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Functional abdominal pain disorders in children: therapeutic strategies focusing
on hypnotherapy
Rutten, J.M.T.M.
Publication date
2015
Document Version
Final published version
Link to publication
Citation for published version (APA):
Rutten, J. M. T. M. (2015). Functional abdominal pain disorders in children: therapeutic
strategies focusing on hypnotherapy.
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CHAPTER 2
PARENTAL PHYSICAL HEALTH STATUS, PSYCHOLOGICAL
DISTRESS, PERSONALITY AND CHILD-REARING STYLE IN
CHILDREN wITH IRRITABLE BOwEL SYNDROME OR FUNCTIONAL
ABDOMINAL PAIN (SYNDROME)
Juliette M.T.M. Rutten, Marieke van Dijk, Babette Peeters, Marc A. Benninga
ABSTRACT
Introduction: Parental factors are suggested to play a role in pediatric irritable bowel syndrome (IBS) and functional abdominal pain (syndrome) (FAP(S)) and may influence treatment. Since studies on parental factors are mainly focused on mothers, the aim of this study is to compare physical health, psychological distress, personality dimensions and parenting behavior of both parents of children with IBS or FAP(S) to parents of controls without abdominal pain related functional gastrointestinal disorders.
Methods: Parents of 91 children with a Rome III diagnosis of IBS or FAP(S), were included in this cross-sectional cohort study. These parents recruited parents of 74 age-matched healthy children to serve as controls. Questionnaires were used to measure demographics, physical health, psychological distress and symptoms, personality dimensions and child-rearing practices.
Results: 59 mothers and 52 fathers of 61 children with IBS or FAP(S) (response rate 61.0%) and 56 mothers and 49 fathers of 59 controls completed the study (response rate 70.9%). Mothers of children with IBS or FAP(S) reported significantly more physical problems, mainly autonomic and gastrointestinal symptoms. Psychological distress and symptoms, personality dimensions and child-rearing practices did not differ between mothers of both groups. Fathers of children with IBS or FAP(S) had significantly lower scores with respect to the child-rearing practice subscale of ignoring of unwanted behavior. All other outcomes did not differ statistically significant between fathers in both groups. No differences with respect to all outcomes were found between parents of children with IBS and parents of children with FAP(S).
Conclusions: Parents of children with AP-FGIDs and healthy peers differ with respect to physical health and child-rearing style. Clinicians should be aware of these differences when treating children with functional abdominal pain disorders.
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INTRODUCTION
Irritable bowel syndrome (IBS) and functional abdominal pain (syndrome) (FAP(S)) are commonly diagnosed pediatric disorders, with a worldwide pooled prevalence of 13.5%.1 These abdominal
pain related functional gastrointestinal disorders (AP-FGIDs) are characterized by chronic or recurrent abdominal pain. In children with IBS, altered bowel movements and/or relief of abdominal pain after defecation are also present.2 IBS and FAP(S) can have significant impact
on the child and their family. Affected children report significantly lower quality of life scores compared to healthy children and are at risk to develop symptoms of depression or anxiety.3–5
Additionally, symptoms often lead to disruption of daily activities and high levels of school absenteeism.5
Although exact mechanisms are still incompletely understood, the biopsychosocial model is thought to conceptualize the pathophysiology of IBS and FAP(S). Psychosocial factors such as early life events, the child’s psychological state and coping style play an important role in this model.6 Within the biopsychosocial model, parental factors are also suggested to play a role.6
Indeed, chronic abdominal pain was shown to be more common in families with higher rates of reported physical illness and psychological symptoms such as anxiety or depression.7–10 In
addition, parental child-rearing styles are known to have profound influence on the (mental) health development of children and adolescents and dysfunctional child-rearing styles are associated with anxiety, depression and low quality of life.11,12 Moreover, adolescents with
IBS reported more perceived dysfunctional parental rearing styles than healthy children.13
Recognition of the presence of specific factors, such as levels of physical health or psychological distress, personality patterns or child-rearing practices, in parents of children with AP-FGIDs may have therapeutic consequences. Parental responses to pain are known to be important in these children and the abovementioned parental traits are likely to influence those responses.14
Given that studies on parental factors in IBS or FAP(S) are mainly focused on mothers of these children, the aim of this study is to compare physical health, psychological distress, personality dimensions and parenting behavior of both mothers and fathers of children with IBS or FAP(S) to parents of children without these AP-FGIDs.
METHODS
A cross-sectional cohort study was carried out at the outpatient clinic of a secondary and tertiary hospital in the Netherlands between January 2010 and November 2014. Parents of children aged 4-16 with a Rome III diagnosis of IBS or FAP(S) were asked to participate in this study.2
Parents who agreed to participate in this study were asked to recruit control parents of a child without IBS, FAP(S) or other chronic diseases with an age comparable to their own child from their own socioeconomic environment. Insufficient knowledge of the Dutch language was an exclusion criterion in this study. The need for informed consent was waived by the local medical ethics committee.
Fathers and mothers of both study groups received personal codes and passwords by email to fill out several questionnaires at home in an online secured testing-environment. To avoid missing data, the online questionnaire was designed in a way that it could only be completed if parents filled out all individual items. Parents were instructed to fill out the questionnaires separately.
Outcome measures
Main outcome measures in this study are differences between parents of children with IBS or FAP(S) and parents of controls with regards to: demographics, physical health, psychological distress, personality dimensions and parenting behavior. Questionnaires were used to assess these outcomes.
Demographic characteristics
A self-designed questionnaire was used to assess demographic characteristics such as sex, age, ethnicity, marital status and educational level.
Physical health
Physical health was assessed by using the Physical Symptom Checklist (PSC), a questionnaire that quantifies the number of reported physical symptoms in the preceding week.15 It includes 51 items
on non-gender specific physical symptoms mentioned in the DSM-III classification, covering a wide range of organ systems.16 Subscales based on the different organ systems can be categorized:
general/neurological symptoms (11 items), autonomic symptoms (10 items), musculoskeletal/pain symptoms (8 items), gastrointestinal symptoms (13 items) urological/genital symptoms (5 items) and feeling hot/cold (4 items). The presence of symptoms is rated on a severity scale (0-3) and symptoms are considered to be present when the item is scored 2 (=bothersome often during the previous week) or 3 (=bothersome most of the time during the previous week). Gender specific average scores for the general Dutch population are available, with separate average scores for the population with and without anxiety or depression. The internal consistency of the PSC in this study was excellent (Cronbach’s alpha >0.9). Consistencies of the subscales varied from 0.7 to 0.9.
Psychological distress and symptoms
The Brief Symptom Inventory (BSI) was used to evaluate current (past 7 days) psychological distress and symptoms. 17 This brief self-report symptom scale is derived from the Symptom Check List – 90
and includes 53 items on 9 subscales: somatization, obsessive-compulsive behavior, interpersonal sensitivity, depression, anxiety, phobic anxiety, paranoid ideation, hostility and psychoticism. Overall psychological distress is measured by the General Severity Index (GSI). Items are scored on a 5-point Likert scale (0-4), with higher scores indicating the presence of more severe complaints. Psychometric properties of this questionnaire where shown to be good.17 Sex-specific norm scores
validated for the general Dutch population are available.18 The internal consistency was excellent
for the BSI in this study (Cronbach’s alpha >0.9). Internal consistencies of the subscales varied from 0.6 to 0.9).
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Personality dimensions
Assessment of personality dimensions was carried out through the Dutch version of the NEO-Five Factor Inventory (NEO-FFI). This validated and shortened questionnaire is based on the longer Personality Inventory. Internal consistency and test-retest reliability of the NEO-FFI are shown to be good.19 It consists of 60 items measuring five basic personality factors:
neuroticism, extraversion, openness to experience, agreeableness and conscientiousness.20 Each
item is scored on a 5-point Likert scale. Raw scores on the five personality factors are calculated as well as sex- and age-dependent norm scores for the general population. The NEO-FFI has an acceptable internal consistency (Cronbach’s alpha 0.7) in this study and consistencies for the subscales varied from 0.7 to 0.8.
Child-rearing practices
The Ghent Parental Behavior Scale (GPBS) measures child-rearing practices. In this study, the parental version of this questionnaire, which provides self-ratings for parental behavior, was used.21 Psychometric properties of this questionnaire were demonstrated to be sufficient to
good. The GPBS consists of 60 items which are scored on a 5-point Likert scale which ranges from ‘never’ to ‘always’. It includes nine subscales: discipline, ignoring of unwanted behavior, harsh punishment, positive parental behavior, rules, autonomy, monitoring, material rewarding and inconsistent discipline. Sex specific norm scores for the general population are available.22
The internal consistency of the GPBS in this study was good (Cronbach’s alpha 0.8). Consistencies of the subscales varied from 0.6 to 0.9.
Statistical analysis
Outcomes are compared between parents of children with IBS or FAP(S) and parents of controls. Additionally, we compared differences in demographics, physical health, psychological distress, personality dimensions and parenting behavior between parents of children with IBS and parents of children diagnosed with FAP(S).
Variables are tested for normality and if normality was confirmed, reported as mean with standard deviation (SD). Normally distributed data are compared between groups using the independent t-test. Skewed continuous variables are reported as medians with interquartile ranges (IQRs) and comparison between groups is carried out using Mann-Whitney U tests or Kruskal-Wallis tests.
Chi-square or Fisher exact test (when required) were used to compare groups with regard to the proportion of parents scoring above the cut-off point appropriate for the concerning subscales. The more conservative significance level of P<0.01 was chosen to correct for multiple testing between groups. Statistical analyses were performed using Statistical Package for the Social Sciences version 20.0 (IBM, Amsterdam, the Netherlands).
RESULTS
Baseline characteristics of the participating children and parents are depicted in Table 1. No statistically significant differences were found between both groups. Parents of 91 children with IBS or FAP(S) agreed to participate in this study. Of these parents, 59 mothers and 52 fathers of 61 children with IBS or FAP(S) completed the study (response rate 61.0%). The control group consisted of 74 parents that gave informed consent to participate. A total of 56 mothers and 49 fathers of 59 children completed the study (response rate 70.9%). No parents were excluded based on the exclusion criteria.
Table 1. Baseline characteristics of participating children and parents
Children with AP-FGIDs (N=61)
Control children (N=59) Children
Mean age child in years (SD) 11.7 (1.96) 11.1 (2.7)
% girls 57.4% 40.7%
% children with divorced/separated parents 3.3% 11.9%
% children with an unemployed parent 16.4% 13.6%
Parents
Number of participating parents: - both mother and father - only mother - only father 111 50 children (82.0%) 9 children (14.7%) 2 child (3.3%) 105 46 children (78.0%) 10 children (16.9%) 3 children (5.1%)
Mean age parents in years (SD) 43.8 (4.9) 43.2 (5.7)
% mothers 53.2% 56.2%
% Caucasian parents 96.4% 97.1%
% highest education parents: - primary school - secondary school - vocational education - university - other 0.9% 26.1% 59.5% 13.5% 0.0% 0.0% 24.8% 57.1% 17.1% 1.0%
Within the group of children with AP-FGIDs, 40 children had IBS (65.6%) and 21 children (34.4%) were diagnosed with FAP(S). The constipation predominant subtype was most commonly diagnosed among children with IBS (62.5%), while FAP and FAPS were equally diagnosed (47.6% vs 52.4%). Mean duration of symptoms in the group of children with AP-FGIDs was 3.3 years (SD 2.8).
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Mothers of children with AP-FGIDs versus mothers of controls
Table 2 provides characteristics of mothers of children with AP-FGIDs and mothers of controls with respect to the outcomes physical health, psychological distress and symptoms, personality dimensions and child-rearing practices.
Physical health
Mothers of children with AP-FGIDs reported significantly more bothersome physical complaints compared to mothers of controls on the PSC. With respect to the subscales of physical symptoms, median scores of mothers of children with AP-FGIDs were significantly higher on the scales for autonomic- and gastrointestinal symptoms.
Psychological distress and symptoms
No differences were found with respect to both raw and sexe specific norm scores on the BSI. The percentage of mothers with high or very high norm scores (score of 6/7 on 1-7 scale) did not differ between groups on all subscales of psychological distress and symptoms (data not shown). The percentage of mothers in the AP-FGIDs group scoring above the cut-off for psychopathology also did not differ from the percentage of mothers with psychopathology in the control group (5.1% vs 1.7%; P=0.62).
Table 2. Differences between parents of children with AP-FGIDs and parents of controls
Parents of children with AP-FGIDs (N=111) Parents of controls (N=105) Mothers (N=59) Fathers (N=52) Mothers (N=59) Fathers (N=46)
Mean age in years (SD) 42.8 (4.9) 44.9 (4.9) 42.5 (5.6) 44.1 (5.8)
% Caucasian 98.3% 94.2% 96.6% 97.8%
% unemployed 15.3% 3.8% 11.9% 2.2%
Physical health (PSC) Raw scoresa
- PSC total score - % > sex specific
cut-off score for general population (>p75) Number of symptoms on subscalea - Autonomic - General/neurologic - Musculoskeletal/pain - Gastrointestinal - Warm/cold/urogenital 1 (0-3)* 16.9 0 (0-0)* 0 (0-2) 0 (0-1) 0 (0-0)* 0 (0-0) 0 (0-0) 15.4 0 (0-0) 0 (0-0) 0 (0-0) 0 (0-0) 0 (0-0) 0 (0-1) 11.9 0 (0-0) 0 (0-0) 0 (0-0) 0 (0-0) 0 (0-0) 0 (0-0) 13.0 0 (0-0) 0 (0-0.8) 0 (0-0) 0 (0-0) 0 (0-0)
Psychological distress & symptoms (BSI) Raw scoresa
- BSI overall score - Somatization - Obsessive compulsive behavior - Interpersonal sensitivity - Depression - Anxiety - Phobic anxiety - Paranoid ideation - Hostility - Psychoticism
Sex specific norm scoresa
- BSI overall score - Somatization - Obsessive compulsive behavior - Interpersonal sensitivity - Depression - Anxiety - Phobic anxiety - Paranoid ideation - Hostility - Psychoticism 0.21 (0.08-0.32) 0.14 (0.00-0.43) 0.17 (0.00-0.67) 0.25 (0.00-0.50) 0.00 (0.00-0.17) 0.17 (0.00-0.33) 0.00 (0.00-0.20) 0.20 (0.00-0.60) 0.20 (0.00-0.40) 0.00 (0.00-0.20) 4 (3-5) 5 (3-6) 4 (3-5) 4 (3-5) 3 (3-4) 4 (3-5) 4 (4-5) 4 (3-5) 4 (3-6) 4 (4-5) 0.18 (0.04-0.32) 0.00 (0.00-0.14) 0.17 (0.00-0.50) 0.25 (0.00-0.50) 0.00 (0.00-0.33) 0.17 (0.00-0.33) 0.00 (0.00-0.20) 0.30 (0.00-0.60) 0.20 (0.00-0.40) 0.00 (0.00-0.20) 4.5 (3-6) 4 (4-6) 4 (3-5) 4 (3-5) 4 (4-6) 4 (3-6) 4 (4-5) 4.5 (3-6) 4 (3-5) 4 (4-5) 0.15 (0.08-0.28) 0.00 (0.00-0.14) 0.17 (0.00-0.50) 0.25 (0.00-0.50) 0.00 (0.00-0.17) 0.00 (0.00-0.33) 0.00 (0.00-0.20) 0.00 (0.00-0.40) 0.20 (0.00-0.20) 0.00 (0.00-0.20) 4 (3-5) 3 (3-5) 4 (3-5) 4 (3-5) 3 (3-4) 3 (3-5) 4 (4-5) 3 (3-5) 4 (3-4) 4 (4-5) 0.17 (0.08-0.31) 0.00 (0.00-0.14) 0.17 (0.00-0.50) 0.25 (0.00-0.25) 0.08 (0.00-0.33) 0.17 (0.00-0.17) 0.00 (0.00-0.00) 0.20 (0.00-0.60) 0.20 (0.20-0.60) 0.20 (0.00-0.20) 4 (3-6) 4 (4-6) 4 (3-5) 4 (3-4) 4.5 (4-6) 4 (3-4) 4 (4-4) 4 (3-6) 4 (4-6) 5 (4-5) Personality dimensions (NEO-FFI) Raw scoresb - Neuroticism - Extraversion - Openness to experience - Agreeableness - Conscientiousness Age specific norm scoresb
- Neuroticism - Extraversion
- Openness to experience - Agreeableness - Conscientiousness Sex specific norm scoresb
- Neuroticism - Extraversion - Openness to experience - Agreeableness - Conscientiousness 29.4 (6.9) 42.6 (5.1) 37.4 (5.7) 47.5 (4.4) 46.8 (5.1) 4.6 (1.7) 5.3 (1.6) 5.2 (1.7) 6.1 (1.7) 5.4 (1.9) 4.3 (1.7) 5.8 (1.7) 5.4 (1.8) 6.0 (1.7) 5.5 (1.9) 28.1 (6.9) 42.5 (7.1) 37.5 (6.5) 43.9 (5.3) 47.0 (6.2) 4.3 (1.7) 5.5 (2.0) 5.3 (2.0) 4.7 (2.0) 5.4 (2.1) 4.7 (1.8) 5.8 (2.1) 5.6 (1.7) 5.5 (2.1) 5.5 (2.1) 27.4 (5.4) 42.9 (4.9) 36.8 (6.1) 47.9 (4.0) 46.8 (4.0) 4.2 (1.4) 5.5 (1.5) 4.9 (1.8) 6.1 (1.5) 5.3 (1.7) 4.0 (1.4) 5.8 (1.5) 5.1 (1.8) 6.1 (1.5) 5.6 (1.6) 27.6 (5.6) 42.1 (5.1) 36.8 (6.6) 43.0 (5.4) 46.8 (4.7) 4.2 (1.4) 5.4 (1.6) 5.0 (2.1) 4.4 (1.9) 5.3 (1.8) 4.7 (1.5) 5.7 (1.6) 5.4 (1.9) 5.2 (2.0) 5.4 (1.7)
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Child-rearing practices (GPBS) Raw scoresb - Autonomy - Discipline - Positive parental behavior - Harsch punishment - Monitoring - Teaching rules - Ignoring of unwanted behavior - Material rewarding - Inconsistent discipline Sex specific norm scoresb- Autonomy - Discipline - Positive parental behavior - Harsh punishment - Monitoring - Teaching rules - Ignoring of unwanted behavior - Material rewarding - Inconsistent discipline 11.2 (1.7) 15.6 (4.3) 45.6 (5.1) 4.3 (0.8) 15.0 (4.7) 25.4 (3.8) 6.1 (1.9) 6.7 (1.8) 7.1 (2.4) 3.0 (0.7) 2.7 (0.8) 3.2 (0.7) 2.2 (0.5) 2.6 (0.9) 2.5 (1.3) 2.6 (0.7) 2.7 (0.7) 2.5 (0.9) 11.7 (1.8) 15.7 (4.1) 45.1 (5.3) 4.4 (1.2) 13.6 (4.2) 25.0 (3.0) 6.2 (2.1)* 7.5 (2.2) 7.5 (2.4) 3.3 (0.8) 2.9 (0.8) 3.3 (0.7) 2.2 (0.6) 2.7 (0.9) 2.5 (1.0) 2.4 (0.9) 2.9 (0.9) 2.5 (1.0) 11.6 (1.8) 16.4 (3.8) 45.7 (6.0) 4.8 (2.0) 15.5 (4.5) 25.6 (3.6) 6.5 (2.6) 6.9 (2.0) 1.9 (2.4) 3.2 (0.8) 3.1 (0.7) 3.3 (0.9) 2.4 (0.8) 2.8 (0.9) 2.5 (1.2) 2.7 (0.8) 2.8 (0.8) 2.8 (0.9) 11.7 (1.7) 16.6 (4.0) 43.0 (5.7) 4.5 (1.0) 14.0 (4.2) 24.8 (3.8) 7.5 (2.7) 7.4 (2.1) 8.1 (2.6) 3.2 (0.8) 3.0 (0.8) 3.2 (0.8) 2.3 (0.6) 2.7 (0.8) 2.7 (1.0) 2.7 (0.8) 2.9 (0.8) 2.7 (1.1)
a Data are median (interquartile range); b Data are mean (standard deviation)
*= difference P<0.01 between the functional abdominal pain disorders group and control group
Personality dimensions
Raw as well as age- and sexe specific scores on the NEO-FFI did not differ between mothers in both groups with respect to all five personality dimensions. The percentage of mothers with a high or very high age- or sex specific norm score (score 7/8/9 on 1-9 scale) did not differ between both groups on all NEO-FFI subscales (data not shown).
Child-rearing practices
No differences in both raw and sexe specific norm scores between both groups were shown with respect to all nine subscales of child-rearing practices.
Fathers of children with AP-FGIDs versus fathers of controls
Characteristics of fathers of children with AP-FGIDs and fathers of controls with respect to the main outcomes are shown in Table 2.
Physical health
The number of physical symptoms reported on the PSC by fathers of both children with AP-FGIDs and controls did not differ.
Psychological distress and symptoms
There were no statistically significant differences in raw and sexe specific norm scores on all BSI subscales. Furthermore, the percentage of fathers with a high or very high norm score (score of 6/7 on 1-7 scale) on all BSI subscales, did not differ between both groups. A total of 7.6% of fathers in the AP-FGIDs group scored above the cut-off for psychopathology and none of the fathers in the control group did, but this difference was not statistically significant (P=0.12).
Personality dimensions
No differences concerning personality dimensions (raw and sexe specific norm scores) were identified between fathers of children with AP-FGIDs and fathers of controls. On all NEO-FI subscales, no differences were found between both groups with respect to the percentage of fathers with a high or very high age- or sex specific norm score (score 7/8/9 on 1-9 scale) (data not shown).
Child-rearing practices
Fathers in the AP-FGIDs group had significantly lower raw scores with respect to the GPBS subscale on ignoring of unwanted behavior, compared to fathers of controls. Sexe specific norm scores on this scale as well as raw and norm scores on all other subscales of child-rearing practices, did not differ between groups.
IBS versus FAP(S)
Mothers of children with IBS and mothers of children with FAP(S) did not differ with respect to any of the assessed outcomes (data not shown). Additionally, no differences in physical health, psychological distress, personality dimensions and child-rearing practices were shown between fathers of children with IBS and fathers of children with FAP(S) (data not shown).
DISCUSSION
This study shows that mothers of children with IBS or FAP(S) report more physical complaints, more specifically autonomic and gastrointestinal symptoms, compared to mothers of healthy controls. No differences were found with respect to psychological distress, personality dimensions and child-rearing practices. Fathers of children with IBS or FAP(S) report similar outcomes with respect to physical health, psychological distress and personality dimensions compared to fathers of controls. However, fathers of children with IBS and FAP(S) have significantly lower scores on the subscale of parenting behavior that assesses the extent to which a parent ignores unwanted behavior. Additionally, no differences were found when comparing parents of children with IBS
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with parents of children with FAP(S).
The increased reporting of physical symptoms by mothers of children with functional abdominal pain disorders is in accordance with earlier studies.7–10,23 More specifically, in the present study,
autonomic and gastrointestinal symptoms were reported significantly more often, which may point towards the presence of somatoform disorders. These disorders were previously shown to be more frequent in parents of children with AP-FGIDs.10,24 It can be hypothesized that these
findings point towards a genetic component of IBS and FAP(S), but it has been suggested that parental behavior is a more important factor.25 Parents that experience many physical symptoms
may transmit this illness behavior to their children, thereby reinforcing the child’s own concerns about physiological and minor medical bodily sensations.26,27 Children may have learned to
display this illness behavior, rather than deal with stress or other emotional problems. Parental somatization could lead to parental catastrophizing of the child’s pain, which can further exacerbate the child’s pain experience.28
In contrast to other studies, we did not find increased parental psychological distress and symptoms, such as anxiety, depression or somatization.7–9 The fact that we did not find
differences with respect to somatization, despite increased reporting of physical symptoms is remarkable and may be due to the sample size of this study. Mean duration of symptoms of the children whose parents were included in this study was 3.3 years, which is long given their mean age. We hypothesize that parents show less psychological distress and symptoms, because they got used to having a child with abdominal pain. Education and physician reassurance are usually the first steps in management of these children.29 It may be the case that this first step was
fairly adequate in this group of parents, since parental distress is shown to be decreased after provision of information and receiving a diagnosis.30
Adult IBS patients are known to score high on the personality dimension neuroticism.31,32 To our
knowledge, this is the first study to assess parental personality dimensions in pediatric IBS and FAP(S). Personality dimensions of parents of children with IBS and FAP(S) and parents of controls did not differ. The fact that we did not find differences in parental personality dimensions, could be caused by the fact that the NEO-FFI only measures the five main personality traits. It is well-known that social learning contributes strongly to symptoms of children with IBS or FAP(S)25,27
and we hypothesize that modeling of parental behavior that arises from increased experience of physical symptoms, is a more important factor for children with IBS and FAP(S) than parental personality traits.
Fathers of children with IBS and FAP(S) were shown to adopt a child-rearing style in which they refrain from ignoring unwanted behavior, such as display of illness behavior of the child. According to the social learning theory, children are more likely to adopt modeled behavior that results in positive outcomes.33 If the child is for example allowed to stay at home instead of
going to school, this further reinforces the child’s illness behavior. Refraining from ignoring of unwanted behavior may represent overprotection, which was shown to be a risk factor for IBS in adolescents and is associated with negative psychosocial outcomes in children.34,35
since clinical and psychosocial factors of pediatric IBS and FAP(S) were also shown to be similar.36
It could be hypothesized that the defecation problems that may still be present in IBS cause additional distress, since studies in constipated children show that especially fecal incontinence is an important stressor in families of those children.37,38 The most important symptom in both
disorders however is chronic abdominal pain and this may explain the similarity in parental factors between IBS and FAP(S).
Most literature on parental factors in children with IBS and FAP(S) has focused on mothers and if fathers were included, scores were not reported separately for both mothers and fathers.23
Mothers were traditionally more involved in upbringing of the children, but these traditional roles are changing nowadays. Since fathers become more involved with their children, they may also play a more important role in treatment of children with functional abdominal pain disorders. The inclusion of both mothers and fathers in this present study is therefore a clear strength. Generalizability of results is increased since we included children in both a secondary and tertiary hospital. Groups however were too small to assess whether parents of children recruited in the secondary hospital differed from those included at the tertiary clinic. The online questionnaires were designed to avoid missing data, thereby decreasing bias. The fact that we had parents rate their own child-rearing practices rather than assess the perceived parenting style by children, might produce more objective data. One could on the other hand hypothesize that parents can give socially accepted answers. Usage of validated questionnaires however should minimize this potential source of bias. The sample size of this study may be perceived a limitation as well as the design. This study is not suited to elucidate whether parental factors are causing symptoms in pediatric IBS or FAP(S) or that they are an effect of having a child with a functional abdominal pain disorder. Longitudinal prospective studies need to be conducted to answer this question on causality.
Parental responses to their child’s abdominal pain and parental involvement in treatment are shown to be important.14,29 The presence of physical complaints in mothers and lower degree
of ignoring of unwanted behavior by fathers can hamper treatment of these children. These factors can also negatively affect the prognosis of children with IBS and FAP(S), since high rates of somatic symptoms and the presence of functional gastrointestinal symptoms in parents, are shown to be predictive of persisting symptoms in children with chronic abdominal pain.39,40
Parental factors therefore should be taken into account by physicians treating children with IBS and FAP(S). Treatment of children with functional abdominal pain disorders should include parental education on the effects of modeling of (illness) behavior. Additionally, parental awareness should also be raised on the fact that their responses to the child complaints can significantly influence the magnitude of symptoms experienced by the child. Clinicians should emphasize that distracting the child rather than paying attention to the child’s pain is helpful and does not have potential negative impact, which is often perceived by parents.14
In conclusion, this study shows that parents of children with AP-FGIDs and healthy peers differ with respect to physical health and child-rearing style. Clinicians should be aware of these
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differences when treating children with functional abdominal pain disorders and take action upon these factors, if needed.
REFERENCES
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