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Objectives To (i) validate the JIA parent global assessment (parent global) as a health-related quality of life (HRQoL) instrument; (ii) evaluate measurement properties of accepted HRQoL measures relative to those of the parent global; and (iii) assess causal pathways determining parent global scores. Methods Data from the Research in Arthritis in Canadian Children emphasizing outcomes (ReACCh-Out) cohort were used. Measurement properties were assessed in 344 patients at enrolment and 6 months later. Causal pathways were tested by structural equation modelling to understand root causes and mediators leading to parent global scores. Results Construct validity was supported by Spearman correlations of 0.53–0.70 for the parent global with the Juvenile Arthritis Quality of Life Questionnaire, Quality of My Life health scale (HRQoML), Pediatric Quality of Life Inventory (PedsQL)-Parent, and Child Health Questionnaire (CHQ)-Physical. Exceptions were PedsQL-Child (0.44) and CHQ-Psychosocial (0.31). Correlations were lower (0.14–0.49) with disease activity measures (physician global assessment of disease activity, active joint count, ESR). Responsiveness of the parent global to improvement according to parent ratings (0.51) was acceptable and within the range (0.32–0.71) of that of other measures. Reliability estimates and measurement errors for all measures were unsatisfactory, likely due to the prolonged time between assessments. Causal pathways for the parent global matched those previously reported for HRQoML. Conclusions Our results offer support for the parent global as a valid measure of HRQoL for JIA. If confirmed, existing studies using the parent global may be re-interpreted, enhancing our knowledge of HRQoL in children with JIA. [ABSTRACT FROM AUTHOR]

Objective Structural equation modelling was applied to data from the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) cohort to help elucidate causal pathways to decreased health-related quality of life (HRQoL) in children with JIA. Methods Based on published literature and clinical plausibility, a priori models were constructed with explicit root causes (disease activity, treatment intensity) and mediators (pain, disease symptoms, functional impairments) leading to HRQoL [measured by the Quality of my Life (QoML) scale and the Juvenile Arthritis Quality of Life Questionnaire (JAQQ)] at five disease stages: (i) diagnosis, (ii) 3–9 months after diagnosis, (iii) flare, (iv) remission on medications, (v) remission off medications. Following structural equation modelling, a posteriori models were selected based on data fit and clinical plausibility. Results We included 561, 887, 137, 186 and 182 patients at each stage, respectively. In a posteriori models for active disease stages, paths from disease activity led through pain, functional impairments, and disease symptoms, directly or through restrictions in participation, to decreased QoML scores. Treatment intensity had detrimental effects through psychosocial domains; while treatment side effects had a lesser role. Pathways were similar for QoML and JAQQ, but JAQQ models provided greater specificity. Models for remission stages were not supported by the data. Conclusion Our findings support disease activity and treatment intensity as being root causes of decreased HRQoL in children with JIA, with pain, functional impairments, and participation restrictions being mediators for disease activity; they support psychosocial effects and side effects as being mediators for treatment intensity. [ABSTRACT FROM AUTHOR]

We validated case ascertainment algorithms for juvenile idiopathic arthritis (JIA) in the provincial health administrative databases of Manitoba, Canada. A population-based pediatric rheumatology clinical database from April 1st 1980 to March 31st 2012 was used to test case definitions in individuals diagnosed at ≤15 years of age. The case definitions varied the number of diagnosis codes (1, 2, or 3), time frame (1, 2 or 3 years), time between diagnoses (ever, >1 day, or ≥8 weeks), and physician specialty. Positive predictive value (PPV), sensitivity, and specificity with 95% confidence intervals (CIs) are reported. A case definition of 1 hospitalization or ≥2 diagnoses in 2 years by any provider ≥8 weeks apart using diagnosis codes for rheumatoid arthritis and ankylosing spondylitis produced a sensitivity of 89.2% (95% CI 86.8, 91.6), specificity of 86.3% (95% CI 83.0, 89.6), and PPV of 90.6% (95% CI 88.3, 92.9) when seronegative enthesopathy and arthropathy (SEA) was excluded as JIA; and sensitivity of 88.2% (95% CI 85.7, 90.7), specificity of 90.4% (95% CI 87.5, 93.3), and PPV of 93.9% (95% CI 92.0, 95.8) when SEA was included as JIA. This study validates case ascertainment algorithms for JIA in Canadian administrative health data using diagnosis codes for both rheumatoid arthritis (RA) and ankylosing spondylitis, to better reflect current JIA classification than codes for RA alone. Researchers will be able to use these results to define cohorts for population-based studies. [ABSTRACT FROM AUTHOR]

There is a paucity of published population-based estimates of the prevalence of chronic inflammatory arthritis in the pediatric population. We used administrative health data to estimate the prevalence of chronic inflammatory arthritis in individuals ≤18 years in three Canadian provinces: Quebec, Manitoba, and Saskatchewan. Cases aged ≤18 years were identified by meeting any one of the following criteria: (a) ≥1 hospital discharge abstract with an ICD-9 code of 714 or ICD-10-CA codes of M05, M06 or M08, or (b) ≥2 ICD-9 714 billing codes ≥8 weeks apart, but within 2 years, or (c) ≥1 ICD-9 714 billing code by a rheumatologist. Crude prevalence estimates per 10,000 population were estimated with 95 % confidence intervals (CIs). Prevalence estimates were 11.7 per 10,000 individuals ≤18 years of age in Manitoba, 9.8 per 10,000 in Saskatchewan, and 8.0 per 10,000 in Quebec. In pairwise comparisons of rate differences, Manitoba and Saskatchewan had higher estimates than Quebec. Prevalence estimates were higher for females than males, with a difference of 5.9 cases per 10,000 residents (95 % CI 5.1, 6.7). Saskatchewan was the only province with a higher estimate in urban compared to rural residents (5.2, 95 % CI 2.5, 8.0). Variations in provincial estimates may be due to differences in underlying population characteristics. Although these estimates have face validity and are in keeping with the range of previously published pediatric prevalence estimates, studies to establish the empiric validity of case-finding algorithms are needed to advance research in pediatric chronic disease epidemiology. [ABSTRACT FROM AUTHOR]

Objective: The aim of the Paediatric Rheumatology International Trials Organisation (PRINTO) juvenile idiopathic arthritis (JIA) classification criteria, which is still in development, is to identify homogeneous groups of JIA patients. This study was undertaken to compare International League of Associations for Rheumatology (ILAR) JIA classification criteria and PRINTO JIA classification criteria using data from the ReACCh‐Out (Research in Arthritis in Canadian Children, Emphasizing Outcomes) cohort. Methods: We used clinicobiologic data recorded within 7 months of diagnosis to assign a diagnosis of JIA and identify subcategories of JIA among 1,228 patients according to the 2 JIA classification systems. We compared the proportions of patients classified and the alignment of classification categories with clinicobiologic subtypes and adult arthritis types. Results: The PRINTO criteria classified 244 patients (19.9%) as having early‐onset antinuclear antibody–positive JIA, 157 (12.8%) as having enthesitis/spondylitis–related JIA, 38 (3.1%) as having systemic JIA, and 10 (0.8%) as having rheumatoid factor–positive JIA. A total of 12% of patients were unclassifiable using the ILAR criteria, while 63.3% were unclassifiable using the PRINTO criteria (777 with other JIA and 2 with unclassified JIA). In sensitivity analyses, >50% of patients remained unclassifiable using the PRINTO criteria. Compared to the PRINTO criteria, ILAR JIA categories aligned better with clinicobiologic subtypes in 131 patients (χ2 = 44, P = 0.005, versus χ2 = 15, P = 0.07 for PRINTO), and ILAR categories aligned better with adult types of arthritis in 389 evaluable patients. Conclusion: Currently identified PRINTO disorders can only be used to classify a minority of JIA patients, leaving a large proportion of JIA patients with other disorders requiring further characterization. Current PRINTO JIA classification criteria do not align better with clinicobiologic subtypes or adult forms of arthritis compared with the older ILAR classification system. [ABSTRACT FROM AUTHOR]

Objective To identify early predictors of disease activity at 18 months in JIA using clinical and biomarker profiling. Methods Clinical and biomarker data were collected at JIA diagnosis in a prospective longitudinal inception cohort of 82 children with non-systemic JIA, and their ability to predict an active joint count of 0, a physician global assessment of disease activity of ≤1 cm, and inactive disease by Wallace 2004 criteria 18 months later was assessed. Correlation-based feature selection and ReliefF were used to shortlist predictors and random forest models were trained to predict outcomes. Results From the original 112 features, 13 effectively predicted 18-month outcomes. They included age, number of active/effused joints, wrist, ankle and/or knee involvement, ESR, ANA positivity and plasma levels of five inflammatory biomarkers (IL-10, IL-17, IL-12p70, soluble low-density lipoprotein receptor-related protein 1 and vitamin D), at enrolment. The clinical plus biomarker panel predicted active joint count = 0, physician global assessment ≤ 1, and inactive disease after 18 months with 0.79, 0.80 and 0.83 accuracy and 0.84, 0.83, 0.88 area under the curve, respectively. Using clinical features alone resulted in 0.75, 0.72 and 0.80 accuracy, and area under the curve values of 0.81, 0.78 and 0.83, respectively. Conclusion A panel of five plasma biomarkers combined with clinical features at the time of diagnosis more accurately predicted short-term disease activity in JIA than clinical characteristics alone. If validated in external cohorts, such a panel may guide more rationally conceived, biologically based, personalized treatment strategies in early JIA. [ABSTRACT FROM AUTHOR]

Background: With modern treatments, the effect of juvenile idiopathic arthritis (JIA) on growth may be less than previously reported. Our objective was to describe height, weight and body mass index (BMI) development in a contemporary JIA inception cohort. Methods: Canadian children newly-diagnosed with JIA 2005-2010 had weight and height measurements every 6 months for 2 years, then yearly up to 5 years. These measurements were used to calculate mean age-and sex-standardized Z-scores, and estimate prevalence and cumulative incidence of growth impairments, and the impact of disease activity and corticosteroids on growth. Results: One thousand one hundred forty seven children were followed for median 35.5 months. Mean Z-scores, and the point prevalence of short stature (height < 2.5th percentile, 2.5% to 3.4%) and obesity (BMI > 95th percentile, 15.8% to 16. 4%) remained unchanged in the whole cohort. Thirty-three children (2.9%) developed new-onset short stature, while 27 (2.4%) developed tall stature (>97.5th percentile). Children with systemic arthritis (n = 77) had an estimated 3-year cumulative incidence of 9.3% (95%CI: 4.3-19.7) for new-onset short stature and 34.4% (23-49.4) for obesity. Most children (81.7%) received no systemic corticosteroids, but 1 mg/Kg/day prednisone-equivalent maintained for 6 months corresponded to a drop of 0.64 height Z-scores (0.56-0.82) and an increase of 0.74 BMI Z-scores (0.56-0.92). An increase of 1 in the 10-cm physician global assessment of disease activity maintained for 6 months corresponded to a drop of 0.01 height Z-scores (0-0.02). Conclusions: Most children in this modern JIA cohort grew and gained weight as children in the general population. About 1 in 10 children who had systemic arthritis, uncontrolled disease and/or prolonged corticosteroid use, had increased risk of growth impairment. [ABSTRACT FROM AUTHOR]

Background/Purpose: According to the ILAR criteria, undifferentiated juvenile idiopathic arthritis (U-JIA) includes children who fail to meet criteria for 1 of the other 6 categories or who meet criteria in more than 1 category. Classification requires category-specific application of 5 exclusion criteria: 1. Psoriasis in the patient or a 1st degree relative; 2. Arthritis beginning after the 6th birthday in an HLA-B27 + male; 3. HLAB27 associated disease in a 1st degree relative; 4. Rheumatoid factor positivity (RF+) on 2 occasions; and 5. The presence of systemic JIA (SoJIA). A pilot single-centre study (n=21) revealed that psoriasis in a 1st degree relative was the most common reason for classifying patients as U-JIA; disregarding this criterion would allow re-classification of most U-JIA patients and had no impact on the classification of JPsA patients (Chan et al., 2011). We aimed to determine the most frequent reasons for classifying children as U-JIA from a large multicenter prospective cohort of children with JIA (n=1104). Methods: Two investigators reviewed data on patients diagnosed with UJIA extracted from the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) database. They identified by consensus the reasons for classifying patients as U-JIA and the JIA category they would fall in if the following two changes were made: disregarding psoriasis in a 1st degree relative, considering patients as RF negative when only a single positive RF test was recorded. Results: 84 patients (51 female), were classified as U-JIA for the reasons shown in the . [ABSTRACT FROM AUTHOR]

We describe a young girl with antiphospholipid syndrome (APS) and moyamoya-like cerebrovascular changes which reversed after anticoagulation. Although there was a risk of hemorrhage from collateral vessels, we speculate that this treatment may have prevented progression of the vascular abnormalities, while resolution of the thrombus resulted in improved cerebrovascular circulation. [ABSTRACT FROM AUTHOR]

Background/Purpose: Previous studies of uveitis in Juvenile Idiopathic Arthritis (JIA) patients have reported prevalence and not incidence. The ReACCh Out cohort, a large inception cohort of newly diagnosed JIA patients provided the opportunity to prospectively ascertain the true incidence of new onset uveitis. The objectives of this study were to determine the overall incidence rate and its trajectory over time. Methods: ReACCh Out recruited newly diagnosed JIA patients between January 2005 and December 2010, from 16 Canadian centres across the country. Prospective data was collected every 6 months for the first 2 years, then yearly. Data was collected on numerous clinical and laboratory measures including the diagnosis of uveitis and its complications, determined by an ophthalmologist. A Poisson model was used to estimate the overall incidence rate. A Kaplan-Meier plot was used to evaluate the time from diagnosis of JIA to the time of diagnosis of new onset uveitis. Results: 1104 patients with newly diagnosed (≤6 months) JIA with ≥1 follow-up visit were reviewed. Patients were predominantly female (63%), age at diagnosis was 9.3 (3.9, 13.0) years. Time from diagnosis to enrollment was 0.3 (0, 1.6) months. Follow-up to last visit or study end was 34.2 (21.5, 48) months. 23 patients whose uveitis status was not available, were excluded. 77 patients with new onset uveitis were identified during the study period. The overall incidence rate of new cases of uveitis following the diagnosis of JIA was 2.9% per year (95% confidence interval 2.3-3.6). Following the trajectory of new cases of uveitis over time, the incidence of new cases showed a slow decline over time (Figure ). Importantly, new cases of uveitis occurred as far out from diagnosis as the end of the study period. Kaplan-Meier plots were also used to evaluate age at diagnosis of new onset uveitis and gender. Results support previously identified risk factors for uveitis including younger age (<5 years) and female gender. The frequency of uveitis occurred in the JIA patients in the following distribution according to subtype: oligoarthritis (43, 56%), polyarthritis RF negative (18, 23%), polyarthritis RF positive (1, 1%), psoriatic (4, 5%), ERA (1, 1%), systemic (1, 1%) and undifferentiated (9, 12%). [ABSTRACT FROM AUTHOR]

Background/Purpose: To determine the incidence of vertebral fracture (VF) in the three years following glucocorticoid (GC) initiation, and the effect of GC on the risk of incident VF in children with rheumatic disorders (RD). Methods: Children with RD were enrolled within 30 days of GC initiation and followed for 3 years, with VF assessed at baseline and then annually using the Genant method on lateral spine radiographs. An incident VF was defined as a new fracture in a previously normal vertebral body or worsening of an existing VF. The annual and the 3 year cumulative incidences were calculated as the number of new cases divided by the number of subjects who completed VF assessment at the specified time periods. Six different time-dependent GC exposure measures were constructed: cumulative dose, average daily dose, duration on GC therapy, dose intensity (cumulative dose divided by duration on GC therapy) over 3 years, recent average daily dose and duration on GC therapy over the preceding 12 months. Extended Cox's models were used with alternative time-dependent variables, adjusting for factors at baseline including age, gender, body mass index, vitamin D and calcium supplementation, disease activity, bone mineral density, physical activity, and presence of prevalent VF. Results: 136 enrolled children (mean ± SD age 9.9 ± 4.4 years, 65% girls) held the following diagnoses: 22% juvenile dermatomyositis (JDM), 21% non-systemic juvenile idiopathic arthritis (JIA), 19% systemic lupus erythematosus (SLE), 18% systemic JIA, 12% systemic vasculitis, and 9% other RD. 9 children had VF at baseline (3 JDM, 2 systemic JIA, 2 SLE, 1 systemic vasculitis, 1 localized scleroderma), with an estimated prevalence of 6.6% (95% confidence interval (CI) 2.4-10.8%). 18 incident VF were identified in 15 children during the 3 years following GC initiation (6 JDM, 4 SLE, 2 systemic vasculitis, 2 systemic JIA, and 1 non-systemic JIA). The 3-year cumulative VF incidence was 13.0%, at a rate of 4.9 per 100 person-years. Of the 18 incident VF events, 7 occurred during the first year at an annual incidence of 6.0% (95% CI 1.7-10.3%); 6 VF occurred during the second year (annual incidence 5.6%; 95% CI 1.2-9.9%); 5 VF occurred during the third year (annual incidence 4.3%; 95% CI 1.0-8.1%). 64% of patients had mild incident VF as the worst grade, 36% had moderate fractures, and none had severe fractures. Of those with incident fractures, 21% had no complaints of back pain in the preceding 12 months. Multivariable models showed that every 100 mg/kg increase in cumulative GC dose was associated with a 30% increased incident VF risk (hazard ratio (HR) = 1.3, 95% CI 1.1, 1.6). Every 0.5mg/kg increase in average daily dose over the 3 year period was associated with a 4.2 fold increased VF risk (HR = 4.2, 95% CI 2.3, 7.7), and every 0.5 mg/kg increase in daily dose during the preceding 12 months was associated with a 2.7 fold increased incident VF risk (HR =2.7, 95% CI 1.3, 5.2). Conclusion: We have shown that 13.0% of children with RD sustained VF within three years followingGC initiation, of which 36% had moderate fractures. Cumulative dose, average daily GC dose, and recent average daily GC dose were associated with a significantly increased VF risk. Funded by CIHR FRN 64285 [ABSTRACT FROM AUTHOR]

Background/Purpose: Although children with JIA have lower fitness levels than healthy peers, little is known about their level of habitual physical activity. The LEAP study is a prospective longitudinal multicentre study of children and teens with JIA, aimed at describing the trajectory of physical activity (PA) in JIA, and its relationship to disease factors, inflammation, quality of life, bone health and muscle function. We report PA levels of children with JIA in early and late disease at study entry. Methods: We enrolled patients with JIA (aged 8-16 y) at 12 pediatric rheumatology centres in Canada as either an inception cohort (early disease; within 6 mos of diagnosis) or an established disease cohort (late disease; > 2yr after diagnosis). We assessed PA with a validated Physical Activity Questionnaire for children (PAQ-C, age 8-13 y) or teens (PAQ-A, age 14-16 y). This 7-day recall self-report tool has scores from 0 (no PA)- 5(high PA). Participants record weekly PA across a wide range of activities and sports. Patients completed a pain scale (VAS 0-100), the Childhood Health Assessment Questionnaire (CHAQ), and Juvenile Arthritis Quality of life Questionnaire (JAQQ). Examining physicians recorded physician global assessment of disease activity (PGA;VAS 0-100) and active joint count. We used univariate and multivariate regression (controlled for gender) to examine relationships between disease and patient factors and PAQ score at study entry. We used PAQ standard population normative values to compare to subjects (female 2.69, SD 0.62; male 3.0 SD 0.72). Results: We included the first 189 patients enrolled (126 F, 63 M, med age 13 y) from March 2012-November 2013. The early cohort included 81 patients (enrolled median 2.4 mo after diagnosis) and the late cohort included 108 patients (enrolled median 4.8 yr after diagnosis). Active arthritis was found in 88 patients, with a mean of 5.5 active joints (range 1-56). PGA was a mean of 13.45 (range 0-74). Overall mean PAQ score for the JIA patients was 2.55 (SD 0.73, range 1-4). Table describes PAQ scores by sex, disease cohort, and presence of active arthritis. When controlled for sex, PAQ scores were significantly different between new onset and late disease, and between patients with active arthritis compared with no active arthritis. Univariate analyses revealed that higher PAQ score were associated with lower pain (p = 0.02), lower CHAQ score (p < 0.0001), higher JAQQ score (p = 0.0001), lower active joints (p = 0.002) and low PGA (p = 0.003). Multivariate analysis confirmed these associations, with R2 = 0.25, p = 0.000 (girls), R2 = 0.17, p = 0.01 (boys). [ABSTRACT FROM AUTHOR]

Background/Purpose: It has been previously shown that early involvement of wrist and ankle are risk factors for extension of oligoarticular onset juvenile arthritis (oligoJA). Our objective was to determine whether early wrist, ankle, upper limb, or lower limb involvement are risk factors for extension to a polyarticular course in a cohort of paediatric patients with oligoJA. Methods: This is a retrospective cohort study of children with oligoJA presenting to paediatric rheumatology clinics at the two Canadian paediatric centres from 1981 to 2010. OligoJA was defined as ≤4 joints at the first and 6 month visits. Risk factors for extension from oligoJA to polyarthritis (>5 joints) by 2 and 5 years after diagnosis were modelled using logistic regression while controlling for sex, ever having used DMARDs, or intraarticular corticosteroid injections. Time to extension was assessed using Cox proportional hazard analysis. Results: 420 patients met eligibility criteria. 56% were female. The median time from disease onset to diagnosis was 136 days (IQR 55.5 days, 365.0 days); 15 patients in the logistic regression models extended by 2 years (n=280, of which 5.4% extended) and 27 by 5 years (n=339, of which 8.0% extended). At 2 years after diagnosis the odds of extension was 6.1 times higher (95% CI 1.9, 24.3) in those with initial wrist involvement than in those without, and at 5 years it was 3.1 times higher (95% CI 1.0, 8.0). The OR of extension in those with initial upper limb involvement versus those without was 7.0 (95% C.I. 2.3, 21.6) at 2 years and 6.3 (95% C.I. 2.5, 15.8) at 5 years. Cox proportional hazard modelling showed a HR of 2.3 (95% CI 1.2, 4.5) in patients with upper limb involvement compared to without upper limb involvement indicating that extension was 2.3 times more likely to occur in the former group. The likelihood ratio was 68.7, p value < 0.0001, degrees of freedom (d.f) = 4, and events per variable = 9.8. Conclusion: This study independently confirms previous published findings that wrist and upper limb arthritis in the first 6 months after diagnosis of oligoJA is a risk factor for extension. Unlike previous reports, we did not find an increased probability of extension in patients with early ankle arthritis. Patients with upper limb arthritis in the first 6 months after diagnosis were more likely to extend sooner than those without early upper limb arthritis. [ABSTRACT FROM AUTHOR]

Background/Purpose: During a recent study we conducted to identify patients, parents, and clinicians' priorities in describing the course of juvenile idiopathic arthritis (JIA), parents expressed intense emotions related to the disease and its management even a decade after their children's diagnosis. Here we describe the predominant emotional experiences reported by parents and how they relate to different phases of the disease manifestation, treatments, and interactions with peers and healthcare providers. Methods: We analyzed focus group transcripts and reciprocal interview answers involving 9 experienced English-speaking parents, 5 experienced French-speaking parents and 8 novice parents (between 2 and 6 months since diagnosis). Their children were 2 to 16 years of age and had a variety of JIA subtypes and disease severity. Qualitative analysis included review of audio recordings to enrich transcripts (based on pauses, noises, and other non-verbal cues), coding of emotional experiences by two investigators using a list of 69 emotion labels, coding verification by two other investigators, and analytical discussion and synthesis by our interdisciplinary team (to agree on what emotions were predominant at different stages of the disease, who or what were those emotions directed at, and how disease characteristics or parent background shaped them). Results: The time between onset and diagnosis was described by parents as a period of mounting anxiety, confusion and frustration with healthcare providers before a firm diagnosis was reached. The time shortly after diagnosis was described as a time of shock, disbelief, and fear during which parents often used denial as a coping mechanism; combined with feeling overwhelmed by a sea of information about the disease. Later in the disease course, at times of disease quiescence the predominant emotions were annoyance and worry about treatment side effects, and the fear of unpredictable flares. At times of increasing or ongoing symptoms the predominant emotions were admiration for the way their children coped with the disease, and frustration with peers and teachers that could not appreciate justification for the changes in the child's willingness to engage in physical activity and school work. This was also a time of frustration with increasing treatment and side effects. Throughout the disease parents felt a sense of powerlessness and that the disease was a 'time-consuming roller coaster.' The subtype of arthritis did not affect the range of emotions experienced, but influenced the proportion of time in quiescence or ongoing symptoms, and the intensity of treatments and side-effects. Conclusion: The emotional experiences of parents of children with JIA can be conceptualized, as a parent put it, as roller coaster ride made of intensely emotional ups and downs. This is similar to the emotional turmoil faced by parents of children with other chronic illnesses, but JIA usually does not confront them with the chronic grief produced by progressive degenerative illnesses or the threat of imminent death. [ABSTRACT FROM AUTHOR]