 |
|
 |
|
 |
 |
|
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PEDIATRICS Vol. 108 No. 1 July 2001, p. e1
From the University of Pittsburgh School of Medicine,
Children's Hospital of Pittsburgh, and Western Psychiatric Institute
and Clinic, Pittsburgh, Pennsylvania.
Objective. To determine whether
medically unexplained recurrent abdominal pain (RAP) in childhood
predicts abdominal pain, irritable bowel syndrome (IBS), other somatic
complaints, and psychiatric symptoms and disorders in young
adulthood.
Methods. A sample of 28 young adults evaluated for RAP
between the ages of 6 and 17 years were compared with 28 individually
matched former childhood participants in a study of tonsillectomy and adenoidectomy. RAP caseness was established by structured retrospective chart review requiring agreement by 2 independent reviewers.
Standardized assessments of abdominal pain, IBS, other somatic
symptoms, psychopathology, perceived health, and history of
maltreatment were performed an average of 11.1 years after the index
visit.
Results. Former RAP patients were significantly more
likely than controls to endorse anxiety symptoms and disorders,
hypochondriacal beliefs, greater perceived susceptibility to physical
impairment, poorer social functioning, current treatment with
psychoactive medication, and generalized anxiety in first degree
relatives. There were trends suggesting associations between childhood
RAP and lifetime psychiatric disorder, depression, migraine, and family history of depression, but group differences on abdominal pain, IBS,
other somatic symptoms, and history of maltreatment were not
statistically significant.
Conclusions. There is a strong and relatively specific
association between childhood RAP and anxiety in young adulthood.
Affected children may be at special risk to perceive physical symptoms
as threatening, and should be evaluated for psychiatric disorder on
initial presentation.
ABSTRACT
Top
Abstract
Methods
Results
Conclusion
References
Recurrent abdominal pain (RAP) has been most consistently
defined in the pediatric literature as at least 3 episodes of abdominal pain occurring during a period of at least 3 months that are severe enough to affect the activities of the child.1,2 RAP is
common, affecting between 7% to 25% of school-aged children and
adolescents,13-11 and may be responsible for 2% to 4%
of pediatric office visits.12 RAP becomes more prevalent
with increasing age into adolescence1,5,7,10 and is more
common in girls,4,13 with an equal gender ratio in early
childhood,11,14 but greater female symptom reporting in
late childhood and adolescence.1,9,10 Specific structural,
infectious, inflammatory, or laboratory abnormalities are unusual in
RAP, particularly in the absence of "red flags" such as
weight loss, gastrointestinal bleeding, pain awakening the child at
night, systemic symptoms such as fever, or laboratory evidence of
anemia or inflammation.15
Medically unexplained RAP is often considered to be a functional
gastrointestinal disorder (FGD), a condition defined as a variable
combination of chronic or recurrent gastrointestinal symptoms in the
absence of explanatory structural or biochemical abnormalities.16 Irritable bowel syndrome (IBS) is a FGD
characterized by recurrent abdominal pain or discomfort occurring over
a 3-month period, where the symptoms are relieved by defecation and/or
are associated with changes in stool frequency or
consistency.17 Although available research is limited,
there is some evidence that many children and adolescents with RAP will
also meet criteria for IBS18 or other FGDs, such as
functional dyspepsia, where the abdominal discomfort is centered in the
upper abdomen and unrelated to bowel function.17
RAP has been consistently associated with comorbid symptoms of anxiety
and depression in both clinical19-22 and community
samples,7,11,23 as well as with other painful somatic
symptoms such as headache,1,4,7,10,14,20,21 including
migraine.3,8,9 RAP has also been associated with
functional impairment, particularly school absenteeism,719-22 and with greater risk for potentially
dangerous and unnecessary medical investigations and
procedures.24 Maltreatment has been associated with
functional abdominal pain in childhood25 and
adulthood.26
Implications of pediatric RAP across the lifespan are not well
understood. Early follow-up studies reported persistence of recurrent
abdominal pain into adulthood for one third to one half of affected
children,24,27,28 but are limited by the lack of
standardized assessments and formal diagnostic criteria, and none used
any formal assessment of psychopathology. In more recent studies using
standardized assessments and control groups, former RAP patients
reported significantly greater abdominal pain, other somatic symptoms,
functional impairment, health service use, and internalizing
psychiatric symptoms in comparison to controls at 5-year follow-up, and
females with a history of RAP were significantly more likely to meet
diagnostic criteria for IBS.29,30 A large,
population-based cohort study of adults born in 1946 in the United
Kingdom compared the 2% of the sample who consistently reported
medically unexplained abdominal pain at ages 7, 11, and 15 years with
study participants without a history of chronic abdominal pain on the
basis of standardized assessments when participants were 36 years old.
Persistent abdominal pain in childhood was significantly associated
with an increased risk of psychiatric disorder in adulthood, but not
with abdominal pain or headache once psychiatric disorder was
controlled for in the regression.31
In this study, young adults with a history of RAP in childhood were
compared with adults with a history of nongastrointestinal pediatric
illness. We hypothesized that adults with a history of pediatric RAP
would be significantly more likely to report: 1) a personal and family
history of psychiatric symptoms and disorders; 2) a personal and family
history of recurrent abdominal pain, IBS, and other somatic symptoms
and disorders; 3) greater subjective sensitivity to bodily sensations
and illness worry; 4) higher health and mental health service use; and
5) a history of maltreatment in childhood.
Case Identification and Recruitment
The Human Rights Committee of the Children's Hospital of
Pittsburgh granted study approval. Potential RAP patients were
identified from records of the pediatric gastroenterology section and a
group of academic general pediatricians at the Children's Hospital of Pittsburgh. Both groups had organized records by presenting complaints and diagnostic categories in the 1980s, including medically unexplained abdominal pain. Charts of children between the ages of 6 and 17 years
at the time of the index visit with a birth date of 1979 or earlier
with presumably medically unexplained abdominal pain were reviewed
independently by the principal investigator (J.V.C.) and a pediatric
gastroenterologist (C.D.L) using a chart review instrument developed
for the study. At least 3 episodes of medically unexplained abdominal
pain occurring during a period of at least 3 months that were severe
enough to affect the activities of the child were necessary for
inclusion. Criteria for exclusion included: abdominal pain with
atypical features, symptoms, or findings suggestive of physical disease
(eg, abnormal physical examination or laboratory findings, persistent
vomiting, gastrointestinal bleeding, constitutional symptoms such as
fever or weight loss); acute or chronic physical disease; and
development disability. There were 133 charts reviewed, with reviewers
both agreeing that 49 cases met study criteria for RAP.
An introductory letter and consent form were sent to the most recent
address, followed by an effort to contact the potential participant by
telephone approximately 1 week later. If the initial letter was
returned and/or available telephone numbers incorrect, efforts were
made to track the patient by directory assistance or via social
security numbers from the records. Initial contact was established with
34 potential RAP participants (contact rate 69%), with only 4 (all
male) declining to participate (refusal rate: 12%). Two RAP
participants withdrew from the study, leaving 28 consenting RAP
participants. Controls were former participants in a study of
tonsillectomy and adenoidectomy in childhood, conducted by Dr Jack
Paradise and colleagues, who were matched to consenting RAP patients
from an existing computerized database. An effort was made to identify
at least 3 potential controls for each consenting RAP participant given
the difficulty of tracking, and a procedure identical to that used to
find and recruit potential RAP patients was then used. From an initial
list of 83 potential controls, initial mailings were sent to 63 and
contact was established with 34 (contact rate: 54%). Of these, 28 agreed to participate, 3 declined (all male; refusal rate: 9%), 2 were
deceased, and 1 was not eligible to participate because of a history of
childhood RAP.
Participants were mailed questionnaires with a stamped, self-addressed
return envelope after informed consent was obtained. A single
experienced psychiatric interviewer who was blind to participant status
subsequently conducted a telephone interview. Psychiatric assessments
were conducted first and participants were advised to avoid
volunteering their participant status or any unsolicited medical
history. The interviewer was not aware of the nature of the control
group, and was advised that complaints of gastrointestinal symptoms in
adulthood were common and not necessarily indicative of childhood RAP.
Psychiatric interviews were reviewed with the principal investigator
(J.V.C.) without the interviewer identifying the participant by name or
study number. Participants who completed the study received payment of
$50 in consideration of their efforts.
Sample Characteristics (Table 1)
Twenty-eight RAP participants (21 females, 7 males) were
successfully recruited. Mean age was 12.6 years (standard deviation [SD]: 2.4) at the index visit and 23.7 years (SD: 3.1) at the time of
assessment, an average of 11.1 years (SD: 2.7) later. One participant
was black and the remainder white. Twenty-eight comparison participants
individually matched for age, gender, race, and parental occupation at
the index pediatric visit were identified, tracked, and successfully
recruited by an analogous procedure. The groups did not differ in
current marital, employment, or educational status. One RAP participant
failed to return completed questionnaires, but all participants
completed the telephone interview, leaving 27 and 28 patient-control
pairs available for analysis of questionnaire and interview based data,
respectively.
TABLE 1
METHODS
Top
Abstract
Methods
Results
Conclusion
References
Demographics
Measures
Data Analysis
Patients and controls were matched based on race, sex, age, and parental occupation. Pair-wise analyses were performed for all outcomes. Data were examined for normality using the Shapiro and Wilks W statistic.43 RAP patients and controls were compared using paired t tests and McNemar's test for agreement. For significantly non-normal distributions, Wilcoxon Sign Rank tests were used. In the case of zero cells, the binomial test was performed to compare proportions. Differences between patients and controls at the P = .05 level were considered statistically significant, with trends in the data being reported for items where the effect size was 0.4 or greater.
| |
RESULTS |
|---|
|
Top
Abstract
Methods
Results
Conclusion
References
|
|---|
Psychiatric Symptoms and Disorders (Tables 2 and 3)
RAP patients were significantly more likely to meet criteria for a lifetime (46.4% vs 17.9%, P = .04) and current (21.4% vs 0%, P = .01) history of anxiety disorder. Regarding specific anxiety disorders associated with childhood RAP, a lifetime history of social phobia was noted in 7 participants (25%), panic disorder in 5 (18%), generalized anxiety disorder in 4 (14%), anxiety disorder not otherwise specified in 4 (14%), obsessive compulsive disorder in 3 (11%), and posttraumatic stress disorder in 3 (11%); the most common current anxiety disorders were generalized anxiety disorder (14%), anxiety order not otherwise specified (14%), and social phobia (11%). There were also trends suggesting differences between the groups on probable or definite lifetime history of at least 1 DSM-IV categorical psychiatric disorder (82.1% vs 53.6%, P = .08) and lifetime history of mood disorder (57.1% vs 28.6%, P = .08). RAP patients were also significantly more likely to endorse symptoms of anxiety than controls on the BSI self-report, with significant differences noted on the Anxiety (P < .001), Phobic Anxiety (P = .04), and Obsessive-Compulsive subscales (P = .006), the Positive Symptom Total (P = .03), and on the Global Severity Index (P = .01), the most sensitive single indicator of overall distress on the BSI.
|
|
Somatic Symptoms and Disorders (Tables 2 and 3)
There were trends suggesting that RAP patients were more likely to interrupt activities because of abdominal pain (40% vs 12%, P = .07), to report a history of appendectomy (11.1% vs 0%, P = .08), and to score higher on the Somatization subscale of the BSI (P = .06) than controls. There was also a trend suggesting that RAP patients endorsed a greater mean number of somatic symptoms on the SCID-NP (4.0 vs 2.3, P = .12). One third of RAP patients endorsed a history of migraine, over twice as many as controls, with a trend toward statistical significance (35.7% vs 14.3%, P = .07), but RAP patients were not significantly more likely to report a history of headache (53.6% vs 42.9%, not significant [NS]), abdominal pain (70.4% vs 44.4%, NS), or recurrent abdominal pain (51.9% vs 25.9%, NS) in the previous year than controls. Although approximately one third of the RAP group met criteria for IBS, patients and controls did not differ significantly on interview measures of IBS (39.3% vs 21.4%, NS), or on self-report measures of IBS (29.6% vs 22.2%, NS) or dyspepsia (33.3% vs. 22.2%, NS). None met criteria for chronic fatigue or fibromyalgia. A somatoform disorder could be diagnosed in 28.6% of RAP patients in comparison to 17.9% of controls, but differences were not significant. Females with RAP did not differ from controls on menstrual complaints or irregularities.
On the Illness Attitude scale, RAP participants scored significantly higher on the Hypochondriacal Beliefs subscale, reflecting greater concerns about undiagnosed physical disease, and on the Effect of Symptoms subscale, suggesting greater perceived susceptibility to functional impairment by pain and other physical symptoms. There were trends toward significance on the Bodily Preoccupation and Thanatophobia subscales, reflecting hypervigilance to physical sensations and fear of death, respectively. Although the RAP group scored somewhat higher on the Somatosensory Amplification Scale, suggesting greater sensitivity to somatic sensations, the difference was not statistically significant.
Health and Health Service Use (Tables 3 and 4)
Control participants made significantly more physician visits in the previous 6 months than RAP participants (P = .003). RAP participants were nevertheless significantly more likely to describe themselves as impaired by physical symptoms and concerns than controls on the MOS 36-Item Short-Form Health Survey, and also rated themselves as doing poorer socially. RAP participants were significantly more likely to report current treatment with psychoactive medication, and although greater use of mental health services was suggested by more than half of RAP participants endorsing some lifetime history of mental health treatment (59.3% vs 37.0%), differences between the groups were not significant.
|
History of Maltreatment
Rates of reported maltreatment in childhood were relatively low in both groups. Physical abuse was reported by 18.5% and sexual abuse by 7.4% of RAP participants compared with 3.7% and 7.4% of controls, respectively. Differences were not significant.
Family History (Table 4)
Participants with a history of childhood RAP were significantly more likely to report having a first-degree relative with generalized anxiety disorder, the most common anxiety disorder reported by participants (40.7% vs 11.1%, P = .04), and there was a trend suggesting group differences on family history of major depression (44.4% vs 18.5%, P = .09). The groups did not differ significantly on family history of IBS, migraine, somatoform disorder, hypochondriasis, alcoholism, substance abuse, or antisocial personality.
| |
CONCLUSION |
|---|
|
Top
Abstract
Methods
Results
Conclusion
References
|
|---|
This is the first systematic follow-back study of pediatric RAP to use a control group with a history of physical illness in childhood and to use standardized assessment interviews for psychiatric disorder, IBS, and migraine. A history of childhood RAP seems to be associated with anxiety and anxiety disorders in adulthood, and generalized anxiety is more common in the families of affected children than in those of controls. Differences between RAP patients and controls also approached statistical significance for mood disorder and psychiatric disorder in general, with the percentages reported being quite high by community standards and suggesting that a history of childhood RAP is associated with a heightened risk of both anxiety and depressive disorders in adulthood. Comorbid psychopathology in individuals with IBS has been considered related to health care seeking rather than characteristic of FGD,44 although recent data suggest that FGD and psychiatric disorder may be related regardless of treatment seeking status.45 The use of a physically ill control group and the finding that controls used significantly more health services in adulthood suggest that there may be a specific association between RAP and anxiety disorder in excess of the risk conferred by physical illness and associated medical help seeking per se.
Although there were trends in the data suggesting that RAP participants were more likely to report common somatic symptoms and migraine, differences between the groups failed to reach statistical significance. The failure to show significant differences in the prevalence of IBS and somatoform disorders between RAP participants and controls was surprising, but consistent with the results of Hotopf and colleagues,31 who found persistent pediatric abdominal pain to be associated with an increased risk of psychiatric disorder in adulthood, but not a comparatively heightened risk of abdominal pain or other physical symptoms after controlling for psychiatric disorder. Our results suggest that pediatric RAP is likely a better predictor of emotional disorder than of somatic disorders and FGD in adulthood. Given our small sample size, a meaningful regression analysis addressing whether trends toward greater somatic symptom reporting in the RAP group would fall away once psychiatric disorder was controlled for in the analysis was not feasible. The relatively high rate of migraine in young adults with a history of childhood RAP is nevertheless intriguing given reports that RAP may bear a special association with headache5 and migraine3,8,9 in childhood, and the consistent association of migraine with anxiety and depression46 and with IBS in adults.47
The relatively specific association between RAP and anxiety across the lifespan is in keeping with previous studies documenting a strong and consistent association between RAP and anxiety during childhood.7,19,20,21 Trait anxiety may correlate positively with the severity, frequency, and duration of pediatric abdominal pain.7 Both community- and clinic-based studies of adults with IBS have similarly documented a powerful association between IBS and anxiety disorders,45,48 and adults reporting abdominal pain and changes in bowel habits in response to stress report higher levels of trait and state anxiety.49 Conversely, children with anxiety disorders commonly report abdominal pain and other somatic symptoms,50,51,52 and somatic complaints have been uniquely related to pediatric anxiety in selected studies.53 Several studies have failed to find significant differences between children with RAP and psychiatric comparison participants on measures of anxiety, although psychiatric groups score higher on measures of disruptive behavior and depression.19-21
Our finding that RAP participants and controls differed primarily on family history of anxiety but not IBS provides additional support for the association between RAP and anxiety. This finding is consistent with the results of a recent family study which found that first degree relatives of adult IBS probands were no more likely to suffer from FGD than those of comparison participants who had undergone cholescystectomy, but were significantly more likely to suffer from anxiety and depressive disorders.54 Parents of children with RAP report higher levels of anxiety, depression, and somatic symptoms than those of unaffected controls,8,11,19,20,55 with levels of anxiety20 and depression indistinguishable from mothers of psychiatrically referred children.19,55 In addition, children of parents with anxiety disorders report more somatic complaints than children of nonanxious parents.56
Contrary to expectations, controls used significantly more health services in adulthood, although RAP participants were more likely to be taking psychoactive medications. Nonetheless, adults with a history of RAP were more likely to suffer from hypochondriacal fears and perceive themselves as susceptible to impairment by physical illness. It has previously been suggested that childhood RAP may be associated with heightened sensitivity to visceral sensations57 and a vulnerability to respond to life stress with somatic symptoms.2,58 Children with RAP have long been described as temperamentally anxious and inhibited1,59 and as more likely to withdraw in novel situations.60 Such temperamental characteristics have been associated with a heightened risk for anxiety disorder later in life62 and greater vulnerability to activate neural circuits that generate distress responses to potentially threatening or uncertain stimuli.61 Differences in temperament may also be linked to differences in biobehavioral reactivity.63 Temperamentally anxious children may be more likely to report somatic symptoms than noninhibited peers,64 and to perceive novel bodily sensations as threatening in a manner consistent with that described by Barsky and colleagues65 in the conceptualization of "somatosensory amplification."
It has been argued that children with RAP likely represent a heterogeneous population from both the physical and psychosocial perspectives.57,66 Efforts are now underway to better categorize children with RAP, including the use of a newly developed classification system for pediatric FGDs.17 Although such efforts deserve empirical study, this diagnostic system has not yet been validated, and its reliability remains unknown. The investigation of physical and psychiatric comorbidity in pediatric RAP may contribute to the identification of relevant subtypes of the disorder, and information regarding differential associations between RAP, anxiety, and other comorbid conditions such as depression or migraine may provide clues to cause. If the observed comorbidity between RAP and anxiety does not prove artifactual, the relationship may be understood by virtue of a causal model where one disorder essentially causes the other, or by a shared vulnerability model, with the comorbid conditions sharing an underlying risk factor or factors or representing different stages of the same disease or pathophysiologic process.67
This study suffers from a number of potential limitations. Like most studies of RAP, this was a referred sample from a specialized care setting. The charts examined may not have been representative of a random sample of referred children with medically unexplained RAP given the possibility of clinician bias when a registry for "functional" abdominal pain was first created. Despite efforts to minimize assessment bias by performing the psychiatric interview before physical health history, it was also difficult to insure blind psychiatric assessment and scoring of interviews in all cases. The sample is predominantly female, perhaps limiting conclusions that can be drawn about males with RAP, as one population-based study identified an association between RAP and anxiety in girls, but not boys.23 Finally, the rates of psychopathology and somatic symptoms in the comparison group were quite high, perhaps providing an overly rigorous test of study hypotheses. This could be derivative of the small sample size or problems in measurement, but may also reflect a truly increased risk of psychopathology and somatic complaints in our chosen control group. Some participants in the tonsillectomy and adenoidectomy study could have been self-referred, and not all met criteria for surgical intervention, perhaps being added to the pool primarily because of parental concern about illness rather than objective disease. Febrile illness and infections during early childhood have been associated with subsequent anxiety disorders,68 and pediatric physical illness has been associated with a heightened risk for psychiatric disorder across development,69 with allergic disorders specifically being associated with depression70 and behavioral inhibition.71
Clinicians should nevertheless be reluctant to dismiss medically unexplained RAP as a completely benign condition or a transient reaction to stress, and children with RAP should be carefully evaluated for psychiatric disorder, particularly anxiety. Current referral rates of patients with RAP to mental health professionals seem to be low, possibly reflecting difficulties in recognizing emotional disorder, concerns about cost, sensitivity to stigma, the belief that the disorder will remit on its own, and/or a lack of faith in available mental health professionals and interventions.72 Internalizing disorders such as anxiety and depression may be especially difficult for pediatricians to detect, so recognition of more readily identified disorders such as RAP could increase the likelihood of recognition for children with and at risk for emotional disorder. The consistent association of RAP with anxiety suggests that future research examine the nature of the observed comorbidity and whether there are additional risk factors that might predispose individuals with an anxious diathesis to develop RAP. Given the existence of efficacious psychotherapeutic73 and psychopharmacologic74 treatments for pediatric anxiety disorders, it seems relevant to explore whether successful treatments for anxiety might be worthy of investigation in the management of pediatric RAP, as well as whether the early identification and treatment of children with RAP might alter the difficult life trajectory of affected children.
| |
ACKNOWLEDGMENTS |
|---|
This study was supported by the Children's Hospital of Pittsburgh. Dr Campo was supported in part and statistical support was provided by National Institute of Mental Health Grant MH 55123, Child and Adolescent Developmental Psychopathology Research Center for Early-Onset Affective and Anxiety Disorders, and by National Institute of Mental Health Grant K23 MH 01780.
This study is dedicated to the memory of Dr Paul Gaffney, our teacher, friend, and collaborator, whose warmth, generosity, and strength of character made us better physicians and people, and to the late Dr Kenneth Rogers, a true scholar.
We thank Dr Jack Paradise and the tonsillectomy and adenoidectomy study staff for their help in the procurement of comparison participants.
| |
FOOTNOTES |
|---|
Received for publication Sep 18, 2000; accepted Feb 8, 2000.
Address correspondence to John V. Campo, MD, Department of Psychiatry, Western Psychiatric Institute and Clinic, 3811 O'Hara St, Pittsburgh, PA 15213. E-mail: campojv{at}msx.upmc.edu
| |
ABBREVIATIONS |
|---|
RAP, recurrent abdominal pain; FGD, functional gastrointestinal disorder; IBS, irritable bowel syndrome; DSM, Diagnostic and Statistical Manual of Mental Disorders; SCID-NP, Structured Clinical Interview for DSM-IV, Non-patient Version; BSI, brief symptom inventory; NS, not significant.
| |
REFERENCES |
|---|
|
Top
Abstract
Methods
Results
Conclusion
References
|
|---|
do doctors agree?
J
Psychosom Res
1999;
47:483-485 This article has been cited by other articles:
 |
|
 |
|
  K J Lindley, D Glaser, and P J Milla Consumerism in healthcare can be detrimental to child health: lessons from children with functional abdominal pain Arch. Dis. Child., April 1, 2005; 90(4): 335 - 337. [Abstract] [Full Text] [PDF]
|
|
Read all P3Rs
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
||
|
||
Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2001 American Academy of Pediatrics. All rights reserved. |
||
|
||
