Mood and Stress Predict Pain in Children With Arthritis

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For children with arthritis, increases in stress and depressed mood worsen disease symptoms and predict cut backs in social and school activities.

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 and 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.

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