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Background

Over the past decades it has increasingly become evident that functional gastrointestinal disorders (FGIDs) are explained by dysregulation of the brain–gut axis. FGID symptoms are not only caused and maintained by gut processes but may also be modified by extraintestinal components such as those related to cognition, emotions, and behavior. Currently, therapies for FGIDs can be divided into two main categories: those directed to the predominant symptom (or-end organ therapy) and treatment aimed at psychosocial aspects of the disorder with a focus on providing patients with adequate tools for modifying disease perception and responses to pain.

Among the various psychosocial interventions available, cognitive behavioral therapy (CBT) has recently gained more popularity as a modality in the treatment for FGIDs. This is not surprising, as CBT has a large evidence base in many conditions that have a psychosomatic component. These include traditional behaviorally based conditions which have some biological base, such as mood, anxiety, personality, and eating disorders, and also established organic disorders, such as inflammatory bowel disease, diabetes, and cardiovascular disease [1–8] which conversely have been found to have a significant psychosocial component. When considering evidence-based treatment, where specific treatments for symptom-based diagnoses are utilized, CBT has been recommended over other psychosocial approaches.

Within childhood FGIDs, CBT is being used to treat various conditions, and data for its effectiveness exists for fecal incontinence [4], rumination [6], aerophagia [7], and cyclic vomiting [9]. But the most evidence for the effectiveness of CBT is in treating functional abdominal pain (FAP) in childhood [10–12]. Therefore, in the remaining part of this chapter, we will discuss the use of CBT in the treatment of FAP. First, we will explore the common components of CBT for the treatment of FAP and show the versatility of the approach to many different situations such as the application of CBT in school, family, and at home. Last, we will discuss the literature on mechanisms that may be responsible for the positive effect seen with CBT [13–15].

It is equally important that the role of parent/family of the affected child be acknowledged when planning a successful intervention for children with FAP and utilizing CBT [11,12]. Human behavior is routinely motivated and rewarded by positive reinforcement. Many well-meaning ­parents show empathy and sympathy for their child’s pain and may give extra attention, gifts, or excuse the child from chores, a behavior which unintentionally reinforces pain complaints and disability. Teaching parents to withhold reinforcement of their child’s pain and replacing it with other techniques such as distraction can improve symptoms in children [16].

Aims of Cognitive Behavioral Therapy

As the name implies, cognitive behavioral therapy combines cognitive and behavioral treatment approaches with the aim to provide the child with the skills to promote pain relief and feelings of well-being [17]. Within a course of 3–12 weekly treatment sessions, the therapist generally usescognitivetechniques to help patients overcome distorted and negative thinking patterns that amplify physical symptoms, andbehavioraltechniques to change dysfunctional responses to pain. Under the guidance of a trained therapist, the child learns how to reduce pain and distress and gradually these techniques become self-administered. For children, CBT can also include changing the thoughts and behaviors of the caregivers. There is no generic model for CBT, in fact CBT refers to a set of behavioral and cognitive interventions which can be used in many different combinations. It is therefore highly adaptable to the disease or disorder and individual to maximize therapeutic benefit [18–24]. This also means that the content of CBT can be very different across therapists, disorders, age range, and other individual or situational characteristics.

Therapeutic Delivery Techniques

The particular therapeutic techniques vary within CBT, but commonly may include questioning and testing cognitions, assumptions, evaluations, and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; trying out new ways of behaving and reacting, and keeping a diary of significant events and associated feelings, thoughts, and behaviors [17–23]. Relaxation, mindfulness, guided imagery, and distraction techniques are usually also included.

Major Components to Cognitive Behavioral Therapy

Education.An explanation of the prevalence and nature of FAP, including the role of the brain–gut axis forms the foundation of therapy. It is important for the family to understand and “buy” into the role of stress and maladaptive thoughts in symptom initiation and maintenance. It is generally preferable to shift the focus from monitoring of symptoms to participation in daily activities (e.g., school attendance, social activities) to emphasize treatment success. The child and caregiver are often reminded of the ultimate goal of returning to a normal routine.

Cognitive techniques. Once the foundation has been laid with education that the primary goal of CBT is to examine, identify, and correct irrational beliefs and automatic thoughts, the therapist guides the patient in discovering his or her cognitive distortions that contribute to the etiology or maintenance of abdominal pain and/or disability. Several techniques are used to counter these distortions. For example, children are taught to identify and replace negative self-talk (e.g., “This pain will never go away”) with more adaptive cognitions (e.g., “I have handled pain like this before, so I can handle it again”). Or children may be asked to test the validity of their beliefs by defending his or her thoughts. If the patient cannot produce objective evidence supporting his or her assumptions, the invalidity, or faulty nature, is exposed (e.g., “When I’m bloated nobody wants to be my friend” in a child that has a rich social life).

Behavioral techniques. The therapist has a large arsenal of behavioral techniques to induce relaxation, improve coping, and extinct unwanted behaviors. Some of the most commonly used strategies are guided imagery and relaxation training:

Guided imagery.This is a form of relaxed, focused concentration similar to hypnosis. The therapist uses verbal guidance to help the patient experience specific detailed vivid imagery that has beneficial effects on the patient behavior, cognitions, emotions, or physiology. With input from a therapist, children develop and imagine a vivid scene such as going to a favorite place, and focus on the elements and sensations of the scene. This imagery makes children calm and relaxed while they also achieve a state of focused attention not unlike playing imaginary games or watching a movie and feeling you are part of a story. During this focused state of attention, children are more open to therapist suggestions for pain reduction and increased well-being.

Relaxation training. Two commonly used relaxation techniques are deep breathing exercises and progressive muscle relaxation; in deep breathing exercises, children are taught diaphragmatic breathing which is deep abdominal breathing, by flexing the diaphragm, rather than shallow breathing by raising the rib cage. Children may learn this by pretending to blow up and deflate a balloon in their stomachs or by lying on the ground trying to keep a book or hand placed on one’s chest from moving, while raising a book/hand on one’s stomach with each breath. In progressive muscle relaxation, children are taught to systematically tense and relax various muscle groups. Age-appropriate explanations are employed to assist children with this task (e.g., young children are asked to pretend to be a “robot” and then a “rag doll”).

Mindfulness training. Mindfulness training involves learning to attend to present moment experiences without evaluating them based on past or future fixations. For example, children may be instructed to observe and describe unwanted thoughts and feelings as they come and go, rather than suppressing them. This process increases children’s ability to know their sensations better and ultimately to reduce the suffering associated with pain.

Homework. In order to encourage self-discovery and reinforce techniques learned in therapy, the therapist usually asks the patient to do homework assignments. These may include practicing newly learned skills or journaling of symptoms, unwanted thoughts, or difficult situations.

The techniques described above are some of the most used approaches in CBT but this list is not exhaustive. Therapists can draw on many more cognitive and behavioral techniques to help their patients, modify unwanted thoughts and behaviors that impact symptoms and disability. In addition, these techniques are simple to learn and safe, without any major side-effects, making them an ideal treatment option for children and adolescents at a vulnerable age of development.

Who Benefits from CBT?

In the early management of children with FGID, it is of paramount importance to identify from both patient and their families the “willingness or acceptance” of psychosocial therapies including CBT [20,21]. Once established, children are highly responsive to many CBT techniques due to their natural ability to use imagination, high suggestibility, and sense of play. However, CBT requires children to be willing participants with a relatively long attention span and fairly good concentration. In addition, cognitive strategies within CBT have the most appeal to children who have developed meta-cognition. This means that children need to have an awareness of their own thinking, an ability to understand how to control and manipulate their thinking, and being able to evaluate success of making changes to their thinking. In short, cognitive strategies appeal the most to children who canthink about their thinking. Therefore, CBT usually is suggested for children age 8 and up but developmental level should be taken into account in all children before recommending and starting CBT [22–24]. In practice, young children can master some of these concepts and may become more proficient at using them over time. Children under the age of 8 can benefit from behavioral approaches and some simple cognitive strategies (such as imagery or positive self-talk) under the guidance of a coach, usually the parent, who prompts and helps the child to implement strategies at home.

Physicians, parents, and patients can often be unintentional obstacles to the early initiation of CBT. They feel CBT is only warranted when significant psychiatric overlap such as anxiety and depression is present. Therefore, few children are referred for CBT who do not have comorbid psychiatric problems. Although CBT is well suited to treat children with these comorbid conditions, it can also be effective in children who do not have any obvious mental health problems but still struggle with significant symptoms and disability.

Effective CBT for Chronic Pain

Investigators from Oregon and others have recently published an updated metanalytical review of randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents [23,24]. The purpose of this meta-analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth [23]. Specifically, systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes were assessed. Twenty-five trials including 1,247 young people met inclusion criteria and were included in the meta-analysis. Meta-analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post-treatment and follow-up in youth with headache, abdominal pain, and fibromyalgia. Small and non-significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes. All cognitive behavioral therapy, relaxation therapy, and biofeedback produced significant and positive effects on pain reduction. Studies directly comparing the effects of self-administered versus therapist-administered interventions found similar effects on pain reduction.

CBT for Abdominal Pain

A number of randomized controlled trials to test the effectiveness of pain interventions on children and their families using a self-management approach that includes components of cognitive behavior therapy have been conducted, yielding encouraging findings for this approach [10–12]. The following techniques are a sample of novel approaches utilized by investigators recently showing that CBT is efficacious in treating FAP and can be delivered in ways to increase access and feasibility.

Therapeutic Delivery Techniques

Family Intervention

Increasingly, parents are recognized as critical partners in CBT programs. Success often depends on the parent’s willingness to encourage the child to practice, including practicing with him or her, and using positive reinforcement for cooperation and successful outcomes. Acceptance by parents of a biopsychosocial model of illness is important for the resolution of FAP in children [11,12]. Discussing these issues in clinical practice is difficult as parents often feel misunderstood and blamed for their child’s pain. Discussing parents’ fears and worries about their children’s chronic abdominal pain may facilitate discussions of social learning of gastrointestinal illness behavior.

In a randomized controlled trial [11], investigators tested the efficacy of an intervention designed to improve outcomes in idiopathic childhood abdominal pain by altering parental responses to pain and children’s ways of coping and thinking about their symptoms. Two-hundred children with persistent FAP and their parents were randomly assigned to one of two conditions: a three-session intervention of cognitive behavioral treatment targeting parents’ responses to their children’s pain complaints and children’s coping responses, or a three-­session educational intervention that controlled for time and attention. Children in the cognitive behavioral condition showed greater baseline to follow-up decreases in pain and gastrointestinal symptom severity (as reported by parents) than children in the comparison condition. Also, parents in the cognitive behavioral condition reported greater decreases in solicitous responses to their child’s symptoms compared with parents in the comparison condition. Investigators concluded that an intervention aimed at reducing protective parental responses and increasing child coping skills is effective in reducing children’s pain and symptom levels compared with an educational control condition.

Community-School Based Intervention

Because assessment of FAP is frequently made at the school nurse level, schools may represent an excellent opportunity for intervention [25]. A questionnaire was sent to 425 school nurses to evaluate perceptions about FAP. Questions seeking to address perceived causes and treatment needs for children with chronic abdominal pain revealed that school nurses are unclear about epidemiologic and etiologic features of FAP and have negative views that may inadvertently contribute to the anxiety felt by affected children. Investigators concluded that increased education of school nurses and communication from physicians may advance strategies designed to reduce the fiscal and social costs associated with FAP.

In order to help school nurses in the community, the same investigators utilized a novel approach to deliver guided imagery directly to children presenting with FAP at school. In a pilot study, the feasibility and efficacy of a school nurse administered guided imagery program was assessed [26]. Nurses recruited children with FAP and no other distress symptoms such as weight loss, fever, or change in bowel habits. Children were randomized to six sessions of Guided Imagery (GIM) or Rest and Relaxation (RR) over 1 week. Initial session was 15 min and five booster sessions lasted 7 min. GIM was delivered via a compact disc. Questionnaires for abdominal pain and disability at initiation, 1-week post-intervention and 3-month follow-up were collected. Guided imagery was associated with greater improvement in pain than RR. At 3 months, pain was still reduced from baseline in both GIM and RR group. No child was diagnosed with alternate disease in the 3-month follow-up. Investigators concluded that school nurse administered guided imagery for abdominal pain was feasible and that larger, prospective studies were needed to confirm these positive results.

Home-Based Interventions

Despite the good evidence in support of CBT for treating FAP in children, psychological services are often difficult for patients to access and may not be covered by insurance. It is also important to note that there is a paucity of therapists who are well trained in cognitive behavioral approaches with children. In addition, families may be resistant to a referral to a mental health professional when they are not well educated about the goals of treatment (learning to cope with pain and disability reduction) and rather see the referral as a sign the physician thinks the pain is “all in the child’s head.” As a consequence few patients with FAP are referred to mental health specialists unless they have additional psychiatric symptoms, with most children being treated exclusively by pediatricians or family physicians without integration with mental health care. Therefore, home-based interventions have been developed including delivery of CBT by phone, Internet, and CD which may increase access to this type of therapy.

CD Delivered CBT Components

Investigators have developed home-based, guided imagery treatment protocols, using audio and video recordings, which are inexpensive, easy for health-care professionals and patients to use, and may be applicable to a wide range of health-care settings [27]. In a pilot study, 34 children, 6–15 years of age, with a physician diagnosis of FAP were assigned randomly to receive 2 months of standard medical care with or without home-based, guided imagery treatment. Children who had received only standard medical care initially, received guided imagery treatment after 2 months. Patients were monitored for 6 months after completion of guided imagery treatment. All treatment materials were reported to be self-explanatory, enjoyable, and easy to understand and to use. The compliance rate was 98.5%. In an intention-to-treat analysis, 63.1% of children in the guided imagery treatment group were treatment responders, compared with 26.7% in the standard medical care-only group. When the children in the standard medical care group also received guided imagery treatment, 61.5% became treatment responders. Treatment effects were maintained for 6 months (62.5% responders). Investigators concluded that guided imagery treatment plus medical care was superior to standard medical care only for the treatment of abdominal pain, and treatment effects were sustained over a long period.

Internet Delivered CBT

Investigators from Sweden have investigated the treatment of adults with irritable bowel syndrome by CBT delivered via the World Wide Web [28,29]. The aim of this study was to investigate if CBT based on exposure and mindfulness exercises delivered via the Internet would be effective. Eighty-six participants were included in the study and randomized to treatment or control condition (an online discussion forum). Participants in the treatment condition reported a 42% decrease and participants in the control group reported a 12% increase in primary IBS symptoms. Investigators concluded that CBT based on exposure and mindfulness delivered via the Internet can be effective in treating IBS patients, alleviating the total burden of symptoms and increasing quality of life.

Computerized CBT

These are cognitive behavioral therapy sessions in which the user interacts with computer software (either on a PC, or sometimes via a voice-activated phone service), instead of face to face with a therapist. For people who are feeling depressed and withdrawn, the prospect of having to speak to someone about their innermost problems can be off-putting. In this respect, computerized CBT can be a good option. Investigators from the Netherlands have piloted a feasibility and efficacy program utilizing PDA (personal digital assistants) or hand-held computers for the self-management of adults with irritable bowel syndrome [30]. The trial was conducted with 38 control group patients receiving standard care and 37 intervention group patients receiving standard care supplemented with a 4-week CBT intervention on PDAs. Between-group comparisons between baseline and follow-up showed improved quality of life improvement, and less catastrophizing thoughts as well as pain in the intervention group. Only improvement in catastrophizing thoughts persisted in the long term. Investigators concluded that CBT relying on pocket-type computers appears feasible and efficacious for improving IBS-related complaints and cognitions in the short term. Future studies should focus on unraveling the effective components of this innovative e-health intervention.

Proposed Mechanism of CBT: Physiological, Parent, Impaired Coping, or All Three?

Even though CBT has been found to be effective in FAP, it is still largely unknown by which mechanism these changes are driven. Identifying the active ingredients of treatment is of utmost importance given the variety of CBT approaches a therapist can choose from. Some approaches applied in CBT, such as guided imagery, have been shown to be effective by itself without addition of other techniques. This suggests that there may be active ingredients of therapy that are more important than other techniques in reducing symptoms. Cognitive behavioral intervention is based on the assumption that changes in active coping, cognitions, emotions, and care-giving strategies are responsible for improvement in FAP; however, these assumptions have not yet been widely validated as research on the mechanism of change is lacking from most treatment trials. Below we will discuss the evidence for various purposed mechanism of change.

Physiological Changes to the Brain and Gut?

Despite CBT’s main focus on psychosocial variables, it has been suggested that it can be accompanied by physiological changes as well, especially in the central nervous system [31–33]. It has been speculated that CBT may affect symptoms through changes in the brain. Brain changes with CBT have been found with other disorders such as Obsessive Compulsive Disorder, Panic Disorder, Major Depressive Disorder, and phobias. In addition, there is some evidence that treatment of psychosocial symptoms in adults with IBS is associated with changes in the central nervous system. For example, Drossman and colleagues followed a young woman with a history of abuse, posttraumatic stress disorder, and functional GI complaints, before and after treatment. Treatment consisted of removing her from an abusive relation, treating posttraumatic distress, and weaning from narcotics. Clinical recovery was associated with reducing psychosocial distress and visceral hypersensitivity to normal levels. Functional Magnetic Resonance Imaging showed increases in area 40, 22 and the anterior insula as well as decreases in prefrontal area 6/44, midcingulate cortex, and the somatosensory cortex. A study on the placebo effect in adult irritable bowel syndrome patients showed a robust positive correlation between symptom amelioration and increases in regional cerebral blood flow as well as the ventrolateral prefrontal cortex, and this correlation was mediated by changes in the dorsal anterior cingulate (dACC), typically associated with pain unpleasantness [34].

Similar studies among children have not been performed but two trials show no effect of psychosocial treatments on pain thresholds. A randomized controlled trial of CBT among 32 children with FAP showed no decreases in somatic pain thresholds [35]. Similarly, a large study among 46 children with FAP receiving hypnosis did not show changes in rectal sensitivity to pain despite clinical recovery [36]. These studies suggest that at least in children no physiological changes in pain thresholds can be found with psychosocial treatments. Evidently more research is needed to study the physiological effects of CBT in FAP.

Changes in Parental Solicitousness

As described earlier in this chapter, Levy and colleagues tested the effect of CBT directed not only at the child but also at the cognitions, emotions, and behaviors of the parents. Specifically parents’ responses to their child’s pain were targeted as well as children’s coping responses. The authors reported greater decreases in parental solicitous responses to their child’s symptoms as well as decreases in parental perceived threat of their child’s pain following CBT. In another study on family CBT, parental strategies such as reinforcing well-behavior, using distraction, ignoring pain, and avoiding modeling the sick role, were independent predictors of child pain behavior post-treatment [16]. These data suggest that changing parental behaviors and beliefs may be an active ingredient in reducing child’s pain and disability.

Changes in Coping

Explanations of chronic pain increasingly highlight the role of coping in understanding FAP. The type of coping response used by the child has been shown to mediate the impact of pain. Active coping responses (efforts to function despite pain or to distract oneself from pain) are thought to increase the child’s sense of control, whereas more passive reactions (depending on others for help and restricting activities) lead to withdrawal, decreased activity, and greater pain.

Children with severe and persistent FAP often have inadequate coping responses and perceive themselves as having little control over their symptoms. The potential usefulness of coping skills training for children with FAP has been suggested by uncontrolled clinical case reports. Relaxation training as a specific coping skill has been used in conjunction with other behavioral and dietary interventions. In addition, CBT has been found to improve active coping such as the use of distraction and pain minimization. No studies have examined whether a change in a child’s coping strategies is the mechanism responsible for improvement in the child’s pain.

It is not all in their Heads!

It is accepted that many FAP patients may suffer from a combination of subtle to overt comorbid psychological and related gastrointestinal dysfunctions often unfairly termed a FGIDs. The role of brain–gut physiology cannot be ignored, and the effects of longstanding symptoms that may indeed cause significant anxiety and depression in both child and caregiver need to be addressed. Given the effects of psychosocial factors on the expression and trajectory of FAP, it could be argued that the effects of CBT are mainly mediated through changes in psychological distress. Although studies in adults with irritable bowel syndrome have shown decreases in anxiety following CBT, there is no evidence that the therapeutic gains depend on changes in patient’s level of psychological distress. In children, there is no evidence that psychological distress improves with CBT treatment. Sander and colleagues found that treatment of FAP decreases internalizing and externalizing behavior measured with the Child Behavior Checklist, but these effects were equal among children receiving CBT or standard medical care [12]. Levy and colleagues also found no effects of CBT on child reported anxiety and depression although parent report of child depression did improve [11]. A recent meta-analysis also observed that psychological therapies in children reduced abdominal pain but not emotional symptoms [23]. Thus, current data do not suggest that the effects of CBT occur through changes in psychological symptoms. CBT should therefore be equally effective in patients with and without psychological comorbidities. In fact, one study in adults found that CBT may be more effective in those without psychiatric comorbidity as CBT did not show benefit for IBS patients with comorbid depression.

Conclusions

In summary, CBT offers an opportunity to effectively treat children with abdominal pain related to FGIDs. Mechanism of action for the therapeutic benefit of CBT is yet to be fully elucidated but most likely reflects a targeted intervention at the root of these pain disorders; namely, a disturbed brain–gut access often leading to an amplification of pain in the setting of impaired coping environment. Thus, it is reasonable to accept that changing maladaptive cognitions is at the heart of CBT therapy and ultimately its success. As clinicians become increasing comfortable with the understanding of the role of the brain–gut axis in the etiology of these common disorders, it is expected that they ultimately will begin to offer CBT delivered in a variety of novel ways much earlier in the treatment paradigm rather than waiting for other comorbid conditions to develop such as anxiety, depression, and impaired function which may lead to a more refractory patient.