Anxiety and somatic complaints in children with recurrent abdominal pain and anxiety disorders

Study protocol for a pilot clinical trial to understand neural mechanisms of response to a psychological treatment for pain and anxiety in pediatric functional abdominal pain disorders (FAPD)

BACKGROUND

Functional abdominal pain disorders (FAPD) are the most common chronic pain conditions of childhood and are made worse by co-occurring anxiety. Our research team found that the Aim to Decrease Pain and Anxiety Treatment (ADAPT), a six-session coping skills program using cognitive behavioral therapy strategies, was effective in improving pain-related symptoms and anxiety symptoms compared to standard care. In follow-up, this current randomized clinical trial (RCT) aims to test potential neural mechanisms underlying the effect of ADAPT. Specifically, this two-arm RCT will explore changes in amygdalar functional connectivity (primary outcome) following the ADAPT protocol during the water loading symptom provocation task (WL-SPT). Secondary (e.g., changes in regional cerebral blood flow via pulsed arterial spin labeling MRI) and exploratory (e.g., the association between the changes in functional connectivity and clinical symptoms) outcomes will also be investigated.

METHODS

We will include patients ages 11 to 16 years presenting to outpatient pediatric gastroenterology care at a midwestern children's hospital with a diagnosis of FAPD plus evidence of clinical anxiety based on a validated screening tool (the Generalized Anxiety Disorder-7 [GAD-7] measure). Eligible participants will undergo baseline neuroimaging involving the WL-SPT, and assessment of self-reported pain, anxiety, and additional symptoms, prior to being randomized to a six-week remotely delivered ADAPT program plus standard medical care or standard medical care alone (waitlist). Thereafter, subjects will complete a post assessment neuroimaging visit similar in nature to their first visit.

CONCLUSIONS

This small scale RCT aims to increase understanding of potential neural mechanisms of response to ADAPT.

TRIAL REGISTRATION

ClinicalTrials.gov registration: NCT03518216.

Effect of cognitive-behavior therapy for children with functional abdominal pain: a meta-analysis

BACKGROUND

Cognitive-Behavior Therapy (CBT) is the validated non-pharmacological treatment for chronic pain in pediatric patients. While some suggested CBT were comparable to the usual care in reducing children's functional abdominal pain. This meta-analysis was designed to systematically review the literature for RCTs that investigated the efficacy of CBT in children with functional abdominal pain (FAP).

METHODS

PubMed, Embase, and the Cochrane library were searched for papers published up to October 2022. Studies applying different CBT delivery methods (in-person, web-based, phone-based) were included in this meta-analysis to evaluate the comprehensive effectiveness of CBT compared with usual care. Weighted and standardized mean difference with the 95% confidence intervals were used for the synthesis of the results. Primary outcome was the decrease of functional disability inventory (FDI) and the secondary outcomes were the decrease of severity in pain intensity, depression, anxiety, gastrointestinal symptoms, and improvement in physical quality of life (QoL).

RESULTS

A total of 10 RCTs with 1187 children were included in the final analysis. The results showed that CBT resulted in better effect in reducing functional disability inventory (SMD=-2.282, 95%CI: -4.537 to -0.027, P = 0.047), pain intensity (SMD=-0.594, 95%CI: -1.147 to -0.040, P = 0.036), and improving QoL (SMD = 14.097, 95%CI: 0.901 to 27.292, P = 0.036) compared with the control groups. Comparable effects were observed in the severity of depression (SMD=-0.493, 95%CI: -1.594 to 0.608, P = 0.380), anxiety (SMD=-0.062, 95%CI: -0.640 to 0.517, P = 0.835), and gastrointestinal symptoms (SMD=-1.096 95%CI: -2.243 to 0.050, P = 0.061) between CBT and usual treatment.

CONCLUSIONS

We observed the differences in post-treatment FAP and pain intensity for children receiving CBT compared with children receiving treatment as usual. CBT in the setting of FAP demonstrates promising developments and highlights the need for future research.

The Clinical Characteristics and Related Factors of Centrally Mediated Abdominal Pain Syndrome

INTRODUCTION

The aim of this study was to explore the clinical characteristics and related factors of centrally mediated abdominal pain syndrome (CAPS).

METHODS

Our study included 73 patients with CAPS and 132 age-matched and gender-matched healthy controls. The general information of the participants was collected, and the questionnaires were completed including the 7-item Generalized Anxiety Disorder Scale, 9-item Patient Health Questionnaire, Hamilton Anxiety Scale, Hamilton Depression Scale Pittsburgh Sleep Quality Index, Visual Analog Scale, and Short-Form 36. Univariate and forward stepwise regression analyses were performed to explore the influencing factors of CAPS.

RESULTS

Nonexercise (adjusted odds ration [AOR] 4.53; confidence interval [CI] 1.602-12.809), mild-to-moderate depression (AOR 7.931; CI 3.236-19.438), married status (AOR 3.656; CI 1.317-10.418), and drinking coffee (AOR 0.199; CI 0.051-0.775) were found to be related with centrally mediated abdominal syndrome. The Hamilton Anxiety Scale score (7-13) was significantly related to moderate-to-severe abdominal pain (AOR 7.043; CI 1.319-37.593). Higher Hamilton Depression Scale score was related to lower mental component scale score (β = -0.726, P < 0.01) and physical component scale score (β = -0.706, P < 0.01).

DISCUSSION

Depression, married status, and nonexercise were the independent risk factors of CAPS. Conversely, coffee intake was an independent protective factor of CAPS. Anxiety was related to the severity of abdominal pain, while depression was related to low health-related quality of life.

Internalizing Symptoms in Adolescents With Sickle Cell Disease

OBJECTIVE

Sickle cell disease (SCD) is a genetic blood disorder that may affect patients' mood and behavior. However, measuring the prevalence of internalizing symptoms (anxiety and depression) in patients with SCD has been elusive. We assessed internalizing symptoms in adolescents with SCD to evaluate prevalence and to test whether neurocognitive performance and frequency of pain-related episodes were associated with internalizing concerns.

METHODS

One hundred eighty-five patients (57% HbSS/HbSß0-thalassemia, 43% HbSC/HbSß+-thalassemia), ages 12-18 years, received a neuropsychological evaluation as a part of a larger cohort study. Internalizing symptoms were measured using the Behavior Assessment System for Children, Second or Third Edition. Scores on the depression and anxiety scales were compared to normative values using Wilcoxon signed rank test. Spearman correlations examined associations between neurocognitive performances and internalizing symptoms. Robust multivariable regression models measured associations between internalizing symptoms and age, sex, sickle genotype, total hemoglobin, fetal hemoglobin, socioeconomic status, and frequency of pain episodes.

RESULTS

Parent- and self-reported ratings of internalizing symptoms were not elevated compared to normative expectations. Overall, 1.8% and 6.3% of the sample displayed clinically elevated symptoms of anxiety and depression based on self-report, respectively. There were no associations between internalizing symptoms and neurocognitive performance (all p > .05). In multivariable analyses, the frequency of pain episodes was positively associated with self-reported anxiety (p = .006) and parent-reported depressive symptoms (p = .017).

CONCLUSIONS

Adolescents with SCD do not report elevated internalizing symptoms compared to normative expectations. Further research is needed to examine the trajectory of internalizing symptoms and the bidirectional relationship between pain and psychosocial functioning in SCD.

Association of anxiety and depression to headache, abdominal- and musculoskeletal pain in children

The comorbidity between recurrent pain, anxiety, and depression among children is frequent and well documented. However, only a few studies of the predictive effect of anxiety and depression on pain have adjusted for symptoms of the other disorder when examining the respective relations to different pain locations, rendering the unique contribution from anxiety and depression undetermined. In the current investigation we explore the strength of associations between pain at different locations with symptoms of anxiety and depression in a community sample of 10-year-old children (n = 703). The children were interviewed about the frequency of pain during the last 3 months. Parents and children were interviewed separately about symptoms of anxiety and depression using a semi-structured diagnostic interview. Results of three multivariate regression models for each of headache, abdominal and musculoskeletal pain revealed that depression was associated with musculoskeletal pain and headache, whereas anxiety was not. The associations for depression were not significantly stronger compared to anxiety. Gender-specific models found that depression was related to headache only among girls, but the association was not statistically different compared to boys. These results may, in turn, influence our interpretation of different forms of pain in children, with less weight given to abdominal symptoms viewed as a strong correlate with psychological problems, compared to for instance headache. The results provided no clear support for neither a differential relationship between anxiety and pain and depression and pain nor gender differences.

The burden and impact of recurrent abdominal pain – exploring the understanding and perception of children and their parents

Background: Recurrent abdominal pain (RAP) is a common complaint for children and can result in a significantly lower quality of life due to the extent it can interfere with normal life. RAP can also significantly impact the quality of life of parents. This study sought to qualitatively explore parents’ and children’s understanding and perceptions of the burden and impact of RAP.

Methods: Semi-structured interviews were conducted with a sample of parent/child dyads or families (N = 5) engaging with a psychology service.

Findings: The findings of the inductive thematic analysis revealed four emergent themes common to both parents and children: (1) Perception, understanding and identification of RAP, (2) Contributing factors, (3) Coping mechanisms/pain management strategies, and (4) Impact and burden of RAP.

Conclusions: These findings have important clinical implications regarding the identification and management of RAP and may also contribute to improving communication between clinicians, parents and children by providing insight from multiple perspectives into how RAP is experienced.

Child and adolescent psychiatry staff's knowledge on pain management

OBJECTIVE

To assess the level of child and adolescent psychiatric staff's knowledge regarding pain management, to determine group differences between the medically more educated (physicians, nurses) and the less educated (psychologists, educators, special therapists) and to investigate the influence of gender, age, or professional experience as well as staff's own pain experiences.

METHODS

A total of 193 staff members from different professional backgrounds from three independent child and adolescent psychiatry clinics in Northern Germany were tested using the German version of the Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain Shriner's revision (PNKAS-Sr).

RESULTS

In total, the staff scored correctly 66% of the inventory questions. There was no difference between medically more educated and less educated staff members regarding the knowledge of pain management. The main factors influencing PNKAS score were age, profession, and pain education training.

CONCLUSIONS

Although chronic pain is not one of the main aspects of continuing education in child and adolescent psychiatry, the resulting level of knowledge was comparable to results of similar surveys with paediatric staffs. Nevertheless, further education is needed to enhance knowledge and understanding of children's pain in child psychiatry staff in order to professionally treat patients with chronic somatic and mental illnesses.

Anxiety problems in children and adolescents: a population-based cohort study on incidence and management in Dutch primary care

BACKGROUND

Due to a large strain on youth mental health care, general practice is suggested as an alternative treatment setting for children and adolescents with anxiety problems. However, research on the current management of these children and adolescents within general practice is scarce.

AIM

To investigate the incidence of coded anxiety in general practice using the International Classification of Primary Care (ICPC), and GPs' management of children and adolescents presenting with anxiety problems.

DESIGN AND SETTING

Population-based cohort study using electronic medical records of 51 212 children (aged 0-17 years) in primary care in the Rotterdam region between 1 January 2012 and 31 December 2018.

METHOD

Incidence of ICPC codes for anxiety were calculated, then the characteristics of children and adolescents consulting their GP with anxiety and the GPs' management were assessed qualitatively using quantitative content analysis.

RESULTS

Incidence of ICPC codes for anxiety in children and adolescents was 5.36 (95% confidence interval [CI] = 5.02 to 5.71) per 1000 person-years. Adolescent females had the highest incidence with 14.01 (95% CI = 12.55 to 15.58) per 1000 person-years. Of the 381 children and adolescents consulting their GP with an initial anxiety problem (median age 13.3 years, 40.4% male), GPs referred 59.3% to mental health care in the first year while 26.5% of children and adolescents were managed by a specialised practice nurse within general practice. Of the 381 children and adolescents, 10.5% received psychiatric medication during the first year, with the trend being for increased prescriptions during adolescence.

CONCLUSION

In general practice children and adolescents frequently received one of two ICPC codes for anxiety, especially adolescent females. Most presenting to their GP with anxiety problems are referred externally or seen by a specialised practice nurse within general practice.

Functional Somatic Symptoms and Emotion Regulation in Children and Adolescents

Background

Functional Somatic Symptoms (FSS; i.e. symptoms without sufficient organic explanation) often begin in childhood and adolescence and are common to this developmental period. Emotion regulation and parental factors seem to play a relevant role in the development and maintenance of FSS. So far, little systematic research has been conducted in childhood and adolescence on the importance of specific emotion regulation strategies and their links with parental factors.

Method

In two studies, children and adolescents (Study 1/Study 2: N = 46/68; 65%/60% female, Age M = 10.0/13.1) and their parents completed questionnaires on children's FSS and adaptive and maladaptive emotional regulation (in Study 2, additionally parental somatization and child/parental alexithymia).

Results

In both studies, child-reported FSS were negatively associated with children's adaptive emotion regulation (r = -.34/-.31, p < .03; especially acceptance) and positively with children's maladaptive emotion regulation and alexithymia (r = .53/.46, p < .001). Moreover, children's maladaptive emotion regulation (β = .34, p = .02) explained incremental variance in child-reported FSS beyond children's age/sex, parental somatization and emotion regulation. In contrast, parental somatization was the only significant predictor (β = .44, p < .001) of parent-reported FSS in children/adolescents.

Conclusion

Our results suggest that particularly rumination and alexithymia and parental somatization are important predictors of FSS in children/adolescents. Overall, the results showed a dependence on the person reporting children's FSS (i.e., method-variance). So, for future studies it is relevant to continue using the multi-informant approach.

Child-Focused Cognitive Behavioral Therapy for Pediatric Abdominal Pain Disorders Reduces Caregiver Anxiety in Randomized Clinical Trial

Pediatric functional abdominal pain disorders (FAPD) are associated with elevated anxiety in youth and their caregivers, both contributing to an adverse impact on functioning in youth with FAPD. While a CBT approach (ie, Aim to Decrease Anxiety and Pain Treatment [ADAPT]) is known to improve health outcomes for youth, it is unknown if child-focused treatment improves caregiver anxiety. This secondary analysis of a larger randomized clinical trial examined if child-focused CBT (ADAPT) for pain and anxiety also impacts caregiver anxiety and explored the relation between caregiver anxiety and child symptoms (ie, pain, disability, anxiety) after treatment. A total of 79 caregiver-child dyads were randomized to ADAPT plus treatment as usual (TAU) or TAU only. Caregiver anxiety and child outcomes (pain, disability, anxiety) were assessed at baseline and approximately 8 weeks later. Caregivers of children who completed ADAPT+TAU demonstrated lower anxiety compared to those who only received TAU. Moreover, regardless of treatment assignment, caregivers with greater anxiety had children who reported more pain and anxiety, but not functional disability at post-assessment. Results suggest a brief, child-focused intervention targeting pain and anxiety may also improve caregiver anxiety. As such, suggestions to improve future treatments are offered. PERSPECTIVE: Caregiver anxiety symptoms diminished after their child with functional abdominal pain completed a course of child-focused CBT targeting pain and anxiety. Further, caregiver anxiety was related to child-reported symptoms (pain and anxiety) after treatment. Therefore, improved caregiver mental health via a child-focused CBT may also improve pediatric outcomes.

Functional abdominal pain symptom severity: Associations between cognition and emotion in a pediatric sample

Functional abdominal pain (FAP) is a common physical complaint in children and adolescents. Prior research has documented associations between FAP symptoms and mood, especially internalizing behaviors. Limited research is available examining the association between symptom burden and cognitive function in this pediatric population. This study explored associations between FAP symptoms, internalizing behaviors, and cognitive and school function in children and adolescents. Twenty-seven participants (mean age = 12.6 years, range 8.8-16.5; 33% male) diagnosed with FAP completed assessments of cognitive, emotional, and behavioral function, as well as FAP symptom severity. Mean performances on cognitive tests were within age-expected ranges. Within this context, however, higher overall burden of FAP symptoms was associated with slower processing speed, more self-reported metacognitive problems and internalizing behaviors, and more school absences. Cognitive function was systematically associated with internalizing behaviors but not physical symptoms. Overall, findings revealed that FAP may be associated with cognitive inefficiencies in addition to internalizing problems. Cognitive symptoms may be linked to internalizing behaviors associated with FAP.

A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report

BACKGROUND & AIMS

Over several decades, changes in health care have negatively impacted meaningful communication between the patient and provider and adversely affected their relationship. Under increasing time pressure, physicians rely more on technology than face-to-face time gathering data to make clinical decisions. As a result, they find it more challenging to understand the illness context and fully address patient needs. Patients experience dissatisfaction and a diminution of their role in the care process. For patients with disorders of gut-brain interaction, stigma leads to greater care dissatisfaction, as there is no apparent structural basis to legitimize the symptoms. Recent evidence suggests that practical communication skills can improve the patient-provider relationship (PPR) and clinical outcomes, but these data are limited.

METHODS

The Rome Foundation convened a multidisciplinary working team to review the scientific evidence with the following aims: a) to study the effect of communication skills on patient satisfaction and outcomes by performing an evidence-based review; b) to characterize the influence of sociocultural factors, health care system constraints, patient perspective, and telehealth on the PPR; c) to review the measurement and impact of communication skills training on these outcomes; and d) to make recommendations to improve communication skills training and the PPR.

RESULTS

Evidence supports the fact that interventions targeting patient-provider interactions improve population health, patient and provider experience, and costs. Communication skills training leads to improved patient satisfaction and outcomes. The following are relevant factors to consider in establishing an effective PPR: addressing health care system constraints; incorporating sociocultural factors and the role of gender, age, and chronic illness; and considering the changing role of telehealth on the PPR.

CONCLUSIONS

We concluded that effective communication skills can improve the PPR and health outcomes. This is an achievable goal through training and system change. More research is needed to confirm these findings.

Engagement during a Mixed In-Person and Remotely Delivered Psychological Intervention for Youth with Functional Abdominal Pain Disorders and Anxiety

Functional abdominal pain disorders (FAPD) are common disabling pain conditions frequently associated with co-occurring mental health problems such as anxiety. Psychological therapies such as cognitive behavioral therapy (CBT) have been shown to be effective. Therefore, it is important to understand participant engagement (i.e., use of intervention tools) to such approaches, and if engagement impacts treatment response. The Aim to Decrease Anxiety and Pain Treatment (ADAPT) is an effective psychological treatment approach using a blend of in-person sessions and interventionist phone support with self-paced web modules to manage pain and anxiety. The current study used a mixed-methods approach to investigate micro-level and macro-level participant engagement during the ADAPT program. In-person/phone session attendance was high (>95%) although scheduling adjustments were common (25.5%). Varied levels of engagement with web tools were observed. Thematic analysis also revealed variability in patterns of use. Additionally, while participants indicated they generally understood how to use certain skills (e.g., problem solving, detective thinking), and these skills were effective in managing symptoms during treatment, these activities were generally underutilized. Further, participant engagement did not predict response to the ADAPT intervention. These findings are important as the demand for accessible psychotherapeutic tools to manage pain and anxiety is likely to remain high.

The Utility of an Anxiety Screening Measure in Youth With Functional Abdominal Pain Disorders and Clinical Characteristics Associated With Presence of Anxiety

OBJECTIVES

Anxiety is common in youth with functional abdominal pain disorders (FAPD) and is related to increased pain-related impairment. However, it is unknown if self-reported anxiety on a clinical screener represents a true anxiety disorder diagnosis in youth with FAPD. Further, little is known about clinical characteristics in youth with FAPD and comorbid anxiety (ANX). Therefore, we evaluated whether the clinical cutoff on the Screen for Anxiety and Related Disorders (SCARED) corresponded with the presence of an anxiety disorder. We predicted a more clinically complex profile (eg, increased pain-related impairment, psychological problems, and family risk factors) in youth with FAPD+ANX compared with youth with FAPD alone.

MATERIALS AND METHODS

Participants completed measures of anxiety, functional disability, pain intensity, pain catastrophizing, and mood, and underwent a semistructured diagnostic interview to assess for psychological disorders. Caregivers completed family characteristics and caregiver distress measures. Analyses of group differences were conducted using χ2 and multivariate tests.

RESULTS

The SCARED appears to be a good proxy for an anxiety disorder in youth with FAPD, particularly for generalized anxiety disorder and social anxiety disorder. Youth with FAPD+ANX reported higher rates of pain-related disability and depressive symptoms compared with those with FAPD alone, but other clinical characteristics and family risk factors were comparable across groups.

DISCUSSION

Findings support the use of the SCARED as a proxy for an anxiety disorder diagnosis in youth with FAPD and suggest youth with FAPD+ANX may have a more complex clinical profile categorized by greater mental health and health-related impairment as compared with youth with FAPD alone.

An elevated anxiety level among prepubertal autistic boys with non-treatment-seeking functional gastrointestinal disorders: A case-control study

Children with autism commonly suffer from comorbid functional gastrointestinal disorders (FGID) and anxiety. The raised prevalence of both conditions in autism suggests complex reciprocal relationships, which are seldom explored in non-treatment-seeking FGID. The relationships between subtypes of FGID and anxiety are also unclear. This study recruited boys with autism and age-matched typically developing (TD) boys, aged 4-11 years, who were not actively seeking help for gastrointestinal problems. Their parents completed the Rome IV Diagnostic Questionnaires for Pediatric FGID. Four groups of children with and without autism/FGID were identified and compared on their anxiety level using the Spence children's anxiety scale. In 69 boys with autism and 69 age-matched TD boys, FGID were identified in 22 and 16 boys, respectively. ANCOVA demonstrated a significant interaction effect of autism and FGID on anxiety (F[1, 129] = 5.43, p = 0.021), while conditional logistic regression identified an interaction effect of autism and anxiety on the odds of FGID (OR 1.038, 95% CI 1.002-1.075, p = 0.038). Explorative post hoc analysis showed higher anxiety in functional nausea and vomiting disorder (p = 0.033) and functional abdominal pain disorder (p = 0.029) among boys with autism than TD boys with the same respective subtypes of FGID. In summary, among prepubertal boys with autism, the presence of FGID that are non-treatment-seeking in nature, has a significantly stronger association with higher levels of anxiety than TD boys. The strength of association may be more prominent in subtypes of FGID. Possible pathomechanisms including the underlying microbiota spectra and inflammatory paths should be explored in future studies. LAY SUMMARY: Anxiety and gastrointestinal problems are common symptoms in autism. Given that gut health could be linked to emotions, their association in young boys with autism was studied. The presence of nausea vomiting, or abdominal pain were associated with raised anxiety among boys with autism, yet this was not observed in typically developing boys. This suggests that anxiety among autistic children could be partly explained by the presence of FGID.

Cognitive Behavior Therapy Tailored to Anxiety Symptoms Improves Pediatric Functional Abdominal Pain Outcomes: A Randomized Clinical Trial

OBJECTIVES

To evaluate the feasibility of a stepped care model, and establish the effect of a tailored cognitive behavioral therapy, the Aim to Decrease Anxiety and Pain Treatment (ADAPT), compared with standard medical treatment as usual on pain-related outcomes and anxiety.

STUDY DESIGN

Eligible patients between the ages of 9 and 14 years with functional abdominal pain disorders (n = 139) received enhanced usual care during their medical visit to a gastroenterologist. Those that failed to respond to enhanced usual care were randomized to receive either a tailored cognitive behavioral therapy (ADAPT) plus medical treatment as usual, or medical treatment as usual only. ADAPT dose (4 sessions of pain management or 6 sessions of pain and anxiety management) was based on presence of clinically significant anxiety. Outcomes included feasibility, based on recruitment and retention rates. Response to ADAPT plus medical treatment as usual vs medical treatment as usual on pain-related outcomes and anxiety measures was also investigated using a structural equation modeling equivalent of a MANCOVA. Anxiety levels and ADAPT dose as moderators of treatment effects were also explored.

RESULTS

Based on recruitment and retention rates, stepped care was feasible. Enhanced usual care was effective for only 8% of youth. Participants randomized to ADAPT plus medical treatment as usual showed significantly greater improvements in pain-related disability, but not pain levels, and greater improvements in anxiety symptoms compared with those randomized to medical treatment as usual only. Anxiety and ADAPT treatment dose did not moderate the effect of treatment on disability nor pain.

CONCLUSIONS

Tailoring care based on patient need may be optimal for maximizing the use of limited psychotherapeutic resources while enhancing care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03134950.

Pain in Youth With Sickle Cell Disease: A Report From the Sickle Cell Clinical Research and Intervention Program

OBJECTIVES

Pain is prevalent among youth with sickle cell disease (SCD). However, previous research has been limited by small sample sizes and lacked examinations of developmental differences in pain, which are critical to minimizing the development of chronic pain as youth transition into adulthood. The primary aim of the current study was to compare pain and pain interference across 4 developmental groups in a large sample of youth with SCD. The secondary aim was to identify risk factors for greater pain and pain interference.

MATERIALS AND METHODS

Utilizing a cross-sectional study design, the expression and predictors of pain and pain interference were compared across 4 developmental stages: toddlers/preschoolers (2 to 4 y), school-aged children (5 to 7 y), preadolescents (8 to 12 y), and adolescents (13 to 18 y). Participants included 386 youth with SCD and their caregivers.

RESULTS

Caregiver-reported pain and pain interference and youth-reported pain interference increased across developmental groups and plateaued approaching adolescence (multivariate analyses of variance P=0.002 for pain and P<0.001 for pain interference). Elevated fatigue, anxiety, and perceived difficulties with pain management were the most robust predictors of higher youth- and caregiver-reported pain (βs ranging from 0.15 to 0.68; P<0.001) and pain interference (βs ranging from 0.18 to 0.64; P<0.001).

DISCUSSION

Disease and treatment-related variables were not associated with pain. Self-reported pain was elevated in older versus younger developmental groups and was largely linked to anxiety, fatigue, and perceptions of pain management, thus highlighting the modifiable nature of factors influencing pain among youth with SCD.

The Co-occurrence of Pediatric Chronic Pain and Anxiety: A Theoretical Review of a Developmentally Informed Shared Vulnerability Model

The development and maintenance of pediatric chronic pain and anxiety are complex, underscoring the need to better understand the interactive forces contributing to their co-occurrence. The shared vulnerability model (SVM) was developed to explain the co-occurrence of chronic pain and posttraumatic stress disorder in adults. Although many core tenets have been well supported by pediatric research, the SVM has yet to be extended to pediatric pain populations. We propose a developmentally informed pediatric SVM for advancing our understanding of the co-occurrence of pediatric chronic pain and anxiety disorders. The proposed SVM postulates that youth at increased risk for the development of chronic pain and/or anxiety share predisposing vulnerabilities, including anxiety sensitivity, and that these shared vulnerabilities give rise to negative emotional responses (child and parent) in the context of stressful events. Consequences of fear and anxiety, including avoidance behavior, further contribute to the development of chronic pain, anxiety, and their co-occurrence. The parental, school, and peer contexts in which these problems develop and are maintained in youth are pertinent to integrate into a SVM, as pediatric chronic pain and anxiety disorders share several social-contextual risk and maintenance factors. We also highlight new areas of inquiry.

Preclinical Considerations about Affective Disorders and Pain: A Broadly Intertwined, yet Often Under-Explored, Relationship Having Major Clinical Implications

Background: Pain, a distinctive undesirable experience, encompasses several different and fluctuating presentations across varying mood disorders. Therefore, the present narrative review aimed to shed further light on the matter, accounting for both experimental animal models and clinical observations about major depressive disorder (MDD) pathology. Method: Major databases were inquired from inception until April 2016 for records about MDD and pain. Results: Pain and MDD are tightly associated with each other in a bi-directional fashion. Several cross-sectional and retrospective studies indicated a high presence of pain in the context of mood disorders, including MDD (up to 65%), but also increased prevalence rates in the case of mood disorders documented among people with a primary diagnosis of either psychological or somatic pain (prevalence rates exceeding 45%). The clinical implications of these observations suggest the need to account for mood and pain manifestations as a whole rather than distinct entities in order to deliver more effective interventions. Limitations: Narrative review, lack of systematic control groups (e.g., people with the primary diagnosis at review, but not the associated comorbidity as a study) to allow reliable comparisons. Prevalence rates and clinical features associated with pain varied across different studies as corresponding operational definitions did. Conclusions: Pain may have a detrimental effect on the course of mood disorders-the opposite holds. Promoting a timely recognition and management of such an often neglected comorbidity would therefore represent a primary goal toward the delivery of effective, multi-disciplinary care.

Does Social Exclusion Alter Sensory and Pain Thresholds in Children and Adolescents with Functional Abdominal Pain? - Results from a Preliminary Study

OBJECTIVE

Functional abdominal pain (AP) is a prevalent issue in childhood and adolescence. The contribution of psychosocial factors in the development and maintenance of this health problem is rather unclear, and experimental studies about underlying mechanisms are lacking. This study investigates whether experimentally induced social exclusion decreases sensory and pain thresholds in children suffering from AP.

SUBJECTS

Twenty children/adolescents with AP and 22 healthy controls.

METHODS

Children/adolescents participated in the Cyberball paradigm, which affects an experience of social exclusion. Thermal sensory and pain thresholds were measured before and after Cyberball.

RESULTS

Children/adolescents with AP showed a divergent reaction regarding their sensory threshold after social exclusion: The control group exhibited a tendency toward a decreased sensory threshold whereas the AP group remained stable. Concerning the pain threshold, no effect of social exclusion could be identified. The increase of both thresholds ("numbing") after Cyberball was positively correlated with symptoms of mental health issues.

CONCLUSIONS

This is the first study to investigate changes in sensory and pain thresholds following painful social interactions in a sample of children/adolescents with a chronic pain condition. Results suggest that AP and control children differ in their reaction of sensory thresholds, which might indicate an altered processing of social exclusion. Replication and further methodological improvements are needed.

Development, preliminary validation and reliability testing of SEDA - Self-Efficacy in Daily Activities for children with pain

BACKGROUND

Self-efficacy can affect a child's ability to perform important activities, infuse him/her with a sense of control and is likely an integral target for successful treatment in pediatric pain rehabilitation. Modern physical therapy treatment includes behavioral aspects and valid measures of self-efficacy are important for both research and clinical practice. In this study, the aim was to develop and perform preliminary testing of a self-efficacy scale for children and adolescents with pain.

METHODS

Children and adolescents participated, along with researchers and healthcare staff, in developing the Self-Efficacy in Daily Activities (SEDA) measure. A total of 109 children and adolescents seeking physical therapy treatment for pain lasting longer than 3 months responded to the SEDA. Pain and pain-related disability were assessed using the Functional Disability Inventory (FDI). Exploratory analyzes for testing validity and reliability - principal component analyses (PCA), intraclass correlation coefficients (ICCs) and bivariate correlations - were performed.

RESULTS

The PCA revealed a 16-item SEDA and a three-component scale. The components represented self-efficacy for physical activities, self-efficacy for personal care and self-efficacy for daily exertion. Validity correlation analyses showed moderate association between SEDA and FDI, -0.72 (p < .01), and low correlation with pain intensity, -0.29 (p = .03).

CONCLUSIONS

The 16-item SEDA has satisfactory psychometric properties in children moderately affected by long-term pain. Further validation of the SEDA in other populations and confirmatory analyses are warranted.

Clinical Reference Points for the Screen for Child Anxiety-related Disorders in 2 Investigations of Youth With Chronic Pain

OBJECTIVE

Anxiety is common in pediatric chronic pain and is related to a higher risk for poor outcomes; thus, there is a need for effective clinical screening methods to identify youth with chronic pain and co-occurring anxiety. The Screen for Child Anxiety-related Disorders (SCARED) is a validated measure that defines clinically significant anxiety using the traditional clinical cut-off, but in pain populations, may fail to screen in youth with subclinical anxiety that may also be at increased risk. Two studies aimed to devise a clinically meaningful approach to capture anxiety severity in pediatric chronic pain.

MATERIALS AND METHODS

Study 1 (n=959) and Study 2 (n=207) were completed at 2 separate pediatric pain clinics, where the SCARED was administered along with measures of disability, activity limitations, pain intensity, quality of life, and pain catastrophizing. Groups with different levels of anxiety were compared on clinical outcomes via multivariate analyses of variance or independent samples t tests.

RESULTS

A tertile solution suggested the following anxiety groupings based on the SCARED: minimal (0 to 12), subclinical (13 to 24), and clinical (≥25). Across both studies, the tertile solution was generally superior in classifying different levels of pain-related outcomes.

DISCUSSION

Future directions include testing the utility of this anxiety classification system to identify youth with subclinical levels of anxiety for early intervention focused on both pain and anxiety management.

External environment and internal state in relation to life-history behavioural profiles of adolescents in nine countries

The external environment has traditionally been considered as the primary driver of animal life history (LH). Recent research suggests that animals' internal state is also involved, especially in forming LH behavioural phenotypes. The present study investigated how these two factors interact in formulating LH in humans. Based on a longitudinal sample of 1223 adolescents in nine countries, the results show that harsh and unpredictable environments and adverse internal states in childhood are each uniquely associated with fast LH behavioural profiles consisting of aggression, impulsivity, and risk-taking in adolescence. The external environment and internal state each strengthened the LH association of the other, but overall the external environment was more predictive of LH than was the internal state. These findings suggest that individuals rely on a multitude and consistency of sensory information in more decisively calibrating LH and behavioural strategies.

Low FODMAP diet in children and adolescents with functional bowel disorder: A clinical case note review

Background and Aims

Functional bowel disorders (FBD), such as irritable bowel syndrome (IBS), are increasingly more common in children and affect up to 20% of children. The etiology is multifactorial with no clear organic cause. Symptoms are recurrent and are associated with a reduced quality of life, school absences, and psychological challenges. Treatment options are variable. FODMAPs are short‐chained carbohydrates, poorly absorbed by the gastrointestinal tract due to their increased osmotic activity and excess gas production from the bacterial fermentation process. There is a paucity of data examining dietary interventions that restrict carbohydrates in children with IBS. The aim of this study was to examine the use of the low FODMAP diet (LFD) in children with an FBD.

Methods

A retrospective clinical case note review of children with an FBD managed with an LFD was undertaken. Anthropometry and clinical data were collected by a pediatric gastroenterology dietitian. An IBS satisfaction survey was used to assess diet outcomes. Statistical analyses were completed using Excel.

Results

Of the 29 children included in this study, complete resolution of gastrointestinal symptoms was observed for 11 of 12 (92%) of those with bloating, 13 of 15 (87%) of those with diarrhea, and 17 of 22 (77%) of those with abdominal pain. Twenty‐three (79%) participants reported an improvement of symptoms. Fructans were the most common symptom‐causing carbohydrate.

Conclusion

The LFD is a useful dietary treatment strategy for children with FBD. This study adds to the small body of evidence supporting FODMAP dietary interventions in children with FBD. Further prospective studies are required.

Nausea exacerbates symptom burden, quality of life, and functioning in adolescents with functional abdominal pain disorders

BACKGROUND

Nausea frequently co-exists with functional abdominal pain disorders (FAPDs) and may be linked to a higher disease burden. This study aimed to prospectively compare multisystem symptoms, quality of life, and functioning in FAPDs with and without nausea.

METHODS

Adolescents ages 11-18 years fulfilling Rome III criteria for a FAPD were grouped by the presence or absence of chronic nausea. Subjects completed validated instruments assessing nausea (Nausea Profile Questionnaire = NPQ), quality of life (Patient-Reported Outcome Measurement Information System), functioning (Functional Disability Inventory), and anxiety (State-Trait Anxiety Inventory for Children). Group comparisons were performed for instruments, multisystem symptoms, school absences, and clinical diagnoses.

KEY RESULTS

A total of 112 subjects were included; 71% reported chronic nausea. Patients with Nausea compared to No Nausea had higher NPQ scores (P ≤ 0.001), worse quality of life (P = 0.004), and greater disability (P = 0.02). State and trait anxiety scores were similar (P = 0.57, P = 0.25). A higher NPQ score correlated with poorer quality of life, more disability, and higher anxiety. Specific comorbidities were more common in Nausea vs No Nausea group: dizziness (81% vs 41%; P ≤ 0.001), concentrating difficulties (68% vs 27%; P ≤ 0.001), chronic fatigue (58% vs 20%; P = 0.01), and sleep disturbances (73% vs 48%; P = 0.02). The Nausea group reported more school absences (P = 0.001) and more commonly met criteria for functional dyspepsia (P = 0.034).

CONCLUSION AND INFERENCES

Nausea co-existing with FAPDs is associated with a higher extra-intestinal symptom burden, worse quality of life, and impaired functioning in children. Assessing and targeting nausea therapeutically is essential to improve outcomes in FAPDs.

Psychological and Social Factors Associated with Pain in Inflammatory Bowel Disease: A Systematic Literature Review of the Evidence in Adult and Pediatric Studies

Background

Pain is commonly experienced in both active and dormant inflammatory bowel disease (IBD). Psychological and social factors, which can be key to pain experience, have been relatively neglected; the only prior comprehensive review focused solely on studies of adults. The present review, therefore, sought to systematically examine relationships between pediatric and adult experience of pain and psychosocial variables.

Method

Systematic searches of 5 databases were conducted to identify studies including measures of pain and psychosocial variables, in pediatric or adult IBD populations. Quality appraisal of studies was undertaken using a qualified assessment tool.

Results

Twenty-three articles met the inclusion criteria. Ten examined relationships between pain and psychosocial variables in adults, and 13 examined in pediatric populations. Inverse relationships were identified between pain and quality of life (QOL) in both populations, with potential differences in pain localization between the two populations. Psychological distress, notably depression, was also important in both populations, with inconsistent evidence for a role for anxiety in pediatric samples. Specific coping styles, and familial responses to communications, also appeared relevant, but with weaker evidence. There was substantial heterogeneity in measures, statistical analyses and sample characteristics, and quality appraisal revealed methodological weaknesses.

Conclusions

Significant relationships were found between pain and various psychological indices, notably QOL and depression. However, most studies were underpowered, did not sufficiently control for key confounds, and almost exclusively reported on Western participants. Adequately powered, statistically sound studies encompassing diverse populations are required to further clarify relationships between pain and psychosocial variables in IBD.

Executive function and somatic problems in adolescents with above target glycemic control

Adolescents with type 1 diabetes may be at elevated risk for somatic problems. This study used cross-sectional, baseline data from an intervention to examine if problems with executive function (EF) were associated with greater somatic problems independent of poor adherence and disease severity in adolescents with type 1 diabetes and above target glycemic control. In addition, it examined whether certain types of EF skills, that is, metacognitive and behavior regulation, accounted for variance in somatic problems. Ninety-three adolescents completed a glycated hemoglobin (HbA1c) blood test and parents completed adherence, somatic problems, and EF questionnaires, which measured metacognitive, behavior regulation, and global EF. Greater somatic problems had significant bivariate associations with greater global (r = 0.42, P < 0.01), metacognitive (r = 0.43, P < 0.01), and behavior regulation EF problems (r = 0.31, P < 0.01), worse adherence (r = -0.39, P < 0.01), and poorer metabolic control (r = 0.26, P < 0.05). However, when adherence, metabolic control, and EF subscales were examined together in the same model, only greater global EF problems (b = 0.15, P < 0.01) and metacognitive EF problems (b = 0.16, P < 0.01) were independently associated with greater somatic problems; behavior regulation EF problems were not independently associated with greater somatic problems when controlling for adherence. Metacognitive EF problems may predict somatic problems in adolescents with above target glycemic control above and beyond physical symptoms related to disease management, underscoring the importance of proper assessment and treatment of these distinct somatic problems.

Integrating Psychological Screening Into Medical Care for Youth With Abdominal Pain

BACKGROUND

Pediatric functional abdominal pain disorders are common, costly, and disabling. Clinical anxiety is highly prevalent and is associated with increased pain and functional disability. Thus, a psychological screening process is recommended but is infrequently used in current practice.

METHODS

A screening process for patient-reported anxiety (Screen for Child Anxiety and Related Disorders), functional disability (Functional Disability Inventory), and pain levels was implemented in a large gastroenterology division within a major medical center. Quality improvement methods and traditional analytic approaches were used to test the feasibility and outcomes of routine screening in patients ages 8 to 18 with abdominal pain.

RESULTS

Screening rates increased from <1% to >80%. A total of 1291 patients who reported having abdominal pain completed the screening during the first 6 months. Clinically significant anxiety (43.1%), at least moderate disability (45%), and elevated pain (61.5%) were common in children with abdominal pain. The presence of clinically significant anxiety corresponded with higher pain and pain-related disability. Twenty-one percent of youth had clinical elevations in all 3 areas. In such instances, medical providers received an automated prompt to tailor care, including to consider a psychological referral. After the project implementation, psychological referral rates increased from 8.3 per 1000 patients to 15.2 per 1000 patients.

CONCLUSIONS

Systematic screening for anxiety, pain, and pain-related disability as a routine part of medical care can be reliably implemented with clinically meaningful results. Future directions include examining the role of anxiety over the long-term and reducing clinician burden.

Does Pain Intensity Matter? The Relation between Coping and Quality of Life in Pediatric Patients with Chronic Pain

PURPOSE

Chronic pain is a complex and debilitating chronic health condition that negatively impacts a child's daily function. Previous investigations of coping behaviors in youth with chronic illness have suggested that secondary control/accommodative coping may be more adaptive than primary control/active coping or disengagement/passive coping. However, studies have not considered how pain intensity may change the effect of various coping strategies on functioning in this pediatric population. The current study examines how coping strategies relate to health-related quality of life (HRQOL) in youth with chronic pain at various levels of pain intensity.

DESIGN AND METHODS

Sixty-five children and adolescents, aged 8-18 (77% female: M=13.6years, SD=2.64) were recruited from a pediatric pain management clinic at an urban children's hospital. The Response to Stress Questionnaire examined coping behaviors of participants. The PedsQL 4.0 Generic Core Scales assessed HRQOL and a 10-cm Visual Analog Scale measured pain intensity.

RESULTS

Primary control engagement coping had a significant main effect to predict higher HRQOL. There was a significant interaction between secondary control engagement coping and pain, and a marginal interaction between disengagement coping and pain. Specifically, secondary control engagement coping significantly related to higher HRQOL when pain was low and disengagement coping marginally related to higher HRQOL when pain was high.

CONCLUSIONS

Findings suggest that the effectiveness of specific coping strategies may vary depending on a child's level of pain.

PRACTICE IMPLICATIONS

These findings suggest that clinicians (e.g., nurses, psychologists) use a more tailored approach when recommending interventions for managing chronic pain.

Trauma and Health Symptoms in a Community Sample: Examining the Influences of Gender and Daily Stress

Although there is a rich body of literature on trauma and health, limited research has investigated the variables of gender, trauma symptoms, physical health, mental health, and daily stress together in a community sample. Considering the deleterious effects of trauma on health, our overarching inquiry was whether trauma symptoms can predict overall mental and physical health with attention to gender and daily stress as potential moderators. Participants (n = 103; 50.5% women) completed self-report measures of trauma symptoms, mental health, physical health, and daily stress, along with demographic information. Trauma symptoms predicted 25.2% of the variance in general health symptoms. Gender significantly added to the variance accounted for, but daily stress was not significant in the model. Trauma symptoms predicted 37.1% of the variance in mental health symptoms. Daily stress significantly added to the model, but gender did not. Results are interpreted through the integration of family stress theory and feminist frameworks, adding to the literature by further illuminating the relationships between gender, daily stress, health symptoms, and trauma in a community sample.

Development of the Aim to Decrease Anxiety and Pain Treatment for Pediatric Functional Abdominal Pain Disorders

OBJECTIVES

To evaluate the feasibility and acceptability of the Aim to Decrease Anxiety and Pain Treatment (ADAPT), a brief, on-line and in-person behavioral intervention targeting pain and anxiety in youth with functional abdominal pain disorders (FAPDs).

METHODS

Patients were recruited from several outpatient pediatric gastroenterology clinics. Nine participants (ages 9-13) completed the full protocol. Thematic analysis of detailed qualitative feedback was obtained via semistructured patient and caregiver interviews after treatment was conducted. Feasibility and preliminary outcomes were examined using nonparametric tests.

RESULTS

Preliminary results indicate that the ADAPT treatment is feasible, acceptable, and potentially effective for youth with FAPD. Treatment completers reported that they enjoyed the program and used the skills to manage their pain and worry. Results also indicated that the majority of participants experienced a reduction in anxiety and several reported reductions in pain and functional disability levels.

CONCLUSIONS

Findings from this study suggest that targeting both pain and anxiety may positively impact outcomes in youth with FAPD. The ADAPT intervention has the potential to provide a cost effective and practical application of cognitive behavioral therapy using an innovative combination of in-person and technology-based platforms. Overall, the ADAPT intervention is a promising and innovative intervention to improve the outcomes of youth with FAPD.

Examination of competing diagnostic models of functional gastrointestinal disorders related to pain in children

BACKGROUND

There have been no empirical validations of the Rome III or Rome IV criteria in children. The aim of the current study was to examine whether symptoms naturally occur in a pattern consistent with Rome III and/or Rome IV pediatric criteria for functional dyspepsia (FD) and irritable bowel syndrome (IBS).

METHODS

We conducted a retrospective cohort study of 250 children, ages 8-17 years, presenting to an abdominal pain clinic with pain of at least 8 weeks duration. We evaluated patterns of gastrointestinal (GI) and non-gastrointestinal (non-GI) symptoms which had been collected in a standardized fashion as part of routine clinical care. Confirmatory factor analyses were used to compare pre-existing models of symptoms clusters, namely Rome III and Rome IV criteria for IBS and FD in children and adolescents. Factor intercorrelations also were examined to determine whether IBS symptoms and non-GI somatic complaints correlate uniquely with FD symptom clusters.

KEY RESULTS

Both models demonstrated good fit with observed data [3-factor: χ² (101, n=250)110.75, P<.05, TLI=.99, CFI=.99; 4-factor: χ² (98, n=250)117.54, P<.05, TLI=.96, CFI=.97]. Fit indices and intercorrelations favored the more parsimonious 3-factor solution (3-factor: AIC=4654.91, BIC=4778.17; 4-factor: AIC=4757.16, BIC=4890.97) consistent with pediatric Rome III criteria that conceptualizes FD as a single diagnostic category. FD demonstrated significant overlap with IBS (.42), while non-GI-specific symptoms correlated significantly with FD (.64), but not IBS (.14) symptoms.

CONCLUSIONS & INFERENCES

GI symptoms in children presenting for initial evaluation of chronic functional abdominal pain occur in a pattern consistent with Rome III and IV pediatric criteria. Rome III offers a more parsimonious model. The presence of FD symptoms is strongly, and uniquely, associated with non-GI symptoms.

School Anxiety in Children and Adolescents with Chronic Pain

Anxiety is highly prevalent in pediatric chronic pain. This comorbidity has been explained by the presence of shared mechanisms underlying the development and maintenance of chronic pain and anxiety. Accumulating evidence demonstrates that school is a significant source of anxiety among youth with chronic pain and that anxiety contributes to school-related functional impairment in this population. This article reviews the cooccurrence of pediatric chronic pain and anxiety, identifies unique sources of heightened school anxiety among youth with chronic pain, and describes current approaches for assessing anxiety in pediatric pain settings. Highlighted by this review is the absence of a comprehensive evidence-based approach for assessing school anxiety in pediatric chronic pain. Given the psychometric limitations inherent to gathering data from a single source, recommendations for advancing measurement methods are provided. Novel approaches may be needed to shed more light on the way in which school anxiety is experienced in pediatric chronic pain.

The natural course of anxiety symptoms in early adolescence: factors related to persistence

BACKGROUND AND OBJECTIVES

Anxiety disorders are the most common mental health problems during childhood and adolescence. This study examined the course of anxiety symptoms in early adolescents from the general population over three phases.

DESIGN

Prospective cohort study.

METHODS

Two hundred and forty-two participants (mean-age of 13.52) from a baseline sample of 1514 (mean-age of 10.23) were followed up three times. Of the 1514 children, those with emotional risk and controls without risk constituted the second-phase sample (n = 562; mean-age of 11.25). The Screen for Child Anxiety Related Emotional Disorders-SCARED was administered in all three phases.

RESULTS

Fifty-six percent and 32% of respondents showed total scores above the SCARED cutoff point at one and three years follow-up, respectively. Eight percent showed fluctuating symptoms. Fifty-five percent of respondents showed high scores for any subtype of anxiety over three years. Social phobia and generalized anxiety symptoms were the most prevalent and persistent. Participants with persistent separation anxiety showed the highest co-occurrence with symptoms of other psychopathological disorders. Participants with persistent anxiety showed lower academic performance. Being male was a protective factor against persistence.

CONCLUSIONS

The data support anxiety maintenance during early adolescence. Early adolescence is a critical period which may involve other serious academic, social, and family problems.

Risk Categorization Predicts Disability in Pain-associated Functional Gastrointestinal Disorders After 6 Months

INTRODUCTION

For a large portion of youth, pain-associated functional gastrointestinal disorders (FGIDs) are associated with significant impairment over time. Clinically feasible methods to categorize youth with FGIDs at greatest risk for persistent pain-related impairment have not yet been identified.

METHODS

Measures of functional disability, pain intensity, and anxiety were collected on 99 patients with FGIDs (ages 8-18) during a visit to a pediatric gastroenterology office to assess for the presence of risk. Follow-up data were obtained on a subset of this sample (n = 64) after 6 months, either in person or via mail. The present study examined whether a greater number of risk factors at baseline predicted greater pain-related disability at follow-up.

RESULTS

Patients were divided into 4 groups based on number of risk factors present at the initial assessment: 0 (18.2%), 1 (24.2%), 2 (26.3%), and 3 (31.3%). The presence of 2 or 3 risk factors significantly predicted greater disability at follow-up compared to those with 0 risk factors (R = 0.311) and those with just 1 risk factor (Cohen's d values of -1.07 and -1.44, respectively).

DISCUSSION

A simple approach to risk categorization can identify youth with FGIDs who are most likely to report increased levels of pain-related impairment over time. These findings have important clinical implications that support the utility of a brief screening process during medical care to inform referral for targeted treatment approaches to FGIDs.

Systematic review of childhood and adolescent risk and prognostic factors for persistent abdominal pain

This review aimed to identify childhood and adolescence risk and prognostic factors associated with onset and persistence of persistent abdominal pain and related disability and assess quality of the evidence. While findings suggest a possible role for negative emotional symptoms and parental mental health as risk and prognostic factors for onset and persistence of persistent abdominal pain, the evidence is of poor quality overall and nonexistent when it comes to prognostic factors associated with disability.

CONCLUSION

Further research is needed to increase confidence in existing evidence and to explore new factors. This research will inform prevention.

Psychosocial interventions for recurrent abdominal pain in childhood

BACKGROUND

This review supersedes the original Cochrane review first published in 2008 (Huertas-Ceballos 2008).Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. No organic cause for this pain can be found on physical examination or investigation for the majority of such children. Although many children are managed by reassurance and simple measures, a large range of psychosocial interventions involving cognitive and behavioural components have been recommended.

OBJECTIVES

To determine the effectiveness of psychosocial interventions for reducing pain in school-aged children with RAP.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the references of identified studies and relevant reviews.

SELECTION CRITERIA

Randomised controlled trials comparing psychosocial therapies with usual care, active control, or wait-list control for children and adolescents (aged 5 to 18 years) with RAP or an abdominal pain-related functional gastrointestinal disorder defined by the Rome III criteria were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Five review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and adolescents with RAP between the ages of 6 and 18 years. The interventions were classified into four types of psychosocial therapy: cognitive behavioural therapy (CBT), hypnotherapy (including guided imagery), yoga, and written self-disclosure. The studies were carried out in the USA, Australia, Canada, the Netherlands, Germany, and Brazil. The majority of the studies were small and short term; only two studies included more than 100 participants, and only five studies had follow-up assessments beyond six months. Small sample sizes and the degree of assessed risk of performance and detection bias in many studies led to the overall quality of the evidence being rated as low to very low for all outcomes.For CBT compared to control, we found evidence of treatment success postintervention (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.18 to 27.32; Z = 2.16; P = 0.03; 4 studies; 175 children; very low-quality evidence), but no evidence of treatment success at medium-term follow-up (OR 3.08, 95% CI 0.93 to 10.16; Z = 1.85; P = 0.06; 3 studies; 139 children; low-quality evidence) or long-term follow-up (OR 1.29, 95% CI 0.50 to 3.33; Z = 0.53; P = 0.60; 2 studies; 120 children; low-quality evidence). We found no evidence of effects of intervention on pain intensity scores measured postintervention (standardised mean difference (SMD) -0.33, 95% CI -0.74 to 0.08; 7 studies; 405 children; low-quality evidence), or at medium-term follow-up (SMD -0.32, 95% CI -0.85 to 0.20; 4 studies; 301 children; low-quality evidence).For hypnotherapy (including studies of guided imagery) compared to control, we found evidence of greater treatment success postintervention (OR 6.78, 95% CI 2.41 to 19.07; Z = 3.63; P = 0.0003; 4 studies; 146 children; low-quality evidence) as well as reductions in pain intensity (SMD -1.01, 95% CI -1.41 to -0.61; Z = 4.97; P < 0.00001; 4 studies; 146 children; low-quality evidence) and pain frequency (SMD -1.28, 95% CI -1.84 to -0.72; Z = 4.48; P < 0.00001; 4 studies; 146 children; low-quality evidence). The only study of long-term effect reported continued benefit of hypnotherapy compared to usual care after five years, with 68% reporting treatment success compared to 20% of controls (P = 0.005).For yoga therapy compared to control, we found no evidence of effectiveness on pain intensity reduction postintervention (SMD -0.31, 95% CI -0.67 to 0.05; Z = 1.69; P = 0.09; 3 studies; 122 children; low-quality evidence).The single study of written self-disclosure therapy reported no benefit for pain.There was no evidence of effect from the pooled analyses for any type of intervention on the secondary outcomes of school performance, social or psychological functioning, and quality of daily life.There were no adverse effects for any of the interventions reported.

AUTHORS' CONCLUSIONS

The data from trials to date provide some evidence for beneficial effects of CBT and hypnotherapy in reducing pain in the short term in children and adolescents presenting with RAP. There was no evidence for the effectiveness of yoga therapy or written self-disclosure therapy. There were insufficient data to explore effects of treatment by RAP subtype.Higher-quality, longer-duration trials are needed to fully investigate the effectiveness of psychosocial interventions. Identifying the active components of the interventions and establishing whether benefits are sustained in the long term are areas of priority. Future research studies would benefit from employing active control groups to help minimise potential bias from wait-list control designs and to help account for therapist and intervention time.

Cognitive Behavioral Therapy for Anxiety and Fear in Pediatric Pain Contexts

Pain is a highly prevalent experience in pediatric medical populations, both in an acute form (e.g., iatrogenic pain from needle procedures) as well as in more chronic forms (e.g., as a result of arthritis, inflammatory bowel disease, or as a disease/disorder in and of itself). Guided by the biopsychosocial model, the overarching objective of this work is to examine cognitive behavioral treatment of anxiety in pain contexts. Specific aims are to (a) provide a brief overview of anxiety in youth with a high fear of needles and those experiencing chronic pain, (b) review the evidence base for cognitive behavioral therapy (CBT) for these populations, (c) outline considerations for implementing CBT-based approaches, and (d) provide two case examples which illustrate the application of CBT in these contexts. Brief concluding remarks include suggestions for future research such as improved screening and treatment of comorbid anxiety in the context of pain.

Eating Disorders in Adolescents With Chronic Pain

INTRODUCTION

Given that youth with chronic pain frequently experience disruptions in eating patterns that may place them at risk for disordered eating, the purpose of this study was to examine the clinical characteristics and illness course of adolescents with chronic pain and comorbid eating disorders.

METHODS

Using a retrospective chart review, 34 adolescents with chronic pain and concurrent eating disorders were identified. These adolescents were compared with 34 age-, gender-, and eating disorder symptom-matched adolescents who had an eating disorder without chronic pain.

RESULTS

The majority of adolescents with chronic pain and an eating disorder had a primary medical diagnosis of abdominal pain (n = 14), followed by autonomic dysfunction (n = 10) and headache (n = 6). Although in 41.2% of teens with chronic pain, eating disorder symptoms developed after the onset of their pain, 35.3% reported having eating disorder symptoms before they experienced chronic pain. Body mass index did not differ between the groups, but the duration of eating disorder symptoms was significantly longer for the chronic pain group (p < .001).

DISCUSSION

Despite comparable severity, eating disorders are undetected for longer periods in patients with chronic pain, which may contribute to a poorer prognosis. Implications for eating disorder conceptualization, detection, and treatment are discussed.

Possible Involvement of Avoidant Attachment Style in the Relations Between Adult IBS and Reported Separation Anxiety in Childhood

Irritable bowel syndrome (IBS) in adults as well as separation anxiety disorder (SAD) and recurrent abdominal pain (RAP) in childhood are associated with anxiety and somatization. Our aim was to examine possible associations between IBS in adulthood and SAD in childhood. Patients with IBS and healthy subjects completed a demographic questionnaire, the Separation Anxiety Symptom Inventory (SASI), the Somatization Subscale of Symptom Checklist-90-R (SCL-90-R), the Attachment Style Questionnaire, and a retrospective self-report questionnaire regarding RAP. Compared with controls, patients with IBS were characterized by an avoidant attachment style and scored higher on the SCL-90-R scale regarding the tendency to somatization (25.35 ± 7.47 versus16.50 ± 4.40, p < 0.001). More patients with IBS (25% versus 7.5%) reported RAP in childhood, but contrary to prediction, also had significantly lower SASI scores. Adults with IBS were characterized by somatization, insecure attachment style and recalled higher rates of RAP and surprisingly less symptoms of SAD in childhood. Based on these results, an etiological model for IBS is suggested, in which an avoidant attachment style and a tendency to somatization play an important role in the development of IBS. Copyright © 2015 John Wiley & Sons, Ltd.

Somatoform Disorders - A Pediatric Experience

Somatization in children consists of the persistent experience and complaints of somatic distress that cannot be fully explained by a medical diagnosis. Working at the Psychophysiological Department at the University Clinic we are dealing with more than 100 children per year manifesting this kind of disorders. The aim of this article is to summarize some specific characteristics of the somatoform disorder in a group of 243 children, mean age 10.31 (± 2.75) years for both genders, selected randomly. The used psychometric instruments are: CBCL, EPQ for children, and MMPI-201 for mothers. The obtained results showed high scores for somatization, extroversion and accentuated anxiety for children; as well as a typical Hs-Hy personality profile for mothers. The treatment with cognitive-behavior therapy and biofeedback showed very positive outcome.

Anxiety Adversely Impacts Response to Cognitive Behavioral Therapy in Children with Chronic Pain

OBJECTIVE

To evaluate whether clinical anxiety in children presenting to a pediatric pain management center is associated with a poorer treatment response for those who completed pain-focused cognitive behavioral therapy (CBT).

STUDY DESIGN

The total sample consisted of 175 children, 40 of whom completed CBT for chronic pain. The Screen for Child Anxiety Related Emotional Disorders was completed at initial evaluation and outcome measures (average pain intensity and the Functional Disability Inventory) were collected during the initial evaluation and at the end of CBT. Group differences in outcomes were examined following CBT. The role of anxiety in CBT initiation and completion was also explored.

RESULTS

Presence of clinical anxiety was associated with greater initiation and/or completion of pain-focused CBT but also a poorer treatment response. Specifically, the group with subclinical anxiety exhibited a substantial reduction in pain intensity, and the group with clinical anxiety exhibited a more limited response to treatment (F [1, 36] = 13.68 P < .01). A similar effect was observed for Functional Disability Inventory, such that the group with clinical anxiety had a significantly smaller response to treatment (F [1, 38] = 4.33 P < .05). The difference in pain and disability between groups following CBT suggest moderate effects (Cohen d = 0.77 and 0.78, respectively).

CONCLUSIONS

Although youths with clinical anxiety are more likely to start and/or complete pain-focused CBT, anxiety has an adverse impact on CBT treatment response in children with chronic pain. Identification of patients with anxiety and use of tailored behavioral interventions may improve clinical outcomes.

Provider Communication Regarding Psychosocial Factors Predicts Pain Beliefs in Parent and Child

OBJECTIVE

To examine the role of provider communication about psychosocial causes of abdominal pain and recommendations for psychosocial intervention during a gastroenterology clinic visit in predicting families' causal beliefs and perceptions of treatment acceptability.

METHOD

Participants were 57 children with a diagnosed or suspected abdominal pain-related functional gastrointestinal disorder (FGID) presenting for an outpatient gastroenterology follow-up visit and their accompanying parent. Children and parents completed questionnaires assessing child anxiety and abdominal pain severity, recall of provider communication about causes of abdominal pain and recommendations for intervention, their own causal beliefs about pain, and perceived acceptability of cognitive behavioral therapy (CBT) and standard medical treatment (SMT) after reading descriptions of each treatment. Providers completed a questionnaire assessing their perceptions and communication about the causes of the child's abdominal pain and perceived acceptability of CBT.

RESULTS

Provider communication about psychosocial causes and interventions was reported infrequently by parents, children, and providers. Parents rated psychosocial causes for abdominal pain as less likely than physical causes, and children and parents rated CBT as less acceptable than SMT. Parents' recall of provider communication about psychosocial causes was associated with their own causal beliefs about pain and their perceived acceptability of CBT. Children's and parents' recall of provider recommendations for psychosocial intervention was associated with their perceived acceptability of CBT.

CONCLUSION

Results highlight the importance of provider communication about psychosocial contributors to abdominal pain and psychosocial interventions for children with FGIDs. Medical and mental health providers can partner to deliver care to children with FGIDs using a biopsychosocial approach.

Doing more for mental health

Mental health is an integral part of all child health, and therefore, a vital part of paediatric practice, for which paediatricians often feel ill-prepared and unsupported. This article aims to outline some of the arguments for the importance of mental health and offers outline suggestions for improvements to everyday paediatric practice.

Anxiety Measures Predict Health-Related Quality of Life in Children and Adolescents with Cyclic Vomiting Syndrome

OBJECTIVE

To evaluate the relationship between anxiety and health-related quality of life (HRQoL) in children and adolescents with cyclic vomiting syndrome (CVS).

STUDY DESIGN

Forty children aged 8-18 years diagnosed with CVS and 40 parents completed the Screen for Child Anxiety Related Emotional Disorders (SCARED) and the child and parent forms of the Pediatric Quality of Life Generic Core Scale, a measure of HRQoL.

RESULTS

Eleven of the 40 children (27%) by self-report and 6 of 40 (15%) by parent-proxy report met the clinical cutoff for an anxiety disorder on the SCARED. Parent and child SCARED ratings were moderately correlated (intraclass correlation coefficient 0.68; P < .001). Child-rated HRQoL (mean ± SD, 74.3 ± 15.2) and parent-rated HRQoL (mean, 72.1 ± 14.6) were lower than healthy norms (P < .001). Disease severity (mean duration of CVS episodes, 3 ± 2.4 days), annual frequency of CVS episodes (mean, 8.2 ± 15.3), chronicity of CVS (mean, 5.8 ± 3.4 years), and delay in diagnosis (mean, 2.4 ± 1.9 years) were not associated with child-reported HRQoL; however, child SCARED scores accounted for approximately 50% of the variance in child-reported HRQoL (adjusted R(2) = 0.49; df = 1, 38; P < .001).

CONCLUSION

Children and adolescents with CVS appear to be at increased risk for anxiety. Anxiety symptoms are a stronger predictor of HRQoL than disease characteristics in children and adolescents with CVS. Assessment and treatment of anxiety in children and adolescents with CVS may have a positive impact on HRQoL.