1. Habit disorders Dr. Ibrahim Khasraw Lecturer in Pediatrics School of Medicine Sulaimani University of

9. Attention Deficit Hyperactivity Disorder

15. Recurrent Abdominal Pain of Childhood (RAP)

16. Definition& Epidemiology Episodes of pain occurring at least monthly for 3 consecutive months with severity that interrupts routine functioning. RAP affects about 10% of school-age children. An organic cause is found in about 10% of cases, however, with new advances in technology the percentage of patients with unexplained pain is decreasing.

17. RAP Periumbilical abdominal pain is the most common pain location. Epigastric pain is associated with symptoms of nonulcer dyspepsia. Pain below the umbilicus is often accompanied by symptoms of irritable bowel syndrome.

18. The Rome II diagnostic criteria for IBS- like in children Pain and discomfort for 12 weeks in the last 12 months plus 2 of the following three: 1. Abdominal pain relieved by defecation 2. Onset of pain with change in stool frequency(>3/day or <3/week. 3. Onset of pain with changes in the stool form (lumpy,loose, hard), the presence of mucus, bloating, abnormal passage(straining, urgency, incomplete evacuation).

19. RAP Diagnosis A wide range of potential organic causes must be considered before establishing a diagnosis of Functional pain. Among the most common cause are chronic constipation parasitic infection (Giardia), GER, IBD, and lactose intolerance. The characteristic presentation of children with RAP includes: onset later than 6 years of age, midline paroxysmal pain most often periumbilical but also localized to the epigastric or suprapubic area. The pain interrupts normal activity.

20. RAP Diagnosis Symptoms suggestive of organic etiology: fever, age less than 6 years, weight loss, joint symptoms, or abnormal growth. Organic pain is usually localized away from the umbilicus and may wake the patient from sleep. Vomiting, diarrhea, and blood in stools are suggestive of organic etiology. Children with RAP have a normal physical examination whereas those with organic etiology may have clinical findings suggestive of the underlying cause.

21. RAP Evaluation The laboratory, radiologic or endoscopic evaluation of children with chronic abdominal pain should be individualized, depending on the findings suggested by a detailed history and physical examination. A CBC, sedimentation rate, stool test and urinalysis are reasonable screening studies. If indicated an ultrasound examination of the abdomen can give information about kidneys, gall bladder, and pancreas.

22. RAP treatment The family and the child with functional RAP may worry about the inability to identify an organic cause and may be resistant to a diagnosis of nonorganic disease. After a thorough history and physical examination, the most important component of treatment is reassurance of the child and the family members. The parents should be instructed to avoid reinforcing the symptoms with secondary gain. Children with RAP should return to regular activities. Medications are generally unhelpful. Close follow up.