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NIH 1R01HD076983-01A1: Predicting Treatment Outcomes in Pediatric Functional Abdominal Pain

Funded by the National Institute of Child Health and Development (2014-2019)

Principal Investigator: Lynn S. Walker, Ph.D.

Co-Investigators: Stephen Bruehl, Ph.D., Judy Garber, Ph.D., Tonya Palermo, Ph.D., Craig A. Smith, Ph.D.

NIH Abstract
The goal of our research is to identify individual differences in pediatric functional abdominal pain (FAP) that predict differential health outcomes in response to an intervention and can be used to further tailor interventions for FAP. FAP is among the most common pain problems in childhood and prospectively predicts risk for chronic pain, disability, and frequent health service utilization (HSU) in early adulthood. Therefore, providing effective treatments of FAP is a critical public health concern. Cognitive behavior therapy (CBT) delivered by highly trained professionals in face-to-face sessions has been found to reduce pain in some FAP patients, but such intensive resources are not generally available to most FAP patients.

The proposed study will evaluate an alternative approach to treating FAP. The study integrates and extends recent work by leading investigators in pediatric pain. In a prospective natural history study of pediatric onset FAP patients followed into late adolescence/early adulthood, PI Walker and colleagues identified three distinct patient profiles (i.e., Low Pain Adaptive, High Pain Adaptive, High Pain Dysfunctional) comprising pain severity, pain cognitions, and effect at the time of the initial FAP evaluation in childhood. These pain profiles predicted chronic pain and disability at follow-up (FU) nearly a decade later. Patients with the High Pain Dysfunctional profile at baseline had the poorest symptom outcomes and also exhibited pro-nociceptive central pain modulation in laboratory pain tests at FU. The heterogeneity of the FAP pain profile groups suggests that they may differ in treatment needs and in the extent to which they benefit from behavioral interventions.

Co-Investigator Palermo developed and tested a CBT intervention (Web-based Management of Adolescent Pain; Web-MAP) for youth with various chronic pain conditions. This efficient, easily disseminated treatment includes separate modules delivered online to youth and parents. WebMAP Online CBT significantly reduced youths’ pain and disability in comparison to a usual care, wait-list control condition.

The current proposal merges these lines of research into an innovative study that will, for the first time: (Aim 1) administer Online CBT adapted specifically for FAP and evaluate its efficacy compared to an Online Information, attention control condition; (Aim 2) evaluate baseline moderators of treatment response, including our previously validated FAP pain profiles, pro-nociceptive central pain modulation, and parent characteristics (protectiveness, modeling pain behavior, catastrophizing about the child’s pain); and (Aim 3) evaluate potential mediators of the effect of  Online CBT on health outcomes.

Following medical evaluation, FAP patients (n = 300) ages 11-17 years and their parents will be randomized to Online CBT or Online Information. Assessments will be at baseline, mid-, and post-treatment, and at six and 12 months post-baseline. The study will produce knowledge that can be used to more efficiently target interventions to FAP patients according to their individual profiles, and thereby extend evidence-based care to more patients and ultimately reduce overall costs of care.

NIH R01HD023264 Developmental Outcomes of Pediatric Chronic Abdominal Pain

Funded by the National Institute of Child Health and Development (2007-2012)

Principal Investigator: Lynn S. Walker, Ph.D.

Co-Investigators: Stephen Bruehl, Ph.D., Bruce Compas, Ph.D., Andre Diedrich, M.D., Ph.D. Judy Garber, Ph.D., D. Brent Polk, M.D., Craig A. Smith, Ph.D.

NIH Abstract
Our goal is to understand biopsychosocial processes associated with pediatric chronic pain with the aim of informing prevention and treatment. Youth with chronic abdominal pain (CAP) have served as a prototype in our study of pain not associated with significant medically explained pathology. These youth are thought to be at risk for functional gastrointestinal disorders (FGIDs), headache, other chronic pain disorders, and psychiatric disorders as adolescents and adults. However, no prospective studies have systematically assessed these outcomes. Additional information is needed to characterize physical, emotional, and functional outcomes of CAP, discover risk factors for adverse outcomes, and identify psychological, behavioral, and physiological factors that may influence the course of CAP from childhood to adolescence and young adulthood.

This application capitalizes on our existing landmark database of more than 800 patients evaluated for CAP at ages eight through 15 years and a similar age control group of 350 well children. Our sample presents a unique opportunity to identify predictors of long-term health and psychosocial outcomes of pediatric onset CAP for individuals in our database who will be adolescents and young adults (ages 13 - 28 years) at follow-up. Former study participants with pediatric onset-CAP and those previously serving as well controls will be contacted for detailed psychosocial and laboratory follow-up assessment. Thus, we will evaluate CAP patients as they pass through the "age of risk" for several disorders associated with considerable impairment and health service use.

We aim to (1) examine health and functional outcomes (including diagnostic criteria for FGIDs, chronic pain disorders, and psychiatric disorders) in adolescents and adults with pediatric onset CAP compared to well controls; (2) assess the relation between baseline risk factors and long-term outcomes; and (3) as a follow-up to our diary study that linked acute stress to CAP symptoms, use laboratory methods to examine experimentally the impact of acute stressors on symptom exacerbation and physiological reactivity across CAP and well controls, and identify potential moderators of the response to stressors.

NIH HD023264: Illness Behavior and Somatization in Children and Adolescents

Funded by the National Institute of Child Health and Development (1987-2006)
Principal Investigator: Lynn S. Walker, Ph.D.
Co-Investigators: Judy Garber, Ph.D., John W. Greene, M. D., D. Brent Polk, M.D., Craig A. Smith, Ph.D.

NIH Abstract
The long-term goal of this program of research is to understand biopsychosocial processes associated with children's illness behavior (i.e., somatic complaints, disability, health service utilization). We are particularly concerned with children who maintain extensive illness behavior out of proportion to medical findings. Children with recurrent abdominal pain (RAP) serve as a prototype for our study of children with high levels of illness behavior not associated with significant organic disease.

Our recent work showed that the within-subject correlation between daily stressors and somatic complaints was significantly stronger for children with RAP than for well children, suggesting that children with RAP may be distinguished from their peers by a tendency to react to stress with somatic symptoms. In the next stage of this research, our first major goal is to identify mechanisms linking environmental and somatic stressors to illness behavior in RAP.

Specifically, using experimental methods in a laboratory setting, we will: (Aim 1) assess the influence of a challenging cognitive task on children's physiological activity, selective attention to somatic cues, and symptom reporting; and (Aim 2) assess the influence of visceral stimulation and parental responses on children's pain complaints. In addition, we will create an index of stress reactivity based on laboratory performance and will assess the utility of that index in predicting health outcomes.

Our second major goal is to identify subgroups of RAP who may have different treatment needs. Specifically, we will: (Aim 3) identify diagnostic subgroups of patients with RAP and compare these with respect to symptomatology, psychosocial characteristics, and course of illness over three months, and (Aim 4) cross-validate a typology of pain coping profiles for patients with RAP and assess the utility of these profiles in predicting health outcomes.

The proposed project combines self-report and psychophysiological measures, experimental laboratory methods, and a longitudinal design. Participants in the Baseline Assessment will include 396 patients with RAP and 842 Well children (ages 8-15). From these groups, children and their parents will be recruited for the Laboratory Computer Task (n =200) and the Laboratory Water Load Task (n = 220). Study results have the potential to yield insights into mechanisms linking stress to illness behavior in RAP and, in addition, to identify intervention targets that prepare children and their parents to better manage RAP.

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