1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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

13. 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?

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

15. 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

16. 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

17. 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

18. 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

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

20. Relaxation Strategies
Deep Breathing
Progressive Muscle Relaxation

21. Relaxation Strategies
Deep Breathing (“balloon” or “belly” breathing)

22. Relaxation Strategies
Progressive Muscle Relaxation

23. Mindful Distraction Strategies
Grounding exercises
Distraction techniques

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

25. 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

26. 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

27. Mindful Distraction Strategies
Scavenger Hunt

28. 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

29. 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

30. Questions?