Chronic abdominal pain is a common problem that affects up to 20 percent of all school-aged children and teens.
Despite how many youth struggle with abdominal pain, there is no clear agreement among medical professionals about how best to manage it.
What professionals do agree on is that abdominal pain is complex and can be difficult to treat effectively.
Craig Friesen, MD, is here to explain how the Gastroenterology Division at Children’s Mercy uses a biopsychosocial approach to chronic pain and has delivered resolution or near resolution of symptoms in 70-80 percent of patients within six weeks.
Selected Podcast
Abdominal Pain: A Biopsychosocial Approach to Improving Outcomes
Featured Speaker:
Learn more about Craig Friesen, MD
Craig Friesen, MD
Craig Friesen, MD, is the Division Director of Gastroenterology at Children’s Mercy Kansas City. He also serves as the Medical Director of Abdominal Pain and is a Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine.Learn more about Craig Friesen, MD
Transcription:
Abdominal Pain: A Biopsychosocial Approach to Improving Outcomes
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is “Abdominal Pain: A Biopsychosocial Approach to Improving Outcomes.” My guest is Dr. Craig Friesen. Dr. Friesen is the Division Director of Gastroneurology at Children’s Mercy Kansas City. He also serves as the Medical Director of Abdominal Pain and is a Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. Dr. Friesen, welcome to the show.
Dr. Craig Friesen (Guest): Thank you. It’s a pleasure to be here.
Dr. Smith: Let’s just start off with how prevalent is chronic abdominal pain in children?
Dr. Friesen: Well, it’s the most prevalent chronic pain syndrome that exists in children. At any point in time, approximately 15-20% of kids will report that they’ve been having pain for at least the last three months, significant enough to interfere with activity. There are some groups like young adolescent females where that prevalence is up as high as 30%. Those have been really consistent numbers that studies have been done over a number of decades and multiple countries. They all tend to settle out at about those same kinds of numbers.
Dr. Smith: Okay. Why isn’t there a clear agreement among medical professionals about how to best treat and manage chronic abdominal pain in kids?
Dr. Friesen: Well, the quick answer is that there really hasn’t been as much research as you would think there would be for something that’s so prevalent. Most of the research that’s been done has been looking at really narrow aspects. For example, how often do children have depression or anxiety? How often do they have a motility problem but very few studies have looked at this and given patients for all the factors that may be operative and, not very often, is it just a single thing, such as anxiety, that’s creating pain in children. Usually, it’s a combination of inflammation in the intestines plus motility, plus the environment, plus sort of what’s going on in the brains and how they think about things. Given the complexity of it, these really narrow views that have been done in the few studies that do exist, just haven’t given us an accurate picture that allows us to take care of the patient in front of us.
Dr. Smith: Since we don’t have clear agreement and we are missing some of that research, when should a general practitioner, a general pediatrician, refer a patient with chronic abdominal pain to Children’s Mercy? Are there some red flags that if we see these signs and symptoms boom! We’re off to Children’s Mercy?
Dr. Friesen: I think on the first visit there are certainly signs that would say, “Don’t even do workup or take a shot at it,” and, for the most part, the big ones are going to be if there’s any bleeding, so if kids are throwing up blood or passing blood in their stools. Those would need to be referred early to get testing done. Children who have lost weight, intractable vomiting, intractable diarrhea, really, if the symptoms other than the abdominal pain are particularly severe, those are things that, in general, should get patients referred. I also think that one of those red flags should be kids who are not functioning. So, if you’re not able to attend school, attend activities and do the normal things that would be expected of a child, those are things where I think referral early is better before the children get really debilitated. Those children really require a lot of services that, frankly, there just isn’t time to perform for those kids in the time allotted in a usual pediatrician’s office.
Dr. Smith: Right. So, at Children’s Mercy, you use a biopsychosocial approach to pain. Can you tell us about this approach? The success of it? Maybe even walk us through what a patient and the family will experience when they come to Children’s Mercy.
Dr. Friesen: In short, the biopsychosocial model of abdominal pain states, which is intuitive in the name, that there’s biological factors, psychological factors and social factors that are contributing to symptom generation and, really, the disease state and the disability associated with the abdominal pain. What we know is that, all three of those factors exist in most children and they interact with each other. The traditional medical approach has, really, for the most part involved looking for those biological or those medical factors. So, what’s the diagnosis? And in the event that there isn’t a diagnosis found or patients don’t respond to treatment, then the approach is just to assume that it’s psychosocial and refer them on for counseling. This approach is really fragmented and, for the most part, doesn’t work. The patients read that as, “You couldn’t find something so now you think I’m crazy.” What we know is, is that it’s probably all three of those. So, this model really says, “Stop looking for the biological answer or the psychological answer or the social answer. What’s going on at school; what’s going on at home,” because at the end you’re probably not going to be able to isolate it to one event. Those things are so interactive. So, for example, if patients have anxiety, should we ask the question why do they get abdominal pain? I would venture to guess that all people and, certainly all adolescents, have some degree of anxiety but why do some get abdominal pain, some get headaches and some get no pain in association with it? So, there are some factors that go on in the gut as part of that and anxiety itself will create dysmotility; will create inflammation. Those, in turn, can create chemicals that actually create anxiety reaction. So, at the end of the day, these things are so interrelated that it’s virtually impossible to separate them out or to say, “Here’s the one key factor for this patient.” So, our model or how we’ve instituted that model here is, that we don’t worry so much about looking for the one cause but we really try to identify all the psychological, all the social and all the biological factors that are contributing in a given patient and go after them all at once. We feel like this has really been the key to having good outcomes in these patients. Certainly, I think it’s more honest or accurate about what’s really going on in a patient. If you come in to Children’s Mercy, the first visit here is going to last anywhere from one and a half to two and a half hours. Patients will come in and we collect a large amount of information from key markers. They end up filling out a lot of paperwork for us but those really assess a number of factors. One, there’s the symptoms, which are going to be the part that’s my main job within this. Are there diagnoses we are missing and what treatment based on their symptoms or what biological factors may be active that we can go after with medications? We also collect data on just the general psychobehavioral aspects for a given patient. So, do they have depression? Do they have anxiety? Do they have anxiety about school, relationships with peers? With teachers? So, kind of a broad psychosocial look at what’s going on. We collect data on how their functioning, how they cope, how their parents interact with them when they’re having pain. Is that in a way that’s generally helpful to decrease the pain or one that may continue to propagate pain behaviors? We collect measures on sleep because we know sleep impacts all biological and psychosocial factors and, again, becomes a target that we’re going to deal with. All those questions outside of medical are generally assessed by my partner which is Dr. Jennifer Sherman. So, we collect all of this data, have a meeting and we put together a plan for those patients. Then, we see them together for that first visit and explain sort of what we think’s going on for each piece of this model, how they interact with each other and put together a plan for them on how we’re going to go after trying to get control of this pain. My interest has really been in unusual forms or sort of novel forms of inflammation and they’re mendable and eosinophils and mast cells in the gut are a significant focus of how we treat this along with sort of visceral hypersensitivity. We use a lot of biofeedback, assisted relaxation training. We found that even those children that don’t have measureable anxiety, they tend to respond to medications better if we do something to try to control stress hormones as part of this. So, in the end, that model as we play it out is to look for all of biological, psychological and social factors and to go after all of them from the first visit going forward. We then follow them up and keep that model going through and make our adjustments. For us, that has been, we think, very effective. I did this before the model even existed in kind of the old medical model and I can tell you this approach is way more successful.
Dr. Smith: Right.
Dr. Friesen: And certainly patient satisfaction is much higher. The ability of those children to cope is much better. We track outcomes in all patients and what we know is, on the first follow up visit, which can be anywhere from two weeks to eight weeks after that initial one, depending on the disability of the children, we have a 56% response rate by six weeks. When we look at it in that fashion, we have a response rate of between 70-80%. There are no national standards for what they do. The natural history of chronic abdominal pain in children, if you just reassure them and don’t intervene, is that over 50% will have pain that progresses into adulthood. Other centers are reporting an approximately 50% response rate at 12 months, so this really does seem to be a model that plays out. I think it’s unique to this facility. There are not many places that have a GI doc and a psychologist will walk into the patient’s room on the first visit with a comprehensive plan.
Dr. Smith: Well, Dr. Friesen, I want to thank you for the work that you’re doing at Children’s Mercy. And I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to childrensmercy.org. That’s childrensmercy.org. I‘m Dr. Michael Smith. Have a great day.
Abdominal Pain: A Biopsychosocial Approach to Improving Outcomes
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is “Abdominal Pain: A Biopsychosocial Approach to Improving Outcomes.” My guest is Dr. Craig Friesen. Dr. Friesen is the Division Director of Gastroneurology at Children’s Mercy Kansas City. He also serves as the Medical Director of Abdominal Pain and is a Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. Dr. Friesen, welcome to the show.
Dr. Craig Friesen (Guest): Thank you. It’s a pleasure to be here.
Dr. Smith: Let’s just start off with how prevalent is chronic abdominal pain in children?
Dr. Friesen: Well, it’s the most prevalent chronic pain syndrome that exists in children. At any point in time, approximately 15-20% of kids will report that they’ve been having pain for at least the last three months, significant enough to interfere with activity. There are some groups like young adolescent females where that prevalence is up as high as 30%. Those have been really consistent numbers that studies have been done over a number of decades and multiple countries. They all tend to settle out at about those same kinds of numbers.
Dr. Smith: Okay. Why isn’t there a clear agreement among medical professionals about how to best treat and manage chronic abdominal pain in kids?
Dr. Friesen: Well, the quick answer is that there really hasn’t been as much research as you would think there would be for something that’s so prevalent. Most of the research that’s been done has been looking at really narrow aspects. For example, how often do children have depression or anxiety? How often do they have a motility problem but very few studies have looked at this and given patients for all the factors that may be operative and, not very often, is it just a single thing, such as anxiety, that’s creating pain in children. Usually, it’s a combination of inflammation in the intestines plus motility, plus the environment, plus sort of what’s going on in the brains and how they think about things. Given the complexity of it, these really narrow views that have been done in the few studies that do exist, just haven’t given us an accurate picture that allows us to take care of the patient in front of us.
Dr. Smith: Since we don’t have clear agreement and we are missing some of that research, when should a general practitioner, a general pediatrician, refer a patient with chronic abdominal pain to Children’s Mercy? Are there some red flags that if we see these signs and symptoms boom! We’re off to Children’s Mercy?
Dr. Friesen: I think on the first visit there are certainly signs that would say, “Don’t even do workup or take a shot at it,” and, for the most part, the big ones are going to be if there’s any bleeding, so if kids are throwing up blood or passing blood in their stools. Those would need to be referred early to get testing done. Children who have lost weight, intractable vomiting, intractable diarrhea, really, if the symptoms other than the abdominal pain are particularly severe, those are things that, in general, should get patients referred. I also think that one of those red flags should be kids who are not functioning. So, if you’re not able to attend school, attend activities and do the normal things that would be expected of a child, those are things where I think referral early is better before the children get really debilitated. Those children really require a lot of services that, frankly, there just isn’t time to perform for those kids in the time allotted in a usual pediatrician’s office.
Dr. Smith: Right. So, at Children’s Mercy, you use a biopsychosocial approach to pain. Can you tell us about this approach? The success of it? Maybe even walk us through what a patient and the family will experience when they come to Children’s Mercy.
Dr. Friesen: In short, the biopsychosocial model of abdominal pain states, which is intuitive in the name, that there’s biological factors, psychological factors and social factors that are contributing to symptom generation and, really, the disease state and the disability associated with the abdominal pain. What we know is that, all three of those factors exist in most children and they interact with each other. The traditional medical approach has, really, for the most part involved looking for those biological or those medical factors. So, what’s the diagnosis? And in the event that there isn’t a diagnosis found or patients don’t respond to treatment, then the approach is just to assume that it’s psychosocial and refer them on for counseling. This approach is really fragmented and, for the most part, doesn’t work. The patients read that as, “You couldn’t find something so now you think I’m crazy.” What we know is, is that it’s probably all three of those. So, this model really says, “Stop looking for the biological answer or the psychological answer or the social answer. What’s going on at school; what’s going on at home,” because at the end you’re probably not going to be able to isolate it to one event. Those things are so interactive. So, for example, if patients have anxiety, should we ask the question why do they get abdominal pain? I would venture to guess that all people and, certainly all adolescents, have some degree of anxiety but why do some get abdominal pain, some get headaches and some get no pain in association with it? So, there are some factors that go on in the gut as part of that and anxiety itself will create dysmotility; will create inflammation. Those, in turn, can create chemicals that actually create anxiety reaction. So, at the end of the day, these things are so interrelated that it’s virtually impossible to separate them out or to say, “Here’s the one key factor for this patient.” So, our model or how we’ve instituted that model here is, that we don’t worry so much about looking for the one cause but we really try to identify all the psychological, all the social and all the biological factors that are contributing in a given patient and go after them all at once. We feel like this has really been the key to having good outcomes in these patients. Certainly, I think it’s more honest or accurate about what’s really going on in a patient. If you come in to Children’s Mercy, the first visit here is going to last anywhere from one and a half to two and a half hours. Patients will come in and we collect a large amount of information from key markers. They end up filling out a lot of paperwork for us but those really assess a number of factors. One, there’s the symptoms, which are going to be the part that’s my main job within this. Are there diagnoses we are missing and what treatment based on their symptoms or what biological factors may be active that we can go after with medications? We also collect data on just the general psychobehavioral aspects for a given patient. So, do they have depression? Do they have anxiety? Do they have anxiety about school, relationships with peers? With teachers? So, kind of a broad psychosocial look at what’s going on. We collect data on how their functioning, how they cope, how their parents interact with them when they’re having pain. Is that in a way that’s generally helpful to decrease the pain or one that may continue to propagate pain behaviors? We collect measures on sleep because we know sleep impacts all biological and psychosocial factors and, again, becomes a target that we’re going to deal with. All those questions outside of medical are generally assessed by my partner which is Dr. Jennifer Sherman. So, we collect all of this data, have a meeting and we put together a plan for those patients. Then, we see them together for that first visit and explain sort of what we think’s going on for each piece of this model, how they interact with each other and put together a plan for them on how we’re going to go after trying to get control of this pain. My interest has really been in unusual forms or sort of novel forms of inflammation and they’re mendable and eosinophils and mast cells in the gut are a significant focus of how we treat this along with sort of visceral hypersensitivity. We use a lot of biofeedback, assisted relaxation training. We found that even those children that don’t have measureable anxiety, they tend to respond to medications better if we do something to try to control stress hormones as part of this. So, in the end, that model as we play it out is to look for all of biological, psychological and social factors and to go after all of them from the first visit going forward. We then follow them up and keep that model going through and make our adjustments. For us, that has been, we think, very effective. I did this before the model even existed in kind of the old medical model and I can tell you this approach is way more successful.
Dr. Smith: Right.
Dr. Friesen: And certainly patient satisfaction is much higher. The ability of those children to cope is much better. We track outcomes in all patients and what we know is, on the first follow up visit, which can be anywhere from two weeks to eight weeks after that initial one, depending on the disability of the children, we have a 56% response rate by six weeks. When we look at it in that fashion, we have a response rate of between 70-80%. There are no national standards for what they do. The natural history of chronic abdominal pain in children, if you just reassure them and don’t intervene, is that over 50% will have pain that progresses into adulthood. Other centers are reporting an approximately 50% response rate at 12 months, so this really does seem to be a model that plays out. I think it’s unique to this facility. There are not many places that have a GI doc and a psychologist will walk into the patient’s room on the first visit with a comprehensive plan.
Dr. Smith: Well, Dr. Friesen, I want to thank you for the work that you’re doing at Children’s Mercy. And I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to childrensmercy.org. That’s childrensmercy.org. I‘m Dr. Michael Smith. Have a great day.