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Meta-Analysis
. 2017 Jan 10;1(1):CD010971.
doi: 10.1002/14651858.CD010971.pub2.

Psychosocial interventions for recurrent abdominal pain in childhood

Rebecca A Abbott  1 , Alice E Martin  2 , Tamsin V Newlove-Delgado  1 , Alison Bethel  1 , Joanna Thompson-Coon  1 , Rebecca Whear  1 , Stuart Logan  1
Affiliations
Meta-Analysis

Psychosocial interventions for recurrent abdominal pain in childhood

Rebecca A Abbott et al. Cochrane Database Syst Rev. .

Abstract

Background: This review supersedes the original Cochrane review first published in 2008 (Huertas-Ceballos 2008).Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. No organic cause for this pain can be found on physical examination or investigation for the majority of such children. Although many children are managed by reassurance and simple measures, a large range of psychosocial interventions involving cognitive and behavioural components have been recommended.

Objectives: To determine the effectiveness of psychosocial interventions for reducing pain in school-aged children with RAP.

Search methods: In June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the references of identified studies and relevant reviews.

Selection criteria: Randomised controlled trials comparing psychosocial therapies with usual care, active control, or wait-list control for children and adolescents (aged 5 to 18 years) with RAP or an abdominal pain-related functional gastrointestinal disorder defined by the Rome III criteria were eligible for inclusion.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. Five review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence using the GRADE approach.

Main results: This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and adolescents with RAP between the ages of 6 and 18 years. The interventions were classified into four types of psychosocial therapy: cognitive behavioural therapy (CBT), hypnotherapy (including guided imagery), yoga, and written self-disclosure. The studies were carried out in the USA, Australia, Canada, the Netherlands, Germany, and Brazil. The majority of the studies were small and short term; only two studies included more than 100 participants, and only five studies had follow-up assessments beyond six months. Small sample sizes and the degree of assessed risk of performance and detection bias in many studies led to the overall quality of the evidence being rated as low to very low for all outcomes.For CBT compared to control, we found evidence of treatment success postintervention (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.18 to 27.32; Z = 2.16; P = 0.03; 4 studies; 175 children; very low-quality evidence), but no evidence of treatment success at medium-term follow-up (OR 3.08, 95% CI 0.93 to 10.16; Z = 1.85; P = 0.06; 3 studies; 139 children; low-quality evidence) or long-term follow-up (OR 1.29, 95% CI 0.50 to 3.33; Z = 0.53; P = 0.60; 2 studies; 120 children; low-quality evidence). We found no evidence of effects of intervention on pain intensity scores measured postintervention (standardised mean difference (SMD) -0.33, 95% CI -0.74 to 0.08; 7 studies; 405 children; low-quality evidence), or at medium-term follow-up (SMD -0.32, 95% CI -0.85 to 0.20; 4 studies; 301 children; low-quality evidence).For hypnotherapy (including studies of guided imagery) compared to control, we found evidence of greater treatment success postintervention (OR 6.78, 95% CI 2.41 to 19.07; Z = 3.63; P = 0.0003; 4 studies; 146 children; low-quality evidence) as well as reductions in pain intensity (SMD -1.01, 95% CI -1.41 to -0.61; Z = 4.97; P < 0.00001; 4 studies; 146 children; low-quality evidence) and pain frequency (SMD -1.28, 95% CI -1.84 to -0.72; Z = 4.48; P < 0.00001; 4 studies; 146 children; low-quality evidence). The only study of long-term effect reported continued benefit of hypnotherapy compared to usual care after five years, with 68% reporting treatment success compared to 20% of controls (P = 0.005).For yoga therapy compared to control, we found no evidence of effectiveness on pain intensity reduction postintervention (SMD -0.31, 95% CI -0.67 to 0.05; Z = 1.69; P = 0.09; 3 studies; 122 children; low-quality evidence).The single study of written self-disclosure therapy reported no benefit for pain.There was no evidence of effect from the pooled analyses for any type of intervention on the secondary outcomes of school performance, social or psychological functioning, and quality of daily life.There were no adverse effects for any of the interventions reported.

Authors' conclusions: The data from trials to date provide some evidence for beneficial effects of CBT and hypnotherapy in reducing pain in the short term in children and adolescents presenting with RAP. There was no evidence for the effectiveness of yoga therapy or written self-disclosure therapy. There were insufficient data to explore effects of treatment by RAP subtype.Higher-quality, longer-duration trials are needed to fully investigate the effectiveness of psychosocial interventions. Identifying the active components of the interventions and establishing whether benefits are sustained in the long term are areas of priority. Future research studies would benefit from employing active control groups to help minimise potential bias from wait-list control designs and to help account for therapist and intervention time.

PubMed Disclaimer

Conflict of interest statement

The work of the evidence synthesis team is funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC). However, the funder had no role in the review itself.

Rebecca A Abbott: none known. Alice E Martin: none known. Tamsin V Newlove‐Delgado: none known. Alison Bethel: none known. Joanna Thompson‐Coon: none known. Rebecca Whear: none known Stuart Logan: none known.

The authors who practice clinical paediatrics are Alice E Martin and Stuart Logan. Alice is a Paediatric Trainee and works under the guidance of various Consultant Paediatricians. Stuart is a Consultant Paediatrician and treats children according to current best evidence, in light of their preference. There are therefore no conflicts of interest with this review.

Figures

1
1
PRISMA flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 1 Treatment success: postintervention.
1.2
1.2. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 2 Treatment success: medium‐term follow‐up (3 to 12 months).
1.3
1.3. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 3 Treatment success: long‐term follow‐up (12 months or more).
1.4
1.4. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 4 Pain intensity: postintervention.
1.5
1.5. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 5 Pain intensity: postintervention sensitivity analysis for allocation concealment (low risk of bias).
1.6
1.6. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 6 Pain intensity: medium‐term follow‐up (3 to 12 months).
1.7
1.7. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 7 Pain intensity: long‐term follow‐up (12 months or more).
1.8
1.8. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 8 Quality of life (physical subscale): postintervention.
1.9
1.9. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 9 Quality of life (psychosocial subscale): postintervention.
1.10
1.10. Analysis
Comparison 1 Cognitive behavioural therapy (CBT) versus control, Outcome 10 Functional disability or activity limitations: postintervention.
2.1
2.1. Analysis
Comparison 2 Hypnotherapy (including guided imagery) versus control, Outcome 1 Treatment success: postintervention.
2.2
2.2. Analysis
Comparison 2 Hypnotherapy (including guided imagery) versus control, Outcome 2 Pain intensity: postintervention.
2.3
2.3. Analysis
Comparison 2 Hypnotherapy (including guided imagery) versus control, Outcome 3 Pain frequency: postintervention.
3.1
3.1. Analysis
Comparison 3 Yoga versus control, Outcome 1 Pain intensity: postintervention.
3.2
3.2. Analysis
Comparison 3 Yoga versus control, Outcome 2 Functional impairment: postintervention.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010971

References

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References to other published versions of this review

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