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Mood and Stress Predict Pain in Children With Arthritis

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Duke Health News 919-660-1306

DURHAM, N.C. - For children with arthritis, increases in
stress and depressed mood worsen disease symptoms and predict
cut backs in social and school activities, according to a Duke
University Medical Center study.

The researchers found mood was a key predictor of flare-ups
in symptoms such as pain, stiffness and fatigue. An analysis of
daily pain diaries kept by children with arthritis showed as
mood worsened, reporting of disease symptoms increased.
Similarly, rising daily stress was linked to increased fatigue
and pain. The diaries showed that children felt pain, stiffness
and fatigue during most days of the two-month study, even with
treatment meant to reduce inflammation and pain.

However, the children reported positive mood on more than 90
percent of days despite these symptoms. Even so, because of
their disease symptoms, many skipped social activities and,
more rarely, school attendance or activities.

"Doctors should aggressively treat pain, stiffness and
fatigue in children, because cutting back on play or school can
exacerbate feelings of isolation, depression and poor
quality-of-life – emotions common in kids with chronic
illness," said lead author Laura Schanberg, M.D. "This
aggressive treatment may not mean changing or adding
medication, but rather more effective application of cognitive
behavioral therapy, relaxation and stress management," said
Schanberg, a pediatric rheumatologist and associate professor
of pediatrics at Duke.

The study was published in the April 2005 issue of Arthritis
& Rheumatism. The research was supported by the Arthritis
Foundation; the National Institute of Arthritis and
Muscoskeletal and Skin Diseases of the National Institutes of
Health; and the Fetzer Institute.

The Duke study was designed to analyze the daily patterns of
stress, mood and disease symptoms in children with
polyarticular arthritis, in which the disease affects many
joints at once. The 51 study participants, ages 8 through 18
years old, were recruited from the Duke Children's Hospital
pediatric rheumatology clinic. Most children were taking a
non-steroidal anti-inflammatory drug (NSAID) and/or
methotrexate -- both common drug treatments for arthritis.

The kid-friendly daily diary included standardized measures
of disease symptoms, stress, mood and function designed to
elicit accurate, truthful responses from children. For example,
daily mood was assessed with the "Facial Affective Scale,"
which consists of nine faces that vary in levels of expressed
distress. Children were asked to, "Please mark the face that
looks like how you felt deep down inside today – not just how
your face looked, but how you really felt inside."

The children's ratings of their daily stress, mood, pain,
stiffness and fatigue varied significantly from day to day. A
drop in mood and an increase in pain symptoms played a role in
predicting a reduction in social activities. However, only mood
and stiffness were crucial predictors of a cutback in school
attendance, the researchers found.

The diaries showed that children were more likely to cut
back on social activities than skip school. Although this
difference may reflect an appropriate emphasis on the
importance of school, the significance of this finding should
not be minimized, because reducing social activities could
contribute to feelings of social isolation and worsen the
quality of life for children, Schanberg said. As Schanberg
explains, research has documented that children with arthritis
are at increased risk for feelings of loneliness and other
difficulties with peer relationships. Limited involvement in
social activities and poor school attendance can hinder
academic progress and social and emotional development, leading
to depression and anxiety, she said.

"Comprehensive care of children with arthritis includes more
than medications to treat pain and immune system dysfunction.
It means helping children and families cope with routine
stresses and strains of life – not the extraordinary issues,
but just the normal day-to-day vagaries of life," Schanberg
said.

Other members of the research team are Karen Gil of the
University of North Carolina at Chapel Hill; Kelly Anthony,
Eric Yow and James Rochon of Duke.

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