Psychosocial problems and childhood recurrent abdominal pain.

Abstract

Recurrent abdominal pain (RAP) is a challenging problem in general pediatrics. The present study aimed to assess psychosocial problems associated with children with RAP.
Children aged 5-15 years with symptoms of abdominal pain for more than 3 months, interfering with their daily life and activities and control children were consecutively enrolled. Psychosocial assessment was obtained by using a semi-structured interview and the Pediatric Symptom Checklist (PSC). Complete physical examination, basic investigations, and esophagogastroduodenoscopy was performed in children with RAP.
Forty-two children with RAP and 45 controls were enrolled into the study. With age and family demographically controlled, psychosocial problems and the PSC scores in children with RAP were not significantly different from those in controls. Psychosocial problems related to RAP could be the primary etiology in some cases, but may be consequent or coexist.
The findings in the study suggest a biopsychosocial approach in children with RAP. Psychosocial assessment should be considered even in RAP with identified organic findings.

Full text

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J Med Assoc Thai Vol. 93 No. 12 20101379
Correspondence to:
Louthrenoo O, Department of Pediatrics, Faculty of Medicine,
Chiang Mai University, Chiang Mai 50200, Thailand.
Phone: 053-945-412, Fax: 053-946-461
E-mail: olouthre@med.cmu.ac.th
Psychosocial Problems and Childhood Recurrent
Abdominal Pain
Orawan Louthrenoo MD*,
Nuthapong Ukarapol MD**, Lumduan Wongsawasdi MD**
* Division of Developmental & Behavioral Pediatrics, Department of Pediatrics, Faculty of Medicine,
Chiang Mai University, Chiang Mai, Thailand
** Division of Pediatric Gastroenterology, Department of Pediatrics, Faculty of Medicine,
Chiang Mai University, Chiang Mai, Thailand
Objective: Recurrent abdominal pain (RAP) is a challenging problem in general pediatrics. The present study aimed to assess
psychosocial problems associated with children with RAP.
Material and Method: Children aged 5-15 years with symptoms of abdominal pain for more than 3 months, interfering with
their daily life and activities and control children were consecutively enrolled. Psychosocial assessment was obtained by using
a semi-structured interview and the Pediatric Symptom Checklist (PSC). Complete physical examination, basic investigations,
and esophagogastroduodenoscopy was performed in children with RAP.
Results: Forty-two children with RAP and 45 controls were enrolled into the study. With age and family demographically
controlled, psychosocial problems and the PSC scores in children with RAP were not significantly different from those in
controls. Psychosocial problems related to RAP could be the primary etiology in some cases, but may be consequent or
coexist.
Conclusion: The findings in the study suggest a biopsychosocial approach in children with RAP. Psychosocial assessment
should be considered even in RAP with identified organic findings.
Keywords: Recurrent abdominal pain, Psychosocial assessment
Recurrent abdominal pain (RAP) is a common
and challenging problem for physicians who take care
of children and adolescents, in which as many as
10-15% of school-age children could have experienced
this condition(1,2). It was firstly defined by Apley and
Naish as three or more episodes of pain, interfering
with normal activities, and occurring over a period of
three months(3). Although only 8% of the cases had
organic abnormalities reported in that study, with
the advance of medical technologies, there has been
increasing report of a higher prevalence of the
organic conditions in recent studies(4-8). Therefore,
organic diseases should be properly evaluated. If
discovered, they should be appropriately treated.
Children with RAP are usually school age
with slight female predominance. The pain is usually
recurrent, rather than constant, and may be associated
with nausea, vomiting, and headache. There are three
clinical presentations, isolated paroxysmal abdominal
pain, abdominal pain associated with symptoms of
dyspepsia and abdominal pain associated with an
altered bowel pattern(9). Children with RAP are classified
into three groups, including those who have organic
diseases, those who have psychological etiology and
the group with functional abdominal pain(10). Because
it also has been suggested that children with RAP,
who are considered to have a functional etiology,
may result from abnormal autonomic response to
stress(4,11,12), some pediatric gastroenterologists
suggest a classification of functional gastrointestinal
disorders associated with recurrent abdominal
pain, known as the ROME II Guidelines(13,14). Possible
assumptions that these children are often worried
about their performance at school or being stressed
by parental pressure have been proposed, however,
there has been no definite supporting evidence. The
episodes appear to be precipitated by stress and
J Med Assoc Thai 2010; 93 (12): 1379-84
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1380J Med Assoc Thai Vol. 93 No. 12 2010
anxiety in some cases(15,16) but also persist by secondary
gain from family and school following organic illnesses.
No matter what causes the psychological problems,
they can affect the child’s schooling, peer relationships,
sports, and daily activity, as well as family events and
social life. Therefore, in children with functional
abdominal pain, besides reassuring the family about
the absence of potential organic causes, psychosocial
assessments should be carefully considered(17,18).
These include cognitive-behavioral therapy(19),
determining precipitating stress, teaching stress
management skills to the child and family, the
elimination of secondary gains and advising the child
to participate in normal activities such as attending
school, as possible.
The objective of the study was to determine
the psychosocial functioning of children with RAP.
The difference in overall functioning between RAP
children with and without identified organic diseases
was also evaluated.
Material and Method
Study sample and design
A sample of 44 children and adolescents with
RAP in the pediatric gastroenterology clinic at Chiang
Mai University Hospital and 45 pain-free controls aged
5-15 years were consecutively enrolled into the study
during 2000-2002. Children with RAP were required to
have experienced three or more episodes of abdominal
pain, severely enough to interfere with their daily
activities in the past three months(3). Control children
were free of chronic pain and did not have chronic
illnesses. Children, whose RAP symptoms were
explained by other physical diseases, were excluded.
Demographic and medical history data were obtained
through an interview.
The semi-structured interview for psycho-
social information and a parent-completed screening
questionnaire were administered by a single
investigator. The psychosocial screening in the
study was assessed using the Pediatric Symptom
Checklist (PSC)(20,21), which consists of 35 items on a
3-point scale (not true, sometimes true, and often true).
The PSC is a feasible tool to screen for psychosocial
problems in school-age children.
Complete physical examination, basic
investigations and esophagogastroduodenoscopy
with biopsy were performed in children with RAP.
All tissue biopsies from the duodenum, stomach and
esophagus, as well as suspected mucosal lesions
were sent for histologic study to further identify
other possible organic causes. Warthin-Starry and
polyclonal antibody stains for Helicobacter pylori
infection were carried out. One biopsy from the gastric
antrum was tested for the presence of H. pylori using
a rapid urease test (Pronto Dry, Medical Instrument
Crop, Solothurn, Switzerland). A written Informed
consent was obtained from the parents. The study was
approved by the Ethics Committee of the Faculty of
Medicine, Chiang Mai University.
Statistical analysis
Data were collected for statistical analysis
using the SPSS program. Chi-square or Fisher’s exact
test, as appropriate and student t-test were used to
compare the two variables. A p-value of < 0.05 was
considered as statistically significant.
Results
Forty-four children with RAP were enrolled
into the study, in which two cases did not undergo
further investigations because psychological
diagnoses were obtained during the initial interviews.
One child had symptoms of generalized anxiety disorder
and the other was diagnosed as somatoform disorder.
Thus, 42 patients underwent upper gastrointestinal
endoscopy with biopsy, as well as testing for H. pylori
infection. The median age was 10.6 years old with a
male-female ratio of 1: 2. Demographic characteristics
between RAP and control group are shown in Table 1,
which were considered comparable. In the study, the
PSC score and behavioral problems reported by
parents were not significant different between the two
groups (Table 2).
Of the 42 RAP children, 21 cases had
identified organic pathologies, including H. pylori
gastritis, duodenitis, parasitic infestation, reflux
esophagitis, bowel vasculitis, gastroparesis, prolapsed
gastropathy, and carcinoma of stomach; whereas the
others were diagnosed as functional gastrointestinal
disorders according to the ROME II classification,
such as cyclic vomiting syndrome, irritable bowel
syndrome, functional constipation, and functional
abdominal pain. RAP children with organic pathology
were significantly older than those without. Again,
there was no statistically significant difference of
the PSC score, behavioral problems reported by the
parents and related psychosocial problems in the RAP
children with and without organic diseases (Table 3).
The psychosocial problems related to children with
RAP included secondary gains from family and school,
moving of family members, parental over-stimulation,

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J Med Assoc Thai Vol. 93 No. 12 20101381
paternal alcohol use, marital problems, change of
schools and school refusal symptoms which had
occurred after the episode of the pain symptoms. The
study also demonstrated that children with organic
findings tended to experience longer duration of
pain compared to those with functional disorders.
Nonetheless, there was no statistically significant
difference.
Discussion
It was found in the study that females
slightly predominated with RAP when compared to
males, as reported in the study by Croffie et al(4).
Additionally, almost half of the RAP children in the
study had organic pathology, consistent with the
previous studies(4-8). Helicobacter pylori gastritis
comprised the most common organic disease.
Although Bode et al demonstrated that the prevalence
of RAP in H. pylori children was not different from
that in non-infected children, organic diseases other
than H. pylori infection were not investigated in that
study(22).
Similar to the study of Stordal et al,
psychosocial problems noted in children with RAP
in the study were not different from controls(6),
although Campo et al reported that children with RAP
had a high level of anxiety and depression(23). Moreover,
Liakopoulou-Kairis et al showed that as many as 81%
of children with RAP had a psychiatric diagnosis(24).
This might result from different cultural backgrounds
regarding health perspectives between Thai population
compared with the Western countries. Apart from
RAP (n = 42)Controls (n = 45)p-value
Age (year) + SD
Gender, % female
Father age (year) + SD
Mother age (year) + SD
Father education (year) + SD
Mother education (year) + SD
Marital status, % married
Number of children
Duration of pain (month) + SD
10.3 + 2.8
66.7
40.4 + 7.7
38.3 + 5.5
8.7 + 5.4
8.4 + 5.0
83.3
2.0 + 1.0
7.6 (3-24)
10.0 + 3.0
48.9
39.1 + 4.7
36.7 + 4.0
8.4 + 4.3
7.8 + 4.1
86.7
2.2 + 0.7
-
0.69
0.09
0.36
0.13
0.79
0.58
0.88
0.23
Table 1. Sociodemographic characteristics of children with RAP and controls
RAP (n = 42)Controls (n = 45)p-value
PSC score
Behavioral problems reported by parents
10.1 + 4.8
4
9.7 + 5.7
3
0.75
0.62
Table 2. Psychosocial characteristics of children with RAP and controls
Organic disorders (n = 21)Functional disorders (n = 21) p-value
Age (year) + SD
Gender, % female
Father age (year) + SD
Mother age (year) + SD
Duration of pain (month) + SD
PSC score + SD
Behavioral problems reported by parents
Related psychosocial problems
11.2 + 2.3
61.9
41.8 + 9.1
38.5 + 6.2
9.1 + 8.1
10.4 + 6.2
2
5
9.4 + 3.1
71.4
39.2 + 6.2
38.1 + 4.9
6.2 + 3.9
9.8 + 3.1
2
6
0.03
0.51
0.31
0.78
0.16
0.68
0.69
0.73
Table 3. Psychosocial characteristics of RAP with and without identified organic causes

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1382J Med Assoc Thai Vol. 93 No. 12 2010
the association between organic diseases and
psychological impacts, emotional problems have been
reported to be associated with irritable bowel
syndrome(2), however, this conclusion was not made
by the study by Nygaard et al(5). Conversely, chronic
pain may lead to emotional consequences, such as
anxiety and distress.
In subgroup analysis, the authors tried to
test the hypothesis that RAP is not exclusively a
functional gastrointestinal disorder. In the study,
the PSC score, behavioral problems reported by their
parents and related psychosocial problems in the
patients with functional gastrointestinal disorders
were not significantly higher than those with organic
causes. Hence, this might strengthen the recent
speculation stating that recurrent abdominal pain
in children is not a purely functional disorder(25).
Although the organic pathology could not be
discovered in all children, we did not perform the
investigations searching for any possible abnormality
in gastrointestinal motility, which could be potentially
contributing to the RAP symptoms. Consequently, it
can explain why the PSC scores were not different
between the two groups.
There were some limitations in the study,
however. First, the study was cross-sectional in
nature. It was not possible to establish a systematic
study of the outcome responses. The concurrent
psychosocial findings could not be distinguished
to be precipitating or co-existing factors. Secondly,
the sample of children with RAP in the pediatric
gastroenterology clinic at the authors’ institute may
not truly represent those in general population
settings, as it was noted that there was high prevalence
of organic pathology in the authors’ series. Lastly,
the sample size was not large enough to identify
the association of various variables. For children
who were diagnosed with functional gastrointestinal
disorders, medical investigations helped in reassuring
the child and family, whilst teaching stress manage-
ment resulted in better adjustment and improving
the pain symptoms.
In conclusion, since organic diseases,
functional disorders, and psychological problems
may coexist, a biopsychosocial approach that is
concerned with the disease and the illness, the
child’s sense of suffering and disability, should be
emphasized(26,27). It was suggested in the study
that organic pathology was more common than
previously thought. Biopsychosocial approach would
be appropriate for children with RAP.
Acknowledgements
The authors would like to thank children and
families for their participation in the study.
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