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Internet-Delivered Cognitive Behavior Therapy for Adolescents With Irritable Bowel Syndrome: A Randomized Controlled Trial

Bonnert, Marianne, MSc1,2; Olén, Ola, MD, PhD3,4; Lalouni, Maria, MSc2,3; Benninga, Marc A, MD, PhD5; Bottai, Matteo, ScD6; Engelbrektsson, Johanna, MSc2; Hedman, Erik, PhD1,7; Lenhard, Fabian, MSc2,8; Melin, Bo, PhD1; Simrén, Magnus, MD, PhD9,10; Vigerland, Sarah, PhD2,8; Serlachius, Eva, MD, PhD2,8; Ljótsson, Brjánn, PhD1,8

American Journal of Gastroenterology: January 2017 - Volume 112 - Issue 1 - p 152–162
doi: 10.1038/ajg.2016.503

Objectives: Few treatments have been able to effectively manage pediatric irritable bowel syndrome (IBS). Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure for abdominal symptoms is effective for adult IBS. The objective of this study was to evaluate the efficacy of Internet-CBT based on behavioral exposure for adolescents with IBS.

Methods: Adolescents with IBS fulfilling the Rome III criteria were randomized to either Internet-CBT or a wait-list control. The Internet-CBT was a 10-week intervention where the main component was exposure to IBS symptoms by reduction of avoidance of abdominal symptoms and instead stepwise provocation of symptoms. The primary outcome was total score on Gastrointestinal Symptoms Rating Scale for IBS (GSRS-IBS). Secondary outcomes included adolescent- and parent-rated quality of life and parent-rated gastrointestinal symptoms. Difference between groups was assessed from pretreatment to posttreatment and the Internet-CBT group was also evaluated at 6 months after treatment completion.

Results: A total of 101 adolescents with IBS (13–17 years of age) were included in this study. Dropout rates were low (6%) and all randomized patients were included in intent-to-treat analyses based on mixed effects models. Analyses showed a significant larger pretreatment to posttreatment change on the primary outcome GSRS-IBS (B=−6.42,P=0.006, effect size Cohen’sd=0.45, 95% confidence interval (0.12, 0.77)) and on almost all secondary outcomes for the Internet-CBT group compared with the control group. After 6 months, the results were stable or significantly improved.

Conclusions: Internet-CBT based on exposure exercises for adolescents with IBS can effectively improve gastrointestinal symptoms and quality of life.

1Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden

2Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden

3Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden

4Department of Pediatric Gastroenterology and Nutrition, Sachs’ Children’s Hospital, Stockholm, Sweden

5Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital/Academic Medical Centre, Amsterdam, The Netherlands

6Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden

7Department of Clinical Neuroscience, Osher Centre for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden

8Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

9Department of Internal Medicine & Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

10Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina, USA

Correspondence: Marianne Bonnert, MSc, Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, CAP Research Center, BUP CPF, Gävlegatan 22, Stockholm 113 30, Sweden. E-mail:

Received 30 June 2016; accepted 26 September 2016

Guarantor of the article: Marianne Bonnert, MSc.

Specific author contributions: Conceived, designed, and planned study: MaBon, OO, MaBen, EH, BM, MS, ES, and BL. Substantial contributions to data collection and conduct of study: MaBon, OO, ML, JE, EH, FL, SV, ES, and BL. Data analysis: MaBon, MaBot, and BL. Interpretation of results and manuscript preparation: MaBon, OO, ML, MaBen, MaBot, JE, EH, FL, BM, MS, SV, ES, and BL. All authors have approved the final draft of the manuscript.

Financial support: The study was supported by grants from the Jan and Dan Olsson Foundation (4-1559/2013), the Swedish Research Council (521-2013-2846), the Kempe-Carlgren Foundation, the Ruth and Richard Julin Foundation (2012Juli0048), the Majblomman Foundation, the Ishizu Matsumurais Donation, the Ihre Foundation (SLS-331861), the Ihre fellowship in Gastroenterology, the Gadelius Foundation, the Samariten Foundation, the Värkstadsstiftelsen Foundation, the Swedish Research Council for Health, Working life and Welfare (2014-4052), the Swedish Society of Medicine (SLS-331681 SLS-410501), and the Stockholm County Council (ALF). Financial support was also provided through the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet (20130129). None of the funding bodies had any influence on study design, implementation, data analysis, or interpretation.

Potential competing interests: None.

Supplementary Material is linked to the online version of the paper at

© The American College of Gastroenterology 2017. All Rights Reserved.
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