Management of Functional Abdominal Pain and Irritable Bowel Syndrome in Children and Adolescents

Eric Chiou; Samuel Nurko


Expert Rev Gastroenterol Hepatol. 2010;4(3):293-304. 

In This Article

Cognitive–behavioral Therapy & Other Psychosocial Interventions

Acceptance of the biopsychosocial model of FGIDs has provided the basis for the use of psychosocial interventions, including parental education, family therapy, cognitive–behavioral techniques, relaxation, distraction, hypnotherapy, guided imagery and biofeedback. Many of these strategies aim not only to have direct effects on somatic symptoms, but also promote the child's ability to self-manage symptoms. Meta-analyses have found that, as a class, psychological treatments are effective in treating somatic symptoms in both adults and children with functional gastrointestinal disorders.[31,32]

The goal of psychoeducation is to communicate information to patients and families about abdominal pain and its connection with psychological triggers, as well as factors that may exacerbate pain, such as social reinforcement and school avoidance.[33] Family therapy targets family interactions and relationships rather than the individual patient in order to change maladaptive behaviors, increase tolerance of symptoms and encourage independent coping skills.[34] Parental attention to children's symptom complaints has been shown to significantly increase those complaints when compared with alternatives, such as distraction.[35]

Cognitive–behavioral therapy (CBT), the most common type of psychotherapy employed for FGIDs, is based on the complex interactions between thoughts, feelings and behaviors. The aims of CBT include learning better coping and problem-solving skills, identification of triggers and reduction of maladaptive reactions to them. Specific techniques can include keeping a diary of symptoms, feelings, thoughts and behaviors; adopting relaxation and distraction strategies; using positive and negative reinforcement for behavior modification; confronting assumptions or beliefs that may be unhelpful; and gradually facing activities that may have been avoided. The American Academy of Pediatrics subcommittee on chronic abdominal pain recently concluded that CBT may be useful in "improving pain and disability outcome in the short term".[36]

Relaxation is usually used in conjunction with other psychosocial therapies with the goal of reducing psychological stress by achieving a physiological state that is the opposite of how the body reacts under stress.[33] A variety of methods can be employed with effects such as decreasing heart rate, respiratory rate, blood pressure, muscle tension, oxygen consumption or brain-wave activity.[37] Abdominal or deep breathing stimulates the parasympathetic nervous system to increase feelings of calmness and relaxation. In progressive muscle relaxation, children are guided to systematically tense and relax each muscle group of the body. Patients are then encouraged to maintain attention on the relaxed feeling that results after tensing muscles. Guided imagery is a specific form of relaxed and focused concentration where patients are taught to imagine themselves in a peaceful scene to create an experience void of stress and anxiety. This can be combined with other relaxation techniques to produce a state of increased receptiveness to gut-specific suggestions and ideas, also known as 'gut-directed' hypnotherapy.

Biofeedback uses electronic equipment in combination with controlled breathing, hypnotic or relaxation techniques to generate a visual or auditory indicator of muscle tension, skin temperature or anal control, allowing the child to have external validation of physiological changes.


In retrospective studies of children with RAP, FAP and IBS, psychosomatic approaches to management resulted in decreased abdominal pain in 70–89% of children.[38,39] Over the years, several small, randomized controlled trials have looked to confirm the efficacy of psychosocial interventions in children. Sanders et al. randomized 16 children diagnosed with RAP according to Apley's criteria to either 8 weeks of CBT or waitlist.[40] Children in the CBT group received weekly sessions of instruction in self-monitoring of pain, distraction techniques and relaxation, while parents also received training in ignoring nonverbal pain behaviors, redirection of children to activity after pain complaints and use of positive and negative reinforcement. Parents in the waitlist group were instructed to continue their usual management of pain complaints. Although patients in both groups had improved pain ratings, 87.5% of children in the CBT group were pain-free at 3 months post-treatment, compared with 37.5% of children in the waitlist group. In 1994, Sanders et al. conducted a larger follow-up study of 44 children with RAP randomized to 8 weeks of cognitive–behavioral family therapy (CBFT) versus standard care.[41] CBFT included verbal and written instructions for both parents and the child on techniques for dealing with pain. Patients in the standard care group received reassurance. Again, there were reductions in pain for both groups post-treatment, but the CBFT group had significantly higher percentages of pain-free subjects based on parental observation (70.6 vs 38.1%). However, there were no significant differences between groups on continuous measures of pain, pain-related behavior or other measures of coping or adjustment.

Humphreys and Gevirtz randomized 64 children (aged 4–18 years) with RAP to 8 weeks of one of four treatment protocols: dietary fiber, biofeedback, CBT and parental support; dietary fiber, biofeedback and CBT; dietary fiber and biofeedback; or dietary fiber alone.[42] All participants consumed at least 10 g of dietary fiber daily in the form of supplied cookies and bars. Biofeedback involved the use of small thermal devices intended to assist progressive muscle relaxation and self control of pain. CBT consisted of eight sessions of discrimination training, reinforcement schedules, rewards and distraction techniques. Analyses of variance reportedly showed no significant differences among the three active treatment groups in terms of outcome effects or interactions. Therefore, despite substantial differences in interventions, the authors combined these three groups into one larger active treatment group for comparison with the fiber-only group. In total, 33 out of 46 (72%) children in the combined, active-treatment group reported being pain-free at the end of 8 weeks, compared with one out of 14 (7%) in the fiber-only group. It is difficult, however, to determine which psychosocial interventions were responsible for this positive effect. Patients in the active-treatment group also reported greater reductions in pain, sick behaviors, school absences and medication use compared with the fiber-only group.

Robins et al. also compared CBT with standard medical care in a randomized controlled trial of 69 children with RAP defined by Apley's criteria (aged 6–16 years).[43] In the treatment group, 40 children received five sessions of CBT, which included psychoeducation, increasing awareness of the relationship between thoughts, feelings and pain, and parental encouragement of positive coping skills. Only 29 children in the control group completed the study owing to higher rates of study refusal. Subjects in the control group received a high-fiber diet, psychoeducation, individualized recommendations and office visits as needed. Both groups reported lower scores on a 50-point abdominal pain index based on pain frequency and intensity at the end of the study. After adjustment for baseline pain scores, age, gender and parent education, the CBT group had significantly lower scores on the abdominal pain index than controls post-treatment and at 6- and 12-month follow-up. However, the standard deviations of these results were not provided and the clinical significance of these differences in scores is unclear.

Duarte et al. studied 32 children with RAP defined by Apley's criteria (aged 5–14 years) in a nonblinded, randomized trial of CBT versus standard medical care.[44] Patients in the CBT group received a total of four monthly sessions of psychoeducation, relaxation and parent training, while patients randomized to receive standard medical care had four sessions with counseling on nutrition, intestinal parasite prophylaxis and accident prevention. By 3 months after beginning the study, patients in the CBT group had a median of two episodes of abdominal pain per month compared with eight episodes per month in the control group, representing a decrease of 86.6 and 33.3%, respectively (p = 0.001). No significant differences in intensity of pain or pressure pain thresholds were found between the two groups.

Hicks and colleagues studied a more diverse group of patients, including children complaining of at least three episodes of recurrent headaches, abdominal pain or both within a 3-month period, and randomizing them to either 7 weeks of online psychological treatment or standard medical care waiting list. Patients in the treatment group received online education, homework exercises and communication with researchers via email or telephone. As a whole, significantly more patients in the treatment group (72%) than the control group (14%) achieved a 50% or greater reduction in total pain score between baseline and 3-month follow-up (p = 0.001). However, data for patients complaining of only abdominal pain were not reported.

Guided Imagery

Weydert et al. aimed to evaluate the efficacy of guided imagery as a treatment for RAP in children.[45] Over four weekly therapy sessions, 22 children were randomized to learn either breathing exercises alone or guided imagery techniques with progressive muscle relaxation. At baseline, the children in the guided imagery group reported significantly more days of pain during the month preceding the study than children in the control group (23 vs 14 days; p = 0.04). The number of days with pain decreased more significantly in patients in the guided imagery group compared with those learning breathing exercises alone after 1 month (67 vs 21%; p = 0.05) and 2 months (82 vs 45%; p < 0.01). The number of days with missed activities also decreased more significantly. It is not clear, however, whether substantial differences in the baseline measures of these two groups accounted for some of the statistical significance observed in the results.


Vlieger et al. implemented a randomized controlled trial that compared a group of 28 children with chronic FAP or IBS (Rome II criteria) who received hypnotherapy with a control group of 25 children with FAP or IBS who received standard medical care.[46] Hypnotherapy consisted of six 50-min sessions conducted over a 3-month period, with a focus on general relaxation and control of abdominal pain and GI tract function. Standard medical treatment included education, dietary advice and supplemental fiber and pain medications as needed. In both groups, pain intensity scores and pain frequency scores decreased significantly at the final end point of 1 year after therapy. Patients in the hypnotherapy group had significantly greater reductions in both pain intensity and frequency compared with the standard medical therapy group (p < 0.002 and p < 0.001, respectively). Overall, 85% of the treatment group were considered to be in clinical remission at the end of 1 year (defined as >80% reduction in both pain intensity and pain frequency scores), compared with 25% in the standard medical therapy group (p < 0.001). These findings support an earlier, uncontrolled study by Anbar and colleagues that also reported resolution of pain after teaching self-hypnosis techniques to children with FAP.[47]

Overall, CBT appears to be an efficacious treatment for children with chronic abdominal pain. However, several of the reviewed studies incorporated multiple interventions in combination with CBT, which makes it more difficult to determine the specific contributions of CBT towards improving symptoms of FAP and IBS. There are also limited but strong data that support the use of hypnotherapy. In general, incorporation of psychological treatments into the management of patients appears to be a reasonable consideration. Variability in the details of treatment protocols should be taken into account. Ultimately, additional studies are needed to elucidate the benefits of psychosocial interventions and understand the role of placebo effects in the pediatric FGID population.


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