Puzzling Gastrointestinal Symptoms Common in Abused Children

 

Children who have been abused appear to have a higher risk for inexplicable gastrointestinal (GI) symptoms compared with their counterparts who have not been abused, new research suggests. The results, from a large database on child maltreatment, also show that this association is at least partially mediated by psychological distress.

"Unexplained GI symptoms in a young patient should be a tipoff to the possibility of prior abuse," Miranda A. L. van Tilburg, PhD, assistant professor of medicine, Center for Functional GI & Motility Disorders, University of North Carolina, Chapel Hill, told Medscape Psychiatry.

"I still hear too many times pediatricians maintaining that they have never seen a child who has been abused in their practice," she said. "We believe that pediatricians need to acknowledge the possibility of neglect and abuse as a contributor to GI symptoms in children."

The study is published in the March/April issue of the Annals of Family Medicine.

Well-Documented Link in Adults

Given that the link between GI symptoms in children and abuse is not well recognized, there are no specific guidelines on how to treat a child with GI symptoms who has been abused, she said. An obvious first step would be to remove the child from the abusive situation. Family counseling and referral of the child to a psychiatrist may also be helpful.

"There are established treatments for abused children and also established treatments for GI symptoms, and we believe that they should be followed, although we would like to develop treatments tailored specifically to GI complaints that can somehow be established to be due to abuse," said Dr. van Tilburg.

The investigators analyzed data on 845 children 4 to 12 years of age who were enrolled in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN), an ongoing registry of pooled data from 5 studies that are examining the antecedents and sequelae of child maltreatment.

The children had a history of confirmed maltreatment or were considered at risk for maltreatment because of sociodemographic and socioeconomic factors.

According to the study, the relationship between child abuse and GI symptoms in adulthood has been widely examined. For example, adults who were abused as children have been found to have twice the risk of developing severe and chronic GI symptoms as adults who have not been abused.

In a tertiary care GI clinic, at least half of patients cited a history of abuse. In addition, sexually abused women have been found to have a high incidence of unexplained GI symptoms. 

Regrettably, child abuse is common in the United States, they add. Each year, roughly 50 in 1000 children are reported to Child Protective Services because of suspected maltreatment, and maltreatment is eventually verified in 25% of these cases. However, the extent of unreported child abuse is difficult to determine because nearly as many cases are reported as are not reported.

"Mounting evidence establishing an association between child abuse and GI symptoms in adults coupled with a high incidence of child abuse mean that it’s absolutely imperative that we have data on the effect of abuse on GI symptoms in children," Dr. van Tilburg said.

However, the relationship between GI symptoms and child abuse has not been systematically studied. In fact, only 1 study has looked at the impact of abuse on GI symptoms in children, and the abuse focused solely on sexual abuse.

All Types of Abuse Potentiate GI Problems

In LONGSCAN, information on GI symptoms was obtained every 2 years from the children’s caregivers, usually their parents. Maltreatment allegations were provided by Child Protective Services. When children reached 12 years of age, they were asked to report GI symptoms, lifetime maltreatment, and psychological distress.

The investigators found that in children who were sexually abused and reported abdominal pain, sexual abuse preceded or coincided with abdominal pain in 91% of cases. The rate of sexual abuse in all "belly achers" was much lower.

Youth recall of ever having been abused — psychologically, physically, or sexually — was significantly associated with both abdominal pain and nausea or vomiting (odds ratio, 1.5 – 2.1).

"This observation suggests that any type of abuse may set the stage of unexplained GI symptoms later on," said Dr. van Tilburg.

The associations between childhood abuse and GI symptoms were documented in both boys and girls. "The absence of gender differences came as a surprise given that gender differences in abdominal pain are pronounced in adults, with abdominal pain occurring in twice as many women as men," she added.

"While it has been suggested that abuse — and specifically sexual abuse — may partly explain why more women develop unexplained abdominal pain than men, we did not find this to be true in our study.

"Gender differences in pain are generally not noticeable until after the age of about 12, which is a later age than the focus of our study, and it will be interesting to follow this sample into adulthood and discover how these associations may change over time," she said.

Psychological distress mediated, in part, the relation between abuse and GI symptoms. This finding is in line with prior research demonstrating increased psychological distress and dysregulation in the hypothalamic-pituitary-adrenal axis in individuals who were abused as children.

Other factors besides psychological distress may contribute to the onset of GI symptoms.

"For example, prior research has shown that early childhood injury to the GI tract can lead to neural hypersensitivity later in life, which is associated with increased reports of abdominal pain," Dr. van Tilburg said.

"Although few children who are abused will be injured, any abdominal injury due to sexual or physical abuse may make the nerves more sensitive and contribute to the onset of GI symptoms," she added.

Potential Limitations

However, the results should be interpreted judiciously given potential study drawbacks, Dr. van Tilburg cautioned. For example, although the study is the largest and most comprehensive examination of child maltreatment to date, the cohort included many children at high risk for maltreatment in early childhood. As a result, the findings cannot be extrapolated to the population at large, she said.

Also, the youth included in the analysis may have had an organic cause for their symptoms, such as lactose intolerance, celiac disease, or inflammatory bowel disease, she added. However, an organic cause probably only accounted for symptoms in a few cases because most cases of abdominal pain are idiopathic.

"As a pediatrician in primary care, I've found the complaint of abdominal pain to be one of the most common and sometimes most frustrating, in practice,” Ken Haller, MD, associate professor of pediatrics at St. Louis University School of Medicine in Missouri, told MedscapePsychiatry.

“While it's always important to consider organic causes, the pattern of abdominal pain very often does not fit any recognizable physical syndrome, and psychological stress needs to be considered. This stress may be the result of something as straightforward as a math test that received insufficient advance study time or as complex and tragic as a history of abuse.”

And what if an organic cause of the GI symptoms is excluded? "When an organic cause has been effectively ruled out, obtaining a detailed social history and a prospective pain diary can be very helpful in eliciting the source of stress," he advised.

Dr. Haller said he agreed with Dr. van Tilburg and her coauthors that unexplained GI symptoms in at-risk youth may be psychosomatic and necessitate prompt scrutiny of possible psychosocial contributors, particularly maltreatment.

The identification of maltreated children with unexplained GI symptoms may be critical for ensuring the safety of the youth and successful treatment, he added.

"Eliciting the history, for example, that a child with a chief complaint of abdominal pain lived through the particularly messy divorce of his parents and always has tummy aches on weekend visits to the father may be the first step on the road to a life-changing intervention for the child," he said.

The study authors and Dr. Haller have disclosed no relevant financial relationships.

Ann Fam Med. 2010;8:134-140.

Authors and Disclosures- Journalist

Jill Stein is a freelance writer for Medscape.

-From “Puzzling Gastrointestinal Symptoms Common in Abused Children” by Jill Stein , Medscape Psychiatry, March 23, 2010, http://www.medscape.com/viewarticle/718658 retrieved 3/24/10.

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