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New Insights Into Functional Abdominal Pain and Irritable Bowel Syndrome in Children: A Multidisciplinary Approach

Psychological/Cognitive Behavioral Treatment of Childhood Functional Abdominal Pain and Irritable Bowel Syndrome

Bursch, Brenda

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Journal of Pediatric Gastroenterology and Nutrition: November 2008 - Volume 47 - Issue 5 - p 706–707
doi: 10.1097/01.mpg.0000338967.47679.e9
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Outcome studies and meta-analyses reveal that psychological treatments such as hypnotherapy and cognitive-behavioral therapy (CBT) are effective in treating somatic symptoms in adults with functional gastrointestinal (GI) disorders (1,2). Preliminary research suggests that improvements achieved with psychological treatments are similar to (or possibly greater than) those obtained with gut-directed pharmacological treatments. Especially interesting, preliminary research suggests that CBT may have direct effects on GI symptoms, independent of psychological distress (3).

Among children and adolescents with functional abdominal pain or irritable bowel syndrome, initial case studies and retrospective reviews suggested effectiveness of cognitive and behavioral interventions, (4–8) and recent randomized trials (using standard pediatric care as the control group intervention) provide more robust evidence for the effectiveness of psychological treatments (9–14). Cognitive behavioral techniques not only have direct effects on symptoms but also promote self-efficacy by increasing the child's ability to self-manage symptoms. Although parents may need an initial explanation to understand how the techniques can alter physiological function to provide symptom relief, some parents are pleased to avoid medications and their possible side effects. Psychological management strategies include parent training, family interventions, psychotherapy/CBT, relaxation, distraction, hypnotherapy/guided imagery, and biofeedback.

Parent training and family therapy approaches are used to facilitate acceptance of a rehabilitation approach to treatment, alter family patterns that maintain disability or exacerbate symptoms, help parents learn to better tolerate distress, and develop behavioral plans that support the child's self-management of symptoms and independent functioning.

Psychotherapy is used to reduce somatic and psychological symptoms, improve coping and functioning, improve communication and problem solving, and reduce stress load. CBT refers to psychotherapy focused on achieving these goals by modifying unhelpful cognitions, assumptions, beliefs, and behaviors. Techniques may include developing a biopsychosocial view of symptoms; keeping a diary of symptoms and associated events, feelings, thoughts and/or behaviors (to identify triggers and outcomes that could be targeted for intervention); learning relaxation and distraction techniques; questioning cognitions, assumptions, and beliefs that may be unhelpful or unrealistic and trying new ones; and gradually facing activities that may have been avoided.

Relaxation techniques, such as progressive muscle relaxation and controlled breathing, can directly alter pain perception by facilitating a relaxation response (including muscle relaxation, reduced heart rate and blood pressure, and improved mood). Distraction techniques shift attention away from pain and have been shown to increase pain tolerance and decrease pain perception. Distraction techniques vary widely but include formal interventions such as hypnotherapy/guided imagery or everyday distracters like games, television, or school. Some distracters, such as school, can also improve functioning and decrease distress by helping the child gain mastery over difficult situations.

Hypnotherapy and guided imagery can focus attention away from symptoms, alter sensory experiences, reduce distress, induce relaxation, reframe symptom experiences, facilitate dissociation from pain, and enhance feelings of mastery/self-control. These techniques can also be used to solve problems (eg, to imagine being calm during a test) and to feel a sense of accomplishment. “Gut-directed” hypnotherapy, which includes gut-specific treatments and suggestions, was developed for individuals with irritable bowel syndrome and digestive disorders. It includes gut-specific treatments and suggestions.

Biofeedback uses a computer paired with controlled breathing, relaxation, or hypnotic techniques. The computer generates a visual or auditory indicator of the child's muscle tension, peripheral skin temperature, or anal control, allowing the child to have external validation of the physiological changes he or she has produced using the techniques.

Future research on cognitive behavioral treatment of childhood functional GI disorders would benefit from direct comparison of efficacy of psychological compared to medication treatments. If both are found to be equally effective, then research designs may then shift to optimizing combinations of cognitive, behavioral, and medication treatments to maximize effectiveness and patient satisfaction. Research on mechanisms of change will require inclusion of specific and repeated measures of dysfunction, such as anxiety sensitivity, vigilance, pain catastrophizing, self-efficacy, physiological measures, and imaging to test theoretical models. Additional recommendations for future research include the inclusion of comorbid psychopathology, standardized inclusion and exclusion criteria, and standardized outcome measures of childhood pain and functioning.

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© 2008 Lippincott Williams & Wilkins, Inc.