Chronic abdominal pain (CAP) is a constant or recurrent pain that lasts for more than three months. Abdominal pain is the most common GI symptom, and it is a leading cause for inpatient and outpatient visits. International prevalence is between 22% and 25%, with more women reporting abdominal pain than men (24% versus 17%). Many diseases can cause CAP. Treatments include celiac plexus neurolysis, celiac plexus blocking agent, various pharmacologic treatment, spinal cord stimulation, and lifestyle modifications.

Now we are really in a rhythm. The only thing that changes from now to the end of the treatment are the characters, related body sensations, and lessons about the body. The Zoomies and Shakies are the first session in which we really focus on emotional experience. If you think of an over-simplified classification system for emotions in terms of valence and arousal, then Session 4 focuses on high-arousal negative emotions (e.g., fear, anger). Betty the Butterfly, Tommy the Thunderbolt, and Julie Jitters are sample characters in this session. A sample investigation would be to try several activities and compare them to see which brings out the most butterflies. In this way, we directly alter the way that children are experiencing their emotions – rather than running or being afraid of them, they are actively seeking these emotional experiences in a playful context.

In this final session, we celebrate! We have a formal graduation ceremony complete with a certificate honoring the graduate of the FBI-Academy, Tummy Pain Division. In the context of the clinical trial, this was celebrated with the award of a memory card game that had a match for every new character that was learned throughout the treatment. This game served as a fun reminder of all that was learned in a way to ensure that the children and parents remember the characters and help maintain their progress towards emotion awareness, self-regulation, and reduced distress about pain. This last chapter also serves as the beginning of the journey for clinicians. We provide suggestions for how the FBI intervention can be integrated into mental health and pediatric primary care practices. We introduce the reader to all the online resources, including our online support community, and invites them to participate in online supervision groups for providers and support groups for families. We are excited to continue this lifelong investigation as we all learn to trust in ourselves and wonder at the wisdom of our bodies.

Clinicians begin the Explosions! with familiar routines: a Henry Heartbeat activity, reviewing homework and adding data to the Body Map, and a new ritual: checking in with our energy and seeing if we need a snack. New characters related to processes of eating and digesting food are introduced: Victor Vomit, Gaggy Greg, Gordon Gotta Go. Investigations explore activities that may induce gagging. Equipped with garbage cans and paper towels, families are prepared for any result of these disgusting but fun investigations. Body Brainstorms explore questions such as who passes the most gas in the family and what foods produce the smelliest farts. Clinicians introduce a decision-tree in the Body Clues Worksheet that helps family members notice their body sensations, figure out what those sensations may mean (e.g., is Betty the Butterfly telling me I am excited?), and design a corresponding investigation (e.g., what happens to Betty the Butterfly if I take some deep breaths while facing my fears?). Families practice using their Body Clues Worksheet to review the highs and lows of the day or to explore the meaning of an intense moment. Armed with these new investigative tools, families are prepared for any intense situation even if it’s disgusting!

Our step-by-step clinician guide continues with Session 2 – the Eats! a fun exploration of the sensations that constitute hunger, fullness, thirst, and utter deliciousness! Every session from this one forward begins with a Henry Heartbeat investigation, which helps children (a) expend their energy so that they can focus on the remainder of the session, and (b) become comfortable and proficient with raising and lowering arousal, a foundation of self-awareness and emotion regulation. The ritual of homework review is introduced: new things learned about the body between sessions are added to the Body Map. Children meet new characters including Georgia the Gut Growler, Solomon Satisfied, and Umm-ma Una. Children and parents conduct investigations such as learning to sense their changing energy from food as they eat, whether food tastes more delicious if you eat it slowly – and more. A body wisdom might be: “your body tells you how much energy you need if you learn to listen.” Following Body Brainstorms, families begin the first two steps of the Body Clues Worksheet to practice monitoring what they are feeling and what their bodies might be communicating. With worksheets, workbooks, and coloring pages, the investigators are off to explore the week ahead!

The Drowsies is our session about sleep. As a restful night of sleep is an important part of any pain management routine, we wanted to devote a session just to that. We explore that sensations that make it hard to get into bed (e.g., Stuck Stephanie – the feeling that you can’t stop doing something that you like doing (like playing video games) to do something you would rather not do (like get ready for bed). We remember some old friends that that may make it hard to fall asleep like Mind-Racing Mikella and Betty Butterfly and we investigate all the sensations that may contribute to a wonderful and cozy night of rest. Cozy Celeste, Sleepy Steven, Cool Cyrus, and Stretched-Out Comfy Cayla are some sensations we explore this session. Wait till you try out all of our different bedtime routines!

Session 5 focuses on the sensations that comprise low-arousal emotions such as sadness, guilt, and boredom. The pit of dread in your gut when you have done something wrong (Ricky the Rock), the feeling of being weighted down with sand that can happen when one is sad (Bertha Blah), or when your mind and body feel like you are utterly empty but still eager for something to do (Empty Eliza) are some friends we meet this session. Seeing what happens to feelings of heaviness when you snuggle with someone or something and challenging an empty mind to come up with 50 things to do are some of the adventures in this session.

In my 35 years as a practicing pediatrician, I saw many children for abdominal pain. This chapter provides a brief overview of my approach to evaluating abdominal pain in children ages 5 to 11 years old (pre-pubertal). This outline is not meant to be comprehensive or exhaustive, and it assumes its readers are clinical providers with training in the medical evaluation of children. We hope that its inclusion will help to provide a structure for excluding medical causes prior to starting the FBI treatment program. However, we include this caveat: your own clinical judgement must be your guide; no outline can substitute for your own evaluation of an individual patient.

Children with sensory superpowers live life out loud! They have a vivid experience of themselves and the world around them that adds richness to life. Pain sensitivity does not have to be a vulnerability. This chapter is about reframing visceral hypersensitivity as an asset that contributes to three specific superpowers. First, children with visceral sensitivity have spell-binding powers of perception. Because of their history of pain, children may become hyper-vigilant and scared of all the sensations they notice. As they become FBI agents, children learn to harness this perception and use playfulness and curiosity to detect body clues and investigate body mysteries. Second, children with visceral hypersensitivity have awe-inspiring self-awareness. Readers learn about the function, power, and experience of emotions. The intensity with which children feel their bodies runs parallel to strong emotions that can provide vital information to help them get to know and trust themselves. Finally, children with sensory superpowers have faster-than-lightening intuitive decision-making capacities. We explore how sensitivity to physical sensations in the gut can translate to strong feelings that help one “go with their gut” reaction. This chapter links how the tools of the FBI intervention are designed to harness and build each of these superpowers.

This chapter discusses the literature on parent-child attachment and the qualities and skills required in responsive parenting (as well as in responsive healthcare provision). Readers are introduced to how the steps of the FBI –Pain Division protocol concretely guide parents in the implementation of responsive parenting strategies. There is an emphasis on the mutability of the system: it is never too late to gain and provide potent benefit by honing responsive parenting skills. This approach establishes a secure base of attachment between parent and child, yielding not dependency but the courage and sense of safety necessary for confident exploration of one’s environment. Responsive parenting also facilitates self-parenting in offspring. One of the tasks of childhood and adolescence is to become our own “self-parents”: attune to our needs, game for investigating further when our needs are elusive, and ready, willing, and able to respond to our needs effectively. When children are taught to be masterful “self-parents”, their self-knowledge and self-trust further contribute to their confidence in venturing out to experience what the world has to offer.

Functional abdominal pain (FAP) is one of the most common medical complaints children present to their pediatricians. Despite the prevalence of FAP as well as its early onset, treatments for young children are particularly rare. Young children are just beginning to learn about the complex messages that their body communicates. Yet, pain can contribute to a fear of the body and an attempt to avoid these important signals. This chapter describes the background and rationale for a new approach to pain for young children, one that conceptualizes the sensitivity to pain and other experiences of the body as a superpower rather than a vulnerability - “sensory superpowers!” We train children to be Feeling and Body Investigators (FBI), individuals who have awe-inspiring curiosity and responsivity towards the many wise communications from their bodies and who respond to these messages with dexterity and skill. The end result is children who are not only fearless about pain, but also who are adept at emotion awareness and regulation. They are Feeling and Body Investigators!

A Feeling and Body Investigator would be incomplete without in-depth explorations of joyous sensations. We explore what it feels like to be so filled with energy that you cannot sit still (Ernie the Energy Ball) or when you have so much music in your heart that you have to dance around (Dancing Darrin). We investigate moments when you are so filled with joy that you feel your heart might burst out of your chest (Bursting Bella), or when you are laughing so hard that your side hurts (Lulu the Laughing Pain). In this session we move. We dance. We giggle. We explore ways to take these joyous sensations and share them and make them even bigger.

In our last session of new material, we focus on body sensations that are soothing and pleasant. Practicing ways to lower our heart rate has been a part of every session and thus, by the time Session 9 occurs, children are very good at noticing and embracing calm, soothing sensations, This session is about rejoicing in moments of slow-moving wonderment – drifting off into a daydream, feeling the warmth of a smile, feeling alert as your senses take in everything around you. Children practice noticing everything surrounding them when they just stop and take in the moment. They see where their mind travels to when they find a restful spot to day dream. They feel time slipping away as they become engrossed in something that really focuses their attention. Catching and holding onto soothing moments is a wonderful way to live.

This chapter provides the rationale and background of interoceptive exposure exercises, the body investigations parents and children (and possibly healthcare providers) will perform in each session. The origins of these exercises in the treatment of panic disorder will be reviewed, while introducing key developmental considerations and explaining the importance of an acceptance-based framework. In brief, in the context of panic disorder, interoceptive exposure exercises were intended to provoke a sensation that was feared and to provide new learning that this experience is not dangerous - new learning that competes with prior beliefs of harm or threat. One of the strengths of the FBI approach is that it uses sensations rather than cognitions as a framework for learning. This is essential for children who often do not have access to the content and meaning of their thoughts, or the language to articulate them with insight. As children do not have well-formed beliefs about threats, body exposure investigations are designed to help children learn how smart and trustworthy their bodies are –experiences that may directly contrast with their prior ones of weakness and vulnerability.

This chapter is where the action starts! We provide a step-by-step guide for clinicians to lead the introductory session for FBI including sample dialogues and examples of how to integrate the therapeutic materials provided (e.g. parent/child workbooks, worksheets, and coloring pages). Therapists are given accessible language to present the case formulation of visceral hypersensitivity as a collection of sensory superpowers that enable children to experience the world and their bodies through a lens of curiosity and excitement rather than fear. Children and parents begin their training as body detectives, Feeling and Body Investigators that harness these superpowers. Children create a “Body Map” a tracing of the child’s body that summarizes the many wisdoms of the body. Children are introduced to their first body characters. Examples include Henry Heartbeat, Samantha Sweat, and Gassy Gus. Children perform their first Body Investigation, a Henry Heartbeat exploration in which they compare strategies to raise and lower their heartbeat. A resulting body wisdom might be: my heart is smart- it knows to beat faster or slower depending on what I need. Body Brainstorms worksheets facilitate generalization of new learning to the outside world. Families are given home-based practices and worksheets to reinforce what they learn.

The Ouchies is our session about pain: emotional pain, poop pain, muscle pain, worry pain – among others. Investigations focus on the important messages of pain and explore what happens to certain pain sensations when you listen and respond to them. For example, what happens to emotional pain when you get a hug? Sample characters include Ella the Emotional Pain and Patricia the Poop Pain. Children challenge themselves to show how strong they are and how much they can do even when they feel a bit uncomfortable.

• Injuries are generally classified based on mechanism as either blunt or penetrating. Each has a different method of evaluation and treatment.

• In blunt injuries, solid organs are commonly injured with acceleration/deceleration injuries (i.e., motor vehicle collisions [MVC], falls from height) and crush injuries. Blunt injuries are associated with greater mortality than penetrating ones. The spleen is the most commonly injured solid organ, followed by the liver.

• A stab wound, one such penetrating injury, is less likely to cause intra-abdominal injury and penetrate the peritoneum requiring surgical intervention when compared with projectile wounds.

Mesenteric ischemia is a generic term referring to hypoperfusion of the intestines. It can be either acute or chronic and is caused by several different etiologies. It is a rare but life-threatening vascular emergency, occurring with increasing frequency (0.1% of all hospital admissions) and with mortality rates between 60% and 80%. It affects primarily those older than 50 years with systemic and cardiovascular disease. The acute form is more common and results in rapid intestinal ischemia, infarction/necrosis, sepsis and death. Splanchnic vascular insufficiency in chronic ischemia can also threaten bowel viability.

Abdominal pain is the most common reason for emergency department visits and is a leading cause of hospital admissions in the United States. Acute abdominal pain is defined as sudden-onset pain lasting < 7 days, due to a wide spectrum of causes that range from benign to life threatening. When the need for surgical intervention is suspected, prompt involvement of appropriate consultants is essential.