Psychogenic Basis for Abdominal Pain in Children and Adolescents

Psychogenic Basis for Abdominal Pain in Children and Adolescents ABBY L. WASS ERMAN. M.D .. PET ER F. WHITINGTO N. M.D ..

AND

FR EDERICK P. RIV ARA. M.D .

Abstract. Eighteen girls and 13 bo ys. referr ed to a pedi atric gastroenterology clinic for recurre nt abd ominal pain. were co m pared with matched classroom control subjects o n measure s of school fu nctioni ng. family environment. life event s. and social and beha vioral trait s. All patients and their parents were interviewed by a child psychiatrist. Th is disorder was found more a lien in anxious. internalizing ch ildren who had been exposed to traumatic events and whose famil y members had a histo ry of abdo minal pain . The persistence of th is disorder in most pat ients o ver a mean 9.5-mo nth follow-up per iod suggests that methods for deal ing with anxiety would be beneficial to the se child ren. 1. ..1m. Acad. Child Adolc sc. Psychiat ry. 1988. 27. 2:179-1 84. Key Words: abdo mi nal pain. anxiet y. traum a. dep ression . establ ished town in northern England. 34% were sulTering from RAP ; there was a highl y significa nt excess of emotiona l disturbance in this group. especiall y of anti social beha vior . compared with their control subjects. Neurotic probl ems were seen in RAP patients by Apley (1975) and by Stone and Barbero (1970). Crossley (1982) found that a significa nt number of children hosp italized for non specific abdom inal pain had emotional disorders. In the onl y publi shed study that has assigned DSM-III diagnoses. psychiatric disorders were present in 100% of th e children and adolescents evaluated (Astrada ct at.. 1981). Unfortunately. there was no contro l group. and this was a highly selected sample (referrals to a psychiatric con sultati on service) . Furthermore. half o f the subjects were hospitalized for their abdominal pain . Th e present study evaluated consecutive referral s to a pediatric outpatient gastroenterology clin ic and compared the se patients with a matched control group. In addi tio n to rating scales that assessed the abdominal pain. famil y envi ronment. beha vior . and life events . ch ildren with RAP were evaluated by a psychiatrist using DSM-11I crite ria. Thi s evaluation was part of a larger . double-blind treatment study of RAP (Whitington et al., 1985).

Recurrent abd ominal pain (RAP) is one of the mo st frequ ent soma tic complaints in child ren. occurring in about 10% of an unselected primary and secondary school population (Aple y and Naish . 1958). Because a specific organic etiology for the pa in is found in only 5 to 10% of symptomatic children (Apley , 1975). psychogenic factors are assumed to pla ya causal role (Green. 1967: Stone and Barbero. 1970) . Goldberg et al. ( 1979) reported that children with mental health problems co mplai n to the ped iatrician of diseases of the digest ive tra ct more frequently than any other symptom complex. Moreover. psychosomatic problems have been reported in 8 to 10 % of children in primary care facilities (Starfield et al., 1980). In addition . people with mental disorders are more frequent users of general medical services than are person s without such d isorders (G oldberg. et al., 1979). Ch ildren with " psychogenic" abdominal pain return repeatedly to the physician for help (Nicol. 1982). Considering the rising costs of med ical ca re. it would be of ben efit to these ch ildren and their famili es if th e emotional component of the RAP could be delineated and treated without the need for multiple organic workups. An identifiable psychiatric disorder was found in the overwhelming majority of adult patients with functi onal gast rointestinal disorders studied by Alpers (19 83). Yet. McGrath et al. (1983) questions whether RAP in children has a psychogenic basis because his study group and co ntrol group did not show an y statistically significant d ilTerences on psychol ogical questionnaires. amount of life stre ss the child experienced. or famil y history of pain. However. he d id not int erview the children for the purpose of mak ing a psychiatric diagnosis. In Faull and Nicol's (1986) study of 5- and 6-year-old s in a newly

Method

Study Population Patients referred to the Pediatric Gastroenterology Clin ic at LeBonheur Children's Med ical Center. from Janua ry I. 1984 to May 31. 1984. were eligible for stud y if the y were between 6 and 16 years of age and had had at least three episodes of nonspecific recurrent abdominal pain severe enough to interfere with activities over a 3-month or longer time period (Aple y, 1975). At the initial evaluation. the patient and parent(s) were asked to participate. a nd informed con sent was obtained accord ing to institutional guidel ines . Control subj ects were cho sen from each patient's schoo l classroom. Teachers were asked to list four children of the same age and gender as the study patient. On e of thes e names was randoml y chosen to be the matched control. If the initial famil y refused to cooperate. another name was chosen unt il a control was obtained . If no control was found in this manner. a matched control subject was obt ained from the practi ce of a local pediatrician who draws from the same socioeconomic strata as the G I clini c.

Accepted August 14, IWI ? This studv wa.l· done at Lellonheu r Children 's Medical Center. University ofTennessee. Memphis, Tennessee. Dr. lI ·a s.H 'fII1Wl is nOl" Director I!( Residency Training. Division ot Child Psychiatry. at Washington University S chool of Medicine. S t. Louis, Missouri. Dr. Whitington is now Chie l or the Sectio n or t iastr oentcrokw v, The University or Chicago School or M edicine . Chicago, Illinoi s. Dr. Rivara is now Director or the llarborview In jury Prevention and Research Center, S calile, lI'ashinR.lon. We wish to thank Sarah Day. A my Thompson, and Jum cy /1011'deshellfor data collection: Roger Vand er Swaa g, Ph.D. and Diane Fa irclough, Dr. P. H filr statistical analysis; (i eorgc Abrahams. Ph.D. and Ravmond Mulhern. Ph.D. tor review otintcrvicw sheets tor DSM1/1 diagn oses; and Christy 1I"right and Alice Friedm an. ·Ph.D, jnr editorial he/fl. Reprint requests to Dr. 11 ·(Jsserm an . Departm ent (Ir Psychiat ry. Washington University School ol' Me dicine. 4940 :l udubon .·h 'e.. St. Louis. ,\/0 fJJ110. 089 0-8567 /88/2702-017 9 $02.00/ 0 «» 1988 by the Ame rican M aderny of Child and Adolescent Psychiatry.

Procedure Before being seen by the ph ysician . all parents co mpleted an Abdominal Pain Questi onnaire (APQ). which is given 17U

180

WASSERMAN ET AI..

routinely to parents of all patients with abdominal pain in the clinic . The patients were then evaluated by the gastroenterologist who scheduled their various tests . The upper gastrointestinal endoscopy, which all the patients had. was scheduled for another day. The physician explained the study to the patient and parenus), who completed the rating scales described below after they agreed to participate in the study. After the medical evaluation but before the endoscopy, the psychiatrist (A. L. W.) met with both the child and parent(s) to ask questions about the abdominal pain . Children and parents were interviewed separately with a structured interview combining items from the Columbia Psychiatric Interview for Children and Adolescents and the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. The combination of these two schedules allows for evaluation of all the DSM-IIl child and adolescent diagnoses (Cantwell. D. P.. personal communication). Both the child and parent parts of the interview schedules were used. DSMIII diagnoses of the patients were made where appropriate. Concordance with the independent diagnosis of a clinical psychologist, based on review of the interview forms , was required . Any stress- or anxiety-producing factor reported by the child or parent was also noted . The patient's teacher was sent the Teacher's Report Form of the Child Behavior Checklist (TCBCL) (Achenbach and Edelbrock. 1983). If any organic etiology for the RAP was discovered after the completed workup, the child was excluded from the study . Families of the selected controls were sent a letter of explanation along with the four self-administered rating scales after they agreed to cooperate. The questionnaires were completed at home and returned by mail. The teacher was asked to complete the TCBCL on the selected control child (with parental permission). Psychiatric interviews of the controls were not possible because of the long distance a number of them would have had to travel. Socioeconomic status for both the patients and controls was rated on a two-factor index of parental education and occupation (Hollingshead. 1975).

Child Behavior Checklist. The CBCL (Achenbach and Edelbrock, 1983) is a self-report inventory for parents of children 4 to 16 years old . Normalized T scores for the social competence scale. the internalization score , the externalization score. and the total behavioral profile score are standardized for age and gender. Because these scores are the most reliable scores of the test. especially in a nonpsychiatric population (Mooney, 1984), and are available for all the age groups that are included in this study (in contrast to the Profile Type scores), they are the only scores compared between groups. Teacher's Child Behavior Checklist. The TCBCL (Achenbach and Edelbrock, 1983) is an inventory designed to obtain demographic data and to determine previous use of special services. repetition of grades, ratings of academic performance, standardized test data, and the child's behavior in school over the past 2 months. The scales that we used to compare the patients and control subjects. which are standardized for age and gender and are available for the ages 6 to 16 years, are the adaptive function score, behavior problem score. internalization score, and the externalization score . School performance was also compared between groups.

Follow-up Eight to 12 months after the initial evaluation, each patient's mother was interviewed by phone about the occurrence and severity of abdominal pain since the child's evaluation. Questions included the relationship between worries or stress and the pain (a question on the APQ) . and changes in stresses previously noted on the LES or in the interview (i.e., resolved . better but still present, the same , or worse). Data Analysis

Two-tailed r-tests or chi-square analyses were used to compare the patients and control subjects on demographic data and the results of the APQ . Analysis of variance (ANOYA) comparing the two groups on the results of the remaining instruments was also done. Because multiple comparisons were made, the 0.0 I level of significance was used to minimize differences that might be present by chance.

Instruments Abdominal Pain Questionnaire. The APQ is a 66-question history form assessing the nature, severity. and treatment of abdominal pain and any perceived relationship to stress; the medical history of patient and family ; sociodemographic information ; and school functioning. Family Environment Scale. The FES (Moos and Moo s, IW~ /) is a 40-item inventory assessing family relationships and organizational structure on 10 subscales: Cohesion, Expressiveness. Conflict. Independence. Achievement Orientation. Intellectual-Cultural Orientation, Active-Recreational Orientation. Moral-Religious Emphasis. Organization. and Control. Life Event Scale. The age-appropriate LES (Coddington. /972) is completed by the parent. The children's scale (ages 6 to II years) lists 35 events, and the adolescent scale (ages 12 to 19 years) 49 events. Each event that occurred during the previous 3 months is assigned life-change-units, which are summed to obtain a total score . The higher the score on the LES, the greater the associated stress and readjustment.

Results

All of the patients' families that were asked to be in the stud y consented. Of the 35 initial patients, four were excluded because of findings of organic disease (peptic ulcer, N = 2; hydronephrotic kidney; and ovarian cyst). The 31 remaining patients (18 female. 13 male) had had RAP for a median of 12 months (range. 3 to 72 months). The mean time to followup was 9.5 months (range. 8.5 to 15 months). The one patient lost to follow-up (a 14-year-old girl) is included in all other analyses. Twenty-nine matched control subjects were obtained from the patients' classrooms and two from the pediatric practice. The patients and controls did not differ significantly on any of the sociodemographic variables examined (Table I). On the APQ, parents of 13 control subjects reported that the child had occasional abdominal pain, but none met the study criteria for RAP. Compared with controls. RAP subjects had missed significantly more school in the current year, were rated as appearing unhappier, and more often had decreased

181

PSYCHOGENIC BASIS FOR ABDOMINAL PAIN T A RL!' I .

Sociodemographic Variables in Patients with RAP and Control S ubjects"

Race White Black Age (mean, years) Range Grade in school Range Socioeconomic status' I and" lll, IV, and V Marital status of parents Married Separated Divorced/widowed Never married Number of siblings Only child One sibling Two siblings Three siblings More than three

Patients

Control

( N= 31)

( N= 31)

25 6 10.6 6-16 4.6 I-II

5 26 25

2 14 7 5 3

3 13 10 3 2

" All differences are nonsignificant (by two-tailed chi-square or test , as appropriate). • Hollingshead two-factor index (1957).

Patients

Variable

( N= 31)

Amount of school m issed/year 2 weeks Unhappy appearance Appetite Normal Increased Decreased Family history of peptic ulcers

9 22

3 2

2. Significant Differences on Abdominal Pain Questionnaire

Bet.....een the Patients and Control Subjects

28 3 lOA 6-17 4.9 1-11

26 1 3 I

I

TABL !'

a

Controls (N=31)

p

Value" <0.001

6 II 14 13

26 4

16

22

3

2 I

o 1

12 14

<0.001 <0.007

4

<0.01

Two-tailed chi-square test.

T A111 .F 3. Psychometric Test Result s (Mean ± S. D.) for Patients with

RAP and Control Subje cts

Variable" t:

appetite (Table 2). No significant differences were seen between groups on the following APQ items: weight change over the past year; complaints of headaches, limb pain . or chest pain : urinary tract problems; enuresis; crying spells: or temper outbursts. The families of patients reported significantly more history of peptic ulcer disease than did the controls. Ten family members of patients were currently being treated for peptic ulcers or spastic colon. There were no reported differences between the patients and control subjects in the occurrence of emotional problems, drug or alcohol use, or headaches among family members.

Rating Scale Scores There were no significant differences between groups on the LES total life-change-units. and the mean scores of hoth groups fell into the range of 75% of the healthy children and adolescents used to evaluate the test. However. the RAP patients were more likely to have a positive response than did control subjects (p < 0.0 I) on three individual items: hospitalization. parental hospitalization, and death of a grandpar-

Life Events Scale Famil y Environment Scale Cohesion Expressiveness Conflict Independence Ach ievement orientation Intellectual/cultural Act ive recreation orientation Moral religious emphasis Organization Control Parent's CBCL Social competence Internalization Externalization Behavior problems Teacher's CBCL School penormance Adaptive function Behavior problems Internalization Externalization

Patients

Controls

( N= 31)

(N= 31)

p Value '

87 ± 58

54 ± 12

NS

± ± ± ± ± ± ±

12 12 12 16 10 12 15

NS NS NS NS NS NS NS

62 ± 8 54 ± 10 52 ± II

NS NS NS NS <0.006 NS NS

51 49 43 44 48 44 40

± II ± 13 ± 12 ± 14 ± 10 ±9 ± 14

62 ± 8 54 ± 10 53 ± 9

54 55 45 41 48 44 42

43 64 54 60

±9 ± 8 ± 10 ± 11

47 57 54 58

± ± ± ±

50 48 58 56 49

± 11 ±9

54 50 54 56 49

± 13 ± 17 ± II ± 9 ± 14

± 7 ±9 ± 8

12 10 13 11

NS NS NS NS NS

ent.

" LES scores are in life-change-un its; all other results arc reported as T scores (mean = 50; S.D. = 10). h ANOVA.

The family dynamics and attributes, as measured by the FES, were similar for the two groups. although there was a trend toward less expressiveness in the patients' families (0.0 I < p < 0.06). Neither patient nor control families differed significantly from scale norms. The children in both groups appeared to have normal social competence, as measured by the parents' ratings on the CBCL. The RAP patients did have significantly higher scores on the internalization scale (Table 3). indicating that they were more likely to be inhibited. fearful. and overcontrolled. This scale

includes a question about abdominal pain ; the difference rema ined significant even when that variable was removed. Sixteen of the patients (52%) were in the clinical range (T score >63) on internalization, compared with 26% of the control subjects. The teachers' ratings on the TCBCL revealed no differences between the RAP group and the controls on school performance. adaptive functioning, or behavior problems.

1 8~

WASSUU1AN IT A !..

Psychiatric Evaluation The psych iatrist's intervie ws of RAP pat ient s and th eir parents revealed that the ch ild ren often worried ahout the ir parents (71 % ) and ahout th em selves (4W:;,). Although hoth o f these worries arc common in child ren , thi s is twice the pr evalence of the general populati on (Lapouse and Monk , 11):'9 ). O ver a th ird of the parents felt th at these worries were related to the ch ild 's ahdom inal pa in . T he re had been a recent dea th among famil y (pa ren t, gra nd pa re nt. first co usi n) o r close friend in :'5 %. Six of th e pat ients had experien ced death of a peer. The de ath of th e m other of o ne child 's best frien d prec ip itat ed th e child' s con stant worry ab out his ow n mother. All o f the pa tien ts rem arked th at these deat hs wer e still o n their mind . Of the 31 children with RAP, 26 recei ved a DSM-III psychiatric di agnosis, not incl ud ing V-codes (Table 4). Conco rda nce of d iagnosis, or no di agnosis, with the psychol ogists was ac hieve d o n " fi rst pa ss" in 27 patients: d iscussi on o f th e d iagn osis was nece ssa ry in four to gai n agreem ent. T wo bo vs and one girl had two d iagn oses: o ne girl had three. . A nxiety-rela ted di sorders were pre sent in 12 patients a nd depression in three : live patients manifested sym ptoms of hoth an xiet y a nd depression with thcir adjustment di sord ers. Almost a ll patients rep ort ed d ep ressive sym pto ms whe n the ahdominal pa in was pre sen t. co nfirm ing Nico l's ( 11)82 ) co ntention that a child who is inc apacitated b y pain freely rep o rts that the pain makes him o r her feel depressed and anxious. Patients given DSM-lII depression or anx iety diagnoses had sy m pto ms regardless of th e pre sence o f pa in in additi on to meet ing th e other DSM -III criteria . For the d iagn osis of psychogenic pain d isorder to he mad e, two of the three info rma nts (pa tien t. parent, or teacher) had to recogniz e th at the ahdom in al pain was directl y related to a n environmental stimulus an d no other di agn osis was appl icable . Adj ustme nt disorders were assoc iated with the fo llowi ng pre cipitan ts: father's accidental death , co us in's murder, parental sep arat ion , brother's psychiatric hosp itali zat ion, cousin 's death with bra in tumor, pat ernal grandmother's death, and fam ily discord (,\' = 3). All of the patients with Attention Deficit Disorder were TAIl LE 4 .

/) ,)'.\[-111

/)/l/K I W .l t' .I'

otPcdiutru: l 'at icn ts with Recu rren t

NOl/.lp '·l' itil' . •bdom inal Pain

----- - _.

- - --

- --

DSM-1I1 Diagnosis - - - _ .-

Adjustment Disorder Anxious mood Mixed emot ional feat ures Depressed mood Separation Anxiety Disorder Overanxious Disorder Avoidant Disorder Psychogenic Pain Disorder Dysthymia Major Depression Attention Deficit Disorder Normal bereavement Life circumstance problem No diagnosis Total

(.; of

No. of Patients"

Total

J 5

n .'J

I

4 4

X.J 2.X I 1.1 I I. I

I

2.X

(,

1(,.7

2

5.5 2.X

I 4

2

I 1.1

2

5.5 2.X 5.5

J(,

'J'J.'J

" Three patients had two diagnoses: one had three.

in resou rce roo ms because o f learnin g di ffic ulties: two had repe at ed a grade . There was no relation sh ip between th e DSM -1l1 d iagn osis and gende r or age, exc ept that the average age of the pat ients with depressive syndromes was I:'.5 years, sign ifica ntly higher than averages for the other diagnoses, as would he expected wit h th e increased rat e of d epression in mid-adolescen ce (Rutter et a l.. )1)76 ), T he psyc hia tric sym pto ms predated the ahdomi na l pain in 14 pat ients. One girl's RAP sta rte d befo re her Adj ust me nt Disorder h ut worsen ed at th e time of her co usin 's murder . For 14 pa tients, the psychi atric di sturban ce and RAP were co ncu rre nt, incl udi ng th e six patients with psych ogen ic pa in d isorder .

Follow-up The mean time to foll ow-up was 1) .5 m onths (range 8.5 to 15 months) at which time 28 patients (1)0 %) had had at least o ne episo de of abd o m ina l pai n withi n th e pr evious 6 m onths. More mothers not iced a relat ionship betwee n stress a nd th e chi ld's pa in in the foll ow-up interview co m pared with the in itia l eval ua tion (22 vs. 13). Three qu art er s of these m others volunteere d th e informat ion that the abdominal pain had bec ome less in ten se a nd m or e m an ageable with the chi ld's und erstand ing o f th is relat ion sh ip, Thc v attrihuted th is understandi ng to th e psych iatric evaluatio n. a ltho ugh the pot ential influence of stress was not addressed directl v, The a bsence of previou sly identified strcsso rs did not appear to account for thi s cha nge. Stressor s noted by th e psychiatrist wer e still pre sent in 21 cases. a ltho ugh in 14 cas es. m others rep orted th at th e seve rity of the stresso r had decreased . Also, for two o f the th ree child re n who were free of a hdo m ina l pain at foll ow-up. ide ntified stresso rs were still pre sent (althou gh less severe). Conclusions The relat ionship between psychiatric d iag nosis and RAP in children a nd adolescents is not clear-cut. It appears that a numher o f OS M-III di agn oses can he related to RAP, although a maj ority o f patients d o have some type of underl yin g a nxiety , in agreement with results of H odges et al ., (1985h ), wh o found that an xiet y was as prevalent in the RAP patients as in pat ients referred to a psychi atric cl ini c. Howe ver , th ey were un abl e to m ak e DSM-1I1 diagn oses o f the R AP pati ents bec au se o f in sufficient dat a. Depressive sy nd ro m es wer e pre sent hut not to the degree as were an xiety sy nd ro m es. Hodges ct al. ( 11)85a ) also found a lack of depressive sy ndro mes in the ir gro up o f RAP pat ients. T he ahdomen was chosen as the target orga n probabl y because of the famil y predispositi onautonomic hypersensiti vit y or modeling behavior or a co m hination of both , In alm ost a third of th e patients, psych iatri c d ysfunct ion was relat ed to a traumatic eve nt. For o ne hal f o f these patients, RAP was precipitated a t the sa me tim e as their psych iatric sy m pto m ato logy, with !N % o f them ha ving m anifestati o ns of anxiet y. Almost a no the r third of th e patients had underl ying an xiet y sy nd ro mes not asso ciated with adj ustme n t d isord ers. In 81)% of thi s grou p, the psych ia tr ic sym pto ms predated the R AP , and no ac t ua l precipitant for the ahdom inal pain was not ed.

183

PSYCHOGENIC BASIS FOR ABDOMINAL PAIN

In addition, the children with psychogenic pain disorder reported, as did their parents and/or teacher, that the abdominal pain was associated with tension and worry about specific situations-usually academic tests or new situations. Altogether, 74 % of this study population had identifiable anxiety. If the children with Attention Deficit Disorder are also included, based on the constant tension they are experiencing trying to meet expectations in the school environment, the percentage of RAP patients with anxiety increases to X7%. This finding is in agreement with Stone and Barbero (1970) and Hodges et al. (1985b), who found high levels of anxiety in their RAP patients given unstructured interviews. Even Hughes (1984), who reported major childhood depressive illness in a hospitalized sample of children with RAP, noted anxiety in these children , especially when they were discussing their mother's health or their own physical well-being. Our group of patients with RAP did have more exposure to illness in general and death than did the controls. as was found by Hughes (1984) and Hodges et al. (1984). Yet. when these events were evaluated in the context of stressors in general afTecting the patients, the amount of stress the patients were experiencing was no difTerent than the control level. as has been reported by McGrath ct al. (1983). In our study, we asked for events within the past 3 months in order to increase the validity of recall. However, during the interviews, it was apparent that a number of the life events thought to be contributing to the abdominal pain occurred longer than 3 months before the evaluation . The 3-month cut-off might have limited the difTerentiation between the patient group and the controls. These illnesses of family members. so me even leading to death, and the associated physician contact, may have influenced the decision to seek medical help for their children with RAP, and thus, might account for this difTerence from control subjects. Because RAP is rare in children below 5 years of age and reaches a peak in the preteen years (Apley and Naish. 1958), some of the patients' RAP may be related to their exposure to illness and death at a stage of development when death is not well understood (Lewis, 1982) or understood but still frightening and anxiety provoking (Sarafino, 1986) . especially in children who still depend on their parents and fear abandonment (Poznanski, 1973). What is most striking about this population of children/ adolescents with recurrent abdominal pain is how similar they were to the matched control group on the rating scales. Most variables that difTered significantl y between the two groups could be accounted for by the RAP itself (missed school. unhappy appearance, and change in appetite). The one significant difTerence on the Child Behavior Checklist (parent's version) indicates a tendency of the children with RAP to be more fearful, inhibited, and overcontrolled. That the teachers did not find a tendency to internalize, whereas the parents did. agrees with the finding that teacher-informant studies tend to give lower prevalences than parent-informant stud ies (Anderson et al., 1987). The major reason why this patient population with diagnosable psychiatric disturbances was not found to be very difTerent from the controls on the CBCL is probably related to the nature of the checklist itself. Because it was originally designed through factor anal ysis, not all the symptoms psy-

chiatrists recognize as being associated anxiety come together on one scale. Most of the symptoms do come under the heading of internalization, which did difTerentiate the patient group and the controls, but there is no anxiety scale alTOSS all the age groups, which one would have expected to have also discriminated the patients from the controls. The characteristics of being an internalizer may actuall y be the reason for the large amount of anxiety exhibited by the RAP patients. Gordon (1983) found that children who are internalizers report being generally sad and socially isolated more often than cxternalizers, which would mean fewer people with whom to discuss their worries and concerns. These worries, then, would continue to bother the children and be reflected in symptoms of anxiety. The long-term prognosis of the abdominal pain in this patient population appears poor: 90 % had had another episode of abdominal pain by the time of the follow-up . Christensen and Mortensen (1975) found that when they contacted adults who had had RAP as child ren. 50 % were still sufTering with abdominal symptoms. Other studies have reported chronic symptoms persisting into adulthood in a third of children studied (Apley, 1975; Apley and Hale. 1973). However, our patient population was better able to cope with the pain at follow-up; the pain was less disabling when they were able to relate it to emotional stress. Perhaps the goal in dealing with these patients is not to eliminate the pain. but to help them understand its etiology so that they can cope with it better. In addition, methods for dealing with anxiety might be more beneficial for these children than prescriptions for pain medication . The authors arc in agreement with Christensen and Mortensen (1975). who stated that the pain in RAP tends to occur in "sensitive" children exposed to emotional tension who have family members with symptoms of abdominal pain . The sensitivity here is probably a combination of genetic predisposition, an environment conducive to modeling, plus a tendency to internalize. The emotional ten sion may in fact not exceed that to which the usual child is exposed. but in these sensitive children, abdominal pain is the result. As Lennard-Jones (1983) pointed out : There is no dividing line between health and disease, only between those who shrug ofT their symptoms, seeking little or no medical help, and those whose lives are afTected to a greater or lesser extent by a troublesome gastrointestinal tract. References Achenbach, T . M. & Edelbrock C. (1983). .vtanual tor the Child Behavior Checklist and RI'I'i.H'd Child Behavior Profi/;·. Queen Citv, VI. : Queen City Printers. . . Alpers. D. H. (1983). Functional gastrointestinal disorders. /10.1'1'. Pract.. 18: 139-153. Anderson. J . C.. Williams. S.. McGee. R . & Silva . P. A. (1987). DSMIII disorders in preadolescent children: prevalence in a large sample from the general population. Arch. Gen . Psvchiatrv, 44 :69:76. Apley , J . & Naish. N. (1958). Recurrent abdomin'al pains: a field survey of 1.000 school children . Arch Dis. Child. 33: 165-170. - - (1975). The Child With Abdominal Pains . 2nd Ed . Oxford : Blackwell Scientific Publications. - - Hale. B. (19 73). Children with recurrent abdominal pain: how do they grow up? Br . AII'd . J . [ Clin. Rcs .], 3:7-9 . Astrada, C. A.. Licarnele. W. L.. Walsh. T . L. & Kessler. E. S. (1981 l.

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