CMAJ: Occurrence of and referral to specialists for pain-related diagnoses in First Nations and non–First Nations children and youth


BACKGROUND: Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non–First Nations children.

METHODS: Data from a study population of age- and sex-matched First Nations and non–First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health).

RESULTS: Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non–First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non–First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non–First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1–3.0, and OR 1.7, 95% CI 1.2–2.3, respectively).

INTERPRETATION: First Nations children were diagnosed with more pain than non–First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non–First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

Indigenous children and adolescents are the fastest-growing cohort of children in Canada,1,2 but their health trajectories have been drastically affected by colonization.2 Structural determinants of health, such as historical events (e.g., residential schools), intergenerational trauma, poverty, food security, and access to adequate housing and health care, all play an integral role in explaining persistently poor health status in Indigenous children in Canada.3 Given the high prevalence of comorbid health conditions in Indigenous Canadians4 compared with non–Indigenous Canadians, there is great potential for a negative effect on healthy child development. More specifically, pain has been found to be more prevalent in Indigenous children and adolescents than in non-Indigenous children, based on data from the First Nations Regional Health Survey5,6 and extensive Western-based evidence.712 Higher levels of pain have been reported in Indigenous children, including ear pain,13,14 dental pain,57 chest pain,8 headaches, 9 musculoskeletal pain8,10 and pain related to rheumatoid arthritis,11 yet these children are less likely to receive treatment.5,13

From an Indigenous perspective, well-being and health are conceptualized from 4 dimensions: mental, physical, spiritual and emotional.15 However, given that health care data capture only physical and mental health diagnoses, these are the dimensions focused on in this study. Both physical pain and mental health conditions, and their relation to each other, are of substantial concern within the Indigenous population, given that Health Canada reports First Nations youth are 5–7 times more likely to commit suicide than non–First Nations youth.16 There is also evidence of a connection between physical and mental health.1724 For example, Indigenous children who reported having dental pain within the previous month were more likely to report poor mental health (specifically, depression), lower school-attendance rates and learning problems at school.6Additional adverse outcomes associated with poorly managed pain and repeated pain exposure include interference with sleep, healthy development and academic performance.2531

Data are lacking on the proportion of First Nations versus non–First Nations children accessing treatment for pain-related conditions and appropriate follow-up specialist care. The primary objective of this retrospective cohort study was to compare the proportion of First Nations and non–First Nations children and youth who accessed care and specialist treatment for painful conditions over a 17-year period. Our secondary objective was to examine the likelihood of experiencing pain in adolescence (e.g., headache or abdominal pain) or a mental health diagnosis based on early exposure to any of the pain conditions studied.

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