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Cognitive Mediators of Treatment Outcomes in Pediatric Functional Abdominal Pain

Levy, Rona L. MSW, PhD, MPH, FACG, AGAF*; Langer, Shelby L. PhD*; Romano, Joan M. PhD; Labus, Jennifer PhD; Walker, Lynn S. PhD§; Murphy, Tasha B. PhD*; van Tilburg, Miranda A.L. PhD; Feld, Lauren D. BA; Christie, Dennis L. MD#; Whitehead, William E. PhD

doi: 10.1097/AJP.0000000000000077
Original Articles

Objectives: Cognitive-behavioral (CB) interventions improve outcomes for many pediatric health conditions, but little is known about which mechanisms mediate these outcomes. The goal of this study was to identify whether changes in targeted process variables from baseline to 1 week posttreatment mediate improvement in outcomes in a randomized controlled trial of a brief CB intervention for idiopathic childhood abdominal pain.

Materials and Methods: Two hundred children with persistent functional abdominal pain and their parents were randomly assigned to 1 of 2 conditions: a 3-session social learning and CB treatment (N=100), or a 3-session educational intervention controlling for time and attention (N=100). Outcomes were assessed at 3-, 6-, and 12-month follow-ups. The intervention focused on altering parental responses to pain and on increasing adaptive cognitions and coping strategies related to pain in both parents and children.

Results: Multiple mediation analyses were applied to examine the extent to which the effects of the social learning and CB treatment condition on child gastrointestinal (GI) symptom severity and pain as reported by children and their parents were mediated by changes in targeted cognitive process variables and parents’ solicitous responses to their child’s pain symptoms. Reductions in parents’ perceived threat regarding their child’s pain mediated reductions in both parent-reported and child-reported GI symptom severity and pain. Reductions in children’s catastrophic cognitions mediated reductions in child-reported GI symptom severity but no other outcomes. Reductions in parental solicitousness did not mediate outcomes.

Discussion: Results suggest that reductions in reports of children’s pain and GI symptoms after a social learning and CB intervention were mediated at least in part by decreasing maladaptive parent and child cognitions.

*School of Social Work

Department of Psychiatry & Behavioral Sciences, University of Washington

#Department of Gastroenterology, Seattle Children’s Hospital, Seattle, WA

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA

§Department of Pediatrics, Vanderbilt University, Nashville, TN

Department of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC

Mt. Sinai School of Medicine, New York, NY

Supported by NIH grant R01HD36069 (Bethesda, MD) awarded to R.L.L. The authors declare no conflict of interest.

Reprints: Rona L. Levy, MSW, PhD, MPH, FACG, AGAF, University of Washington, Mailstop 354900, Seattle, WA 98105 (e-mail:

Received August 19, 2013

Received in revised form February 12, 2014

Accepted January 15, 2014

© 2014 by Lippincott Williams & Wilkins