Internet-Delivered Cognitive Behavioral Therapy for Children With Pain-Related Functional Gastrointestinal Disorders: Feasibility Study

Abstract

BackgroundPain-related functional gastrointestinal disorders (P-FGIDs; eg, irritable bowel syndrome) are highly prevalent in children and associated with low quality of life, anxiety, and school absence. Treatment options are scarce, and there is a need for effective and accessible treatments. Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure exercises is effective for adult and adolescent irritable bowel syndrome, but it has not been evaluated for younger children.ObjectiveThe objective of this study was to assess acceptability, feasibility, and potential clinical efficacy of Internet-CBT for children with P-FGIDs.MethodsThis was a feasibility study with a within-group design. We included 31 children aged 8-12 years and diagnosed with P-FGID, according to the ROME III criteria. Mean duration of abdominal symptoms at baseline was 3.8 years (standard deviation [SD] 2.6). The treatment was therapist-guided and consisted of 10 weekly modules of exposure-based Internet-CBT. The children were instructed to provoke abdominal symptoms in a graded manner and to engage in previously avoided activities. The parents were taught to decrease their attention to their children’s pain behaviors and to reinforce and support their work with the exposures. Assessments included treatment satisfaction, subjective treatment effect, gastrointestinal symptoms, quality of life, pain intensity, anxiety, depression, and school absence. Data were collected at pretreatment, posttreatment, and 6-month follow-up. Means, standard errors (SEs), and Cohen d effect sizes were estimated based on multi-level linear mixed models.ResultsMost children 25/31 (81%) completed 9 or 10 of the 10 treatment modules. Almost all children, 28/31 (90%), reported that the treatment had helped them to deal more effectively with their symptoms, and 27/31 (87%) children declared that their symptoms had improved during the treatment. Assessments from the parents were in accordance with the children’s reports. No child or parent reported that the symptoms had worsened. We observed a large within-group effect size on the primary outcome measure, child-rated gastrointestinal symptoms from pretreatment to posttreatment (Cohen d=1.14, P<.001, 95% CI 0.69-1.61), and this effect size was maintained at 6-month follow-up (Cohen d=1.40, P<.001, 95% CI 1.04-1.81). We also observed significant improvements from pretreatment to posttreatment on a wide range of child- and parent-rated measures including quality of life, pain intensity, anxiety, depression, and school absence. All results remained stable or were further improved at 6-month follow-up.ConclusionsThis study shows that children with longstanding P-FGIDs, and their parents, perceive exposure-based Internet-CBT as a helpful and feasible treatment. The included children improved significantly despite a long duration of abdominal symptoms before the intervention. The treatment shows potential to be highly effective for P-FGIDs. The results need to be confirmed in a randomized controlled trial (R...

Clinical and Cost Effectiveness of Online Cognitive Behavioral Therapy in Children With Functional Abdominal Pain Disorders

“…The high adherence rate was consistent with our prior trials 13,15,16 and probably reflected satisfaction with the treatment. Explicit instructions to log-in to new modules on weekends and automatic reminders also probably were helpful.…”

“…13 Adaptations were made to include all common FAPDs, not only IBS, and to make the treatment age appropriate. 15,16 The children's exercises included exposure to symptom-provoking stimuli (eg, eating certain food or wearing tight clothes) and situations in which they feared having symptoms (eg, physical exercise or being in school). They also decreased their symptom-controlling strategies (eg, precautionary toilet visits and as-needed medications).…”

“…An overview of the treatment is presented in Supplementary Figure 2 and a comprehensive description of the treatment protocol is available elsewhere. 16…”

Functional abdominal pain disorders in children: An update on treatment

“…As in the case of hypnotherapy, CBT may not always be available to patients. Lalouni et al compared 10-week internet-based treatments with a waiting list 47 . Children were instructed to provoke their symptoms without using avoidance strategies while parents were to decrease their attention to the pain symptoms and support their child's work.…”

Focus on the use of antidepressants to treat pediatric functional abdominal pain: current perspectives

“…Emerging evidence on new ways to provide these techniques in a cost-effective and accessible manner including telephone-delivered CBT and exposure-based Internet-CBT are promising. 13 , 14 Central neuromodulators have also been used as a therapy, and the antidepressants are the central modulators that have been more extensively used and studied for the management of AP-FGIDs in adult and pediatric population ( Tables 1 and 2 ). 15 – 19 …”