Psychological Distress and Coping Efficacy in Children with Disorders of Gut-Brain Interaction

Abstract

Background

Multiple psychological factors influence disorders of gut-brain interaction (DGBIs). We aimed to evaluate psychological distress in Colombian school children with and without DGBIs.

Methods

We included children ages 8 to 18 years without organic medical conditions from largest regional public schools in Colombia. Children completed Spanish versions of Rome III diagnostic questionnaire for DGBIs, State Trait Anxiety Inventory for Children (STAIC), Children’s Somatization Inventory (CSI), and a measure of coping efficacy. These data, demographic and socioeconomic characteristics were compared between children with DGBIs and healthy peers. Exploratory analyses investigated differences between youth with symptoms of functional abdominal pain disorders (FAPDs) compared with healthy peers.

Results

Of 1496 children, 281 (mean age 12.9 ± 2.2y, 49.8% females) self-reported criteria for DGBIs and 125 reported (44.5%) FAPDs. Children with DGBIs had higher trait anxiety, emotional sensitivity, somatization including GI, non-GI, pain-related and non-pain related subscales (p<0.001 each) and lower coping efficacy (p=0.02) compared to healthy peers. Females had higher trait anxiety and somatization (p=0.04 and p=0.005 respectively). State and trait anxiety and coping efficacy differed based on location in children with DGBIs (p=0.02, p=0.03 and p<0.001, respectively). Children with FAPDs had higher trait anxiety (p=0.02) and somatization (p<0.001) compared to healthy youth.

Conclusions

Children with DGBIs had higher anxiety, emotional sensitivity and somatization, and lower coping efficacy compared with healthy youth. This highlights the importance of appraising psychological distress characteristics as well as incorporating conflict resolution, assertiveness training, and resilience building during the treatment of DGBIs

Graphical Abstract

School-aged children with Disorders of Gut-Brain Interaction and more so Functional Abdominal Pain Disorders reported higher rates of trait anxiety, somatization, emotional sensitivity and lower coping efficacy compared with healthy peers. This emphasizes the role of psychological functioning in DGBIs and FAPDs and need for specialized screening and treatments for outcome optimization.

INTRODUCTION

Disorders of Gut-Brain Interaction (DGBIs) include functional abdominal pain disorders (FAPDs) such as functional dyspepsia (FD), irritable bowel syndrome (IBS), functional abdominal pain-not otherwise specified (FAP-NOS), and abdominal migraine as well as other non-pain manifestations such as functional constipation (FC), non-retentive fecal incontinence, aerophagia, cyclic vomiting syndrome, functional vomiting, functional nausea, and rumination.^{1, 2} The prevalence rates of FAPDs differ across cultures, with evidence that lower socioeconomic status is associated with higher pain prevalence.³ Ethnicity, race, climate, society, and culture may also affect the epidemiology of FAPDs.² In South American children, for example, our group found a prevalence rate of 16.8%, which is higher than the prevalence rates of FAPDs found in European children (10.5%).⁴

Multiple psychological factors including psychological distress and coping efficacy influence the development, progression, and resolution of symptoms of DGBIs. There is data suggesting that youth with FAPDs such as IBS have worse psychological distress (e.g., anxiety, depression, somatization) and poorer coping than those with non-pain related DGBIs like FC.⁵ Studies in children have shown that FAPDs are associated with negative psychological outcomes, including higher rates of child anxiety^6–12 and depression,^{9–11, 13–16} somatization^{7, 12, 17} and poor coping.^{4, 7, 10} Most of these studies were conducted in developed countries (e.g., USA, Sweden).^{4, 6–10, 12–17} Variability among cultural and socioeconomic factors^18–21 that are associated with DGBIs, is understudied, and the specific influence of psychological factors such as anxiety and somatization in children with DGBIs in Latin America has never been studied.^{11, 22}

Understanding of the impact of psychological functioning on DGBIs in children of different geographical regions can advance our understanding of the pathophysiology of DGBIs and help design more tailored treatments for FAPDs. Thus, we aimed to analyze psychological functioning in children and adolescents with DGBIs compared with healthy peers in Colombian schools. We sought to establish the association between psychological factors and symptoms in children with DGBIs. We explored similar associations in the subset of children with FAPDs. In addition, we attempted to identify other factors from item-level analysis of questionnaires that would differ between children with DGBIs and healthy peers. We hypothesized that children in Colombia with DGBIs would have higher anxiety and somatic symptoms, and lower coping efficacy than healthy peers.

MATERIALS AND METHODS

This study analyzed a dataset of responses from children ages 8 to 18 years from the largest public school in five geographical dispersed regions of Colombia: Cartagena (Atlantic region), Florencia (Amazonic region), La Unión (Andean region) and Quilichao (Pacific region). Data was collected by members of the research team of Functional International Digestive Epidemiological Research Survey (FINDERS), the largest international consortium dedicated to accruing data on children with DGBIs. This study was approved by the Institutional Review Board and Human Subjects Committee of Universidad del Valle of Cali, Colombia and the academic authorities of each school.

Demographic information (marital status of parents, size of household) and information on gastrointestinal (GI) family history and the participant’s past medical history was obtained from the parents. The study included children from third to eleventh grade without a history of organic medical conditions. Children received instructions regarding the study questionnaires completion by the research team at each school. At the end of the instruction session, children were encouraged to ask for clarification on questions or wording that they may have not understood. A member of the research team was present during study completion to assure confidentiality and provide assistance in case the children had difficulties completing the questionnaires. Measures of DGBIs classification (QPGS-III questionnaire), anxiety, somatization, and coping efficacy were collected (see below).

Spanish translation of questionnaires:

All questionnaires were originally developed for use in the English language. To conduct this study, first, the questionnaires were translated into Spanish and adapted to the local language by 3 bilingual physicians of the Functional International Digestive Epidemiological Research Survey FINDERS. The Spanish versions subsequently underwent reverse translation and were assessed for fidelity by comparison with the original English versions of each questionnaire with the translated version. Focus groups of school children and adolescents confirmed their understanding of the terms of the questionnaire. To evaluate the possibility of transcriptional errors, 10% of the records were reviewed and compared with the original forms.

Statistical Analyses

Data from participants who had DGBIs and those who did not have DGBIs (healthy peers) per the ROME III criteria was compared. We further sub-classified those with DGBIs as FAPDs versus non-pain predominant DGBIs. Data analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina). We assessed reliability of the measures in our study using Cronbach’s alpha. In general, a score of more than 0.7 was considered acceptable. Continuous variables were reported as mean ± SD and categorical variables were reported as count and percentage. Comparisons between groups were analyzed using Student’s t-test for normally distributed and Mann–Whitney U or Kruskal–Wallis rank test for non-normally distributed continuous data. Sub-group analysis was used to inspect other factors affecting outcome measures, given the modest sample size. To evaluate group differences, univariate and multivariable analysis was performed between each of the exposure variables of interest and the effect variable. Correlation among various measures was analyzed using Spearman correlation coefficient. P-values of less than 0.05 were considered statistically significant. Item level analysis for all DGBIs measures were analyzed using Chi-squared test and for cell counts less than 5, Fisher’s exact test with themes/sub-groups of interest being identified for comparison between the groups.

Measures:

Questionnaire on Pediatric Gastrointestinal Symptoms–Rome III Version (QPGS-III)²³:

The QPGS-III is a validated questionnaire based on Rome 3 criteria to diagnose DGBIs in children 4–18 years of age. Questions review gastrointestinal symptom location, frequency, and severity as well as related disability and somatic symptoms on a five-point scale. Patients filled the QPGS-III questionnaire for Rome 3 criteria since the Rome 4 diagnostic questionnaire was not validated at the time of data collection.

State-Trait Anxiety Inventory for Children (STAIC)²⁴:

The State-Trait Anxiety Inventory for Children (STAIC) is a measure of general anxiety symptoms in children. It is validated for children ages 9–12 years but can be used in populations under 18 years of age. The child-response questionnaire consists of two 20-item subscales with responses scored on a three-point system. State anxiety (context specific) is designed to measure subjective, consciously perceived feelings of tension, worry, and apprehension that differ in intensity and fluctuate over time, that is, how one feels at a particular moment in time. Trait anxiety evaluates differences between children in propensity to experience anxiety conditions; that is how one generally feels. The scores for each scale can range from 20–60 with higher scores suggesting worse anxiety. In addition to these subscales, we assessed differences in items on the state anxiety measure related to a positive affect versus a negative affect.

Children’s Somatization Inventory (CSI)^{25, 26}:

The Children’s Somatization Inventory (CSI) is a 35-item measure of the severity of bothersome nonspecific somatic symptoms experienced by children and adolescents (ages 8–17 years) and was originally designed for children with recurrent abdominal pain. Participants rate the items on a 5-point scale over a period of two weeks (Cronbach’s alpha = 0.9). Scores can range from 0 to 140 with higher scores indicating higher level of somatization. Although it needs standardization and validation, the endorsement of 13 or more symptoms (corresponding with a score at or greater than 13) is generally considered to indicate clinically significant somatic distress. The scale is further split into sub scales of GI and non-GI related somatization items. In addition to evaluating these subscales, we also conducted an item level analysis and attempted to identify themes in the questionnaires, such as differences in specific pain-related items versus other items between the groups.

Coping efficacy:

We used a 7-item questionnaire that assessed general coping in children derived from the “How I Cope” measure of the Children’s Coping Strategies Checklist (CCSC): Divorce Adjustment Project scale (test-retest reliability ranging from 0.64 – 0.80).²⁷ For the proposed study, participants were asked to rate both their feelings and perceptions around addressing problems, either in the context of the past six weeks or in the future on a 4-point scale. Total coping score was a summation of items 1–7 and ranged from 7–28. Coping within the past six weeks was measured via the summation of items 1–4, with a score range between 0 and 12. Future coping was measured via summation of items 5–7, with a score range between 0–9. During item level analysis, we grouped items that measured past coping with future coping efficacy.

RESULTS

Demographic and baseline characteristics:

Of 1842 participants approached, 152 declined participation and 165 did not meet inclusion criteria. Of the remaining 1525 participants, 29 did not complete questionnaires and were not included in the analyses. Of 1496 children, 281 (19%) met criteria for a DGBIs (mean age 12.9 ± 2.2y, 49.8% females) (Table 1). Children without DGBIs (n=1215) had a mean age of 12.7 ± 2.1y and 50.6% females. The DGBIs group had a trend for more children in the 13–18 years compared with healthy youth (p=0.09). There were no other baseline differences between children with DGBIs and healthy peers (p>0.05).

Table 1.

Demographics

Type	Sample Size	Mean Age	Gender
		Years (SD)	% Female
Children with DGBIs	281	12.9 (2.2)	49.8 %
Children with FAPDs	125	12.8 (2.4)	53.8 %
Healthy Peers	1215	12.7 (2.1)	50.6 %

DGBIs: Disorders of Gut-Brain Interaction, FAPDs: Functional Abdominal Pain Disorders

Of the DGBIs group, 125 had a FAPDs (mean age 12.8±2.4y, 53.8% females): 20 had FD, 56 IBS, 14 abdominal migraine, 14 functional abdominal pain syndrome, 21 FAP-NOS. The others had non-pain related DGBIs: 138 FC, 1 non-retentive fecal incontinence, 4 aerophagia, 6 cyclic vomiting, and 7 had rumination.

Psychological measures in children with DGBIs and healthy peers:

Anxiety:

Children with DGBIs had higher trait (p<0.001) and lower state (p=0.04, Table 2) anxiety than healthy peers. There was no significant difference between DGBIs and healthy peers while assessing positive affect (p=0.16) and negative affect (p=0.22) subscales of state anxiety between children with DGBIs and healthy peers.

Table 2.

Comparison of psychological measures and subscales between children with disorders of gut brain interaction (DGBIs) and healthy peers

Measure		Healthy children (n=1215)	DGBIs (n=281)	Total (N=1496)	P value
		Mean (SD)	Mean (SD)	Mean (SD)
State anxiety (STAIC 1)	Total	45.9 (5.1)	45.3 (5.0)	45.9 (5.1)	0.04
	Positive affect†	18.0 (4.7)	17.6 (4.6)	18.0 (4.6)	0.16
	Negative affect†	25.2 (2.8)	25.0 (2.8)	25.1 (2.8)	0.22
Trait anxiety (STAIC 2)		32.4 (6.3)	34.1 (6.5)	32.7 (6.4)	<0.001
Somatization (CSI)	Total	8.5 (6.7)	11.8 (9.0)	9.2 (7.3)	<0.001
	CSI GI	1.8 (2.2)	2.7 (2.7)	2.0 (2.3)	<0.001
	CSI non-GI	6.7 (5.2)	9.1 (6.9)	7.1 (5.6)	<0.001
	Pain-related items CSI†	4.0 (3.0)	5.2 (3.7)	4.2 (3.2)	<0.001
	Non-pain related items CSI†	7.1 (6.6)	10.3 (8.8)	7.1 (5.6)	<0.001
Coping efficacy	Total	20.0 (3.7)	19.4 (3.6)	19.9 (3.7)	0.02
	Past†	7.1 (2.4)	6.7 (2.4)	7.0 (2.4)	0.02
	Future†	5.9 (1.9)	5.7 (1.9)	5.8 (1.9)	0.06

DGBIs: Disorders of Gut-Brain Interaction; STAIC 1: State-Trait Anxiety Inventory for Children – State Anxiety; STAIC 2: State-Trait Anxiety Inventory for Children – Trait Anxiety, CSI: Children’s Somatization Inventory; GI: Gastrointestinal

^†Subscales identified during the study

Somatization:

Children with DGBIs had higher somatization scores than their healthy counter parts (p<0.001, Table 2 and Figure 1). In subgroup analysis of scales, both GI (p<0.001) and non-GI symptoms (p<0.001) reported on the CSI were higher in those with DGBIs. Those with DGBIs also had higher scores on pain-related (p<0.001) and non-pain related CSI items (p<0.001).

Figure 1. Differences in somatization between children with DGBIs and FAPDs with healthy peers.

Panel A. Total somatization scores between DGBIs and healthy peers.

Panel B. GI CSI subscales between DGBIs and healthy peers.

Panel C. Non-GI CSI subscales between DGBIs and healthy peers.

Panel D. Total somatization scores between FAPDs and healthy peers.

DGBIs: Disorders of Gut-Brain Interaction; FAPDs: Functional Abdominal Pain Disorders; CSI: Children’s Somatization Inventory, GI: Gastrointestinal

^†All data are reported as mean (SD).

P values <0.05 indicate statistical significance.

Coping efficacy:

Children with DGBIs had lower coping efficacy compared with healthy peers (p=0.02, Table 2). Similarly, past coping was lower in those with DBGIs (p=0.02) while there was a trend for future coping to be lower compared with healthy peers (p=0.06).

After adjusting for age and sex, children with DGBIs had higher trait anxiety (p<0.001) and somatization scores (p<0.001) but they had lower coping efficacy (p=0.02) and a trend for lower state anxiety (p=0.06, Table 3) than healthy peers.

Table 3.

Psychological measure comparisons adjusted for age and sex

Measure	State anxiety (STAIC 1)			Trait anxiety (STAIC 2)			Somatization (CSI)			Coping efficacy
DGBIs	LSM	SE	P value	LSM	SE	P value	LSM	SE	P value	LSM	SE		P value
DGBIs (n=281)	45.4	0.3	0.06	34.0	0.4	<0.001	11.8	0.4	<0.001	19.4		0.2	0.02
Healthy (n=1215)	46.0	0.2		32.4	0.2		8.5	0.2		20.0		0.1
Age
8–12 years (n=117)	46.1	0.2	0.003	32.5	0.3	<0.001	9.6	0.3	0.004	19.9		0.2	0.09
13–18 years (n=164)	45.3	0.2		33.9	0.3		10.7	0.3		19.5		0.2
Sex
Female (n=140)	45.5	0.2	0.24	34.2	0.3	<0.001	11.3	0.3	<0.001	19.7		0.2	0.87
Male (n=141)	45.8	0.2		32.1	0.3		8.9	0.3		19.7		0.2
FAPDs
FAPDs (n=125)	45.2	0.5	0.08	33.7	0.6	0.02	12.1	0.6	<0.001	19.5		0.3	0.20
Healthy (n=1215)	46.0	0.2		32.4	0.2		8.5	0.2		20.0		0.1
Age
8–12 years (n=57)	46.0	0.3	0.002	32.3	0.4	<0.001	9.7	0.4	<0.001	20.0		0.2	0.05
13–18 years (n=68)	45.2	0.3		33.8	0.3		10.9	0.4		19.6		0.2
Sex
Female (n=67)	45.4	0.3	0.32	34.1	0.3	<0.001	11.5	0.4	<0.001	19.7		0.2	0.63
Male (n=58)	45.7	0.3		32.0	0.3		9.1	0.4		19.8		0.2

DGBIs: Disorders of Gut-Brain Interaction; FAPDs: Functional Abdominal Pain Disorders; STAIC 1: State-Trait Anxiety Inventory for Children – State Anxiety; STAIC 2: State-Trait Anxiety Inventory for Children – Trait Anxiety; CSI: Children’s Somatization Inventory; LSM: Least Square Means; SE: Standard Error

Correlation between scores in children with DGBIs:

There was a strong positive correlation between total somatization and GI as well as non-GI symptom subscales (r=0.84 and r=0.98 respectively, Table 4). There was a moderate positive correlation between somatization and trait anxiety scores (r=0.50) and between past and future coping efficacy scores (r=0.43).

Table 4.

Correlation between psychological measures in children with disorders of gut-brain interaction (DGBIs)

	Total CSI	CSI GI subscale	CSI non-GI subscale	Past coping efficacy	Future coping efficacy	State anxiety (STAIC1)	Trait anxiety (STAIC2)
Total CSI	1	0.84	0.98	−0.07	−0.08	−0.14	0.50
CSI GI subscale		1	0.70	−0.05	−0.10	−0.12	0.34
CSI non-GI subscale			1	−0.07	−0.06	−0.13	0.52
Past coping efficacy				1	0.43	0.15	−0.21
Future coping efficacy					1	0.17	−0.06
State anxiety (STAIC1)						1	−0.08
Trait anxiety (STAIC2)							1

Significant Pearson correlation (p-value < 0.05) are in bold; STAIC 1: State-Trait Anxiety Inventory for Children

– State Anxiety; STAIC 2: State-Trait Anxiety Inventory for Children – Trait Anxiety; CSI: Children’s Somatization Inventory; GI: Gastrointestinal

Item level analysis for measures between DGBIs and healthy peers:

Supporting information 1 provides details of item level analysis to assess potential differences between children with DGBIs and healthy peers. As expected, children with DGBIs exhibited more GI symptoms compared to healthy peers. Interestingly, they also had worse mental health symptoms and emotional sensitivity than healthy peers. For instance, they reported feeling more upset, worried about making mistakes and what others thought of them, had trouble deciding what to do and felt like crying more often than healthy peers. Moreover, they reported greater psychosomatic symptoms such as “noticing their hearts beating fast” and “having a funny feeling in their stomachs.” They had higher pain and fatigue related non-GI somatic symptoms such as headaches, chest pain, musculoskeletal pain, muscle weakness, gait disturbances and lower energy than their healthy counterparts. Lastly, they reported other extraintestinal symptoms such as dyspnea, hot or cold spells, lump in throat, loss of voice, deafness, blindness, and dysuria. Coping efficacy (general coping to past and future situations) did not differ much between children with DGBIs and healthy peers. However, healthy peers reported increased ability to improve difficult situations in the past six weeks (p=0.02) and in the future (p=0.009) compared to children with DGBIs.

Differences in scores based on demographic characteristics:

Females had higher levels of trait anxiety (p=0.04) and somatization (p=0.005) comparing all DGBIs. Scores differed based on different cities (La Union, Cartagena, Florencia, Quilichao) with state anxiety (p=0.02), trait anxiety (p=0.03), and coping efficacy (p<0.001). However, they did not differ based on age, only child status, separated parents, or nutritional status between DGBIs cases and healthy children (Table 5).

Table 5.

Psychological measures based on demographic and baseline characteristics in children with disorders of gut brain interaction (n=281)

Measure	State anxiety (STAIC 1)	P value	Trait anxiety (STAIC 2)	P value	Somatization (CSI)	P value	Coping efficacy	P value
	Mean (SD)		Mean (SD)		Mean (SD)		Mean (SD)
City
La Union (n=81)	44.8 (5.2)	0.02	34.3 (5.7)	0.03	11.3 (9.2)	0.06	18.5 (3.5)	<0.001
Cartagena (n=83)	46.6 (5.4)		32.4 (6.7)		11.1 (9.7)		20.7 (3.1)
Florencia (n=86)	44.3 (4.6)		35.4 (6.9)		13.9 (8.3)		18.7 (3.7)
Quilichao (n=31)	45.9 (3.9)		34.4 (6.5)		9.5 (8.0)		20.1 (3.6)
Age
8–12 years (n=117)	45.5 (5.3)	0.54	33.5 (6.2)	0.21	11.6 (9.6)	0.75	19.4 (3.9)	0.84
13–18 years (n=164)	45.1 (4.8)		34.5 (6.7)		12.0 (8.6)		19.3 (3.3)
Descendant status
Only child (n=245)	45.2 (5.0)	0.32	34.2 (6.6)	0.53	12.1 (9.2)	0.14	19.4 (3.6)	0.60
Not an only child (n=36)	46.1 (5.3)		33.4 (6.3)		9.8 (7.6)		19.1 (3.5)
Parental status
Unseparated (n=152)	45.2 (5.0)	0.71	33.9 (6.4)	0.57	12.0 (9.6)	0.77	19.4 (3.6)	0.49
Separated (n=129)	45.4 (5.1)		34.3 (6.7)		11.7 (8.3)		19.4 (3.5)
Body mass index
Overweight (n=53)	45.4 (5.3)	0.71	34.4 (7.0)	0.61	10.5 (7.7)	0.44	19.1 (3.6)	0.69
Normal (n=215)	45.2 (4.9)		34.1 (6.4)		12.2 (9.3)		19.5 (3.5)
Underweight (n=13)	46.4 (5.9)		32.4 (6.7)		10.9 (10.1)		19.0 (4.2)
Sex
Female (n=140)	45.0 (5.1)	0.36	34.9 (6.9)	0.04	13.4 (9.6)	0.005	19.5 (3.6)	0.55
Male (n=141)	45.6 (5.0)		33.3 (6.1)		10.3 (8.2)		19.2 (3.6)

STAIC 1: State-Trait Anxiety Inventory for Children – State Anxiety; STAIC 2: State-Trait Anxiety Inventory for Children – Trait Anxiety; CSI: Children’s Somatization Inventory

Internal consistency of measures and subscales in our study:

Anxiety

The internal consistency for state and trait anxiety calculated in our study was found to be 0.75 and 0.83 respectively (Cronbach’s alpha). This is comparable with prior validation studies that reported state anxiety values of 0.82 for males and 0.87 for females, and trait anxiety values of 0.78 for males and 0.81 for females.²⁴ Within the state anxiety measure, internal consistency of items related to positive affect versus negative affect was found to be 0.85 and 0.84 respectively (Cronbach’s alpha).

Somatization

The internal consistency calculated for total CSI was 0.87 (Cronbach’s alpha 0.66 and 0.83 for GI and non-GI CSI scales respectively) and was comparable with prior validation studies (Cronbach’s alpha = 0.9²⁵ and 0.88²⁶ respectively). Cronbach’s alpha for pain related items and for non-pain related items compared to total CSI was 0.91 and 0.98, respectively.

Coping

Cronbach’s alpha for total, past, and future coping efficacy was 0.90, 0.72, and 0.62, respectively.

Psychological differences between FAPDs and healthy peers:

Children with FAPDs had higher trait anxiety (p=0.02) and somatization (p<0.001, Table 5) than healthy peers. There was a trend for lower state anxiety in FAPDs compared with healthy peers (p=0.07). However, coping efficacy did not differ between FAPDs and healthy peers (p>0.05). After adjusting for age group and sex, children with FAPDs had higher trait anxiety (p=0.02), and somatization (p<0.001, Table 3) than healthy peers. There was a trend for lower state anxiety in FAPDs compared with healthy peers (p=0.08) but, coping efficacy did not differ (p≥0.05). Females with FAPD had higher levels of somatization (p=0.04). Scores also differed based on different cities (La Union, Cartagena, Florencia, Quilichao) with state anxiety (p=0.03) and trended to differ with trait anxiety (p=0.08), somatization (p=0.05) and coping efficacy (p=0.08). They did not differ based on age, only child status, separated parents, or nutritional status between children with FAPDs and healthy peers.

DISCUSSION

Disorders of the Gut Brain Interaction result from the interplay of genetic, biological, psychological, social, and environmental factors.^{1, 2} Similar to rates in the US (25 and 13.3% respectively²⁸), 19% children in our study had DGBIs and 8.4% had FAPDs. While this rate of FAPDs was lower than that previously published in South American children, comparable rates have been found for FAPDs in Europe (10.5 and 7.7% respectively).^{4, 17} The aim of this study was to explore the association of psychological outcomes in Latin American children with DGBIs and compare with healthy peers. We found higher rates of trait anxiety, somatization and lower coping efficacy in children with DGBIs compared with healthy peers. While females had worse anxiety and somatization which differed based on geographic location, other demographic and socioeconomic factors did not differ. Importantly, this is one of the largest studies to report psychological functioning outcomes in children with DGBIs and healthy peers.

Trait anxiety was higher in children with DGBIs while state anxiety at any given point of time had a trend to be lower than healthy peers. This is consistent with higher rates of anxiety (40–77%) reported in prior studies^{7–9, 11, 29–34} of DGBIs including cyclic vomiting syndrome (64%),³¹ fecal incontinence (77%),³⁴ rumination,^{29, 30} and nausea.³³ The difference between the two subscales can potentially be explained by the fact that the trait anxiety is generally more stable and generally demonstrated better internal consistency (Cronbach’s alpha > 0.78) and test–retest reliability after 6 weeks.²⁴

One important finding from this study is that individuals with DGBIs differed from healthy peers in terms of their emotional sensitivity (e.g., worry about making mistakes, worry about what others thought of them, feeling like crying) as well as being more attentive to bodily sensations (e.g., greater symptoms of stomach pain in addition to more frequent headaches, lower back pain, etc). Such youth may have a shared risk factor, such as high behavioral inhibition, a pattern of behaviors involving fear/avoidance and over-arousal of the sympathetic nervous system, which is a predictor of the development of both DBGI^{35, 36} and anxiety disorders³⁷ in youth.⁷

Somatization includes experiencing symptoms affecting multiple organ systems that cannot be explained medically.^{9, 32} In addition to endorsing many GI specific symptoms (e.g., abdominal pain, nausea), children with DGBIs reported other mental health symptoms (e.g., worry, feeling like crying) and physical symptoms such as widespread pain complaints including headaches, chest pain, lower back pain, joint pain, and pain in the arms or legs. Thus, an item level analysis allowed us to gain a nuanced understanding of common physical and mental symptoms impacting youth with DGBIs. We found higher total scores, GI, and non-GI somatic symptoms in children with DGBIs than controls. Both GI and non-GI subscales highly correlated in our sample. This is similar to previously reported literature within both adolescents and adults in the US³¹ as well as children in Germany.¹⁷

In addition, we also sub-grouped pain related and non-pain related items which were both higher in children with DGBIs than healthy controls. Somatization has resulted in worse psychosocial and functional outcomes in DGBIs.⁹ Somatic symptoms frequently co-occur with chronic abdominal pain in children³⁷ and sometimes non-GI somatic symptoms precede the diagnosis of functional abdominal pain (FAP).^35,12 In fact, somatization has shown to mediate the relationship between anxiety and symptom severity in adult and pediatric IBS patients.^{9, 10, 32} This is consistent with our findings where somatization scores correlated with trait anxiety.

We also found lower general coping efficacy and lower resilience in handing difficult situations in children with DGBIs compared to healthy controls. Both past coping and future coping efficacy subscales were lower in children with DGBIs. Thus, conflict resolution, assertiveness training or resilience building could be beneficial to improve outcomes for this population. Unlike prior studies, we did not find a strong correlation between general coping efficacy and somatization or anxiety.³⁸ This may be secondary to culturally specific factors such as mental health stigma which may be more prevalent in Latin American countries.^{39, 40}

There is conflicting literature on the impact of demographic and socioeconomic factors on DGBIs in Latin America. Some studies have shown that older children, children with a higher socioeconomic status,²¹ females,²⁰ and children whose parents were separated¹¹ have a greater prevalence of DGBIs. In contrast, another study did not find any difference in the prevalence of DGBIs with race, family composition, parent marital status, or history of DGBIs in the household.²⁰ We found that the DGBIs group had more children in the 13–18 years compared with healthy youth. However, we did not find any difference in prevalence of DGBIs, or score responses with age, composition of household, marital status of parents, or nutritional status. In addition to prevalence, we compared score responses based on different demographic and socioeconomic factors in children with DGBIs. Females had worse trait anxiety and somatization than males with DGBIs. Coping efficacy was lower in La Union and Florencia compared with Cartagena and Quilichao regions. Somatization was higher in Florencia compared with La Union, Cartagena, and Quilichao regions. While the reason for these differences is unclear, these cities are in different regions of the country where there are climatic, social, cultural, and economic differences. They have differences in the number of inhabitants. Some are state capitals and while others are county cities, and these could potentially explain the differences.

FAPDs in particular have been related to negative psychological outcomes like anxiety^{6–8, 10, 12} and depression,^{10, 13, 15, 16} somatization and poor coping. Similarly, we found that children with FAPDs had worse trait anxiety and somatization, and a trend for lower trait anxiety compared with healthy peers.

Anxiety is reported in 42–85% youth with FAPDs and has been related to increased functional disability, somatization, social and academic impairment, heightened pain sensitivity, and long-term persistence of pain.^{7, 41} Somatic symptoms have been associated with greater pain severity and pain-related functional disability, negative pain cognitions, and emotional distress.^{10, 12, 36, 42, 43} In our sample, coping efficacy did not differ between FAPDs and healthy peers unlike all DGBIs. This is contrary to prior studies reporting passive coping responses to be associated with more pain via somatization and either anxiety or depression.^{7, 10} The caveat could be that these studies used pain-specific coping measures which may be more useful while assessing coping mechanisms in FAPDs.

In terms of social and demographic determinants, coping efficacy in patients with FAPDs was lower in La Union and Florencia compared with Cartagena and Quilichao regions while somatization was higher in Florencia compared with La Union, Cartagena, and Quilichao regions. A German study cited higher prevalence of FAPDs within children not living within one household compared with those who had parents in one household.¹⁷ However, we did not find a such a difference within our cohort.

The strength of our study was the large sample size of Colombian youth with a prospective study design which facilitated analyzing multiple aspects of different psychological dimensions. We performed an item level and subscale analyses to infer meaningful comparisons. We used child reported measures in our sample in contrast to caregiver reports. While emotional and behavioral health has been reported to be more impacted in children 6–10 years of age according to caregiver reports,¹⁷ other studies have shown that children may be more sensitive informants of their own anxiety in comparison.⁶ This stresses the importance of screening with child reported measures to avoid missing internalizing symptoms. We included social determinants of health such as parental status, descendant status, and geographical location in our assessments. This may be particularly important and affect health care disparities and access to care in children with DGBIs. DGBIs have been thought to be diagnosed less frequently in lower socioeconomic populations as these patients and families may not often be seen by medical providers.⁴⁴ Our study provided data in the general population demonstrating a more real-life prevalence.

We were limited by the cross-sectional nature of the study allowing for only a snapshot for comparison between children with DGBIs and healthy peers rather than assessing the stability of these measures over time. Limiting the investigation to participants from public schools alone could limit the generalizability of the study. With our current study design, we were unable to compare differences between FAPDs and non-pain related DGBIs. However, this could be the basis for future studies to understand how their differences could affect treatment strategies as well as outcome. The influence of behavioral therapy on psychological measures can also be explored in future studies. In conclusion, our study demonstrated the role of trait anxiety, somatization, and lower coping efficacy in children with DGBIs compared with healthy peers in Latin America. Most treatment strategies in children with DGBIs are focused on gut-mediated therapies, despite widespread extra-intestinal manifestations.⁴⁵ Our study emphasizes the role of psychological functioning in these children, and the need for effective screening and treatments targeted to their improvement which can in turn, improve GI symptoms and optimize outcomes. There may be a shortage of mental health providers or barriers to access in Latin America. However, newer technologies such as internet-delivered therapy, telephone-guided treatments, and mobile applications may be of assistance in such situations to optimize care.

Supplementary Material

Table S1

Supporting Information 1. Item level analysis of measures This table provides item level analysis data on STAIC (1 and 2), CSI, and Coping efficacy measures between DGBIs and healthy peer study groups. P values <0.05 indicate statistical significance. P values were calculated using Chi-square test, except for cell counts less than 5, where Fisher’s exact test was conducted. DGBIs: Disorders of Gut-Brain Interaction; STAIC 1: State-Trait Anxiety Inventory for Children – State Anxiety; STAIC 2: State-Trait Anxiety Inventory for Children – Trait Anxiety, CSI: Children’s Somatization Inventory; GI: Gastrointestinal

Data Availability Statement:

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.