Mediation of outcomes for cognitive behavioral therapy targeted to parents of children with Functional Abdominal Pain Disorders.

OBJECTIVE: There is a large body of evidence for the efficacy of Cognitive Behavioral Therapy (CBT) in treating Functional Abdominal Pain Disorders (FAPD) in children. In most CBT interventions for FAPD, parents participate together with their children. However, only one study to date has examined targeting parents alone for treatment. The aim of the current study was to examine mediators of a parent-only CBT treatment incorporating social learning (SLCBT) for FAPD in children. METHODS: We examined mediators of child outcomes in an existing randomized controlled trial (n = 316) of parent-only social learning CBT compared to an education condition. Hypothesized mediators (parental protectiveness, perceived threat of pain, catastrophizing) were assessed at 3 months post-treatment, and outcomes (parent ratings of disability, quality of life, school absences, and health care visits) were assessed at 6 months post-treatment. Mediation analyses were performed using Hayes' PROCESS macro. RESULTS: Pain catastrophizing significantly mediated treatment effects for all outcomes (B ranged from -1.65 to 2.22). Reduction in pain threat was a significant mediator for all outcomes (B ranged from -1.84 to 3.13) except school absences and health care visits. Decrease in parental protectiveness mediated effects on disability and missed school (B ranged from -1.47 to 1.34). Mediation effects did not differ by in-person or remote delivery of SLCBT. CONCLUSION: Changes in maladaptive parental thoughts and behaviors following parent-only SLCBT intervention appeared to mediate the effects of the intervention. Parental catastrophizing appears to be a particularly important target given that decreases in that variable mediated all outcomes.

Psychological Distress and Quality of Life in Pediatric Crohn Disease: Impact of Pain and Disease State.

OBJECTIVES: For patients with Crohn disease (CD), symptom reporting may not coincide with disease state; patients in remission may continue to report symptoms and pain, whereas other patients may be symptom-free despite a flare. This phenomenon has been documented in adults but only recently assessed in pediatric patients. The present study assessed the role of pain reporting and disease state in pediatric patients with CD in understanding psychological distress and quality of life. METHODS: Participants included 116 children and adolescents ages 8 to 18 years with CD who completed self-report questionnaires assessing pain, disease symptoms, depression, anxiety, functional disability, and quality of life. Physicians completed the Pediatric Crohn's Disease Activity Index to assess disease activity (scores ≤10 = remission, scores >10 = flare). RESULTS: Approximately two thirds of participants reported pain concordant with disease state. For patients in remission, those with pain experienced significantly increased disability and decreased quality of life compared to patients in remission without pain. For patients in a flare, those without pain experienced significantly decreased disability and depressive symptoms, and improved quality of life compared to patients in a flare with pain. CONCLUSIONS: For pediatric patients with CD, report of pain, while in remission or a flare, is associated with increased disability and reduced quality of life. Although levels of depression did not differ by disease state, depressive symptoms did differ by pain report (presence or absence) for those in a flare. Pain reporting in CD appears to be associated with both physical and psychological state and should be assessed regardless of disease activity.

Brief telephone-delivered cognitive behavioral therapy targeted to parents of children with functional abdominal pain: a randomized controlled trial.

Pediatric functional abdominal pain disorders (FAPDs) are associated with increased health care utilization, school absences, and poor quality of life (QoL). Cost-effective and accessible interventions are needed. This multisite study tested the effects of a 3-session cognitive behavioral intervention delivered to parents, in-person or remotely, on the primary outcome of pain severity and secondary outcomes (process measures) of parental solicitousness, pain beliefs, catastrophizing, and child-reported coping. Additional outcomes hypothesized a priori and assessed included functional disability, QoL, pain behavior, school absences, health care utilization, and gastrointestinal symptoms. The study was prospective and longitudinal (baseline and 3 and 6 months' follow-up) with 3 randomized conditions: social learning and cognitive behavioral therapy in-person (SLCBT) or by phone (SLCBT-R) and education and support condition by phone (ES-R). Participants were children aged 7 to 12 years with FAPD and their parents (N = 316 dyads). Although no significant treatment effect for pain severity was found, the SLCBT groups showed significantly greater improvements compared with controls on process measures of parental solicitousness, pain beliefs, and catastrophizing, and additional outcomes of parent-reported functional disability, pain behaviors, child health care visits for abdominal pain, and (remote condition only) QoL and missed school days. No effects were found for parent and child-reported gastrointestinal symptoms, or child-reported QoL or coping. These findings suggest that for children with FAPD, a brief phone SLCBT for parents can be similarly effective as in-person SLCBT in changing parent responses and improving outcomes, if not reported pain and symptom report, compared with a control condition.

Psychological Factors May Play an Important Role in Pediatric Crohn's Disease Symptoms and Disability.

OBJECTIVE: To examine the relative contributions of disease activity and psychological factors to self-reported symptoms and disability in children with Crohn's disease. STUDY DESIGN: Participants (n = 127 children age 8-18 years) completed questionnaires on symptom severity and disability, as well as psychological measures assessing anxiety, depression, pain beliefs and coping. Disease activity was measured by the Pediatric Crohn's Disease Activity Index. Structural equation modeling was used to test the effects of disease activity and psychological factors on symptoms and disability. RESULTS: In the hypothesized model predicting symptoms, psychological factors (ß = 0.58; P < .001) were significantly associated with disease symptoms but disease activity was not. The model for disability yielded significant associations for both psychological factors (ß = 0.75; P < .001) and disease activity (ß = 0.61, P < .05). CONCLUSION: Crohn's disease symptoms in children and adolescents are not only driven by disease activity. Coping, anxiety, depression, and cognition of illness are important in the patient-reporting of symptom severity and disability. Physicians need to be aware that symptom self-reporting can be driven by psychological factors and may not always be simply an indicator of disease activity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00679003.

Effects of a Cognitive Behavioral Therapy Intervention Trial to Improve Disease Outcomes in Children with Inflammatory Bowel Disease.

BACKGROUND: Studies testing the efficacy of behavioral interventions to modify psychosocial sequelae of inflammatory bowel disease in children are limited. This report presents outcomes through a 6-month follow-up from a large randomized controlled trial testing the efficacy of a cognitive behavioral intervention for children with inflammatory bowel disease and their parents. METHODS: One hundred eighty-five children aged 8 to 17 years with a diagnosis of Crohn's disease or ulcerative colitis and their parents were randomized to one of two 3-session conditions: (1) a social learning and cognitive behavioral therapy condition or (2) an education support condition designed to control for time and attention. RESULTS: There was a significant overall treatment effect for school absences due to Crohn's disease or ulcerative colitis (P < 0.05) at 6 months after treatment. There was also a significant overall effect after treatment for child-reported quality of life (P < 0.05), parent-reported increases in adaptive child coping (P < 0.001), and reductions in parents' maladaptive responses to children's symptoms (P < 0.05). Finally, exploratory analyses indicated that for children with a higher level of flares (2 or more) prebaseline, those in social learning and cognitive behavioral therapy condition experienced a greater reduction in flares after treatment. CONCLUSIONS: This trial suggests that a brief cognitive behavioral intervention for children with inflammatory bowel disease and their parents can result in improved child functioning and quality of life, and for some children may decrease disease activity.

Role of Coping With Symptoms in Depression and Disability: Comparison Between Inflammatory Bowel Disease and Abdominal Pain.

BACKGROUND: Inflammatory bowel disease (IBD) and abdominal pain of functional origin (AP) are common gastrointestinal disorders in children, which are associated with increased risk for depression and disability. Both symptom severity and coping with symptoms may contribute to these outcomes. We hypothesized that children with AP use different coping strategies compared with those with IBD for a number of reasons, including the fact that fewer treatment options are available to them. We also examined whether coping was related to depression and functional disability beyond the contributions of symptom severity. METHODS: The study method included secondary data analysis of 2 existing data sets including 200 children with AP (73% girls, mean age 11.2 years) and 189 children with IBD (49% girls, mean age 13.8 years). RESULTS: Compared with patients with IBD, patients with AP reported more use of coping strategies of self-isolation, behavioral disengagement, and catastrophizing, as well as problem solving and seeking social support. Multivariate analyses revealed that, in both samples, ≥1 coping strategies were associated with depression and functional disability, independent of symptom severity, and controlling for age and sex. In IBD, symptoms were not a significant predictor of depression but coping was. Catastrophizing predicted depression and disability in both samples. CONCLUSIONS: Patients with AP report more frequent use of several of the coping strategies we measured compared with patients with IBD. Certain types of coping, particularly catastrophizing, were associated with greater depression and functional disability in both groups. Clinicians should be aware of maladaptive coping, which may be a risk factor for poor psychosocial and functional outcomes in both patient groups.

Fructose intolerance/malabsorption and recurrent abdominal pain in children.

OBJECTIVES: The purpose of the present study was to ascertain whether pediatric patients with chronic abdominal pain had concurrent fructose intolerance as determined by a standardized dose breath hydrogen test (BHT), and whether symptoms would improve with a low-fructose diet. METHODS: The fructose BHT test was administered to patients evaluated in clinic with unexplained chronic abdominal pain alone or associated with constipation, gas or bloating, and/or diarrhea. The patients were given a standard dose of 1 g/kg fructose to maximum of 25 g. Hydrogen and methane were measured at 8 time points. The test was presumed positive if breath hydrogen exceeded 20 ppm above baseline. If positive, patients were given a dietitian-prescribed low-fructose diet. RESULTS: A total of 222 patients were part of the study. Ages ranged from 2 to 19 years with a mean of 10.5. BHT for fructose was performed in all of the patients and it was positive for fructose intolerance in 121 of 222 patients (54.5%). A total of 101 of 222 (45.5%) patients had negative BHT for fructose intolerance. All BHT-positive patients had a nutrition consult with a registered dietitian and were placed on a low-fructose diet. Using a standard pain scale for children, 93 of 121 patients (76.9%) reported resolution of symptoms on a low-fructose diet (P < 0.0001). Furthermore, 55 of 101 patients (54.4%) with negative BHT for fructose reported resolution of symptoms without a low-fructose diet (P = 0.37). CONCLUSIONS: Fructose intolerance/malabsorption is common in children with recurrent/functional abdominal pain and a low-fructose diet is an effective treatment.

Long-term treatment of primary sclerosing cholangitis in children with oral vancomycin: an immunomodulating antibiotic.

BACKGROUND: Primary sclerosing cholangitis is a rare chronic cholestatic condition of unknown etiology, frequently associated with inflammatory bowel disease and characterized by diffuse fibrosing and inflammatory destruction of the intra- and/or extrahepatic biliary duct system. PATIENTS AND METHODS: The study involved 14 children with primary sclerosing cholangitis confirmed by either liver biopsy, endoscopic retrograde cholangiopancreatography, and/or magnetic resonance cholangiogram. In each of the 14 cases, liver histology showed characteristic features consistent with primary sclerosing cholangitis. Eleven children had intrahepatic biliary beading and strictures (6 by endoscopic retrograde cholangiopancreatography; 5 by magnetic resonance cholangiogram). Biochemical tests of liver function including alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transpeptidase and the erythrocyte sedimentation rate were elevated for a mean 17 +/- 22 months before vancomycin treatment was initiated. All of the patients were shown to have inflammatory bowel disease histologically; 13 of those patients had clinical evidence of colitis. Oral vancomycin was given to all 14 patients. RESULTS: All 14 patients showed improvement in their alanine aminotransferase (P = 0.007), gamma-glutamyl transpeptidase (P = 0.005), erythrocyte sedimentation rate (P = 0.008), and clinical symptoms with oral vancomycin treatment. There was less improvement noted in the patients with cirrhosis when compared with the patients without cirrhosis. CONCLUSIONS: Before this study, there has not been an effective long-term treatment for sclerosing cholangitis to prevent the usual progression of this disease to cirrhosis. This study showed that oral vancomycin could be an effective long-term treatment of sclerosing cholangitis in children, especially those without cirrhosis.

The role of esophagogastroduodenoscopy in the initial evaluation of childhood inflammatory bowel disease: a 7-year study.

OBJECTIVES: To assess the role of esophagogastroduodenoscopy in the evaluation of children with suspected inflammatory bowel disease. METHODS: All children with inflammatory bowel disease who underwent esophagogastroduodenoscopy during their initial evaluation at our institution during a 7-year period (December 1993 to November 2000) were included in the study. RESULTS: The study included 115 patients: 81 with Crohn disease (mean age, 11.34 years; 42 males) and 34 with ulcerative colitis (mean age, 11.79 years; 20 males). Abnormal findings on esophagogastroduodenoscopy were noted in 64% of patients with Crohn disease and 50% of children with ulcerative colitis; histologic abnormalities were found in 81.6% and 70.6% of the patients, respectively. Granulomas were found in the upper gastrointestinal tracts of 23 of 81 patients (28.4%), with the most common site being the gastric mucosa. Nine of these 23 patients had granulomas solely in the upper gastrointestinal tract. Additional unsuspected pathology noted included: candidiasis, hiatal hernia, Helicobacter pylori infection, and giardiasis. CONCLUSIONS: Endoscopic and histologic abnormalities were found in the upper gastrointestinal tracts of a significant number of children with inflammatory bowel disease. While the mechanism(s) underlying these abnormalities in patients with ulcerative colitis is unclear, the pathology can contribute to the patient's clinical condition. Pathology in the upper gastrointestinal tract should not exclude a diagnosis of ulcerative colitis. Granulomas, confirming the diagnosis of Crohn disease, were found in the upper gastrointestinal tracts of 28% of our patients with Crohn disease. In some cases, granulomas were found solely in the upper gastrointestinal tracts. Based on our data, esophagogastroduodenoscopy with biopsy should be performed in all pediatric patients with suspected inflammatory bowel disease.