Systematic review and meta analysis of psychological interventions to prevent or treat pediatric chronic disease in rural communities.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to examine the effectiveness of psychological interventions at improving physical or mental health outcomes for youth living in rural communities who have, or are at-risk for, any chronic medical condition in comparison to control interventions conducted in rural communities. METHODS: Following prospective registration (OSF.IO/7TDQJ), 7 databases were searched through July 1, 2023. Studies were included if they were a randomized control trial of a psychological intervention conducted with youth living in a rural area who had, or were at-risk for, a chronic medical condition. Risk of bias was assessed with the Cochrane risk of bias version 2 tool. A qualitative synthesis and meta-analysis were conducted. RESULTS: 15 studies met inclusion criteria. Obesity studies (n = 13) primarily focused on body mass index metrics, with limited significant findings across studies. Asthma treatment interventions (n = 2) showed no impact on hospitalizations. 3 studies evaluated mental health outcomes with no significant group differences observed. We meta-analytically analyzed 9 studies that evaluated body mass index z-scores and identified an overall null effect (Hedge's g = 0.01, 95% CI [-0.07, 0.09], p = .85). CONCLUSIONS: Most included studies focused on pediatric obesity, and there was a limited range of health outcomes reported. Compared to controls, minimal significant improvements in health outcomes were identified for psychological interventions for youth living in rural communities. Future efforts may benefit from situating this work more systematically within a health disparities framework with a focus on understanding mechanisms of disparities and translating this work into interventions and policy changes.

Hedonic Appetite, Affect, and Loss of Control Eating: Macrotemporal and Microtemporal Associations in Adolescents.

OBJECTIVE: Loss of control eating (LOC) is a dysregulated eating behavior relevant to eating disorders and weight-related health concerns. Hedonic appetite and affect (positive/negative) are dynamic microtemporal processes that influence LOC, but they have been studied predominantly in a static, macrotemporal manner. The present study examined associations of hedonic appetite and positive/negative affect, on macrotemporal and microtemporal levels, with LOC in adolescents. METHODS: Adolescent participants 13-18 years old (n = 43; Mage = 15.1, SD = 1.6; 69.8% female) completed smartphone surveys for 6 evenings, assessing LOC, hedonic appetite, and positive/negative affect. Scores on items were calculated to create microtemporal and macrotemporal assessments of these constructs. Multilevel models were run to examine associations between hedonic appetite and positive/negative affect with LOC. RESULTS: Both macrotemporal and microtemporal hedonic appetite were significantly positively related to LOC (ß = .73, p < .001; ß = .47, p < .001, respectively). Macrotemporal positive affect was significantly negatively associated with LOC (ß = -.09, p < .001). Macrotemporal negative affect was significantly positively associated with LOC (ß = .13, p < .001). No significant relationships emerged between microtemporal positive/negative affect and LOC. CONCLUSIONS: Hedonic appetite appears to be associated with LOC on both microtemporal and macrotemporal levels, suggesting that both momentary fluctuations and having higher hedonic appetite than others can be risk factors for LOC. However, affect appears to be associated with LOC only at the macrotemporal level. Findings may inform theoretical work and clinical and research assessment strategies.

The Development and Initial Validation of Items to Assess Parent Fear of Nighttime Hypoglycemia.

OBJECTIVE: Parents of youth with type 1 diabetes (T1D) are fearful their children will experience nighttime hypoglycemia. Currently, the Hypoglycemia Fear Survey for Parents (HFS-P) lacks items that specifically assess parents' nighttime fear. This study aimed to fill this gap by rigorously identifying new items to specifically assess parent fear of nighttime hypoglycemia and then examine the psychometric properties of the revised Hypoglycemia Fear Survey for Parents including Nighttime Fear (HFS-P-NF). METHODS: For Phase 1, we recruited 10 pediatric diabetes providers and 15 parents/caregivers of youth with T1D to generate items related to fear of nighttime hypoglycemia. For Phase 2, we recruited an additional 20 parents/caregivers to pilot-test the newly generated items. For Phase 3, we recruited another 165 parents/caregivers to evaluate structural validity via confirmatory factor analyses, reliability, and content validity of the revised HFS-P-NF. RESULTS: In Phase 1, we generated 54 items. In Phase 2, we removed 34 items due to violations of distributional normality and nonsignificant correlations. In Phase 3, a four-factor model reflecting behaviors maintaining high glucose, helplessness, negative social consequences, and nighttime worries was the best fitting model for the HFS-P-NF. The new items demonstrated strong internal consistency (α = 0.96) and strong to moderate relationships with criterion and content validity measures. CONCLUSION: The current study provides initial evidence of validity and reliability for new items on the HFS-P-NF that broadened the conceptualization of parent fear of nighttime hypoglycemia. These findings are important to clinicians who may consider screening for parent fear of nighttime hypoglycemia more comprehensively.

Caregiving and Confidence to Avoid Hospitalization for Children with Medical Complexity.

OBJECTIVE: To test associations between parent-reported confidence to avoid hospitalization and caregiving strain, activation, and health-related quality of life (HRQOL). STUDY DESIGN: In this prospective cohort study, enrolled parents of children with medical complexity (n = 75) from 3 complex care programs received text messages (at random times every 2 weeks for 3 months) asking them to rate their confidence to avoid hospitalization in the next month. Low confidence, as measured on a 10-point Likert scale (1 = not confident; 10 = fully confident), was defined as a mean rating <5. Caregiving measures included the Caregiver Strain Questionnaire, Family Caregiver Activation in Transition (FCAT), and caregiver HRQOL (Medical Outcomes Study Short Form 12 [SF12]). Relationships between caregiving and confidence were assessed with a hierarchical logistic regression and classification and regression trees (CART) model. RESULTS: The parents were mostly mothers (77%) and were linguistically diverse (20% spoke Spanish as their primary language), and 18% had low confidence on average. Demographic and clinical variables had weaker associations with confidence. In regression models, low confidence was associated with higher caregiver strain (aOR, 3.52; 95% CI, 1.45-8.54). Better mental HRQOL was associated with lower likelihood of low confidence (aOR, 0.89; 95% CI, 0.80-0.97). In the CART model, higher strain similarly identified parents with lower confidence. In all models, low confidence was not associated with caregiver activation (FCAT) or physical HRQOL (SF12) scores. CONCLUSIONS: Parents of children with medical complexity with high strain and low mental HRQOL had low confidence in the range in which intervention to avoid hospitalization would be warranted. Future work could determine how adaptive interventions to improve confidence and prevent hospitalizations should account for strain and low mental HRQOL.

Applying Behavioral Economics Theories to Interventions for Persons with Diabetes.

PURPOSE OF REVIEW: To introduce behavioral economics (BE), provide a description of how recent prevention and treatment interventions in persons with diabetes have incorporated BE in their intervention strategies, and discuss how BE could be used to inform new treatments for the clinical setting or research. RECENT FINDINGS: In most of the trials described, researchers incorporated BE into their design in the form of incentives, which can align with present bias, optimism bias, and loss aversion. With only two exceptions, these trials reported preliminary support for using incentives to promote lifestyle modifications and diabetes-related tasks. Additionally, two trials reported promising results for behavior change strategies informed by default bias, while three trials reported promising results for behavior change strategies informed by social norms. Recent trials incorporating BE in prevention and treatment interventions for persons with diabetes generally report promising results, though gaps exist for research and clinical deployment.

Location-specific psychosocial and environmental correlates of physical activity and sedentary time in young adolescents: preliminary evidence for location-specific approaches from a cross-sectional observational study.

BACKGROUND: A better understanding of the extent to which psychosocial and environmental correlates of physical activity are specific to locations would inform intervention optimization. PURPOSE: To investigate cross-sectional associations of location-general and location-specific variables with physical activity and sedentary time in three common locations adolescents spend time. METHODS: Adolescents (N = 472,Mage = 14.1,SD = 1.5) wore an accelerometer and global positioning systems (GPS) tracker and self-reported on psychosocial (e.g., self-efficacy) and environmental (e.g., equipment) factors relevant to physical activity and sedentary time. We categorized each survey item based on whether it was specific to a location to generate psychosocial and environmental indices that were location-general or specific to either school, non-school, or home location. Physical activity (MVPA) and sedentary time were based on time/location match to home, school, or all "other" locations. Mixed-effects models investigated the relation of each index with location-specific activity. RESULTS: The location-general and non-school physical activity psychosocial indices were related to greater MVPA at school and "other" locations. The school physical activity environment index was related to greater MVPA and less sedentary time at school. The home activity environment index was related to greater MVPA at home. The non-school sedentary psychosocial index was related to less sedentary time at home. Interactions among indices revealed adolescents with low support on one index benefited (i.e., exhibited more optimal behavior) from high support on another index (e.g., higher scores on the location-general PA psychosocial index moderated lower scores on the home PA environment index). Concurrent high support on two indices did not provide additional benefit. CONCLUSIONS: No psychosocial or environment indices, including location-general indices, were related to activity in all locations. Most of the location-specific indices were associated with activity in the matching location(s). These findings provide preliminary evidence that psychosocial and environmental correlates of activity are location specific. Future studies should further develop location-specific measures and evaluate these constructs and whether interventions may be optimized by targeting location-specific psychosocial and environmental variables across multiple locations.

Daily adherence variability and psychosocial differences in adolescents with asthma: a pilot study.

Adolescents with asthma endorse psychosocial difficulties as barriers to inhaled corticosteroid adherence. This study examined patterns of variability in adherence and within-person associations of psychosocial variables with adherence across days. Participants included twenty-five adolescents (Mage = 14.7, SD = 1.68; 48% male) with persistent asthma. We measured adherence via electronic monitoring. Adolescents completed daily surveys measuring asthma symptoms, stress, mood, and affect. We examined within-person differences in the effect of symptoms and psychosocial variables on adherence. Adherence decreased over time. The addition of a random slope improved model fit (- 2ΔLL(1) = 9.36, p < .01). Greater asthma symptoms were significantly associated with higher adherence at the within-person level and with lower adherence between persons. We observed evidence of individual differences in the associations of stress and affect with adherence. Within-person, day-level fluctuations in adherence occur. Symptoms and psychosocial variables may influence adherence. Individually tailored interventions may effectively address nonadherence.

Parent-Child Conflict Moderates the Relationship Between Executive Functioning and Child Disruptive Behaviors in Youth with T1D.

Executive function (EF) skills, parent-child conflict, and high blood glucose (BG) may impact child externalizing behaviors. We examined these child and parent factors in families of 5-9 year olds with recent-onset type 1 diabetes (T1D). Parents (N = 125) reported child EF, child externalizing behaviors, and conflict regarding T1D-specific tasks. We used self-monitoring BG uploads to calculate the percentage of time children had high BG (> 180 mg/dl). We entered data into a moderated path analysis using MPlus8. The path analysis revealed a positive direct effect for parent-reported child EF and child externalizing behavior (p < .01). Further, T1D-specific conflict moderated the positive association between parent-reported child EF and child externalizing behaviors (p < .05). Early screening of child EF, externalizing behavior, and family conflict may be particularly important in the recent-onset period of T1D. The introduction of T1D-related conflict after diagnosis may impact child externalizing behavior and limited child EF skills that pre-date diagnosis.

Individual Differences in the Relationship Between Pain Fear, Avoidance, and Pain Severity in a Chronic Abdominal Pain Sample and the Moderating Effect of Child Age.

BACKGROUND/PURPOSE: Most studies examining the components of the fear-avoidance model have examined processes at the group level. The current study used ecological momentary assessments to: (a) investigate the group and intraindividual relationships between pain fear, avoidance, and pain severity, (b) identify any heterogeneity between these relationships, and (c) explore the role of moderators to explain such heterogeneity. METHODS: Seventy-one pediatric patients with chronic abdominal pain (M = 13.34 years, standard deviation = 2.67 years) reported pain fear, avoidance, and pain severity four times per day over 14 days. RESULTS: Results indicated significant individual differences in the relationship between pain fear and pain avoidance predicting pain severity. Child age helped explain the heterogeneity in the relationships between pain avoidance and pain severity such that older children had a stronger and more positive relationship between these variables. The random effect between pain fear and pain severity also indicated a moderator trend of child age such that older children were likely to have a stronger and more positive relationship. CONCLUSIONS: The present study extends the fear-avoidance model by highlighting the importance of identifying potential individual differences when examining pain fear, avoidance, and pain severity. Furthermore, the current study suggests that child development should be considered in the model. However, future randomized control designs are necessary to explore the causal relationships between pain fear and avoidance on pain severity and potential developmental differences.

Meta-Analysis of Adherence Promotion Interventions in Pediatric Asthma.

BACKGROUND: Youth with asthma commonly have suboptimal adherence to inhaled corticosteroids (ICS). It is critical to systematically evaluate the effectiveness of ICS adherence promotion interventions and discern which techniques are most effective. OBJECTIVE: This study aims to (1) quantify the extent to which interventions improve ICS adherence in pediatric asthma, (2) explore differences in effect size estimates based on intervention and study characteristics, and (3) characterize the risk of bias across interventions. METHODS: We conducted literature searches across five databases. Included studies quantitatively measured ICS adherence as an intervention outcome among youth (<18 years old) diagnosed with asthma and were published after 1997. We analyzed aggregate effect sizes and moderator variables using random-effects models and characterized risk of bias using the Cochrane Collaboration tool. RESULTS: Thirty-three unique studies met inclusion criteria. At post-intervention, the aggregate effect size for pediatric ICS adherence promotion interventions was small but significant (n = 33, g = 0.39, 95% confidence interval [CI] = 0.24-0.54); however, the aggregate effect size at follow-up was not statistically significant (n = 6, g = 0.38, 95% CI = -0.08 to 0.83). Method of adherence measurement and intervention format were significant moderators. Most interventions had a high risk of performance bias and an unclear risk of bias in one or more domains. CONCLUSIONS: ICS adherence promotion interventions are effective among youth with asthma. Additional longitudinal research is needed to quantify a more precise measure of intervention effectiveness over time, and moderators of intervention effectiveness should be reassessed as the literature base expands.

Adaptive mHealth Intervention for Adolescent Physical Activity Promotion.

OBJECTIVE: The present nonrandomized controlled trial aimed to evaluate feasibility, acceptability, and preliminary efficacy of a tailored text message intervention for increasing adolescent physical activity, as compared with passive monitoring. METHODS: Forty adolescents (13-18 years old) received either a tailored text messaging intervention (Network Underwritten Dynamic Goals Engine [NUDGE]; N = 20), or participated in an attention-control condition (N = 20), for 20 days. Physical activity was measured for all participants via continuous accelerometry. Frequency analyses were conducted on program usage and satisfaction ratings to evaluate feasibility and acceptability, and multilevel models were used to evaluate the efficacy hypotheses. RESULTS: The vast majority of participants (90%) reported being very or mostly satisfied with the NUDGE program and rated their enjoyment as above average. The intervention group was estimated to spend an average of 20.84 more minutes per day in moderate-to-vigorous physical activity relative to the attention-control group (ß = 20.84, SE = 8.19). Exploratory analyses revealed that the intervention group also engaged in 82 fewer minutes of sedentary time per day on average, although this effect was not significant due to the large variability in sedentary time (ß = -81.98, SE = 46.86). CONCLUSIONS: The NUDGE tailored text messaging intervention was feasible, acceptable, and efficacious in increasing physical activity in this sample. Findings warrant additional evaluation of NUDGE as both a standalone physical activity intervention or as part of a multicomponent package.

Evaluating associations between fitspiration and thinspiration content on Instagram and disordered-eating behaviors using ecological momentary assessment: A registered report.

INTRODUCTION: Greater use of appearance-focused social media, such as Instagram, is associated with increased body dissatisfaction and eating disorder (ED) symptoms; however, questions remain about the mechanism connecting social media use to disordered-eating behaviors (DEBs). The proposed study evaluates how and for whom exposure to fitspiration or thinspiration on Instagram is associated with DEBs. METHODS: We will evaluate a hypothesized pathway from Instagram use to disordered-eating mediated by negative affect. We will test how individual differences in internalized weight stigma, trait self-esteem, and trait self-comparison moderate the pathway from social media use to negative affect. We will recruit 175 undergraduate women who report engaging in DEBs on average at least once per week over the past 3 months. Participants will complete a 7-day ecological momentary assessment protocol, during which they will report their Instagram use, affect, and engagement in DEBs. RESULTS: Multi-level modeling will be used to assess moderated mediation. Results from this study will provide increased specificity about how Instagram usage is linked to eating pathology and who may be most vulnerable to experiencing distress. DISCUSSION: Information about negative affect from Instagram and engagement in DEBs could contribute to the development of Just-In-Time Interventions for problematic social media use.

Differences in adolescent activity and dietary behaviors across home, school, and other locations warrant location-specific intervention approaches.

BACKGROUND: Investigation of physical activity and dietary behaviors across locations can inform "setting-specific" health behavior interventions and improve understanding of contextual vulnerabilities to poor health. This study examined how physical activity, sedentary time, and dietary behaviors differed across home, school, and other locations in young adolescents. METHODS: Participants were adolescents aged 12-16 years from the Baltimore-Washington, DC and the Seattle areas from a larger cross-sectional study. Participants (n = 472) wore an accelerometer and Global Positioning Systems (GPS) tracker (Mean days = 5.12, SD = 1.62) to collect location-based physical activity and sedentary data. Participants (n = 789) completed 24-h dietary recalls to assess dietary behaviors and eating locations. Spatial analyses were performed to classify daily physical activity, sedentary time patterns, and dietary behaviors by location, categorized as home, school, and "other" locations. RESULTS: Adolescents were least physically active at home (2.5 min/hour of wear time) and school (2.9 min/hour of wear time) compared to "other" locations (5.9 min/hour of wear time). Participants spent a slightly greater proportion of wear time in sedentary time when at school (41 min/hour of wear time) than at home (39 min/hour of wear time), and time in bouts lasting ≥30 min (10 min/hour of wear time) and mean sedentary bout duration (5 min) were highest at school. About 61% of daily energy intake occurred at home, 25% at school, and 14% at "other" locations. Proportionately to energy intake, daily added sugar intake (5 g/100 kcal), fruits and vegetables (0.16 servings/100 kcal), high calorie beverages (0.09 beverages/100 kcal), whole grains (0.04 servings/100 kcal), grams of fiber (0.65 g/100 kcal), and calories of fat (33 kcal/100 kcal) and saturated fat (12 kcal/100 kcal) consumed were nutritionally least favorable at "other" locations. Daily sweet and savory snacks consumed was highest at school (0.14 snacks/100 kcal). CONCLUSIONS: Adolescents' health behaviors differed based on the location/environment they were in. Although dietary behaviors were generally more favorable in the home and school locations, physical activity was generally low and sedentary time was higher in these locations. Health behavior interventions that address the multiple locations in which adolescents spend time and use location-specific behavior change strategies should be explored to optimize health behaviors in each location.

The Association Between Affect and Sleep in Adolescents With and Without FGIDs.

OBJECTIVE: Adolescents with chronic pain associated with functional gastrointestinal disorders (FGIDs) experience negative impacts on their health behaviors (i.e., sleep) and are at risk for a range of problems related to negative affect, which may serve to exacerbate one another in a reciprocal fashion. This study aimed to determine if the strength of the relationship between affect and sleep differs across community adolescents and adolescents with FGIDs. It was hypothesized that shorter sleep durations would be associated with more negative affect and longer sleep durations would be associated with more positive affect, and that group membership would moderate these relationships. METHODS: Twenty-five adolescents with FGIDs were compared with 25 matched peers to examine the differential association between affect and total sleep time (TST). Models were estimated using SAS PROC MIXED for inter- and intraindividual differences. RESULTS: Models predicting TST revealed a significant three-way interaction among weekday, group status, and negative affect. Simple slopes indicated that when negative affect is one standard deviation below the child's own average on weekends, participants with FGIDs obtained significantly more sleep than those in the comparison group (ß = 47.67, p < .05). CONCLUSIONS: The findings of the present study show that when adolescents with FGIDs have lower negative affect on the weekend, when demands are likely reduced, they are able to obtain more TST. These findings confirm that unique relationships exist between negative affect and sleep duration for youth with FGIDs, and their interaction may hold value in understanding and addressing these targets.

Dietary Motivation and Hedonic Hunger Predict Palatable Food Consumption: An Intensive Longitudinal Study of Adolescents.

Background: Understanding interactions between stable characteristics and fluctuating states underlying youth's food choices may inform methods for promoting more healthful food intake. Purpose: This study examined dietary motivation and hedonic hunger as interacting predictors of adolescents' consumption of palatable foods. Methods: Intensive longitudinal data were collected from 50 adolescents (aged 13-18) over 20 days. Participants completed a measure of dietary motivation at baseline and reported on hedonic hunger and palatable food consumption via a smartphone app at the end of each day. Results: Results indicated that 66.7% of the variability in hedonic hunger was between-person (BP) and 33.3% was within-person (WP). BP hedonic hunger was positively associated with fatty food consumption (ß = 0.28, p < .05), and WP hedonic hunger was positively associated with starchy food consumption (ß = 0.38, p < .0001). Autonomous motivation was negatively associated with consumption of fast foods (ß = -0.14, p < .05). Significant cross-level interactions were found: WP hedonic hunger and controlled motivation were positively associated with starchy food consumption, and WP hedonic hunger and autonomous motivation were negatively associated with fast food consumption. Conclusions: Findings indicated that hedonic hunger has the potential to fluctuate, and conceptualization of the variable as both trait and state may be most appropriate. Adolescents with controlled dietary motivation may be vulnerable to the influence of hedonic hunger and prone to eating higher quantities of starchy foods. Adolescents with autonomous dietary motivation may be less vulnerable to hedonic hunger and less likely to consume fast food.

Bidirectional Associations Between Psychological States and Physical Activity in Adolescents: A mHealth Pilot Study.

Objective: To understand the predictors and consequences of adolescent moderate-to-vigorous physical activity (MVPA) and sedentary behavior in nearly real-time. Methods: Participants were 26 adolescents ( M age = 15.96, SD = 1.56) who provided 80 self-reports of subjective states and continuous objective reports of MVPA and sedentary behavior over 20 days. Results: Random effects were observed for all of the models with affect and feeling variables predicting MVPA. There was a negative fixed effect for within-person positive affect and sedentary behavior and the inverse association for negative affect. Within-person MVPA was a significant positive predictor of positive affect and energy. There was a random effect for within-person MVPA and fatigue. There was a significant random effect for within-person sedentary behavior predicting positive affect. Within-person sedentary behavior was a significant negative predictor of energy. Conclusions: Findings highlight the importance of the intrapersonal nature of the associations among subjective states and physical activity.

Health-Related Quality of Life and Parental Stress in Children With Fecal Incontinence: A Normative Comparison.

OBJECTIVE: The aim of the present study was to describe the quality of life and parenting stress associated with a child with fecal incontinence (FI). METHODS: Female caregivers (n = 170) of children of 3 to 12 years age with FI completed a broad and general measure of quality of life and a measure of parenting stress. Results were compared with proxy reports for a normative sample of healthy children. RESULTS: Caregivers of children with FI reported significantly impaired quality of life for their children and increased parenting stress in all of the respective domains relative to healthy controls. Impairments reported by caregivers were large in magnitude. Similarly, rates of parenting stress were at or greater than the 98th percentile for caregivers of children with FI. CONCLUSIONS: Children with fecal incontinence and their families are in need of interventions targeting their quality of life and the stress associated with caregiving. FI appears to be particularly stressful for caregivers who may be in need of support beyond medical management of their child's bowel. Moreover, additional refinements in disease-specific quality of life assessment are needed in this population. Such refinement would allow for more precise measurement of the quality of life processes that are unique to FI.

Child Maltreatment, Trauma, and Physical Health Outcomes: The Role of Abuse Type and Placement Moves on Health Conditions and Service Use for Youth in Foster Care.

OBJECTIVE: The purpose of the study was to investigate the relations between abuse types, non-maltreatment-related trauma, and health service utilization in a sample of youth in foster care with and without chronic medical conditions. METHOD: A total of 213 youth, aged 8-21 years, provided self-report of general trauma and abuse exposure. Medicaid claims for each child were collected from official state databases. RESULTS: Exposure to sexual abuse, neglect, or general trauma but not exposure to physical abuse or psychological abuse increased the rates of medical visits, while only general trauma increased medical hospitalizations. CONCLUSIONS: Trauma types are not equally predictive of health care utilization for youth with chronic health conditions.

Parent Perceptions of Illness Uncertainty and Child Depressive Symptoms in Juvenile Rheumatic Diseases: Examining Caregiver Demand and Parent Distress as Mediators.

OBJECTIVE: Examine caregiver demand and general parent distress as mediators in the parent illness uncertainty-child depressive symptom association in youth with juvenile rheumatic diseases. METHODS: Children and adolescents completed the Child Depression Inventory; caregivers completed the Parent Perceptions of Uncertainty Scale, the Care for My Child with Rheumatic Disease Scale, and the Brief Symptom Inventory. The pediatric rheumatologist provided ratings of clinical disease status. RESULTS: Analyses revealed significant direct associations between illness uncertainty and caregiver demand, and between caregiver demand and both parent distress and child depressive symptoms. Results also revealed significant parent uncertainty → caregiver demand → parent distress and parent uncertainty → caregiver demand → child depressive symptom indirect paths. CONCLUSIONS: Results highlight the role of illness appraisals in adjustment to juvenile rheumatic diseases, and provide preliminary evidence that parent appraisals of illness uncertainty impact parent distress and child depressive symptoms indirectly through increased perceptions of caregiver demand.