Exposure-Based Cognitive Behavior Therapy for children with abdominal pain: A pilot trial

The exposure-based cognitive behavior therapy for children with  pain-related functional gastrointestinal disorders is feasible, acceptable and potentially efficacious.

Abdominal pain without an organic explanation is often considered as a major symptom of pain-related functional gastrointestinal disorders (P-FGIDs). Other symptoms include bloating, nausea and fecal disturbances. The reported prevalence of P-FGIDs is about 13.5%. According to the Rome III criteria, irritable bowel syndrome (IBS), functional abdominal pain (FAP) and functional dyspepsia (FD) are the most common P-FGID. Patients suffering from IBS have noticeable fecal disturbances along with the pain, whereas patients with FD experience pain in their upper abdomen and patients with FAP notice pain in the lower or all over the abdomen. The effect of P-FGIDs on children’s lives is highly considerable as it is linked with school-absenteeism, depression, anxiety and impaired quality of life. For children with P-FGID, neither medication nor diet have been proven to be effective. Fortunately, many cognitive behavioral therapies (CBTs) have shown to produce promising results; however, it is still not clear that which components of CBT are effective. In adults, gastrointestinal specific anxiety and avoidance of symptom-provoking stimuli play a key role in IBS maintenance. Children with P-FGIDs show the same behavioral pattern, with avoidance of situations in which they are afraid of having symptoms, and avoidance of symptom-provoking stimuli. Exposure therapy is a backbone in CBT for anxiety disorders and using exposure exercises to reduce avoidance behaviors could be an effective intervention for children with P-FGIDs. In exposure therapy, the child willingly provokes symptoms and approaches feared situations and aversive stimuli to decrease fear of symptoms and avoidant behaviors. Exposure-based CBT in adults with IBS has shown efficacy with large effect sizes in several studies, and has also been tested for adolescents with P-FGIDs with promising results.

Rationale behind research:

• No study has been found to investigate the feasibility, perceived usefulness and potential efficacy of a novel exposure-based CBT protocol in young children
• This is the first study to assess the effect of exposure-based CBT for young children with P-FGIDs and their parents

Objective:

The aim of the study was to investigate the feasibility, perceived usefulness and potential efficacy of a novel exposure-based CBT protocol for children 8–12 years with P-FGIDs and their parents.

Study outcomes:

• Child-rated outcome measures: The primary outcome was child-rated pain intensity on the Faces Pain Rating Scale. Secondary outcomes included: pain frequency measured by the question:“How many days during the last week did you have pain or discomfort?”; gastrointestinal symptoms measured by Pediatric Quality of Life Inventory Gastrointestinal Symptom Scale (PedsQL Gastro); quality of life measured by Pediatric Quality of Life Inventory (PedsQL QOL); somatic symptoms measured by Children’s Somatization Inventory (CSI- 24); anxiety measured by Spence Children Anxiety Scale (SCAS); depressive symptoms measured by Child Depression Inventory (CDI); gastrointestinal symptom profile measured by a shortened version of ROME-III; behavioral avoidance measured by IBS behavioral responses questionnaire (IBS-BRQ); and satisfaction with the treatment measured by Client Satisfactory Questionnaire (CSQ). School absenteeism was examined with two questions. The first question (absence) assessed how many hours the child was absent from school due to the pain, and the second question (leaving) assessed how many times in a month the child went home from school due to the pain.
• Parent-rated outcome measures: The parented-rated assessments included parental versions of: PedsQL Gastro measuring the child’s gastrointestinal symptoms; PedsQL QOL measuring the child’s quality of life, and CSQ measuring the parent’s satisfaction with the treatment. Parental responses to children’s pain symptoms were measured by Adult Responses to Children’s Symptoms (ARCS) subscales Protect and Monitor, found to be sensitive to change .

Time points: Baseline, post-treatment and after 6 months of follow up.

Outcomes

Primary outcome measure: Significant but small improvements were observed at post-treatment on faces, the child-rated primary outcome measure for pain intensity, d=0.40. At 6 month follow-up the children reported statistically significant further improvement compared to post-treatment, d=0.41, and the pre- to 6 month follow-up effect-size was large, d=0.85.

Figure 1: Comparison of pain intensity post treatment and after 6 month follow up

Secondary outcome measures: Five of the secondary outcomes rated by the children showed a moderate effect size at post-treatment (pain frequency, gastrointestinal symptoms, depression, school absenteeism and avoidance behavior) and three had a small effect size (quality of life, anxiety and somatization). At 6 month follow up, six of the nine child-rated outcomes showed statistically significant further improvement. Five of the pre-treatment to 6 month effect sizes were large (pain intensity, pain frequency, gastrointestinal symptoms, quality of life and avoidance behavior) and four were moderate (depression, anxiety, school absenteeism [absence] and somatization). Only three children reported no pain-related school absenteeism, a month before the treatment. At post and follow-up assessments, no pain-related school absenteeism during the last month was reported by 11 and 12 children. On the school absenteeism measure of leaving school during the day, we did not observe any significant effects at any assessment point. Four of the parent-rated measures showed large effectsizes at post (child’s gastrointestinal symptoms, school absenteeism [absence], and parental protective and monitoring behaviors), and one showed a moderate effectsize (child’s quality of life). Although we did not observe any significant furtherimprovement from post-treatment to 6 month follow-up, all pre- to 6-month follow-up effectsizes on the parent-rated measures were large. No effects were observed on leaving the school during the day.

Exposure-based CBT for children with P-FGIDs is feasible, acceptable and potentially efficacious. Pain-inducing exposures may be very aversive, so the first question was: would the children engage in the exposure exercises? Nineteen of the 20 children did carry out exposures and completed between 8 and 10 sessions, indicating that an exposure-based approach is acceptable to children with P-FGIDs and their parents. This was strengthened by the fact that 19 of 20 children were satisfied with the treatment and all children perceived the treatment as helpful for dealing with their symptoms. Regarding potential efficacy, the results of this study showed significantreductions in pain, gastrointestinal symptoms, somatization, depression, anxiety and school absenteeism as well as an increase of the quality of life from pre to posttreatment. Results were maintained, and for most child-rated measures the effectswere significantly larger at 6 month follow-up. Parental protectiveness and monitoring of the child’s symptoms significantly decreased and these results were maintained at 6-month follow-up. The decreased school absenteeism shown in this study is an important result. School absenteeism is considered to be a serious public health issue and key risk factor for problems like psychiatric disorders and economic deprivation in adulthood. Even though P-FGIDs are associated with increased school absenteeism, only a few previous CBT intervention studies have assessed this. Reductions in depressive and somatic symptoms as shown in this study may also be of specific importance, since it is linked to maintenance of abdominal problems into adulthood.

Most CBT protocols that have been proven effective for pain-related disorders in children use other strategies than exposures, such as coping strategies, relaxation and cognitive techniques. The resuls of this study suggests that using exposures without adding any of these commonly used components may also lead to symptom reduction. Whether the treatment mechanisms in these different approaches are similar or not and which approach is most effective remains to be investigated.