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Background State-of-the-art behavioral weight loss treatment (SBT) can lead to clinically meaningful weight loss, but only 30–60% achieve this goal. Developing adaptive interventions that change based on individual progress could increase the number of people who benefit. Purpose Conduct a Sequential Multiple Assignment Randomized Trial (SMART) to determine the optimal time to identify SBT suboptimal responders and whether it is better to switch to portion-controlled meals (PCM) or acceptance-based treatment (ABT). Method The BestFIT trial enrolled 468 adults with obesity who started SBT and were randomized to treatment response assessment at Session 3 (Early TRA) or 7 (Late TRA). Suboptimal responders were re-randomized to PCM or ABT. Responders continued SBT. Primary outcomes were weight change at 6 and 18 months. Results PCM participants lost more weight at 6 months (−18.4 lbs, 95% CI −20.5, −16.2) than ABT participants (−15.7 lbs, 95% CI: −18.0, −13.4), but this difference was not statistically significant (−2.7 lbs, 95% CI: −5.8, 0.5, p = .09). PCM and ABT participant 18 month weight loss did not differ. Early and Late TRA participants had similar weight losses (p = .96), however, Early TRA PCM participants lost more weight than Late TRA PCM participants (p = .03). Conclusions Results suggest adaptive intervention sequences that warrant further research (e.g., identify suboptimal responders at Session 3, use PCMs as second-stage treatment). Utilizing the SMART methodology to develop an adaptive weight loss intervention that would outperform gold standard SBT in a randomized controlled trial is an important next step, but may require additional optimization work. Clinical Trial information ClinicalTrials.gov identifier; NCT02368002

Background Individuals receiving behavioral weight loss treatment frequently fail to adhere to prescribed dietary and self-monitoring instructions, resulting in weight loss clinicians often needing to assess and intervene in these important weight control behaviors. A significant obstacle to improving adherence is that clinicians and clients sometimes disagree on the degree to which clients are actually adherent. However, prior research has not examined how clinicians and clients differ in their perceptions of client adherence to weight control behaviors, nor the implications for treatment outcomes. Purpose In the context of a 6-month weight-loss treatment, we examined differences between participants and clinicians when rating adherence to weight control behaviors (dietary self-monitoring; limiting calorie intake) and evaluated the hypothesis that rating one’s own adherence more highly than one’s clinician would predict less weight loss during treatment. Methods Using clinician and participant-reported measures of self-monitoring and calorie intake adherence, each assessed using a single item with a 7- or 8-point scale, we characterized discrepancies between participant and clinician adherence and examined associations with percent weight change over 6 months using linear mixed-effects models. Results Results indicated that ratings of adherence were higher when reported by participants and supported the hypothesis that participants who provided higher adherence ratings relative to their clinicians lost less weight during treatment (p < 0.001). Conclusions These findings suggest that participants in weight loss treatment frequently appraise their own adherence more highly than their clinicians and that participants who do so to a greater degree tend to lose less weight.

Goals The goal of this study was to describe the influence of the COVID-19 pandemic on ability to engage in activities and the influence on psychological distress and gastrointestinal symptoms among individuals with irritable bowel syndrome (IBS) and comorbid anxiety and/or depression. Background Individuals with IBS and comorbid anxiety and/or depression report increased symptoms and decreased quality of life compared with individuals with IBS alone. The current COVID-19 pandemic has the potential to further influence symptoms among individuals with IBS and comorbid anxiety and/or depression. Study Individuals who met the Rome-IV IBS criteria and reported mild to severe anxiety and/or depression were included. Participants completed an online survey with questions about anxiety, depression, impact of COVID on activities and symptoms, and demographics. Results Fifty-five individuals participated in the study. The COVID-19 pandemic most commonly influenced their ability to spend time with friends and family, shop for certain types of food, and access health care. Participants also reported increased stress (92%), anxiety (81%), and depressive symptoms (67%). Finally, around half the sample reported increases in abdominal pain (48%), diarrhea (45%), or constipation (44%). Conclusions The COVID-19 pandemic is related to self-reported increases in psychological distress and gastrointestinal symptoms among individuals with IBS and comorbid anxiety and/or depression. Additional research is needed to intervene on these symptoms.

Background Pain is a common symptom in pediatric inflammatory bowel disease (IBD) and is associated with poor health outcomes, yet additional knowledge about the psychosocial correlates of pain is needed to optimize clinical care. The purpose of this study is to systematically review the psychosocial factors associated with pain and pain impact in youth diagnosed with IBD within a developmentally informed framework. Methods Manual and electronic searches yielded 2641 references. Two authors conducted screening (98% agreement), and data extraction was performed in duplicate. Average study quality was rated using the National Institutes of Health Quality Assessment Tool. Results Ten studies (N = 763 patients; N = 563 Crohn disease, N = 200 ulcerative/ indeterminate colitis) met the inclusion criteria. Findings showed consistent evidence that higher levels of child depression symptoms and child pain catastrophizing were associated with significantly greater pain and pain impact (magnitude of association ranged from small to large across studies). Greater pain and pain impact were also associated with higher levels of child anxiety symptoms, child pain threat, child pain worry, and parent pain catastrophizing. Within the included studies, female sex and disease severity were both significantly associated with pain and pain impact. Study quality was moderate on average. Conclusions There is evidence that child psychosocial factors are associated with pain and pain impact in pediatric IBD; more studies are needed to examine parent- and family-level psychosocial factors. Youth with IBD should be routinely screened for pain severity, pain impact, and psychosocial risk factors such as anxiety/depression.

BACKGROUND Irritable bowel syndrome (IBS) is linked with lower health-related quality of life. Cognitive behavioral therapy (CBT) designed for IBS management can improve outcomes but further research of more accessible implementations of this treatment approach for IBS is needed. This study assessed the feasibility of a web-delivered CBT program among adults with IBS to apply to a future clinical trial. METHODS Twenty-five participants were randomized to receive an unguided web-based, CBT program for IBS. The primary outcome was changes in IBS symptom severity (IBS Symptom Severity Scale [IBS-SSS]). Secondary outcomes included IBS-specific CBT therapeutic mechanisms of change (GI-specific anxiety, unhelpful IBS behaviors, and GI-focused cognitions) and changes in depressive (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder-7 scale [GAD-7]) symptom severity. KEY RESULTS Among participants randomized to receive web-based CBT, the average baseline IBS-SSS score was 296.3 (SD=100.9). IBS symptom severity significantly improved at 2-month (p

STUDY OBJECTIVES: Research indicates a deleterious effect of sleep disturbances on pain and illness-related functioning across pediatric populations. Sleep problems in youth with functional gastrointestinal disorders (FGIDs) are understudied, despite studies in adult FGIDs indicating sleep disruptions increase pain and symptom severity. This study sought to better characterize sleep problems in school-age children with FGIDs and to assess relationships with demographic characteristics and gastrointestinal symptoms. METHODS: Sixty-seven children with FGIDs (pediatric Rome IV criteria) and 59 parents completed questionnaires assessing sleep problems, and children completed a 2-week pain/stooling diary. Sleep problems in this sample were compared with published normative samples, and children above and below the clinical cutoff were compared on demographics and FGID symptoms. RESULTS: Of the sample, 61% were above the clinical cutoff for sleep disturbances, with significantly greater bedtime resistance, sleep onset delay, sleep duration, and daytime sleepiness than the comparison group. Children above the clinical cutoff reported greater mean abdominal pain severity and pain interference. Relative to White participants, Black/African-American participants were more likely to be above the clinical cutoff and indicated more frequent night wakening and symptoms of sleep-disordered breathing, but lower maximum and overall mean abdominal pain severity. CONCLUSIONS: Sleep problems in children with FGIDs are common and related to greater day-to-day abdominal pain severity and pain interference. Results suggest sleep–pain relationships may differ across racial/ethnic groups. Assessing sleep in children with FGIDs is important, and further research is needed to assess underlying mechanisms and evaluate sleep as a potential treatment target in this population. CITATION: Jansen J, Shulman R, Ward TM, Levy R, Self MM. Sleep disturbances in children with functional gastrointestinal disorders: demographic and clinical characteristics. J Clin Sleep Med. 2021;17(6):1193–1200.

Women of childbearing age experience the highest prevalence of irritable bowel syndrome (IBS), yet little is known about their psychosocial and parenting needs, which may influence their children&rsquo, s experience of future gastrointestinal or pain-related conditions. The aims of this study were to conduct qualitative interviews to understand the psychosocial and parenting needs of mothers with IBS who have young school-age children, and to assess mothers&rsquo, potential interest in and acceptability of a preventive parenting intervention program. Ten mothers with IBS who have young (age 5&ndash, 10), healthy children were interviewed. Interviews were coded with thematic analysis and three themes were identified: (1) Guilt about how IBS impacts children, (2) Worry that children will develop IBS, and (3) Already on high alert for children&rsquo, s health. All mothers expressed interest in an Internet-based preventive intervention and identified tools and strategies they would want included. Results demonstrate that mothers experience guilt about how IBS has impacted their children in their daily lives, concern that they need to pay attention to children&rsquo, s early signs and symptoms that could indicate gastrointestinal problems, and worry about children developing IBS in the future&mdash, suggesting that a preventive intervention may address important concerns for this population.

Background The majority of participants in weight loss trials are non-Hispanic White women, while men and women of color are underrepresented. This study presents data obtained from non-targeted and targeted recruitment approaches in a trial of behavioral weight loss programs to (1) describe the yields from each approach and (2) compare the demographics, weight control histories, and study involvement of samples recruited by each approach. Methods Data for this observational study include source of recruitment, demographic information, weight loss experiences (e.g., lifetime weight loss, current weight loss behaviors), and completion of the 6-month assessment visit. Results Men comprised 14.2% of participants who responded to non-targeted recruitment efforts, while targeted efforts yielded 50.4% men. Similarly, people of color comprised 12.8% of those who responded to non-targeted approaches, whereas targeted recruitment methods yielded 47.2% people of color. Men recruited through targeted methods were younger (p = 0.01) than men recruited through non-targeted means but were otherwise similar. Women of color recruited through targeted methods reported use of fewer weight loss strategies relative to women of color recruited through non-targeted means (p = 0.006) but were otherwise similar. There were no differences by recruitment method on retention to the study. Conclusions Using targeted recruitment methods increased the ethnic and gender diversity of the recruited sample without reducing study retention. This targeting also increased the enrollment of women with less weight loss experience who may not have otherwise sought out a weight loss program. Developing and implementing a targeted recruitment plan should be considered early in the clinical trial development process. Trial registration Clinicaltrials.gov, NCT02368002. Registered on 20 February 2015.

Background. Behavioral interventions to prevent pediatric obesity have shown inconsistent results across the field. Studying what happens within the “black box” of these interventions and how differences in implementation lead to different outcomes will help researchers develop more effective interventions. Aim. To compare the implementation of three features of a phone-based intervention for parents (time spent discussing weight-related behaviors, behavior change techniques used in sessions, and intervention activities implemented by parents between sessions) with study outcomes. Methods. A random selection of 100 parent–child dyads in the intervention arm of a phone-based obesity prevention trial was included in this analysis. Sessions were coded for overall session length, length of time spent discussing specific weight-related behaviors, number of behavior change techniques used during the sessions, and number of intervention-recommended activities implemented by the parents between sessions (e.g., parent-reported implementation of behavioral practice/rehearsal between sessions). The primary study outcome, prevention of unhealthy increase in child body mass index (BMI) percentile, was measured at baseline and 12 months. Results. Overall session length was associated with decreases in child BMI percentile ( b = −0.02, p = .01). There was no association between the number of behavior change techniques used in the sessions and decreases in child BMI percentile ( b = −0.29, p = .27). The number of activities the parents reported implementing between sessions was associated with decreases in child BMI percentile ( b = −1.25, p = .02). Discussion. To improve future interventions, greater attention should be paid to the intended and delivered session length, and efforts should be made to facilitate parents’ implementation of intervention-recommended activities between sessions (ClinicalTrials.gov, No. NCT01084590).

Objective There is a large body of evidence for the efficacy of Cognitive Behavioral Therapy (CBT) in treating Functional Abdominal Pain Disorders (FAPD) in children. In most CBT interventions for FAPD, parents participate together with their children. However, only one study to date has examined targeting parents alone for treatment. The aim of the current study was to examine mediators of a parent-only CBT treatment incorporating social learning (SLCBT) for FAPD in children. Methods We examined mediators of child outcomes in an existing randomized controlled trial (n = 316) of parent-only social learning CBT compared to an education condition. Hypothesized mediators (parental protectiveness, perceived threat of pain, catastrophizing) were assessed at 3 months post-treatment, and outcomes (parent ratings of disability, quality of life, school absences, and health care visits) were assessed at 6 months post-treatment. Mediation analyses were performed using Hayes' PROCESS macro. Results Pain catastrophizing significantly mediated treatment effects for all outcomes (B ranged from −1.65 to 2.22). Reduction in pain threat was a significant mediator for all outcomes (B ranged from −1.84 to 3.13) except school absences and health care visits. Decrease in parental protectiveness mediated effects on disability and missed school (B ranged from −1.47 to 1.34). Mediation effects did not differ by in-person or remote delivery of SLCBT. Conclusion Changes in maladaptive parental thoughts and behaviors following parent-only SLCBT intervention appeared to mediate the effects of the intervention. Parental catastrophizing appears to be a particularly important target given that decreases in that variable mediated all outcomes.

For patients with Crohn disease (CD), symptom reporting may not coincide with disease state; patients in remission may continue to report symptoms and pain, whereas other patients may be symptom-free despite a flare. This phenomenon has been documented in adults but only recently assessed in pediatric patients. The present study assessed the role of pain reporting and disease state in pediatric patients with CD in understanding psychological distress and quality of life.Participants included 116 children and adolescents ages 8 to 18 years with CD who completed self-report questionnaires assessing pain, disease symptoms, depression, anxiety, functional disability, and quality of life. Physicians completed the Pediatric Crohn's Disease Activity Index to assess disease activity (scores ≤10 = remission, scores10 = flare).Approximately two thirds of participants reported pain concordant with disease state. For patients in remission, those with pain experienced significantly increased disability and decreased quality of life compared to patients in remission without pain. For patients in a flare, those without pain experienced significantly decreased disability and depressive symptoms, and improved quality of life compared to patients in a flare with pain.For pediatric patients with CD, report of pain, while in remission or a flare, is associated with increased disability and reduced quality of life. Although levels of depression did not differ by disease state, depressive symptoms did differ by pain report (presence or absence) for those in a flare. Pain reporting in CD appears to be associated with both physical and psychological state and should be assessed regardless of disease activity.

Standardized methods are needed to evaluate what occurs within the 'black box' of behavioral interventions to prevent pediatric obesity. The purpose of this research is to evaluate methods to specify the behavior change techniques used and the amount of time spent discussing target weight-related behaviors in an intervention for parents of children at risk for becoming overweight or obese. Independent coders were trained to identify behavior change techniques and time spent discussing weight-related behaviors in audio recordings and transcripts of intervention sessions from 100 randomly selected participants. The behavior change technique taxonomy (BCTTv1) was used to code techniques present in sessions. A newly-developed tool was used to code time spent discussing each target weight-related behavior (e.g., physical activity, screen time). Sessions from a subset of these participants (N = 20) were double coded to evaluate inter-rater reliability. After revisions to coding protocols, coders reliably coded behavior change techniques used and time spent discussing target weight-related behaviors in sessions from the subset of 20 participants. The most commonly discussed target weight-related behavior was physical activity followed by energy intake and fruit and vegetable intake. On average, 13.9 (SD = 2.8) unique behavior change techniques were present across sessions for a given participant. These results offer reliable methods for systematically identifying behavior change techniques used and time spent discussing weight-related behaviors in a pediatric obesity prevention intervention. This work paves the way for future research to identify which specific target behaviors and techniques are most associated with the prevention of unhealthy weight gain in children.

Pediatric functional abdominal pain disorders (FAPD) are associated with increased healthcare utilization, school absences, and poor quality of life (QoL). Cost-effective and accessible interventions are needed. This multi-site study tested the effects of a 3-session cognitive-behavioral intervention delivered to parents, in person or remotely, on the primary outcome of pain severity and secondary outcomes (process measures) of parental solicitousness, pain beliefs, catastrophizing, and child-reported coping. Additional outcomes hypothesized a priori and assessed included functional disability, quality of life, pain behavior, school absences, healthcare utilization, and gastrointestinal symptoms. The study was prospective and longitudinal (baseline, 3 and 6 months follow-up) with three randomized conditions: social learning and cognitive-behavioral therapy in-person (SLCBT) or by phone (SLCBT-R) and education/support condition by phone (ES-R). Participants were children aged 7–12 with FAPD and their parents (N = 316 dyads). While no significant treatment effect for pain severity was found, the SLCBT groups showed significantly greater improvements compared to controls on process measures of parental solicitousness, pain beliefs and catastrophizing, and additional outcomes of parent-reported functional disability, pain behaviors, child healthcare visits for abdominal pain, and (remote condition only) quality of life and missed school days. No effects were found for parent and child-reported gastrointestinal symptoms, or child-reported quality of life or coping. These findings suggest that for children with FAPD, a brief phone SLCBT for parents can be similarly effective as in-person SLCBT in changing parent responses and improving outcomes, if not reported pain and symptom report, compared to a control condition.

Behavioral weight loss programs help people achieve clinically meaningful weight losses (8–10% of starting body weight). Despite data showing that only half of participants achieve this goal, a “one size fits all” approach is normative. This weight loss intervention science gap calls for adaptive interventions that provide the “right treatment at the right time for the right person.” Sequential Multiple Assignment Randomized Trials (SMART), use experimental design principles to answer questions for building adaptive interventions including whether, how, or when to alter treatment intensity, type, or delivery. This paper describes the rationale and design of the BestFIT study, a SMART designed to evaluate the optimal timing for intervening with sub-optimal responders to weight loss treatment and relative efficacy of two treatments that address self-regulation challenges which impede weight loss: 1) augmenting treatment with portion-controlled meals (PCM) which decrease the need for self-regulation; and 2) switching to acceptance-based behavior treatment (ABT) which boosts capacity for self-regulation. The primary aim is to evaluate the benefit of changing treatment with PCM versus ABT. The secondary aim is to evaluate the best time to intervene with sub-optimal responders. BestFIT results will lead to the empirically-supported construction of an adaptive intervention that will optimize weight loss outcomes and associated health benefits.

SUMMARY: BACKGROUND: Pediatric primary care is an important setting for addressing obesity prevention. OBJECTIVE: The Healthy Homes/Healthy Kids 5‐10 randomized controlled trial evaluated the efficacy of an obesity prevention intervention integrating pediatric primary care provider counseling and parent‐targeted phone coaching. METHODS: Children aged 5 to 10 years with a BMI between the 70th and 95th percentile and their parents were recruited from pediatric primary care clinics. Participants received well‐child visit provider counseling about obesity and safety/injury prevention and were then randomized to a 14‐session phone‐based obesity prevention (OP; n = 212) or safety and injury prevention contact control (CC; n = 209) intervention. The primary outcome was 12 and 24‐month child BMI percentile. RESULTS: There was no overall significant treatment effect on child BMI percentile. Caloric intake was significantly lower among OP compared with CC participants at 12 months (P < .005). In planned subgroup analyses, OP condition girls had significantly lower BMI percentile (P < .05) and BMI z‐score (P < .02) at 12 and 24 months relative to CC girls and were less likely to be overweight (38.0% vs 53.0%, P < .01) or (obese 3.4% vs 8.8%, P < .10) at follow‐up. CONCLUSIONS AND RELEVANCE: An obesity prevention intervention integrating brief provider counseling and parent‐targeted phone counseling did not impact 12 and 24‐month BMI status overall but did have a significant impact on BMI in girls.

Inflammatory bowel disease (IBD) and abdominal pain of functional origin (AP) are common gastrointestinal disorders in children, which are associated with increased risk for depression and disability. Both symptom severity and coping with symptoms may contribute to these outcomes. We hypothesized that children with AP use different coping strategies compared with those with IBD for a number of reasons, including the fact that fewer treatment options are available to them. We also examined whether coping was related to depression and functional disability beyond the contributions of symptom severity.The study method included secondary data analysis of 2 existing data sets including 200 children with AP (73% girls, mean age 11.2 years) and 189 children with IBD (49% girls, mean age 13.8 years).Compared with patients with IBD, patients with AP reported more use of coping strategies of self-isolation, behavioral disengagement, and catastrophizing, as well as problem solving and seeking social support. Multivariate analyses revealed that, in both samples, ≥1 coping strategies were associated with depression and functional disability, independent of symptom severity, and controlling for age and sex. In IBD, symptoms were not a significant predictor of depression but coping was. Catastrophizing predicted depression and disability in both samples.Patients with AP report more frequent use of several of the coping strategies we measured compared with patients with IBD. Certain types of coping, particularly catastrophizing, were associated with greater depression and functional disability in both groups. Clinicians should be aware of maladaptive coping, which may be a risk factor for poor psychosocial and functional outcomes in both patient groups.

The widely used Adult Responses to Children's Symptoms measures parental responses to child symptom complaints among youth aged 7 to 18 years with recurrent/chronic pain. Given developmental differences between children and adolescents and the impact of developmental stage on parenting, the factorial validity of the parent-report version of the Adult Responses to Children's Symptoms with a pain-specific stem was examined separately in 743 parents of 281 children (7–11 years) and 462 adolescents (12–18 years) with chronic pain or pain-related chronic illness. Factor structures of the Adult Responses to Children's Symptoms beyond the original 3-factor model were also examined. Exploratory factor analysis with oblique rotation was conducted on a randomly chosen half of the sample of children and adolescents as well as the 2 groups combined to assess underlying factor structure. Confirmatory factor analysis was conducted on the other randomly chosen half of the sample to cross-validate factor structure revealed by exploratory factor analyses and compare it to other model variants. Poor loading and high cross-loading items were removed. A 4-factor model (Protect, Minimize, Monitor, and Distract) for children and the combined (child and adolescent) sample and a 5-factor model (Protect, Minimize, Monitor, Distract, and Solicitousness) for adolescents was superior to the 3-factor model proposed in previous literature. Future research should examine the validity of derived subscales and developmental differences in their relationships with parent and child functioning. Perspective This article examined developmental differences in the structure of a widely used measure of caregiver responses to chronic pain or pain-related chronic illness in youth. Results suggest that revised structures that differ across developmental groups can be used with youth with a range of clinical pain-related conditions.

Theoretical models of pediatric chronic pain propose longitudinal associations between children's pain experiences and parent and family factors. A large body of cross-sectional research supports these models, demonstrating that greater parent distress and maladaptive parenting behaviors are associated with greater child disability. Family-based cognitive-behavioral therapy interventions have been developed for youth with chronic pain which aim to improve child disability and reduce maladaptive parenting behaviors. However, little is known about temporal, longitudinal associations between parent and child functioning in this population. In the present study, we conducted a secondary analysis of data from 138 families of youth with chronic pain aged 11 to 17 years old who received family-based cognitive-behavioral therapy delivered through the Internet as part of a randomized controlled trial. Measures of child disability, parent protective behavior, and parent distress were obtained at pretreatment, immediate posttreatment, 6-month follow-up, and 12-month follow-up. Latent growth modeling indicated that child disability, parent protective behavior, and parent distress improved with treatment over the 12-month study period. Latent growth modeling for parallel processes indicated that higher parent distress at pretreatment predicted less improvement in child disability over 12 months. No other predictive paths between parent and child functioning were significant. These findings indicate that parent distress may increase the risk of poor response to psychological pain treatment among youth with chronic pain. At present, parent distress is not routinely targeted in psychological interventions for pediatric chronic pain. Research is needed to determine optimal strategies for targeting parent and family factors in the treatment of pediatric chronic pain.

This laboratory-based study examined lagged associations between child pain behavior and maternal responses as a function of maternal catastrophizing (CAT). Mothers completed the parent version of the Pain Catastrophizing Scale. Children participated in a validated water ingestion procedure to induce abdominal discomfort with mothers present. Video recordings of their interactions were edited into 30-second segments and coded by 2 raters for presence of child pain behavior, maternal solicitousness, and nontask conversation. Kappa reliabilities ranged from 0.83 to 0.95. Maternal CAT was positively associated with child pain behavior and maternal solicitousness, P values

Summary Background Cross-cultural, multinational research can advance the field of functional gastrointestinal disorders (FGIDs). Cross-cultural comparative research can make a significant contribution in areas such as epidemiology, genetics, psychosocial modulators, symptom reporting and interpretation, extra-intestinal co-morbidity, diagnosis and treatment, determinants of disease severity, health care utilisation, and health-related quality of life, all issues that can be affected by geographical region, culture, ethnicity and race. Aims To identify methodological challenges for cross-cultural, multinational research, and suggest possible solutions. Methods This report, which summarises the full report of a working team established by the Rome Foundation that is available on the Internet, reflects an effort by an international committee of FGID clinicians and researchers. It is based on comprehensive literature reviews and expert opinion. Results Cross-cultural, multinational research is important and feasible, but has barriers to successful implementation. This report contains recommendations for future research relating to study design, subject recruitment, availability of appropriate study instruments, translation and validation of study instruments, documenting confounders, statistical analyses and reporting of results. Conclusions Advances in study design and methodology, as well as cross-cultural research competence, have not matched technological advancements. The development of multinational research networks and cross-cultural research collaboration is still in its early stages. This report is intended to be aspirational rather than prescriptive, so we present recommendations, not guidelines. We aim to raise awareness of these issues and to pose higher standards, but not to discourage investigators from doing what is feasible in any particular setting.

Childhood obesity in the United States is a significant public health concern. Prevalence estimates from 2009-2010 indicate that approximately 17% of U.S. children ages 2-19 are obese and 15% are overweight.1 Obesity is associated with multiple health comorbidities in childhood and adolescence, including type 2 diabetes,2,3 hypertension,2-4 and weight-related stigma.5 The negative health effects of obesity extend beyond childhood; children who are overweight or obese are at a greater risk for obesity and its health consequences in adulthood.6 The health risks associated with obesity and its high prevalence among U.S. children highlight the need for obesity prevention efforts. Parents are key partners in efforts to prevent childhood obesity, given their influence on multiple risk factors for overweight and obesity in children. Parent-level factors, such as encouraging child physical activity (PA),7 and setting rules about child TV use,8 and modeling of healthy eating behaviors9,10 are among the determinants of child PA level, media use, and dietary intake, all of which affect a child’s risk of obesity. Parental recognition of and concern about child weight status are other factors that may influence children’s weight status. Interestingly, there is a lack of concordance between the actual weight status of the child and parent perceptions of child weight. It is well documented that many parents do not recognize when their child is overweight or obese11-14 and many report low levels of concern about their child’s weight.15-17 Additionally, a recent study found that many parents of overweight or obese children did not recognize that their child’s weight posed a health risk, even among parents who accurately perceived their child as overweight.18 Parental misperception of child weight status, coupled with low levels of parental concern about child weight and its health consequences, are potential barriers to obesity prevention efforts.14,18 Perception of health risk is often viewed as a key component of behavior change,19,20 and several studies have recommended intervention strategies and clinical care practices targeting components of risk perception, including parental awareness and concerns about child weight.15,17,18,21 It is important that these strategies activate parent’s recognition of child weight-related health risks in a way that facilitates practices promoting healthy child growth, rather than contributing to anxiety and unhealthy weight control strategies. However, prior research in this area does not provide clear or consistent evidence indicating how parental beliefs regarding child weight are associated with weight-related parenting practices, parent engagement in child obesity prevention and/or treatment interventions, or child weight outcomes. In this study, we focus on parental concern regarding child weight. Few studies have examined the relationship between parental concern about child weight and weight-related parenting practices, and those that have reach varying conclusions about whether parental concern is associated with healthy parental behaviors. A recent study of average weight and overweight children and adolescents found parents who were concerned about child weight, compared to those who were unconcerned, reported greater use of several strategies to promote healthy child weight, including limiting child screen time, decreasing restaurant use, and decreasing soda intake.21 Similarly, an Australian study of average weight and overweight children ages 5-6 and 10-12 years found parental concern about a child’s future weight was associated with parental action to prevent child overweight.16 Conversely, maternal concern about child weight has been associated with potentially negative weight-related parenting practices, such as greater use of restrictive feeding practices among mothers of preschoolers,22 elementary school children,23 and early adolescents24 across the BMI spectrum, as well as with pressure to eat feeding strategies among mothers of early adolescents.24 These studies suggest parental concern about child weight may be associated with weight–related parenting practices, but additional research is needed to more fully examine these relationships given the small number of studies in this area, differences in study populations, and mixed findings. In the present study, we describe parental perception of child weight and concern about child weight among parents of young children between the ages of 5 and 10, who are overweight (BMI percentiles 85-95th) or are at-risk for becoming overweight (BMI percentiles 70-84th). We then investigate the relationship between parental concern about child weight and child-, household-, and parent-level factors in 3 domains: diet, PA, and media use. In doing so, we sought to: 1) assess accuracy of parental perceptions of child weight status and describe parental concerns about child weight; 2) assess demographic correlates of accuracy of parental perceptions of child weight status and parental concern about child weight; and 3) examine the relationship between parental concern about child weight and weight-related dietary, PA, and media factors at the child, household, and parent levels.

Previous studies have shown that parental protectiveness is associated with increased pain and disability in Functional Abdominal Pain Disorder (FAPD) but the role that perceived child self-efficacy may play remains unclear. One reason why parents may react protectively towards their child’s pain is that they perceive their child to be unable to cope or function normally while in pain (perceived low self-efficacy). This study sought to examine (a) the association between parent-perceived child pain self-efficacy and child health outcomes (symptom severity and disability); and (b) the role of parental protectiveness as a mediator of this association. Participants were 316 parents of children aged 7–12 years with FAPD. Parents completed measures of perceived child self-efficacy when in pain, their own protective responses to their child’s pain, child gastrointestinal (GI) symptom severity, and child functional disability. Parent-perceived child self-efficacy was inversely associated with parent-reported child GI symptom severity and disability, and parental protectiveness mediated these associations. These results suggest that parents who perceive their child to have low self-efficacy to cope with pain respond more protectively when they believe he/she is in pain, and this, in turn, is associated with higher levels of GI symptoms and disability in their child. This finding suggests that directly addressing parent beliefs about their child’s ability to manage pain should be included as a component of FAPD, and potentially other child treatment interventions.

BACKGROUND Studies testing the efficacy of behavioral interventions to modify psychosocial sequelae of inflammatory bowel disease in children are limited. This report presents outcomes through a 6-month follow-up from a large randomized controlled trial testing the efficacy of a cognitive behavioral intervention for children with inflammatory bowel disease and their parents. METHODS One hundred eighty-five children aged 8 to 17 years with a diagnosis of Crohn's disease or ulcerative colitis and their parents were randomized to one of two 3-session conditions: (1) a social learning and cognitive behavioral therapy condition or (2) an education support condition designed to control for time and attention. RESULTS There was a significant overall treatment effect for school absences due to Crohn's disease or ulcerative colitis (P < 0.05) at 6 months after treatment. There was also a significant overall effect after treatment for child-reported quality of life (P < 0.05), parent-reported increases in adaptive child coping (P < 0.001), and reductions in parents' maladaptive responses to children's symptoms (P < 0.05). Finally, exploratory analyses indicated that for children with a higher level of flares (2 or more) prebaseline, those in social learning and cognitive behavioral therapy condition experienced a greater reduction in flares after treatment. CONCLUSIONS This trial suggests that a brief cognitive behavioral intervention for children with inflammatory bowel disease and their parents can result in improved child functioning and quality of life, and for some children may decrease disease activity.

The present review summarizes many of the major research trends investigated in the past five years regarding pediatric functional abdominal pain, and also summarizes the primary related findings from the authors’ research program. Specific areas discussed based on work within the authors’ group include familial illness patterns, genetics, traits, and mechanisms or processes related to abdominal pain. Topics covered from research published in the past five years include prevalence and cost, longitudinal follow-up, overlap with other disorders, etiology and mechanisms behind functional abdominal pain and treatment studies. It is hoped that findings from this work in abdominal pain will be interpreted as a framework for understanding the processes by which other pain phenomena and, more broadly, reactions to any physical state, can be developed and maintained in children. The present article concludes with recommendations for clinical practice and research.

Decrease in the level of high density lipoprotein cholesterol (HDLC) has been observed in women who start dieting, but not in men. Patterns of HDLC change during intentional weight loss through 30-months of follow-up, and their association with changes in anthropometric measurements were examined in obese women (N=112) and men (N=100). Missing HDLC values at 6-, 12-, 18-, and 30-month follow-up (N=16, 34, 55, and 50, respectively) due to drop-out were imputed by multiple imputation. Mean ages and body mass indices (BMIs) of subjects at baseline were 47.2 years and 34.8 kg/m2 for women, and 50.4 years and 35.0 kg/m2 for men. On average, participants lost weight steadily for 12 months, followed by slow regain. During the first six months, HDLC decreased significantly in women (−4.1 mg/dl, P=0.0007), but not in men. Significant HDLC increases were observed in both men and women from 6- to 12-month follow-up. HDLC changes in women were positively associated with changes in hip circumference from baseline to 12-month independent of changes in triglycerides, glucose and insulin. Rapid decrease of predominantly subcutaneous fat in the femoral and gluteal area might be associated with HDLC decrease in women during initial weight loss.

To evaluate a maintenance-tailored therapy (MTT) compared to standard behavior therapy (SBT) for treatment of obesity.change in body weight.A non-blinded, randomized trial comparing effectiveness of MTT and SBT in facilitating sustained weight loss over 18 months; 213 adult volunteersor =18 years participated. SBT had fixed behavioral goals, MTT goals varied over time. Study conducted at the University of Minnesota, School of Public Health, January 2005 through September 2007.Mean (SD) weight losses at 6, 12, and 18 months were 5.7 (5.0) kg, 8.2 (8.6) kg and 8.3 (8.9) kg for MTT and 7.4 (3.9) kg, 10.7 (8.2) kg and 9.3 (8.8) kg for SBT. Total weight loss did not differ by group at 18 months, but the time pattern differed significantly (p0.001). The SBT group lost more weight in the first 6 months. Both groups lost similar amounts between 6 and 12 months; MTT had stable weight between 12 and 18 months, while SBT experienced significant weight gain.The MTT approach produced sustained weight loss for an unusually long period of time and not achieved in previous trials of behavioral treatment for weight loss. The MTT approach, therefore, deserves further study.

To compare the enrollment, attendance, retention and weight losses of young adults in behavioral weight loss (BWL) programs with older participants in the same trials. Data were pooled from three NIH-funded adult BWL trials from two clinical centers in different regions of the country (total N=298); young adults were defined as those aged 18–35 years. Both young adults and adults were compared on session attendance, retention at the 6-month assessment, weight loss and physical activity at 6 months. Young adults represented 7% of the sample, attended significantly fewer sessions than did adults (52 vs 74%, respectively; P

Solicitous parental responses to stomachaches may perpetuate chronic abdominal pain in children. Discussing these issues in clinical practice is difficult because parents feel misunderstood and blamed for their child's pain. Focusing on parental worries and beliefs that motivate solicitous responses may be better accepted.Our aim was to determine parental fears, worries, and beliefs about their child's chronic abdominal pain that influence parental responses to child's pain.In 2 studies, a large online sample and a smaller community sample consisting of parents with children who have abdominal pain, we developed and evaluated a self-report questionnaire to assess parental Worries and Beliefs about Abdominal Pain (WAP).Principal component analysis identified 4 subscales: "pain is real," "desire for care," "worry about coping," and "exacerbating factors." The WAP is easily understood and possesses adequate initial reliability (Cronbach alpha=0.7-0.9). It shows good initial validity (ie, families who consulted a physician for their child's pain scored higher on the WAP than families who did not consult a physician and the WAP correlates with parental reactions to the child's pain).Discussing parents' fears and worries about their children's chronic abdominal pain may facilitate discussions of social learning of gastrointestinal illness behavior.

This study examined predictors of maternal responses to children's abdominal pain symptoms. Mothers (N = 450) provided data on psychological distress (self and child), responses to their children's symptoms, and perceived symptom severity. Several demographic factors predicted protectiveness and/or symptom monitoring: younger or male child, maternal non-Caucasian race or less education, and no father in the home. Psychosocial predictors included maternal somatization (related to greater monitoring and less minimization) and child distress (related to greater minimization). A child gender × condition severity interaction indicated greater protection of boys based on perceived severity, but no such discrimination for girls.

Objective To examine the sensitivity to change and responsiveness of the Adult Responses to Children's Symptoms (ARCS) among parents of youth with chronic pain. Methods Participants included 330 youth (89 children aged 7-11 years, 241 children aged 12-17 years) and their parents who participated in randomized controlled trials of family-based cognitive-behavioral therapy for chronic pain. Child pain and disability, parental emotional functioning, and parental responses to child pain were assessed at baseline and posttreatment. Results The Protect and Monitor scales of the ARCS were sensitive to change following intervention for both developmental groups, with clinically meaningful reductions in these behaviors, thereby demonstrating responsiveness. Among the adolescent sample, greater change on some ARCS scales was associated with better parental emotional functioning and lower child pain at posttreatment. Conclusions Findings support the sensitivity to change and responsiveness of the Protect and Monitor scales among parents of youth with chronic pain.

To assess the validity of the Protect Scale of the Adult Responses to Children's Symptoms (ARCS) Questionnaire with regard to mothers' responses to their children's abdominal pain.Mothers with High (n=32) and Low (n=35) Protect scores on the ARCS questionnaire were recruited from participants in a larger study of family illness behavior. Mothers completed a 28-day diary report of responses to their children's abdominal pain episodes. Records of their children's annual health service utilization and costs were obtained from their health maintenance organization (HMO).Mothers' scores on the ARCS Protect Scale were significantly correlated with their subsequent diary reports of protective responses to their children's abdominal pain. Compared to children of mothers in the Low Protect group, children of mothers in the High Protect group made significantly more health care visits for gastrointestinal symptoms and had significantly higher health care costs.Results supported the validity of the Protect Scale of the ARCS and demonstrated that mothers' protective responses to children's abdominal pain complaints at home predicted subsequent health service use for gastrointestinal symptoms.

Reports of “Satisfactory Relief” by IBS Patients Receiving Usual Medical Care Are Confounded by Baseline Symptom Severity and Do Not Accurately Reflect Symptom Improvement

This article outlines the rationale and use of cognitive behavior therapy in the treatment of the gastrointestinal symptoms and illness behavior associated with Recurrent Abdominal Pain (RAP), often described as the childhood variant of IBS. It begins with a conceptualization of the social learning perspective of RAP, and then covers the relationship between childhood social learning and adult and childhood illness behavior. Studies that have utilized a cognitive behavior therapy approach for treating adult pain are summarized. Finally, specific cognitive behavior therapy trials for treating RAP, as well as moderators of treatment effectiveness, are discussed. Keywords: recurrent abdominal pain (RAP); pain; children; illness behavior; social learning As has been discussed elsewhere in this issue, cognitive behavior therapy for IBS symptoms includes assessment and treatment of the behavioral, cognitive, and physiological phenomena associated with gastrointestinal symptoms and "illness behavior." Illness behavior is a term that refers to the way people perceive and react to somatic sensations that might signify disease (Mechanic, 1978). Illness behavior falls on a continuum, ranging from failure to notice such sensations or refusal to let even serious illness interrupt one's normal routine, to misinterpretation of normal somatic sensations as symptoms of disease and seeking unnecessary medical treatment for minor complaints. Both ends of the continuum are of concern to health care providers: Denial may lead individuals to postpone diagnostic investigations or to not adhere to medical regimens. Preoccupation with illness, on the other hand, creates a costly burden on the health care system (Drossman et al., 1993). This article will provide the rationale for and description of the use of cognitive behavior therapy in the treatment of the gastrointestinal symptoms and illness behavior associated with Recurrent Abdominal Pain (RAP), often described as the childhood variant of IBS. Less than 25% of physical complaints presented to physicians have known or demonstrable organic or physiological causes (Nezu, Nezu, & Lombardo, 2001). RAP is one of these many disorders in children that has significant societal and personal costs. Although 10% to 15% of children have RAP (Apley, 1975), children with RAP fall into the category of those presenting with such symptoms of unknown cause. A child is labeled with RAP when, in the absence of physical or laboratory findings, she/he has experienced at least three episodes of pain over a 3-month period that affect the child's activities (Apley & Naish, 1958). The term RAP encompasses a heterogeneous group of functional gastrointestinal disorders, such as irritable bowel syndrome, in which abdominal pain is a primary complaint (Boyle, 1997; Von Baeyer & Walker, 1999). New diagnostic criteria have been proposed for the various functional gastrointestinal disorders of childhood that constitute the subgroups of RAP, but these have not yet been validated (Drossman et al., 2000; Rasquin-Weber et al., 1999). Thus, current research in this area continues to use Apley's broad definition of RAP in patient selection, although efforts are underway to validate the diagnostic subgroups and to standardize tools for their identification (e.g., Walker, et al., 2004). RAP is the most common recurrent pain complaint of childhood (McGrath, 1990) and typically generates multiple clinic visits, extensive medical evaluations, and considerable school absence. Five years after their initial medical evaluation, adolescents and young adults with a history of RAP still have significantly more school and work absence and greater illness-related impairment than their peers (Walker, Guite, Duke, Barnard, & Greene, 1998). RAP is more common in girls than boys, is most prevalent during middle childhood (ages 8 to 11), and is frequently associated with a variety of vague, nonspecific symptoms such as fatigue, dizziness, and headaches (Murphy, 1993; Stone & Barbero, 1970; Walker, Garber, & Greene, 1991). …

Participants in weight loss programs typically set unrealistically high weight loss goals that some believe are detrimental to success. This study examined outcomes associated with goal and ideal body mass index (BMI). Participants (N=1801) were enrolled in a weight loss trial comprised of low-intensity mail or telephone interventions vs usual care. Goal and ideal weight losses were assessed by asking participants how many pounds they expect to lose in the program (goal) and how much they would like to weigh (ideal). Goal and ideal weight losses were unrealistically high (men: -16 and -19%, women: -21 and -27%). For women, less realistic goals were associated with greater weight loss at 24 months. Goals were not associated with participation or weight loss for men. Results are more supportive of the idea that higher goals motivate women to lose weight than of the hypothesis that high goals undermine effort.

Summary Aims : To determine what constitutes usual medical care for irritable bowel syndrome, which patient characteristics influence choice of treatment and how satisfied patients are with care. Methods : Patient encounters in a health maintenance organization were prospectively monitored to identify visits coded irritable bowel syndrome, abdominal pain, constipation or diarrhoea. Within 2 weeks these patients were sent postal questionnaires (n = 1770, 59% participation) to assess patient characteristics and treatment recommendations. Responders were sent follow-up questionnaires 6 months later (77% participation) to assess adherence and satisfaction with treatment. Results : Treatments employed most frequently were dietary advice, explanation, exercise advice, reassurance, advice to reduce stress and antispasmodic medications. Primary care physicians and gastroenterologists provided similar treatments. Patient confidence was higher for lifestyle advice (63–67, 100-point scale) than for medications (46–59). However, adherence was greater for medications (62–79 vs. 59–69, 100-point scale). Satisfactory relief was reported by 57%, but only 22% reported that symptom severity was reduced by half. Usual medical treatment was less effective for irritable bowel syndrome than for constipation, diarrhoea, or abdominal pain. Conclusions : Usual medical care for irritable bowel syndrome emphasizes education and lifestyle modification more than drugs; patients have a greater expectation of benefit from lifestyle modification than drugs. Overall 57% of irritable bowel syndrome patients report satisfactory relief.

To examine the relative contributions of disease activity and psychological factors to self-reported symptoms and disability in children with Crohn's disease.Participants (n = 127 children age 8-18 years) completed questionnaires on symptom severity and disability, as well as psychological measures assessing anxiety, depression, pain beliefs and coping. Disease activity was measured by the Pediatric Crohn's Disease Activity Index. Structural equation modeling was used to test the effects of disease activity and psychological factors on symptoms and disability.In the hypothesized model predicting symptoms, psychological factors (β = 0.58; P .001) were significantly associated with disease symptoms but disease activity was not. The model for disability yielded significant associations for both psychological factors (β = 0.75; P .001) and disease activity (β = 0.61, P .05).Crohn's disease symptoms in children and adolescents are not only driven by disease activity. Coping, anxiety, depression, and cognition of illness are important in the patient-reporting of symptom severity and disability. Physicians need to be aware that symptom self-reporting can be driven by psychological factors and may not always be simply an indicator of disease activity.ClinicalTrials.gov: NCT00679003.

OBJECTIVES We evaluated eating behaviors and quality of life (QOL) in preadolescent children at risk for obesity, with and without abdominal pain (AP). METHODS Participants were parent-child dyads enrolled in a randomized, controlled obesity prevention trial. The children were between 5 and 10 years of age and at risk for obesity (70th-95th percentile of body mass index, n = 420). Parents completed measures of their child's eating behaviors, QOL, AP, and bowel function and their own depression status, concern about child weight, and feeding practices. Children's height and weight were also measured. RESULTS Children with frequent AP (≥2/month, n = 103) were compared with children reporting infrequent AP (

AIM: To examine familial aggregation of irritable bowel syndrome (IBS) via parental reinforcement/modeling of symptoms, coping, psychological distress, and exposure to stress. METHODS: Mothers of children between the ages of 8 and 15 years with and without IBS were identified through the Group Health Cooperative of Puget Sound. Mothers completed questionnaires, including the Child Behavior Checklist (child psychological distress), the Family Inventory of Life Events (family exposure to stress), SCL-90R (mother psychological distress), and the Pain Response Inventory (beliefs about pain). Children were interviewed separately from their parents and completed the Pain Beliefs Questionnaire (beliefs about pain), Pain Response Inventory (coping) and Child Symptom Checklist [gastrointestinal (GI) symptoms]. In addition, health care utilization data was obtained from the automated database of Group Health Cooperative. Mothers with IBS (n = 207) and their 296 children were compared to 240 control mothers and their 335 children, while controlling for age and education. RESULTS: Hypothesis 1: reinforcement of expression of GI problems is only related to GI symptoms, but not others (cold symptoms) in children. There was no significant correlation between parental reinforcement of symptoms and child expression of GI or other symptoms. Hypothesis 2: modeling of GI symptoms is related to GI but not non-GI symptom reporting in children. Children of parents with IBS reported more non-GI (8.97 vs 6.70, P < 0.01) as well as more GI (3.24 vs 2.27, P < 0.01) symptoms. Total health care visits made by the mother correlated with visits made by the child (rho = 0.35, P < 0.001 for cases, rho = 0.26, P < 0.001 for controls). Hypothesis 3: children learn to share the methods of coping with illness that their mothers exhibit. Methods used by children to cope with stomachaches differed from methods used by their mothers. Only 2/16 scales showed weak but significant correlations (stoicism rho = 0.13, P < 0.05; acceptance rho = 0.13, P < 0.05). Hypothesis 4: mothers and children share psychological traits such as anxiety, depression, and somatization. Child psychological distress correlated with mother’s psychological distress (rho = 0.41, P < 0.001 for cases, rho= 0.38, P < 0.001 for controls). Hypothesis 5: stress that affects the whole family might explain the similarities between mothers and their children. Family exposure to stress was not a significant predictor of children’s symptom reports. Hypothesis 6: the intergenerational transmission of GI illness behavior may be due to multiple mechanisms. Regression analysis identified multiple independent predictors of the child’s GI complaints, which were similar to the predictors of the child’s non-GI symptoms (mother’s IBS status, child psychological symptoms, child catastrophizing, and child age). CONCLUSION: Multiple factors influence the reporting of children’s gastrointestinal and non-gastrointestinal symptoms. The clustering of illness within families is best understood using a model that incorporates all these factors.

Objective To describe the proportion of children adhering to recommended physical activity and dietary guidelines, and examine demographic and household correlates of guideline adherence. Design Cross-sectional (pre-randomization) data from a behavioral intervention trial designed to prevent unhealthy weight gain in children. Participants A total of 421 children (aged 5–10 years) at risk for obesity (body mass index percentile, 70–95). Main Outcomes Measured Physical activity (accelerometry), screen time (parent survey), and fruit and vegetable and sugar-sweetened beverage intake (24-hour dietary recall). Analysis Proportions meeting guidelines were calculated. Logistic regression examined associations between demographic and household factors and whether children met recommended guidelines for (1) physical activity (≥ 60 min/d), (2) screen time (≤ 2 h/d), (3) fruit and vegetable intake (≥ 5 servings/d), and (4) sugar-sweetened beverage avoidance. Results Few children met more than 1 guideline. Only 2% met all 4 recommended guidelines and 19% met none. Each guideline had unique sociodemographic and domain-specific household predictors (ie, availability of certain foods and beverages, media, and active play and exercise equipment). Conclusions and Implications Families equipped to promote healthy child behavior patterns in 1 activity or dietary domain may not be in others. Results have implications for the development of interventions to affect children's weight-related behaviors and growth trajectories.

Objectives Cognitive-behavioral (CB) interventions improve outcomes for many pediatric health conditions, but little is known about which mechanisms mediate these outcomes. The goal of this study was to identify whether changes in targeted process variables from baseline to 1 week posttreatment mediate improvement in outcomes in a randomized controlled trial of a brief CB intervention for idiopathic childhood abdominal pain. Materials and methods Two hundred children with persistent functional abdominal pain and their parents were randomly assigned to 1 of 2 conditions: a 3-session social learning and CB treatment (N=100), or a 3-session educational intervention controlling for time and attention (N=100). Outcomes were assessed at 3-, 6-, and 12-month follow-ups. The intervention focused on altering parental responses to pain and on increasing adaptive cognitions and coping strategies related to pain in both parents and children. Results Multiple mediation analyses were applied to examine the extent to which the effects of the social learning and CB treatment condition on child gastrointestinal (GI) symptom severity and pain as reported by children and their parents were mediated by changes in targeted cognitive process variables and parents' solicitous responses to their child's pain symptoms. Reductions in parents' perceived threat regarding their child's pain mediated reductions in both parent-reported and child-reported GI symptom severity and pain. Reductions in children's catastrophic cognitions mediated reductions in child-reported GI symptom severity but no other outcomes. Reductions in parental solicitousness did not mediate outcomes. Discussion Results suggest that reductions in reports of children's pain and GI symptoms after a social learning and CB intervention were mediated at least in part by decreasing maladaptive parent and child cognitions.

This study sought to model and test the role of parental catastrophizing in relationship to parent-reported child pain behavior and parental protective (solicitous) responses to child pain in a sample of children with Inflammatory Bowel Disease and their parents (n=184 dyads). Parents completed measures designed to assess cognitions about and responses to their child’s abdominal pain. They also rated their child’s pain behavior. Mediation analyses were performed using regression-based techniques and bootstrapping. Results supported a model treating parent-reported child pain behavior as the predictor, parental catastrophizing as the mediator, and parental protective responses as the outcome. Parent-reported child pain behavior predicted parental protective responses and this association was mediated by parental catastrophizing about child pain: indirect effect (SE) = 2.08 (0.56); 95% CI = 1.09, 3.30. The proportion of the total effect mediated was 68%. Findings suggest that interventions designed to modify maladaptive parental responses to children’s pain behaviors should assess, as well as target, parental catastrophizing cognitions about their child’s pain.

Heredity has been suggested to explain the finding that irritable bowel syndrome (IBS) tends to run in families. Research in this area has been limited. The aim of the present study was to assess the relative contribution of genetic and environmental (social learning) influences on the development of IBS by comparing concordance rates in monozygotic and dizygotic twins to concordance between mothers and their children.Questionnaires soliciting information on the occurrence of more than 80 health problems, including IBS, in self and other family members were sent to both members of 11,986 twin pairs.Analysis is based on 10,699 respondents representing 6060 twin pairs. Concordance for IBS was significantly greater (P = 0.030) in monozygotic (17.2%) than in dizygotic (8.4%) twins, supporting a genetic contribution to IBS. However, the proportion of dizygotic twins with IBS who have mothers with IBS (15.2%) was greater than the proportion of dizygotic twins with IBS who have co-twins with IBS (6.7%, P0.001), and logistic regression analysis showed that having a mother with IBS and having a father with IBS are independent predictors of irritable bowel status (P0.001); both are stronger predictors than having a twin with IBS. Addition of information about the other twin accounted for little additional predictive power.Heredity contributes to development of IBS, but social learning (what an individual learns from those in his or her environment) has an equal or greater influence.

Selective attention to GI sensations has been suggested as an important mechanism that affects symptom perception in patients with irritable bowel syndrome (IBS), but this hypothesis has not yet been tested empirically. Differential recall of words describing negative affect has been used to demonstrate that depressed patients selectively attend to negative affect words. This technique may be useful for examining selective attention to somatic sensations. The aim of this study was to determine whether patients with IBS demonstrate selective recall of GI sensations compared with neutral words and words describing respiratory sensations.A total of 16 IBS patients, nine asthmatic patients (medical controls), and eight healthy controls were shown 10 GI sensation words or phrases, 10 respiratory sensation words or phrases, and 10 neutral words in random order for 3 s each. After a distraction task, subjects wrote down all of the words or phrases they could remember.As predicted, IBS patients were more likely to recall GI words than other categories. Asthmatic patients were more likely to recall respiratory words in comparison with healthy controls.IBS patients selectively recall words describing GI sensations; this suggests that they may selectively attend to GI sensations, thus supporting the cognitive-behavioral theory of IBS.