Relationship between School Absenteeism and Depressive Symptoms among Adolescents with Juvenile Fibromyalgia

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Journal of Pediatric Psychology Advance Access published April 1, 2010

Relationship between School Absenteeism and Depressive Symptoms
among Adolescents with Juvenile Fibromyalgia
             Susmita Kashikar-Zuck,1,3 PHD, Megan Johnston,1 BA, Tracy V. Ting,2,3 MD, Brent T. Graham,4 MD,
             Anne M. Lynch-Jordan,1,3 PHD, Emily Verkamp,1 BS, Murray Passo,5 MD, Kenneth N. Schikler,6 MD,
             Philip J. Hashkes,7 MD, Steven Spalding,8 MD, Gerard Banez,9 PHD, Margaret M. Richards,9 PHD,
             Scott W. Powers,1,3 PHD, Lesley M. Arnold,10 MD, and Daniel Lovell,2,3 MD, MPH
              Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center,
              Rheumatology Division, Cincinnati Children’s Hospital Medical Center, 3Department of Pediatrics, University
             of Cincinnati College of Medicine, 4Division of Pediatric Rheumatology, Vanderbilt University School of
             Medicine, 5Division of Pediatric Rheumatology, Medical University of South Carolina, 6Division of Pediatric
             Rheumatology and Adolescent Medicine, University of Louisville School of Medicine, 7Pediatric Rheumatology
             Unit, Shaare Zedek Medical Center, Jerusalem, 8Department of Rheumatic and Immunologic Diseases,

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             The Cleveland Clinic, 9Division of Pediatrics, The Cleveland Clinic Foundation, and                       10
                                                                                                                          Department of
             Psychiatry, University of Cincinnati College of Medicine

             All correspondence concerning this article should be addressed to Susmita Kashikar-Zuck, Ph.D, Division of
             Behavioral Medicine and Clinical Psychology, MLC 3015, Cincinnati Children’s Hospital Medical Center,
             Cincinnati, OH, 45229, USA. E-mail:
             Received September 4, 2009; revisions received February 25, 2010; accepted February 26, 2010

             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 ¼ 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.

             Key words        depressive symptoms; juvenile fibromyalgia; pediatric pain; school absences; school functioning.

Juvenile primary fibromyalgia syndrome (JPFS) is a poorly                       research indicates that chronic pain in children has a neg-
understood pediatric chronic pain condition affecting pri-                      ative impact on multiple domains of functioning, including
marily girls and is typically first diagnosed in the adoles-                    the developmentally critical area of school functioning
cent years (Yunus & Masi, 1985). The cardinal symptoms                          (Gauntlett-Gilbert & Eccleston, 2007; Konijnenberg
of JPFS include widespread musculoskeletal pain of greater                      et al., 2005; Logan, Simons, Stein, & Chastain, 2008;
than 3 months duration, multiple painful tender points,                         Vetter, 2008). Within the broader domain of school func-
disrupted sleep, chronic fatigue, and other associated fea-                     tioning, difficulty with school attendance is an area that
tures such as irritable bowel symptoms, lightheadedness/                        deserves special attention. Attending school is a key devel-
syncope, anxiety, and recurrent headaches. Previous                             opmental expectation in the adolescent years, and

                                                         Journal of Pediatric Psychology pp. 1–9, 2010
        Journal of Pediatric Psychology ß The Author 2010. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
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2   Kashikar-Zuck et al.

    longitudinal studies have shown that increased school                Another potential psychosocial factor that may be
    absenteeism is a risk factor for school drop-out and           associated with higher disability in pediatric pain patients
    multiple economic, marital, social, and psychiatric prob-      is a parental history of chronic pain (Jamison & Walker,
    lems in adulthood (Kearney, 2008).                             1992; Kashikar-Zuck et al., 2008a; Lynch, Kashikar-Zuck,
         Patients with JPFS may be particularly vulnerable to      Goldschneider, & Jones, 2006; Schanberg, 2001;
    school absenteeism because of their unremitting wide-          Schanberg, Keefe, Lefebvre, Kredich, & Gil, 1998).
    spread pain, disrupted sleep, and chronic fatigue. At          Maternal history of chronic pain, in particular, is com-
    least two prior studies have indicated that school absen-      monly reported in adolescents with JPFS and a higher
    teeism might be a significant problem for patients with        number of pain conditions reported by mothers was
    JPFS. Reid, Lang, & McGrath (1997) found that adoles-          found to be associated with greater functional impairment
    cents with JPFS missed an average of 22.6 (SD ¼ 16.63)         among the adolescents (Kashikar-Zuck et al., 2008a). A
    days of school in an academic year and Kashikar-Zuck,          family environment in which one or more parents suffer
    Vaught, Goldschneider, Graham, & Miller (2002) found           from chronic pain is thought to confer a risk for greater
    that adolescents with JPFS reported missing 5.23 days          disability in the child in part due to social learning influ-
    (SD ¼ 7.76; range ¼ 0-–30) in the last 30 days of school.      ences such as parent modeling of pain behavior or pain

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    Both these studies had relatively small sizes (
Relationship between School Absenteeism and Depressive Symptoms          3

not separately describe this subgroup. Therefore, little is      school or homeschooled because of their JPFS symptoms.
known about the clinical and psychosocial characteristics        One JPFS patient who was homeschooled due to personal
of patients who elect to be homeschooled.                        beliefs and two patients who were in college were excluded
      The objectives of this study were to address gaps in the   from the sample.
literature by (1) describing school absences and home-
schooling rates in children and adolescents with JPFS,           Procedure
(2) examining whether pain intensity, depressive symp-           Written informed consent was obtained from parents and
toms and maternal pain history were associated with              written and verbal assent were obtained from all partici-
school absenteeism, (3) examining whether school                 pants prior to study participation. The study was approved
absences significantly differed among patients with or with-     by each hospital’s Institutional Review Board. Measures in
out a diagnosis of an anxiety, depressive, or attentional        this study were administered as part of a comprehensive
disorder, and (4) describing the subset of JPFS patients         baseline assessment for the treatment study. A research
who are homeschooled with respect to their pain intensity,       assistant mailed pain diaries with instructions to the par-
depressive symptoms, and maternal pain history. Based            ticipants prior to the assessment, and participants brought
upon past studies, it was anticipated that pain intensity        the completed diaries to the study visit. During the assess-

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would not be significantly associated with school absences       ment, parents and children completed self-report question-
in children and adolescents with JPFS. However, it was           naires separately and a trained psychologist or psychology
hypothesized that depressive symptoms and maternal his-          fellow conducted a standardized psychiatric interview.
tory of chronic pain would be significantly associated with      Upon completion, participants were given a gift coupon
school absences. It was also expected that children and          in appreciation for their time and effort.
adolescents with JPFS who had a co-morbid psychiatric
diagnosis would have significantly more school absences          Measures
than those without. Given the lack of prior work in home-
                                                                 Demographic Information
schooled pain patients, no specific hypotheses were made
                                                                 Parents completed a demographic information form. Items
regarding characteristics of JPFS patients who were home-
                                                                 on the form included child’s gender, age, race/ethnicity,
schooled versus those in regular school.
                                                                 current grade in school, parents’ education levels, and
                                                                 socioeconomic status including annual household
                                                                 income and parents’ occupations. An index of socioeco-
Method                                                           nomic status based upon occupational prestige was calcu-
Participants                                                     lated for mothers and fathers (Nakao & Treas, 1992).
The study sample consisted of 102 children and adoles-
cents ages 11–18 years with JPFS and their parents (pri-         Pain Intensity
marily mothers) from a larger sample of patients who were        Daily pain diaries were mailed to participants along with
screened for participation in a clinical trial of                instructions to begin diaries one week prior to the assess-
cognitive-behavioral treatment for JPFS. Inclusion and           ment. Diaries consisted of a 10-cm visual analog scale
exclusion criteria for the study, as well as a description       (VAS) anchored on the ends by ‘‘no pain’’ and ‘‘worst
of psychiatric diagnoses in a subset of this sample              possible pain.’’ VAS scales have been validated for use in
(N ¼ 76) have been previously published (Kashikar-Zuck           school age children and have been recommended for use in
et al., 2008b). Briefly, participants were recruited from        assessment of recurrent/chronic pain in children over
four pediatric rheumatology clinics in the Ohio and              8 years of age (Stinson, Kavanagh, Yamada, Gill, &
Kentucky region. Patients were eligible if they met Yunus        Stevens, 2006). Average pain intensity score based upon
and Masi criteria (Yunus & Masi, 1985) for juvenile fibro-       one week of daily diaries was calculated. While pain inten-
myalgia and had no other rheumatic disease (e.g. systemic        sity might fluctuate in JPFS, the pain experience in fibro-
lupus erythematosus, juvenile idiopathic arthritis). For this    myalgia tends to be chronic (as compared to recurrent pain
study, which was focused on school attendance difficulties       conditions such as headaches or abdominal pain where
related to JPFS, patients had to be enrolled in regular          individuals may have several days of no pain). Therefore,
4   Kashikar-Zuck et al.

    a one week time frame is considered sufficient to capture       School Attendance and Type of Schooling
    pain intensity in JPFS patients.                                School attendance data were obtained by parent report as
                                                                    well as directly from school records to ensure that the
    Depressive Symptoms                                             information was reliable and accurate. Information about
    Participants completed the Children’s Depression                the reasons for each school absence was not available and
    Inventory (CDI). The CDI is a 24-item index of depressive       all school absences were counted (including days that may
    symptoms that has been validated for use in children ages       have been missed for doctor’s visits or for reasons unre-
    7–17 years (Kovacs, 1992). It has strong psychometric           lated to JPFS symptoms). Late starts (tardy days) were not
    properties and is frequently used in pediatric pain research    counted unless they were denoted as a ‘‘half-day absence’’
    (Conte, Walco, & Kimura, 2003; Eccleston et al., 2004;          on school reports. Average number of school days missed
    Kashikar-Zuck, Goldschneider, Powers, Vaught, &                 per month was calculated by dividing the total number of
    Hershey, 2001). Respondents select one of three state-          days missed since the first day of school by the number of
    ments for each item. A total raw score and age- and             months the child had been in school for the academic year.
    gender-normed T-scores can be calculated. The total raw         School attendance records were obtained directly from the
    scores were used for analyses because the full range of         school by faxing a request along with a permission form
    scores can be utilized (unlike T-scores which are truncated     signed by the participant’s parent. Parents reported on the

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    with a minimum T-score of 35).                                  type of schooling: regular school or homeschooled (defined
                                                                    as full-time homeschooling, home-bound, or internet-
    Psychiatric Diagnoses                                           based home program) and reason for homeschooling.
    The Kiddie schedule for affective disorders and schizophre-     Although we recognize that the category of ‘‘home-
    nia (K-SADS-PL) (Chambers et al., 1985; Kaufman et al.,         schooling’’ combines several types of options, all preclude
    1997), a semi-structured psychiatric interview, was used to     attendance in regular school with its associated expecta-
    arrive at diagnoses according to the Diagnostic and             tions of consistent attendance, sitting in class for long
    Statistical Manual of Mental Disorders – Fourth Edition         periods, and daily interaction with teachers and peers.
    (DSM-IV). Adolescents received a complete assessment of         The rationale for combining homeschooling options is
    DSM-IV psychiatric disorders as described in detail in a        that—aside from academic expectations, successful navi-
    previous publication (Kashikar-Zuck et al., 2008b). For         gation of the demands and expectations in regular school is
    the purpose of this study, adolescents were categorized         an important developmental activity for school-age chil-
    into whether or not they had a current anxiety disorder         dren and adolescents, which is missing for those who are
    (panic disorder, agoraphobia, specific phobia, social           not in the regular school environment. Of note, children
    phobia, obsessive–compulsive disorder, post traumatic           were aware that their attendance information was being
    stress disorder, generalized anxiety disorder, or separation    gathered from their school and parents. However, in this
    anxiety disorder), a depressive disorder (major depressive      study, information was gathered for the months prior to
    disorder, dysthymic disorder, depressive disorder NOS), or      their study enrollment and therefore school absenteeism
    an attentional disorder [attention deficit hyperactive disor-   rates were not affected by their knowledge that attendance
    der (ADHD) inattentive type, ADHD hyperactive type,             data would be examined.
    ADHD combined type, or ADHD NOS].
                                                                    Statistical Analysis
    Maternal Pain History                                           Data were entered and analyzed using SPSS Version 15
    The parent pain history questionnaire, a measure used in        statistical software (SPSS, Chicago, IL). Descriptive infor-
    prior pediatric pain studies (Lester, Lefebvre, & Keefe,        mation about school absences, rates of homeschooling,
    1994; Schanberg et al., 1998), was used to obtain maternal      pain intensity, pain duration, depressive symptoms, and
    pain history. The parent pain history form contains a list of   psychiatric status were computed. The relationship
    a variety of pain conditions on which the respondent indi-      between potential confounding variables (age, socioeco-
    cates whether or not they suffered from each type of pain       nomic index, and pain duration) with school absences
    and whether or not they received treatment for that con-        depressive symptoms were first examined. Age, socioeco-
    dition. The total number of pain conditions was calculated      nomic index and pain duration were not found to be sig-
    using this questionnaire.                                       nificantly related to depressive symptoms or school
Relationship between School Absenteeism and Depressive Symptoms                  5

absences. Therefore, these variables were not used as cov-                  (68.6%) with the remaining in middle school. Most of
ariates in further analyses. Next, a multiple regression ana-               the parents who participated were mothers (91.8%). The
lysis was conducted to analyze whether pain intensity,                      average socioeconomic index was 40.40 for mothers and
depressive symptoms and/or maternal history of chronic                      53.65 for fathers, which is equivalent to clerical retail sales
pain were associated with school absences (parent report)                   and lower to mid-level manager, respectively.
in adolescents attending regular school. Pain intensity was
entered in the first step of the regression analyses, followed              Attendance Rates
by depressive symptoms and maternal pain history, in                        Of the 89 school attendance reports requested directly
order to examine the effects of the latter variables after                  from schools, 82 reports were returned (92%). As shown
accounting for pain intensity. The role of depressive symp-                 in Table I, the average number of school days missed per
toms was further explored by comparing adolescents with                     month was 2.88 days per school report and 2.90 days per
high versus low levels of school absences (based upon a                     parent report (Pearson r ¼ .880), which indicates a high
median split of the distribution of school absences) using                  level of concordance between school and parent report.
an independent samples t-test. Finally, t-tests were con-                   As noted in prior studies, there was a great deal of vari-
ducted to compare parent report of school absences in                       ability in school absences (SD ¼ 2.89 days per month;

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adolescents with and without a diagnosis of anxiety                         range ¼ 0–15.35) and the distribution of school absences
disorder, mood disorder, and attention deficit disorder.                    was positively skewed with about two-thirds of the adoles-
                                                                            cents (68.8%) missing three days or less of school per
                                                                            month, and about one third missing more than 3 days of
Results                                                                     school per month.
There were a total of 102 adolescent JPFS participants in                   Homeschooling
the study. The majority of them were female (87.3%) and                     Thirteen participants (12.7%) were homeschooled or
Caucasian (85.3%) with a mean age of 14.96 (SD ¼ 1.82).                     enrolled in home-based instruction due to their fibromyal-
Over two-thirds of the adolescents were in high school                      gia symptoms. In comparison, the national rate for

Table I. Descriptive Data on Pain, Depressive Symptoms, School Absences, Psychological Diagnoses, and Parental Pain History

                                                      Regular school (n ¼ 89)           Home school (n ¼ 13)           Total (n ¼ 102)

Variable                                          M                 SD              M               SD             M             SD

Average pain intensity (0–10 VAS)                 5.20              1.98            5.20            2.11           5.20          1.99
Pain duration(in months)                          35.33             27.00           38.76           34.01          35.77         27.83
CDI total raw score (0–81)                        12.65             7.08            15.85           8.55           13.07         7.32
CDI T-score                                       54.37             11.02           59.69           13.67          55.07         11.47
School days missed each month (school report)     2.88              2.84
School days missed each month (parent report)     2.90              2.87            2.52            3.14           2.85          2.89
Maternal pain conditions (total)                  5.07          2.98                5.00          3.16             5.06        2.99
                                                  Frequency (%)                     Frequency (%)                  Frequency (%)
Depressive disorder
  No                                             71 (82.6)                          9 (69.2)                    80 (80.8)
  Yes                                            15 (17.4)                          4 (30.8)                    19 (19.2)
Anxiety disorder
  No                                             41 (47.7)                          4 (30.8)                    45 (45.5)
  Yes                                            45 (52.3)                          9 (69.2)                    54 (54.5)
Attentional deficit hyperactivity disorder
  No                                             65 (75.6)                         10 (76.9)                    75 (75.8)
  Yes                                            21 (24.4)                          3 (23.1)                    24 (24.2)
6   Kashikar-Zuck et al.

    homeschooling in the general population is 2.2%                 Table II. Regression Analysis Examining the Role of Pain Intensity,
                                                                    Depressive Symptoms, and Maternal Pain History on School Absences
    (Statistics, 2006).                                             for those in Regular School

                                                                                                   Adjusted b         P-value        r2
    Pain, Depressive Symptoms and Maternal Pain
    History                                                         Step 1
                                                                      Average pain intensity          .093             .391          –
    Average pain duration for the sample was 35.77 months,
                                                                    Step 2
    or nearly 3 years. Pain intensity levels were in the moderate
                                                                       CDI total score                .285             .007          –
    range with an average VAS of 5.20. On average, self-report
                                                                      Maternal pain history           .058             .572          –
    of depressive symptoms on the CDI were in the mildly            Total r2 ¼ .086
    elevated range compared to age and gender norms, but
    25% of the sample scored above the clinical cut-off
    (T-score ¼ 65) for depressive symptoms. As shown in
                                                                    absences reported significantly greater depressive symp-
    Table I, pain duration and pain intensity did not appear
                                                                    toms (t ¼ 2.11; p ¼ .03) on the CDI. In contrast to the
    to differ between adolescents in regular school versus
                                                                    significant differences based on depressive symptoms on
    homeschool. The homeschooled adolescents appeared to
                                                                    the CDI, adolescents who met criteria for a diagnosis of
    have slightly higher CDI scores, but statistical analyses

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                                                                    depressive disorder based upon psychiatric interview were
    were not possible due to the small number of home-
                                                                    not found to have significantly higher school absences than
    schooled participants. Mothers of adolescents with JPFS
                                                                    those who did not (t ¼ .98; p ¼ .33). Adolescents with
    reported suffering from an average of 5 pain conditions
                                                                    anxiety or attentional disorders also did not have signifi-
                                                                    cantly greater school absences than those without these
    Psychiatric Diagnoses                                           diagnoses (t ¼ –.62; p ¼ .53 and t ¼ .52; p ¼ .61, respec-
                                                                    tively). Given the inconsistent findings on the CDI
    Findings from the KSADS interview were consistent with
                                                                    self-report data on depressive symptoms and diagnosis of
    our prior published data on a subset of this clinical trial
                                                                    depressive disorders based upon clinical interview, we fur-
    sample showing that anxiety disorders are widely prevalent
                                                                    ther explored the CDI data by comparing adolescents with
    in JPFS with over half the sample meeting the DSM-IV
                                                                    scores above the clinical cut-off for depressive symptoms
    criteria for one or more anxiety disorders. About 24% of
                                                                    (T-score > 65) and those below the cut-off. Results were
    adolescents met criteria for an attentional disorder and
                                                                    similar to the regression analysis that is, adolescents who
    19% met criteria for a depressive disorder (Table I). It
                                                                    scored above the clinical cut-off for depressive symptoms
    should be noted that fewer participants met diagnostic
                                                                    had significantly greater school absences than those below
    criteria for depressive disorder on the clinical interview
                                                                    the cut-off (mean of 4.4 absences per month versus 2.4;
    than those scoring above the clinical cut-off on the CDI
                                                                    p < .05) but still discrepant with the psychiatric interview
    (19% versus 25% of the sample). The overlap between the
    two groups was substantial but not identical with 65% of
    those meeting diagnostic criteria for depressive disorder
    also scoring above the CDI cut-off.
    Factors Related to School Attendance                            This study supports and extends the findings of past
    Results of the regression analysis (Table II) indicated that    research documenting the problem of school absenteeism
    neither pain intensity nor maternal pain history were sig-      in children and adolescents with JPFS. The rate of home
    nificantly related to school absences. However, greater         schooling (12.7%) was found to be higher than the
    depressive symptoms by adolescent self-report on the            national average of about 2%, and the average number of
    CDI were significantly related to higher rates of school        school absences for JPFS patients who attended regular
    absences. Due to skewness in the distribution of school         school was nearly 3 days per month (which is about
    absences, we compared adolescents with a high level of          27 days in a 9-month school year). In comparison, the
    school absences (above the median of 2 days per month)          regional data for school absences (Kentucky, 2008; Ohio,
    with a low level of school absences (below the median) on       2008) obtained from the state report cards of districts in
    depressive symptoms. Consistent with the results of the         the Ohio and Kentucky region indicate average school
    regression analysis, the group with a high level of school      attendance in the 95% range (or about 9 days of absences
Relationship between School Absenteeism and Depressive Symptoms         7

in the entire school year). The current study likely presents      was modest, and the lack of significant effect of having a
the most robust estimates of school absences among clin-           diagnosis of depressive disorder was a new finding. This
ically referred adolescents with JPFS compared to the              lack of correspondence may be because the psychiatric
research literature so far because of the larger sample size       interview is an in-depth assessment conducted by a clini-
(over 100 patients), inclusion of patients from four differ-       cian with both child and parent, and may provide a more
ent pediatric rheumatology clinics, and the fact that data         stringent standard for clinical depression, resulting in
were gathered for the entire duration of the current school        fewer participants who were classified as having a current
year with confirmation from school attendance records.             mood disorder. Nevertheless, elevated depressive symp-
The implications of missing nearly a month out of the              toms on the CDI (regardless of whether or not a clinical
school year, especially in the high school years, cannot           diagnosis was present) seemed to be consistently asso-
be underestimated because the academic curriculum is               ciated with more school absences. Along with depressive
typically more demanding in high school and adolescents            symptoms, there may be additional factors not assessed in
often report that they have trouble keeping up with assign-        this study (such as peer and familial relationships, and
ments and homework. As might be expected, parents are              coping factors such as catastrophizing about pain) that
often concerned about their child’s grades and school per-         may affect school absenteeism.
formance, and schoolwork can become a potential source                  Study results provided new information about the

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of exacerbated familial stress.                                    characteristics of adolescents with JPFS who were home-
      The long-term implications of early school absentee-         schooled. Although the relatively small number of home-
ism are potentially of concern with regard to future career        schooled patients precluded statistical analyses, there did
options. Preliminary findings from a follow-up study               not appear to be any evidence of differences in pain sever-
(Kashikar-Zuck et al., manuscript under review) showed             ity and depressive symptoms between those who were
that adolescents with JPFS were somewhat less likely to            homeschooled compared to those who were enrolled in
go to college in the early adult years than their same age         regular school. Findings from another recent study in pedi-
and gender-matched healthy control classmates (39.6% of            atric chronic pain indicated that children who were
JPFS versus 55.8% of healthy controls). More longitudinal          allowed accommodations in school (such as being sent
research is needed to examine whether difficulties with            to the nurse’s office, sent home when in pain, reduced
attending school or homeschooling due to pain-related fac-         workload or hours in school, extensions on assignments)
tors is associated with longer term effects on college and/or      had higher levels of school impairment and their grades
occupational outcomes in JPFS as well as other chronic             were no higher than those who were not provided with
pain conditions.                                                   accommodations (Logan et al., 2008). Contrary to expec-
      As reported in other studies in pediatric chronic pain,      tations, maternal pain history was not associated with
results of this study indicated that pain intensity does not       school absenteeism. This study did not specifically assess
appear to be associated with school absences in children           coping with pain symptoms in parents with a positive pain
and adolescents with JPFS. The consistent findings in the          history; thus, this is an interesting area for further
literature that pain characteristics bear little to no relation-   investigation.
ship with ability to participate in routine activities, such as         The results of this study should be interpreted with
going to school, strongly suggest that the presence of other       caution because it cannot be assumed that depressive
factors might explain pain-related disability. Clinical            symptoms were causally related to greater school absentee-
impressions and past studies (Kearney, 2008) suggest               ism. However, our findings are in concordance with
that psychiatric comorbidity may play a role in school             research indicating that depressive symptoms are one of
absenteeism in adolescents and the current study con-              the most common psychiatric conditions linked to school
firmed that a number of JPFS patients meet criteria for a          absenteeism (Kearney, 2008). Moreover, past research has
psychiatric condition. However, a current diagnosis of             shown that pain and related conditions such as fatigue,
depressive disorder, anxiety disorder, or attentional disor-       headaches, irritable bowel, dysmenorrhea, and sleep prob-
der was not found to be associated with number of school           lems are also cited as being some of most common medical
absences in JPFS patients. Rather, higher levels of                reasons associated with school absenteeism (Kearney,
self-reported depressive symptoms on the CDI were signif-          2008). Therefore, it would seem that adolescent patients
icantly associated with more school absences. However,             who have pain as well as increased depressive symptoms
the amount of variance explained by depressive symptoms            would be at added risk. Addressing psychological issues
8   Kashikar-Zuck et al.

    related to school attendance in JPFS is an important goal        Eccleston, C., Crombez, G., Scotford, A., Clinch, J.,
    because it may lead to a vicious cycle of school avoidance.          & Connell, H. (2004). Adolescent chronic pain: pat-
         One limitation of this study was that specific informa-         terns and predictors of emotional distress in adoles-
    tion about the reasons for school absences was not col-              cents with chronic pain and their parents. Pain,
    lected. Therefore, the absences could be due to pain, other          108(3), 221–229.
    physical symptoms, medical appointments, or other rea-           Gauntlett-Gilbert, J., & Eccleston, C. (2007). Disability
    sons. Other limitations are the lack of a comparison group           in adolescents with chronic pain: Patterns and pre-
    and the small sample size of homeschooled adolescents.               dictors across different domains of functioning. Pain,
    Finally, the results are generalizable only to JPFS patients         131(1–2), 132–141.
    seen in tertiary care pediatric rheumatology settings, and       Jamison, R. N., & Walker, L. S. (1992). Illness behavior
    may not be as applicable to those seen in primary care or            in children of chronic pain patients. International
    those who do not seek treatment.                                     Journal of Psychiatry in Medicine, 22, 329–342.
         Despite the limitations, this study found that difficulty   Kashikar-Zuck, S., Goldschneider, K. R., Powers, S. W.,
    with school attendance can be a significant problem in               Vaught, M. H., & Hershey, A. D. (2001). Depression
    clinically referred adolescents with JPFS and depressive             and functional disability in chronic pediatric pain.
                                                                         The Clinical Journal of Pain, 17(4), 341–349.

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    symptoms were significantly associated with school
    absences. The findings highlight the need for a greater          Kashikar-Zuck, S., Lynch, A. M., Slater, S., Graham, T.
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