Efficacy of a Brief Relaxation Training Intervention for Pediatric Recurrent Abdominal Pain

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Cognitive and Behavioral Practice 20 (2013) 81-92 www.elsevier.com/locate/cabp

Efficacy of a Brief Relaxation Training Intervention for Pediatric Recurrent Abdominal Pain Katrina M. Bell and Elizabeth A. Meadows, Central Michigan University This study is a preliminary investigation of the efficacy of a brief intervention for recurrent abdominal pain (RAP) via a multiple baseline across subjects design. The intervention consisted of a single 1-hour session including psychoeducation and coaching of breathing retraining; the length, duration, and content of the intervention were designed with a goal of maximum portability to primary-care settings. Five children with recurrent abdominal pain participated in this study, 1 of whom served as a pilot participant. Children received the intervention at 1-week intervals. Parent and child reports of each child's abdominal pain, general somatic complaints, functional disability, and anxiety were collected throughout the study. All children participated in a 3-month follow-up session. Results indicated that this brief intervention was successful in lessening abdominal pain, as demonstrated by decreased Abdominal Pain Index (API) scores in two children and decreased abdominal pain following breathing retraining practice in all children. The intervention was also successful in decreasing some children's general somatic symptoms. Functional disability and anxiety symptoms remained consistent for all children throughout the study, which may be due to low levels of these symptoms pretreatment. Limitations and directions for future research are discussed.

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abdominal pain (RAP) is a prevalent chronic pain condition in children that has been implicated in the development of other gastrointestinal disorders over time (Colletti, 1998; Feuerstein & Dobkin, 1990; Stickler & Murphy, 1979; Walker, Garber, Van Slyke, & Greene, 1995; Walker, Guite, Duke, Barnard, & Greene, 1998). Children with RAP experience abdominal pain in the absence of an identifiable biological cause and generally have functional impairment in a variety of settings (Apley, 1975; Kaminsky, Robertson, & Dewey, 2006). Anxiety has been hypothesized to be a causal factor in the development of RAP, because parental anxiety predicts the occurrence of RAP in children and because somatic complaints such as stomach pain are common in anxious individuals (Garber, Zeman, & Walker, 1990; LiakopoulouKairis et al., 2002; Ramchandani, Stein, Hotopf, & Wiles, 2006; Wasserman, Whitington, & Rivara, 1988; Woodbury, 1993). Children with RAP are typically treated by their pediatricians or family practitioners; however, standard ECURRENT

Keywords: recurrent abdominal pain; breathing retraining; pediatric

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medical treatment has not proven to be effective with this population (Frazer & Rappaport, 1999; Walker, Garber, Smith, Van Slyke, & Claar, 2001). Some cognitive-behavioral treatments for RAP have appeared promising (e.g., Banez & Gallagher, 2006; Janicke & Finney, 1999; Robins, Smith, Glutting, & Bishop, 2005), but multiple barriers to these types of treatments for RAP exist, including length of the interventions and service setting (Robins et al., 2005; Walker et al., 2001). Brief treatments for anxiety may be beneficial in lessening costs, increasing compliance, and improving RAP complaints (Ramchandani et al., 2006). With the goal of creating a brief, one-session intervention that could be implemented in a physician's office, where most children with RAP do seek treatment (Walker et al., 2001), the aim of this multiple baseline across subjects study was to create a preliminary investigation of the effect of psychoeducation and breathing retraining on RAP symptoms. These two interventions are commonly used in cognitive-behavioral treatments of anxiety disorders and can be taught in one session. Breathing retraining can directly affect physiological responding (Chorpita & Southam-Gerow, 2006; Hazlett-Stevens & Craske, 2003; Houghton & Saxon, 2007; Ley, 1999) and can also provide its users with a sense of control (Garssen, de Ruiter, & Van Dyck, 1992), which is related to lower levels of anxiety (e.g., Sanderson, Rapee, & Barlow, 1989; Weems, Silverman, Rapee, & Pina, 2003). The hypotheses of this study were that children would report fewer and less intense abdominal

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pain episodes, less functional disability, fewer somatic complaints, and fewer anxiety symptoms following the intervention.

Methods Participants Five children between the ages of 6 and 16 participated in this study. All children had nonorganic recurrent abdominal pain or recurrent abdominal pain in excess of that expected from the child's medical condition, as determined by each child's physician. Only children who had undergone medical evaluation to rule out medical conditions that could account for recurrent abdominal pain were accepted into the study. Children whose physicians determined they did not have an organic cause for their pain or who had pain in excess of what their physicians deemed likely to occur from their medical condition were admitted into the study. Children were included if they had demonstrated abdominal pain consistent with Apley's (1975) definition of RAP (e.g., three or more pain episodes in the last 3 months), as well as some level of functional disability (e.g., missed school due to pain). In order to participate in this study, parents agreed that their children would not pursue additional treatments, either medical or psychological, during the study duration, although children did continue with treatment as usual (e.g., medications they had already been stabilized on). One child was recruited through a gastroenterology clinic in a regional children's hospital and was used as a pilot case, as the first author was subsequently unable to recruit additional participants from this location. The other four children were recruited locally from advertising in the community, and were treated in a multiple baseline across subjects design. The child in the pilot case, “Jeffrey,” was a 9-year-old Caucasian boy who had been having stomach pain for 1 year and was diagnosed with irritable bowel syndrome (IBS) 6 months before enrolling in the study. Throughout the duration of the study, he continued to take a medication for IBS that he had been stabilized on for a month before joining the study. The first child in the multiple baseline design, “Lisa,” was an 8-year-old Caucasian girl who had been having stomach pain for over a year and had been diagnosed with acid reflux. Throughout the duration of the study, she continued to take an antacid medication that she had been stabilized on for 3 months prior to joining the study. The second child, “Brittany,” was a 16-year-old Caucasian girl who had a history of stomach pain, especially in response to eating certain foods. There was no known medical cause for her pain. The third child, “Samantha,” was an 11-year-old Caucasian girl with no known medical cause for her stomach pain, which had been occurring for the past 3 years. Finally, the fourth child, “Sophie,” was a 7-year-old

African American girl. Sophie had been having stomach pain for the last 5 years, without any known medical cause. Measures The Abdominal Pain Index (API; Walker & Greene, 1989) The API allows for both parent and child responders and consists of five items, two items that measure frequency, two items that measure intensity, and one item that measures duration of abdominal pain in the previous 2 weeks. Scores range from 0 to 38, with higher scores being more severe. Alpha reliability of the API ranges from .80 to .93 (Walker & Greene). In this study the API was modified to measure abdominal pain that day, with the exception of one item asking about frequency of abdominal pain over the course of the week. The Children's Somatization Inventory (CSI; Garber, Walker, & Zeman, 1991; Walker & Garber, 2003; Walker, Garber, & Greene, 1991) The CSI has both parent and child forms and assesses symptoms of nonspecific somatic complaints, such as headaches or dizziness, commonly found in children with recurrent abdominal pain. Scores range from 0 to 140, with higher scores indicating more severe somatization. Threemonth test-retest reliability for the CSI is .50 for well patients and .66 for patients with chronic pain (Walker et al., 1991). The Functional Disability Inventory (FDI; Walker & Greene, 1991) The FDI includes both child and parent reports and assesses disturbances in physical and psychosocial functioning over the previous 2 weeks due to pain and associated health difficulties. Scores range from 0 to 60, with higher scores indicating more functional disability. The FDI has good internal consistency and 3-month test-retest reliability above .60 for children with RAP. Additionally, it has been significantly correlated with school absence (Walker & Greene). In this study the FDI was modified to measure functional disability that day. The Revised Children's Manifest Anxiety Scale, 2 nd edition (RCMAS; Reynolds & Richmond, 2008) The RCMAS includes items measuring anxiety symptoms in the areas of physiological anxiety, worry/oversensitivity, and social concerns. Scores are represented in T scores. Cronbach's alpha reliability for the RCMAS subscales and total anxiety scale range from .70 to .92 (Reynolds & Richmond). The Child Behavior Checklist (CBCL; Achenbach, 1991) The CBCL measures parents’ views of their children's psychological and somatic symptoms over the last 6 months. It contains 118 problem behaviors rated on a 3-point Likert scale ranging from not true (0) to often or always true (2). This study focused specifically on the Anxiety/Depression and Somatic Complaints subscales. The test-retest reliability is .86 for the Anxiety/Depression

Efficacy of a Brief Relaxation Intervention subscale and .95 for the Somatic Complaints subscales (Achenbach). Breathing Retraining Monitoring Form (BRMF) The BRMF created for this study tracks the time each child spends practicing the breathing technique each day. Children rated their abdominal pain and subjective feeling of relaxation on an 11-point scale before and after practicing breathing retraining. The scale ranged from 0 to 10, with 0 representing no pain or no relaxation and 10 representing the most pain possible or the most relaxation possible. Evaluation Questionnaire (EQ) The evaluation questionnaire created for this study measures parent views of the overall helpfulness of the intervention. Brittany and Samantha (ages 16 and 11) were also administered the evaluation questionnaire themselves, as it appeared these children would be better able than their parents to indicate the helpfulness of the intervention, given that they often did not report their symptoms to their parents. It consists of 10 items, rated on a 5-point Likert scale, with qualitative descriptors for each item: 0 = not at all; 1 = a little; 2 = some; 3 = a lot; 4 = extremely. Items tap amelioration of abdominal pain, amelioration of anxiety, improved health, increased participation in activities, improved school attendance, lessened doctors’ visits, appeal of the intervention, ease of understanding the intervention, ease of use of the intervention, and overall helpfulness of the intervention. Procedure This study employed a multiple baseline across subjects design, with the exception of Jeffrey, who was used as a pilot case. Each child had a separate baseline phase, all differing in length. All children began their baseline phase at the same time, with the difference in the length of the baseline. Ideally, a stable baseline would have been established for each child before any intervention or experiment was implemented (Hersen & Barlow, 1976). However, to provide services in a timely manner, it was determined a priori by the authors that the first child to receive the relaxation intervention would be the first one to establish a stable baseline or would have been monitoring symptoms for a maximum of 2 weeks, whichever came first. It was also determined that the other children would receive the intervention at 1-week intervals, with the child with the second most stable baseline being chosen next and so on. The children's initial levels of pain, functional disability, somatization, and anxiety were established in the baseline phase. As the focus of this study was abdominal pain, the level of abdominal pain as measured by the API was used to determine stabilization. Stabilization of the API was defined as little to no

fluctuation in the child's pain ratings across data points, so that the graph of the baseline appears mainly flat, with only a few small aberrations. No numeric benchmark was used to determine stability; instead, the authors performed a visual inspection of graphed data. Although all children began the baseline phase on the same day, each child and his or her parent(s) had separate appointments at the psychology clinic to explain the purpose of the study and obtain informed consent. During this initial meeting, the child forms of the API, CSI, FDI, and RCMAS measures were administered to children. Lisa (age 8) and Sophie (age 7) had some trouble reading and understanding the forms, and so the first author answered questions Lisa had about meanings of words and read the forms to Sophie, who provided verbal responses to each item. The parent forms of the API, CSI, FDI, as well as the CBCL, were administered to all of the children's parents. Children and parents were asked to fill out the API, FDI, and RCMAS every other day for the length of their assigned baseline phase, as well as the CSI weekly, and then to send them in the mail to the first author in preaddressed, stamped envelopes. Lisa's and Samantha's mothers, but not their fathers, participated in the study, so all parent ratings for these two girls represent mother ratings. Both of Brittany's parents participated in the study. Her parent ratings are a combination of both mother and father ratings, as each parent filled out packets on different days, although only her mother attended follow-up. Both of Sophie's parents participated in all phases of treatment and both parents filled out all packets, so parent ratings for Sophie are an average of her mother's and father's ratings. Lisa received treatment first because she was the first child to establish a stable baseline for abdominal pain. As was decided a priori, the other three children in the study received the intervention at 1-week intervals. Each successive child was chosen based on the stability of their baseline phases, so that each child could be as close to having a stable baseline phase as possible before learning the relaxation technique. The second child to receive the treatment, Brittany, began intervention 1 week after the intervention was introduced to Lisa. The third child, Samantha, began intervention 2 weeks, rather than 1 week, after the intervention was introduced to Brittany due to unavoidable scheduling difficulties. Sophie began intervention 1 week after the intervention was introduced to Samantha. After receiving treatment, each child and his or her participating parents continued to complete the API, FDI, and RCMAS every other day for a month, the BRMF every day for a month, and the CSI weekly for a month, sending the measures through the mail to the first author. Finally, each family participated in a 3-month follow-up, where the child and his or her participating parents completed the

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API, FDI, CSI, RCMAS, CBCL, and EQ. Each family also received a $25 gift card to a local store as compensation

for participating in the study. Treatment Treatment sessions were conducted by the first author at a university psychology training clinic, with the exception of Jeffrey, who was seen at the children's hospital. Treatment sessions began with psychoeducation regarding the role of anxiety in somatization, where some people experience emotional distress by feeling physically sick (e.g., headaches, stomachaches). The three components of anxiety—thoughts, physical sensations, and behaviors— and their interaction were also explained. Psychoeducation covered the same principles for all children, but was modified as needed to be developmentally appropriate. For instance, for younger children the first author drew a picture of the child on a whiteboard to help illustrate where the child feels anxiety in his or her body. Psychoeducation with Brittany included more mature examples, like how she might feel if she is anxious at school about a test. The first author also explained what anxiety meant to make sure that children understood the term and used the words that they were most comfortable using to explain the feeling (e.g., nervous). Following psychoeducation, the children were taught breathing retraining. First, children were given information about how anxiety can cause a person to breathe quickly and shallowly through his or her chest. Shallow breathing was demonstrated in order to ensure the children understood. Next, the children were informed that slow and steady breathing from the diaphragm can calm people down, making them feel very relaxed and comfortable. Diaphragmatic breathing was demonstrated with the technique of placing one hand on the chest and one hand on the stomach, such that it is easier to identify where the breath is moving in the body. Finally, the children practiced this technique until they were able to properly breathe in this way and affirmed feeling comfortable doing so. The first author made modifications to the instruction of breathing retraining as needed. For instance, Jeffrey had a difficult time learning this technique, so the first author asked him to lie facedown on the floor so he could feel his stomach move against the floor. The first author also lay on the floor to make Jeffrey more comfortable. This technique was effective in teaching him breathing retraining. After the children were proficient at breathing retraining, they were told that they could use this technique whenever they experience anxiety, distress, or abdominal pain in order to help them feel more comfortable. The children were also asked to practice this breathing technique every day for the following three months for 10 minutes a day.

Results Pilot Case During baseline, Jeffrey's abdominal pain report was stable. Jeffrey had a baseline of just over a week. After the intervention, pain ratings were variable. Specifically, on two days scores peaked considerably higher than even during baseline; this was due to Jeffrey's having the stomach flu, and thus were discarded. Jeffrey's BRMF indicated improvements in abdominal pain. Each time he had pain before his practice, his pain decreased after practicing breathing retraining. Jeffrey's reported pain shows a decrease postintervention, with a change in mean values of pain from 9.57 during baseline to 7.46 during the phase change. A Reliable Change Index (Jacobson & Truax, 1991) was calculated for Jeffrey and his reduction in pain did not reach the 1.96 cutoff for significance. There was no significant change in Jeffrey's anxiety, somatization, or functional disability after the intervention. Overall, his anxiety was in the normal range. At 3-month follow-up Jeffrey reported his pain as a 1 on the API, indicating minimal abdominal pain that day. His mother's average rating on the EQ was 2.0 out of 4.0, which has a qualitative description of “some,” suggesting that, in general, Jeffrey's mother found participation in the intervention to be somewhat helpful for her child. Jeffrey and his family reported being fairly satisfied with the process of being enrolled in the study and had little trouble with filling out forms, turning in packets, or understanding the intervention. Additionally, Jeffrey did see some improvements in abdominal pain, suggesting that it would be useful to further study the intervention. Because both the process and outcome of the pilot case were promising, the researcher proceeded with the study as planned with the children in the multiple baseline design, with no modifications made except for recruitment site. Abdominal Pain Results from the BRMF indicate that all children experienced reductions in abdominal pain after using the breathing exercise. Success rate was calculated by dividing the frequency of breathing practices where pain decreased after the practice by the frequency of breathing practices where there was pain present before the practice. Success rates were high for Sophie (89%), Lisa (90%), and Samantha (100%). These results mirrored Jeffrey's preliminary results, where he had a 100% success rate for his

use of breathing retraining. Brittany's success rate was a more modest but still noteworthy 58%. All children also rated their relaxation as increased after engaging in this technique each time. Figure 1 shows each child's report of abdominal pain in each phase of the study. During the baseline phase, Lisa and Brittany demonstrated relatively stable abdominal

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Lisa

Brittany

Samantha

Sophie

Figure 1. Child rated abdominal pain before and after treatment. The lines in between data points indicate where treatment was administered. Brittany and Sophie experienced decreases in their abdominal pain after the treatment session, while Lisa's pain increased and Samantha's pain remained constant.

pain. Brittany had one outlier value of 0, which was discarded so as not to artificially inflate any change following the intervention (although results both including and excluding the outlier were similar). Samantha's and Sophie's abdominal pain was variable throughout the baseline phase. Samantha's abdominal pain continued to fluctuate after the intervention, and her average level of pain throughout the entire study was consistent. Table 1 demonstrates changes in mean scores for each child. Reliable Change Indices were calculated for all child and parent ratings. Brittany and Sophie demonstrated statistically significant reliable change after the intervention, RC = − 2.02, p b .05 and RC = −2.81, p b .05, respectively. Both of Sophie's parents also reported statistically significant improvements in Sophie's pain postintervention,

RC = −2.16, p b .05; RC = −2.46, p b .05. Both Brittany and Sophie showed some maintenance of their API gains at 3-month follow-up. Functional Disability All children except Brittany established stability in the baseline phase. Brittany's functional disability scores varied between 0 and 10 throughout the baseline phase, which is still consistently low (the FDI has a top score of 60). Table 1 illustrates functional disability mean ratings and Reliable Change Indices for children and parent reports of functional disability. All children's functional disability ratings remained fairly consistent and low, indicating that children did not report significant impairment in daily activities

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Table 1

Clinical Ratings, Pre- and Postintervention Child

Abdominal Pain Index (API) Ratings Child Ratings Mean Baseline

Parent Ratings Mean Post-Tx

Jeffrey Lisa Brittany Samantha Sophie

9.57 4.82 13.14 10.52 12.23

7.46 7.25 9.73 9.94 7.50

Child

Functional Disability Inventory (FDI) Ratings

RCI

Mean Baseline

Mean Post-Tx

RCI

−1.25 1.44 −2.02* −.34 −2.81*

7.71 4.18 8.29 4.96 11.88 12.62

7.54 5.69 9.40 7.00 8.00 8.19

−.09 .84 .62 1.13 − 2.16* − 2.46*

Mean Post-Tx

RCI

2.20 .75 .72 4.56 .06 1.31

− 1.59 .18 .08 2.31 − 1.17 .13

Child Ratings Mean Baseline Jeffrey Lisa Brittany Samantha Sophie

Child

3.43 1.91 4.36 2.00 1.35

Parent Ratings Mean Post-Tx 2.23 2.00 2.40 2.00 1.13

RCI

Mean Baseline

−1.08 .08 −1.76 .00 −.20

Child Somatization Inventory (CSI) Ratings Child Ratings

Jeffrey Lisa Brittany Samantha Sophie

4.00 .55 .63 1.95 1.38 1.46

Parent Ratings

Mean Baseline

Mean Post-Tx

RCI

Mean Baseline

Mean Post-Tx

RCI

7.00 2.50 27.40 1.57 13.00

9.00 5.25 14.25 1.25 2.00

.23 .32 −1.51 −.04 −1.26

9.00 5.50 17.40 .86 11.29 8.75

9.33 5.75 5.75 1.50 .50 .00

.04 .05 − 2.55 .14 − 2.36 − 1.19

Note. Sophie's two parents’ ratings are included; she is the only child who had both parents report. The Reliable Change Index (RCI) for child report was calculated using the grand mean, standard deviation of all children's mean baseline and posttreatment scores, and the reliability of each measure (API, FDI, and CSI) for children with chronic pain. The same procedure was used for parent report. Mean Post-Tx: Mean score for each measure from post-intervention data. *p b .05.

due to abdominal pain. Brittany was the only child who could feasibly attain a significant RCI score. Mathematically it was impossible for Lisa, Samantha, or Sophie to demonstrate significant improvement, because their initial scores were too low. Brittany demonstrated a mean value decrease, but this was not significant. Samantha's mother reported a statistically significant increase in Samantha's functional disability after the intervention, RC = 2.31, p b .05. At follow-up Samantha's functional disability scores were lower than during baseline and postintervention phases. (Follow-up results can be found in Table 4.) Samantha's mother reported during the follow-up session that her daughter had been more active since learning the intervention and was more willing to go to school or a friend's if her stomach hurt. She described how her daughter used to lie in bed all day when feeling sick, but after learning breathing

retraining would say, “It's okay, I can use my breathing and then go.” Other Somatic Complaints Lisa, Brittany, and Samantha demonstrated stability in the baseline condition, while Sophie's CSI scores were a little more variable but still relatively stable during this initial phase. Table 1 presents CSI data. Children's scores were fairly low, as the CSI has a top value of 140, meaning that they did not endorse many somatic symptoms outside of abdominal pain. For this reason, only Brittany's initial scores were high enough for her to reach a clinically significant RCI score posttreatment. Brittany's somatization ratings fell after treatment implementation, but the Reliable Change Index was not significant (RC = −1.51,

Efficacy of a Brief Relaxation Intervention p N .05); her parents’ report of her somatization, however, did indicate a significant decrease, M = 17.40 to M = 5.75, RC = −2.55, p b .05. Sophie's ratings also decreased after the intervention, but it was not mathematically possible for Sophie to reach a significant RCI score given her initial CSI mean rating. Sophie's father's ratings indicated significantly decreased somatization in his daughter, M = 11.29 to M = 0.50, RC = −2.36, p b .05. Samantha and Lisa's somatization remained stable after the intervention. Three-month follow-up CSI ratings indicate that in general treatment gains in somatization were maintained. In addition to using the CSI to measure children's somatization, the Child Behavior Checklist's Somatic Complaints subscale was administered to parents once before the baseline condition and once at follow-up. Table 2 demonstrates parents’ CBCL Somatic Complaints ratings for their children before and after treatment. All children's parents endorsed fewer items on this subscale at follow-up, suggesting a decrease in somatic symptoms after the intervention. This decrease in scores was statistically significant, p b .05, for Brittany (RC = −5.67), Samantha (RC = −2.84), and Sophie (RC = −5.20), but not for Lisa (RC = − 1.89).

Anxiety Table 3 demonstrates children's anxiety levels throughout the study. All children's anxiety scores throughout the study were in the normal range, as indicated by T scores below 60. In general, the children's anxiety remained

Table 2

Child Behavior Checklist Anxiety/Depression and Somatic Complaint Ratings Pre- and Postintervention Child

Baseline CBCL Score

Posttreatment CBCL Score

Reliable Change Index

Anxiety/Depression Subscale Jeffrey 9.00 Lisa 5.00 Brittany 1.00 Samantha 7.00 Sophie 5.00

10.00 2.00 .00 4.00 1.00

.64 −1.91 −.64 −1.91 −2.55*

Somatic Complaints Subscale Jeffrey .00 Lisa 5.00 Brittany 7.00 Samantha 3.00 Sophie 8.50

.00 3.00 1.00 0.00 3.00

.00 −1.89 −5.67* −2.84* −5.20*

Note. The Reliable Change Index for was calculated using the mean and standard deviation of parents’ CBCL rating scores at baseline and posttreatment and the reliability of the CBCL subscales. CBCL = Child Behavior Checklist. *p b .05.

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Table 3

Anxiety Ratings Pre- and Postintervention Child

Mean Baseline Mean Posttreatment Reliable RCMAS Score RCMAS Score Change Index

RCMAS TOT Jeffrey 33.00 Lisa 33.73 Brittany 38.83 Samantha 48.26 Sophie 40.19

29.07 37.38 35.50 48.07 35.25

−1.04 .96 −.88 −.05 −1.31

RCMAS PHY Jeffrey 37.86 Lisa 40.36 Brittany 49.58 Samantha 48.48 Sophie 41.46

33.20 46.69 43.00 51.25 38.88

−.26 1.98* −2.06* .87 −.81

RCMAS WOR Jeffrey 33.14 Lisa 31.64 Brittany 34.00 Samantha 47.22 Sophie 44.58

32.00 35.00 34.00 46.94 38.63

−.26 .76 .00 −.06 −1.34

RCMAS SOC Jeffrey 34.00 Lisa 35.27 Brittany 35.00 Samantha 56.04 Sophie 34.31

34.40 38.38 35.00 53.94 32.00

.07 .53 .00 −.36 −.39

Note. The Reliable Change Index for was calculated using the grand mean and standard deviation of all children's mean baseline and posttreatment RCMAS scores and the mean reliability of the RCMAS (as studies found a range of reliability values). RCMAS TOT = Revised Children's Manifest Anxiety Scale Total Score; RCMAS PHY = Revised Children's Manifest Anxiety Scale Physical Anxiety Scale; RCMAS WOR = Revised Children's Manifest Anxiety Scale Worry Scale; RCMAS SOC = Revised Children's Manifest Anxiety Scale Social Anxiety Scale. *p b .05.

relatively constant and low both at baseline and following the intervention, with the exception of a few fluctuations. The only statistically significant results were that Lisa's scores on the physiological anxiety subscale increased significantly after intervention, M = 40.36 to M = 46.69, RC = 1.98, p b .05, while Brittany's decreased significantly after intervention, M = 49.58 to M = 43.00, RC = −2.06, p b .05. In addition to the child-reported anxiety symptoms on the RCMAS, parents rated their children's anxiety using the CBCL Anxiety/Depression subscale both before the baseline phase and at 3-month follow-up. Table 2 presents these findings. All children's parents endorsed fewer items on this subscale at follow-up, demonstrating a decrease in anxiety and depression in children following the intervention, however, the Reliable Change Index was

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only statistically significant for Sophie's parents’ ratings, M = 5.00 to M = 1.00, RC = −2.55, p b .05. Three-Month Follow-up Feedback Table 4 includes 3-month follow-up data for the API, FDI, CSI, and RCMAS. Lisa and her mother reported at follow-up that although Lisa continued to get stomachaches just as frequently as she had before the treatment session, breathing retraining had helped to decrease the amount of pain that she experienced. They noted that while sometimes Lisa's pain would not disappear completely, it was generally lessened by using the relaxation technique. Brittany stated that she found the breathing retraining to be especially easy to use when she had stomachaches at school and that it was helpful in lessening her pain. However, she stated that she still had pain fairly frequently and that breathing retraining did not always eliminate her pain completely. Samantha reported that she had been using breathing retraining for stomachaches and that it had been helpful in lessening pain. Her mother noted that since Samantha learned breathing retraining she had begun engaging in more activities when in pain or when anticipating being in pain. Samantha confirmed that she felt more in control of her pain. She also noted that many of the times she indicated extreme pain on her forms she had been experiencing menstrual cramps. Her mother reported that through the self-monitoring for this study they had discovered this seemed to be the worst cause of Table 4

Three-Month Follow-up Ratings Child

Child Report Jeffrey Lisa Brittany Samantha Sophie

API FDI CSI RCMAS RCMAS RCMAS RCMAS TOT PHY WOR SOC

1 19 10 0 10

2 18 2 1 4

4 12 19 1 2

Parent Report Jeffrey 9 Lisa 11 Brittany 7 Samantha 0 Sophie 12 8

5 2 0 1 1 0

9 3 6 0 4

35 45 34 33 39

40 54 41 36 41

38 47 34 38 47

34 38 35 34 32

0

Note. API = Abdominal Pain Index; FDI = Functional Disability Inventory; CSI = Children's Somatization Inventory; RCMAS TOT = Revised Children's Manifest Anxiety Scale Total Score; RCMAS PHY = Revised Children's Manifest Anxiety Scale Physical Anxiety Scale; RCMAS WOR = Revised Children's Manifest Anxiety Scale Worry Scale; RCMAS SOC = Revised Children's Manifest Anxiety Scale Social Anxiety Scale.

Samantha's pain, and were considering trying over-thecounter medication for menstrual cramps to alleviate the pain at these times. Finally, Sophie reported that she had not had many stomachaches lately. Her parents remarked that the relaxation technique had helped their daughter a lot and that they had been reminding her to use it every time she complained of a stomachache. Her mother noted that she had also started using it herself, as she also suffers from occasional stomachaches and diarrhea. All children and families expressed gratitude for the help they had received. Mothers of Jeffrey, Lisa, Brittany, and Samantha completed the EQ, while both Sophie's mother and father completed the form. Brittany and Samantha also filled out the EQ themselves due to their age and reading ability. The EQ mean values could range from 0 to 4, with 4 representing the highest level of satisfaction with the helpfulness of the intervention. (See the Measures section for full list of qualitative descriptors.) Jeffrey's mother's ratings (M = 2.0) suggested that she found the intervention to be somewhat helpful. Lisa's mother's ratings (M = 2.6) suggested she found the intervention to be somewhat to a lot helpful. Brittany's ratings indicated she found the intervention to be somewhat helpful (M = 2.2), while her mother only found it to be a little helpful (M = 1.0), although her mother noted that she does not normally speak to Brittany about her pain and was estimating. Samantha's ratings indicated that she deemed the intervention somewhat to a lot helpful (M = 2.5), while her mother deemed it a lot helpful (M = 2.9). Sophie's father's ratings indicated he found the intervention between somewhat and a lot helpful (M = 2.4), while her mother's ratings indicated she found the intervention a lot to extremely helpful (M = 3.4). Thus, overall, both parents and children responded positively to the intervention.

Discussion Recurrent abdominal pain is a chronic condition in children that is often unresponsive to standard medical care, causing families to accrue medical bills without finding relief for their children (Banez & Gallagher, 2006; Colletti, 1998; Frazer & Rappaport, 1999; Walker et al., 2001). This study provides preliminary data on the efficacy of a brief and portable intervention for RAP that includes two common anxiety treatment components that can be taught in one session: psychoeducation and breathing retraining. It was predicted that children would report fewer and less intense episodes of abdominal pain following this intervention. Two children showed significant decreases in abdominal pain after the intervention as measured by API scores. There are several possibilities for why the other two children did not show marked improvement in pain after their respective treatment sessions. First, Lisa's API scores

Efficacy of a Brief Relaxation Intervention were minimal throughout the study, making it difficult to improve upon them, especially given her acid reflux. She would likely always endorse some items on the API, such as the first item, which asks how many days that week she had any abdominal pain. Second, Samantha's scores indicated great variability both in baseline and posttreatment phases, making it difficult to get an accurate measure of her everyday pain level. Furthermore, as the researcher learned in the follow-up meeting, Samantha and her family discovered via study monitoring that much of her severe pain may be related to menstrual cramps and not really a form of RAP after all. In this sense her API scores may not accurately reflect recurrent abdominal pain in the Apley sense, making it difficult to determine whether the intervention was helpful in targeting her RAP symptoms. Third, the API does not directly measure changes in pain throughout the day and can be inflated by a severe maximum pain rating for the day. For example, a child could have a high API score because she had a maximum pain amount of 10 during that day, even if that pain fell to a 2 or 3 after completing the breathing exercise. Although the API is a helpful tool in measuring abdominal pain, it may not reflect changes in pain as sensitively as necessary. For this reason, it is important to consider the BRMF, which does measure pain before and after the child practices the relaxation exercise and provides a clearer answer as to whether the exercise works to reduce abdominal pain. Lisa, Samantha, and Sophie reported decreased pain consistently following the breathing exercise, with success rates of 91%, 100%, and 89%

respectively. This adds support to the high success rate (100%) found in the pilot study. Brittany also used the breathing exercise successfully more times than not, but with a lower success rate than the other children (58%). This was somewhat surprising, as she showed significant decreases in pain on the API. Furthermore, at 3-month follow-up, all children reported that they had benefitted from breathing retraining and that it had helped lessen their stomach pain when they used it. Taken together, all four children from the multiple baseline design and the one child in the pilot case demonstrated some form of improvement in abdominal pain following the intervention, supporting the use of breathing retraining for children with recurrent abdominal pain. It was predicted that children would report less functional disability following this intervention. No children in this study reported significant changes in functional disability on the FDI postintervention; however, it was mathematically impossible for any of the children except Brittany to attain a significant change. The other children's pretreatment mean scores were too low, such that even if children's scores fell to a 0, RCI scores would not reach the cutoff for significance. Brittany did not show a significant

decrease in functional disability, suggesting it is also possible that the intervention was not powerful enough to decrease functional impairment. However, given that all children and parents reported specific examples of improved functioning at 3-month follow-up (e.g., Samantha engaging in more activities, Brittany successfully lessening pain at school by using breathing retraining), it seems more likely that the lack of significant change in measured functional disability was due primarily to the initially low scores on the FDI. It was predicted that children would report fewer and less intense somatic complaints following this intervention. This hypothesis was only partially supported. No child reports demonstrated significant reductions in somatic complaints; however, it was mathematically possible only for Brittany to obtain a significant RCI score, as the other children's initial CSI scores were too low to change significantly. Brittany's parents and Sophie's father reported significant decreases on the CSI, and Brittany's, Samantha's, and Sophie's parents reported significant reductions in somatic complaints on the CBCL. Therefore, there was some support for this intervention improving somatization beyond stomach pain. It is possible that the intervention may not have decreased general somatic complaints across all children because the main focus of psychoeducation and breathing retraining was alleviating stomach pain rather than other forms of somatization. Also, because these children were enrolled in the study due to their RAP, they may have forgotten the piece of information about anxiety leading to other types of physical symptoms and may not have tried to relax when experiencing some of these other somatic symptoms. It was predicted that children would report fewer anxiety symptoms following this intervention. As measured by the RCMAS, children's anxiety was initially in the normal range and on the whole did not substantially change after participation in the intervention. Results of the CBCL suggest that anxiety decreased after the intervention, as all children in the multiple baseline design demonstrated a drop in scores between baseline and 3-month follow-up. However, this was a statistically significant change for only one child, Sophie. It is possible that this treatment led to decreases in anxiety, but that the anxiety measures chosen did not accurately reflect that. For instance, as all children reported greater relaxation after using the breathing retraining exercise and because it is physiologically impossible to be relaxed and anxious at the same time (Asteria, 1985), this finding suggests that children's anxiety was decreased by this intervention, at least in the short-term. The RCMAS does not reliably demonstrate changes in anxiety level in children who do not have pathological anxiety, but rather differentiates between normal anxiety and pathological anxiety (Reynolds & Richmond, 2008). One possibility is that the anxiety experienced by children with RAP focuses solely or primarily on their

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abdominal pain and the anticipation of such pain, rather than being a more diffuse form of anxiety. For example, a child with RAP may not reach clinical severity for an anxiety disorder, but may for whatever reason have a tendency toward stomachaches; upon noticing the stomachache, the child may become anxious about the pain, which in turn exacerbates the pain. This interplay between physiological sensations and cognition could become a learned pattern. If this hypothesis about RAP is true, the types of symptoms measured by the RCMAS may not be the most applicable to children with RAP who have predominantly somatic symptoms and do not manifest anxiety in more cognitive or behavioral ways. A simple 0-to-10 rating of a child's anxiety before and after practicing breathing retraining and of a child's daily anxiety may be a better measure of this intervention's effect on anxiety level in children with RAP, as was suggested by the clear immediate impact of the breathing retraining on children's ratings of relaxation on the BRMF. Limitations of the Study There were several limitations to this preliminary study. While use of a multiple baseline design provides methodological rigor beyond that of a simple case study, findings from such a small sample size, with a range of ages, physical symptoms, and treatment histories, must be interpreted with caution. Nonetheless, this initial study demonstrated some success with this small heterogeneous group, suggesting that this intervention could benefit a diverse group of children and warrants more extensive investigation. The range of ages included also impacted the standardization of the procedure, as developmental modifications to the procedure were made as needed. However, developmental considerations are necessary in clinical settings, such that losses in statistical control here are made up for by gains in external validity. Similarly, parent reporting was not consistent across all subjects, leading to a lack of uniformity in some results (e.g., Brittany's parents alternated in providing ratings and as a result a combination of their ratings was used). Although having different reporters can complicate the findings, this type of reporting may also better reflect clinical practice, where a child may not always come for services with the same parent each time. Another potential issue is that while participants did not begin new treatments while participating in this study, two of the children were taking medication. It is possible that some changes may have been due to medication effects rather than to the intervention. However, this seems less likely an explanation for symptom change, as Jeffrey and Lisa were stabilized on their medications before beginning the study for periods of 1 month and 3 months, respectively. This suggests that their baseline reflected any effects

of medication and that any changes posttreatment were more likely due to the intervention than to the medication on which they were already stabilized. That not all children established steady baseline conditions makes interpretation of some results difficult. Even significant changes in scores after intervention cannot be wholly attributed with confidence to the intervention without baseline stability. However, given the nature of the study, it was deemed more important to provide services in a timely manner than to await stability for all children, especially as abdominal pain tends to be episodic. Despite this limitation, some children did have stable baselines, which allows a clearer examination of intervention effects, as does the fact that some treatment gains independent of baseline stability were evident in all children (i.e., immediate decreases in pain on the BRMF), thus again suggesting that the intervention warrants further investigation. In general, children in this study did not report severe levels of anxiety, functional disability, or somatization on baseline measures. The fact that self-report and parentreport produced subclinical symptom scores is surprising as all families in the study sought involvement because of severe distress or impairment. At the time of study enrollment, all children not only met Apley's (1975) definition of RAP, but also exceeded the frequency of stomachaches specified in his definition. In addition, all families did report some level of impairment. One potential reason for the discrepancy in reporting is that at the time of prescreening parents were providing a brief history of their children's problems and so may have specifically recalled and focused on only the most severe, distressing, and impairing pain episodes, even if those episodes were not typical, especially since they were seeking help for these symptoms. Also, it must be noted that the information initially gained from speaking with the families was retrospective, as compared to the information gained from the measures which was current to the day or week the form was being filled out. This could lead to differences in the severity of symptoms reported, in that frequent self-monitoring may have led to overall fewer symptoms being reported, as again only occasionally did children have severe episodes (the ones that parents most easily recalled) and on most days children fared fairly well. This is congruent with Apley's (1975) definition of RAP. A final reason that the families in this study reported subclinical levels of functional disability, anxiety, and somatization may be that these characteristics were not necessarily related to these children's stomachaches, at least not to a clinical level. The low initial scores on some measures also led to range restriction, where small changes in symptoms need to be interpreted cautiously. For instance, even though some changes were statistically significant, the decrease in scores may not be marked enough to be clinically significant. Conversely, some children's baseline scores on some

Efficacy of a Brief Relaxation Intervention measures were so low that it would not have been mathematically possible to achieve significant posttreatment scores. Although this study serves as a useful pilot test of this brief intervention for RAP in a small sample, it will be important in future investigations to examine the intervention's impact on more severe symptom levels. This study was also limited by the type of data gathered at 3-month follow-up. The abdominal pain and functional disability measures only inquire about symptoms on the day of the follow-up, with the exception of one item on the API asking about stomachaches during the week. Similarly, the CSI only asks about somatization from the past week. The information gathered from these measures could easily be biased by a nontypically good or bad day (as was the case of Lisa, whose friend moved away the day of the follow-up meeting). For this reason, 3-month follow-up scores should be interpreted with caution. Additionally, there were limitations to the use of the EQ. It was a particularly subjective measure that was created for this study. Only two children were administered the EQ, with the remainder of the results being parent ratings. Parents are often not accurate reporters of their children's symptoms and so there may be limited clinical utility for these ratings, although children may not always be accurate reporters themselves. Furthermore, it is still general practice when assessing children to collect information from child and parent to limit the biases of either source and to reduce measurement error by using multiple sources (Merrell, 2008). On the other hand, a strength of the 3-month follow-up is that qualitative information gained from talking with the children and their parents may give a clearer picture of what the last few months had been like for these children, in ways that may not have been captured by symptom measures. That several participants were able to clearly describe how the intervention led them to decrease pain-related avoidance, for example, provided additional evidence that the intervention is promising enough to warrant further study. Summary and Future Directions A built-in limitation of a single-subject design study is that the number of participants is small, making generalization to larger populations more difficult. Nonetheless, the replication demonstrated in a multiple baseline design provides support for an intervention (Kazdin, 1998). This study was designed as a preliminary examination of the brief intervention. Results were generally positive, with all children responding to the intervention with lessened pain in some way. However, the intervention was not as successful as hypothesized, which may suggest the intervention was not as powerful as had been hoped for, and/or may be partially due to the limitations outlined above. Nonetheless, the findings from this study support previous research that

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breathing retraining is beneficial in reducing physiological arousal and improving somatic symptoms (Clark, Salkovskis, & Chalkley, 1985; Fried, 1993; McCaul, Solomon, & Holmes, 1979; Salkovskis, Jones, & Clark, 1986) and demonstrate that this technique could be promising with the RAP population. Future research should expand upon this preliminary, small-scale study in the form of a larger, more controlled study. Such studies might also include an emphasis on children with higher initial severity scores. Future research might also focus on accessibility and portability of this brief intervention to the target population. As children with RAP are generally seen in primary-care settings and are not receiving effective treatments (Banez & Gallagher, 2006; Frazer & Rappaport, 1999; Walker et al., 2001), dissemination to and evaluation in medical settings is imperative. Should the intervention continue to demonstrate promise in larger studies, future research could focus on teaching this intervention to nurse practitioners and other health professionals or implementing this intervention in an online program. This intervention could be beneficial in lessening costs and improving RAP complaints for many children.

Disclosure Statement Financial support: The first author received a financial grant from her university for conducting this study for her master's thesis.

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