Cognitive behavioral therapy for the treatment of juvenile fibromyalgia: a multisite, single-blind, randomized, controlled clinical trial.

OBJECTIVE: Juvenile fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain disorder in children and adolescents for which there are no evidence-based treatments. The objective of this multisite, single-blind, randomized clinical trial was to test whether cognitive-behavioral therapy (CBT) was superior to fibromyalgia (FM) education in reducing functional disability, pain, and symptoms of depression in juvenile FMS. METHODS: Participants were 114 adolescents (ages 11-18 years) with juvenile FMS. After receiving stable medications for 8 weeks, patients were randomized to either CBT or FM education and received 8 weekly individual sessions with a therapist and 2 booster sessions. Assessments were conducted at baseline, immediately following the 8-week treatment phase, and at 6-month followup. RESULTS: The majority of patients (87.7%) completed the trial per protocol. Intent-to-treat analyses showed that patients in both groups had significant reductions in functional disability, pain, and symptoms of depression at the end of the study, and CBT was significantly superior to FM education in reducing the primary outcome of functional disability (mean baseline to end-of-treatment difference between groups 5.39 [95% confidence interval 1.57, 9.22]). Reduction in symptoms of depression was clinically significant for both groups, with mean scores in the range of normal/nondepressed by the end of the study. Reduction in pain was not clinically significant for either group (<30% decrease in pain). There were no study-related adverse events. CONCLUSION: In this controlled trial, CBT was found to be a safe and effective treatment for reducing functional disability and symptoms of depression in adolescents with juvenile FMS.

Actigraphy-based physical activity monitoring in adolescents with juvenile primary fibromyalgia syndrome.

UNLABELLED: Juvenile primary fibromyalgia syndrome (JPFS) is a chronic pain condition associated with significant impairment in physical functioning, but no studies have used newer technologies such as actigraphy to document objective physical activity levels in JPFS. This is the first study to objectively describe physical activity in JPFS patients and examine the relationship of pain, perceived functional impairment, and depressive symptoms on physical activity. One hundred four clinically referred adolescents with JPFS (ages 11 to 18 years) wore a hip-mounted actigraph for 1 week. Data on pain intensity, functional disability, depressive symptoms, and psychiatric diagnoses were obtained using self- and parent-report measures and a standardized psychiatric interview. Results showed that younger patients were more active. Pain intensity was not significantly associated with physical activity levels overall, but the most highly active group of adolescents reported lower levels of pain and disability than the least active. Parent report of adolescents' physical functioning and depressive symptoms were significantly correlated with adolescents' physical activity levels. Actigraphy provides a unique source of information about physical functioning which is distinct from adolescents' self-report of physical functioning in JPFS. Preliminary findings suggest that further study of factors that predict perceived and actual physical functioning in JPFS is warranted. PERSPECTIVE: This study presents the results of physical activity monitoring in adolescents with JPFS using actigraphy. Results indicate that actigraphy provides a unique source of objective information that can advance our understanding of physical disability in JPFS and the factors associated with physical impairment.

Chronic constipation, atypical eating pattern, weight loss, and anxiety in a 19-year old youth.

CASE: A 19-year-old female was admitted to a children's hospital weighing 75 pounds. She lost 75 pounds over 2 years and did not menstruate for a year. Despite her dissatisfaction with her thin appearance and desire to weigh more, her inpatient treatment focused on "disordered eating." Adolescent medicine, nutrition, and gastroenterology specialists were consulted. A pediatric psychology consultation was initiated to address anxiety associated with eating as well as abnormal toileting behaviors. The patient reported that she had chronic constipation since the age 3 years with a large, hard, and painful bowel movement once every 1-3 weeks. She had numerous medical and nutritional interventions to improve her bowel functioning, including extensive laxative use and a diet high in fiber (mostly fruits and vegetables). Additionally, an extensive medical evaluation to look for physiological causes for chronic constipation, including Hirschsprung's disease, was not diagnostic. The patient described purposeful stool withholding due to her concern over painful bowel movements. She also avoided peer activities because she did not want to use toilets outside her home. The patient acknowledged that her disordered eating stemmed largely from her toileting difficulties. She described altering her eating habits to avoid bowel movements (e.g., eating small meals, not eating at school) and anxious thoughts while defecating. Defecation anxiety was now affecting other areas of her life. For example, she frequently used copious amounts of toilet paper to ensure thorough cleaning. The patient's parents confirmed her need to thoroughly clean after toilet use, using "almost half a roll of toilet paper." They described other concerning "routines," including refusing to use towels after showering. She dried herself with a fan because of fear that her towel may be dirty. They indicated that during early adolescence, she frequently washed her face to prevent acne breakouts. According to parents, the patient followed doctors' instructions "as though they (were) gospel," deviating from suggestions only with extreme resistance.

Relationship between school absenteeism and depressive symptoms among adolescents with juvenile fibromyalgia.

OBJECTIVE: To describe school absences in adolescents with Juvenile Primary Fibromyalgia Syndrome (JPFS) and examine the relationship between school absenteeism, pain, psychiatric symptoms, and maternal pain history. METHODS: Adolescents with JPFS (N = 102; mean age 14.96 years) completed measures of pain and depressive symptoms, and completed a psychiatric interview. Parents provided information about the adolescents' school absences, type of schooling, and parental pain history. School attendance reports were obtained directly from schools. RESULTS: Over 12% of adolescents with JPFS were homeschooled. Those enrolled in regular school missed 2.9 days per month on average, with one-third of participants missing more than 3 days per month. Pain and maternal pain history were not related to school absenteeism. However, depressive symptoms were significantly associated with school absences. CONCLUSION: Many adolescents with JPFS experience difficulties with regular school attendance. Long-term risks associated with school absenteeism and the importance of addressing psychological factors are discussed.

Anxiety, mood, and behavioral disorders among pediatric patients with juvenile fibromyalgia syndrome.

BACKGROUND: Mood and anxiety disorders are common psychiatric conditions among adult patients with fibromyalgia syndrome, but little is known about whether psychiatric disorders are prevalent among pediatric patients with fibromyalgia. OBJECTIVE: The primary objective of this study was to assess the prevalence of mood, anxiety, and behavioral disorders in a clinical sample of children and adolescents with juvenile primary fibromyalgia syndrome (JPFS) and assess the relationship between psychiatric disorders and JPFS symptom severity. METHODS: Standardized psychiatric interviews were conducted with children and their parents/primary caregivers, and measures of symptom severity including pain intensity and physician global ratings were obtained for 76 children and adolescents diagnosed with JPFS (ages 11 to 18 y) in pediatric rheumatology clinics at 4 hospitals in the Midwest. RESULTS: A total of 67.1% of patients had at least 1 current and 71.5% had at least 1 lifetime DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-fourth edition) psychiatric diagnosis. The most frequent psychiatric diagnosis was anxiety disorder (57.5% of JPFS patients). Although mood difficulties were also common, the presence of major depression was lower than has been reported for adults with fibromyalgia syndrome. Physicians' global assessment of functioning was significantly lower for patients with a current anxiety disorder. There were no significant differences in pain severity among patients with and without anxiety, mood, or behavioral disorders. DISCUSSION: There seems to be a high prevalence of anxiety disorders in patients with JPFS, and presence of anxiety disorder is associated with poorer physician-rated functioning. Future research should explore whether early anxiety symptoms are predictive of long-term functioning.

Repressive adaptation in a nonclinical sample: consistent and inconsistent reports of child psychosocial functioning across informants.

Using multiple indicators (self-report, parent report, school grades, and disciplinary referrals), we compared the psychosocial functioning of children across Weinberger's (1990) and Weinberger, Schwartz, and Davidson's (1979) repressive adaptive style (RAS) groups. Participants included 134 children ages 10 to 13 years that were recruited from public schools and 117 of their caregivers. Relative to nonrepressors, we hypothesized repressors to evidence lower levels of self-reported distress but higher parent-reported distress on the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992). Summary scores from the BASC self-report differed significantly between repressors and nonrepressors in the expected directions. No significant group differences in parent-reported distress or school functioning emerged. Consistent with Phipps (2005), results question the predominant assumption that the RAS is associated with risk of psychosocial difficulties in children.

Children's self-reported coping strategies: the role of defensiveness and repressive adaptation.

This study examined differences in self-reported coping strategies across children classified according to Weinberger et al.'s (1979) adaptive style paradigm. Consistent with the larger literature, it was hypothesized that repressors (i.e. characterized by high self-reported defensiveness and low self-reported distress) would endorse fewer behaviorally and cognitively avoidant coping strategies than other adaptive style groups. Participants included 134 children, ranging in age from 10 to 13 (M=11.26, sd=.59), who completed measures of defensiveness, trait anxiety, and coping. Consistent with the hypotheses, results indicated significantly lower endorsement of avoidant coping strategies, and significantly higher endorsement of approach-oriented strategies among repressors, but no significant differences across adaptive style groups for other forms of coping. Results indicate that, consistent with other indicators of psychological functioning, the measurement of coping strategies is subject to the effects of socially desirable responding. Further, results provide evidence that measures of coping may be contaminated by items reflecting adjustment problems.