Treatment for pediatric gut-brain interaction disorders relies on caring for the whole child
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Disorders of gut-brain interaction cause symptoms throughout the digestive tract including pain, changes in bowel patterns, nausea, regurgitation or vomiting, which can be upsetting or embarrassing for children and teens
As a result, disorders of gut-brain interaction (DGBIs) often interfere with daily routines like attending school, participating in social activities or eating a normal diet. Additionally, pediatric DGBIs can impact the entire family; parents and primary caregivers may worry about the cause or prognosis of symptoms, experience stress related to children’s school absences or their own missed work and may have difficulty encouraging their children to continue typical daily routines despite discomfort and distress.
Effective health care for pediatric DGBIs requires attention both to gastrointestinal symptom management and associated psychosocial concerns that may otherwise lead to ongoing health and lifestyle problems.
Treatment targets both symptoms and impact
DGBIs are biopsychosocial conditions, and effective treatment often targets biological, psychological and social processes simultaneously. Biological contributors to DGBI symptoms – including gut motility, sensation and bacterial flora – may be targeted with pharmacotherapy, dietary interventions or physical therapy. Psychological and social factors that contribute to DGBI symptoms, such as symptom-related anxiety, exposure to trauma and other stressors and how caregivers respond to symptoms, are often targeted by psychological therapies.
Some treatments may impact more than one target. For example, neuromodulators may impact both GI physiology and symptom-related anxiety. Among pharmacotherapies, neuromodulators have the intuitive appeal of addressing visceral pain perception, GI physiology and associated psychiatric symptoms, especially for patients with functional abdominal pain disorders (FAPDs).
The observed comorbidity of FAPD symptoms with anxiety and depression has increased interest in neuromodulating therapies. However, the evidence base for neuromodulation in pediatrics remains limited by relatively few published studies focused on tricyclic antidepressants and selective serotonin reuptake inhibitors, small sample sizes and other methodologic limitations. Treatment effectiveness remains unclear and the potential for adverse effects, especially adverse cardiac events and suicidal ideation, must be closely monitored.
Psychological or behavioral therapies for FAPDs may affect more than one treatment target. In randomized controlled trials, gut-directed hypnotherapy for FAPDs has demonstrated durable effects on pain and other GI symptoms. Similarly, cognitive behavioral therapy has demonstrated positive effects on GI symptoms, daily functioning and quality of life. Heart rate variability biofeedback for FAPDs has received relatively less study but may alleviate symptoms.
Additionally, psychological and behavioral therapies for children often integrate parents and primary caregivers to directly modify the social environment in which symptoms occur. For example, encouraging caregivers to respond to their children’s symptoms with warmth and validation while encouraging active coping and activity engagement is an important component of psychological intervention for pediatric DGBIs.
Encouraging effective engagement in psychological treatment leads to greater benefit
In order to benefit from psychological and behavioral therapies for DGBIs, families must understand the role of psychological treatment. Health care providers treating youth with DGBIs can take several steps to encourage successful engagement. These include, but are not limited to:
1. Present the referral for psychological treatment as wholly consistent with a positive DGBI diagnosis;
2. Guide families to shift their focus from acute illness management – when it is often appropriate to rest, refrain from socializing and limit energy expenditure – to chronic illness management – when an emphasis on daily functioning is more appropriate and beneficial;
3. Acknowledge that this shift can be challenging for families;
4. Normalize that children and teens often feel upset by their symptoms and worry about daily life disruptions;
5. Acknowledge that caregivers may struggle to encourage adherence to medical management and active coping strategies like behavioral relaxation and engaging in activities despite symptoms. Many families struggle with a cycle of symptoms, emotional distress, avoidance and consequent stress;
6. Clarify that emotional and cognitive responses can maintain symptoms and impairment and are, therefore, important targets of psychological treatment;
7. Educate families that psychological treatment for DGBIs is typically active, problem-focused and short-term.
There is a growing group of behavioral health professionals who specialize in psychological and behavioral treatment for DGBIs including health psychologists and pediatric psychologists who have specific training to help people manage chronic illnesses or health-related concerns. Many elements of psychological or behavioral treatment for DGBIs have been adapted from treatments for other health conditions like chronic pain and anxiety; behavioral health professionals can apply existing skill sets to working with youth with DGBIs with some additional training.
Behavioral health professionals who wish to learn more about this area of specialty can access training resources through the Rome Foundation’s Gastropsych section at theromefoundation.org.
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