Functional abdominal pain (FAP) within the context of internalizing disorders in childhood; A randomized controlled cognitive-behavioural family intervention.

Abdominal pain (AP) in children is ranked in the top five of visits to the general practitioner and cross-sectional functional AP (FAP) is reported to occur in 7-25% of the school age population. In these children significantly higher scores for internalizing emotional symptoms (depression and anxiety) are observed and studies suggest that ‘little bellyachers’ grow up to suffer from psychiatric ailments as adults.
We hypothesize that cognitive behavioural family treatment (CBT) will be more effective compared to medical care (MC) in regard to the perception of FAP and resolution of co morbid internalizing psychopathology.
To study this we will enrol 100 patients (2x50/30 months) with moderate to severe FAP, including children with comorbid anxiety and/or depression and examine the effect on the severity of FAP and changes in disability, anxiety and depressive symptoms. Also, a number of mediators and moderators of the treatment effect will be studied.

1. Cognitive behavioural family treatment (CBT) will be more effective compared to medical care (MC) in decreasing the abdominal pain and improving secondary outcomes (less comorbid internalizing psychopathology, less other somatic complaints, less functional disability, higher quality of life, less school absenteeism, less health care use).

2. The following factors will mediate the treatment effects: negative thoughts about pain, coping with pain, experienced control over pain, selective attention to pain, parental reactions to pain.

3. The following moderators will influence the treatment effects: emotion awareness, negative life-events, general coping skills, control over anxious feelings, anxiety sensitivity and selective attention to anxiety, modeling.

1. Prior to treatment

2. 2-3 weeks after treatment

3. 6 months after treatment

4. 12 months after treatment

MC:

In line with the current practice of pediatricians in treating children with FAP:
supportive physician-patient relationship and empathy for the family with reassurance that no serious disease is present. Dietary advice will be offered (f.i. fiber intake). If necessary pharmacological agents can be prescribed (laxative medication, spasmolytic drugs, H2 blockers or PP-inhibitors). No referrals to psychotherapist and/or hypnotherapist will take place and no ‘alternative’ medical therapy (such as acupuncture, homeopathy) will be prescribed.

MC will be offered in the same frequency as the CBT will take place.



CBT:

Six treatment sessions with the patient and at least one with the parents that will contain:

1. information about the treatment model (influence of cognitions and behaviour on the pain experience);

2. learning pain management techniques (relaxation, breathing, imagery, physical exercises);

3. discussing dysfunctional cognitions (learning helping thoughts in stead of catastrophizing thoughts) if applicable;

4. changing parent’s dysfunctional behaviour, if applicable;

5. changing children's dysfunctional behaviour, if applicable (f.i., school absence).
The content of the modules are described in detail in a protocol ‘CBT for FAP’.




During this period no outpatient visit to the pediatrician will take place. Also no other referrals (such as hypnotherapy or ‘alternative’ medical therapy (such as acupuncture, homeopathy) will be initiated.