Evolution of Parent-Targeted Interventions for Pain-Predominant Disorders of Gut-Brain Interactions: Research and Clinical Practice Considerations.

Objective: Abdominal pain-related Disorders of Gut-Brain Interaction (DGBIs) in children are best understood from a biopsychosocial model, including particular attention to the child's environment. Interventions have begun to increasingly target parents as important agents of change in this population. The purpose of this manuscript is to summarize the evolution of parent-targeted interventions for pediatric pain-related DGBIs and provide recommendations for application of the model to clinical practice. Methods: A topical review of literature regarding parent-targeted interventions and related factors in the treatment of pediatric pain-related DGBIs was conducted, followed by a discussion of these findings to clinical practice settings. Results: A growing body of research has supported parent-targeted interventions in the treatment of pediatric pain-related disorders of gut-brain interactions (DGBI), although translation of these findings to practice settings is complicated by numerous factors. Strategies for obtaining physician buy-in and parental engagement are discussed, as are potential logistical considerations of multiple caregivers, child age, and billing considerations. Conclusions: There is a promising and growing evidence-base for parent-targeted interventions for pain-related DGBIs, which have not yet been widely adopted into clinical practice recommendations. Engaging all stake-holders and attending to the nuances of this approach are recommended to successfully apply parent-targeted interventions into clinical practice settings.

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.

Parental Response to Only Children: Breaking the Stereotypes.

While much has been written about the relationship between only child status and parents' behavior toward children, and consequent personality and intelligence, little is known about the relationship between only child status, parental response to illness, and subsequent child illness behavior. In this study, 227 mothers of 342 children completed measures designed to assess: (a) their children's school attendance, (b) their own psychological status, and (c) their own responses to their children's expressions of stomach pain. Parents of only children were more likely to minimize their children's gastrointestinal symptoms than were parents of children with at least one sibling. In addition, only children were less likely to miss school. Parental protectiveness did not differ as a function of only child status. These findings are somewhat discrepant with commonly held beliefs about parents' patterns of responding to only children.

Acute kidney injury and chronic kidney disease after non-kidney solid organ transplantation.

BACKGROUND: SOT is the treatment of choice for end-stage organ disease. Improved long-term survival after NKSOT has uncovered chronic morbidity including CKD. AKI is common after NKSOT and may be associated with long-term CKD. METHODS: We performed a retrospective cohort study looking at AKI and CKD after pediatric heart (n = 109) or liver (n = 112) transplant. AKI was defined using KDIGO creatinine-based criteria. pAKI was AKI ≤ 7 days post-transplant; CKD3-5 was eGFR < 60 mL/min/1.73 m2 by modified Schwartz formula for > 3 months. We looked at the incidence of CKD3-5 and the effect of perioperative pAKI on the slope of eGFR post-transplant. RESULTS: pAKI was seen in 63% (n = 69) after heart and 38% (n = 43) after liver transplant. pAKI was associated with longer ICU and hospital stays. Cumulative incidence (95% CI) of CKD3-5 at 60 months post-heart transplant was 40.9% (27.9%-57.1%) in patients with AKI vs 35.8% (17.1%-64.8%) in those without (P = NS). Post-liver transplant, the cumulative incidence of CKD3-5 at 60 months was 0% in those without pAKI vs 10% (3.2%-29.3%) in those with (P = .01). Patients with pAKI had lower eGFR at last follow-up. CONCLUSION: pAKI and CKD are common after NKSOT. Incidence of CKD is higher in those with pAKI. AKI episodes are associated with a drop in eGFR during follow-up. Identifying patients who have had AKI is an important first step in identifying those at risk of repeated AKI episodes. These patients would benefit from closer monitoring for CKD, lower nephrotoxic drug use, and follow-up with nephrology.

Selective screening for atrial fibrillation using multivariable risk models.

OBJECTIVE: Atrial fibrillation can lead to stroke if untreated, and identifying those at higher risk is necessary for cost-effective screening for asymptomatic, paroxysmal atrial fibrillation. Age has been proposed to identify those at risk, but risk models may provide better discrimination. This study compares atrial fibrillation risk models with age for screening for atrial fibrillation. METHODS: Nine atrial fibrillation risk models were compared using the Atherosclerosis Risk in Communities study (11 373 subjects, 60.0±5.7 years old). A new risk model (Screening for Asymptomatic Atrial Fibrillation Events-SAAFE) was created using data collected in the Monitoring Disparities in Chronic Conditions study (3790 subjects, 58.9±15.3 years old). The primary measure was the fraction of incident atrial fibrillation subjects who should receive treatment due to a high CHA2DS2-VASc score identified when screening a fixed number equivalent to the age criterion. Secondary measures were the C statistic and net benefit. RESULTS: Five risk models were significantly better than age. Age identified 71 (61%) of the subjects at risk for stroke who subsequently developed atrial fibrillation, while the best risk model identified 96 (82%). The newly developed SAAFE model identified 95 (81%), primarily based on age, congestive heart failure and coronary artery disease. CONCLUSIONS: Use of a risk model increases identification of subjects at risk for atrial fibrillation. One of the best performing models (SAAFE) does not require an ECG for its application, so that it could be used instead of age as a screening criterion without adding to the cost.

Maladaptive Coping and Depressive Symptoms Partially Explain the Association Between Family Stress and Pain-Related Distress in Youth With IBD.

Objective: To extend existing research on the pain burden experienced by youth with inflammatory bowel disease (IBD) by examining the complexity of psychosocial factors involved in pain-related distress. Methods: Parents completed measures of family stress and their child's pain-related expressions of distress and coping. Youth with IBD rated their depressive symptoms (n = 183 dyads). Mediation analyses were performed using regression-based techniques and bootstrapping. Results: Greater family stress was positively related to children's pain-related expressions of distress and passive coping. Significant indirect effects were found in the relationship between family stress and expressed pain-related distress through parent-reported passive coping, depressive symptoms, and both passive coping and depressive symptoms sequentially. Conclusions: Results suggest that family stress can place children at risk for greater expressed pain-related distress through effects on coping and depressive symptoms. Addressing psychosocial difficulties is important for closing the gap between disability and health in youth with IBD.

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.

Parental Protectiveness Mediates the Association between Parent-Perceived Child Self-Efficacy and Health Outcomes in Pediatric Functional Abdominal Pain Disorder.

Previous studies have shown that parental protectiveness is associated with increased pain and disability in Functional Abdominal Pain Disorder (FAPD) but the role that perceived child self-efficacy may play remains unclear. One reason why parents may react protectively towards their child's pain is that they perceive their child to be unable to cope or function normally while in pain (perceived low self-efficacy). This study sought to examine (a) the association between parent-perceived child pain self-efficacy and child health outcomes (symptom severity and disability); and (b) the role of parental protectiveness as a mediator of this association. Participants were 316 parents of children aged 7-12 years with FAPD. Parents completed measures of perceived child self-efficacy when in pain, their own protective responses to their child's pain, child gastrointestinal (GI) symptom severity, and child functional disability. Parent-perceived child self-efficacy was inversely associated with parent-reported child GI symptom severity and disability, and parental protectiveness mediated these associations. These results suggest that parents who perceive their child to have low self-efficacy to cope with pain respond more protectively when they believe he/she is in pain, and this, in turn, is associated with higher levels of GI symptoms and disability in their child. This finding suggests that directly addressing parent beliefs about their child's ability to manage pain should be included as a component of FAPD, and potentially other child treatment interventions.

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.

Biopsychosocial Aspects of Functional Gastrointestinal Disorders.

In this paper, we provide a general framework for understanding the functional gastrointestinal disorders (FGID) from a biopsychosocial perspective. More specifically, we provide an overview of the recent research on how the complex interactions of environmental, psychological, and biological factors contribute to the development and maintenance of the FGID. We emphasize that considering and addressing all these factors is a conditio sine qua non for appropriate treatment of these conditions. First, we provide an overview of what is currently known about how each of these factors - the environment, including the influence of those in an individual's family, the individual's own psychological states and traits, and the individual's (neuro)physiological make-up - interact to ultimately result in the generation of FGID symptoms. Second, we provide an overview of commonly used assessment tools which can assist clinicians in obtaining a more comprehensive assessment of these factors in their patients. Finally, the broader perspective outlined earlier is applied to provide an overview of centrally acting treatment strategies, both psychological and pharmacological, which have been shown to be efficacious to treat FGID.

Comparative Estimates of Crude and Effective Coverage of Measles Immunization in Low-Resource Settings: Findings from Salud Mesoamérica 2015.

Timely and accurate measurement of population protection against measles is critical for decision-making and prevention of outbreaks. However, little is known about how survey-based estimates of immunization (crude coverage) compare to the seroprevalence of antibodies (effective coverage), particularly in low-resource settings. In poor areas of Mexico and Nicaragua, we used household surveys to gather information on measles immunization from child health cards and caregiver recall. We also collected dried blood spots (DBS) from children aged 12 to 23 months to compare crude and effective coverage of measles immunization. We used survey-weighted logistic regression to identify individual, maternal, household, community, and health facility characteristics that predict gaps between crude coverage and effective coverage. We found that crude coverage was significantly higher than effective coverage (83% versus 68% in Mexico; 85% versus 50% in Nicaragua). A large proportion of children (19% in Mexico; 43% in Nicaragua) had health card documentation of measles immunization but lacked antibodies. These discrepancies varied from 0% to 100% across municipalities in each country. In multivariate analyses, card-positive children in Mexico were more likely to lack antibodies if they resided in urban areas or the jurisdiction of De Los Llanos. In contrast, card-positive children in Nicaragua were more likely to lack antibodies if they resided in rural areas or the North Atlantic region, had low weight-for-age, or attended health facilities with a greater number of refrigerators. Findings highlight that reliance on child health cards to measure population protection against measles is unwise. We call for the evaluation of immunization programs using serological methods, especially in poor areas where the cold chain is likely to be compromised. Identification of within-country variation in effective coverage of measles immunization will allow researchers and public health professionals to address challenges in current immunization programs.

Health and wealth in Mesoamerica: findings from Salud Mesomérica 2015.

BACKGROUND: Individual income and poverty are associated with poor health outcomes. The poor face unique challenges related to access, education, financial capacity, environmental effects, and other factors that threaten their health outcomes. METHODS: We examined the variation in the health outcomes and health behaviors among the poorest quintile in eight countries of Mesoamerica using data from the Salud Mesomérica 2015 baseline household surveys. We used multivariable logistic regression to measure the association between delivering a child in a health facility and select household and maternal characteristics, including education and measures of wealth. RESULTS: Health indicators varied greatly between geographic segments. Controlling for other demographic characteristics, women with at least secondary education were more likely to have an in-facility delivery compared to women who had not attended school (OR: 3.20, 95 % confidence interval [CI]: 2.56-3.99, respectively). Similarly, women from households with the highest expenditure were more likely to deliver in a health facility compared to those from the lowest expenditure households (OR 3.06, 95 % CI: 2.43-3.85). Household assets did not impact these associations. Moreover, we found that commonly-used definitions of poverty do not align with the disparities in health outcomes observed in these communities. CONCLUSIONS: Although poverty measured by expenditure or wealth is associated with health disparities or health outcomes, a composite indicator of health poverty based on coverage is more likely to focus attention on health problems and solutions. Our findings call for the public health community to define poverty by health coverage measures rather than income or wealth. Such a health-poverty metric is more likely to generate attention and mobilize targeted action by the health communities than our current definition of poverty.

Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings.

BACKGROUND: Health has improved markedly in Mesoamerica, the region consisting of southern Mexico and Central America, over the past decade. Despite this progress, there remain substantial inequalities in health outcomes, access, and quality of medical care between and within countries. Poor, indigenous, and rural populations have considerably worse health indicators than national or regional averages. In an effort to address these health inequalities, the Salud Mesoamérica 2015 Initiative (SM2015), a results-based financing initiative, was established. METHODS: For each of the eight participating countries, health targets were set to measure the progress of improvements in maternal and child health produced by the Initiative. To establish a baseline, we conducted censuses of 90,000 households, completed 20,225 household interviews, and surveyed 479 health facilities in the poorest areas of Mesoamerica. Pairing health facility and household surveys allows us to link barriers to care and health outcomes with health system infrastructure components and quality of health services. RESULTS: Indicators varied significantly within and between countries. Anemia was most prevalent in Panama and least prevalent in Honduras. Anemia varied by age, with the highest levels observed among children aged 0 to 11 months in all settings. Belize had the highest proportion of institutional deliveries (99%), while Guatemala had the lowest (24%). The proportion of women with four antenatal care visits with a skilled attendant was highest in El Salvador (90%) and the lowest in Guatemala (20%). Availability of contraceptives also varied. The availability of condoms ranged from 83% in Nicaragua to 97% in Honduras. Oral contraceptive pills and injectable contraceptives were available in just 75% of facilities in Panama. IUDs were observed in only 21.5% of facilities surveyed in El Salvador. CONCLUSIONS: These data provide a baseline of much-needed information for evidence-based action on health throughout Mesoamerica. Our baseline estimates reflect large disparities in health indicators within and between countries and will facilitate the evaluation of interventions and investments deployed in the region over the next three to five years. SM2015's innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.

Eating behaviors and quality of life in preadolescents at risk for obesity with and without abdominal pain.

OBJECTIVES: We evaluated eating behaviors and quality of life (QOL) in preadolescent children at risk for obesity, with and without abdominal pain (AP). METHODS: Participants were parent-child dyads enrolled in a randomized, controlled obesity prevention trial. The children were between 5 and 10 years of age and at risk for obesity (70th-95th percentile of body mass index, n = 420). Parents completed measures of their child's eating behaviors, QOL, AP, and bowel function and their own depression status, concern about child weight, and feeding practices. Children's height and weight were also measured. RESULTS: Children with frequent AP (≥2/month, n = 103) were compared with children reporting infrequent AP (<2/month, n = 312). Age and body mass index did not differ between groups, but AP was more prevalent in girls. Child emotional overeating and parental depression scores were higher in the frequent AP group (P < 0.01), and child QOL was lower (P < 0.01). In multivariable analysis, female gender (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.20-3.97), emotional overeating (OR 2.28, 95% CI 1.37-3.81), and parental depression (OR 1.23, 95% CI 1.12-1.35) were associated with more frequent AP. Secondary analyses were completed for children who met Rome III criteria for irritable bowel syndrome. CONCLUSIONS: Clinicians working with children with AP at risk for obesity should consider assessing for and, when appropriate, addressing parent and child factors that could exacerbate AP.

Cognitive mediators of treatment outcomes in pediatric functional abdominal pain.

OBJECTIVES: Cognitive-behavioral (CB) interventions improve outcomes for many pediatric health conditions, but little is known about which mechanisms mediate these outcomes. The goal of this study was to identify whether changes in targeted process variables from baseline to 1 week posttreatment mediate improvement in outcomes in a randomized controlled trial of a brief CB intervention for idiopathic childhood abdominal pain. MATERIALS AND METHODS: Two hundred children with persistent functional abdominal pain and their parents were randomly assigned to 1 of 2 conditions: a 3-session social learning and CB treatment (N=100), or a 3-session educational intervention controlling for time and attention (N=100). Outcomes were assessed at 3-, 6-, and 12-month follow-ups. The intervention focused on altering parental responses to pain and on increasing adaptive cognitions and coping strategies related to pain in both parents and children. RESULTS: Multiple mediation analyses were applied to examine the extent to which the effects of the social learning and CB treatment condition on child gastrointestinal (GI) symptom severity and pain as reported by children and their parents were mediated by changes in targeted cognitive process variables and parents' solicitous responses to their child's pain symptoms. Reductions in parents' perceived threat regarding their child's pain mediated reductions in both parent-reported and child-reported GI symptom severity and pain. Reductions in children's catastrophic cognitions mediated reductions in child-reported GI symptom severity but no other outcomes. Reductions in parental solicitousness did not mediate outcomes. DISCUSSION: Results suggest that reductions in reports of children's pain and GI symptoms after a social learning and CB intervention were mediated at least in part by decreasing maladaptive parent and child cognitions.

The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.

IMPORTANCE: Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. OBJECTIVES: To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. DESIGN: We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. RESULTS: US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. CONCLUSIONS AND RELEVANCE: From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.