Acceptance-based interoceptive exposure for young children with functional abdominal pain

Abstract

Functional abdominal pain (FAP) is a common childhood somatic complaint that contributes to impairment in daily functioning (e.g., school absences) and increases risk for chronic pain and psychiatric illness. Cognitive behavioral treatments for FAP target primarily older children (9 + years) and employ strategies to reduce a focus on pain. The experience of pain may be an opportunity to teach viscerally hypersensitive children to interpret the function of a variety of bodily signals (including those of hunger, emotions) thereby reducing fear of bodily sensations and facilitating emotion awareness and self-regulation. We designed and tested an interoceptive exposure treatment for younger children (5-9 years) with FAP. Assessments included diagnostic interviews, 14 days of daily pain monitoring, and questionnaires. Treatment involved 10 weekly appointments. Using cartoon characters to represent bodily sensations (e.g., Gassy Gus), children were trained to be "FBI agents" - Feeling and Body Investigators - who investigated sensations through exercises that provoked somatic experience. 24 parent-child dyads are reported. Pain (experience, distress, and interference) and negative affect demonstrated clinically meaningful and statistically significant change with effect sizes ranging from 0.48 to 71 for pain and from 0.38 to 0.61 for pain distress, total pain: X² (1, n = 24) = 13.14, p < 0.0003. An intervention that helps children adopt a curious stance and focus on somatic symptoms reduces pain and may help lessen somatic fear generally.

Clinical trial registration: NCT02075437.

Keywords: Functional abdominal pain; Interoceptive awareness; Interoceptive exposure; Somatic fear; Visceral hypersensitivity.

Figure 1. Body characters of the FBI intervention

Characters were used to portray different bodily sensations. A few new characters were learned each session. The program started with more basic sensations such as hunger and fullness and progressed onto sensations of emotional experience (for example, Ricky the rock, Betty butterfly, Julie jitters) and different forms of pain (for example, Patricia the poop pain, Harold the hunger pain). Study Characters, © 2017 Duke University. All Rights Reserved.

Figure 2. Worksheet for the FBI intervention

Sections of the worksheet were added as the intervention progressed. The goal of the worksheet was to help children learn to understand the messages of bodily experiences and to respond to those messages in an investigative fashion. The intention was to teach children that bodily signals communicate needs and if you listen to your body and learn more about what you need to get to know yourself and trust yourself and your body. Contact the first author for intervention materials (Nancy.Zucker@duke.edu).

Figure 3. Recruitment and Eligibility Flow Diagram

An active recruitment strategy was employed in which recruiters remained on-site at a pediatric primary care practice. Nurses asked families deemed eligible by age and medical chart review if they were interested in learning more about a treatment study for abdominal pain in children aged 5 to 9 years old. In this manner, we attempted to screen all potentially eligible children presenting to primary care.

Figure 4. Parent ratings of child pain and child pain distress

Parents rated their child’s pain for two weeks prior to the intervention and two weeks post-intervention. Ratings about pain were made at several time points: overnight – assessed as soon as the child woke up; beginning of day, between 6 and 9 AM; before dinner – between 5 PM and 8 PM; end of day, approximately between 7 PM and 9 PM. End of day ratings reflected worse pain experienced during that day and overall mood throughout the day. Total effect sizes reflect all individual data points combined across all time periods. All posttreatment scores were significantly below Bonferroni corrected levels of significance.

Figure 5. Child ratings of pain and negative affect

Children rated their pain for two weeks prior to the intervention and two weeks post-intervention. Ratings about pain and negative affect were made at several time points: beginning of day, between 6 and 9 AM and before dinner – between 5 PM and 8 PM. Total effect sizes reflect all individual data points combined across all time periods. All posttreatment scores were significantly below Bonferroni corrected levels of significance.