Ch i d F ti lChronic and Functional Gastrointestinal Symptoms:  Is There y p

a Magic Pill?

Contemporary Pediatrics ConferenceApril 9, 2010

H. Shashidar, MDK. Lommel, DO, MHAD. Whitehurst, ARNP

M B H ff PhDM. B. Huff, PhD

Seminar ‐ Overall Outline

• Introduction: Case volume and cost of care • Case presentation (4 cases)

– 2 “organic” as primary diagnosis and discuss mgmt• ManagementManagement 

–Medical– Psychosocial & Psychopharmacological

2 “f nctional” as primar diagnosis and disc ss– 2 “functional” as primary diagnosis and discuss management

• Management M di l–Medical

– Psychosocial & Psychopharmacological• Conclusions

Functional GI disorders The case load & costThe case load & cost

30

25

15

20 June

July

A t

10

15 August

Sep

Total

5

Total

0Abd pain dyspep Vomitng Total

Functional GI disorders Th l d &The case load & cost

404550

253035

Endoscopy

101520

Endoscopy

05

Normal Abnormal Total

Avg. reimbursement: Colonoscopy $774 EGD $ 665

CTScan $ 144-184

3 outcomes3 outcomes

• Organic EtiologyOrganic Etiology

• Psychological

i d• Mixed– Strong family hx of anxiety/depression

– “Diagnosable Disorder” (IBD)

Chronic GI Condition with Associated Psychiatric Signs/Symptoms

CASE 1D.O.

CASE 1

Case 1: D.O. (1)Case 1: D.O. (1)

• 15 year old female with intermittent bright15 year old female with intermittent bright red blood per rectum

• Other symptoms: early satiety poor energy• Other symptoms: early satiety, poor energy

• 4 year history of sacro‐iliac pain on NSAIDs 

• Co morbid rheumatoid arthritis 

• Exam remarkable for peri‐anal skin tags, p g ,fistulous opening and pain on digital examination 

D.O. (2)D.O. (2)

• Psychiatric Symptoms & IssuesPsychiatric Symptoms & Issues– Suicidal Ideation

Depression– Depression

– Weight Gain

S l A lt 2– Sexual Assault 2 years ago

– Victim of bullying (recent)

D.O. (3)D.O. (3)

• Laboratory evaluation :Laboratory evaluation :

ESR 42

CCRP 15.7

Hb/Hct 10.6/33

July : Upper and lower endoscopy confirmed inflammatory bowel disease – Crohnsy

D.O. (4)D.O. (4)

• Treated for one month with Pentasa with littleTreated for one month with Pentasa with little improvement

• September ‘08: Started Humira ( Adalimumab)September  08: Started Humira ( Adalimumab) 1 ½  months after diagnosis with rapid improvement in symptoms

• Weight gain 10# since diagnosis• December ‘08: Discontinued medicationsDecember  08: Discontinued medications• February ‘09: Inpatient admission in psychiatric unit for depressionpsychiatric unit for depression

D.O. (5)D.O. (5)

• April ’09: restarted medicationsApril  09: restarted medications• May ‘09: sporadic compliance with medicationsmedications

• June ‘09: complete refusal to take medications; further weight gain 10#.medications; further weight gain 10#. 

• October ‘09: Doing well despite bout of C difficile colitisC difficile colitis 

• February ’10: doing well not taking medications for a monthmedications for a month 

Chronic Condition with associated hPsych Symptoms

• Presence of a diagnosable disorderPresence of a diagnosable disorder

• Specific therapy for the disorder exists

i l / i• Treatment is long term / ongoing

• Compliance is key

Crohn’s as a model of chronic diseaseCrohn s as a model of chronic disease

• Persistent and progressive

• Periodic exacerbation

• Impact on quality of life 

• Cost burden• Cost burden

• Controlled but not ‘cured’ 

• Association with other chronic illnesses

Impact of disease on QOLImpact of disease on QOL

• Worsening disease leads to worse QOL inWorsening disease leads to worse QOL in adults,

• But may not be so in children!• But may not be so in children! 

• Adolescents are more affected than younger hildchildren

Impact of Disease on QOL: Children & adolescents*Children & adolescents*

• Areas of concern:Bowel symptomsBody image & weighty g gOstomyTransition to college/ young adulthoodTransition to college/ young adulthood

Less so: steroids hospital admission and length Less so: steroids, hospital admission and length of disease

*Inflam Bowel Disease 2009 Epub

Ch i GI C diti ith A i t d P hi t iChronic GI Condition with Associated Psychiatric Signs/Symptoms

H.S.

CASE 2

S

CASE 2

Case 2: H.S.Case 2:  H.S.

8/078/07

• 6 year old with 2 year history of abdominal pain sporadic vomitingpain, sporadic vomiting

• Suspected constipation and started stool fsofteners

• Started soiling 6 months ago.

• Problems with constipation with school 

• No other medical problemsNo other medical problems

H.S. (2)

• Encopresis persists despite aggressive glycolaxEncopresis persists despite aggressive glycolax regimen at home.

• 12/07 and 2/08 : inpatient clean out• 12/07 and 2/08 :  inpatient clean out 

• Lost to follow up until 7 months later when he d i h i f l ilipresented with persistent fecal soiling.

H.S. (3)( )

• History includes apparent inattention to urge toHistory includes apparent inattention to urge to defecate and not apparently bothered even after  a soiling incident

• 4/08 : A second inpatient clean out 

• Given lack of improvement, also underwent a pBarium enema and MRI spine – both normal

• Referral to child psychology for behavioral therapy

• 9/08 – grandmother reports doing well; Mom not involved at this point. No or minimal soiling

H.S. (4)H.S. (4)• 2/09 follow up: refractory soiling

• Mom enters child’s life; father released from prison and considers taking child but eventually declines. Multiple social stressors and abusive situation had been identified in the interim generating a DCBS referral

• 6/09 follow up : he is now under state / pcustody under care of grandmother 

• 10/09 follow up :persistent improvement10/09 follow up :persistent improvement

P i t t d !

• Persistent symptoms generated additional

Points to ponder!

Persistent symptoms generated additional testing

• Medical therapy was completely ineffective• Medical therapy was completely ineffective

• Improvement occurred only after appropriate l i d i dd hevaluation and action to address psycho ‐

social situation 

Impact of psychosocial function on p p ydisease

• Psychosocial function may be independent ofPsychosocial function may be independent of disease activity

• Depression may be associated with more relapse in adults*

• Adolescents with IBD more depressed than children ith th di **with other diseases** 

• Adolescents coping better have better QOL†

*Am J Gastroenterol 2002; 97:1994**JPGN 2004;39:395†Qual Life Res 2004;13;1011

Impact of psychosocial functioning on ddisease management

• Coping skills = improved outlook

• Illness perception predicts adjustment to IBDIllness perception predicts adjustment to IBD

• Lack of control & lack of functional independence also affect diseaseindependence also affect disease management 

Abdominal Pain as Manifestation of Psychiatric Issues

R.J.

CASE 3

J

CASE 3

RJ (1)RJ (1)

• 12 yo WF with history of retching, vomiting12 yo WF with history of retching, vomiting and constipation 

• Symptoms began April 2009Symptoms began April 2009• Resolved over the summer• Returned August 2009• Returned August 2009• Poor school attendance

Missed last 2 months of school (‘08 ’09)– Missed last 2 months of school ( 08‐ 09)– Missed all but 2‐3 weeks of school (‘09‐’10)

• Multiple care providers involved• Multiple care providers involved 

RJ (2)RJ (2)

• Recurrent episodes of morning vomiting with p g gabdominal cramping.

• Irregular bowel habits with history of constipation.• Fall of 2009

– Continued to present to multiple care providersMRI f h d ( HA & iti ) NORMAL• MRI  of head (re: HA & vomiting) ‐ NORMAL

• KUB revealed stool impaction> bowel cleanout and addition of laxative to stool softener.

• EGD 9/9/09 revealed only nonspecific inflammation in area of GE junction: plan was to continue PPI and cyproheptadine for CVS.yp p

RJ (3)RJ (3)

• Re‐evaluated 2 months  later for recurrence of vomiting and abdominal pain– Constipation resolved. 

• Differential Diagnoses  – Cyclic Vomiting SyndromeCeliac Disease– Celiac Disease

– Functional Abdominal Pain

• Referral to therapist for Cognitive BehavioralReferral to therapist for Cognitive Behavioral Therapy 

RJ (4)RJ (4)

• Continued school absence, multiple phoneContinued school absence, multiple phone calls/visits to Adolescent Medicine and Peds GI to report symptoms – Questioning legitimacy of reported symptoms.

• 3 day hospital admission– Mother’s visitation limited to 2 hours/day

– Munchausen by Proxy suspected

– General Peds team consulted Child Psychiatry• Nursing staff to document retching, vomiting and behavioral interactions with the mother/child 

RJ (5)RJ (5)

• Timelinee e– 9/9/09  EGD

– 9/17/09 Eye exam for “blackouts”

– 9/24/09 OB/GYN Eval

– 9/24/09 Adol Med for blackouts

– 9/28/09 Holter monitor x 48hrs– 9/28/09 Holter monitor x 48hrs

– 10/2/09 Neurology for headaches

– 10/9/09 “sprained thumb” to UTC

– 10/9/09 Topomax started for headaches

– 10/22/09 GI & PCP seen in same day

RJ (6)RJ (6)

• StressorsStressors– Bullying

• “He stabbed me with a shank”

• Holter Monitor

• Pushing

• Sleep overSleep over

• Bus ride home

– Death of loved ones

– Stepmom

RJ (7)RJ (7)

• PMH

– Acute Illnesses: Retching/Cyclic Vomiting

– Chronic Illnesses: Migraine HA, Reflux, Constipation

– Surgeries: 2 ankleSurgeries: 2 ankle 

– Meds in past 6‐9 months:

• Topamax, Phenergan, Zofran, Excedrin, Z‐pack, Propranolol, Prilosec Claritin Elavil Miralax Coenzyme Q10Prilosec, Claritin, Elavil, Miralax, Coenzyme Q10

• Review of Systems:

– Cardiac 

– GI

RJ (8)RJ (8)

• Family Psychiatric History– Depression

• Maternal Grandfather– “sick all the time” – “has brain tumor” 

– Anxiety• Mom

– Substance Abuse• + Nicotine – all members (all 4 parents)• Step Father drinks 1‐2 beers daily.p y

– Bullying• Mom (victim)

Abdominal Pain as Manifestation of Psychiatric Issues

G.N.

CASE 4

G

CASE 4

Case Presentation 4: GNCase Presentation 4: GN

• 12 y/o referred to PGI for 2nd opinion related to y ppersistent severe nausea and vomiting and parental disbelief of recommendations.

• Prior evaluation (Cincinnati Children’s Hospital GI andPrior evaluation (Cincinnati Children s Hospital GI and an outside community hospital surgeon):CT abdomen Lab evaluation Meckel’s Scan HIDA Scan

UnremarkableHIDA Scan SBFT

Case Presentation 4: GNCase Presentation 4: GN

• CCHMC PGI evaluation recommended CBTCCHMC PGI evaluation recommended CBT.

• Surgical evaluation resulted in laparoscopic appendectomy with normal appendixappendectomy with normal appendix

Case 4: GNCase 4: GN

• Differential diagnosis IBS‐Constipation vsDifferential diagnosis IBS Constipation vs. Rumination Syndrome due to absence of weight loss and nocturnal symptomsweight loss and nocturnal symptoms.

• Recommendation made for Cognitive Behavioral Therapy with relaxationBehavioral Therapy with relaxation techniques.

EGD 1/10 l d l i fl i f• EGD 1/10 revealed only inflammation of gastric cardia so PPI was prescribed.

Case 4: GNCase 4: GN

• Parent’s report regarding frequency of  symptoms p g g q y y pduring the visit was inconsistent: worsening of gagging and nausea on PPI Vs rare symptoms vs nonstop symptoms??p y p

• Parent’s report of CBT evaluation did not correlate with Dr Huff’s documentationR d d i iti ti f it i t li f• Recommended initiation of amitriptyline for functional symptoms, after EKG @ PCP office documented as normal.

• Family did not follow‐through with recommendations.

Chronic Abdominal Pain‘ d fl ’‘Red flags’ 

• Recurrent significant vomiting or dysphagiag g y p g• GI bleeding: hematemesis or melena• Localized pain or tenderness/mass palpable, especially RUQ & RLQespecially RUQ & RLQ

• Weight loss/ slowed growth• Nocturnal symptomsNocturnal symptoms• Unexplained fever, anorexia• Family history of Inflammatory bowel disease

Common functional GI disordersCommon functional GI disorders40

30

Functional constipation

Functional Abdominal Pain Syndrome (FAPS)

20

% total children

% children with FGID

Infant regurgitation

Dyspepsia

IBS

Functional Fecal RetentionFunctional Fecal Retention (FFR)

Functional Diarrhea (FD)

Cyclic Vomiting Syndrome 10(CVS) 

0Constipan FAPS Regurg Dyspep IBS FFR CVS Diarrhea

Suggested evaluation in pediatric GI Syndromes 

Pediatrics. 2010 Jan;125(1):e155‐61. Epub 2009 Dec 14.Syndrome Laboratory evaluation Imaging/Endoscopy

Infant regurgitation None None

Functional constipation None None

Functional dyspepsia Lipase Amylase UltrasoundFunctional dyspepsia Lipase, Amylase

tTG antibody, AST/ALT

Ultrasound

FAPS CBC, ESR, Urine analysis, O & P, tTG antibody

Abdominal ultrasound

IBS As above Colonoscopy with warning symptoms

Functional fecal retention None NoneFunctional fecal retention None None

Functional diarrhea None mandatory

Cyclic vomiting syndrome  CBC, CMP, Lipase, lactate, pyruvate, CPK, NH3, Venous blood gas

Endoscopy, ultrasound, MRI etc

Psychosocial history Diagnostic valueDiagnostic value

• Anxiety, depression or behavior problems ‐do not distinguish between FAPS & other causes g(evidence quality B).

• Compared to healthy community controls, children with RAP have:with RAP have:↑ anxiety and depression (internalizing emotional symptoms)In contrast, no increased conduct disorder & oppositional behavior (externalizing emotional symptoms)symptoms)

Chronic Abdominal Pain In Children: A Technical Report of the AAP and the NASPGHANthe AAP and the NASPGHAN JPGN 40:249–261 March 2005

Diagnostic value of psychosocial historyDiagnostic value of psychosocial history

• Do emotional/behavioral symptoms predict severe sx, course or response to treatment?to treatment? No data (evidence quality D). 

• Are children with recurrent abdominal pain at risk of later emotional symptoms and psychiatric disorders? y p p yYes (evidence quality B). 

• Do parents of patients with recurrent abdominal pain have more anxiety, depression and somatization than parents of other pediatric patients ? 

( d l )Yes (evidence quality C). • Do families of patients with recurrent abdominal pain differ from other 

families in broad areas of family functioning, such as cohesion/ conflict/ marital satisfaction ? No (evidence quality C)

Chronic Abdominal Pain In Children: A Technical Report of the AAP and theChronic Abdominal Pain In Children: A Technical Report of the AAP and the NASPGHAN JPGN 40:249–261 March 2005

Functional GI disorder in children:b i di i d l ibarriers to diagnosis and evaluation

• A study among 151 children with FAPA study among 151 children with FAP, positive attention and activity restriction predicted symptom maintenance at 2 weekspredicted symptom maintenance  at 2 weeks from illness

W lk LS Z JL P l hild ill b h i J P diWalker LS, Zeman JL. Parental response to child illness behavior. J Pediatr Psychol 1992;17:49–71.

Functional GI disorder in children:b i di i d l ibarriers to diagnosis and evaluation

• ‘‘Pain is real’’ : struggle between showing sympathy and ignoring the pain, worry about the pain intensity.  Parents want clinician to identify a medical cause

• ‘‘Worry about coping’’ : Inability of parents to know how toWorry about coping : Inability of parents to know how to cope with their child’s symptoms. Feel inadequate and frustrated because they are unable to help their child with painpain 

• ‘‘Desire for care’’ : – focuses on the need for diagnosis, treatment, and care 

t i t f t ti b t t i i th d i d i t– taps into frustrations about not receiving the desired or appropriate medical care. 

– Parental expectations that the physician can find a cause (whether physiological or psychosocial) and cure the painphysiological or psychosocial) and cure the pain. 

MANAGEMENTMANAGEMENT

ManagementManagement

• Levels of evaluationsLevels of evaluations– PCP

OSH– OSH

– UK

R i t– Rsi;ts

Functional GI disorder in childrenlSolutions 

• Pain is real :  acknowledge pain is real and then g pdistract. Pain is disabling, not the underlying pathology

b h l f l• Worry about coping: help families regain some control over the pain by– identifying helpful medicationsidentifying helpful medications,– teaching coping strategies such as distraction,– providing clear strategies as to when to keep the child

out of school, when to use medications, ‐ when to contact a physician immediately or for a regular appointmentappointment

Functional GI disorder in childrenlSolutions …

• Desire for care:Desire for care: 

Important for the provider to give patients control over the paincontrol over the pain 

make them responsible for their care, 

establish clear expectations of the treatment goals and shared responsibility. 

The focus is symptom management, not cure.

Functional GI disorder in childrenSolutions …

• Reassurance that the pain can be managedReassurance that the pain can be managed

• Education:  Altered brain‐gut connection, potential longevity of FAPpotential longevity of FAP 

QUESTIONSQUESTIONS

• Don’t be afraid to ask the “scary questions”Don t be afraid to ask the  scary questions– Have a plan in mind for what you’re going to do with the answers before asking the questionwith the answers before asking the question

• How do YOU deal w/patient seeing in office for abd pain x 6 wks no school anxiety notedfor abd pain x 6 wks, no school, anxiety noted

• How to approach in office?  

Screening and guidelines for referral– Screening and guidelines for referral• Pediatric Symptom Checklist (Parent/Youth)

• http://www.cincinnatichildrens.org/svc/alpha/c/special‐needs/resources/mental‐health.htm#tools

How to “Open the Door”How to  Open the Door

• Parent and Child complete the PediatricParent and Child complete the Pediatric Symptom Checklist (PSQ)– Score >28 (ages 6 16)– Score >28 (ages 6‐16)

– Score > 24 (ages 4‐5)• Psychological Impairment• Psychological Impairment

– Look for discrepancies between child/parent reports….DISCUSSreports….DISCUSS

Pediatric Symptom Checklist (Parent Version)

Never  Sometimes  Often

• 1 Complains of aches and pains• 1. Complains of aches and pains  _______ _______ _______

• 2. Spends more time alone  _______ _______ _______

• 3. Tires easily, has little energy  _______ _______ _______

• 4. Fidgety, unable to sit still     g y, _______ _______ _______

• 5. Has trouble with teacher  _______ _______ _______

• 6. Less interested in school  _______ _______ _______

• 7. Acts as if driven by a motor  _______ _______ _______

• 8. Daydreams too much  _______ _______ _______

• 9. Distracted easily  _______ _______ _______

• 10. Is afraid of new situations  _______ _______ _______

• 11 Feels sad unhappy• 11. Feels sad, unhappy  _______ _______ _______

• 12. Is irritable, angry _______ _______ _______

• 13. Feels hopeless  _______ _______ _______

• 14. Has trouble concentrating  _______ _______ _______g _______ _______ _______

• 15. Less interested in friends  _______ _______ _______

Pediatric Symptom Checklist (Youth Version)

Never Sometimes Often

• 1. Complain of aches or pains   _______ _______ _______

• 2. Spend more time alone  _______ _______ _______

• 3. Tire easily, little energy  _______ _______ _______

• 5 Have trouble with teacher• 5. Have trouble with teacher  _______ _______ _______

• 6. Less interested in school  _______ _______ _______

• 10. Are afraid of new situations  _______ _______ _______

• 11. Feel sad, unhappy  _______ _______ _______ppy _______ _______ _______

• 12. Are irritable, angry  _______ _______ _______

• 13. Feel hopeless  _______ _______ _______

• 14. Have trouble concentrating  _______ _______ _______

• 15. Less interested in friends  _______ _______ _______

• 16. Fight with other children  _______ _______ _______

• 17. Absent from school  _______ _______ _______

• 18 School grades dropping• 18. School grades dropping  _______ _______ _______

• 19. Down on yourself  _______ _______ _______

Management Issues ( h l l)(Non‐pharmacological)

• Bullying (KL)Bullying (KL)

• Family Transitions (KL)

( )• Past Trauma (KL)

• Peer Interactions (MH)

• Parental Expectations (MH)

• Parental Anxiety (MH)Parental Anxiety (MH)

Role of Primary Care ProviderRole of Primary Care Provider

• Never underestimateNever underestimate– YOUR ability to understand the family dynamics contributing to the problemcontributing to the problem

– The power of YOUR words 

• Always keep in mind that if the lab results are• Always keep in mind that if the lab results are abnormal….what will you do then?

I i ff f i• Iatrogenic effects of unnecessary testing – Physical and psychological

DEFINITION OF BULLYINGDEFINITION OF BULLYING

• BullyingBullying

A i b h i th t i i t ti l t d– Aggressive behavior that is intentional, repeated over time, and involves an imbalance of power or strengthstrength.

Child who is being bullied has a hard time– Child who is being bullied has a hard time defending himself or herself.

TYPES OF BULLYINGTYPES OF BULLYING• Physical

• Verbal

• Non‐verbal / Emotional

• Cyberbullying

*Taken from an i-SAFE America survey of students nationwide.

STATISTICSSTATISTICS

• Most studies show that 15‐25% of American students are bullied with some frequency (i.e., “sometimes or more often). (Melton et al., 1998; Nansel et al., 2001). 

STATISTICSSTATISTICS

A di t th l t t S t S i S fAccording to the latest Secret Service Safe School Initiative, almost 75 percent of students who used violent weapons at school (e.g., guns or knives) to attack ( g , g )others felt persecuted, bullied, threatened, attacked, or injured by others prior to the incident

EARLY EFFECTSEARLY EFFECTS

• VICTIMS:• VICTIMS:– Psychological distress

• Anxious avoidance of settings in which bullying may occur. • Suicidal thoughts• Feelings of Anger & Depression• Feelings of Anger & Depression• Low self esteem

– Physical Distress• Greater incidence of illness 

I t d i ti b lli d k i d h lth f tl• In one study, victims bullied once a week experienced poorer health, more frequently contemplated suicide and suffered from:

– Depression

– Anxietyy

– Social Dysfunction

– Insomnia

INDIVIDUALS INVOLVEDINDIVIDUALS INVOLVED• Active Role

– Bully, Victim, Bully‐victim, Reinforcer/ Assistant to Bully, Defender of the Victim

• Passive Role• Passive Role– Bystanders/ Outsiders

Family TransitionsFamily Transitions

• DivorceDivorce

• Death

i h f Sibli• Birth of Sibling

Past TraumaPast Trauma

• Physical AbusePhysical Abuse

• Sexual Abuse

i i l• Domestic Violence

• Neglect

• Loss of Loved one due to injury or trauma

“Chicken or the Egg”Chicken or the Egg

• Depression with underlying medical conditionDepression with underlying medical condition (Crohn’s, SLE….)

• Anxiety with underlying medical condition• Anxiety with underlying medical condition

VERSUSVERSUS

• Abdominal pain as manifestation of depression or anxiety

Management( h h l l)(Psychopharmacological)

• AntidepressantsAntidepressants– SSRI’s

SNRI’s– SNRI s

– TCA’s

A i l ti• Anxiolytics– Hydroxyzine

– Benzodiazepines

AntidepressantsAntidepressants

• Serotonin‐Norepinephrine Reuptake InhibitorsSerotonin Norepinephrine Reuptake Inhibitors (SNRIs)– Duloxetine (Cymbalta) SNRI– Duloxetine (Cymbalta) ‐ SNRI

• FDA approval – MDD, GAD, DPN (diabetic peripheral neuropathy) and Fibromyalgia (ALL in adults) 

– Off‐label use in children and adolescents

» Juvenile Primary Fibromyalgia Syndrome» Juvenile Primary Fibromyalgia Syndrome

» IBD is part of 10 minor Yunus and Masi Criteria

– Side Effects• GI upset (often reason to d/c)

Antidepressants (2)Antidepressants (2)

• SNRIs (cont’d)SNRIs (cont d)– Venlafaxine (Effexor XR)

• Increased tolerabilityIncreased tolerability

• Key side effect to monitor – elevated BP

Antidepressants (3)Antidepressants (3)

• Serotonin Selective Reuptake InhibitorsSerotonin Selective Reuptake Inhibitors– Citalopram (Celexa) and Escitalopram (Lexapro)

Sertraline (Zoloft)– Sertraline (Zoloft)

– Fluoxetine (Prozac)

P ti (P il)– Paroxetine (Paxil)

AnxiolyticsAnxiolytics

• Sometimes necessary to get child back toSometimes necessary to get child back to school

• Just knowing “something” is there helps!• Just knowing  something  is there helps! 

• First Generation Antihistamine– Hydroxyzine (Atarax, Vistaril)

• Benzodiazepines– Clonazepam (Klonopin)

– Diazepam (Valium)p ( )

Cognitive‐Behavior TherapyCognitive Behavior Therapy

• Cognitive‐behavioral family interventionsCognitive behavioral family interventions address dysfunctional perceptions of bodily sensations and maladaptive illness conceptssensations and maladaptive illness concepts, provide coping strategies for episodes of pain, reduce secondary gain that reinforces painreduce secondary gain that reinforces pain behaviors and try to reestablish the psychosocial functioning of the childpsychosocial functioning of the child.  

Cognitive‐Behavior TherapyCognitive Behavior Therapy

• Use diaries to record the pain experiencesUse diaries to record the pain experiences (connect pain experiences with associated circumstances)circumstances) 

• Reinforce well behaviors and promote distracting behaviors have ewer pain reportsdistracting behaviors have ewer pain reports over time

Teaching Self‐RegulationTeaching Self Regulation

• Relaxation techniquesRelaxation techniques

• Guided imagery for abdominal pain 

S lf h i• Self‐hypnosis

• Yoga 

• Meditation

• BiofeedbackBiofeedback 

Considerations of the parental roleConsiderations of the parental role

• Research emphasizes the importance of the families’ illness concepts Whether parentsfamilies  illness concepts.  Whether parents consider psychological causes of the child’s abdominal pain has been found to beabdominal pain has been found to be correlated with children’s recovery from severe chronic abdominal pain (C h ll lsevere chronic abdominal pain (Crushell et al., Pediatrics 2003; 112: 1368‐1372)

Considerations of the parental roleConsiderations of the parental role

• Refusal to utilize psychological services, unwillingness to acknowledge psychosocialunwillingness to acknowledge psychosocial influences on symptoms and frequent utilization of the health care system wereutilization of the health care system were described as risk factors for continued pain and failure to normalize in daily functioningand failure to normalize in daily functioning (Lindley et al.,  Arch Dis Child 2005: 90: 332‐333)

Considerations of the parental roleConsiderations of the parental role

• Somatization : Tendency to experience and i i hcommunicate somatic symptoms that are 

unaccounted for by pathological findings, to attribute these to physical illness & seek medical helpthese to physical illness & seek medical help.  

• For children, this construct may be modified to a perspective encompassing the whole familyperspective encompassing the whole family, especially the role of the caregivers in the process of somatization

Lipowski (1988) (Campo & Fritz, Psychosomatics 2001; 42: 467‐476)

Psychosocial InterventionPsychosocial Intervention

Parental Response Child ResponseParental Response

• Concerned & Fearful

• School excused by parents

Child Response

• Pain Worsens 

• Pain worsens; When painSchool excused by parents Pain worsens; When pain eases, child does not notify parent

b l l f• Mom brings home a “treat” • Verbal complaints of pain increase based on the reward structure

• Parent use distraction activities to manage verbal

Pain complaints decreaseactivities to manage verbal complaints of pain 

Parental AnxietyParental Anxiety

• During the management phase parents need:During the management phase, parents need: – To receive information

Assurance– Assurance

– To be comfortable

T b th ti t– To be near the patient 

– Identify one treatment provider to serve as contact to the familycontact to the family

Peer InteractionsPeer Interactions

• During the middle school years, same‐age peerDuring the middle school years, same age peer relationships become paramount.  When disturbed or dysfunctional, children may suffer from:  

– Lower levels of social self‐esteem (perceived non‐acceptance by )peers)

– Low levels of social interaction (homebound instruction) 

– Higher levels of social anxiety

– Elements of fear and power in same‐age peer  relationships (bullying)