Family-level coping in juvenile rheumatoid arthritis: assessing the utility of a quantitative family interview

Psychological characteristics of caregivers of pediatric patients with chronic rheumatic disease in relation to treatment adherence

BACKGROUND

Adherence to treatment for chronic diseases is lower in children than in adults, less extensively studied in children and is associated with multiple related factors. The aim of this study is to perform a descriptive analysis of psycho-cognitive aspects of primary caregivers of pediatric patients with chronic rheumatic diseases, as well as socioeconomic and clinical factors, family functioning and treatment satisfaction.

METHODS

Primary caregivers of 90 patients were included. Pairs (caregiver plus patient) were grouped as presenting good adherence (n = 50) or poor adherence (n = 40) according to the Morisky Adherence Test. Psycho-cognitive aspects were evaluated by Adult Self-Report and Wechsler Adult Intelligence Scale tests. For statistical comparisons, quantitative variables with normal distribution were analyzed by Student's t test, and those with non-Gaussian distribution with the Mann Whitney test. Categorical variables were analyzed by Chi square test. A multivariate logistic regression analysis was performed to estimate the contribution of the independent variables to adherence.

RESULTS

Compared to caregivers in the good adherence group, caregivers in the poor adherence group were more likely to be classified as clinical on the scales for attention problems and externalizing problems, which include impulsiveness and aggressiveness. They also scored higher on the depressive problem scale. In addition, the average number of children per caregiver and the mean age of caregivers and patients were significantly higher in the poor adherence group, while the proportion of caregivers with higher education was lower. The poor adherence group also included a higher incidence of pediatric patients assuming sole responsibility for managing medications. Economic status, clinical factors, treatment satisfaction, family functioning and caregiver cognitive profile were not related to adherence, except for working memory index.

CONCLUSION

Older patients, patients as the one solely responsible for medication management, and caregivers with externalizing problems, were observed to be the most strongly associated to poor adherence. Interventions aimed at adolescent patients are needed. Also, psychological programs and interventional studies to better determine caregivers' behavioral/emotional status, and parent-child relationships are recommended.

Qualitative Methods to Advance Care, Diagnosis, and Therapy in Rheumatic Diseases

This article provides an overview of the basis, usefulness, and validity of qualitative methods in research. It is aimed to enhance the understanding of a broad spectrum of readers, ranging from those mystified by such approaches, to those wanting a better critical knowledge to apply to literature review, and for health care providers considering developing an interest in the field. Qualitative research is crucial in augmentation of disease knowledge as well as the development of incremental care strategies and operational aspects of care that improves health outcomes.

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.

Methotrexate polyglutamates as a potential marker of adherence to long-term therapy in children with juvenile idiopathic arthritis and juvenile dermatomyositis: an observational, cross-sectional study

Introduction

Methotrexate (MTX) is a cornerstone of treatment in a wide variety of inflammatory conditions, including juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM). However, owing to its narrow therapeutic index and the considerable interpatient variability in clinical response, monitoring of adherence to MTX is important. The present study demonstrates the feasibility of using methotrexate polyglutamates (MTXPGs) as a biomarker to measure adherence to MTX treatment in children with JIA and JDM.

Methods

Data were collected prospectively from a cohort of 48 children (median age 11.5 years) who received oral or subcutaneous (SC) MTX therapy for JIA or JDM. Dried blood spot samples were obtained from children by finger pick at the clinic or via self- or parent-led sampling at home, and they were analysed to determine the variability in MTXPG concentrations and assess adherence to MTX therapy.

Results

Wide fluctuations in MTXPG total concentrations (>2.0-fold variations) were found in 17 patients receiving stable weekly doses of MTX, which is indicative of nonadherence or partial adherence to MTX therapy. Age (P = 0.026) and route of administration (P = 0.005) were the most important predictors of nonadherence to MTX treatment. In addition, the study showed that MTX dose and route of administration were significantly associated with variations in the distribution of MTXPG subtypes. Higher doses and SC administration of MTX produced higher levels of total MTXPGs and selective accumulation of longer-chain MTXPGs (P < 0.001 and P < 0.0001, respectively).

Conclusions

Nonadherence to MTX therapy is a significant problem in children with JIA and JDM. The present study suggests that patients with inadequate adherence and/or intolerance to oral MTX may benefit from SC administration of the drug. The clinical utility of MTXPG levels to monitor and optimise adherence to MTX in children has been demonstrated.

Trial registration

ISRCTN Registry identifier: ISRCTN93945409. Registered 2 December 2011.

Caregiver recall of treatment recommendations in juvenile idiopathic arthritis

OBJECTIVE

Health care providers in juvenile idiopathic arthritis (JIA) might refer to caregivers' self-report of children's treatment-related behaviors to assist in clinical decisions. However, caregivers may believe that they are adhering to treatment even though they have a different understanding of recommendations than that intended by the medical team. We examined whether caregiver recall of children's JIA treatment matched actual recommendations at baseline and 3, 6, 9, and 12 months.

METHODS

A total of 235 primary caregivers were recruited from rheumatology clinics at 2 pediatric university-based teaching hospitals in Canada. Using the Parent Adherence Report Questionnaire, caregivers indicated whether their child was prescribed medications and/or exercises. Medical charts were reviewed to determine the prescribed treatment. Level of agreement between both sets of data was then examined.

RESULTS

A total of 175 caregivers provided complete data. Mean age of the children was 10.2 years (68.6% girls); 44.6% were diagnosed with oligoarthritis. Kappa coefficients for medication represented substantial to almost perfect agreement beyond chance, with better levels of agreement at 12 months (kappa = 0.81, 95% confidence interval [95% CI] 0.68, 0.94) than at baseline (kappa = 0.61, 95% CI 0.47, 0.76). Kappa coefficients for exercise represented slight to moderate agreement beyond chance, with better agreement at 12 months (kappa = 0.44, 95% CI 0.24, 0.63) than at baseline (kappa = 0.27, 95% CI 0.08, 0.47).

CONCLUSION

Weaker agreement for the exercise regimen raises concern that caregivers may pay less attention to exercise recommendations or that these recommendations may not be easily understood.

Pilot Study of Pain and Coping Among Patients With Osteoarthritis

BACKGROUND AND OBJECTIVES

Few studies have examined patterns of pain and coping among patients with osteoarthritis (OA). This pilot study used a daily diary approach to examine pain and coping strategy use among white and nonwhite veterans with OA.

METHODS

Participants (23 white, 13 nonwhite; 89% male; mean age = 63 years) completed diaries of pain (10-cm visual analog scale) and coping (total, problem-focused, and emotion-focused) for 30 days. Analyses examined relationships of mean self-reported pain severity and variability with coping strategy use as well as racial differences in these associations.

RESULTS

The mean pain level (4.46 [scale of 0-10], standard deviation [SD] = 2.12) and mean within-subject pain variance (1.94, SD = 1.79) were similar between white and nonwhite participants. With respect to pain variability, 2 distinct subgroups were observed, with approximately half of participants reporting high variability and half reporting low variability. The mean total coping score (on a scale of 0-7) was 2.62 (SD = 1.77), with problem-focused strategies being used more often than emotion-focused. There were no significant associations between coping (total, problem-focused, and emotion-focused) and mean pain severity, but the direction of these relationships differed according to race.

CONCLUSION

Results of this pilot study showed considerable between-subject variability in pain and coping strategy use as well as some racial differences. Medical treatment and self-management approaches may be improved if they can be tailored according to patients' pain patterns and preferred coping strategies.

Illness trajectories in Mexican children with juvenile idiopathic arthritis and their parents

BACKGROUND

We hypothesize that the qualitative approach of socio-cultural aspects in children with juvenile idiopathic arthritis (JIA) and their parents would improve the understanding of their illness.

OBJECTIVE

To explain the phenomenon of experiencing JIA within a specific cultural context.

METHODS

The theoretical position of this research was based on the substantive theories of suffering, explanatory models and illness experience. Its design was that of qualitative field, and its analysis followed the interpretative grounded theory methodology. Data were collected by in-depth interviews and notes; tape recordings were transcribed verbatim, read and imported into the ATLAS/ti 4.2 software. Data conceptualization, categorization and interpretation were based on the constant comparison method.

RESULTS

A total of 16 adults and six children from 10 families were interviewed. 'Pilgrimage' (metaphorically referred by some of the parents) was a major code in the study that reflected the religious reference to the trajectory of pain, faith and hope. For children, pilgrimage was conformed by immediate concepts; for parents, by historical and immediate experiences influenced by JIA subtype. Pilgrimage was consistent with the model of the illness trajectory theory, which conceptually relates to the idea that the course of chronic diseases is variable and modifiable throughout time.

CONCLUSION

The qualitative approach of JIA provides wide and deep information on the perception that children and parents have about the disease. The illness trajectory theory corresponds to pilgrimage, the theoretical model for JIA in this study.

Parental illness, family functioning, and adolescent well-being: a family ecology framework to guide research

A family ecology model for understanding adolescents' reactions to parental illness is presented and used to (a) critically evaluate existing research that examines direct effects of parental illness on family functioning and youth well-being and (b) provide a blueprint for future research in the area. Theoretical, clinical, and empirical literature is reviewed for each mediational and moderational pathway in the model, and limitations of the existing research are discussed. The blueprint for future research emphasizes a greater understanding of the mediational pathways in the model, which is essential for developing effective interventions for families experiencing parental illness. In addition, greater elucidation of moderator variables, such as the youth's developmental stage, social support, and cultural norms will provide critical information on contextual factors that enhance or impede adolescents' adaptation to serious parental illness.

Development and evaluation of a cognitive-behavioral intervention for juvenile fibromyalgia

OBJECTIVE

To describe the development and test the efficacy of a cognitive-behavioral intervention (CBT) for juvenile fibromyalgia.

METHOD

Sixty-seven children with fibromyalgia and their parents were recruited to participate in an 8-week intervention that included modules of pain management, psychoeducation, sleep hygiene, and activities of daily living. Children were taught techniques of cognitive restructuring, thought stopping, distraction, relaxation, and self-reward. Additionally, they kept daily pain and sleep diaries. Children completed questionnaires of pre- and post-treatment measuring physical status and psychological functioning.

RESULTS

Following CBT, children reported significant reductions (p < .006) in pain, somatic symptoms, anxiety, and fatigue, as well as improvements in sleep quality. Additionally, children reported improved functional ability and had fewer school absences.

CONCLUSION

Children with fibromyalgia can be taught CBT strategies that help them effectively manage this chronic and disabling musculoskeletal pain disorder.

What does "active disease" mean? patient and parent perceptions of disease activity in the systemic arthritis form of juvenile idiopathic arthritis (SO-JIA)

OBJECTIVE

The systemic onset form of juvenile idiopathic arthritis (SO-JIA) is a very serious chronic illness of childhood. At present, there is no specific tool to measure disease activity for SO-JIA. Our long-term goal is to develop a disease activity measure for SO-JIA using a consensus (Delphi) approach. In preparation for the development of this measure, we interviewed both patients and their parents. We sought to elicit specific items reflecting their perceptions of active disease that may be considered for inclusion in a disease activity measure for SO-JIA.

METHODS

SO-JIA patients followed at The Hospital for Sick Children and their parents were chosen by purposive sampling. A trained research coordinator interviewed all participants using open-ended questions to elicit aspects of disease activity (defined as reversible manifestations of disease) of relevance to families. A list of these aspects was then generated and organized by categories to allow item reduction.

RESULTS

Fourteen patients (eight females) with a mean age of 11.8 yr (mean disease duration 5.2 yr) and their parents were interviewed. A total of 292 items were generated, with an average of 11 items generated per interview. Arthralgia, ambulation difficulties, rash, decreased energy level and fever were the most common items mentioned by patients and their parents. Mood disturbances, decreased activity levels, arthritis severity and decreased school attendance were also common items identified as relevant aspects of disease activity.

CONCLUSION

This study has allowed us to include patient and parent perspectives in preparation for developing a disease activity measure for SO-JIA. The resulting items will be added to future physician surveys in the further development and validation of a disease activity measure for SO-JIA.

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.

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.

Life stressors, social resources, and coping skills in youth: applications to adolescents with chronic disorders

After setting out a conceptual framework that focuses on how personal and social resources aid adolescents in managing acute and chronic stressors, I describe methods by which to assess adolescents' family environments and specific life stressors and social resources, and the approach and avoidance coping responses adolescents use to manage life stressors. I then review some research that employs these concepts and methods to focus on the families and life contexts, and coping skills, of youth with chronic medical disorders, including juvenile rheumatic disease (JRD). I close by drawing implications for assessment and intervention and describing some fruitful areas for future research, such as examining the reciprocal linkages between parental and youth behavior, how adolescents' personal characteristics shape their life context, and how life crises and transitions enhance adolescents' development and maturation.