Rethinking psychological treatment targets for pediatric rumination syndrome: Clinical implications from a case series analysis

Abstract

Rumination syndrome (RS) is a common pediatric disorder of gut–brain interaction. However, a dearth of research on efficacious treatment to help guide clinical decision‐making remains. Thus, relying on well‐established treatment recommendations for other conditions with similar mechanisms or symptom profiles may be helpful; for example, conceptualizing RS treatment targets to address it as a “tic disorder of the gut” could be beneficial. To demonstrate the clinical utility of this conceptualization, we presented two cases that provide broad implications for treating pediatric RS. In both cases, akin to pediatric tic and related disorders, cognitive distress and physical discomfort were alleviated temporarily by rumination episodes. Thus, we recommend a targeted diagnostic assessment, including a functional analysis incorporating a transdiagnostic evaluation of symptoms. Close comanagement with specialty physicians and psychologists is also highly recommended. The patients represent complex yet standard cases seen in pediatric psychology outpatient clinics, suggesting the clinical utility of implications for psychologists and allied health professionals.

What is Known

• Rumination syndrome (RS) is the second‐most common pediatric disorder of gut–brain interaction.

• Current evidence‐based treatment for pediatric RS typically includes behavioral interventions and psychoeducation of contributory mechanisms maintaining the syndrome.

What is New

• Pediatric patients diagnosed with RS within the current case series experienced symptoms similar to pediatric tic and related disorders.

• For clinical practice, proactive consideration of symptoms through a transdiagnostic and multicultural framework may help improve intervention efficacy.

1. INTRODUCTION

Rumination syndrome (RS) is the second‐most common pediatric disorder of gut–brain interaction (DGBI), characterized by effortless, repetitive, and painless regurgitation of food associated with spitting or re‐mastication and re‐swallowing of the regurgitant. ¹ , ² Although the exact etiology of RS remains uncertain, ³ a biopsychosocial model has been recommended to understand its etiology and pathogenesis. ⁴ Functional impairments from RS include social ostracization, emotional distress, inflammatory responses, electrolyte imbalance, weight loss, dental erosion, and malnutrition. ⁵

Consistent with a biopsychosocial framework, treatment includes behavioral and cognitive interventions as well as psychoeducation about contributory mechanisms maintaining RS. Specifically, diaphragmatic breathing effectively reduces the frequency and intensity of symptoms by inducing parasympathetic arousal and allowing the abdominal wall to relax. ⁶ Additional interventions for RS include functional analysis of food regurgitation (i.e., identification of antecedents and consequences to rumination), utilizing competing responses to delay/prevent regurgitation (e.g., humming, singing, reading aloud, and chewing gum), cognitive restructuring, relaxation strategies, and providing positive reinforcement for use of competing responses. ⁴ , ⁶ Coordinated care, including medical (e.g., pharmaceutical and surgical options) and psychological interventions (e.g., diaphragmatic breathing paired with habit reversal, cognitive restructuring) may be indicated as they relate to the complexity and severity of impairment. Care may be provided in various settings, including outpatient clinics, intensive outpatient programs, and/or inpatient admission. ⁷ , ⁸

With the lack of research on pediatric RS treatment, relying on well‐established intervention recommendations for other conditions with similar mechanisms or symptom profiles may be useful. Thus, conceptualizing RS treatment targets to address it as a “tic disorder of the gut” could be beneficial. For example, diaphragmatic breathing is associated with the greatest effectiveness when paired with re‐swallowing, which acts as a competing response that helps individuals resist the urge/signal to ruminate until the urge dissipates, similar to the treatment for tic disorders. To demonstrate the clinical utility of this conceptualization, we present a case series describing interventions and outcomes for patients with RS in a psychology outpatient clinic colocated in a gastroenterology (GI), hepatology, and nutrition division within a pediatric academic medical center. In doing so, we propose a novel conceptualization and recommendations for biopsychosocial treatments of RS for psychologists and allied health professionals.

2. METHODS

Appropriate steps were taken to adhere to current ethical standards regarding case series/reports. For example, the research team reviewed electronic medical records and adhered to applicable confidentiality/access laws.

2.1. Ethics statement

The Institutional Review Board through Indiana University School of Medicine classified this project as exempt. The study team obtained verbal and written permission from patients and their families, and the case‐study authorization of consent was printed and securely stored.

3. RESULTS

3.1. Patient‐A

Patient‐A (see Table 1) was referred at 15 years of age for outpatient pediatric psychological intervention for treatment of RS with daily food regurgitation since age 8. Before referral, she received medical care from three separate GI clinics spanning 4 years, underwent extensive medical workup, and attended both disordered eating and RS partial hospitalization programs. While she restored and maintained a healthy weight, she still experienced 80+ rumination episodes per day. Patient‐A endorsed functional impairment in academic attainment; although highly motivated, she reported chronic concentration and memory challenges. At the initiation of outpatient psychology treatment, Patient‐A reported feeling discouraged as attempts to keep food down were often unsuccessful. In developing a multifactorial conceptualization of barriers to treatment adherence, Patient‐A identified experiencing medical trauma and lack of trust in the medical system related to many years of misdiagnosis and unsuccessful/painful treatments, contributing to learned helplessness. Additionally, Patient‐A disclosed that she experienced obsessive thought patterns with accompanying compulsive behaviors since she was 8 years old. She was spending over half her day thinking about and engaging in a variety of repetitive behaviors to achieve a “just right” feeling and was subsequently diagnosed with moderate‐to‐severe obsessive‐compulsive disorder (OCD); she also presented with diagnoses of psychological factors affecting other medical conditions and trichotillomania. Together, co‐occurring mental health concerns limited time and ability to effectively monitor and implement RS interventions. Multiple interventions were employed to address her medical trauma, obsessions/compulsions, rumination, and anxiety/stress (Table 2). She also trialed baclofen, which is still under investigation but has been reported to reduce the frequency of regurgitation episodes in some pediatric patients with RS ⁹ ; however, it was discontinued after minimal benefit. After treatment of trauma and OCD, Patient‐A endorsed an improved response to psychological interventions targeting RS symptoms and demonstrated functional improvement and decreased healthcare utilization, noting that “rumination persists as a backdrop of her life.”

Table 1.

Patient demographic characteristics.

Characteristic	Patient‐A	Patient‐B
Age at referral (years)	15	14
Race	White	South Asian
Language	English	Bilingual
Gender/sex	Cisgender female	Cisgender female
Prior mental health treatment	Yes	No
Daily medicines prescribed	Yes	Yes
Before treatment onset	Hydroxyzine 10 mg	Famotidine 40 mg
	Melatonin 3 mg	Lansoprazole 30 mg
	Omeprazole 20 mg	—
During treatment	Fluoxetine 30 mg	Baclofen 5–10 mg
	—	Fluoxetine 30 mg
Prior rumination treatment	Yes	Noa
Type	Partial hospitalization	Outpatient
Daily rumination episodes at onset	80	50
Visit interval (weeks)	2–4	2
Total visits	18	10

Abbreviations: GI, gastroenterology; DGBI, disorders of gut–brain interaction.

^aPatient‐B initiated rumination treatment at age 14, received GI psychology‐focused intervention, and then engaged in treatment within a specialty clinic for tic, anxiety, and compulsions, after which she re‐established care and resumed receiving DGBI‐specific intervention every 2 weeks for 5 months.

Table 2.

Treatment components.

Intervention modality	Patient‐A	Patient‐B
	Total Tx	Initial Tx	Subsequent Tx
Psychoeducation		X
Functional assessment of rumination			X
Re‐swallowing	X	X
Diaphragmatic breathing	X	X
Food trials		X
Biofeedback		X
Adherence promotion	X
Stress management	X
Trauma narrative	X
Cognitive‐behavioral	X	X	X
Self‐efficacy enhancement			X
Motivational interviewing techniques	X		X
Acceptance‐commitment	X		X
Referral to specialty mental health services (e.g., exposure therapy)	X	X

Abbreviation: Tx, treatment.

3.2. Patient‐B

Patient‐B (see Table 1) was referred for outpatient pediatric psychological intervention at 14 years of age due to rumination episodes occurring 50+ times per day. At the time of intake, Patient‐B had received no prior mental health treatment. Outpatient treatment initially focused on psychoeducation about rumination and skill acquisition (Table 2). Patient‐B was able to master behavioral skills for the management of rumination and reported subjective improvement in symptom impairment; however, she demonstrated inconsistent treatment engagement, resulting in the discontinuation of intervention and referral to outpatient therapy for management of generalized anxiety, with ultimate diagnoses of OCD and psychological factors affecting other medical conditions. After 2 years, Patient‐B re‐engaged with a pediatric psychologist to treat RS symptoms. Of note, she was also prescribed investigational drugs such as baclofen as well as antacid and related medications (i.e., famotidine and lansoprazole) as pharmacotherapy, resulting in subtle improvement. The re‐initiation of treatment began with a functional assessment of rumination symptoms. Patient‐B regularly identified catastrophic, inflexible, and obsessive thinking, especially related to school performance and health. She reported more difficulty managing rumination when she felt particularly “stressed.” Patient‐B identified cultural factors leading to hesitancy around medical intervention and prioritization of academic achievement over other aspects of life. As such, subsequent sessions focused on highlighting the role that rumination plays in Patient‐B's life, including the possibility of rumination interfering with Patient‐B's goals (e.g., moving to attend a prestigious college) as well as identifying links between her anxiety and rumination symptoms. At discharge, Patient‐B articulated that she had “changed her way of thinking” about the transient nature of stressors and endorsed less than 20 episodes of rumination daily.

4. DISCUSSION

This brief series presents two cases that provide broad clinical implications for treating pediatric RS, including the following:

• 1.In both cases, akin to pediatric tic and related disorders, cognitive distress and physical discomfort were alleviated temporarily by rumination episodes. Thus, for future clinical care, we recommend targeted psychological assessment, including a functional analysis that incorporates transdiagnostic evaluation of co‐occurring predisposing, precipitating, perpetuating, and protective factors as well as developing patient goals through a multicultural framework.
• 2.Psychologists and allied medical/mental health professionals should also incorporate motivational interviewing techniques to promote engagement with psychotherapeutic intervention since patients may present with ambivalence and/or lack of insight into factors influencing and maintaining RS.
• 3.It would benefit patients with RS if there were improved access to care via pediatric psychologists with competence in gastrointestinal‐related issues and expertise in childhood developmental and psychopathological conditions (e.g., anxiety, eating, or neurodevelopmental disorders, etc.) that may co‐occur or maintain RS symptomatology.
• 4.Close comanagement and prioritization of coordinated treatment with specialty physicians and psychologists are also highly recommended.

Limitations of the current case study include the small number of participants, which limits generalizability. However, the patients represent complex, yet standard cases seen in GI psychology outpatient clinics, suggesting the clinical utility of implications for psychologists and allied health professionals. Future research should investigate longitudinal outcomes of patients with RS using the conceptualization recommendation indicated in the current case series.

5. CONCLUSION

Pediatric RS is a burgeoning research area. Pediatric psychologists can contribute by appropriately selecting, administering, and monitoring treatments for RS. Psychological interventions may be enriched by proactively considering transdiagnostic factors, such as symptoms that are also common in tic and related disorders, to help tailor interventions and ultimately reduce severity.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Piña‐Anastasiadis WA, Gloe LM, Johnson‐Kwochka A, et al. Rethinking psychological treatment targets for pediatric rumination syndrome: Clinical implications from a case series analysis. JPGN Rep. 2025;6:382‐386. 10.1002/jpr3.70074