Impact of juvenile arthritis on families. An educational assessment

Children's experiences of living with juvenile idiopathic arthritis: a thematic synthesis of qualitative studies

OBJECTIVE

To describe the experiences and perspectives of children and adolescents living with juvenile idiopathic arthritis (JIA).

METHODS

We conducted a systematic review of qualitative studies that explored the experiences of children living with JIA. We searched electronic databases (to week 2 of July 2011) and reference lists of relevant articles.

RESULTS

Twenty-seven studies that reported the experiences of more than 542 participants were included. Six major themes were identified: aversion to being different (unrelenting and unpredictable pain, disablement, internal disfigurement, differential treatment, and forced dependency on others); striving for normality (preserving social identity, resourcefulness, sense of community, focus on remission, and mastery over body and pain); stigma and misunderstanding (trivialization of disease, invisible pain, and discrimination); suspension in uncertainty (control versus powerlessness, hope versus disappointment); managing treatment (benefits of taking medicines, respect and involvement in health care, and motivation for physical therapy); and desire for knowledge (medical treatment and advances, lifestyle management).

CONCLUSION

JIA disrupts a child's sense of normality and impairs his or her capacity for social participation. Children with JIA have a sense of being misunderstood and stigmatized, and they feel perpetually caught between having hope and control over their bodies and overwhelming pain and despair. To increase their confidence, the ability to manage pain, and their resourcefulness for self-management, children need ongoing information about treatments and lifestyle management, strong social support, community advocacy, and active involvement in their own health decision making.

Growing up and moving on in rheumatology: development and preliminary evaluation of a transitional care programme for a multicentre cohort of adolescents with juvenile idiopathic arthritis

This article describes the development and initial evaluation of an evidence-based transitional care programme recently implemented in a multicentre controlled trial in the United Kingdom. The individual components of the programme are described. Evaluation of the acceptability and utilization of these components employed questionnaires administered to users (adolescents with juvenile idiopathic arthritis and their parents) and providers (rheumatology health professionals). The results confirm the acceptability and utilization of the programme components in addition to further innovative developments during the course of the study. In conclusion, the evidence-based transitional care programme components reported here are acceptable and useful to both user and provider and are potentially feasible in clinical practice in a revised format.

Adjustment to chronic arthritis of childhood: the roles of illness-related stress and attitude toward illness

OBJECTIVE

To examine the relationship of psychosocial stress and attitude toward illness to psychological adjustment among youth with chronic arthritis.

METHODS

Seventy-five youths with chronic arthritis aged 8-18 years were administered a semi-structured interview assessing illness-related and nonillness-related stressors in important life domains. Children also completed measures of attitude toward illness, depressive symptoms, and anxiety. Parents completed a measure of child psychosocial adjustment.

RESULTS

Higher levels of illness-related and nonillness-related stress were associated with higher levels of anxiety and depressive symptoms and parent-reported adjustment problems, while a more positive attitude toward illness was associated with lower levels of anxiety and depressive symptoms. Attitude toward illness moderated the relationship between stress and depressive symptoms.

CONCLUSIONS

Results suggest the importance of assessing life stress and attitude toward illness among youth with arthritis and developing interventions to help children cope with arthritis-related stressors and promote a more positive attitude toward illness.

Development and preliminary validation of a self-efficacy measure for use among parents of children with juvenile idiopathic arthritis

OBJECTIVE

To develop a valid and reliable measure to assess parents' perceived ability to control, or manage, aspects of their children's juvenile idiopathic arthritis (JIA).

METHODS

Construction of the Parent's Arthritis Self-Efficacy Scale (PASE) was based on existing knowledge and the results of focus groups with parents of children with JIA, children with JIA, and health professionals. Data for validation of the PASE were collected by self-administered questionnaires completed by 178 parents and 89 children with JIA.

RESULTS

Analyses revealed a 2-factor structure for both mothers and fathers. These factors related to parents' self-efficacy for managing children's arthritis-related symptoms and psychosocial health. Taken together, the two factors explained 75.5% and 65.8% of the total variance (mothers' and fathers,' respectively). The PASE demonstrated high internal consistency, concurrent validity, and construct validity, particularly among mothers.

CONCLUSION

Preliminary findings suggest that the PASE is worthy of further psychometric testing and may have the potential to help delineate variations in adjustment among parents of children with JIA.

Daily pain and symptoms in children with polyarticular arthritis

OBJECTIVE

To analyze patterns of daily pain, stiffness, and fatigue related to juvenile arthritis; to examine the relationships of demographics, disease severity, and psychological adjustment to daily disease symptoms; and to examine daily disease symptoms as predictors of reduced participation in school and social activity.

METHODS

For a 2-month period, 41 children with polyarticular juvenile arthritis completed daily diaries that included measures of symptoms and function. Children also underwent an initial evaluation and 4 followup evaluations that included a joint count, laboratory testing, and completion of questionnaires assessing physical and psychosocial functioning.

RESULTS

Children reported having pain an average of 73% of days, with the majority of children (76%) reporting pain on >60% of all days. On average, children described the intensity of their daily pain as being in the mild to moderate range; however, a significant subgroup (31%) reported pain in the severe range. Higher physician global assessment ratings, increased functional disability, and increased anxiety were significantly associated with increased daily pain and other daily symptoms. Multilevel random-effects analyses indicated that increased daily symptoms of pain, stiffness, and fatigue were significant predictors of reduced participation in school and social activities.

CONCLUSION

Physicians should consider treating pain more aggressively in children with arthritis, in order to preserve function in school and social domains, as well as physical function. Moreover, optimal pain management in children with arthritis should include therapeutic regimens addressing anxiety as well as standard pharmacologic interventions.

Health-related quality of life in children with arthritis

Health status results from an individual's values placed on the interactions among a person's physical state, associated mental perceptions and emotions, resulting behaviors, and environment. Improving health-related quality of life is the goal of all disease treatment. This article reviews the components of health status, summarizes relevant studies in children with rheumatic and related diseases, and considers the role that future studies will play in improving care for children with rheumatic diseases.

Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritis

OBJECTIVE

To investigate the effects of an 8-week, 24-session weight-bearing physical conditioning program on disease signs and symptoms in children with chronic arthritis.

METHODS

In a within-subjects, repeated measures design, 25 subjects, ages 8-17 years, with chronic polyarticular juvenile rheumatoid arthritis (JRA), were assessed at study entry, after an 8-week control period, and after an 8-week exercise period, for 1) disease status, based on joint count (JC) and articular severity index (ASI) (sum of scores for joint swelling, pain on motion, tenderness, and limitations of motion); 2) worst pain during the past week, using a 10-cm visual analog scale (VAS), and 3) aerobic endurance, using the 9-minute run-walk test of the Health Related Physical Fitness Test battery. The 60-minute conditioning program included warm-up (10 minutes), low-impact aerobics (25 minutes), strengthening (15 minutes), and cool-down and flexibility exercises (10 minutes). Subjects exercised twice a week at their rheumatology center and once a week at home, using a commercial exercise video-tape supplied by the investigator.

RESULTS

Significant improvement was found in the ASI (Friedman analysis of variance [ANOVA]), JC, and 9-minute run-walk test (repeated measures ANOVA) from the pre- to post-exercise tests. Mean VAS pain scores decreased 16% from study entry to the post-exercise test. Statistically significant improvement (reliable change index > 1.96) occurred in 80% of subjects on the ASI and 72% on the JC.

CONCLUSION

Children and adolescents with chronic polyarticular JRA can improve their aerobic endurance through participation in weight-bearing physical conditioning programs without disease exacerbation or increased pain, and may achieve decreased joint signs and symptoms through increased physical activity.

Quantitative and qualitative assessments of pain in children with juvenile chronic arthritis based on the Norwegian version of the Pediatric Pain Questionnaire

Quantitative and qualitative aspects of pain were studied using a standardized questionnaire (the Varni/Thompson Pediatric Pain Questionnaire--PPQ). Fifty-seven of 64 consecutive in- and out-patients (6-18 yrs) with juvenile chronic arthritis (pauciart. n = 27, polyart. n = 30) and 52 parents participated. The patients were examined by the same rheumatologist and randomly interviewed by either a disabled or a non-disabled person. Present pain, worst pain intensity and disease severity were scored (on visual analogue scales [10 cm. VAS]) by patients, parents and rheumatologist. Eighty-two percent of the children reported pain lasting from 30 min up to 24 h daily (mean 4.3 h). No significant differences were found between median pain scores of children, parents and the physician, but the correlations found between children's and parent's assessment of pain and assessment of disease severity were low, indicating that the two sets of raters did not agree to an acceptable level. Two-thirds of the adolescents reported that they would become more physically active if pain disappeared. Should the pain suddenly vanish, a positive change in family relationships was anticipated by one out of four patients. Forty-two percent of the patients thought it valuable to be interviewed by a disabled physician. The Norwegian Varni/Thompson PPQ is easy to administer to children down to six years and makes it possible to compare results internationally. Lack of agreement on the assessment of pain by a child and his/her parent indicates the need to interview both parties.

Arthritis and the family

OBJECTIVES

This paper reviews the literature on arthritis and the family in two areas, juvenile rheumatic diseases and adult-onset arthritis.

METHODS

All published papers related to arthritis and the family were identified through a Medline search and through hand searching of the major rheumatology journals.

RESULTS

The literature on the family and juvenile arthritis is somewhat inconsistent, in that some studies demonstrate significant psychosocial impact among children and families, while others find no differences in children who have arthritis compared to normative data or to siblings. Lack of consistency in the literature is largely related to methodologic problems, as most studies are retrospective reports, consisting of relatively small, nonrepresentative samples of children with rheumatic diseases. The influence of adult-onset rheumatoid arthritis and osteoarthritis on family role functioning and the performance of household responsibilities is well documented, and a body of literature on the importance of family functioning to well-being is accumulating.

CONCLUSIONS

Future studies should expand sample sizes in order to investigate family impact on juvenile rheumatoid arthritis more thoroughly. More studies on the factors that contribute to improved family functioning and subsequent improvements in well-being, especially in conditions other than rheumatoid arthritis and osteoarthritis, are needed. Intervention studies to reduce perceived pain and functional disability in arthritis by incorporating a family-systems perspective are particularly lacking.

Predicting pain among children with juvenile rheumatoid arthritis

OBJECTIVE

Children and adolescents with juvenile rheumatoid arthritis (JRA) often report pain as a major symptom that affects their daily activities. Little is known about the factors that contribute to pain, however. Demographic, disease status, and social-psychologic variables were used to predict pain of JRA.

METHODS

Participants were 37 girls and 23 boys who were 7 to 17 years old. Measures included the Hopelessness Scale for Children, the Sadness Scale from the Differential Emotions Scale--IV, and the Social Support Questionnaire--Revised. A pain visual analogue scale served as the criterion measure.

RESULTS

Reported pain was modestly correlated with disease duration and age. A hierarchical regression indicated that the predictor variables accounted for a modest amount of variance in pain scores.

CONCLUSIONS

The results suggest that the factors contributing to pain in children with JRA are different from those in adults with rheumatoid arthritis (RA). Research is needed to identify the psychologic and socioenvironmental variables that influence pain among children with JRA.