Clinical Practice in Pediatric Psychology

Disorders of gut–brain interaction (DGBI, formerly known as functional gastrointestinal disorders [FGIDs]) are highly prevalent in the pediatric population. DGBIs in youth are often associated with academic, physical, and psychosocial impairments. Assessment and treatment of DGBIs are best conceptualized using a biopsychosocial approach. The inclusion of psychological therapies as part of integrated care for pediatric DGBIs is well supported. The purpose of this special issue is to present innovations in the psychological treatment of pediatric DGBIs.

Articles inclusive of topics on novel assessment and treatment approaches, quality improvement work, program development, case examples, and commentaries addressing pediatric DGBIs were considered for this special issue.

This special issue includes eight articles that highlight innovations in the psychological treatment of pediatric DGBIs. Articles cover a wide range of conditions, treatment delivery models, and intervention modalities. Future directions for areas of study, as well as discussion of clinical challenges, disparities in care, program development initiatives, and dissemination opportunities within pediatric psychogastroenterology are also offered.

The articles included in this issue are expected to guide future evidence-based assessment and treatment of pediatric DGBIs across various settings.

This special issue seeks to expand the current research base on psychological assessment and intervention for pediatric disorders of gut-brain interaction. Guidance regarding ethical, logistical, financial, and other potential barriers to expansion and delivery of psychological DGBI-related care are embedded throughout the special issue.

Psychological intervention is an essential treatment component of disorders of gut–brain interaction (DGBIs), but engagement in evidence-based intervention is far from routine. A group-based treatment delivered via telehealth may expand access to evidence-based care for adolescents with DGBIs. The current study describes the development and initial feasibility and acceptability of the Gastroenterology psychology skills for adolescents (GPS-A), a five-session cognitive behavioral group intervention that teaches adolescents evidence-based skills to manage a range of DGBI symptoms.

Participants were 33 adolescents with a range of DGBI diagnoses who completed the intervention group and provided quantitative and qualitative feedback. Participant-reported outcomes (somatic symptoms, functional disability, quality of life [QoL]) were collected pre- and postintervention and at 1-month follow-up.

Fifty-one percent of patients contacted (30% of all potentially eligible patients) agreed to participate in the group intervention. Retention was high, with 100% of participants completing five sessions. Participants identified skills, community and interpersonal connections, and validation of their gastrointestinal condition and experience as the most helpful intervention components. There was a significant positive difference in overall and emotional QoL from preintervention to 1-month follow-up, though no significant differences were found in somatic symptoms or functional disability.

Unlike previously developed cognitive behavioral therapy interventions, GPS-A was both specific to patients with DGBI symptoms and flexible enough to incorporate a range of disorders (e.g., Irritable Bowel Syndrome, functional dyspepsia, and functional abdominal pain). Future directions include testing preliminary effectiveness in a larger sample and expanding diversity of the sample (gender, race/ethnicity).

Psychological interventions have gained recognition as an indispensable component in the treatment of disorders of gut–brain interaction (DGBIs) but access to evidence-based intervention is often challenging. The present study describes the development of a virtual, group-based, cognitive behavioral intervention for adolescents with DGBIs. Developed and piloted in a real-world clinical setting, the intervention proved feasible and acceptable, and as such represents a step toward increasing access to evidence-based care for adolescents with DGBIs.

Rumination syndrome is a disorder of gut–brain interaction that involves effortless postprandial regurgitation of gastric contents. It frequently occurs in otherwise healthy children and adolescents, and is associated with significant physical and psychological consequences. Treatment of Rumination syndrome is largely behavioral, and more severe illness was traditionally treated with intensive inpatient treatment. While largely successful, inpatient treatment is very costly and frequently denied by insurance.

As such, the intensive outpatient program (IOP) for treating Rumination syndrome was developed. This paper describes the novel IOP approach to treating pediatric Rumination syndrome in detail.

Data on both treatment and cost-effectiveness of the IOP are reviewed, demonstrating that IOP is as effective yet significantly cheaper than intensive inpatient treatment. The tiered method of care used within this model, adaptation to telehealth, and translatability of the program to other providers and institutions are also reviewed.

Intensive outpatient treatment for pediatric Rumination syndrome is an effective form of treatment that is significantly less costly than inpatient care, more readily approved by insurance, and more easily translated to telehealth or other institutions and providers for use.

The intensive outpatient program for treating pediatric Rumination syndrome is effective while costing significantly less than previously relied upon inpatient treatment and is described in detail in this article. Adaptation to telehealth as well as ability of other providers or institutions to use this model to treat pediatric Rumination syndrome is reviewed.

Disorders of gut–brain interaction (DGBI) affect a large segment of the pediatric population, significantly impacting quality of life and functioning. Recent findings indicate emerging psychological therapies targeting autonomic mechanisms may be effective treatment approaches. This article reviews utilization of conjunctive heart rate variability biofeedback (HRVB) alongside acceptance and commitment therapy (ACT) in the treatment of DGBI.

This study includes a topical review of HRVB as an adjunct to ACT in the context of autonomic regulation in DGBI intervention. An overview of our treatment model at the Center for Applied Biobehavioral Sciences (CABS) and procedures for future replication is provided. Clinic referrals, administrative processes, patient intake, education and measures, and treatment protocol are outlined. A review of previous studies at CABS and their outcomes are detailed.

Previous data suggests that utilization of HRVB as an adjunctive approach to psychological therapies which target autonomic regulation, such as ACT, alongside standard medical treatment should be considered in pediatric DGBI management. CABS outcomes support the inclusion of HRVB to target autonomic dysregulation in DGBI to improve symptomatology and functioning in this population.

HRVB and ACT appear to be promising treatments for pediatric DGBI to be included in psychological and multidisciplinary clinical settings. Given the correlates of autonomic nervous system dysregulation in adults and preliminary findings in pediatric DGBI, these may be useful approaches for targeting the autonomic mechanisms of DGBI symptomatology. We address future directions for research to replicate and extend the findings for use in clinical settings.

Heart rate variability biofeedback and acceptance and commitment therapy may be effective and promising treatments to be included in psychological and multidisciplinary clinical settings for pediatric disorders of gut–brain interaction (DGBI). These interventions may work by targeting the autonomic nervous system, potentially improving DGBI symptoms and functioning in the pediatric population. These treatments require further research and validation, which this article aims to demonstrate.

Rumination syndrome (RS) is a disorder of gut–brain interaction (DGBI) for which evidence-based intervention includes behavioral treatment (BT). However, youth with DGBIs, including RS, face numerous barriers to accessing behavioral health care. This brief report describes the initiation of a quality improvement project that (a) assessed RS education and referral practices within our gastroenterology (GI) division, (b) developed patient education materials about RS and BT, and (c) implemented a process to monitor the educational initiative’s impact on BT referrals.

Baseline referral and education practices were assessed by a provider survey. The authors developed a patient handout, a two-part video, and a provider documentation phrase about RS and BT to be used in the electronic medical record (EMR). A newly developed EMR-based registry tracks patients diagnosed with RS, use of education materials, and referrals to BT. A follow-up survey assessed providers’ knowledge and use of new education tools.

Data from 39 GI providers indicated multiple BT referral barriers. Providers expressed confidence in educating patients/families about RS but endorsed limited time for comprehensive education. In response, we developed and disseminated educational materials about RS and BT. Follow-up data from 25 providers indicated general awareness of education materials, with 50% of providers disseminating RS materials to patients/families. After this educational intervention, BT referrals increased from 53.6% to 74.8% of patients diagnosed with RS.

Development and distribution of RS educational materials increased referrals to BT. Providing standard educational materials may decrease variability in care and increase the acceptability of appropriate therapy for RS and, potentially, other DGBIs.

Youth with rumination syndrome (RS) may not be referred for evidence-based behavioral treatment (BT) in a timely manner. Medical providers also have limited time and resources to fully educate patients and families about treatment. This study suggests that providing consistent education materials to medical providers, patients, and families increases how many newly diagnosed patients with RS are referred to BT.

Effective treatment for disorders of gut–brain interaction (DGBIs) is furthered by integrated interdisciplinary care. Initial efforts at psychology integration in pediatric gastroenterology (GI) clinics may encounter physician referral variability and low patient utilization as barriers to patient access and program growth.

In this brief report, clinical service approaches and educational efforts to address these barriers and enhance biopsychosocial care for pediatric patients with DGBIs are described, including program structure and growth considerations, levels of outpatient care (e.g., group interventions, specialized interdisciplinary clinics) for patients with DGBIs, and innovative physician and patient/family education on biopsychosocial treatment for DGBIs.

Over a decade, our established GI Psychology program has grown both in terms of service providers and visit volume to achieve increased access to psychological services and biopsychosocial care for patients with DGBIs and other GI conditions.

Recommendations for GI Psychology program growth with financial sustainability are discussed.

Gastroenterology (GI) Psychology programs can utilize clinical service expansion and educational efforts to enhance biopsychosocial care for pediatric patients with disorders of gut–brain interaction (DGBIs). A strong partnership between GI Psychology and GI leadership is essential to successful program growth and sustainability. Specific strategies that may reduce barriers to biopsychosocial care for patients with GI conditions include distinct levels of outpatient GI Psychology care, Health and Behavior Assessment and Intervention codes for billing, provision of telehealth services, scheduling access via multiple avenues, and departmental efforts to improve health care equity.

Abdominal pain-related disorders of gut–brain interaction (DGBIs) in children are best understood from a biopsychosocial model, including particular attention to the child’s environment. Interventions have begun to increasingly target parents as important agents of change in this population. The purpose of this article is to summarize the evolution of parent-targeted interventions for pediatric pain-related DGBIs and provide recommendations for application of the model to clinical practice.

A topical review of literature regarding parent-targeted interventions and related factors in the treatment of pediatric pain-related DGBIs was conducted, followed by a discussion of these findings to clinical practice settings.

A growing body of research has supported parent-targeted interventions in the treatment of pediatric pain-related DGBIs, although translation of these findings to practice settings is complicated by numerous factors. Strategies for obtaining physician buy-in and parental engagement are discussed, as are potential logistical considerations of multiple caregivers, child age, and billing considerations.

There is a promising and growing evidence-base for parent-targeted interventions for pain-related DGBIs, which have not yet been widely adopted into clinical practice recommendations. Engaging all stakeholders and attending to the nuances of this approach are recommended to successfully apply parent-targeted interventions into clinical practice settings.

The role of parents in treating children with pain-related disorders of gut–brain interaction (DGBIs) has been an increasing area of study. This article summarizes the research on interventions for DGBIs that focus on parents as agents of change and provides practical considerations for applying this research to clinical, “real-world” settings.

Social media (SM) use among adolescents is commonplace and an extension of their daily lives, with emerging attention to how SM can impact healthcare behaviors. In particular, the clinical and ethical nuance of maladaptive SM use among adolescents with disorders of gut–brain interaction (DGBI) diagnoses remains unclear and pressing to consider.

This article presents case examples of maladaptive SM use in (a) a pediatric patient with DGBI and (b) a caregiver of a pediatric patient with a DGBI. We then contextualize these case examples in existing ethical frameworks (e.g., the American Psychological Association Ethics Code) and the extant literature.

SM use in pediatrics can negatively impact healthcare behaviors and can lead to consumption of medical misinformation; this impact is particularly significant in pediatric DGBI and merits clinical assessment of maladaptive SM use in this population.

SM use can be adaptive or maladaptive for adolescents with DGBIs and caregivers, with maladaptive SM use presenting significant clinical and ethical considerations. In addition to discussing ethical considerations, recommendations, and resources, we also provide clinical questions and takeaways for healthcare professionals to implement in pediatric DGBI care.

Adolescents commonly use social media (SM), with growing attention to how SM can negatively impact health. Adolescents with disorders of gut–brain interaction may be particularly sensitive to this, and healthcare professionals working with this population should consider the ethical and clinical implications of maladaptive SM use.

There has been increased attention to health equity, or the opportunity to obtain one’s health potential without disadvantage caused by discriminatory social systems, in recent years. The social determinants of health (SDoH), including economic stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social and community context, are the social, political, and systems-level factors that contribute to health inequities.

In this commentary, the authors will review the ways in which structural and systemic racism impact health, discuss what is known about SDoH in pediatric DGBIs and propose a call to action for pediatric psychologists to promote health equity via research, clinical work, teaching, and advocacy.

Unfortunately, very limited research on SDoH in pediatric disorders of gut–brain interaction (DGBIs) has been conducted to date. What we do know is that exposure to early life stressors influences DGBI prevalence and symptoms in both childhood and adulthood (Chitkara et al., 2008). Thus, addressing SDoHs in pediatric gastroenterology has the potential to improve population health and reduce functional disability.

Upstream, systems-level interventions are needed in order to make measurable change in health outcomes in pediatric DGBIs.

Social determinants of health have been linked with health care disparities within pediatric disorders of gut–brain interaction. Pediatric psychologists are embedded members of medical teams, who possess the knowledge and skills needed to create upstream interventions to directly address social and systemic root causes of disparities.