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
1
Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center,
2
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: susmita.kashikar-zuck@cchmc.org
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
doi:10.1093/jpepsy/jsq020
Journal of Pediatric Psychology ß The Author 2010. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org2 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 schoolRelationship 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.
Demographics
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-
themselves.
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
data.
two groups was substantial but not identical with 65% of
those meeting diagnostic criteria for depressive disorder
also scoring above the CDI cut-off.
Discussion
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 absencesRelationship 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 issues8 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.
focus on reducing school absenteeism in adolescents B., Swain, N. F., & Noll, R. B. (2008a). Family fac-
with JPFS. Behavioral and cognitive-behavioral treatments tors, emotional functioning, and functional impair-
should consider including a greater focus on comprehen- ment in juvenile fibromyalgia syndrome. Arthritis &
sive planning and implementation of strategies to address Rheumatism, 59(10), 1392–1398.
school absenteeism. More longitudinal research into the Kashikar-Zuck, S., Parkins, I. S., Graham, T. B.,
long-term implications of early school-related disability is Lynch, A. M., Passo, M., Johnston, M., et al.
needed, as well as research on peer and family factors that (2008b). Anxiety, mood, and behavioral disorders
can maintain or exacerbate school problems. among pediatric patients with juvenile fibromyalgia
syndrome. The Clinical Journal of Pain, 24(7),
620–626.
Kashikar-Zuck, S., Vaught, M. H., Goldschneider, K. R.,
Funding
Graham, T. B., & Miller, J. C. (2002). Depression,
National Institutes of Health, National Institute of coping, and functional disability in juvenile primary
Arthritis and Musculoskeletal and Skin Diseases (NIAMS) fibromyalgia syndrome. Journal of Pain, 3(5),
(R01AR050028 to S.K.-Z.). 412–419.
Conflicts of interest: None declared. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C.,
Moreci, P., et al. (1997). Schedule for Affective
Disorders and Schizophrenia for School-Age
Children-Present and Lifetime Version (K-SADS-PL):
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