title: Identifying Targets for Improving Mental Healthcare of Adolescents with Systemic Lupus Erythematosus: Perspectives from Pediatric Rheumatology Clinicians in the United States and Canada.
abstract: To identify targets for improving mental healthcare of adolescents with systemic lupus erythematosus (SLE) by assessing current practices and perceived barriers for mental health intervention by pediatric rheumatology clinicians.
  
  
  
  Members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) completed a Web-based survey assessing current mental health practices, beliefs, and barriers. We examined associations between provider characteristics and the frequency of barriers to mental health screening and treatment using multivariable linear regression.
  
  
  
  Of the 375 eligible CARRA members, 130 responded (35%) and 119 completed the survey. Fifty-two percent described identification of depression/anxiety in adolescents with SLE at their practice as inadequate, and 45% described treatment as inadequate. Seventy-seven percent stated that routine screening for depression/anxiety in pediatric rheumatology should be conducted, but only 2% routinely used a standardized instrument. Limited staff resources and time were the most frequent barriers to screening. Respondents with formal postgraduate mental health training, experience treating young adults, and practicing at sites with very accessible mental health staff, in urban locations, and in Canada reported fewer barriers to screening. Long waitlists and limited availability of mental health providers were the most frequent barriers to treatment. Male clinicians and those practicing in the Midwest and Canada reported fewer barriers to treatment.
  
  
  
  Pediatric rheumatology clinicians perceive a need for improved mental healthcare of adolescents with SLE. Potential strategies to overcome barriers include enhanced mental health training for pediatric rheumatologists, standardized rheumatology-based mental health practices, and better integration of medical and mental health services.
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Knight
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Vickery
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Eyal
authors.initials: E
authors.lastname: Muscal
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Alaina M
authors.initials: AM
authors.lastname: Davis
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Julia G
authors.initials: JG
authors.lastname: Harris
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Arzu
authors.initials: A
authors.lastname: Soybilgic
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Karen B
authors.initials: KB
authors.lastname: Onel
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Laura E
authors.initials: LE
authors.lastname: Schanberg
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Tamar
authors.initials: T
authors.lastname: Rubinstein
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: Beth S
authors.initials: BS
authors.lastname: Gottlieb
authors.affiliation: From the Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the Children's Hospital of Philadelphia (CHOP); Perelman School of Medicine, and Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, Pennsylvania; Baylor College of Medicine; Department of Pediatric Medicine, Division of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Texas; Division of Pediatric Rheumatology, Vanderbilt University School of Medicine, Monroe Carell Junior Children's Hospital, Nashville, Tennessee; Division of Rheumatology, Children's Mercy Kansas City; Kansas City School of Medicine, University of Missouri, Kansas City, Missouri; Division of Pediatric Rheumatology, University of Illinois at Chicago; University of Illinois Hospital and Health Sciences System; Division of Pediatric Rheumatology, University of Chicago; University of Chicago Medicine, Chicago, Illinois; Division of Pediatric Rheumatology, Duke University Medical Center; Duke School of Medicine, Durham, North Carolina; Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore; Division of Pediatric Rheumatology, Cohen Children's Medical Center of New York, New York; The Hofstra North Shore-LIJ School of Medicine, Hempstead; Clinical and Translational Sciences Institute, Rochester, New York; Division of Pediatric Rheumatology, University of California San Francisco School of Medicine, San Francisco, California, USA.A.M. Knight, MD, MSCE, Attending Physician, Faculty, Division of Pediatric Rheumatology, and Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP, and Assistant Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania; M.E. Vickery, MPH, Center for Pediatric Clinical Effectiveness, and PolicyLab at the CHOP; E. Muscal, MD, MS, Attending Physician, Department of Pediatric Medicine, Division of Immunology, Allergy and Rhe
authors.forename: David S
authors.initials: DS
authors.lastname: Mandell
authors.forename: Emily
authors.initials: E
authors.lastname: von Scheven
mesh_terms: D000293:Adolescent; D016497:Adolescent Health Services / Q000592:standards*; D002170:Canada; D019538:Health Care Surveys; D006801:Humans; D008180:Lupus Erythematosus, Systemic / Q000523:psychology*; D008403:Mass Screening; D001523:Mental Disorders / Q000523:psychology / Q000628:therapy*; D008605:Mental Health Services / Q000592:standards*; D010818:Practice Patterns, Physicians'; D058996:Quality Improvement; D012219:Rheumatology / Q000592:standards*; D014481:United States
keywords: ANXIETY; DEPRESSION; MENTAL HEALTH; PEDIATRIC RHEUMATOLOGY; SYSTEMIC LUPUS ERYTHEMATOSUS