Publications by authors named "Lynn S Walker"

91 Publications

Does Quantitative Sensory Testing Improve Prediction of Chronic Pain Trajectories? A Longitudinal Study of Youth with Functional Abdominal Pain Participating in a Randomized Controlled Trial of Cognitive Behavioral Treatment.

Clin J Pain 2021 Jun 30. Epub 2021 Jun 30.

Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN Department of Psychology and Human Development, Vanderbilt University, Nashville, TN Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.

Objectives: Youth with functional abdominal pain (FAP) experience significant pain-related distress and functional impairment. Although quantitative sensory testing protocols have identified alterations in pain modulatory systems that distinguish youth with FAP from healthy controls, the extent to which evoked pain responses predict subsequent trajectories of pain symptoms and disability over and above established psychosocial risk factors is unclear.

Methods: The present study included 183 adolescents with FAP who were enrolled in a randomized controlled trial comparing an 8-week, internet-delivered program of cognitive behavior therapy (n=90) or pain education (n=93). Participants completed a quantitative sensory testing protocol prior to the intervention and were followed for 12-months post-treatment.

Results: Whereas adolescents with FAP who exhibited stronger baseline conditioned pain modulation reported decreases in pain-related interference over follow-up (b=-0.858, SE=0.396, P=0.032), those with weaker conditioned pain modulation exhibited high, relatively stable levels of pain-related interference over time (b=-0.642, SE=0.400, P=0.110). Conditioned pain modulation status predicted changes in pain-related interference after controlling for the effects of treatment condition and psychosocial risk factors. Static measures of pain sensitivity (i.e., pain threshold, pain tolerance) and temporal summation of second pain were not associated with changes in measures of abdominal pain, gastrointestinal symptom severity, or pain-related interference over follow-up.

Discussion: The present findings contribute to a growing literature on the predictive utility of quantitative sensory testing indices and suggest that conditioned pain modulation may complement existing psychosocial risk measures in determining individualized pain-related risk profiles.
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http://dx.doi.org/10.1097/AJP.0000000000000956DOI Listing
June 2021

Noninvasive bladder testing of adolescent females to assess visceral hypersensitivity.

Pain 2021 Apr 12. Epub 2021 Apr 12.

Department of Ob/Gyn, NorthShore University HealthSystem Evanston, IL, United States, Department of Ob/Gyn, University of Chicago, Pritzker School of Medicine, Chicago, IL, United States, Department of Psychology, Loyola University of Chicago, Chicago, IL, United States, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States.

Abstract: Excess pain after visceral provocation has been suggested as a marker for chronic pelvic pain risk in women. However, few noninvasive tests have been validated that could be performed readily on youth in early risk windows. Therefore, we evaluated the validity and reliability of a noninvasive bladder pain test in 124 healthy premenarchal females (median age 11, [interquartile range 11-12]), as previously studied in adult women. We explored whether psychosocial, sensory factors, and quantitative sensory test results were associated with provoked bladder pain and assessed the relation of bladder pain with abdominal pain history. Compared with findings in young adult females (age 21 [20-28]), results were similar except that adolescents had more pain at first sensation to void (P = 0.005) and lower maximum tolerance volume (P < 0.001). Anxiety, depression, somatic symptoms, and pain catastrophizing predicted provoked bladder pain (P's < 0.05). Bladder pain inversely correlated with pressure pain thresholds (r = -0.25, P < 0.05), but not with cold pressor pain or conditioned pain modulation effectiveness. Bladder pain was also associated with frequency of abdominal pain symptoms (r = 0.25, P = 0.039). We found strong retest reliability for bladder pain at standard levels of sensory urgency in 21 adolescents who attended repeat visits at 6 to 12 months (intraclass correlations = 0.88-0.90). Noninvasive bladder pain testing seems reproducible in adolescent females and may predict abdominal pain symptomatology. Confirmation of our findings and further investigation of the bladder test across menarche will help establish how visceral sensitivity contributes to the early trajectory of pelvic pain risk.
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http://dx.doi.org/10.1097/j.pain.0000000000002311DOI Listing
April 2021

Response to "retrograde slow wave activation: A missing link in gastric dysfunction?"

Neurogastroenterol Motil 2021 04 8;33(4):e14124. Epub 2021 Mar 8.

Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

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http://dx.doi.org/10.1111/nmo.14124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188259PMC
April 2021

Sex Moderates the Relationship Between Nausea Severity and Heart Rate Variability in Adolescents and Young Adults.

Dig Dis Sci 2021 Feb 19. Epub 2021 Feb 19.

Department of Anesthesiology, Vanderbilt University Medical Center, 701 Medical Arts Building, 1211 Twenty-First Avenue South, Nashville, TN, 37212, USA.

Background: Nausea is a common complaint among children and is particularly prevalent in children with functional abdominal pain (FAP), with nearly half of children with FAP also endorsing nausea. Dysfunction of the autonomic nervous system, which can be indexed by heart rate variability (HRV), leads to abnormalities in gastric electrical activity that are associated with GI symptoms.

Aims: To evaluate that relationship between nausea severity and HRV in adolescents and young adults with a history of FAP and to assess for sex differences.

Methods: Participants were pediatric patients with a diagnosis of FAP who were recruited from a pediatric GI clinic between 1993 and 2007 for a prospective study of the course of FAP. Study analyses focused on the cross-sectional relationship between HRV, indexed by standard deviation of the R-R interval (SDRRI) and high-frequency (HF) power, and nausea severity collected during a follow-up visit in late adolescence and young adulthood.

Results: Controlling for age and BMI, a significant nausea by sex interaction emerged for both SDRRI and HF power. Tests of conditional effects of nausea by sex showed that the inverse relation between nausea severity and both SDRRI and HF was significant for females but not for males.

Conclusions: This is the first study to evaluate the relationship between nausea severity and HRV. Greater nausea severity was associated with lower HRV in females but not in males. Further validation of these results may provide insight into novel treatment approaches for females with nausea that target vagal tone.
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http://dx.doi.org/10.1007/s10620-021-06892-9DOI Listing
February 2021

The effect of chronic nausea on gastric slow wave spatiotemporal dynamics in children.

Neurogastroenterol Motil 2021 05 20;33(5):e14035. Epub 2020 Nov 20.

Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Chronic nausea in adolescents with functional gastrointestinal disorders is an increasingly reported but poorly understood symptom that negatively affects quality of life. Functional gastrointestinal disorders are known to correlate closely with slow wave rhythm disturbances. The ability to characterize gastric electrophysiologic perturbations in functional nausea patients could provide potential diagnostic and therapeutic tools for nausea patients.

Methods: We used high-resolution electrogastrograms (HR-EGG) to measure gastric slow wave parameters in pediatric chronic nausea patients and healthy subjects both pre- and postprandial. We computed the dominant frequency, percentage power distribution, gastric slow wave propagation direction, and speed from HR-EGG.

Key Results: We observed significant differences in the dominant frequency and power distributed in normal and bradyarrhythmia frequency ranges when comparing patients and healthy subjects. Propagation patterns in healthy subjects were predominantly anterograde, while patients exhibited a variety of abnormalities including retrograde, anterograde, and disrupted patterns. There was a significant difference in the preprandial mean slow wave direction between healthy subjects (222° ± 22°) and patients (103° ± 66°; p ˂ 0.01), although the postprandial mean direction between healthy subjects and patients was similar (p = 0.73). No significant difference in slow wave propagation speed was found between patients and healthy subjects in either pre- (p = 0.21) or postprandial periods (p = 0.75).

Conclusions And Inferences: The spatiotemporal characterization of gastric slow wave activity using HR-EGG distinguishes symptomatic chronic nausea patients from healthy subjects. This characterization may in turn inform and direct clinical decision-making and lead to further insight into its pathophysiology.
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http://dx.doi.org/10.1111/nmo.14035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193999PMC
May 2021

Subgroups of Pediatric Patients With Functional Abdominal Pain: Replication, Parental Characteristics, and Health Service Use.

Clin J Pain 2020 12;36(12):897-906

Pediatrics, Vanderbilt University Medical Center.

Objectives: Prior work in a cohort of youth with functional abdominal pain (FAP) identified patient subgroups (High Pain Dysfunctional, High Pain Adaptive, Low Pain Adaptive) that predicted differences in the course of FAP from childhood into young adulthood. We aimed to replicate these subgroups in a new sample of adolescents with FAP using the original classification algorithm and to extend subgroup characteristics to include parental characteristics and health service use.

Methods: Adolescents (n=278; ages 11 to 17 y, 66% females) presenting to a gastroenterology clinic for abdominal pain, and their parents (92% mothers) completed self-report measures; adolescents also completed a 7-day pain diary.

Results: The replicated patient subgroups exhibited distress and impairment similar to subgroups in the original sample. Moreover, in novel findings, the High Pain Dysfunctional subgroup differed from other subgroups by the predominance of mother-daughter dyads jointly characterized by high levels of anxiety, depressive symptoms, pain behavior, and pain catastrophizing. The High Pain Dysfunctional subgroup used more health care services than Low Pain Adaptive but did not differ from High Pain Adaptive.

Discussion: Findings replicate and extend the original FAP classification and suggest that the subgroups have unique patient and parent features that may reflect distinct illness mechanisms requiring different treatments.
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http://dx.doi.org/10.1097/AJP.0000000000000882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666007PMC
December 2020

Comorbid Sleep Disturbance in Adolescents with Functional Abdominal Pain.

Behav Sleep Med 2021 Jul-Aug;19(4):471-480. Epub 2020 Jun 23.

Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.

Objective/background: Sleep disturbances have been commonly reported as comorbid in youth with pain conditions, but prior research specific to functional abdominal pain (FAP) is limited. This study describes individual factors associated with increased risk for sleep disturbance and characterizes the relationship between sleep disturbance and pain-related variables.

Participants: Participants included 278 adolescents (age 11 to 17 years, M age = 15 years; 89% Caucasian; 65% female) with FAP.

Methods: Participants reported on sleep disturbances, abdominal pain severity, functional disability, somatic symptoms, and healthcare utilization.

Results: Female adolescents reported greater sleep disturbance than male adolescents ((276) = 5.52, < .001, Cohen's = 0.70) and increased age was associated with greater sleep disturbance ( =.20, =.001). In hierarchical regressions controlling for age, sex, and abdominal pain, greater sleep disturbance was significantly associated with greater functional disability (β =.32), non-gastrointestinal somatic symptoms (β =.35), and emergency department visits (β =.29).

Conclusions: Results suggest that sleep disturbance is common and should be assessed in youth presenting with FAP and may be a potential target for intervention.
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http://dx.doi.org/10.1080/15402002.2020.1781634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063352PMC
June 2020

Validation of the Health-Related Felt Stigma and Concealment Questionnaire.

J Pediatr Psychol 2020 06;45(5):509-520

Department of Psychology and Human Development, Vanderbilt University.

Objective: Stigma is associated with many health conditions, including chronic pain. Research on health-related stigma is limited by the lack of validated instruments that distinguish among various stigma-related constructs. We aimed to develop and validate such a measure for pediatric functional abdominal pain (FAP). Felt stigma (FS) was defined as comprising both perceived and internalized stigma. Stigma concealment (SC) was defined as efforts by stigmatized individuals to prevent others from learning of their condition.

Methods: Using a theory-driven approach, we adapted items from existing self-report measures of stigma to construct the health-related FS and Concealment Questionnaire (FSC-Q). Patients with FAP (N = 179, ages 11-17) completed the preliminary FSC-Q and health-related measures hypothesized to be associated with stigma. Cognitive interviewing and exploratory factor analysis (EFA) informed the final version of the measure.

Results: EFA identified a 2-factor model comprised of FS and SC. The FS and SC scales exhibited good internal consistency and construct validity. Consistent with study hypotheses, both factors were significantly associated with anxiety, depression, pain catastrophizing, pain threat, physical symptoms, and pain interference/disability. Higher FS was associated with higher mental healthcare utilization. The subset of participants meeting criteria for irritable bowel syndrome (IBS) reported higher FS and SC compared with those without IBS.

Conclusion: The FSC-Q may help advance research on health-related stigma in FAP and other chronic health conditions by allowing for assessment of distinct stigma-related constructs.
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http://dx.doi.org/10.1093/jpepsy/jsaa030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234182PMC
June 2020

Commentary: Understanding Somatic Symptoms: From Dualism to Systems, Diagnosis to Dimensions, Clinical Judgement to Clinical Science.

Authors:
Lynn S Walker

J Pediatr Psychol 2019 Aug;44(7):862-867

Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center.

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http://dx.doi.org/10.1093/jpepsy/jsz050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6655464PMC
August 2019

Somatic Symptoms in Pediatric Patients With Chronic Pain: Proposed Clinical Reference Points for the Children's Somatic Symptoms Inventory (Formerly the Children's Somatization Inventory).

J Pain 2019 08 13;20(8):932-940. Epub 2019 Feb 13.

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California.

Among youth with chronic pain, elevated somatic symptoms across multiple body systems have been associated with greater emotional distress and functional disability and could represent poor adaptation to pain. The Children's Somatic Symptoms Inventory (formerly the Children's Somatization Inventory) is commonly used to assess somatic symptoms in children. However, no studies have evaluated the clinical usefulness of the measure in the assessment of pediatric patients with chronic pain. This study evaluated the factor structure and clinical relevance of the 24-item Children's Somatic Symptoms Inventory (CSSI-24) in youth (n = 1,150) with mixed chronic pain complaints presenting to a tertiary pain clinic. The CSSI-24 total scores were equal or superior to factor scores as indicators of patients' clinical characteristics (functional disability, pain catastrophizing, fear of pain, and anxiety and depressive symptoms) and parental catastrophizing and protective responses. Tertile-derived clinical reference points for the CSSI-24 total score (<18, low; 19-31, moderate; ≥ 32, high) significantly differed on measures of clinical characteristics and parent factors. Controlling for age, sex, pain intensity, and primary pain complaint, the high somatic symptoms group exhibited significantly greater health care use compared with the moderate and low groups. The assessment of somatic symptoms in pediatric patients with chronic pain may provide useful information regarding patients' psychosocial risk and tendency to access health services. Perspective: Clinical reference points based on the CSSI-24 total scores meaningfully differentiated youth with chronic pain on measures of emotional distress, functioning, parent catastrophizing and protective responses, and health care use. Assessing somatic symptoms could provide useful information regarding a pediatric patient's psychosocial risk, tendency to access health services, and need for enhanced care coordination.
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http://dx.doi.org/10.1016/j.jpain.2019.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689439PMC
August 2019

Development and Validation of a Nausea Severity Scale for Assessment of Nausea in Children with Abdominal Pain-Related Functional Gastrointestinal Disorders.

Children (Basel) 2018 Jun 1;5(6). Epub 2018 Jun 1.

Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.

The objective of this study was to develop a pediatric measure of chronic nausea severity, the Nausea Severity Scale (NSS), and evaluate its reliability and validity in youth with abdominal pain-related functional gastrointestinal disorders (AP-FGID). Pediatric patients (aged 11⁻17 years-old, = 236) presenting to an outpatient clinic for evaluation of abdominal pain completed the NSS, Children's Somatization Inventory (CSI), Functional Disability Inventory (FDI), Abdominal Pain Index (API), Patient-Report Outcomes Measurement Information System (PROMIS), Anxiety and Depression Scales and the Pediatric Rome III Questionnaire for FGIDs. The NSS demonstrated good concurrent, discriminant, and construct validity, as well as good internal consistency. One-third (34%) of AP-FGID patients reported experiencing nausea "most" or "every day" in the previous two weeks. The severity of nausea was higher in females than males and correlated significantly with the severity of somatic symptoms, functional disability, anxiety, and depression. The NSS is a valid and reliable measure of nausea in children with AP-FGID.
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http://dx.doi.org/10.3390/children5060068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6025273PMC
June 2018

Is Resolution of Chronic Pain Associated With Changes in Blood Pressure-related Hypoalgesia?

Ann Behav Med 2018 05;52(7):552-559

Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: In healthy individuals, elevated resting blood pressure (BP) is associated with reduced pain responsiveness and lower temporal summation. Prior work indicates that this BP-related hypoalgesia is reduced in individuals with chronic pain.

Purpose: This study evaluated whether resolution of chronic pain was associated with greater BP-related hypoalgesia compared to nonresolution.

Methods: From a prospective sample of adolescents and young adults diagnosed with chronic functional abdominal pain an average of 9 years earlier, 99 individuals in whom the condition had resolved and 51 individuals with ongoing abdominal pain were studied. Resting systolic BP was assessed, followed by evaluation of thermal pain threshold and tolerance, and assessment of temporal summation to thermal pain stimuli.

Results: Higher resting systolic BP was significantly associated with higher pain threshold and tolerance, and lower temporal summation only in the group with resolved functional abdominal pain (p < .05). Hierarchical regressions revealed that interactions between BP and resolution of chronic pain were significant only for pain tolerance (p < .05). Analyses by sex indicated that interactions between BP and resolution status were significant for the temporal summation outcome in males but not in females.

Conclusions: Results suggest that BP-related hypoalgesic mechanisms may be more effective in individuals in whom chronic pain has resolved compared to those with ongoing chronic pain. Findings hint at sex differences in the extent to which resolution of chronic pain is associated with BP-related hypoalgesia. Whether greater BP-related hypoalgesia is a consequence of, or alternatively a contributor to, resolution of chronic pain warrants further investigation.
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http://dx.doi.org/10.1093/abm/kax021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6361258PMC
May 2018

Reply.

Pain 2017 Dec;158(12):2497-2498

Departments of aAnesthesiology bPediatrics and cPsychology and Human Development, Vanderbilt University, Nashville, TN, USA.

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http://dx.doi.org/10.1097/j.pain.0000000000001072DOI Listing
December 2017

Social learning pathways in the relation between parental chronic pain and daily pain severity and functional impairment in adolescents with functional abdominal pain.

Pain 2018 02;159(2):298-305

Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.

Having a parent with chronic pain (CP) may confer greater risk of persistence of CP from childhood into young adulthood. Social learning, such as parental modeling and reinforcement, represents one plausible mechanism for the transmission of risk of CP from parents to offspring. Based on a 7-day pain diary in 154 pediatric patients with functional abdominal CP, we tested a model in which parental CP predicted adolescents' daily average CP severity and functional impairment (distal outcomes) via parental modeling of pain behaviors and parental reinforcement of adolescent's pain behaviors (mediators) and adolescents' cognitive appraisals of pain threat (proximal outcome representing adolescents' encoding of parents' behaviors). Results indicated significant indirect pathways from parental CP status to adolescent average daily pain severity (b = 0.18, SE = 0.08, 95% confidence interval: 0.04-0.31, P = 0.03) and functional impairment (b = 0.08, SE = 0.04, 95% confidence interval: 0.02-0.15, P = 0.03) over the 7-day diary period via adolescents' observations of parent pain behaviors and adolescent pain threat appraisal. The indirect pathway through parental reinforcing responses to adolescents' pain did not reach significance for either adolescent pain severity or functional impairment. Identifying mechanisms of increased risk of pain and functional impairment in children of parents with CP ultimately could lead to targeted interventions aimed at improving functioning and quality of life in families with CP. Parental modeling of pain behaviors represents a potentially promising target for family-based interventions to ameliorate pediatric CP.
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http://dx.doi.org/10.1097/j.pain.0000000000001085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889361PMC
February 2018

Interacting influences of gender and chronic pain status on parasympathetically mediated heart rate variability in adolescents and young adults.

Pain 2017 08;158(8):1509-1516

Department of Medicine, Division of Clinical Pharmacology, Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, TN, USA.

Considerable research links chronic pain to autonomic nervous system (ANS) dysfunction, specifically low heart rate variability (HRV) mediated by reduced parasympathetic activity. However, little is known about factors that influence ANS function in chronic pain. The ANS is the primary pathway for brain-gut communication, making it of particular interest in gastrointestinal disorders, such as irritable bowel syndrome, characterized by functional abdominal pain (FAP). We evaluated the relation of sex, pain severity, and psychological stress to ANS function in adolescents/young adults from a database of pediatric FAP and control participants enrolled 8 years earlier in a prospective study of pain. At follow-up in adolescence/young adulthood (Mean age = 19.46, SD = 3.48), we classified participants as Pain-Remit (n = 130), Pain-Persist (n = 96), and pain-free controls (n = 123). We recorded electrocardiogram data at rest and during laboratory stressors. Results demonstrated significantly lower HRV in Pain-Persist females compared with Pain-Remit females, female controls, and all males regardless of pain category. Spectral analysis of electrocardiogram showed that Pain-Persist females had reduced power in the high frequency domain of cardiac activity, ie, reduced parasympathetic "braking" of sympathetic activity, both at rest and during stress. Pain-Remit females exhibited levels of autonomic imbalance intermediate between those of females with persistent FAP and all other participants. Parasympathetically mediated low HRV in young women with persistent FAP may reflect a peripheral mechanism (eg, gut dysfunction) or a central nervous system mechanism (eg, pain amplification or poor emotion self-regulation) involving prolonged sympathetic activation.
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http://dx.doi.org/10.1097/j.pain.0000000000000942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5528172PMC
August 2017

Brief telephone-delivered cognitive behavioral therapy targeted to parents of children with functional abdominal pain: a randomized controlled trial.

Pain 2017 04;158(4):618-628

Gastroenterology, Group Health Cooperative, Seattle, WA, USA.

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.
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http://dx.doi.org/10.1097/j.pain.0000000000000800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5370191PMC
April 2017

Adolescents' Observations of Parent Pain Behaviors: Preliminary Measure Validation and Test of Social Learning Theory in Pediatric Chronic Pain.

J Pediatr Psychol 2017 01;42(1):65-74

Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, TN, USA.

Objective: Evaluate psychometric properties of a measure of adolescents’ observations of parental pain behaviors and use this measure to test hypotheses regarding pain-specific social learning.

Methods: We created a proxy-report of the Patient Reported Outcomes Measurement Information System (PROMIS) Pain Behavior–Short Form (PPB) for adolescents to report on parental pain behaviors, which we labeled the PPB-Proxy. Adolescents (n = 138, mean age = 14.20) with functional abdominal pain completed the PPB-Proxy and a parent completed the PPB. Adolescents and their parents completed measures of pain and disability during the adolescent’s clinic visit for abdominal pain. Adolescents subsequently completed a 7-day pain diary period.

Results: The PPB-Proxy moderately correlated with the PPB, evidencing that adolescents observe and can report on parental pain behaviors. Both the PPB-Proxy and PPB significantly correlated with adolescents’ pain-related disability.

Conclusions: Parental modeling of pain behaviors could represent an important target for assessment and treatment in pediatric chronic pain patients.
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http://dx.doi.org/10.1093/jpepsy/jsw038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544085PMC
January 2017

Effects of maternal health anxiety on children's health complaints, emotional symptoms, and quality of life.

Eur Child Adolesc Psychiatry 2017 May 1;26(5):591-601. Epub 2016 Dec 1.

The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Barthsgade 5, 8200, Aarhus N, Denmark.

Little is known about family risk factors and intergenerational transmission of psychological disturbance in the development of health anxiety (HA). This study investigated HA and related concepts in 8- to 17-year-old children who had been exposed to different maternal health status. Using a family case-control design, three family groups were included: (1) 50 case children of mothers with severe (HA); (2) 49 control children of mothers with rheumatoid arthritis (RA); and (3) 51 control children of healthy mothers. Children and mothers completed a battery of standardised questionnaires. Case children reported significantly higher level of HA symptoms than children of mothers with RA but not compared to children of healthy mothers. There was no significant difference between the children's self-reports in the three groups with regard to anxiety symptoms in general, physical complaints, or quality of life. In contrast, mothers with HA reported their children as having more emotional and physical symptoms than mothers in one or both control groups. Compared to mothers with RA but not healthy mothers, mothers with HA also reported more visits to the general practitioner with their children during the past year. The findings suggest that maternal HA only weakly affects children's own report of HA and thereby may not be a strong risk factor for the development of HA symptoms in childhood. However, mothers with severe HA seem to conceive their children as more ill and present them more often in the health care system which could, therefore, be an important target for intervention in adult patients.
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http://dx.doi.org/10.1007/s00787-016-0927-1DOI Listing
May 2017

Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis.

Clin Psychol Rev 2017 02 8;51:142-152. Epub 2016 Nov 8.

Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, TN, USA.

Previous meta-analyses have shown that psychotherapy improves gastrointestinal symptoms in adults with irritable bowel syndrome (IBS); however, the impact on functioning in daily activities is unknown. Meta-analysis was used to estimate the effect of psychotherapy on mental health and daily functioning in adults with IBS. An extensive literature search located 28 eligible randomized controlled trials (RCTs) providing outcome data for mental health and 18 RCTs providing data for daily functioning. Compared to a mixed group of control conditions, psychotherapy produced significantly greater improvements to mental health (d-=0.41) and daily functioning (d-=0.43). Cognitive behavior therapy (CBT) was evaluated in the largest number of trials (21 trials), followed by hypnosis (4 trials), psychodynamic (3 trials), and relaxation (2 trials). The psychotherapeutic modalities were comparable with respect to their effect on mental health. CBT produced the greatest improvements to daily functioning, and this effect was significantly larger than that produced by relaxation therapy. These results have important clinical implications for treatment of adults with IBS.
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http://dx.doi.org/10.1016/j.cpr.2016.11.001DOI Listing
February 2017

Nausea in Children With Functional Abdominal Pain Predicts Poor Health Outcomes in Young Adulthood.

Clin Gastroenterol Hepatol 2017 May 16;15(5):706-711. Epub 2016 Jul 16.

Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.

Background & Aims: Nausea is common among children with functional abdominal pain (FAP). We evaluated the relation of nausea to short- and long-term morbidity in pediatric patients with FAP.

Methods: We performed a prospective study of 871 children with FAP (age, 8-17 y) seen in a pediatric gastroenterology practice; follow-up data were collected from 392 of the patients at 8.7 ± 3.3 years later. Participants were defined as having significant nausea if they reported nausea "a lot" or "a whole lot" within the past 2 weeks. Validated questionnaires assessed abdominal pain, gastrointestinal and somatic symptoms, and depression. Baseline measures, anxiety, and the Rome III criteria were assessed in the follow-up evaluation.

Results: At baseline, 44.8% of the patients reported significant nausea. Those with nausea reported worse abdominal pain, gastrointestinal symptoms, somatic symptoms, and depression than those without nausea (P < .001 for all). When the children had reached young adulthood, those with nausea in childhood continued to have more severe gastrointestinal (P < .001) and somatic symptoms (P = .003) than patients without nausea in childhood, as well as higher levels of anxiety (P = .02) and depression (P = .02). In the follow-up evaluation, somatic symptoms, depression, and anxiety remained significant after controlling for baseline abdominal pain severity.

Conclusions: Pediatric patients with FAP and nausea have more severe short- and long-term gastrointestinal and somatic symptoms than patients with FAP without nausea, as well as reductions in mental health and daily function. Pediatric patients with FAP and nausea therefore need intensive treatment and follow-up evaluation.
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http://dx.doi.org/10.1016/j.cgh.2016.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5239764PMC
May 2017

Effects of a Cognitive Behavioral Therapy Intervention Trial to Improve Disease Outcomes in Children with Inflammatory Bowel Disease.

Inflamm Bowel Dis 2016 09;22(9):2134-48

*School of Social Work, University of Washington, Seattle, Washington; †Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina; ‡Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, Washington; §Department of Pediatrics, Vanderbilt University, Nashville, Tennessee; ‖Department of Oral Health Sciences, University of Washington, Seattle, Washington; ¶School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin; **Department of Gastroenterology, Seattle Children's Hospital, Seattle, Washington; ††Prime Health Clinic, Federal Way, Washington; ‡‡St. Charles Health System, Bend, Oregon; §§HealthPoint, Bothell, Washington; and ‖‖Alcohol and Drug Abuse Institute, University of Washington, Seattle, Washington.

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.
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http://dx.doi.org/10.1097/MIB.0000000000000881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4995069PMC
September 2016

Functional Nausea in Children: A Review of the Literature and Need for Diagnostic Criteria.

Children (Basel) 2016 Mar 10;3(1). Epub 2016 Mar 10.

Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.

Nausea is common amongst children with functional gastrointestinal disorders and is associated with a high burden of somatic and psychosocial comorbidities in both the short and long-term. Current treatments including medications, phytotherapy, stress-reduction techniques, and gastric electrical stimulation for recalcitrant cases, are reviewed. Functional nausea merits its own diagnostic criteria as a pediatric functional gastrointestinal disorder.
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http://dx.doi.org/10.3390/children3010005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934479PMC
March 2016

Impaired conditioned pain modulation in youth with functional abdominal pain.

Pain 2016 10;157(10):2375-2381

Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.

Functional abdominal pain (FAP) is associated with enhanced pain responsiveness. Although impaired conditioned pain modulation (CPM) characterizes adults with a variety of chronic pain conditions, relatively little is known about CPM in youth with FAP. This study assessed CPM to evoked thermal pain in 140 youth (ages 10-17), 63 of whom had FAP and 77 of whom were healthy controls. Multilevel models demonstrated weaker CPM effects in youth with FAP than in healthy youth, as evident in slower within-person decreases in pain ratings during the conditioning phase. Weaker CPM effects were associated with greater somatic symptom severity and functional disability. Pain responses in youth with FAP were heterogeneous, with 43% of youth showing an unexpected increase in pain ratings during the conditioning phase, suggesting sensitization rather than CPM-related pain inhibition. These findings highlight directions for future research on the emergence and maintenance of FAP in youth.
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http://dx.doi.org/10.1097/j.pain.0000000000000660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5028273PMC
October 2016

Pediatric Pain Beliefs Questionnaire: Psychometric Properties of the Short Form.

J Pain 2016 09 27;17(9):1036-44. Epub 2016 Jun 27.

Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee.

Unlabelled: Cognitive appraisals inform and shape individuals' pain experiences. As researchers examine mechanisms of cognitive-behavioral interventions for chronic pain, psychometrically sound measures based in cognitive theory are needed to directly assess pain beliefs. The Pain Beliefs Questionnaire (PBQ), a 32-item self-report measure informed by coping and appraisal theory, was designed to assess children's pain threat appraisals, problem-focused pain coping efficacy, and emotion-focused pain coping efficacy. The present study aimed to: 1) create a short form of the PBQ, and 2) evaluate the psychometric properties of the reduced measure in a large database of pediatric patients with functional abdominal pain (n = 871). Item reduction analyses identified an 18-item short form of the PBQ (PBQ-SF) that exhibited psychometric properties similar to the original measure. All 3 subscales of the PBQ-SF exhibited strong internal consistency (α levels ranged from .79 to .80) and adequate test-retest reliability at 2 weeks. Evidence for construct validity was provided by examining patterns of partial correlations for each subscale. The PBQ-SF represents a valid and reliable measure for evaluating children's pain beliefs. Future studies should investigate the treatment sensitivity of the PBQ-SF to evaluate its appropriateness for use in clinical trials.

Perspective: This article presents the psychometric properties of a reduced 18-item version of a measure used to assess children's pain beliefs in a large sample of children with functional abdominal pain. This measure could help identify processes and individual differences underlying children's responses to psychological treatments for chronic pain.
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http://dx.doi.org/10.1016/j.jpain.2016.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5032835PMC
September 2016

Rome IV Diagnostic Questionnaires and Tables for Investigators and Clinicians.

Gastroenterology 2016 Feb 13. Epub 2016 Feb 13.

Chinese PLA General Hospital Beijing, China.

The Rome IV Diagnostic Questionnaires were developed to screen for functional gastrointestinal disorders (FGIDs), serve as inclusion criteria in clinical trials, and support epidemiological surveys. Separate questionnaires were developed for adults, children/adolescents, and infants/toddlers. For the adult questionnaire, we first surveyed 1,162 adults without gastrointestinal disorders, and recommended the 90 percentile symptom frequency as the threshold for defining what is abnormal. Diagnostic questions were formulated and verified with clinical experts using a recursive process. The diagnostic sensitivity of the questionnaire was tested in 843 patients from 9 gastroenterology clinics, with a focus on clinical diagnoses of irritable bowel syndrome (IBS), functional constipation (FC), and functional dyspepsia (FD). Sensitivity was 62.7% for IBS, 54.7% for FD, and 32.2% for FC. Specificity, assessed in a population sample of 5,931 adults, was 97.1% for IBS, 93.3% for FD, and 93.6% for FC. Excess overlap among IBS, FC, and FD was a major contributor to reduced diagnostic sensitivity, and when overlap of IBS with FC was permitted, sensitivity for FC diagnosis increased to 73.2%. All questions were understandable to at least 90% of individuals, and Rome IV diagnoses were reproducible in ¾ of patients after one month. Validation of the pediatric questionnaires is ongoing.
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http://dx.doi.org/10.1053/j.gastro.2016.02.014DOI Listing
February 2016

Short-term and Long-term Efficacy of Psychological Therapies for Irritable Bowel Syndrome: A Systematic Review and Meta-analysis.

Clin Gastroenterol Hepatol 2016 07 22;14(7):937-947.e4. Epub 2015 Dec 22.

Department of Psychology and Human Development, Peabody College, Vanderbilt University, Nashville, Tennessee; Department of Pediatrics, Vanderbilt University, Nashville, Tennessee.

Background & Aims: Several meta-analyses have demonstrated the efficacy of psychological therapies for reducing gastrointestinal (GI) symptoms in patients with irritable bowel syndrome (IBS). However, no meta-analysis has investigated the duration of these effects. We performed a meta-analysis to assess the immediate, short-term, and long-term efficacy of psychotherapy for reducing GI symptoms in adults with IBS.

Methods: We searched PubMed, PsycINFO, Science Direct, and ProQuest Dissertations and Theses through August 15, 2015 for randomized controlled trials that compared psychological therapy with an active or non-active comparison (control) condition for treatment of GI symptoms in adults with IBS.

Results: Forty-one trials were included in our meta-analysis, comprising data from 2290 individuals (1183 assigned to psychotherapy and 1107 assigned to a control condition). Compared with a mixed group of control conditions, psychological therapies had a medium effect on GI symptom severity (d¯ = 0.69) immediately after treatment. On average, individuals who received psychotherapy had a greater reduction in GI symptoms after treatment than 75% of individuals assigned to a control condition. After short-term follow-up periods (1-6 months after treatment) and long-term follow-up periods (6-12 months after treatment), this effect remained significant and medium in magnitude (d¯ = 0.76 and d¯ = 0.73, respectively).

Conclusions: Psychological therapies reduce GI symptoms in adults with IBS. These effects remained significant and medium in magnitude after short-term and long-term follow-up periods.
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http://dx.doi.org/10.1016/j.cgh.2015.11.020DOI Listing
July 2016

The Sensitivity to Change and Responsiveness of the Adult Responses to Children's Symptoms in Children and Adolescents With Chronic Pain.

J Pediatr Psychol 2016 Apr 22;41(3):350-62. Epub 2015 Oct 22.

Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Departments of Anesthesiology, Pediatrics, and Psychiatry, University of Washington School of Medicine.

Objective: To examine the sensitivity to change and responsiveness of the Adult Responses to Children's Symptoms (ARCS) among parents of youth with chronic pain. 

Methods: Participants included 330 youth (89 children aged 7-11 years, 241 children aged 12-17 years) and their parents who participated in randomized controlled trials of family-based cognitive-behavioral therapy for chronic pain. Child pain and disability, parental emotional functioning, and parental responses to child pain were assessed at baseline and posttreatment. 

Results: The Protect and Monitor scales of the ARCS were sensitive to change following intervention for both developmental groups, with clinically meaningful reductions in these behaviors, thereby demonstrating responsiveness. Among the adolescent sample, greater change on some ARCS scales was associated with better parental emotional functioning and lower child pain at posttreatment. 

Conclusions: Findings support the sensitivity to change and responsiveness of the Protect and Monitor scales among parents of youth with chronic pain.
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http://dx.doi.org/10.1093/jpepsy/jsv095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896805PMC
April 2016

Psychosocial mechanisms for the transmission of somatic symptoms from parents to children.

World J Gastroenterol 2015 May;21(18):5532-41

Miranda AL van Tilburg, William E Whitehead, Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC 27599, United States.

Aim: To examine familial aggregation of irritable bowel syndrome (IBS) via parental reinforcement/modeling of symptoms, coping, psychological distress, and exposure to stress.

Methods: Mothers of children between the ages of 8 and 15 years with and without IBS were identified through the Group Health Cooperative of Puget Sound. Mothers completed questionnaires, including the Child Behavior Checklist (child psychological distress), the Family Inventory of Life Events (family exposure to stress), SCL-90R (mother psychological distress), and the Pain Response Inventory (beliefs about pain). Children were interviewed separately from their parents and completed the Pain Beliefs Questionnaire (beliefs about pain), Pain Response Inventory (coping) and Child Symptom Checklist [gastrointestinal (GI) symptoms]. In addition, health care utilization data was obtained from the automated database of Group Health Cooperative. Mothers with IBS (n = 207) and their 296 children were compared to 240 control mothers and their 335 children, while controlling for age and education.

Results: Hypothesis 1: reinforcement of expression of GI problems is only related to GI symptoms, but not others (cold symptoms) in children. There was no significant correlation between parental reinforcement of symptoms and child expression of GI or other symptoms. Hypothesis 2: modeling of GI symptoms is related to GI but not non-GI symptom reporting in children. Children of parents with IBS reported more non-GI (8.97 vs 6.70, P < 0.01) as well as more GI (3.24 vs 2.27, P < 0.01) symptoms. Total health care visits made by the mother correlated with visits made by the child (rho = 0.35, P < 0.001 for cases, rho = 0.26, P < 0.001 for controls). Hypothesis 3: children learn to share the methods of coping with illness that their mothers exhibit. Methods used by children to cope with stomachaches differed from methods used by their mothers. Only 2/16 scales showed weak but significant correlations (stoicism rho = 0.13, P < 0.05; acceptance rho = 0.13, P < 0.05). Hypothesis 4: mothers and children share psychological traits such as anxiety, depression, and somatization. Child psychological distress correlated with mother's psychological distress (rho = 0.41, P < 0.001 for cases, rho= 0.38, P < 0.001 for controls). Hypothesis 5: stress that affects the whole family might explain the similarities between mothers and their children. Family exposure to stress was not a significant predictor of children's symptom reports. Hypothesis 6: the intergenerational transmission of GI illness behavior may be due to multiple mechanisms. Regression analysis identified multiple independent predictors of the child's GI complaints, which were similar to the predictors of the child's non-GI symptoms (mother's IBS status, child psychological symptoms, child catastrophizing, and child age).

Conclusion: Multiple factors influence the reporting of children's gastrointestinal and non-gastrointestinal symptoms. The clustering of illness within families is best understood using a model that incorporates all these factors.
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http://dx.doi.org/10.3748/wjg.v21.i18.5532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4427675PMC
May 2015

Heightened Temporal Summation of Pain in Patients with Functional Gastrointestinal Disorders and History of Trauma.

Ann Behav Med 2015 Dec;49(6):785-92

Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.

Background: Individuals with functional gastrointestinal disorders (FGIDs) report experiencing trauma more often than healthy controls, but little is known regarding psychophysical correlates.

Purpose: The purpose of this study was to test the hypothesis that adolescents and young adults with FGIDs since childhood and a trauma history (n = 38) would exhibit heightened temporal summation to thermal pain stimuli, an index of central sensitization, and greater clinical symptoms compared to patients with FGIDs and no trauma history (n = 95) and healthy controls (n = 135).

Methods: Participants completed self-report measures, an experimental pain protocol, and psychiatric diagnostic interview as part of a larger longitudinal study.

Results: FGID + Trauma patients exhibited greater temporal summation than FGID + No Trauma patients and healthy controls. Additionally, FGID + Trauma patients exhibited greater gastrointestinal and non-gastrointestinal symptom severity, number of chronic pain sites, and disability.

Conclusions: Assessing for trauma history in patients with FGIDs could identify a subset at risk for greater central sensitization and pain-related symptoms.
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http://dx.doi.org/10.1007/s12160-015-9712-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636446PMC
December 2015

Role of Coping With Symptoms in Depression and Disability: Comparison Between Inflammatory Bowel Disease and Abdominal Pain.

J Pediatr Gastroenterol Nutr 2015 Oct;61(4):431-6

*Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC †School of Social Work ‡Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA §Department of Pediatrics, Vanderbilt University, Nashville, TN ||Prime Health Clinic, Puyallup ¶Division of Pediatric Gastroenterology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle WA.

Background: Inflammatory bowel disease (IBD) and abdominal pain of functional origin (AP) are common gastrointestinal disorders in children, which are associated with increased risk for depression and disability. Both symptom severity and coping with symptoms may contribute to these outcomes. We hypothesized that children with AP use different coping strategies compared with those with IBD for a number of reasons, including the fact that fewer treatment options are available to them. We also examined whether coping was related to depression and functional disability beyond the contributions of symptom severity.

Methods: The study method included secondary data analysis of 2 existing data sets including 200 children with AP (73% girls, mean age 11.2 years) and 189 children with IBD (49% girls, mean age 13.8 years).

Results: Compared with patients with IBD, patients with AP reported more use of coping strategies of self-isolation, behavioral disengagement, and catastrophizing, as well as problem solving and seeking social support. Multivariate analyses revealed that, in both samples, ≥1 coping strategies were associated with depression and functional disability, independent of symptom severity, and controlling for age and sex. In IBD, symptoms were not a significant predictor of depression but coping was. Catastrophizing predicted depression and disability in both samples.

Conclusions: Patients with AP report more frequent use of several of the coping strategies we measured compared with patients with IBD. Certain types of coping, particularly catastrophizing, were associated with greater depression and functional disability in both groups. Clinicians should be aware of maladaptive coping, which may be a risk factor for poor psychosocial and functional outcomes in both patient groups.
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http://dx.doi.org/10.1097/MPG.0000000000000841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4581886PMC
October 2015
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