Guts over fear : internet therapy for abdominal pain in children

Abstract

Background: Pediatric functional abdominal pain disorders (FAPDs) are prevalent and associated with painful symptoms, low quality of life, and functional impairments. The origin is likely multifactorial and includes psychological factors (e.g., anxiety and coping mechanisms), biological factors (e.g., visceral sensitivity and gut microbiota), and social factors (e.g., interaction with parents or teachers). There is limited support for dietary and pharmacological treatments in FAPDs, but support for the effectiveness of cognitive behavioral therapy (CBT) is growing.

Aims: The overall aim of the thesis was to develop and evaluate a therapist-supported exposure-based CBT for children 8-12 years with FAPDs, which could, if proven effective, increase accessibility of treatments for children with FAPDs. The specific aims were to: - Assess feasibility, acceptability, and potential effectiveness of the preliminary protocol of exposure-based CBT in a face-to-face setting (Study I). - Assess feasibility, acceptability, and potential effectiveness of the exposure-based CBT converted to an internet platform (Internet-CBT, Study II). - Evaluate effectiveness and cost effectiveness of the Internet-CBT compared with treatment as usual (Study III). - Investigate if gastrointestinal-specific anxiety and avoidance behaviors mediated a change in gastrointestinal symptoms in Internet-CBT compared with treatment as usual and if baseline values of the proposed mediators moderated the mediation (Study IV).

Methods: All participants were children 8-12 years with FAPDs referred to the studies by their physicians. Treatment consisted of therapist-supported exposure-based CBT, delivered face-to-face (Study I) or online (studies II-IV) along with parental sessions or modules. All measures were self-assessed by children and parents. Primary outcome was pain intensity (Study I) and gastrointestinal symptoms (Study II-IV). Secondary outcomes included quality of life, school absence, anxiety, and parental responses to their children´s symptoms (Studies I-III), cost effectiveness and parental catastrophizing (Study III), gastrointestinal-specific anxiety (Study II-IV), and avoidance behavior (Study I-IV). Statistical analyses used to test within- and between-group effects were t-tests (Study I) and multi-level linear mixed models (Study II and III). Differences in costs between groups were assessed with generalized linear models (Study III). Univariate and multivariate growth models were used to assess mediation and moderated mediation (Study IV).

Results: Therapist-supported exposure-based CBT, delivered face-to-face or online, rendered high adherence and treatment completion (Study I-III). Participating children and parents were satisfied with the treatment and perceived it to be helpful in dealing with abdominal symptoms (Study I-III). There were significant treatment effects in gastrointestinal symptoms, quality of life, gastrointestinal-specific anxiety, avoidance behavior, anxiety, parental catastrophizing, and parental responses to their child’s symptoms for Internet-CBT when compared with treatment as usual (Study III). Internet-CBT was found to be cost effective and even cost saving compared with treatment as usual (Study III). A reduction in gastrointestinal-specific anxiety and avoidance behavior mediated a reduction in gastrointestinal symptoms for children receiving Internet-CBT compared with children receiving treatment as usual (Study IV). Baseline values of gastrointestinal specific-anxiety and avoidance behavior moderated the mediation (Study IV).

Conclusions: Internet-CBT based on exposure exercises and parental support for children with FAPDs is feasible, acceptable, clinically effective, and cost effective compared with treatment as usual. Gastrointestinal-specific anxiety and avoidance behavior are potential mechanisms of change in exposure-based Internet-CBT compared with treatment as usual. Internet-CBT seems to be particularly effective for children with high levels of gastrointestinal-specific anxiety and avoidance behaviors. The treatment has the potential to increase the availability of evidence-based treatments a large group of children with FAPD.