Organic Gastrointestinal Disorders

Abstract

Organic gastrointestinal (GI) disorders in children are common and have a significant impact on a child’s physical and emotional well-being. Symptoms of organic GI disorders, such as soiling accidents, frequent stooling, vomiting, and abdominal pain, can be quite painful, socially limiting, and embarrassing. Body image can be negatively impacted by symptoms or treatment side effects (e.g., having an ostomy, swelling from steroids, growth delays). Absenteeism from normal activities such as school and social outings is quite common due to symptoms or treatment demands, and treatments of organic GI disorders can be time-consuming, complex, and burdensome. For all of these reasons, the pediatric consultation-liaison psychologist plays an essential role and has a profound impact on the overall wellness of these youths. This chapter will describe some of the more commonly diagnosed organic GI disorders and the major areas of practice for the pediatric consultation-liaison psychologist. From case formulation to intervention and treatment across inpatient and outpatient settings, this chapter will highlight evidence-based approaches and contextual factors that capture the unique needs of children with organic GI disorders.

Appendices

Appendix 1

Appendix 2: Getting Back to School: A Guide for Parents

Many children with gastrointestinal (GI) disorders have school problems. They may miss school days (or even weeks!) because of symptoms, doctor’s visits, being in the hospital, or school policies meant to prevent illness from spreading. They also may have a hard time paying attention in class, get behind in daily school work, or feel overwhelmed by make-up work.

Your child may require your help and support to get back to school full-time. The key to accomplishing this goal will be creating a plan to gradually increase daily expectations .

Graduated School Re-Entry

If your child has been out of school for a long time, he or she may need a shortened school day at first. This would be followed by longer and longer periods of attendance (as strength, stamina, and confidence increase). This gradual increase in time at school would continue until your child is back at school full time. We call this plan “graduated school re-entry.” The key steps are listed below:

• Step 1. Choose a block of class time that your child is able to attend every day withoutincreasedGI symptoms. Start with a small enough amount of time to ensure your child’s success and build from there. This may be as little as 1 h, a single class period, or a half day. Pay attention to what time of the day your child’s symptoms tend to be the most manageable in setting up this plan. You may want to avoid starting with any classes are particularly stressful. Starting with a favorite class or activity is fine—any amount of time spent at school will increase strength, stamina, and confidence!

• Step 2. Your child should go to school at the agreed upon time and stay at school until the scheduled ending time for that day. This should happen regardless of pain (or other symptom) complaints. Your child should leave school at the scheduled ending time even if he or she is feeling well. Doing this will encourage feelings of success and help prevent symptoms from getting worse on the following day(s).

• Step 3. Your child’s progress should be re-evaluated weekly (on Wednesday or Thursday, if possible). If your child has been able to complete the plan for the previous week without increased symptoms, then class time should be increased slightly. Again, this added time may be as little as 30 min. Remember, slow and steady is the key!

Supporting Success and Attendance at School

There are lots of ways to support your child’s success in the classroom and encourage regular school attendance. Here are a few strategies that might be helpful to your child:

• Allow easy access to the bathroom at school. Asking permission to leave class can be embarrassing and increase fears about not getting to the bathroom in time. It sometimes helps to work with teacher(s) to develop a private system of communication. For example, some children put a colored index card on their desk when they need to leave for the bathroom. This lets the teacher know, but allows the child to get to the bathroom quickly without disturbing the class.

• Encourage taking brief breaks to use stress and pain management skills. Children can help themselves feel better and stay at school by using relaxation strategies (including biofeedback), as needed. These skills can be done sitting in an office or any other place where your child’s presence and activity won’t bother other students. Breaks should last 10–15 min, followed by a return to class.

• Encourage participation in clubs and sports while working on getting back to school. Participation in these activities, even on a limited basis, may help a child stay connected with friends and improve mood. Social isolation and depression can get in the way of recovery. These feelings also can make it harder to get back to school.

• Carefully consider make-up work. Getting overwhelmed with schoolwork is a problem. It can increase the chance of symptoms getting worse. This can result in a cycle of missing more school, getting further behind, and getting more stressed. Sometimes it can help to reduce the amount of required schoolwork during the school re-entry process. It also can help to extend the time for completing make-up work and tests. Reducing your child’s workload should be done in a thoughtful way to ensure that he or she is learning the necessary concepts while minimizing the quantity of work required (and the associated stress).

• Set up a reasonable schedule for completing make-up work at home. Some children have lots of make-up work to finish as they get back to school. Plus, they still have regular daily assignments and projects! We encourage parents to set up a schedule for completing make-up work that is consistent, without being stressful or overly demanding. Set a timer for 30 min. During this time, ask your child to focus only on make-up work. After that time, have your child take a break, even if the make-up work is not fully completed. One more 30-min session can be scheduled for later in the evening, if needed. Avoid scheduling any more than these two daily 30-min periods for completing make-up work. Spending too much time on make-up work, in addition to daily assignments, may be counterproductive to recovery.

• Consider asking for aSection 504 Planfor your child based on his or her health issues. This plan is a written agreement between you, your child, and the school. It can help make your child’s back-to-school support plan more formal and encourage participation across all school staff.

Special Situations

• Homebound. In general, we discourage ongoing homebound services as a way for children to complete school requirements. For academic, social, emotional, and behavioral reasons, the best place for your child to spend his or her days is in school. If your child currently is receiving homebound services, it is important that you work with your child’s medical team to help your child return to school, on a graduated basis, as part of his or her overall treatment plan. Your support and participation in this aspect of your child’s treatment plan is critical.

• Staying Home from School. Sometimes it can be hard to tell whether a child is sick when they have frequent abdominal pain and other GI symptoms. Parents often wonder when to let their children stay home from school. To help you navigate this tricky issue, we recommend keeping your child home from school when he or she has:

  • 1. frequent or uncontrollable stooling through the day;

  • 2. a temperature of 100° or higher in the last 24 h;

  • 3. repeated vomiting and/or diarrhea in the last 24 h;

  • 4. inability to keep down clear liquids; and/or

  • 5. evidence of contagious infection.

• If your child is too sick to go to school (using the above guide), he or she should rest quietly in bed (e.g., no TV, computer, or video games). If your child feels better before the school day ends, he or she may go to school late or work on schoolwork at home. When in doubt, send your child to school and call your child’s GI physician to discuss your child’s symptoms.

Important Reminders for Parents During the Back-to-School Process

• Return to school is essential for your child’s physical, social, and emotional health.

• It may take several weeks for your child to return to his or her usual school routine. The key to accomplishing this goal will be to create a plan for gradually increasing daily expectations.

• Offering praise, rewards, or special activities for reaching important milestones (e.g., first full day back at school, first week at school without an absence) is encouraged.

Appendix 3

Date

Parents’ address

Dear Parents,

As you know, your son/daughter, _, has a history of significant abdominal pain and other gastrointestinal (GI) issues that have greatly affected his/her daily functioning—his/her ability to attend school and spend time with friends and family, as well as his/her mood. In addition to pursuing medical care for _ through the X Clinic, we understand that you have sought psychological and behavioral support for him/her through a local mental health provider to address some of these concerns.

Individual mental health treatment is something we routinely recommend as an adjunct to our patients’ medical treatment regimens. We believe that regular mental health support can help patients to regain their previous level of functioning and, in the longer term, indirectly improve their GI symptoms.

Specific therapy targets often addressed by therapists working with our patients include:

• Maintaining a consistent daily schedule that encourages functioning with GI symptoms

• Addressing sleep problems

• Targeting social issues that have developed secondary to lengthy absences from school and withdrawal from social activities (e.g., developing “scripts” for helping children to address peers’ questions, encouraging social interaction by formalizing “play dates” or other structured social get-togethers with peers)

• Targeting academic issues that have developed secondary to prolonged school absences (e.g., coordinating with teachers to address make up work, making recommendations regarding appropriate accommodation at school)

• Encouraging active strategies (e.g., positive self-talk, deep breathing and other forms of relaxation, distraction, problem-solving) for managing physical complaints, including abdominal pain, and any known stressors

• Intervening with apparent co-morbid anxiety and depressive symptoms

• Collaborating with parents to ensure that the home environment is supportive of all the changes recommended and discussed within individual therapy visits

We appreciate your interest in working with us on behalf of _ and encourage you to share the above list with his/her current mental health practitioner. Should you have any questions regarding _’s care please contact us at 000-000-0000.

Sincerely,