CBT Might be Useful in Children With Severe Recurrent Abdominal Pain

Marlene Busko

February 04, 2008

February 4, 2008 — A review of 6 small trials of cognitive behavioral therapy (CBT) vs other interventions for recurrent abdominal pain suggests that most children are likely to improve with reassurance and time, but CBT might be warranted for children with severe or continuing problems. The authors caution, however, that evidence for the effectiveness of CBT is relatively weak, since the studies were small and had methodological flaws.

The review is published online January 23, 2008 in the Cochrane Database of Systematic Reviews.

"The most important finding here is that there seems to be some evidence of benefit of psychosocial interventions in reducing the pain of school-age children with recurrent abdominal pain," lead author, Angela Huertas-Ceballos, MD, from Garrett Anderson Hospital, in London, the United Kingdom, said in a press release.

"To my knowledge, this is the most thorough and exhaustive review so far on this topic," Charlotte Rask, MD, from Aarhus University Hospital, in Denmark, who was not associated with this review but who coauthored another review of this data, said. One of the key findings is that working with the parents as well as the child may be very important, she noted.

Sore Tummies in Stressful Situations

Recurrent abdominal pain is very common in children, and between 4% and 25% of school-age children complain of pain that is severe enough to interfere with daily activities, the group writes. The abdominal pain is often accompanied by headaches, limb pain, pallor, and vomiting.

In most cases, no organic causes can be identified, and the etiology of the pain remains unclear, the group writes. Child temperament along with anxiety in parents is a strong predictor of this problem. Food allergies and a low-fiber diet have been suggested as possible causes, and some authors recommend dietary manipulations. A variety of drugs, including sedatives, have occasionally been used. But most clinicians continue to view this as a psychogenic problem, and many children receive psychological interventions.

"In recurrent abdominal pain cases, there is evidence that the pain is real," said Dr. Huertas-Ceballos, adding that "although the main organic cause is still not clear, it seems that there is an important mental component."

Abdominal Migraine

Most of the body's serotonin is in the nerves of the bowels, not the brain, so problems with this system could be a factor in recurrent abdominal pain of the "abdominal-migraine" type, the press release states.

The researchers sought to determine the effectiveness of psychosocial interventions for recurrent abdominal pain or irritable bowel syndrome in school-age children.

They identified 6 randomized trials (with a total of 167 participants) in Australia, Brazil, and the United States. The findings were published between 1989 and 2006 in 9 papers.

Four studies compared CBT vs waiting list or standard care, 1 study compared online cognitive behavior intervention vs waiting list, and 1 study compared 4 different treatments involving dietary fiber, biofeedback, CBT, and parental support.

In the CBT component of the different trials, children were taught skills to cope with pain. The skills included performing relaxation and deep breathing exercises, replacing negative thoughts with positive ones, distracting themselves by watching television or playing games, or using problem-solving strategies for dealing with pain in high-risk situations, such as examinations. Parents were trained to act as coaches to help their children with coping strategies and to give positive reinforcement when the child handled the situation well.

Primary outcomes included pain intensity or frequency.

In 5 studies, children randomized to CBT had a significant improvement in pain intensity or frequency compared with children randomized to standard medical care or wait list. The sixth study, which looked at online psychological intervention vs wait list, had too few children with recurrent abdominal pain to provide interpretable data.

"For children with more severe or continuing problems or who do not respond to other forms of treatment, the evidence from this review suggests that it may be appropriate to consider interventions based on cognitive behavioral therapy," the authors summarize. They caution that the evidence is relatively weak, however, since the trials were small and heterogenous, and some failed to give appropriate detail regarding the numbers of children assessed.

There is an urgent need for further trials of the many interventions that have been suggested for use in this condition, they note.

Cochrane Database Syst Rev. 2008;(1):CD003014.


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