Recurrent Abdominal Pain in Children 401at least 25% of pediatric emergency room visits for abdomi-
nal pain are due to RAP.
One particularly interesting question associated with RAP
is that of its relationship with adulthood IBS. Do children
with RAP go on to develop IBS as an adult? Christensen and
Mortensen (1975) report that 47% of patients at follow-up
warranted a diagnosis of what was then called •irritable
colon.Ž L. S. Walker, Guite, Duke, Barnard, and Greene
(1998) used Manning Criteria to diagnose IBS in a “ve-year
follow-up of RAP patients, and found that 35% of females
and 32% of males met such criteria. We can cautiously con-
clude, then, that while RAP tends to remit in childhood in
most cases, about one-third of children with RAP will go on
to meet criteria for IBS as adults.
Etiology
Like irritable bowel syndrome, RAP is considered a disorder
of gastrointestinal motility. Also, like IBS, a de“nitive •causeŽ
has not been determined. However, some theories have been
proposed. First, there is the model of dysfunctional GI motil-
ity. In this model, pain can be caused by distention and spasm
of the distal colon, with bombardment of stimuli leading to the
perception of pain (Davidson, 1986). This model also ac-
counts for a familial tendency to a hypersensitive gut that may
be exacerbated by stress and food (Davidson, 1986).
Another model proposes that RAP is a disorder of the au-
tonomic nervous system (ANS). This model implies that there
is a de“cit in the child•s ANS that makes it dif“cult for him to
recover from stress (Page-Goertz, 1988). Unfortunately, there
have been no studies to con“rm this theory (see Barr, 1983;
Fueuerstein, Barr, Francoeur, Hade, & Rafman, 1982).
The “nal model proposes a psychogenic cause for recur-
rent abdominal pain. A study by Robinson and colleagues
(1990) used the Children•s Life Events Inventory (Monaghan,
Robinson, & Dodge, 1979) to show that children with RAP
did not differ from controls in the total life events scores two
years prior to the pain, but that in the 12 months directly pre-
ceding pain onset, RAP children scored markedly higher.
These “ndings suggest that such events (including parental
divorce and separation) may be important triggers in predis-
posed children (Robinson et al., 1990). A discussion of psy-
chological distress and RAP follows in the next section.
Finally, Levine and Rappaport (1984) suggest that a mul-
titude of factors •causeŽ abdominal pain, including lifestyle
and habit (i.e., daily routines, diet, elimination patterns, school/
family routine), temperament/learned responses (i.e., be-
havioral style, personality, affect, learned coping skills),
milieu/critical events (i.e., characteristics of the child•s
surroundings, positive or negative stressful events), and a
somatic predisposition to pain localized in the abdomen (i.e.,
dietary intolerance, constipation, underlying dysfunction/
disorder). Similarly, Compas and Thomsen (1999) conceptu-
alize RAP as a problem of psychological stress, individual
differences in reaction to stress, and maladaptive coping.
They maintain that the way children cope with such stress
greatly in”uences the severity, frequency, and duration of
RAP episodes; a disruption in the process of self-regulation
and stress reactivity may precipitate abdominal pain.Psychosocial Factors and RAPAs is the case in the IBS literature, RAP researchers have
failed to agree regarding the possibility of there being differ-
ences between organic and nonorganic pediatric GI patients
on a variety of psychosocial measures. Children with RAP
have often been described as anxious and perfectionistic
(Liebman, 1978). Typically, studies have compared children
with functional GI disorders to children with organic GI dis-
eases on the occurrence of stressful life events, anxiety, de-
pression, behavior problems, and general family functioning.
Walker, Garber, and Greene (1993) report that RAP patients
had higher levels of emotional and somatic symptoms and
came from families with a higher incidence of illness and en-
couragement of illness behavior than well children, but did
not differ with respect to negative life events, competence
levels, or family functioning. When compared to child psy-
chiatric patients, RAP patients exhibited fewer emotional and
behavioral problems, and tended to have better family func-
tioning and higher levels of social competence, despite hav-
ing more somatic complaints. Finally, RAP patients did not
differ from organic abdominal pain patients on either emo-
tional or organic symptoms; as discussed previously, similar
“ndings have been described in the adult literature.
Some studies have found that RAP patients experienced
signi“cantly more negative life events than well controls and
general medical patients (J. Greene, Walker, Hickson, &
Thompson, 1985; Hodges, Kline, Barbero, & Flanery, 1984;
Robinson et al., 1990), while others claim that there are
no such differences (Hodges et al., 1984; Risser, Mullins,
Butler, & West, 1987; L. S. Walker et al., 1993; Wasserman,
Whitington, & Rivara, 1988). Further, some studies have
shown that RAP patients actually experiencefewernegative
life events than other behaviorally disordered groups
(J. Greene et al., 1985; L. S. Walker et al., 1993).DepressionTypically, differences in depression levels appear only when
comparing RAP children to well samples (Hodges, Kline,