It's not all in your head: Understanding the psychosocial components of and treatments for functional abdominal pain Elizaveta Bourchtein, M.S. Clinical Psychology Doctoral Student Virginia Commonwealth University

Objectives Participants will be able to identify psychosocial risk factors contributing to functional abdominal pain in children/adolescents Participants will learn basics of cognitive/behavioral evidence-based treatment approaches for pediatric functional abdominal pain Participants will learn about resources for working with patients with functional abdominal pain

Abdominal pain in children 10-20% of school-aged children Weekly in 13-17% One of the most common problems seen by school nurses Intermittent or continuous Sudden or slow onset Organic or functional

Organic abdominal pain 5-10% of abdominal pain Examples: inflammatory bowel disease, celiac disease, stomach virus, food allergies Typical symptoms: Vomiting*, gastrointestinal bleeding, weight loss, diarrhea*, fever, dehydration, localized pain, nocturnal awakenings from pain * Also can be present in functional abdominal pain

Functional abdominal pain Part of functional gastrointestinal disorders (FGID) No known medical etiology A “rule out” disorder – BUT some symptoms may indicate increased likelihood of FAP

Functional abdominal pain Typical symptoms: Nausea (rarely has organic basis in children) Headaches often associated with FAP Pain on morning awakening, may become worse again before bedtime Rarely awakens at night Periumbilical or generalized pain Children may attribute to stress or poor sleep

Functional abdominal pain Includes Functional dyspepsia Early fullness, epigastric pain, burning Irritable bowel syndrome Constipation and/or diarrhea, cramping, gas, pain Abdominal migraine Pain in midline, may be generalized, accompanied by lack of eating, nausea, vomiting, pallor Functional abdominal pain – not otherwise specified One third of children with recurrent abdominal pain continue to experience it 5 years later

Perceptions of abdominal pain What causes functional abdominal pain? Youssef et al., 2007

Perceptions of abdominal pain Over 60% of surveyed school nurses believed recurrent abdominal pain was explained by children seeking attention Nearly 50% believed that the child was faking it 78% believed the child was lazy Youssef et al., 2007

Functional abdominal pain May be related to visceral hyperalgesia Increased sensitivity to changes/pain in internal organs Misinterpreting bodily sensations (e.g., bloating) Brain imaging confirms changes in brain during functional pain episodes  may be abnormal processing of pain in brain Exacerbated (but likely not solely caused by) by stress, anxiety, low mood

What do you do? “My tummy was hurting in class so I came here.” – Frequent Flyer What do you usually do? What would you do if time/resources were unlimited?

Breaking the Cycle of Stress and Missed Class Pain Missing class Missing work/ information Stress

Breaking the Cycle of Stress and Missed Class Goal: have child take ownership of own treatment Instill belief in student that they have tools necessary to reduce pain Maintain expectations for school and functioning while providing supportive, calm environment

Creating a “Toolkit” Collection of evidence-based strategies for pain that are student-driven Over time, builds child’s efficacy in employing appropriate coping strategies Reduces time needed to devote to each student May reduce school nurse visits

Setting an Example Normal to feel frustrated/scared/mad For you and for student! Try to remain calm in front of child Take breath/break if necessary

Setting an Example Normal to feel frustrated/scared/mad For you and for student! Try to remain calm in front of child Take breath/break if necessary Discuss pain neutrally, repeat back the words the child is saying “How long has it been feeling like there’s explosions going on in your tummy?” Avoid minimizing pain E.g., “you’ll be fine” “it’s all in your head” Work with child to build alliance and trust

Toolkit for Functional Abdominal Pain Relaxation strategies Mindful distraction strategies Distraction > attention

Relaxation Strategies Deep Breathing Progressive Muscle Relaxation

Relaxation Strategies Deep Breathing (“balloon” or “belly” breathing) https://www.youtube.com/watch?v=Wdbbtgf05Ek

Relaxation Strategies Progressive Muscle Relaxation https://youtu.be/8Xp2UzG7UYY?t=1m16s

Mindful Distraction Strategies Grounding exercises Distraction techniques

Mindful Distraction Strategies Grounding exercises Using your five senses to focus on the present, external world

Mindful Distraction Strategies Grounding exercises Name five things you can see What is the shiniest thing you see? What is the smallest thing you see? What is the _______ thing you see? Name two things you can hear What is the quietest thing you can hear? What is the loudest thing you can hear? Name two things you can feel Softest, hardest

Mindful Distraction Strategies Grounding exercises Name one thing you can smell right now Describe the smell to someone who can’t smell Name one thing you can taste right now Describe the taste to someone who cannot taste

Mindful Distraction Strategies Scavenger Hunt

Mindful Distraction Strategies Scavenger Hunt Something blue An object that is at least 10 years old Something smaller than an iPhone Something the size of a microwave Etc… Adjust as needed

Taking the Skills into the Classroom “What did you try before you came to see me?” Show me how you did it Try it again If it doesn’t work, what will you try next? Older students: Pros/cons of going to see nurse vs. staying in class Pros/cons of trying strategies in class

Questions? bourchteine@vcu.edu