Conclusion

Earlier reports on the psychosocial disease impact in children and young people with rheumatic disease tended to be negatively biased due to weak study designs (56) and due to the prevailing focus on disturbance instead of resilience in the pediatric psychology literature. In the meantime, more sophisticated studies have substantially corrected this picture. However, at least some authors suspect that we might overemphasize normalcy, today. Some even argued that the ostensible normalcy of JIA patients might be their problem in that it showed a kind of hyperadaptation (48,65). Two editorials on studies with overwhelmingly "positive" results did not go that far but explicitly questioned the positive overall impressions (66,67). They claim that future research should focus more on the severely ill young people who—by virtue of the low frequency of the underlying diseases—mostly represent small subsets in previous studies. It may well be that psychosocial consequences emerge only at or above certain levels of disease severity, functional impairment, and treatment intensity. The reciprocal influences of adolescent psychosocial development and the diversity of the rheumatic diseases have not yet been adequately addressed, especially regarding rheumatic diseases beyond the JIA spectrum (SLE, vasculitis, etc.). On the other hand, disease characteristics have not demonstrated a consistent relationship with psychosocial adjustment, so that identifying those at greatest risk for problems will not be a simple task. As the most recent study shows, negative attitude towards illness may well be one important stress processing factor (61). Therefore, future research should rely more on homogeneous samples (regarding diversity) and should focus more on mediating factors than on the general issue of a disease related, increased risk of disturbances. Finally, we should keep in mind the "power of positive thinking" (68): these young people as well as their healthy peers (should) focus on real-life targets, and having meaningful goals to pursue will help them overcome some of the inescapable strains of illness.

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