Psychosocial adaptation in juvenile rheumatic disease: A controlled evaluation

A systematic review of the psychosocial factors associated with pain in children with juvenile idiopathic arthritis

BACKGROUND

Pain is one of the most frequently reported experiences amongst children with Juvenile Idiopathic Arthritis (JIA); however, the management of JIA pain remains challenging. As pain is a multidimensional experience that is influenced by biological, psychological, and social factors, the key to effective pain management lies in understanding these complex relationships. The objective of this study is to systematically review the literature on psychosocial factors of children with JIA and their caregivers 1) associated with and 2) predictive of later JIA pain intensity, frequency, and sensitivity in children 0-17 years of age.

METHODS

The Joanna Briggs Institute methodology for etiology and risk and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement guided the conduct and reporting of this review. Terms related to pain and JIA were searched in English without date restrictions across various databases (PubMed, CINAHL, PsycINFO, Embase, Scopus, and the Cochrane Central Register of Controlled Trials) in September 2021. Two independent reviewers identified, extracted data from, and critically appraised the included studies. Conflicts were resolved via consensus.

RESULTS

Of the 9,929 unique studies identified, 61 were included in this review and reported on 516 associations. Results were heterogeneous, likely due to methodological differences and moderate study quality. Results identified predominantly significant associations between pain and primary and secondary appraisals (e.g., more child pain beliefs, lower parent/child self-efficacy, lower child social functioning), parent/child internalizing symptoms, and lower child well-being and health-related quality of life. Prognostically, studies had 1-to-60-month follow-up periods. Fewer beliefs of harm, disability, and no control were associated with lower pain at follow-up, whereas internalizing symptoms and lower well-being were predictive of higher pain at follow-up (bidirectional relationships were also identified).

CONCLUSIONS

Despite the heterogeneous results, this review highlights important associations between psychosocial factors and JIA pain. Clinically, this information supports an interdisciplinary approach to pain management, informs the role of psychosocial supports, and provides information to better optimize JIA pain assessments and interventions. It also identifies a need for high quality studies with larger samples and more complex and longitudinal analyses to understand factors that impact the pain experience in children with JIA.

TRIAL REGISTRATION

PROSPERO CRD42021266716.

Mental health and adjustment to juvenile idiopathic arthritis: Level of agreement between parent and adolescent reports according to Strengths and Difficulties Questionnaire and Adolescent Outcomes Questionnaire

The aims of this study were threefold. Firstly, to analyze the psychometric properties of the Polish-language Pediatric Outcomes Data Collection Instrument (PODCI) questionnaire in the self-report Adolescent Outcomes Questionnaire (adolescents, 11-18 years of age) and in the parent-report Adolescent Outcomes Questionnaire (completed by a parent or guardian of an adolescent aged 11-18 years). Secondly, to determine the level of agreement between parents and adolescents in rating dysfunction in juvenile idiopathic arthritis (JIA) and thirdly, to examine associations between psychological adjustments of patients to JIA and disease as well as their socio-demographic characteristics. The study sample consisted of 52 participants. 26 adolescents between the ages of 11 and 18 years with a diagnosis of JIA and 26 parents were considered for inclusion. Disease course was classified as pauciarticular (n = 12, 46.2%) and polyarticular (n = 14, 53.8%). Participants completed the PODCI (self- and parent- report) twice and the Strengths and Difficulties Questionnaire-25 (SDQ-25). Considering the distribution of results regarding PODCI normative scores, 73.1% of parents and 69.2% of patients scored below 50 on the Global Functioning Scale; that is lower than the average for the general healthy population. Regarding the parent report, the total score of the SDQ-25 equaled 11.86 (SD 2.66), whereas the patient report equaled 11.23 (SD 2.78). The study groups do not differ significantly in regards to either the PODCI or the SDQ-25 results. Parents and adolescents with JIA appear to hold very similar perceptions of patients' health. Greater differences emerge as disease severity and age of patients increase. Excellent internal consistency, intrarater and test-retest reliability of the Global Functioning Scale have been confirmed in the Polish version of the PODCI, the questionnaire may therefore aid identification of patients reporting significant problems in this group.

Leisure in children and adolescents with juvenile idiopathic arthritis: a systematic review

The aim of this systematic review is to describe participation in social and physical leisure activities among children and adolescents with JIA, as well as identify potential determinants of leisure participation.

METHODS

Electronic databases were systematically searched for articles published up until June 2013 pertaining to participation in leisure activities among youth with JIA and other rheumatic diseases. Studies were included if they measured involvement in either social or physical leisure activities. Selection and quality appraisal of articles were completed independently by two authors.

RESULTS

Eight hundred and ninety-three articles were found through electronic and reference search. One hundred and nine full articles were reviewed to assess for eligibility. Twelve articles met inclusion criteria and findings were reviewed. Most focused on describing participation in physical rather than social activities. Results suggest that youth with JIA participated less in both social and physical leisure activities as compared to healthy peers, and those with JIA did not meet national recommendations for physical activity. Potential determinants of leisure participation were socio-demographic (age, sex), anthropometric (height, weight) and disease-related (JIA subtype, disease duration, pain, number of swollen or painful joints, stiffness, fatigue, well-being) factors.

CONCLUSION

Characterization of leisure activity remains limited and mostly focused on physical activity in JIA. Assessment of more comprehensive outcome measures is warranted to obtain a better description of leisure in this population. Evidence of the influence of contextual factors as potential determinants of involvement in leisure among children with pediatric rheumatologic diseases is needed.

Amplified ambivalence: having a sibling with juvenile idiopathic arthritis

Despite increased awareness of family responses to chronic illness and disability, there is still a need to understand experiences of well siblings. We begin to address this issue by asking, 'What is it like to have a sibling with juvenile idiopathic arthritis?' (JIA). Eight families with an adolescent diagnosed with JIA participated. Four members of each family, including one healthy sibling, were interviewed and transcripts analyzed using grounded theory. Analysis suggests healthy siblings see their family as different to 'normal' families, forfeit time with peers, share vicariously adverse experiences of their ill sibling, and feel inadequately informed. Such experiences amplify the ambivalent nature of sibling relationships and are possibly felt most strongly during late childhood and early adolescence. Support from extended family can reduce these negative experiences and facilitate social and emotional adjustment which also occurs over time as the children mature. These findings have implications for healthcare professionals and voluntary organizations.

Body experiences, emotional competence, and psychosocial functioning in juvenile idiopathic arthritis

We investigated self-image, psychological functioning, and quality of life in children and adolescents with juvenile idiopathic arthritis (JIA). Thirty-nine children with JIA were compared with 80 healthy peers. We first administered the Human Figure Drawing Test (HFDT) to all subjects; children also completed standardized questionnaires evaluating health-related quality of life (PEDSQL 4.0 Generic Core Scales) and the main aspects of psychological functioning: anxiety (SAFA-A) and depression (CDI). Parents were asked to complete the Child Behaviour Checklist (CBCL) and the PEDSQL 4.0. For each patient with JIA, clinical notes were gathered and a global disease assessment (visual analog scale--VAS) was performed. Compared to healthy peers, patients with JIA reported reduced maturity quotients at HFDT, more depressive traits, greater anxiety, and lower health-related quality of life. Among the subjects with JIA, HFDT revealed that adolescents had a greater impairment in all areas investigated. Furthermore, there was a significant correlation between the physical well-being rated by VAS and the perception of poorer quality of life in patients, mostly in the psychosocial domains. Children and adolescents with JIA exhibit emotional difficulties and a delay of psychological development leading to low self-esteem, a distorted self-image, more anxiety and depression traits, and a worse quality of life, when compared to healthy subjects.

Impact of juvenile idiopathic arthritis on schooling

Background

Juvenile idiopathic arthritis (JIA) is the most common arthropathy of childhood. Different diseases affect school attendance to varying degrees. The aim of this study was to assess the impact of juvenile idiopathic arthritis (JIA) on Moroccan children’s schooling.

Methods

Thirty-three children with JIA were included in this study, having been previously diagnosed according to the classification criteria of the International League of Associations for Rheumatology (ILAR). Seventy-four healthy children were recruited to serve as controls. Data was obtained for all children on their school level, educational performance, and attendance. The rate of absenteeism due to health complications was noted.

Results

All healthy children were able to attend school (p<0.0001), while 33% of children with JIA were unable to attend school due to their condition. The students with JIA who were able to attend school were absent much more often than controls (63% compared to 20%), with a highly significant p value (p<0.0001). Slightly less than half of the JIA patients (48.5%) failed in their schooling. In univariate analysis, there was an association between absenteeism and tender joints (p=0.02), disease activity score (DAS28) (p=0.007), Childhood Health Assessment Questionnaire (CHAQ) (p=0.01), and erythrocyte sedimentation rate (ESR) (p=0.03). In multivariate analysis, the only association persisted between DAS28 and absenteeism.

Conclusions

Our study suggested that the schooling of children with JIA was negatively impacted due to the disorder. More studies, with a larger sample of children, are needed to confirm our findings.

Development of a multi-dimensional measure of resilience in adolescents: the Adolescent Resilience Questionnaire

Background

The concept of resilience has captured the imagination of researchers and policy makers over the past two decades. However, despite the ever growing body of resilience research, there is a paucity of relevant, comprehensive measurement tools. In this article, the development of a theoretically based, comprehensive multi-dimensional measure of resilience in adolescents is described.

Methods

Extensive literature review and focus groups with young people living with chronic illness informed the conceptual development of scales and items. Two sequential rounds of factor and scale analyses were undertaken to revise the conceptually developed scales using data collected from young people living with a chronic illness and a general population sample.

Results

The revised Adolescent Resilience Questionnaire comprises 93 items and 12 scales measuring resilience factors in the domains of self, family, peer, school and community. All scales have acceptable alpha coefficients. Revised scales closely reflect conceptually developed scales.

Conclusions

It is proposed that, with further psychometric testing, this new measure of resilience will provide researchers and clinicians with a comprehensive and developmentally appropriate instrument to measure a young person's capacity to achieve positive outcomes despite life stressors.

Agreement between proxy and adolescent assessment of disability, pain, and well-being in juvenile idiopathic arthritis

OBJECTIVES

Adolescents with juvenile idiopathic arthritis have demonstrated substantial disagreement with their proxy's assessment of their disability, pain, and well-being. Our objective was to describe the clinical and psychological factors associated with discordance.

STUDY DESIGN

This analysis included 204 proxy-adolescent (median age, 13 years) dyads that completed a Childhood Health Assessment Questionnaire for disability with 100-mm visual analogue scales for pain and well-being. Depressive symptoms in adolescents were measured by the Mood and Feelings Questionnaire and in proxies the General Health Questionnaire. Disagreement was assessed using Bland-Altman plots. Associations with discordance were identified using logistic regression analyses.

RESULTS

There was higher agreement for disability (84%) than for pain (71%) and well-being (66%). Regression analyses found no association between age, sex, or disease duration and disagreement. However, relationships between disease activity and disagreement in outcomes were identified. Independent associations were found between increasing Mood and Feelings Questionnaire scores and disagreement in pain and well-being.

CONCLUSIONS

Proxy and adolescent reports of pain and well-being are more likely to disagree in those with severe disease. Adolescents who report depressive symptoms are also more likely to disagree with their proxy. The reasons for these are multifactorial, and considerations of both reports are important when assessing outcomes in juvenile idiopathic arthritis.

Is parental coping associated with the level of function in children with physical disabilities?

OBJECTIVES

The objectives of this study are: (1) to describe parental coping in a cohort of children with physical disabilities (PDs); (2) to determine whether the child's level of function is associated with parental coping; and (3) to explore whether socio-demographic factors such as child's age, maternal education and family structure are associated with parental coping.

METHODS

Parents of 150 children with PDs were interviewed after being referred to community rehabilitation services. They answered the following: the Coping Health Inventory for Parents, the Functional Independence Measure for children (WeeFIM) and a study questionnaire that addressed socio-demographic characteristics. Multiple linear regression models were used to determine the association between level of function and other factors and parental coping.

RESULTS

Mean (SD) age of the children was 40.9 (15.2) months and 64.7% were male. Parental coping scores, measured by the Coping Health Inventory for Parents, indicated that the parents in our study found seeking out social support from community resources useful. Parents of children with moderate to severe dysfunction in mobility (WeeFIM) found coping behaviours related to communicating with the healthcare professionals regarding their child's condition useful (beta coefficient, 2.07; 95% CI, 0.37, 3.78). Greater perceived usefulness of maintaining social support through community resources was associated with lower maternal education, working parents and two-parent families.

CONCLUSION

These findings underscore the importance of helping parents of children with PDs maintain social support. It is important to help parents understand their child's medical situation, especially those whose children have more severe mobility dysfunction.

Educational and occupational outcomes among young adults with juvenile idiopathic arthritis

OBJECTIVE

To examine educational and occupational outcomes among young adults with juvenile idiopathic arthritis (JIA) and peers during the transition from adolescence to emerging adulthood.

METHODS

Families were recruited when children with JIA were 8-14 years old. At that time, each child with JIA was matched to a classmate of similar age, sex, and race for inclusion in a comparison group. For the current followup (12.64 years postdiagnosis), 45 participants with JIA, 46 peers, and their parents completed questionnaires soon after the young person's 18th birthday. Disease type and severity were rated by health care providers.

RESULTS

Young adults with JIA and peers were similar on a variety of factors, including family background, scholastic and occupational self-concept, and academic competence. The proportion of participants who graduated from high school, were working, and expressed plans to attend postsecondary education or seek employment was similar between groups. Disease type, initial severity, and time since diagnosis were generally not associated with indices of educational and occupational attainment.

CONCLUSION

Despite the challenge of having a chronic illness, young adults with JIA were similar to peers on numerous educational and occupational outcomes during the transition from adolescence to emerging adulthood. Interventions to assist academic or occupational functioning may not be necessary for all children with JIA, but additional research is needed to identify subgroups at risk for long-term difficulties.

An expanded Transactional Stress and Coping Model for siblings of children with sickle cell disease: family functioning and sibling coping, self-efficacy and perceived social support

AIM

To investigate the application of an expanded Transactional Stress and Coping Model for the psychological adjustment of non-chronically ill, African-American siblings of children with sickle cell disease (SCD).

METHODS

Ninety-seven siblings (M = 11.24 years) from 65 families who care for a child with SCD participated. Primary caregivers completed the Coping Health Inventory for Parents, the Family Relations Scale and the Child Behaviour Checklist, while siblings completed the Kidcope, the Children's Self-Efficacy for Peer Interaction Scale, and the Social Support Scale for Children.

RESULTS

Family processes were predictive of sibling adjustment, revealing that family coping, expressiveness and support improved adjustment, while family conflict predicted poor adjustment.

CONCLUSION

Findings suggest that family-centered interventions stressing family expressiveness and support, while minimizing conflict, will contribute to sibling psychological adjustment.

Comparison between Children with Juvenile Idiopathic Arthritis (JIA) and their Parents Concerning Perceived Quality of Life

The aim of the study was to determine the level of agreement between the perceptions of children with JIA and their parents concerning quality of life. Fifty patients aged 9-18 years and their parents, who attended the JIA clinic at the Montreal Children's Hospital, completed the Juvenile Arthritis Quality of Life Questionnaire (JAQQ). Paired t-tests were employed to compare parents' and children's scores and agreements were analyzed by intraclass correlation coefficients (ICCs). Linear regression was used to explore factors associated with agreements and with the perceptions of quality of life. ICCs (95% confidence interval) for the subscales of the JAQQ were 0.62 (0.42,0.77) for gross motor function, 0.35 (0.08,0.57) for fine motor function, 0.61 (0.41,0.76) for psychosocial function, 0.70 (0.52,0.82) for systemic symptoms and 0.60 (0.38,0.75) for pain. Agreement was higher for psychosocial function among younger children and for overall quality of life among those who had the disease longer. Higher agreement levels on pain were associated with more severe disease. Disease severity was associated with perceptions of quality of life (p < 0.01). There seems to be good agreement between the perceptions of children with JIA and their parents concerning quality of life, except for fine motor function.

Learned helplessness in children and adolescents with juvenile rheumatic disease

OBJECTIVE

To examine a learned helplessness conceptualization of psychological sequela in children and adolescents with juvenile rheumatic diseases (JRD) via an experimental procedure utilizing behavior-outcome contingent and noncontingent feedback.

METHODS

Thirty-eight children and adolescents with JRD completed measures of transient affect, self-efficacy for functional ability, and causal attributions prior to and immediately following a computerized learned helplessness induction procedure.

RESULTS

Children across contingent and noncontingent feedback conditions experienced decreased positive affect with a slightly more pronounced decline in the noncontingent condition. Noncontingent feedback resulted in poorer internalization of success for problem solving, while contingent feedback resulted in greater internalization of success for problem solving. Additionally, posttreatment control self-efficacy was significantly greater for children in the contingent condition that initially endorsed higher levels of internal task attributions.

CONCLUSIONS

Children with JRD who experience behavior-outcome contingency in their environment may develop increased perceptions of control over functional ability. Furthermore, environmental noncontingency may result in poorer internalization of success, whereas contingent reinforcement may enhance cognitive appraisal mechanisms (i.e., causal attributions) associated with favorable disease outcome. Despite a modest decline in positive affect for children in the noncontingent condition, mood dysfunction is not entirely explicable within the context of noncontingent reinforcement.

Level of agreement between children, parents, and physicians in rating pain intensity in juvenile idiopathic arthritis

OBJECTIVE

To investigate the level of agreement between patients, mothers, fathers, and physicians in rating pain intensity in juvenile idiopathic arthritis (JIA), and to identify factors explaining discrepancies between raters.

METHODS

Ninety-four children with JIA and their mothers and fathers were asked to rate independently the intensity of present pain and pain in the previous week on a visual analog scale. The physicians rated pain intensity after physical examination. Agreement between raters was determined using intraclass correlation coefficient and Bland and Altman method. Correlations of explanatory variables with discordance in rating pain intensity were determined by univariate and multivariate analyses. Explanatory variables included sex, age, JIA category, disease duration, results of study ratings, joint inflammation measures, and erythrocyte sedimentation rate.

RESULTS

Agreement in rating present pain was moderate between children and mothers, but was poor between children and fathers and children and physicians. The agreement in rating pain in the previous week was moderate between children and mothers and children and fathers. Mother-father agreement was good. Parents and physicians agreed at a moderate level. In multiple regression analyses, only intensity of present pain was significantly associated with discordance within child-mother, child-father, and child-physician dyads.

CONCLUSION

Children's ratings of pain were only in moderate agreement with those of their parents and were in poor agreement with those of the physicians, whereas the father and mothers agreed at a good level. The intensity of pain was the strongest determinant of discordance between children and other raters.

Scholarly Literature Review: Efficacy of Psychological Interventions for Pediatric Chronic Illnesses

OBJECTIVE

To review empirical studies of the efficacy of psychological interventions as adjuvant therapies for children with pediatric diabetes, cancer, cystic fibrosis, and sickle cell disease.

METHODS

A search was conducted for qualifying studies published since 1980. Only studies meeting basic criteria for external and internal validity were included. Nineteen studies were identified, providing data on 62 outcome variables. Effect sizes (ESs) were analyzed by illness type, intervention type, and strength of internal and external validity of the research design.

RESULTS

Overall, interventions were associated with large ESs, which were not significantly moderated by illness type or intervention type. However, larger ESs were associated with lower scores on validity of research design.

CONCLUSIONS

Adjuvant psychological interventions for pediatric chronic illnesses appear in general to be efficacious, associated with a large mean ES across a range of outcome variables. However, until more studies have been completed using stronger research designs, only tentative conclusions can be drawn.

Lebensqualität und psychosoziale Anpassung bei Kindern und Jugendlichen mit juveniler idiopathischer Arthritis und reaktiven Arthritiden

OBJECTIVE

We sought to measure self-reported health related quality of life (HRQOL) and psychosocial adaptation in children and adolescents with juvenile idiopathic arthritis (JIA) and reactive arthritis and to determine factors associated with these outcomes.

METHODS

We interviewed 72 children and adolescents with chronic arthritis, age 8-16, about HRQOL (KINDL-R-Questionnaire) and functional ability in activities of daily living (Childhood Health Assessment Questionnaire-CHAQ). Mothers reported behavior problems (Child Behavior Checklist-CBCL).

RESULTS

Children and adolescents with juvenile idiopathic arthritis and reactive arthritis reported lower HRQOL compared to normative data in several areas. Children reported lower QOL in the dimensions self-esteem; adolescents reported lower QOL in the dimensions physical well being and total QOL. Almost 20% of the sample appeared to have serious behavior problems, mostly social isolation and depression/anxiety. Functional limitations affected HRQOL and behavior problems. Inpatient children and adolescents and those with shorter disease duration reported lower QOL than outpatient children and adolescents and those with longer disease duration. Best predictors for impaired HRQOL were functional limitations, social isolation and depression/anxiety.

CONCLUSIONS

Self-reported HRQOL and behavior problems may be relevant outcome measures in children and adolescents with chronic arthritis and useful to monitor psychosocial support in this population.

Pain, stiffness, and fatigue in juvenile polyarticular arthritis: Contemporaneous stressful events and mood as predictors

OBJECTIVE

To analyze patterns of stress, mood, disease symptoms, and activity reduction in children with polyarticular arthritis, using a prospective daily diary method.

METHODS

For a 2-month period, 51 children with polyarticular arthritis (mean age 12.4 years, 65% female) completed daily diaries that included measures of symptoms of pain, stiffness, and fatigue, as well as stress, mood, and activity reduction. Functional status and disease activity were assessed at the initial and followup evaluations with use of the Childhood Health Assessment Questionnaire, physician global assessment, joint count, and laboratory testing.

RESULTS

Children reported having pain, stiffness, and fatigue on >70% of days, with significant variability in symptom levels. Results revealed significant same-day relationships between stress, mood, and disease symptoms, after controlling for covariates. Specifically, daily fluctuations in both stress and mood were predictive of increased pain, stiffness, and fatigue. Increases in daily stress, mood, and disease symptoms were also significantly related to decreased participation in social activities on a day-to-day basis. Only mood and stiffness were predictors of a cutback in school attendance.

CONCLUSION

Stress and mood are important predictors of daily disease symptoms in children with polyarticular arthritis. Moreover, daily fluctuations in stress, mood, and disease symptoms are predictive of aspects of daily function, including participation in school and social activities. Thus, health care providers should solicit daily symptom reports when making decisions regarding clinical management. Nonpharmacologic interventions such as cognitive-behavioral therapy and stress management may be useful adjuvant therapy when treating the disease symptoms of children with polyarticular arthritis.

Unmet education and training needs of rheumatology health professionals in adolescent health and transitional care

OBJECTIVES

To determine the perceived education and training needs of health professionals involved in transitional care for adolescents with juvenile idiopathic arthritis (JIA).

METHODS

Two distinct questionnaires to identify transitional issues in JIA were distributed to key health professionals (n = 908) and clinical personnel involved in the implementation of a transitional care programme (n = 22).

RESULTS

The first survey was completed by 263 professionals. Education needs were reported by 114 (43%) of health professionals. Transition issues and informational resources were the most frequently reported areas of need. The second survey was completed by 22 clinical personnel who rated 'lack of training', 'lack of teaching materials geared towards adolescents' and 'limited clinic time' as the main barriers to providing developmentally appropriate care to adolescents.

CONCLUSION

Unmet education and training needs of health care professionals exist in key areas of transitional care and provide useful directions for the development of future training programmes.

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.

Validation of the French version of the Childhood Health Assessment Questionnaire (CHAQ) in juvenile idiopathic arthritis

OBJECTIVES

To translate, cross-culturally adapt, and validate the functional disability tool Childhood Health Assessment Questionnaire (CHAQ), a variant of the Health Assessment Questionnaire (HAQ), in children with juvenile idiopathic arthritis (JIA).

CHILDREN AND METHODS

The disability index is the mean of the scores on the eight domains of the CHAQ and can range from 0 (no disability) to 3 (maximum disability). The CHAQ was first translated into French and adapted, then validated in a multicenter cross-sectional study in 306 children with JIA (systemic onset, 23%; polyarticular onset, 22%; extended oligoarticular subtype, 25%; and persistent oligoarticular subtype, 30%).

RESULTS

Overall CHAQ scores discriminated between the four JIA subtypes (systemic: 1.1 +/- 0.9; polyarticular: 0.8 +/- 0.7, extended oligoarticular 0.8 +/- 0.7, and persistent oligoarticular: 0.4 +/- 0.5 [P < 0.0001]). Reproducibility evaluated by test-retest at a 7-day interval was excellent (intraclass coefficient, 0.91), as was agreement between the Parent's and Children's versions of the questionnaire (intraclass coefficient, 0.89). Significant correlations were found between the overall CHAO score and variables reflecting disease severity (joint counts, physician's and parent's global assessments, and erythrocyte sedimentation rate), indicating excellent convergent validity of the tool.

CONCLUSION

The French version of the CHAQ displays good psychometric characteristics, although its sensitivity to change remains to be established. The French version of the CHAO should prove useful in international studies and can be expected to be helpful for monitoring individual patients with JIA.

Transition: a future promise for children and adolescents with special health care needs and disabilities

Transitions are a part of everyone's life experience. Most young people with special health care needs and disabilities (SHCN/D) become independent partners in adult society, but some need deliberate guidance and support. This latter group is growing in number. Through a new consensus statement from the American Academy of Pediatrics and the U.S. Federal Government (Healthy People 2010), society is recognizing the need to assist young people with SHCN/D in attaining their potential in adulthood. This article discusses the growing number of young people with SHCN/D, their desires for their transition, the definition and areas of transition that should be addressed, and the key elements of successful transition programs. The article ends with a suggested list of actions a health care professional can undertake to foster a successful transition and a selected list of helpful resources for health professionals, families, and young people with SHCN/D.

Development and preliminary validation of a children's arthritis self-efficacy scale

OBJECTIVE

To develop a valid and reliable measure of arthritis self-efficacy for use with school-age children with juvenile idiopathic arthritis (JIA).

METHODS

Construction of the 11-item Children's Arthritis Self-Efficacy Scale (CASE) was based on an existing body of knowledge and the results of focus groups with children, their parents, and health professionals. Data for validation of the CASE were collected by self-administered questionnaires completed by 89 children and 151 caregivers.

RESULTS

Analyses revealed a 3-factor structure relating to self-efficacy for managing symptoms, emotional consequences, and activities, explaining 76.5% of the total variance. The CASE demonstrated high internal consistency, concurrent validity, and construct validity.

CONCLUSION

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

The relationship of daily mood and stressful events to symptoms in juvenile rheumatic disease

OBJECTIVES

The purpose of this study was 3-fold: 1) to assess the feasibility of a daily diary for use with children with juvenile rheumatic disease (JRD), 2) to describe daily variation in mood, stressful events, and symptoms in children with JRD, and 3) to examine the extent to which daily mood and daily stressful events predict daily symptoms in children with JRD.

METHODS

Twelve children with JRD completed a daily booklet for 7 days. The daily booklet included measures of daily mood, daily stressful events, daily symptoms, and daily function. The children also completed a visual analog scale for pain and the Children's Depression Inventory.

RESULTS

Subjects showed good compliance with scheduled completion and return of the daily diaries. Results indicated that children with JRD showed variability in daily mood, frequency of daily stressful events, and daily symptoms across days. Multilevel fixed effects models showed that more negative daily mood and more daily stressful events significantly predicted increased reports of fatigue, stiffness, and cutting back on daily activities. Negative daily mood also correlated with increases in daily reported pain.

CONCLUSIONS

These results indicate that daily diary research is both feasible and potentially informative in children with JRD. Our data emphasize the need for further investigation into the role of daily mood and daily stressful events on disease course in JRD.

Psychosocial outcomes and health status of adults who have had juvenile rheumatoid arthritis: a controlled, population-based study

OBJECTIVE

The goal of this study was to evaluate the physical and psychosocial impact of juvenile rheumatoid arthritis (JRA) among a population-based cohort of adults who had the disease during childhood, compared with a control cohort of subjects with no history of JRA.

METHODS

The Rochester Epidemiology Project database was used to identify all cases of JRA (based on the American College of Rheumatology [formerly, the American Rheumatism Association] 1977 criteria) among Rochester, Minnesota residents first diagnosed between January 1, 1960 and December 31, 1993. Controls were age- and sex-matched to the cases as of the date of diagnosis of JRA. A pretested postal survey was mailed to all adult cases (whose date of birth was before December 31, 1975) and matched controls from the same population, to obtain information on socioeconomic issues and functional status (using the Health Assessment Questionnaire and the Health Status Questionnaire). The complete medical records of all cases and controls were reviewed to obtain information on demographics and clinical manifestations of JRA.

RESULTS

Of the 50 eligible cases, 44 (88%) responded to the survey. There were 102 age- and sex-matched controls (2-3 per case) who responded to the survey. Seventy-three percent of the cases had pauciarticular-onset JRA, 16% had polyarticular-onset JRA, and 11% had systemic-onset JRA. Average followup was 24.7 years and 24.5 years after the index date for cases and controls, respectively. Greater disability (P = 0.0002), more bodily pain (P = 0.0002), increased fatigue (P = 0.0112), poorer health perception (P = 0.0004), and decreased physical functioning (P = 0.0002) were reported by the cases compared with the controls. JRA cases reported significantly lower rates of employment (P = 0.015) and lower levels of exercise (P = 0.0002) than did controls. Level of educational achievement, annual income, health insurance status, and rate of pregnancy and childbirth were similar for both cases and controls.

CONCLUSION

Adults who have had JRA during childhood experience long-term physical and psychosocial impairment.

A family retreat as a comprehensive intervention for children with arthritis and their families

OBJECTIVE

Family resources and coping skills are important to adaptation to pediatric chronic illness. Psychological and educational interventions have been found to enhance the coping skills of children with juvenile rheumatic disease (JRD) and their families. We examined the efficacy of a 3-day family retreat as a multidisciplinary, comprehensive treatment.

METHODS

Children with JRD and their caregivers completed questionnaires assessing the children's behavioral and emotional functioning, pain, strain on caregivers' work and leisure activities, and caregivers' psychological distress before and 6 months after the family retreat. Principal caregivers were both parents for 16 children, mothers only for 10 children, and an aunt for 1 child.

RESULTS

Improvements were found in children's emotional functioning, strain on caregivers' work, and strain on caregivers' leisure activities. Reductions in reported pain were not consistently revealed.

CONCLUSIONS

Family retreats are an efficacious, multidisciplinary approach to helping families of children with JRD cope with the disease and its manifestations. Importantly, retreats offer a comprehensive intervention package that might not be available to families on an individual basis.

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.

Functional measures in children with rheumatic diseases

The measurement of function in children with rheumatic diseases is an intimate part of not only the initial diagnostic work-up, but also of every clinic visit during the course of these chronic diseases. This article focuses on the development of specific and general instruments used to systematically measure function and thus, outcome of the rheumatic diseases and their treatments. Reference is made to instruments developed for use in the general pediatric and adult rheumatology population as a basis for the discussion of the instruments in use in pediatric rheumatology. Specifically, the dimensions of physical function, psychosocial impact, economic impact and quality of life are addressed.

The role of children in reporting their physical disability

OBJECTIVE

To explore the contributions of children during the development of a disability scale, and their competence using the new scale.

DESIGN

A new self-report measure of pediatric physical performance, the Activities Scale for Kids (ASK), was developed based on interviews and pilot testing with children. The ASK was then filled out by children on two occasions 2 weeks apart to assess the reliability of child self-report. Validity was assessed by comparison of interview data and ASK scores from children with similar data collected from their parents, and to clinician and family global ratings of disability.

SETTING

The study was conducted at a pediatric tertiary care hospital and its affiliated rehabilitation center.

PATIENTS

All subjects, 5 to 15 years of age, experienced activity limitations because of musculoskeletal disorders and were free of cognitive impairment. Thirty children (mean age, 11.5 years) participated in the development of the ASK, and 28 children (mean age, 11.4 years) participated in testing of reliability and validity.

RESULTS

Children generated items similar to those generated by parents (85% agreement) and identified 10 items not obtained from parents or the literature. Children demonstrated excellent test-retest reliability (intraclass correlation coefficient [ICC] = .97) using the ASK, and their scores were highly concordant with parent-reported ASK scores (ICC = .96). Validity was ascertained by comparison of ASK scores across different levels of disability based on global ratings of families and clinicians (p = .0023).

CONCLUSION

Children are able to play an important role in pediatric physical disability evaluation.

An educational needs assessment of children with juvenile rheumatoid arthritis

OBJECTIVE

Our objective is to describe the use of the PRECEDE model (predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation) to organize needs assessment data in order to define self-management behaviors and plan an educational intervention for children with juvenile rheumatoid arthritis (JRA) and their families.

METHODS

Analysis was done of needs assessment data collected from several sources: 1) literature review, 2) survey of parents of 51 children with JRA, 3) group interview of seven parents of children with JRA, 4) results of pilot programs, and 5) clinical experience of an interdisciplinary pediatric rheumatology team.

RESULTS

Two sets of interrelated behavioral factors were identified through the needs assessment: 1) those related to managing the school environment to facilitate optimal participation and to minimize school-related disability, and 2) those related to treating pain and stiffness, intervening in the disease process, and preserving joint function.

CONCLUSION

Both of these sets of behavioral factors may be related to the optimization of children's mobility, joint function, and autonomy of activities of daily living and should be targets of an educational intervention.

Parental risk and resistance factors among children with juvenile rheumatic disease: a four-year predictive study

Examined the extent to which baseline functioning and parental risk and resistance factors predicted disease-related (functional disability and pain) and psychosocial functioning (social competence and behavior problems) 4 years later among 172 children with juvenile rheumatic disease. The study also examined the extent to which fathers' risk and resistance factors explained patients' adaptation, above and beyond maternal factors. Poorer baseline functioning was a strong risk factor that predicted poorer functioning 4 years later. In addition, parental risk and resistance factors at baseline predicted patients' adjustment after patients' age and baseline functioning were controlled. Mothers' and fathers' personal strain and depressed mood, and fathers' drinking problems, were associated with poorer patient adjustment; mothers' and fathers' social functioning appeared to aid patients' adjustment. Fathers' risk and resistance factors contributed independently from those of mother, to predict patients' outcome.

Family functioning and injury severity as predictors of child functioning one year following traumatic brain injury

This study examined changes in children's functioning in the year following traumatic brain injury (TBI) and the preinjury family and injury factors most predictive of children's overall adaptive functioning and social competence at 1 year. Ninety-four children with TBI (mild = 50, moderate = 25, severe = 19) and their families were consecutively enrolled from two regional medical centers. The age range was from 6 years to 15 years. Interviewer ratings and standard measures of family and child functioning were completed within 3 weeks of injury (measuring preinjury status), at 3 months and 1 year. Mean preinjury parent and teacher ratings of child functioning were within normal range. Older children (> or = 12 years) had worse preinjury functioning than younger children. Declines in child functioning were significantly associated with injury severity. Mild and moderately injured children had few declines in overall functioning. Severely injured children had the most dramatic early declines and improved only slightly between 3 months and 1 year; however, older children from poorly functioning families deteriorated in the same period. Injury severity and preinjury family functioning explained from 25% to 39% of the variation in child functioning at 1 year and up to 57% when the child's preinjury status was included. Children at risk for poorer adaptation following TBI can be identified and for optimal recovery should receive appropriate support services for optimal recovery.

Psychosocial effects of juvenile rheumatic disease. The family and peer systems as a context for coping

The psychosocial effects of juvenile rheumatic diseases and disease activity were examined among 24 children and their families (12 children with a rheumatic disease and 12 children with no chronic illness). Each child with rheumatic illness was paired with a healthy control child nominated by their classroom teacher. Family and child functioning was assessed through measures of competence, coping, and adjustment and through direct observation of social functioning with peers at school. Multivariate and univariate analyses were performed to examine scores on the assessment measures, percentages of time spent in peer activities, and frequency scores for types of peer interactions. The results of these analyses indicated that juvenile rheumatic disease (JRD) is not associated with detrimental psychosocial outcomes. Instead, the results indicated that JRD children and their families actively utilize multiple coping strategies. These findings stress the importance of including and examining the family and peer systems as contexts for coping in future research.

Health status (arthritis impact) in children with chronic rheumatic diseases. Current measurement issues and an approach to instrument design

Arthritis outcome measures in adults have evolved from biologic "disease activity," to observations of motor/movement based "functional status," to assessment of "health status." This monograph suggests a framework for developing a pediatric arthritis health status (impact) instrument in which measurable global outcome dimensions include psychological, social, ADL, pain, school, family, behavioral, and developmental variables. Physical and laboratory parameters of inflammation/disease activity are not part of either functional status or arthritis impact, but rather perhaps the most important predictor variable of outcome. Juvenile rheumatoid arthritis (JRA) is a prototypic chronic disease for development of a health status instrument for children. Prior obstacles have been (a) that systemic, polyarticular, and pauciarticular JRA appear to have very different amounts of impact on health status; and (b) although juvenile arthritis has proven a useful term for medical and public education, its value as a study entry criterion for functional status instrument development is limited. Any new pediatric arthritis impact instrument must fulfill five criteria: enable quantification; demonstrate reliability, validity, and precision; and specify data collection procedures. Important design issues include (a) developing a self-report format for children, (b) ensuring generalizability across age groups, and (c) the parent as proxy in most patient-related dialogue and interventions. Instrument elements could come from 8-10 adult and pediatric health/functional status instruments already in use. By 10 years of age, children can provide much independent information. Whether global assessments by patient, parent, and physician should be included, or be a separate "gold standard," is not yet clear. The creation of better health status measures is an important and formidable challenge for pediatric rheumatology.