24 years) with heightened risk for suicide, adolescents from racial and ethnic minority groups known to be at increased risk of suicide, or those exposed to crime or violence. Pairs of independent reviewers selected and appraised studies. Findings This review included 65 studies (33 randomized clinical trials, 13 comparative observational studies, and 19 before-after studies) reporting on 14 534 patients (median age, 15.1 years; 75.1% female patients). Psychosocial interventions comprised psychotherapy interventions (33 studies; cognitive behavioral therapy, dialectical behavioral therapy, collaborative assessment and management of suicidality, dynamic deconstructive psychotherapy, attachment-based family therapy, and family-focused therapy), acute (ie, 1-4 sessions or contacts) psychosocial interventions (19 studies; safety planning, family-based crisis management, motivational interviewing crisis interventions, continuity of care after crisis, and brief adjunctive treatments), and school- or community-based psychosocial interventions (13 studies; social network interventions, school-based skills interventions, suicide awareness or gatekeeper programs, and community-based, culturally tailored adjunct programs). Dialectical behavior therapy showed moderate strength of evidence for reducing suicidal ideation. Other categories of psychosocial treatments showed insufficient to low strength of evidence for reducing suicidal outcomes. None of the studies evaluated adverse events. The evidence base on pharmacologic treatment for youths at risk of suicide was largely nonexistent. Conclusions and Relevance This systematic review found that the current evidence on available interventions targeting youths at heightened risk of suicide is uncertain. Medication, neurotherapeutics, and emerging therapies remain unstudied among this population. The limited evidence base calls for the development of novel, developmentally and trauma-informed treatments, as well as multilevel interventions to target the increasing suicide risk among youths.

Context Adolescence is a critical period for bone development. Due to an elevated risk for low body mass index (BMI) and/or low energy availability, certain adolescent athletes are at increased risk of bone stress injury (BSI) and eating disorders (EDs). Despite this risk, the incidence of EDs in patients with BSI is unclear. Objective To compare the incidence of a premorbid drop in BMI percentile in a sample of adolescent athletes diagnosed with a BSI between 2005 and 2016. We also evaluated the relative risk of developing an ED for this sample, compared with a sex-matched, age-matched (±6 months), and time-matched (±2 years) sample of active adolescents with knee pain. Design Retrospective cohort study. Setting Data collected through the Rochester Epidemiology Project. Patients or Other Participants One hundred eighty-seven adolescent (aged 13–18) athletes with BSI and 187 active adolescents with knee pain. Main Outcome Measure(s) Conditional logistic regression was used to assess whether premorbid weight loss was a risk factor for BSI. A stratified log-rank test was used to evaluate the association between ED diagnosis and case-control status up to 5 years postinjury. Results Patients with a BSI had 1.53 times the odds of premorbid BMI percentile drop compared with controls (95% CI = 0.83, 2.12; P = .17). A total of 14 patients with a BSI had ED diagnoses after injury compared with 8 controls ( P = .13). Patients from weight-based or aesthetic sports had 1.93 times the odds of a BSI compared with controls (95% CI = 1.23, 3.02; P = .0040). The Kaplan-Meier estimates indicate that the case group had a greater risk of ED diagnosis. Conclusions Results suggest a trend toward a greater drop in BMI percentile and increased frequency of ED diagnoses in the BSI group compared with controls. The documented co-occurrence of weight loss, stress fractures, and EDs in adolescent athletes should inform guidelines for screening and treatment of adolescent athletes with BSIs.

Background: Diagnostic delay and error represent pervasive problems in healthcare with grave implications for treatment and prognosis. Though characteristic of human cognition, cognitive biases commonly contribute to delays in the physician decision-making process, particularly in atypical or complex presentations in youth. Methods: We present a case series of three adolescent athletes with varied clinical presentations whose diagnostic conceptualization and treatment were delayed in part due to cognitive biases with consequences for overall health and development, as well as return to sport. Results: The first case depicts how an atypical presentation of celiac disease was attributed to growing pains, illustrating the contribution of anchoring bias and confirmation bias in medical decision making. The second case represents the misattribution of chronic exertional compartment syndrome pain to growing pains and post-exercise soreness, highlighting the influence of ascertainment bias on the initial misdiagnosis. The third case describes how a vertebral mass was misdiagnosed as a left shoulder strain from weightlifting, depicting the contribution of anchoring bias and ascertainment bias in medical decision making. Conclusions: Early recognition of cognitive biases, including confirmation bias, anchoring bias, and ascertainment bias, is crucial for improving medical decision making, particularly in cases of rare or atypical presentations, reducing unnecessary diagnostic delays, and setting more realistic patient expectations. Through discussion of these cases, we highlight concrete steps to manage bias to facilitate timely diagnosis within the primary care and sports medicine setting.

ABSTRACTObjectiveTo examine the outcomes of a clinical sample of young patients with restrictive eating disorders who received Family‐Based Treatment for Primary Care (FBT‐PC).MethodsParticipants were 134 youth (mean age = 15.7 years) and their caregiver(s). Participants and caregivers completed measures of eating disorder symptomatology, quality of life, and caregiver self‐efficacy.ResultsOf the 134 patients who received at least one session of FBT‐PC, 55.9% completed treatment, 20.1% were followed until they began a higher level of care, and 23.8% were non‐completers. Weekly measures for the full sample were evaluated using intention‐to‐treat analyses. Patient‐reported scores on the ED‐15 improved by −0.1 (SE = 0.02, F (1,133)= 26.4, p < 0.0001) per week, and caregivers' ratings of patient symptoms also improved by 0.85 (SE = 0.2, F (1,133)=13.1, p = 0.0003) per week. Patient's BMI percentile increased by 1.25 points per week (SE = 0.14, F (1,133) = 83.9, p < 0.0001). For patients who completed FBT‐PC, eating disorder symptoms, per patient‐ (M = −1.43, p < 0.0001) and caregiver‐report (M = −1.33 p < 0.0001) decreased significantly from baseline to end of treatment. Patient's quality of life increased significantly from baseline to end of treatment (M = 21.6, p < 0.0001) and caregivers showed significant increases in self‐efficacy (M = 3.41, p < 0.0001, d = 0.856). At the end of treatment, 62.5% of patients with complete data met criteria for full research remission, and 44.6% met criteria for full clinical remission.DiscussionFindings provide preliminary support for FBT‐PC as an effective treatment for youth with restrictive eating disorders. Additional research is needed to replicate these findings in other primary care settings and to understand the durability of treatment effects.

Background/Objectives: Adolescents with autonomic disorders who attend Intensive Interdisciplinary Pain Treatment (IIPT) programs report improvements in functioning. However, it is unclear whether they experience corresponding improvements in physiological measures. As such, the aim of this pilot study was to examine changes in physiological measures in youth attending an IIPT program who demonstrated excessive postural tachycardia on an active stand test. The secondary goal was to examine associations between physiological measurements and self-reported measures of chronic orthostatic intolerance (cOI) and functioning. Methods: At admission and discharge, eighteen adolescents and young adults (AYAs) attending IIPT (M age = 17.39 years; SD = 2.15 years) completed an active stand test, measures of breathing rate and muscle tension, as well as self-reported measures of cOI symptoms and functioning. Results: AYAs showed significant reduction in active stand test heart rate increase (p < 0.001; d = 1.07) and maximum heart rate (p = 0.002, d = 0.76) from admission to discharge. Improvements were also observed in resting respiration rate (p = 0.001, d = 89) and resting trapezoid tension (p = 0.03, d = 0.49). Although patients showed significant improvements on self-report measures of functioning (p < 0.001, d = 1.78), changes on subjective report of cOI symptoms did not reach significance. Exploratory analyses that only included patients with a POTS diagnosis were consistent with the overall results. Conclusions: Youth who demonstrated excessive postural tachycardia on active stand test at admission to an IIPT showed significant improvements from admission to discharge in their active stand maximum heart rate and heart rate increase, as well as respiration rate, muscle tension, and reports of their functioning. Future research is necessary to examine the mechanisms of change that contribute to symptom improvement.

AbstractObjectivesAdolescents with functional abdominal pain (FAP) often experience pain and other gastrointestinal symptoms in the context of eating, which may place them at risk for eating disorders. This study compared disordered eating and its sequalae in adolescents with FAP to those with chronic headache.MethodsParticipants in this retrospective chart review study were 270 adolescents and young adults (mean age 15.9; standard deviation [SD] = 1.63; 60% female) attending an intensive, interdisciplinary pain treatment program, including 135 youth with FAP and an age‐ and gender‐matched control group with a primary pain diagnosis of chronic headache. Information was extracted related to eating‐ and weight‐related symptoms.ResultsIndependent t‐tests and χ2 analyses found that compared with adolescents with chronic headache, patients with FAP showed significantly more eating pathology as reflected by scores on the Eating Attitudes Test—26 (EAT‐26) (p < 0.001), endorsement of pain‐related restrictive eating (p < 0.01), eating disorder history (p < 0.001), and avoidant restrictive food intake disorder (ARFID) diagnoses (p < 0.001). Compared to those with chronic headache, significantly more patients with FAP had lost 10 pounds or more (p < 0.01) and a higher proportion were underweight (p < 0.001). Among all participants, a history of exclusion diets used to manage symptoms significantly increased the risk for ARFID (p < 0.001).ConclusionThe results of this study highlight the increased risk of eating‐related concerns among youth with FAP, as well as the judicious use of exclusion diets to manage symptoms in these patients.