“My tummy hurts” is one of the most common complaints of childhood. Yet for up to 25 percent of school-age children, ongoing abdominal pain is serious enough to interfere with school, playtime and family life. In most of these cases, there are no medical problems— and reassurance and support are all the child needs.
For children whose pain persists, however, a new review of the research suggests that cognitive behavioral therapy (CBT) can help.
“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,” said Angela Heurtas-Ceballos, consultant neonatologist at Elizabeth Garrett Anderson Hospital in London, and lead review author.
The review examined six studies including 167 children, but only five of the studies had interpretable results that the researchers could use.
The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
“To my knowledge, this is the most thorough and exhaustive review so far on this topic,” says Charlotte Rask, M.D., a trainee in child psychiatry at Aarhus University Hospital in Denmark who was not associated with this review. Rask co-authored an earlier review of the data published in a Danish journal.
“There are surprisingly few randomized controlled trials in this area considering the number of children with this problem,” Rask said.
Because of the small number of patients in the trials and the fact that the control groups included various other treatments, the new review could not quantify how effective CBT is for this condition.
Previous findings indicate that cognitive behavioral therapies help with other types of pain, but the effectiveness of CBT for this condition does not mean that the pain is really “all in the child’s head.”
“In recurrent abdominal pain cases, there is evidence that the pain is real,” said Huertas-Ceballos, adding, however, that, “Although the main organic cause is still not clear, it seems like there is an important mental component.”
In fact, recent research has shown that the gut actually has a “brain” of its own. For example, most of the body’s serotonin (the chemical best known for targeting by Prozac and similar drugs) is in the nerves in the bowels, not the brain. There are more nerve cells in the “gut brain” than in the spinal cord.
Many now believe that bowel disorders relate to problems with this system and its interaction with the brain itself. Such problems could be a factor in some recurrent abdominal pain, which could be a type of “abdominal migraine.” Another possible diagnosis is irritable bowel syndrome. Still, in most cases, there is no known pathology related to the source of the pain.
So how does CBT work for recurrent abdominal pain?
“This technique shows some evidence of benefit mainly because pain eases when the muscle relaxes, and this therapy includes relaxation or distraction techniques,” Huertas-Ceballos said.
In addition, some research finds that parental anxiety has a connection with the development of recurrent abdominal pain. One study found that an important difference between people who seek help for the problem and those who do not was the mother’s concerns about the child’s pain, not its actual intensity or frequency.
Further research found that ongoing maternal anxiety over the condition related to its persistence; in other words, the more worried the mothers were, the longer the child was likely to suffer with the problem.
Consequently, “Working with parents as well as the child may be very important,” Rask said.
In most of the studies reviewed, both parents and children received CBT. In order to prevent the children from focusing on their pain to get extra attention and affection, the clinicians instructed parents to avoid “reinforcing” the pain in this way. Instead, parents learned to give positive attention when the child copes well.
Many affected children worry that the pain means that something is seriously wrong with them — perhaps because of their parents’ anxieties over it. This fear can enhance their pain. In this context, CBT teaches parents to reassure their children and encourages the children to reassure themselves that this pain is not a sign of danger or injury. The kids also learn relaxation techniques and ways of distracting themselves when it occurs.
Said Huertas-Ceballos, “Different components are used to achieve change, such as teaching the child pain management techniques and training the parents to be ‘coaches,’” who remind them to use these tactics when the pain occurs.”
Reference: Heurtas-Ceballos A, et al. Psychosocial interventions for recurrent abdominal pain (RAS) and irritable bowel syndrome (IBS) in childhood (Review). Cochrane Database of Systematic Reviews 2008, Issue 1.
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