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. Author manuscript; available in PMC: 2024 Dec 1.
Published in final edited form as: Clin Pract Pediatr Psychol. 2023 Dec;11(4):423–434. doi: 10.1037/cpp0000496

Evolution of Parent-Targeted Interventions for Pain-Predominant Disorders of Gut–Brain Interactions: Research and Clinical Practice Considerations

Katherine Lamparyk 1, Jacklyn Stellway 2, Cathleen Turnage 2, Tasha B Murphy 3, Jovita Echere 4, Rona L Levy 3
PMCID: PMC10907008  NIHMSID: NIHMS1932492  PMID: 38433851

Abstract

Objective:

Abdominal pain-related Disorders of Gut-Brain Interaction (DGBIs) in children are best understood from a biopsychosocial model, including particular attention to the child’s environment. Interventions have begun to increasingly target parents as important agents of change in this population. The purpose of this manuscript is to summarize the evolution of parent-targeted interventions for pediatric pain-related DGBIs and provide recommendations for application of the model to clinical practice.

Methods:

A topical review of literature regarding parent-targeted interventions and related factors in the treatment of pediatric pain-related DGBIs was conducted, followed by a discussion of these findings to clinical practice settings.

Results:

A growing body of research has supported parent-targeted interventions in the treatment of pediatric pain-related disorders of gut-brain interactions (DGBI), although translation of these findings to practice settings is complicated by numerous factors. Strategies for obtaining physician buy-in and parental engagement are discussed, as are potential logistical considerations of multiple caregivers, child age, and billing considerations.

Conclusions:

There is a promising and growing evidence-base for parent-targeted interventions for pain-related DGBIs, which have not yet been widely adopted into clinical practice recommendations. Engaging all stake-holders and attending to the nuances of this approach are recommended to successfully apply parent-targeted interventions into clinical practice settings.

Keywords: Parent-targeted Interventions, Disorders of Gut-Brain Interactions (DGBI), Functional GI Disorders (FGID), Functional Abdominal Pain (FAP), cognitive behavior therapy

Introduction

Abdominal pain-related Disorders of Gut-Brain Interaction (DGBIs), previously known as Functional Gastrointestinal Disorders (Schmulson & Drossman, 2017), are best understood from a biopsychosocial model (Reed-Knight et al., 2017) and, more specifically complex interactions within the ‘microbiota-gut-brain axis’ (Thapar et al., 2020). As such, psychological therapies provided alongside dietary and medical interventions are recommended (Thaper et al., 2020) with the strongest support for cognitive behavioral therapy (CBT) interventions specifically (Gordon, et al., 2022). CBT interventions for children with DGBIs have evolved to include increased focus on parents as agents of change, with some treatment models even targeting parents exclusively with promising results in child health outcomes.

Parent involvement in treatment research to improve child emotional, behavioral, or physical functioning is not a novel approach. For example, parent training has been used to address behavioral concerns, improve adherence, or model coping behaviors (Kahhan & Junger, 2021). Despite the growing evidence of parent-targeted interventions in clinical research, however, these findings have not yet been regularly included in clinical recommendations (Santucci et al., 2020) nor, the clinical practice of pediatric psychologists in applied settings. This is presumed to be due to numerous factors including a potential lack of knowledge of current research on this topic, the translation of this empirical research to facilitate both physician and parent buy-in for this novel treatment approach and overcoming potential logistical considerations.

This paper describes the evolution of parent-targeted clinical research trials, in which parents are engaged in treatment to affect their child’s health outcomes in a topical literature review. This is followed by considerations for applying this empirical research to clinical settings. Clinical applications address specific potential barriers including a) obtaining physician buy-in for an appropriate and successful referral process, b) gaining and maintaining parent-engagement for a treatment model that may initially present as counter-intuitive to standard medical interventions, and c) addressing practical and logistical considerations including medical billing and handling varying family and child characteristics. As most research in this area has focused on the biological parent, the term parent will be primarily utilized throughout the paper; however, the authors acknowledge that parenting often occurs in many forms and the application of the parent-targeted research should also be considered for other caregivers assuming a parenting role.

Parent-Targeted Interventions in Functional Abdominal Pain

Parents as Agents of Change

Research studies have increasingly explored the roles of parents in pediatric chronic pain and pain-related DGBIs. Parental chronic pain, and DGBI status specifically, has been associated with increases in children’s GI and non-GI symptoms, catastrophizing, functional disability, and medical utilization (Wilson et al., 2013; Levy et al., 2014). Parents with chronic pain are also more likely to recognize and catastrophize about their adolescents’ pain (Wilson & Fales, 2015).

Beyond the status of parents’ own health, the relationship between pediatric illness complaints and parental coping strategies and responses towards their child’s health concerns has also been demonstrated. The impact of parent catastrophizing on adolescent symptoms and disability extends beyond the contribution of parent pain status (Wilson et al., 2014). Further, parents’ catastrophizing cognitions about their own pain or their child’s symptoms has been shown to predict protective or solicitous responses (behaviors that teach children to adopt the sick role through either positive and/or negative reinforcement), which in turn predicts the child’s symptoms and disability (Langer et al, 2009, Walker et al., 2002), including poor school attendance and overall school impairment (Logan et al., 2012) and depression and anxiety (Sieberg, 2011).

Specific protective or solicitous parenting behaviors have been explored. In a study comparing parental attention versus distraction during an experimental task that induced stomach discomfort, parental distraction was associated with decreased complaints of pain from both healthy children and children with chronic abdominal pain, although notably parents of the children with chronic abdominal pain reported beliefs that distraction would have a greater potential negative impact on their children (Walker et al., 2006). Solicitous parenting has also been shown to be more highly associated with somatic symptoms (Walker et al., 2002) and decreased pain acceptance (Wagoner, et al., 2022). The impact of maladaptive parenting behaviors, including solicitousness but also criticism, discounting of pain, and granting special privileges, may be particularly profound for children and adolescents with higher levels of emotional distress (Claar et al., 2008) and girls with DGBIs (Walker, et al., 2006)

As maladaptive parent responses have been shown to have an impact on child symptoms, interventions have begun to focus on altering parent behaviors. A unified model of parental factors and child outcomes revealed associations among numerous parental factors, including chronic pain status, physical functioning, responses to child pain, and parent psychological factors on child pain and functioning, resulting in recommendations to include parent as targets in the assessment and intervention of youth with chronic pain (Cordts et al., 2019).

Parent-targeted Interventions

Abdominal Pain-Related Interventions

Interventions for functional abdominal pain-related DGBIs have focused largely on Cognitive Behavioral Therapy (CBT) and related cognitive and behavioral approaches, including hypnosis and biofeedback. In a meta-analytic review of psychosocial interventions treating pediatric functional abdominal pain, cognitive behavioral therapy (CBT) has been associated with increased treatment success, including decreased intensity and frequency of pain, although the role of parents in these interventions was inconsistently identified (Gordon, et al., 2022). In a review of eighteen CBT-based psychological interventions for children with chronic pain, four interventions specifically addressing child abdominal pain between 2005 – 2015 included an identified parent-target. The other two interventions focused on biofeedback or hypnotherapy, indicating a likely confounding aspect between the type of the therapy and the inclusion of parents as intervention-targets (Coakley & Wihak, 2017).

Though family-based CBT interventions have not commonly been utilized in this population, some research studies have demonstrated their effectiveness (Robins et al., 2005; Duarte et al., 2006), along with relaxation and guided imagery (van Tilburg et al., 2009). These earlier approaches primarily utilized parents in the supportive or coaching role, with parent-directed materials focused on enhanced education and parallel information provided to the child/adolescent.

Involving parents as agents of change, wherein parents gain skills that can be used to support child health and wellbeing (Kahan & Junger, 2021), has been used in interventions for children with diabetes and sleep disorders (Kichler & Kaugars, 2021; Jemcov, Keys, & Corkum, 2021). The role of parents as change agents in children with DGBIs was specifically addressed later in social learning and cognitive behavioral therapy (SLCBT) approaches (Levy et al., 2010; Levy et al., 2013), which directly focused on decreasing parents’ solicitous responses to their child’s symptoms. In these interventions, treatment sessions lasted 75 minutes. Approximately 20% of time in the session was spent with the parent alone, 20% was with just the child, and 60% of the time included both the parent and the child together (Levy et al., 2010). Results demonstrated improvements in pain and other GI symptoms in children as well as solicitous behaviors in parents (Levy et al., 2010), with these results mediated by a reduction in parent threat appraisals (Levy et al., 2014).

Expanding upon these outcomes, Levy et al. (2017) conducted a RCT comparing two brief (three session) social learning CBT interventions targeting parents alone (telephone and in-person arms) to an attention placebo condition. One rationale for testing the remote (telephone only) condition was to address logistical barriers of family-based, in-person care. Results demonstrated improvements in parental solicitousness, pain threat, parent catastrophizing, and children’s coping skills, functional disability, pain behaviors, and healthcare utilization for both telephone and in-person SLCBT interventions, as compared to the attention control condition. No differences were demonstrated in the severity of children’s abdominal pain.

Additional RCTs have since included parent-targeted interventions as part of the overall treatment, but no additional parent-only interventions for functional abdominal pain have been identified. Nieto et al. (2019) evaluated a web-based intervention with 50% of the program targeted toward parents including education, goal-setting, parental responses, and cognitive restructuring as primary components in a parallel curriculum to that provided to the children and adolescents. Compared with a wait-listed control arm, the intervention group experienced significant decreases in pain frequency (but not pain severity) and depressive symptoms, and significantly increased child quality of life. Notably, parents’ solicitous behaviors and promotion of well-behaviors were the only process variables that showed significant change, versus child-focused process variables.

Pas et al. (2020) included parents as observers in the child-targeted intervention of hypnosis with and without additional neuroscience pain education, with improvements on parental pain catastrophizing along with child’s functional disability and pain sensitivity in both groups. Additionally, Walker et al. (2021) included parents in a CBT protocol for treating functional abdominal pain, focusing on the impact of patients’ pain-related psychological characteristics on treatment effects versus parent characteristics.

Other Chronic Pain Parent-Targeted Interventions

Beyond DGBIs, a systematic review of psychological interventions specifically targeting parents of children and adolescents with chronic illness, including chronic pain, found that both parenting behaviors and parent mental health demonstrated both immediate and long-term improvement from these interventions (Law et al., 2019). The impact on child outcomes, including behavior/disability and medical symptoms, was variable, with a greater improvement noted for CBT modalities over problem-solving therapies (Law et al., 2019). This review included any psychological treatment designed to change parental cognition or behavior, including those that also involved a child-targeted component to the treatment.

Of the studies focused on treatment of chronic pain, two include parent-only targeted interventions (Levy et al., 2017; Palermo et al., 2016), the first of which focused solely on functional abdominal pain and has been discussed earlier. Palermo et al. (2016) evaluated a parental problem-solving skills training intervention on children diagnosed with abdominal pain along with other pain conditions (i.e. headache, musculoskeletal). The intervention targets included improving parental mental health symptoms, physical health and well-being, and parenting behaviors, and child outcomes of pain, emotional functioning, and physical functioning. The intervention was delivered over 4 – 6 individual sessions lasting 60-minutes. A telephone option was available but was minimally utilized (14% of total sessions) and most sessions occurred in-person. Treatment results demonstrated improvement in parental mental health and pain catastrophizing and child mental health factors, including child’s pain-specific anxiety. There was no significant improvement in children’s pain intensity.

Since the systematic review by Law et al. (2019), two additional studies have been identified (Lee, et al., 2021; Burns et al., 2022), which both evaluate a parent-targeted intervention that was implemented while children and adolescents were participating in a separate intervention. Lee et al. (2021) described the development of a parent-targeted group intervention for parents of children being treated through an interdisciplinary pediatric chronic pain clinic. The CBT intervention consisted of 5 weekly 2-hour sessions. Treatment results demonstrated improvements in parental protectiveness, monitoring, minimizing behaviors and parental psychological flexibility. Impact on child behaviors or symptoms was not measured. Burns et al. (2022) evaluated the specific impact of the parent-targeted intervention delivered in a single-day intensive 6-hour format focusing on education, skills training, and social support. Treatment results demonstrated improvements in parents’ pain catastrophizing and child’s pain self-efficacy compared to controls. There was no significant change in parenting protectiveness behaviors or parent-report child pain severity.

Mechanism of Change in Parent-targeted Interventions

The specific mechanisms of change in parent-targeted interventions have been more recently examined, focusing on variables of parental protectiveness/solicitousness, perceived threat of pain, and parent catastrophizing mediating the effects of CBT-related interventions on child symptoms. Parents’ pain catastrophizing has been the most consistent change mechanism, mediating treatment effects on child disability, school absences, healthcare utilization, and child quality of life (van Tilburg et al., 2021; Lalouni et al., 2022).

Other mediating variables have demonstrated more inconsistent results. A reduction of parental perceived pain threat has mediated treatment effects for child GI and pain symptoms severity, child disability and quality of life but not school absences or healthcare utilization (Levy et al., 2014; van Tilburg et al., 2021). Parental protectiveness and solicitousness has mediated intervention effects on child disability and school absenteeism in one intervention study (van Tilburg, 2021), but not another (Lalouni, 2022).

A different perspective has focused on the prospective reciprocal relationship of child and parent treatment factors. Calvano & Warschburger (2022) evaluated both child and parent outcomes over the course of treatment and follow-up time points. An improvement of parental personal time-burden at post-treatment was predictive of improved pain and impairment in children at follow-up time-points, suggesting that addressing parental personal time burden may be an additional treatment target of which to focus.

Applications of Parent-Targeted Interventions in Clinical Practice

Clinically, parent-targeted interventions may offer both practical and emotional benefits, particularly when offered separate from patient-targeted interventions. Parents have reported emotional benefits in working directly with a psychologist on their child’s functional pain, including validation, support, and emotional containment (McGorgan, 2022). The ability to speak openly about parenting-specific or adult-oriented material provides additional value to parent-only targeted interventions. Practically, parents have reported ease of scheduling and improved accessibility when seen separately from their children to numerous authors of this manuscript. Despite these benefits, providing parent-targeted interventions can pose challenges related to physician buy-in, parent-engagement, and logistical considerations.

Physician Buy-in

Physician Education

In clinical practice settings, physicians are often the first point of contact for children presenting with pain-related DGBIs and, ideally, provide the introduction of psychological treatments. Therefore, it is critical that physicians appreciate behavioral treatments in general and parent-targeted interventions more specifically. While medical education and physician training is perhaps the first step in this development, historically, the medical system ethos has focused on the patient-directed assessment and intervention, with less emphasis on a holistic conceptualization of an individual’s disease that would include environmental factors such as parenting. Education from a biopsychosocial framework, including the impact of environmental factors, is useful to improve physician’s support for incorporating families into the evaluation and treatment, let alone parent-targeted interventions. Fortunately, this conceptualization has begun to shift with the movement towards population-based and person-centered care, including an increased understanding of the value and importance of a patient’s environment.

Parent-directed Communication

Following the physician’s own education and understanding of parent-targeted interventions, it is important to consider the medical provider’s communication with families regarding these treatments: what information are they sharing with families prior to referring to GI psychology and how are they delivering this information? Despite there being long history of psychological treatments for disorders of the brain-gut interaction, a medical provider’s understanding of the role of psychology and non-pharmacological interventions for treatment will inform this process. Anecdotally, the quality of this conversation exists on a continuum and parents present to their first psychology appointment with a variable understanding of the role of behavioral interventions in the treatment of DGBIs. While some families may understand the rationale well, many families have an inaccurate understanding of psychological treatment of pain (e.g., “The provider said it’s all in my child’s head”, “Stomach aches are caused by anxiety, and you’re supposed to help us with anxiety.”). While understanding can impact both treatment initiation and success, this can be especially impactful for parent-targeted interventions that rely heavily on parent buy-in.

Modifying the language used by physicians in their education of patients and caregivers can be a valuable strategy at improving parent buy-in and increasing engagement. A well-articulated and informed explanation for parent-targeted treatment should set clear expectations for families. Although these communication practices are ideally developed during medical training, psychologists who work collaboratively with physicians are well suited to improve this process by encouraging physicians to utilize more parent-targeted language. For example, “A psychologist will teach your child AND YOU strategies for coping.”, or even more directly, “Research has shown that helping parents directly can lead to a reduction of symptoms and disability.”

By evaluating the medical space more broadly, potential factors impacting physician buy-in for parent-targeted treatments can be identified. For example, the integration of psychology within a medical setting can vary depending on a variety of factors including logistical challenges, cultural differences, funding, and personal or relational factors. Regardless, given the biopsychosocial etiology of DGBIs, research supports an interdisciplinary approach to treatment. Compared to standard care, multidisciplinary settings that consider the interactions between biological, psychological, and social processes that impact symptoms and treatment has been shown to improve short-term outcomes of patients diagnosed with DGBI (Reed-Knight, 2016; Bray, et al. 2022). The nature of interdisciplinary patient care supports the conceptualization of pediatric patients as individuals living in a broader context that impacts their disease progression and treatment. As such, the ability to engage in parent-targeted interventions is improved when the treatment environment values contributing environmental factors, such as maladaptive parenting responses.

Physician-Psychologist Relationship

Even in the most ideal settings in which providers work on a multidisciplinary team within a collaborative treatment model, a valued relationship between the psychologist and each medical team member can improve acceptance of behavioral treatment modalities in general, and parent-targeted interventions specifically. A level of trust is required for the medical provider to make treatment decisions based on interventions they may not entirely understand or are outside their standard methods of practicing, which is especially true for behaviorally based parent-targeted interventions. The historical hierarchical nature of providers in medical settings and cultural norms of “sharing” a patient with a provider from another discipline may further complicate this dynamic. Fortunately, pediatric psychologists are well-suited to navigate interpersonal challenges, understanding these relationships from a systems-perspective and utilizing empirical evidence to guide decision-making.

There is a substantial body of literature exploring the relationship between psychologists and physicians the area of pediatric primary care, where pediatricians and psychologists have been moving towards models of collaborative and integrated practice. Some suggested tips for successful collaboration include effective and frequent communication, open minded-ness, continued growth through learning, and knowing one’s own and other’s professional functions and roles. Interdisciplinary relationships where shared decision making is at the forefront of patient care requires negotiating conflict and respecting team contributions (Chahin, Apple, and Dickson, 2022; McDaniel et al., 2014).

Parent Engagement

Evaluation & Rapport Building

Motivation to engage in parent-focused interventions is likely complex and influenced by a variety of factors, including parent rapport and trust in their medical and psychological providers, beliefs about their child’s pain and associated treatment expectations, and other individual characteristics including their own anxiety and hopelessness related to their child’s pain (Drossman et al., 2021). It is important for providers to assess each of these factors to better understand and improve parent buy-in with treatment. When assessing patient and family engagement with recommendations after a pediatric multidisciplinary pain treatment clinic, “negative attitudes and beliefs about the treatment recommendations” has been found to be the most frequent barrier to follow through across psychology, physical therapy, and medical recommendations (Simons et al., 2010). As expected, a family’s familiarity and positive expectations for psychological interventions were associated with better adherence to psychological treatment recommendations. Assessment of parents’ understanding and beliefs about pain can occur through provider-parent discussions or utilizing measures such as the Concept of Pain Inventory (COPI; Pate et al., 2022).

Psychologists working directly with parents of a child with abdominal pain are in a unique position to not only assess but also improve parent engagement. While this begins with the first interaction, it can be assumed that for some parents it may take time. Compared to medical providers, psychologists involved in parent-targeted treatment typically have more frequent and consecutive touch points with parents, where rapport can be established and a relationship based on trust can be formed. In addressing barriers in treatment stemming from parent engagement, the psychologist is encouraged to reflect on the importance of validating and normalizing parent concerns, especially as the recommended parent interventions may be counter-intuitive to parenting behaviors used in the past. When challenges arise, the psychologist may find it useful to relate to parents by using an example specific to the parent’s own life experience. (E.g. Can you [parent] identify a time in your life when your own pain was influenced by something occurring in your environment?). Working alongside parents to empower them as agents of change will be an essential component of treatment.

Education

While the empirical research supports the importance of parenting behaviors on pediatric abdominal pain symptoms and treatment outcomes, communicating these findings to caregivers can be challenging for a variety of reasons (Drossman et al., 2021). However, in order for parents to be engaged in parent-focused treatment, a rationale for their direct involvement as agents of change is essential. Pain science education includes a “basic understanding of the scientific basis for persisting pain, the biopsychosocial nature of pain, and the potentially large disconnect between pain and tissue damage” (Pate et al., 2022, pg. 3). Assessing parents’ concept of pain and understanding of the brain-gut connection offers an important framework for providing said education. Education of pain neuroscience and brain-gut connection must be presented in an acceptable and accessible format to parents, with attention to both health literacy and biomedical biases which may otherwise impede initial engagement with multidisciplinary teams (Coakley & Wihak, 2017). Understandably, parents may be surprised to learn that treatment recommendations involve modifying parent behaviors. Thoughtful communication regarding the rationale for parent-focused cognitive and behavioral interventions, while intentionally avoiding language that would suggest blame or shame, can decrease feelings of defensiveness and potentially improve the parent and provider relationship.

Contextual Factors

In addition to poor initial experiences in their pain-treatment journey or poor understanding of pain science education and rationale of treatment, contextual factors also present as barriers to parent engagement in a child’s pain treatment. Research exploring engagement in child mental health treatment more broadly has identified numerous factors including poverty, stress levels of families and parents specifically, single-parent status, matching treatment modality to parental preference, and general family factors including discipline strategies, family cohesion, and family organization (Goalan et al., 2010). While parent engagement in children’s mental health more broadly is beyond the scope of this paper, medical and mental health providers treating pediatric patients with DGBI should be aware that cultural, familial, societal, and environment factors can also present as barriers to parent-focused interventions. These factors should be considered in provider-family communication, identifying barriers to engagement, and treatment recommendations.

A pediatric psychologists’ own individual factors may also contribute to parent engagement in treatment. While little is known about the impact of clinician factors within the DGBI population specifically, literature from child and adolescent mental health more broadly supports the influence of the therapeutic alliance on family engagement and retention (Ingoldsby, 2010). Alternatively, recent research has found that clinicians may have more concerns about therapeutic alliance than their patients (Lopez et al., 2019).

Specific therapist factors, including therapist level of experience, may also impact alliance and outcomes in child and adolescent mental health treatment (Ryan, Berry, & Hartley, 2021). While the research on the impact of psychologist experience on patient outcomes has been mixed (Heinonen & Nissen-Lie, 2019), early career pediatric psychologists may be at a disadvantage in this complex multi-layered situation. The authors of this manuscript have noticed how a psychologist’s perceived confidence and competence in this area can increase with time, experience, and professional development.

Developing experience working on a multidisciplinary treatment team, increasing comfort with knowledge of the microbiota-gut-brain axis complexities, and building confidence in effectively engaging parents who may be older or at a different stage of life than themselves may also be helpful. When taken together, these suggestions will aid a psychologist in developing comfort, expertise, and integration to improve working relationships with parents in the delivery of DGBI treatment.

Logistical Considerations

Multiple Caregivers

Parent-targeted interventions may be further complicated in situations involving parental-separation, split-custody arrangements, and other situations that result in multiple caregivers or multiple environmental influences. Even in single-home, intact families the caregiver-responses to a child’s pain and GI symptoms are often highly variable and communication or alignment between family members may be challenged. While research on the impact of parents in DGBIs is often practically limited to one parent, more general research has demonstrated differences in how parenting is affected by both gender (Morawska, 2020) and the parents’ relationships, with a risk of triangulation impacting parental overprotectiveness (van Petegem et al., 2022). It is therefore important for psychologists to assess and address parent engagement for all parents and/or caregivers that have a role in influencing the child’s environment, recognizing that there will likely be variability. As much as possible, providing consistent interventions with as many caregivers as possible is recommended. When it is not feasible to provide parent-targeted interventions to all applicable caregivers at the same time, psychologists may consider offering separate sessions or utilizing handouts or written summaries to communicate with all involved caregivers.

Child Age

The age of the child with a DGBI is important to consider regarding when and how parents are engaged in treatment. Parent-targeted interventions for a variety of conditions have generally focused on younger children, with some research indicating younger children demonstrate improved outcomes compared with older children in parent-targeted intervention studies (Dishion et al., 1992; Baumel et al., 2016). Broadly speaking, parents have more control over their child’s physical and social environment when they are younger and the environmental influences broaden and shift as children begin attending school, spend more time outside the home environment, and look towards peer influences in adolescence (Collado et al., 2019). This would suggest that parent-targeted interventions may be both less practical and less efficacious with older children and adolescents; however, it may be worthwhile to also consider this on an individual basis as many older children and adolescents with longstanding chronic pain do not fit into this broad conceptualization. The functional disability that often impacts adolescents with chronic pain and DGBIs (Wojtowicz & Banez, 2015; Gauntlett-Gilbert & Eccleston, 2007) may also limit the external behavioral influences, and therefore may indicate a more persistent need and benefit from including parents as a focus of treatment.

Billing

Billing for Individual Psychotherapy (CPT® codes 90832, 90834, and 90837) requires that the patient be a part of the session. When this is not the case, Family Psychotherapy without the patient present (CPT® code 90846) can be utilized. Each of these psychotherapy codes require that the service is for the treatment of a DSM diagnosis of a mental health condition (APA Services, 2022), which is not always the case in patients presenting with a functional abdominal pain disorder.

When services address symptom management or adjustment to a physical health issue, Health and Behavior (H & B) service codes can be utilized. These codes include assessment and intervention in individual, group, and family formats for services that treat the behavioral, social, and psychological factors in the management of physical health problems. Unfortunately, the only H&B service not covered by Medicare is the H&B Family Intervention without the Patient Present (CPT® code 96115) (APA Services, 2016).

It is important for clinicians to be mindful of each of these sets of codes and associated rules when considering billing and reimbursement for services of parent-targeted interventions. Often a patient being treated for a functional abdominal pain condition will also meet criteria for a DSM mental diagnosis, which would allow for the reimbursement of parent-only interventions. In situations where this is not the case and H&B codes would be used, then adjusting the sessions to include the patient along with the parents would be recommended from a reimbursement standpoint.

Conclusion

Additional logistical or practical considerations related to potential contraindications for parent-targeted treatment may be considered by practicing psychologists but require further study for future clarity in clinical decision making. Research on the ideal age for parent-targeted interventions has suggested that older children and adolescents would reap less benefits from this intervention modality; however, further research is needed to determine more specific age limits and if these recommendations are applicable to the DGBI population where adolescent-autonomy is more likely be thwarted by nature of their diagnosis. Further, while the authors considered potential contra-indications for parent-targeted interventions to include significant family dysfunction, it may also be the case that these situations would reap the most benefit from a systems-focused intervention. Research on the impact of baseline family functioning on treatment outcomes would help to guide clinical decision making in these circumstances. Finally, while pediatric psychologists are trained and generally adept at biopsychosocial education and multidisciplinary relationship-building, further empirical guidance on how to effectively apply these skills in practice settings could aide in advancing our fields’ clinical utility.

While there is a promising and growing evidence-base for parent-targeted interventions in clinical research trials, clinical practice recommendations have not yet widely adopted this intervention modality and therefore parent-targeted interventions are not fully utilized. Applying control trial research to a clinical practice setting requires pediatric psychologists to creatively and flexibly utilize their broader set of psychological training skills to build engagement and buy-in from all necessary stakeholders, while critically attending to the practical considerations of incorporating these interventions into their own settings.

Implications for Impact Statement:

The role of parents in treating children with pain-related Disorders of Gut-Brain Interaction (DGBIs) has been an increasing area of study. This paper summarizes the research on interventions for DGBIs that focus on parents as agents of change and provides practical considerations for applying this research to clinical, “real-world” settings.

Funding Source:

National Institute of Nursing Research, Project Number: 1 R01 NR 016786-01A1

Footnotes

The authors have no known conflict of interest to disclose.

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