“Implementing psychological therapies for gastrointestinal disorders in pediatrics”

Bonney Reed, Jessica Buzenski & Miranda A.L van TilburgExpert Review of Gastroenterology & Hepatology (2020), DOI: 10.1080/17474124.2020.1806055 Full Text: Implementing psychological therapies for gastrointestinal disorders in pediatrics

This article is a useful and up-to-date review on the role of psychology to treat children with gastrointestinal disorders, particularly targeting functional GI disorders as well as children with inflammatory bowel disease. Also, I want to recognize Bonney and Jessica who have been so helpful for so many of our patients.

Areas covered:

  • Cognitive behavioral therapy (CBT)
  • Gut-directed hypnotherapy
  • Biofeedback-assisted relaxation training
  • E-treatment/telemedicine
  • Emerging therapies: Mindfulness, and Acceptance and Commitment therapy

Resources/Referrals:

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Advice on Abdominal Pain for Everyone Who Cares for Children

A recent editorial (MK Farrell. J Pediatr 2016; 177: 16-17) provides many useful pointers from a master clinician along with commentary on an epidemiology study of recurrent abdominal pain (ML Lewis et al. J Pediatr 2016; 177: 39-43).

The main finding of the study which used an internet survey of mothers (children 4-18) was that 23% of US children met the Rome III criteria for a functional GI disorder.  Constipation was the most common.

Key points in commentary:

  • John Apley’s monograph The Child with Abdominal Pains “should be read by all who care for children.”
  • Worldwide prevalence of functional GI disorders has been estimated to be 13%. Peak ages were 4-6 years and early adolescence with a greater prevalence in females
  • “A variety of phamacologic and nonpharmacologic treatments have been proposed, but none have been consistently effective except perhaps cognitive behavioral therapy and hypnotherapy.”
  • “Negative studies are not reassuring” [to families]

Pithy observations from Apley:

  • “The more time the doctor spends on the history, the less time he is likely to spend on treatment.”
  • “Doctors who treat the symptoms tend to file a prescription. Doctors who treat the patient are more likely to offer guidance.”
  • “It is a fallacy that a physical symptoms always has a physical cause and needs a physical treatment.”
  • “Anxiety like courage is contagious.”

My take: Dr. Farrell urges more research focus on interventions (diet, behavioral, alternative therapies, medical treatments) to improve outcomes and less focus on epidemiology.

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

The Lawn, University of Virginia

The Lawn, University of Virginia

 

Anxiety and Functional Abdominal Pain

A recent review highlights the importance of anxiety and functional abdominal pain (FAP) (JPGN 2013; 56: 469-74).

“Preliminary evidence suggests that anxiety frequently co-occurs with FAP.  This is not to suggest that FAP is a manifestation of a psychological disorder, but rather that anxiety and FAP may frequently co-occur because of potentially shared etiological factors (eg. heightened physiological arousal) or as a consequence of coping with recurrent pain.”

“Anxiety disorders are estimated to affect 42-85% of youth with FAP.”

Proposed guidelines for assessment and treatment of youth with FAP and anxiety:

Initial evaluation: build rapport between family and medical provider, assess for red flags, perform standard testing, anticipate and predict normal testing results, validate the pain experience is real, educate regarding pain sensation via brain-gut axis, administer anxiety screener (see below)

Management: reassure family that FAP is not a failure to identify an organic condition, avoid extensive testing, consider a low-dose antidepressant when appropriate

Psychosocial: if elevated levels of anxiety, refer for assessment by a psychologist, educate families about cognitive-behavioral treatment

With regard to screening, the authors propose the Screen for Child Anxiety and Related Disorders (SCARED) tool.  From the University of Pittsburgh website,

http://www.psychiatry.pitt.edu/sites/default/files/Documents/assessments/SCARED%20Child.pdf:

  • Target Population: Children ages 8-18 years
  • Intended Users: Clinicians and psychiatrists
  • Time to Administer: 10 minutes
  • Completed By: Children and parents
  • Modalities Available: Handwritten
  • Scoring Information: Severity of symptoms for the past three months is rated using a 0 to 2-point rating scale with 0 meaning not true or hardly ever true, 1 meaning sometimes true, and 2 meaning true or often true.

Many other subspecialists joke about the need for a psychiatry degree to be an effective pediatric gastroenterologist; this review suggests that they are not far off the mark.

Take-home message: the review covers important aspects of this ubiquitous problem.  Trying to get patients (and their parents) to address anxiety will likely improve outcomes of children with FAP.

Related blog links:

Additional references:

  • -JPGN 2011; 53: 200. n=98. 79% of FAP responded to low dose tricyclics
  • -Gastroenterol 2009; 137: 1261, 1207– Editorial. Amitriptyline helped in 66% vs 58% w placebo. n=90. dose 10mg <35kg, 20mg >35kg. 89% had failed Rx prior to study. ‘inability to use placebo.. in practice may justify amitriptyline Rx. Consider hypnotherapy/CBT first.’
  • Distraction/ignoring important: Pain 2006; 122: 43-52. (Walker LS et al), J Pain 2006; 7: 319-26.
  • -J Peds 2009; 154: 313 (editorial), 322. Prospective school study. n=237. Weekly prevalence of abd pain was 38%. 18% with persistence for >12 weeks. FAP persists into adulthood in 1/3 to 1/2 of cases (Clin Gastro Hepatol 2008; 6: 329-32).
  • -Acta Paediatr 2007; 96: 697-701. Maternal anxiety is most consistent predictor of outcome.