When Pediatric GI Symptoms Need Both Gastroenterology and Psychology

Even after medical evaluations and treatments are initiated, many children with gastrointestinal (GI) symptoms continue to experience unresolved primary symptoms. Behavioral health can be an integral part of the therapeutic approach for the individual patient and family, and integrated care helps address both inflammation and nervous-system-driven clinical symptomatology.

Collaboration between gastroenterology and behavioral health teams is critical for managing complex chronic GI diseases and disorders, including inflammatory bowel diseases (IBD) and disorders of the gut-brain interaction (DGBI). The seamless integration of both services is a point of distinction at Cleveland Clinic Children’s.

Key differences between IBD and DGBI

IBD and DGBI, formerly known as functional gastrointestinal disorders, are separate but interconnected diagnoses, with different primary etiologies that can often have overlapping symptoms. One significant difference: Inflammation is a clinical hallmark of IBD, while DGBI involves the interplay between the brain and the GI tract enteric nervous system.

Integrating psychological care into the management of chronic diseases, like IBD, isn’t a new concept. However, growing data on DGBI highlights the effectiveness of behavioral interventions as part of the treatment model. This includes addressing the nervous system and using coping skills, rather than medication alone.

“This is something families don't often think about in a primary care setting,” says Ethan Benore, PhD, Chair of the Division of Pediatric Behavioral Health at Cleveland Clinic Children’s. “However, behavioral interventions for gastrointestinal problems are well-established as an effective treatment strategy.”

Dr. Benore and Sandra Kim, MD, Chair of the Division of Pediatric Gastroenterology, Hepatology and Nutrition, have been partnering to create integrated gastroenterology and psychology programs that support young patients with different categories of GI conditions.

Integrating psychology into an IBD model

“The involvement of GI psychology is integral for effective care for many chronic disorders and diseases, including the multidisciplinary care model for chronic gastrointestinal diseases like IBD,” explains Dr. Kim.

This begins with an initial evaluation to assess patients’ and families’ understanding of the condition, what kind of support and education they need, the difference between chronicity versus acuity in illness, and processing what life with IBD will be like, which Alina Vaisleib, PsyD, says can be a really intense and complex emotional experience.

“We talk about how symptoms might manifest in their daily lives, ways to explain challenges like pain, frequent bathroom use or absences to friends, teachers and coaches, and skills for calming their nervous system when they feel anxious,” she says. These discussions happen more broadly with the entire family, she notes, as IBD can impact all aspects of family life.

Dr. Vaisleib and her colleagues also help children overcome the fear and anxiety that often accompanies treatment and promote adherence, whether they are getting injections at home or coming in for infusion therapy. “Building a plan around treatment days helps to reduce anticipatory anxiety.”

Expanding care for DGBI and other common GI concerns

Two other popular GI programs are led by pediatric psychologists at Cleveland Clinic and focus on all types of chronic abdominal pain and constipation, respectively.

The Functional Abdominal Pain Program was developed in response to excessive need, according to Dr. Benore. “Abdominal pain or distress is one of the leading causes of childhood absences from school. It's one of the first things that kids may struggle with regularly,” says Dr. Benore.

Within the program, clinicians treat pain, often associated with acid reflux, constipation and diarrhea in various parts of the abdomen. After underlying pathology is ruled out, symptoms tend to persist despite medication management. The program has dedicated behavioral health clinicians trained in cognitive behavioral therapy, biofeedback and relaxation therapy to treat functional abdominal pain, rumination, cyclic vomiting and avoidant restricted food intake disorder.

“Poop School,” also known as the Functional Constipation Clinic, directed by Katherine Corvi, PsyD, helps children ages 3 to 7 with constipation and/or withholding behaviors, as well as those prone to stooling accidents or excessive constipation. These problems can greatly affect quality of life for a child and their family.

The care path is slightly different for those age 8 and older, as their needs differ from those of younger populations. They’ve typically been living with constipation for a longer time and may have more fears about managing it, Dr. Vaisleib explains.

“These kids may struggle in school, activities and social situations, and parents are struggling, too, because they're feeling like this is something that they should have been able to master,” adds Dr. Benore.

Scheduled sitting, breathing strategies, adherence to stool softener, and creative hygiene practices are among the interventions for these patients.

Complementary, not competing, care

Referrals to psychology and gastroenterology services are not mutually exclusive, Dr. Benore emphasizes.

“We are complementary services. We work in tandem to address IBD and DGBI from two different angles. It’s completely appropriate to refer your patients to both GI and pediatric psychology to assess gastrointestinal conditions,” he concludes.