Psychosocial interventions for recurrent abdominal pain in childhood

70 Pages·2017·0.96 MB·English

ORE Open Research Exeter
TITLE
Psychosocial interventions for recurrent abdominal pain in childhood
AUTHORS
Abbott, RA; Martin, AE; Newlove-Delgado, TV; et al.
JOURNAL
Cochrane Database of Systematic Reviews
DEPOSITED IN ORE
12 June 2018
This version available at
http://hdl.handle.net/10871/33166
COPYRIGHT AND REUSE
Open Research Exeter makes this work available in accordance with publisher policies.
A NOTE ON VERSIONS
The version presented here may differ from the published version. If citing, you are advised to consult the published version for pagination, volume/issue and date of
publication
CochraneDatabaseofSystematicReviews
Psychosocial interventions for recurrent abdominal pain in
childhood (Review)
AbbottRA,MartinAE,Newlove-DelgadoTV,BethelA,Thompson-CoonJ,WhearR,LoganS
AbbottRA,MartinAE,Newlove-DelgadoTV,BethelA,Thompson-CoonJ,WhearR,LoganS.
Psychosocialinterventionsforrecurrentabdominalpaininchildhood.
CochraneDatabaseofSystematicReviews2017,Issue1.Art.No.:CD010971.
DOI:10.1002/14651858.CD010971.pub2.
www.cochranelibrary.com
Psychosocialinterventionsforrecurrentabdominalpaininchildhood(Review)
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 25
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 68
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Psychosocialinterventionsforrecurrentabdominalpaininchildhood(Review) i
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Psychosocial interventions for recurrent abdominal pain in
childhood
RebeccaAAbbott1,AliceEMartin2,TamsinVNewlove-Delgado1,AlisonBethel1,JoannaThompson-Coon1,RebeccaWhear1,Stuart
Logan1
1NIHRCLAHRCSouthWestPeninsula(PenCLAHRC),UniversityofExeterMedicalSchool,Exeter,UK.2Paediatrics,RoyalDevon
andExeterHospital,Exeter,UK
Contactaddress:RebeccaAAbbott,NIHRCLAHRCSouthWestPeninsula(PenCLAHRC), UniversityofExeterMedicalSchool,
SouthCloisters,StLuke’sCampus,Exeter,England,EX12LU,[email protected],[email protected].
Editorialgroup:CochraneDevelopmental,PsychosocialandLearningProblemsGroup.
Publicationstatusanddate:New,publishedinIssue1,2017.
Citation: AbbottRA,MartinAE,Newlove-DelgadoTV,BethelA,Thompson-CoonJ,WhearR,LoganS.Psychosocialinterventions
for recurrent abdominal pain in childhood. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD010971. DOI:
10.1002/14651858.CD010971.pub2.
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
ThisreviewsupersedestheoriginalCochranereviewfirstpublishedin2008(Huertas-Ceballos2008).
Between4% and 25% of school-aged children complain of recurrent abdominal pain (RAP)severe enough to interfere with their
dailyactivities.Noorganiccauseforthispaincanbefoundonphysicalexaminationorinvestigationforthemajorityofsuchchildren.
Althoughmanychildrenaremanagedbyreassuranceandsimplemeasures,alargerangeofpsychosocialinterventionsinvolvingcognitive
andbehaviouralcomponentshavebeenrecommended.
Objectives
Todeterminetheeffectivenessofpsychosocialinterventionsforreducingpaininschool-agedchildrenwithRAP.
Searchmethods
In June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the
referencesofidentifiedstudiesandrelevantreviews.
Selectioncriteria
Randomised controlledtrialscomparing psychosocial therapieswith usual care,active control,or wait-list controlfor childrenand
adolescents(aged5to18years)withRAPoranabdominalpain-relatedfunctionalgastrointestinaldisorderdefinedbytheRomeIII
criteriawereeligibleforinclusion.
Datacollectionandanalysis
WeusedstandardmethodologicalproceduresexpectedbyCochrane.Fivereviewauthorsindependentlyselectedstudies,assessedthem
forriskofbias,andextractedrelevantdata.WealsoassessedthequalityoftheevidenceusingtheGRADEapproach.
Psychosocialinterventionsforrecurrentabdominalpaininchildhood(Review) 1
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and
adolescentswithRAPbetweentheagesof6and18years.Theinterventionswereclassifiedintofourtypesofpsychosocialtherapy:
cognitivebehaviouraltherapy(CBT),hypnotherapy(includingguidedimagery),yoga,andwrittenself-disclosure.Thestudieswere
carriedoutintheUSA,Australia,Canada,theNetherlands,Germany,andBrazil.Themajorityofthestudiesweresmallandshort
term;onlytwostudiesincludedmorethan100participants,andonlyfivestudieshadfollow-upassessmentsbeyondsixmonths.Small
samplesizesandthedegreeofassessedriskofperformanceanddetectionbiasinmanystudiesledtotheoverallqualityoftheevidence
beingratedaslowtoverylowforalloutcomes.
ForCBTcomparedtocontrol,wefoundevidenceoftreatmentsuccesspostintervention(oddsratio(OR)5.67,95%confidenceinterval
(CI)1.18to27.32;Z=2.16;P=0.03;4studies;175children;verylow-qualityevidence),butnoevidenceoftreatmentsuccessat
medium-termfollow-up(OR3.08,95%CI0.93to10.16;Z=1.85;P=0.06;3studies;139children;low-qualityevidence)orlong-
termfollow-up(OR1.29, 95%CI0.50to3.33; Z=0.53; P=0.60; 2studies;120children;low-quality evidence).Wefoundno
evidence ofeffectsof intervention onpainintensity scoresmeasuredpostintervention (standardised meandifference(SMD) -0.33,
95%CI-0.74to0.08;7studies;405children;low-qualityevidence),oratmedium-termfollow-up(SMD-0.32,95%CI-0.85to
0.20;4studies;301children;low-qualityevidence).
Forhypnotherapy(includingstudiesofguidedimagery)comparedtocontrol,wefoundevidenceofgreatertreatmentsuccesspostin-
tervention(OR6.78,95%CI2.41to19.07;Z=3.63;P=0.0003;4studies;146children;low-qualityevidence)aswellasreductions
inpainintensity(SMD-1.01,95%CI-1.41to-0.61;Z=4.97;P<0.00001;4studies;146children;low-qualityevidence)andpain
frequency(SMD-1.28,95%CI-1.84to-0.72;Z=4.48;P<0.00001;4studies;146children;low-qualityevidence).Theonlystudy
oflong-termeffectreportedcontinuedbenefitofhypnotherapycomparedtousualcareafterfiveyears,with68%reportingtreatment
successcomparedto20%ofcontrols(P=0.005).
Foryogatherapycomparedtocontrol,wefoundnoevidenceofeffectivenessonpainintensity reductionpostintervention(SMD-
0.31,95%CI-0.67to0.05;Z=1.69;P=0.09;3studies;122children;low-qualityevidence).
Thesinglestudyofwrittenself-disclosuretherapyreportednobenefitforpain.
Therewasnoevidenceofeffectfromthepooledanalysesforanytypeofinterventiononthesecondaryoutcomesofschoolperformance,
socialorpsychologicalfunctioning,andqualityofdailylife.
Therewerenoadverseeffectsforanyoftheinterventionsreported.
Authors’conclusions
ThedatafromtrialstodateprovidesomeevidenceforbeneficialeffectsofCBTandhypnotherapyinreducingpainintheshortterm
inchildrenandadolescentspresentingwithRAP.Therewasnoevidencefortheeffectivenessofyogatherapyorwrittenself-disclosure
therapy.TherewereinsufficientdatatoexploreeffectsoftreatmentbyRAPsubtype.
Higher-quality, longer-duration trials are neededto fully investigate theeffectivenessof psychosocial interventions. Identifying the
activecomponentsoftheinterventionsandestablishingwhetherbenefitsaresustainedinthelongtermareareasofpriority.Future
researchstudieswouldbenefitfromemployingactivecontrolgroupstohelpminimisepotentialbiasfromwait-listcontroldesignsand
tohelpaccountfortherapistandinterventiontime.
PLAIN LANGUAGE SUMMARY
Psychosocialtherapyforrecurrentabdominalpaininchildhood
Reviewquestion
Dopsychosocialtherapiesreducepaininchildrenandadolescentswithrecurrentabdominalpain?
Background
Between4%and25%ofschool-agedchildrencomplainofrecurrentabdominalpainsevereenoughtointerferewiththeirdailyactivities.
Noorganiccauseforthispaincanbefoundonphysicalexaminationorinvestigationforthemajorityofsuchchildren.Althoughmany
Psychosocialinterventionsforrecurrentabdominalpaininchildhood(Review) 2
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
childrenaremanagedbyreassuranceandsimplemeasures,alargerangeofpsychologicalandbehavioural(’psychosocial’)therapieshave
beenrecommended.
Methodsandstudycharacteristics
AsofJune2016,weidentified18randomisedcontrolledtrials(atypeofscientificexperimentinwhichpeoplearerandomlyassigned
tooneoftwoormoretreatments),whichincluded928childrenandadolescentsbetweentheagesof6and18years.Thesestudies
comparedarangeofpsychosocialtherapytousualcareorsomeformofnon-therapycontrol(suchaseducationorbreathingexercises).
Weidentifiedfourdifferentkindsofpsychosocialtherapy:cognitivebehaviouraltherapy,hypnotherapy,yoga,andwrittenself-disclosure
(atherapythatinvolveswritingdownthoughtsandfeelingsaboutsomethingdistressing).Thedurationoftheincludedstudiesranged
fromfivedaystothreemonths.ThestudieswereconductedintheUSA,Australia,Canada,theNetherlands,Germany,andBrazil.
Keyresults
Wefoundthatcognitivebehaviouraltherapyandhypnotherapymaybeeffectiveintermsofreducingpainintheshortterm.Therewas
littleevidenceoflong-termbenefit.Therewasnoevidencethateithertherapyhadabeneficialeffectonqualityoflife,dailyactivities,
orpsychologicaloutcomessuchasanxietyanddepression.Yogatherapyandwrittenself-disclosureasatherapyhadnoeffectonpain,
qualityoflife,ordailyactivities.Noadverseeffectswerereportedfromanyofthesetherapies.
Qualityoftheevidence
Weratedtheoverallqualityoftheevidenceaslowtoverylowforalloutcomes.Manyofthestudieshadsmallsamplesizesorweaknesses
intheirstudydesign.Theauthorsreportednoconflictsofinterestinrelationtofunding.
Conclusion
Cognitivebehaviouraltherapyandhypnotherapywarrantconsiderationbycliniciansaspartofthemanagementstrategyforchildren
withrecurrentabdominalpain.Theoverallqualityoftheevidencewaslowtoverylow.Morehigh-qualityresearchisneededtoevaluate
theparticularaspectsofthetherapiesthatareeffectiveandtoestablishwhetherbenefitsaremaintainedovertime.
Psychosocialinterventionsforrecurrentabdominalpaininchildhood(Review) 3
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
CopyrighPsychoso SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
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atiobdo controlorusualcare CBT (95%CI) (studies) (GRADE)
nm
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ubal Treatment success: 211per1000 494per1000 PooledOR5.67(1.18to 175(4) ⊕(cid:13)(cid:13)(cid:13)1 Var-
lishepain postintervention 27.32) Verylow ieddefinitionsof ’treat-
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byJohnchildho aduutchtioornso(fp1a0inpforienets; roen-
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td up (between 3 and 12 ment success’ used by
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ductionof 10pointson
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tervention 0.33SDslower(95%CI-0.74to0.08)thaninthe Low 0.2 SD represents a
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ab
tiodo scale): postinterven- groups was,on average,0.71 SDs higher (95% Verylow 0.2 SD represents a
nm
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ubal Higher score equals oreducationcontrolgroups a moderate difference,
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. cial subscale): postin- CBT groups was, on average, 0.43 SDs higher Low 0.2 SD represents a
tervention (95%CI-0.21to1.06)thanintheusualcare,wait- smalldifference,0.5SD
Higher score equals list,oreducationgroups a moderate difference,
betterQOL. and 0.8 SD a large dif-
ference
2 studies used Ped-
sQL (Varni 2001), 1
studyused KIDSCREEN
(Ravens-Sieberer2005)
.
Functional disability Functional disability in the CBT groups was,on - 176(4) ⊕(cid:13)(cid:13)(cid:13)7 As a rule of thumb,
or activity limitations: average,0.57 SDs lower (95%CI -1.34 to 0.19) Verylow 0.2 SD represents a
postintervention than in the usual care, wait-list, or education smalldifference,0.5SD
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ubal KIDSCREEN:HealthRelatedQualityof LifeQuestionnaireforChildrenandYoungPeople;KINDL-R:measureof health-relatedqualityof life;OR:oddsratio;PedsQL:Pediatric
lishepain Qualityof LifeInventory;QOL:qualityof life;SD:standarddeviation
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L 1Downgraded three levels: high risk of bias across the studies in study design and outcome assessment; high level of
td
. unexplainedheterogeneity(>70%);andalownumberof participantsincludedintheanalysis,wideCIs.
2Downgradedtwolevels:highriskof biasacrossthestudiesinstudydesignandalownumberof participantsincludedinthe
analysis,wideCIs.
3Downgradedtwolevels:highlevelofunexplainedheterogeneity(>70%)andhighriskofbiasacrossthestudies,withbaseline
differencesinprimaryoutcomesinthelargeststudy.
4Downgradedtwolevels:highlevelofunexplainedheterogeneity(>70%)andhighriskofbiasacrossthestudies,withbaseline
differencesinprimaryoutcomesinthelargeststudy.
5Downgraded three levels: high risk of bias across the studies in study design;high level of unexplained heterogeneity (>
70%);andalow numberof participantsincludedintheanalysis,wideCIs.
6Downgradedtwolevels:highriskof biasacrossthestudiesinstudydesignandalownumberof participantsincludedinthe
analysis,wideCIs.
7Downgraded three levels:high risk of bias across the studies in study design;high level of unexplained heterogeneity (>
70%);andalow numberof participantsincludedintheanalysis,wideCIs.
6
Descriptionoftheintervention
BACKGROUND
Thefocusofthisreviewisanyinterventionbasedonpsychologi-
calorbehaviouraltheory(a’psychosocial’intervention).Avariety
ofapproacheshavebeenused,includingbehaviouralandcogni-
Descriptionofthecondition
tive behavioural techniques (Sanders 1994; Scharff 1997), psy-
Recurrentabdominal pain(RAP)isacommonprobleminpae- chotherapy(Vasquez1992),family-centredapproaches(Liebman
diatricpractice.Between4%to25%ofschool-agedchildrensuf- 1976;Walker1999;Wetchler1992),multicomponenttherapies
feratsomepointfromRAPthatinterfereswiththeiractivitiesof (Edwards 1991; Finney 1989; Hicks 2003; Humphreys 1998),
dailyliving(Konijnenberg2005;Williams1996;Youssef2006). and more recently, a variety of what has been termed ’mind-
Thecondition isrelatedtoschoolabsences,hospitaladmissions bodyapproaches’,suchasguidedimagery,yoga,andhypnother-
and,onoccasion,unnecessarysurgicalintervention(Scharff1997; apy (Weydert2006).Specifictotheinterventions found inthis
Størdal2005;Walker1998).Symptomssometimescontinueinto review,cognitivebehaviouraltherapy(CBT)mayinvolvethefam-
adulthood(Apley1975;Walker1995;Youssef2008).Theabdom- ily or may focus only on the child. CBT can be carriedout on
inalpainiscommonlyassociatedwithothersymptoms,including anindividual basisorinagroupformat,andcanbeperformed
headaches,recurrentlimbpains,pallor,andvomiting(Abu-Arafeh face-to-faceorremotelythroughtheuseofCDsandDVDs.CBT
1995;Devanarayana2011;Hyams1995).RAPcancausesignifi- involves the teaching of coping and distraction strategies and
cantanxietyinparentsandcarers,whomaybecomeoverwhelmed relaxation techniques; identification and change of pain-related
byfearofseriousdiseaseandfeelhelplessbecausetheyareunable thoughts; and modification of family responses to pain (Groβ
torelievetheirchild’spain(Paul2013). 2013).Throughhypnosis,hypnotherapyingrouporindividual
ItisgenerallyacceptedthatRAPinchildrenrepresentsagroupof sessionshelpsthepatienttorelaxandthinkaboutcontrollingtheir
functionalgastrointestinaldisordersthathaveanunclearaetiology. painandstrengthensthepatient’sselfefficacyinmanagingtheir
Childrensuffereitherchronicorrecurrentgastrointestinalsymp- pain(Vlieger2007).Guidedimagerycanalsobecarriedouton
tomsnotexplainedbyastructural,biochemical,orinflammatory agrouporindividualbasis.Guidedimageryissimilarinconcept
process.Apleyfirstsoughttodefinethecondition inthe1950s, to hypnotherapy, and is considered to be a form of self regula-
and suggested that the diagnostic label should be based on the tiontherapy,whichaimstoinducedeeprelaxationandfacilitate
presenceofatleastthreeepisodesofsevereabdominalpain(often, thecreationofimagestohelpbringresolutiontopainandsymp-
butnotnecessarily,associatedwithsystemicsymptoms),overthree toms (Weydert 2006). In yoga therapy, the patient learns a se-
months (Apley 1958), with no established organic cause. More riesofphysicalposturesalongwithadailypracticeofbreathing
recently,aninternational consensus definitionwithasymptom- and meditation techniques (Kuttner 2006). Written self-disclo-
basedclassificationsystemhasbeencreated:theRomeIIIcriteria, suretherapy,sometimescalledexpressivewriting,involvesbeing
whichhasspecificcategoriesforpaediatricpresentations(Rasquin giventhe opportunity inaquiet space,to write down thoughts
2006).WehaveusedRAPthroughoutthisreviewasanumbrella andfeelingsaboutsomethingdeeplydistressing,onthreetofour
termtorefertothefourcategoriesincludedwithinthisclassifica- occasionsoveracoupleofweeks,withnosubsequentdiscussion
tion, whichare:functional dyspepsia,irritable bowelsyndrome, orfollow-up.(Wallander2011).
abdominal migraine, andfunctional abdominal pain syndrome.
ThepainclassificationforeachoftheRomeIIIdiagnosesisde-
finedbyatleastoneepisodeperweekforatleasttwomonths;this
Howtheinterventionmightwork
variesfromApley’soriginaldefinitionofRAP(Apley1958).The
Romeclassificationisnotbasedonknownpathophysiologicaldif- Theaetiologyofpain-relatedfunctionalgastrointestinaldisorders
ferencesbetweentheconditions, butratherontheconstellation isunclear.Ithasbeensuggestedthatvisceralhypersensitivity(Di
ofclinicalfeatures.Theextenttowhichseparatingchildreninto Lorenzo2001;VanGinkel2001),autonomicdysfunction(Good
these categories defines groups that are distinct clinical entities 1995),andgutdysmotilitymaycontribute,andthismaybeini-
whoarelikelytoresponddifferentlytotreatmentremainsunclear. tiatedbyaninflammatory,infective,traumatic,orallergictrigger
Nonetheless,thisclassificationhasbeenwelcomedfollowingthe (Mayer2002;Milla1999).Aswithanychronicpaincondition,
historical use of diverse terms, some of which imply causation, it is likelythat psychological factors are important in both pre-
including: “abdominal migraine” (Bain 1974; Hockaday 1992; sentationandtreatment.Manycliniciansbelievethatabdominal
Symon 1986), “abdominal epilepsy” (Stowens 1970), “the irri- pain-relatedfunctional gastrointestinal disorders originate from,
tablebowelsyndromeinchildhood”(Stone1970),“allergic-ten- or are contributed to, by psychogenic factors (Friedman 1972;
sion-fatiguesyndrome”(Sandberg1973;Speer1954),“neuroveg- Raymer1984).Historically,authorshavesuggestedthatchildren
etativedystonia”(Peltonen1970;Rubin1967),“functional gas- withRAPcomefrom“psychosomaticfamilies”(Osborne1989).
trointestinaldisorder”(Drossman1995),and“theirritatedcolon Apopulation-basedstudybyRamchandani2006foundthatanxi-
syndrome”(Harvey1973;Painter1964). etyinparents,whichaddedtoaspecificchildtemperamentbefore
Psychosocialinterventionsforrecurrentabdominalpaininchildhood(Review) 7
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.