402 Irritable Bowel Syndrome
Barbero, & Flanery, 1985; Walker & Greene, 1989; L. S.
Walker et al., 1993). In a particularly thorough study of RAP
patients, patients with organic peptic disease and well chil-
dren, RAP children and the organic group scored signi“cantly
higher than well children on the Child Depression Inventory
(CDI; Kovacs, 1980/1981) but the RAP and organic groups
did not differ from each other (Walker et al., 1993). When
RAP children are compared to children with organic abdomi-
nal pain, there are usually no differences between groups on
levels of depression, as measured by the CDI (Garber, Zeman,
& Walker, 1990; Hodges, Kline, Barbero, & Flanery, 1985;
L. S. Walker & Greene, 1989). The exception to this “nding is
a study done by Gold, Issenman, Roberts, and Watt (2000),
who found signi“cant dif ferences in CDI scores between chil-
dren with a functional GI disorder and children with IBD.
However, neither group scored in the clinically signi“cant
range on the CDI so it is dif“cult to conclude that depression
is an underlying factor in the development of RAP.
Anxiety
Studies have consistently found that, when compared to con-
trol children, children with RAP do tend to report more anxi-
ety on measures such as the Child Behavior Checklist
(CBCL; Achenbach & Edelbrock, 1983) and Child Assess-
ment Schedule [CAS: Hodges, Kline, & Fitch, 1981, 1990;
(Garber et al., 1990; Hodges, Kline, Barbero, & Woodruff,
1985; Hodges, Kline, Barbero, & Flanery, 1985; Robinson
et al., 1990)]. Again, however, it appears that they do not dif-
fer from children with organic explanations for their symp-
toms (Garber et al., 1990; L. S. Walker & Greene, 1989), at
least to a clinically signi“cant degree (L. S. Walker et al.,
1993). This may suggest that anxiety may be speci“cally as-
sociated with having abdominal pain.
Somatization
When compared to their organic GI counterparts, children
with functional RAP had signi“cantly higher scores on the
somatic complaints scale of the CBCL, and were more likely
to have relatives with Somatization Disorder (Routh & Ernst,
1984). Results in a study done by E. A. Walker and col-
leagues (Walker, Gelfand, Gelfand, & Katon, 1996) were
similar, with RAP children reporting higher levels of somati-
zation symptoms than children with organically based pain
and well controls at both initial assessment and three month
follow-up.
We should keep in mind, however, that anxiety, depres-
sion, and somatization symptoms tend to be higher in patients
with organic diseases in general (P. J. McGrath, Goodman,
Firestone, Shipman, & Peters, 1983; Raymer, Weininger, &
Hamilton, 1984; Routh & Ernst, 1984; L. S. Walker &
Greene, 1989). We are therefore unable to determine the role
that recurrent abdominal pain itself may play in such psycho-
logical symptoms. However, psychological interventions, as
in IBS, seem to be moderately effective.Treatment of RAPApley and Naish (1958) recommend that children presenting
with abdominal pain receive: (a) a careful and thorough med-
ical work-up to rule out organic causes of pain, (b) reassur-
ance that there is no organic or structural reason for the pain,
and (c) support for both parent and child as they deal with the
functional problem. This approach is fairly effective about
half of the time (Apley & Hale, 1973; Stickler & Murphy,
1979). In the rest of the cases, however, it is important to ex-
amine other treatment options. Early interventions included
operant approaches (see Miller & Kratochwill 1979; Sank &
Biglan, 1974) and “ber treatments (see Christensen, 1986;
Feldman, McGrath, Hodgson, Ritter, & Shipman, 1985).
However, results in these areas were mixed. The majority of
research into treatments for RAP has involved cognitive-
behavioral approaches.
On the “rst line of defense, brief tar geted therapy deliv-
ered in primary health care settings has had some effect on a
range of problems associated with RAP. In one study, brief
targeted therapy consisted of individualized interventions
based on behavioral concerns and symptoms de“ned during
the assessment process, and included techniques such as self-
monitoring, relaxation training, limited reinforcement of
illness behavior, dietary “ber supplementation, and participa-
tion in routine activities. In this study, 16 children with RAP
underwent the brief targeted therapy and were evaluated on a
variety of outcome measures, including medical care utiliza-
tion, school records (absences and nurses visits), and symp-
tom ratings. Treated children were compared to 16 untreated
children. After treatment, most parents rated their children•s
pain symptoms as improved. Children undergoing treatment
also missed signi“cantly fewer days of school (Finney,
Lemanek, Cataldo, Katz, & Fuqua, 1989).
Sanders et al. (1989) found that an eight-session CBT pro-
gram that included self-monitoring of pain, operant behav-
ioral training for parents distraction techniques, relaxation
training, imagery for pain control, and self-control techniques
such as self-instruction in coping statements was superior to
a symptom-monitoring control condition. At posttreatment,
six of eight (75%) treated children were pain free, and by
three-month follow-up, seven of eight (87.5%) were pain
free, as opposed to 37.5% of the controls. In a replication of