Does asthma or treatment with theophylline limit children's academic performance?

The Temporal Hyper-Morbidity of Asthma and Attention Deficit Disorder: Implications for Interpretation Based on Comparison of Prospective and Cross-Sectional Population Samples

OBJECTIVE

The purpose of this study was to test the hypothesis that a significant temporal relationship exists between asthma and attention deficit hyperactivity disorder (ADHD).

METHODS

The population dataset consisted of 95,846,511 physician diagnoses for 768,460 (46% male) individuals spanning 1993-2010. Four groups were labeled as having neither Asthma nor ADHD, Asthma only, ADHD only, or both Asthma and ADHD and formed the basis of calculating the odds ratios for each sex describing the association of Asthma and ADHD by age, and, in addition, a prospective sample age (<5 years) between 1993 and 1996 was utilized to evaluate the temporal association between Asthma and ADHD.

RESULTS

There was a significant relationship between ADHD and Asthma within the age strata of the sample, one from the cohort and two from the whole sample. When both ADHD and Asthma were diagnosed in the same patients, the age was younger in both cross-sectional and prospective cohort samples. ADHD arose significantly more often after Asthma in the cross-sectional samples stratified on age and in the prospective cohort sample.

CONCLUSION

The results are consistent with previous literature where ADHD has been linked to allergic diseases, such as asthma.

Quality of life in at-risk school-aged children with asthma

INTRODUCTION

Asthma is the most common chronic condition of childhood. Urban, minority children from families of lower socioeconomic status have disproportionately higher rates of asthma and worse outcomes. We investigated the association between the presence of asthma and asthma severity among American, urban, minority children and reported quality of life (QOL) of children and their families.

METHODS

We performed a prospective, cross-sectional study comparing QOL of urban, minority elementary school-age children with and without asthma. A convenience sample of children was enrolled from the pediatric emergency department (ED) and a specialized asthma clinic, at a large urban children's hospital. We measured child and parent QOL using the Pediatric Quality of Life Inventory Version 4 (PEDSQL4), and evaluated associations with asthma, parental educational attainment, and frequency of ED visits.

RESULTS

We enrolled 66 children, 76% were African American, and 61% were female. Overall child QOL was higher for those without asthma (p = 0.017, d = 0.59). Children with asthma also visited the ED almost twice as frequently (t [64] = -3.505, p < 0.001, d = 0.8), and parents of children with asthma reported a lower overall QOL (p = 0.04, d = 0.53) than those without asthma. Among children with asthma, a higher overall child QOL was associated with decreased asthma severity, more ED visits, and higher parental educational attainment.

CONCLUSIONS

Urban, minority elementary school-age children with asthma report a lower QOL than those children without asthma, and decreased asthma severity was associated with higher QOL.

Asthma and subsequent school performance at age 15-16 years: A Swedish population-based sibling control study

Asthma may negatively affect children’s school performance, such as grades and exam results. Results from previous studies have shown varying results and may have suffered from confounding and other biases. We used a Swedish population-based cohort of 570,595 children with data on asthma (including severity and control) in Grades 7–8 and 9, school performance from Grade 9 (grade point sum, non-eligibility for upper secondary school and national test results) and measured confounders from national registers. We used sibling comparisons to account for unmeasured familial factors. Children with asthma and severe asthma performed slightly better in school than children without asthma when adjusting for measured confounders, but the associations were attenuated in sibling comparisons. In contrast, children with uncontrolled asthma performed slightly worse (e.g. Grade 9: β_adj = −9.9; 95% CI −12.8 to −7.0; Cohen’s d = 0.16). This association remained for uncontrolled asthma in Grade 9 in sibling comparisons (Grade 9: β = −7.7 points; 95% CI −12.6 to −2.6; Cohen’s d = 0.12), but not for Grades 7–8. The attenuation of estimates when controlling for familial factors using sibling comparisons suggests that the differences were due to familial factors, rather than being causal. The remaining associations in sibling comparisons between uncontrolled asthma in Grade 9 and school performance are consistent with a causal association.

A Comparison of the Academic Performance and Intelligence Scores of Asthmatic and Nonasthmatic Primary School Pupils in Enugu State, Nigeria

Background:

Children with asthma (subjects), just as their non asthmatic colleagues, are expected to perform optimally academically and with a good intelligent score. A number of activities in children with asthma may be affected by asthmatic attacks including their education/academic performance. Report on academic performance and IQ of school children with asthma and comparisons with those without asthma (controls) within and outside Nigeria are scanty.

Aims:

This study compared the academic performance and IQ of asthmatics and nonasthmatic school children.

Materials and Methods:

One hundred and twenty children with asthma aged 5-11 years were consecutively recruited at the asthma clinic of UNTH Enugu and their age, gender and socio-economic class-matched normal classmates were enrolled as controls. Academic performance of the children with asthma was studied using the overall scores achieved in the three term examinations in the preceding academic year (2012/2013), while their IQ was determined using the Draw-A-Person-test. The findings were compared with that of the 120 controls.

Results:

The median (range) overall academic scores for the subjects 79.04% (36.08%-99.57%) was similar to that of controls 80.01% (50.65%-97.47%) (U = 6804, P = 0.461). However, a significant number of subjects compared to controls had poor academic performance. The mean IQ scores for subjects (123.28 ± 21.45) and controls (118.41 ± 19.87) did not differ significantly (t = 1.83; P = 0.069). There was also a significant and negative correlation (Pearson's) between age and mean DAPQ in both the subjects and controls (r = -0.377, P < 0.001; r = -0.492, P < 0.001 respectively.

Conclusions:

The intelligence scores and overall academic performance of children with asthma compares favorably with that of children without asthma.

Exploring the intersection of executive function and medication adherence in school-age children with asthma

Asthma is one of the most common chronic diseases of childhood. For children with persistent asthma, asthma control is largely related to controller medication adherence. With increasing calls for children to be involved in their own asthma management, there is a gap in our knowledge about the executive functioning of children with asthma.

OBJECTIVE

The purpose of this study was to explore the relationship between executive function, asthma, and medication adherence among school-age children with asthma.

METHODS

Thirty-one children ages 7 to 11 years (M = 8.9 ± 1.51) and one of their parents were enrolled in this study. Parents reported on asthma control while children reported on asthma control, medication beliefs, medication adherence, and completed an executive function battery that assessed inhibition, updating, shifting and planning.

RESULTS

Compared to the reference sample, children in this study had significantly lower composite scores in inhibition, t (31) = -3.84, p =. 001, and shifting, t (30) = -3.73, p =. 001. Controlling for age and asthma control, hierarchical regression analyses revealed that shifting accounted for 16% of the variance in child-reported medication adherence.

CONCLUSIONS

This study revealed lowered executive functioning scores among school-age children with persistent asthma. Furthermore, it appears executive functioning and controller medication adherence are intertwined and warrant future exploration.

The influence of comorbid asthma on the severity of symptoms in children with attention-deficit hyperactivity disorder

OBJECTIVE

The current study examined the association between asthma and attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical pediatric sample.

METHODS

Demographic and neuropsychological data for children with a billing diagnosis of ADHD were extracted from a clinical database. Families completed standard rating scales. Seventy-one patients with a co-morbid asthma diagnosis were identified and matched by age to a group of 71 patients with only ADHD.

RESULTS

Children with asthma and ADHD were more likely to display clinically elevated levels of hyperactivity, externalizing behaviors, anxiety, and hyperactive/impulsive behaviors compared to children with ADHD alone. Boys with asthma and ADHD had more symptoms than boys with only ADHD of somatization and emotional internalizing, while girls with asthma and ADHD had more symptoms of hyperactivity/impulsivity, conduct problems, anxiety, and emotional internalizing compared to girls with only ADHD.

CONCLUSIONS

Findings suggest that in children with ADHD, co-morbid asthma is associated with increased behavioral and internalizing symptoms, with distinct gender differences present. Increased behavioral and internalizing symptoms seen in children with both asthma and ADHD may be due to the burden of their medical condition. No difference was found on cognitive variables, suggesting chronic hypoxia may be less influential in explaining these differences. Future research should determine the specific mechanisms of these differences.

Indoor and outdoor PM10 levels at schools located near mine dumps in Gauteng and North West Provinces, South Africa

BACKGROUND

Few studies in South Africa have investigated the exposure of asthmatic learners to indoor and outdoor air pollution at schools. This study compared outdoor PM10 and SO2 exposure levels in exposed (1-2 km from gold mine dumps) and unexposed schools (5 km or more from gold mine dumps). It also examined exposure of asthmatic children to indoor respirable dust at exposed and unexposed schools.

METHODS

The study was conducted between 1 and 31 October 2012 in five schools from exposed and five from unexposed communities. Outdoor PM10 and SO2 levels were measured for 8-h at each school. Ten asthmatic learners were randomly selected from each school for 8-h personal respirable dust sampling during school hours.

RESULTS

The level of outdoor PM10 for exposed was 16.42 vs. 11.47 mg.m-3 for the unexposed communities (p < 0.001). The outdoor SO2 for exposed was 0.02 ppb vs. 0.01 ppb for unexposed communities (p < 0.001). Indoor respirable dust in the classroom differed significantly between exposed (0.17 mg.m-3) vs. unexposed (0.01 mg.m-3) children with asthma at each school (p < 0.001).

CONCLUSION

The significant differences between exposed and unexposed schools could reveal a serious potential health hazard for school children, although they were within the South African Air Quality Standards' set by the Department of Environmental Affairs. The indoor respirable dust levels in exposed schools could have an impact on children with asthma, as they were significantly higher than the unexposed schools, although there are no published standards for environmental exposure for children with asthma.

Influences of asthma on reported health indicators and access to health care among children

BACKGROUND

Studies on the influences of pediatric asthma on health and access to health care were conducted in limited geographic areas or age groups.

OBJECTIVE

To investigate associations of asthma with health, use of medical care, mental health or educational services, activity limitations, problems in paying bills, and frustrations in obtaining health care among children in the United States. Caregivers reported children's conditions.

METHODS

Logistic regression models were adjusted for sociodemographic factors in the nationally representative 2011/2012 National Survey of Children's Health.

RESULTS

Of the 91,116 children 0 to 17 years old, 14.6% had reported asthma. Of children 0 to 17 years old with asthma, 21.2% were non-Hispanic black. Of children 0 to 17 years old without asthma, 12.2% were non-Hispanic black. In children 0 to 17 years old, compared with children without asthma, children with asthma had an increased odds to have reported fair or poor health, receive more medical care, mental health, and educational services than usual, have activity limitations, have medical bills that the family had problems paying (odds ratio 1.5, 95% confidence interval 1.3-1.7), and have caregivers who were frustrated in obtaining care (odds ratio 1.5, 95% confidence interval 1.2-1.7). The odds ratios for the associations between asthma and all outcomes were higher in the 0- to 5-year-old compared with the 6- to 17-year-old group.

CONCLUSION

When adjusting for sociodemographic variables, caregivers have problems paying bills and obtaining health care services for their child. To develop age-appropriate interventions, more research is needed to understand why families have difficulties accessing health care.

Lung disease as a determinant of cognitive decline and dementia

Almost 40 million people currently live with dementia but this is estimated to double over the next 20 years; despite this, research identifying modifiable risk factors is scarce. There is increasing evidence that cognitive impairment is more frequent in those with chronic lung disease than those without. Chronic obstructive pulmonary disease affects 210 million people, with cognitive impairment present in 60% of certain populations. Co-morbid cognitive dysfunction also appears to impact on important outcomes such as quality of life, hospitalisation and survival. This review summarises the evidence of an association between cognition, impaired lung function and obstructive lung disease. It goes on to examine the contribution of neuro-imaging to our understanding of the underlying pathophysiology. While the mechanisms of brain pathology and cognitive impairment are likely to be complex and multi-factorial, there is evidence to suggest a key role for occult cerebrovascular damage independent of traditional vascular risk factors, including smoking.

The associations between ADHD and asthma in Korean children

BACKGROUND

The aim of this study was to investigate the associations between attention deficit hyperactivity disorder (ADHD), the most common neuropsychiatric disorder in school children, and childhood allergic disease by evaluating their respective prevalence.

METHODS

Subjects were comprised of first and second grade students in twenty two elementary schools in a city in the Republic of Korea. The mode of measurement for ADHD was based on DSM-IV from clinical interviews conducted by child psychiatrists. Along with the diagnostic interviews, we also used the epidemiological questionnaires, Computerized Attention Deficit-Hyperactivity Disorder Diagnostic System, the abbreviated Conner's Parent Rating Scale (CPRS), and DuPaul's ADHD Rating Scales. Allergic conditions, such as asthma, have been separately evaluated based on the questionnaire items whose validity and reliability were proved by the International Study of Asthma and Allergies in Children (ISAAC). All questionnaires were completed by the subjects' parents.

RESULTS

The lifetime prevalence rate of asthma in ADHD patients was 36.6%, compared to a prevalence of 24.3% in control subjects. The lifetime prevalence rate of allergic rhinitis in ADHD patients was 59.0%, compared to a prevalence of 47.0% in control subjects. Statistically significant difference has been found between the two groups. In the logistic regression model of the ADHD and the control group, the relative risk of asthma was 1.60 times higher (confidence interval 1.301-1.964), the relative risk of allergic rhinitis was 1.38 times higher (confidence interval 1.124-1.681), which showed statistical significance.

CONCLUSIONS

The findings of this study suggest significant association between ADHD and childhood asthma and allergic rhinitis. Therefore, appropriate evaluation and treatment are needed for asthmatic children with attention-deficit symptoms, or allergic rhinitis with ADHD. Besides, further research is needed to determine the etiological approach towards ADHD, asthma, and allergic rhinitis.

Communication about ADHD and its treatment during pediatric asthma visits

The objectives of the study were to examine provider-family communication about attention deficit disorder during pediatric asthma visits. Children with asthma, aged 8 through 16 and their parents were recruited at five pediatric practices. All medical visits were audio-taped. There were 296 asthmatic children enrolled into the study and 67 of them also had attention deficit hyperactivity disorder (ADHD). ADHD communication elements suggested by national guidelines were discussed infrequently. Providers were more likely to discuss, educate, and ask one or more questions about ADHD medications if the visit was non-asthma related. Providers included child input into the ADHD treatment regimen during 3% of visits and they included parent input during 4.5% of visits. Only one child and three parents asked questions about ADHD. Providers may neglect essential aspects of good ADHD management and communication in children who have ADHD plus another chronic condition such as asthma. Providers should set appropriate treatment expectations, establish target symptoms, and encourage children and parents to ask questions so mutual decision-making can occur.

Chronic health conditions and school performance among children and youth

PURPOSE

Chronic health conditions are common and increasing among U.S. children and youth. We examined whether chronic health conditions are associated with low school performance.

METHODS

This retrospective cohort study of 22,730 children and youth (grades 2-11) in San Jose, California, was conducted from 2007 through 2010. Health conditions were defined as chronic if reported in each of the first 2 years, and school performance was measured using standardized English language arts (ELA) and math assessments.

RESULTS

Chronic health conditions were independently associated with low ELA and math performance, irrespective of ethnicity, socioeconomic status, or grade level. Adjusted odds ratios for the association between any chronic health condition and low ("basic or below") performance were 1.25 (95% confidence interval [CI], 1.16-1.36; P < .001) for ELA and 1.28 (95% CI, 1.18-1.38; P < .001) for math, relative to students without reported health conditions. Further adjustment for absenteeism had little effect on these results. The strongest associations were found for ADHD, autism, and seizure disorders, whereas a weak association was found for asthma before but not after adjusting for absenteeism, and no associations were found for cardiovascular disorders or diabetes.

CONCLUSIONS

Chronic neurodevelopmental and seizure disorders, but not cardiovascular disorders or diabetes, were independently associated with low school performance among children and youth.

Therapeutic management of allergic diseases

Allergic diseases are characterized by the activation of inflammatory cells and by a massive release of mediators. The aim of this chapter was to describe succinctly the modes of action, indications, and side effects of the major antiallergic and antiasthmatic drugs. When considering the ideal pharmacokinetic characteristics of a drug, a poorly metabolized drug may confer a lower variability in plasma concentrations and metabolism-based drug interactions, although poorly metabolized drugs may be prone to transporter-based disposition and interactions. The ideal pharmacological properties of a drug include high binding affinity, high selectivity, and appropriate association and dissociation rates. Finally, from a patient perspective, the frequency and route of administration are important considerations for ease of use.

Attention deficit and hyperactivity symptoms in children with asthma

BACKGROUND

Asthma that is chronic may influence children's behavioral health and quality of life (QoL) negatively.

OBJECTIVE

To evaluate the frequency of attention deficit and hyperactivity symptoms in children with asthma and to determine if these symptoms are associated with a deterioration of QoL.

METHODS

Mothers of 62 children with moderate asthma and those of 38 healthy children aged between 7-12 years were included in the study. Conners' Parent Rating Scale-48 (CPRS), a 48-item multiple-choice questionnaire, was completed by the mothers to identify attention deficit and hyperactivity symptoms in children. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) was filled in by children to measure QoL.

RESULTS

Mean age was 9.2 +/- 1.5 years for asthmatic children (37 male, 25 female) and 10.1 +/- 1.3 years for control group (20 male, 18 female). The two groups were similar regarding age and sex. Attention deficit score in the asthma group was significantly higher than that in the control group (p = 0.01). The frequency of hyperactivity was higher in the asthmatic group but the difference between the groups was not significant (p = 0.36). Attention deficit and hyperactivity scores of Conners-P were not correlated with PAQLQ scores (regarding total, activity, emotional and symptom domains).

CONCLUSION

Increased rates of attention deficit symptoms in children with asthma, as reported by mothers, might reflect the negative impact of asthma on neurobehavioral health. Asthmatic children, especially the ones who display attention deficit symptoms, must be considered for further evaluation regarding attention deficit hyperactivity disorder.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Academic performance in children with new-onset seizures and asthma: a prospective study

The purpose of this study was to compare teachers' ratings of academic performance over 24 months between children with new-onset seizures (N=121) and those with new-onset asthma (N=54) aged 4 to 14. At each data collection point (baseline, 12 months, 24 months), children with seizures were placed into two groups according to their recurrent seizure status (yes/no) during that period. Longitudinal linear mixed models were used to explore differences between the asthma group and the two seizure groups and to determine if differences in teachers' ratings of performance in children with seizures were associated with age, gender, or use of medication. In the seizure sample, scores for children in both groups (with and without recurrent seizures) initially declined at 12 months; however, at 24 months, children who did not have recurrent seizures improved, whereas children who continued to have recurrent seizures declined. There was a trend for younger children to decline more than older children.

Do indoor pollutants and thermal conditions in schools influence student performance? A critical review of the literature

To assess whether school environments can adversely affect academic performance, we review scientific evidence relating indoor pollutants and thermal conditions, in schools or other indoor environments, to human performance or attendance. We critically review evidence for direct associations between these aspects of indoor environmental quality (IEQ) and performance or attendance. Secondarily, we summarize, without critique, evidence on indirect connections potentially linking IEQ to performance or attendance. Regarding direct associations, little strongly designed research was available. Persuasive evidence links higher indoor concentrations of NO(2) to reduced school attendance, and suggestive evidence links low ventilation rates to reduced performance. Regarding indirect associations, many studies link indoor dampness and microbiologic pollutants (primarily in homes) to asthma exacerbations and respiratory infections, which in turn have been related to reduced performance and attendance. Also, much evidence links poor IEQ (e.g. low ventilation rate, excess moisture, or formaldehyde) with adverse health effects in children and adults and documents dampness problems and inadequate ventilation as common in schools. Overall, evidence suggests that poor IEQ in schools is common and adversely influences the performance and attendance of students, primarily through health effects from indoor pollutants. Evidence is available to justify (i) immediate actions to assess and improve IEQ in schools and (ii) focused research to guide IEQ improvements in schools.

PRACTICAL IMPLICATIONS

There is more justification now for improving IEQ in schools to reduce health risks to students than to reduce performance or attendance risks. However, as IEQ-performance links are likely to operate largely through effects of IEQ on health, IEQ improvements that benefit the health of students are likely to have performance and attendance benefits as well. Immediate actions are warranted in schools to prevent dampness problems, inadequate ventilation, and excess indoor exposures to substances such as NO(2) and formaldehyde. Also, siting of new schools in areas with lower outdoor pollutant levels is preferable.

Reexamining the familial association between asthma and ADHD in girls

The objective of this study is to further evaluate the association between asthma and ADHD, addressing issues of familiality in female probands. A case control study of referred ADHD proband girls, controls, and relatives are used. Participants include 140 ADHD proband girls and 122 non-ADHD comparisons, with 417 and 369 first-degree biological relatives, respectively. Relatives are stratified into four groups according to proband ADHD and asthma status. The authors compare rates of asthma and ADHD in relatives. ADHD does not increase the risk for asthma in probands. Patterns of familial aggregation are mostly consistent with independent transmission of ADHD and asthma in families of girl probands. The results extend to female probands' previously reported findings that asthma and ADHD are independently transmitted in families. These findings further support the conclusion that ADHD symptoms should not be dismissed as part of asthma symptomatology or a consequence of its treatment.

The social and economic consequences of childhood asthma across the lifecourse: a systematic review

BACKGROUND

Asthma prevalence rates are high, and may be increasing in the Western world, particularly among children. The aim of this study was to evaluate the longer-term social and economic consequences of having asthma as a child and to determine whether adverse consequences are more severe for poorer children.

METHODS

Results from published and unpublished, quantitative and qualitative studies were synthesized narratively to examine the impact of childhood-onset asthma on school attendance, academic achievement and employment in adulthood. The question of whether the impact differed for different social groups was also examined.

FINDINGS

Twenty-nine good quality studies were identified, including in total 12 183 children with asthma or wheeze. Compared with asymptomatic children, those with asthma missed more days of school (additional absence as a result of asthma ranged from 2.1 to 14.8 days). Studies of academic achievement found that children with asthma performed as well as their healthy peers. The existing evidence on labour market performance is sparse, but there is an indication that people with asthma during childhood experience disadvantage in later employment. In an examination of consequences by social position, children with asthma from deprived areas were more likely to miss school than their more affluent peers, and minority ethnic children were also more likely to have poor school attendance. The only qualitative study suggested that children with asthma strove to participate fully in every aspect of their daily lives.

INTERPRETATION

Although asthma limits children's daily activities and affects their social activities, this research synthesis found little evidence of major, adverse long-term social and economic consequences in studies reviewed. Further longitudinal research using comparison groups is needed to fill key gaps in the existing evidence base.

Childhood overweight and academic performance: national study of kindergartners and first-graders

OBJECTIVE

To examine the association between children's overweight status in kindergarten and their academic achievement in kindergarten and first grade.

RESEARCH METHODS AND PROCEDURES

The data analyzed consisted of 11,192 first time kindergartners from the Early Childhood Longitudinal Study, a nationally representative sample of kindergartners in the U.S. in 1998. Multivariate regression techniques were used to estimate the independent association of overweight status with children's math and reading standardized test scores in kindergarten and grade 1. We controlled for socioeconomic status, parent-child interaction, birth weight, physical activity, and television watching.

RESULTS

Overweight children had significantly lower math and reading test scores compared with non-overweight children in kindergarten. Both groups were gaining similarly on math and reading test scores, resulting in significantly lower test scores among overweight children at the end of grade 1. However, these differences, except for boys' math scores at baseline (difference = 1.22 points, p = 0.001), became insignificant after including socioeconomic and behavioral variables, indicating that overweight is a marker but not a causal factor. Race/ethnicity and mother's education were stronger predictors of test score gains or levels than overweight status.

DISCUSSION

Significant differences in test scores by overweight status at the beginning of kindergarten and the end of grade 1 can be explained by other individual characteristics, including parental education and the home environment. However, overweight is more easily observable by other students compared with socioeconomic characteristics, and its significant (unadjusted) association with worse academic performance can contribute to the stigma of overweight as early as the first years of elementary school.

Psychosocial functioning and stress-processing of children with asthma in the school context: differences and similarities with children without asthma

OBJECTIVE

To characterize children with asthma by their stress processing at school and their psychosocial functioning. To establish similarities and differences between children with and without asthma.

METHODS

Participants were 79 children with asthma and 359 children without asthma (ages 8-12). Children completed questionnaires on stress processing and their well-being at school. Parents filled in a questionnaire on behavior problems, and teachers provided data on school performance and absence rate.

RESULTS

Children with asthma had higher scores on absence rates, teacher-rated well-being, internalizing behavior problems, occurrence of "rejection by peers," and use of aggression when coping with "problems with school work." However, using discriminant analyses, the groups could not reliably be distinguished from one another by these variables.

CONCLUSIONS

Children with asthma are similar to other children with regard to their stress processing at school and their psychosocial functioning. The value of conducting multivariate analysis over several univariate tests is underscored.

Outcome of asthma in children and adolescents at a specialty-based care program

BACKGROUND

Asthma remains a major cause of morbidity for children despite national guidelines.

OBJECTIVE

To evaluate outcome from a structured specialty-based care program.

METHODS

Comparison of previous and subsequent years for children ranging from infancy to adolescence who entered a specialty clinic program at a university hospital serving a widely dispersed patient population. One hundred fifty-seven patients previously receiving primary care for their respiratory symptoms were seen during the study period; 23 were lost to followup, 15 were excluded because of other serious concurrent medical problems, and 119 were available for outcome analysis. Evaluation included historical data base from a structured interview, evaluation of pulmonary physiology, and allergy skin testing. Treatment decisions were evidence-based. Patient and/or family education was targeted at decision-making. Toll-free telephone access to the specialty service was provided around the clock. Frequency of unscheduled medical care, hospitalizations, sleep disturbance, activity interference, attainment of defined criteria for control, and medication use were quantified.

RESULTS

Seven hundred thirty-five acute care visits were reduced to 47, and 99 hospitalizations were decreased to 10 (P < 0.001 for both). Nocturnal symptoms and exercise limitation decreased significantly (P < 0.001 for both). All criteria for control of asthma were met in 89% of 75 without tobacco smoke exposure and 50% of 44 with exposure (P < 0.0001 for the difference in outcome). Frequent antibiotic use for respiratory symptoms were eliminated after entering the program. Maintenance medications were not used in 72 with an intermittent pattern of viral respiratory infection-induced asthma. Inhaled corticosteroid use increased from 38 to 68% among 47 subjects with a chronic pattern.

CONCLUSIONS

Morbidity from asthma is largely prevented with often less, but better selected, medication than had been occurring in previous primary care. These data have implications for revised guidelines directed at primary care physicians.

School attendance and school performance: a population-based study of children with asthma

OBJECTIVE

To analyze school attendance and school achievement as outcomes of the care of children with asthma.

METHODS

A previously identified Rochester, Minnesota, cohort of children with asthma and age- and sex-matched children without asthma were studied. School attendance, standardized achievement test scores, grade point average, grade promotion, and class rank of graduating students for children with asthma and control subjects were obtained from the Rochester Public School system.

RESULTS

Children with asthma (n = 92) and age- and sex-matched non-asthmatic control subjects with 640 school-years of observation were studied. Children with asthma had 2.21 (95% CI, 1.41 to 3.01) more days absent than children without asthma. There was no significant difference in standardized achievement test scores (reading percentile difference 1.22% [95% CI, -3.68 to 6.12], mathematics percentile difference 2.36% [95% CI, -2.89 to 7.60], language percentile difference 2.96% [95% CI, -4.03 to 7.15]). There was no significant difference in grade point average, grade promotion, or class rank of graduating students.

CONCLUSION

In this community, although children with asthma had 2 excess days of absenteeism, the school performance of children with asthma was similar to that of children without asthma.

Prevalence of DSM IV anxiety and affective disorders in a pediatric population of asthmatic children and adolescents

A series of 82 children and adolescents with moderate and severe persistent asthma was studied. Their psychopathological problems were compared to those of 82 healthy subjects, matched for age, sex and socio-economic status. The patients completed the Child Depression Inventory, an inventory of fears and anxiety (ECAP) and the Coopersmith Self Esteem Inventory. Parents of asthmatic children filled in the Child Behavior Check List to assess their social competence. The patients were examined with the revised Kiddie Schedule for Affective Disorders and Schizophrenia. There were more anxiety symptoms in the asthmatic group than in the control group. Asthmatics were not significantly more depressed than controls and their self-esteem was as good. We found 29 anxiety disorders, four affective disorders and four disruptive behavior disorders. Generalized anxiety disorder was the main diagnosis (n=24). The asthmatic subgroup presenting anxiety and affective disorders had poorer self esteem, fewer activities and worse social competence than other asthmatics and controls. Adolescents did not seem to have more emotional disturbances than younger patients. Girls did not have more DSM IV anxiety or affective disorders than boys.

Neurocognitive functioning in children with mild and moderate asthma in the childhood asthma management program. The Childhood Asthma Management Program (CAMP) Research Group

BACKGROUND

The Childhood Asthma Management Program (CAMP) is a multicenter double-blind, randomized, placebo-controlled, clinical trial of two anti-inflammatory agents and placebo in children with mild and moderate asthma.

OBJECTIVE

The interrelationship between asthma severity and neurocognitive functioning among 1041 children (age range, 5-12 years) enrolled in the CAMP trial was examined.

METHODS

Asthma severity was established at baseline with a clinical history of asthma symptomatology and measures of lung function (spirometry and methacholine challenge). Diary cards were used in a screening to record nighttime awakenings and doctor contacts caused by asthma symptoms, symptom severity, and number of puffs from a rescue inhaler. All children received a comprehensive neurocognitive assessment at the end of the 28-day screening period (before randomization), including measures of intelligence, attention, memory, and academic achievement.

RESULTS

Significant differences were found between children with mild and moderate asthma on lung function and symptom outcome variables (log(e)FEV(1)PC(20), DeltaFEV(1) percent predicted, change in peak flow percent predicted, nighttime awakenings caused by asthma, average symptom severity score, and average daily number of puffs from a rescue inhaler) but not on neurocognitive variables. Multiple regression analyses revealed that asthma outcomes could not be predicted by neurocognitive variables despite controlling for socioeconomic status. The prevalence of neurocognitive dysfunction, as indicated by the use of psychostimulant medication, was found to be consistent with that found in the existing literature.

CONCLUSION

Mild and moderate asthma symptoms are not related to neurocognitive functioning in the children enrolled in CAMP. Mean performance on neurocognitive variables was found to be similar to that of national normative data.

Prevalence of DSM-IV disorders in children and adolescents with asthma versus diabetes

OBJECTIVE

To evaluate the relationships between asthma and type and incidence of psychiatric problems in a pediatric population.

METHODS

A series of 93 children and adolescents with asthma presenting during a 1-year period to a pediatric pneumology and allergy service was studied. Their psychopathological problems were compared with those of 93 children with insulin-dependent diabetes mellitus (IDDM). Various questionnaires were completed by the patients: the Child Depression Inventory (CDI), the State-Trait Anxiety Inventory for Children (STAIC), and the Coopersmith Self-Esteem Inventory (SEI). Their parents were administered the Child Behavior Checklist (CBCL). The patients were examined using the revised Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-R).

RESULTS

There were more symptoms in the asthma group than in the IDDM group, as indicated by total CBCL scores, internalization and externalization CBCL subscores, and the STAIC scores. Asthma was often associated with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) psychiatric disorders. We found 30 anxiety disorders, 5 affective disorders, and 6 disruptive behaviour disorders. Asthmatic children did not seem to be more depressed than the IDDM group, and their self-esteem, overall, was good. However, the asthma subgroup presenting with psychiatric disorders had poorer self-esteem and social competence. Adolescents did not seem to suffer more psychiatric disturbances than did younger patients. Girls did not suffer more psychiatric disturbances than did boys.

CONCLUSION

Asthma appears to be associated both with higher overall incidence of psychiatric problems than in IDDM and with particular categories of psychiatric problems. In particular, the problems include anxiety disorders, internalizing symptoms, and disruptive behaviours.

School absence and treatment in school children with respiratory symptoms in The Netherlands: data from the Child Health Monitoring System

STUDY OBJECTIVE

To assess the prevalence of respiratory problems, and the relation of these problems with school attendance, medicine use, and medical treatment.

DESIGN

The Child Health Monitoring System.

SETTING

Nineteen public health services across the Netherlands.

PARTICIPANTS

5186 school children aged 4-15 years, who were eligible for a routine health assessment in the 1991/1992 school year.

MAIN RESULTS

Respiratory symptoms were present in 12% of the children. Recent symptoms suggestive of asthma (wheezing or episodes of shortness of breath with wheezing in the past 12 months, or chronic cough, or a combination of these) were reported for 8%. These symptoms were most frequent in the younger children, and in children at school in towns with less than 20,000 inhabitants. Of the children with recent symptoms suggestive of asthma, 37% reported school absence for at least one week during the past 12 months, compared with 16% in children without respiratory symptoms. School absence because of respiratory illness was reported for 22%, and medicine use for respiratory problems for 38% of the children with recent symptoms suggestive of asthma. Of these children, 21% were receiving medical treatment, compared with 15% of the asymptomatic children.

CONCLUSIONS

Respiratory symptoms are a common health problem in children, and they are an important cause of school absence and medicine use. However, the percentage of children receiving medical treatment seemed quite low, indicating that proper diagnosis and treatment are probably still a problem.

Neuropsychological and behavioral changes in asthmatic children treated with beclomethasone dipropionate versus theophylline

OBJECTIVE

Results from previous investigations that examined the psychological side effects of theophylline have been inconsistent, and none have reported about inhaled corticosteroids. The objective of this study was to assess the relative psychological side effects of theophylline and beclomethasone in asthmatic children.

METHODS

This was a multicenter, randomized, double-blind, parallel-groups study in which 102 asthmatic patients were assigned to one of two treatments: beclomethasone three times daily or theophylline twice daily. At baseline, 1 month, and 1 year, parents completed standardized behavioral questionnaires while the children received psychometric testing of attention and concentration, memory and learning, and problem-solving.

RESULTS

Although power was sufficient to detect meaningful mean score changes, no consistent differential treatment effects were observed. Two significant treatment-by-period interactions were discordant, with one suggesting slightly better attention in the theophylline group, whereas the other indicated a small advantage in attention scores in the beclomethasone group. Numerous significant period effects revealed that behavior and cognitive test performance improved over the 1-year period, regardless of treatment, and confirmed a well established practice effect resulting from repeated administrations of such tests.

CONCLUSIONS

Neither theophylline nor beclomethasone should be avoided out of concern for significant psychological side effects. The possibility remains that a subset of asthmatic children may be susceptible to such medication-induced changes; investigators have suggested that preschool children may be at particular risk, although no controlled studies with this age group have been conducted. Parental perceptions of medication side effects can be influenced by temporary effects present at initiation of treatment or by erroneous attribution of the psychological effects of the chronic illness. Reports of psychological changes in response to asthma medications must be addressed respectfully but objectively, with due consideration of available evidence and an awareness of other potential explanations.

Effects of theophylline and ipratropium on cognition in elderly patients with chronic obstructive pulmonary disease

OBJECTIVES

To determine whether chronic therapy with theophylline or ipratropium has an adverse effect on cognition and psychomotor skills in geriatric patients with chronic obstructive pulmonary disease.

DESIGN

The study design was a randomized, repeated measures, double-blind, double-dummy, placebo-controlled comparison of theophylline and ipratropium treatments.

SETTING

Ambulatory patients were tested at the Clinical Trials Center of the University of California, San Diego, Medical Center.

PATIENTS

Ambulatory patients with chronic obstructive pulmonary disease aged 65 years or more with FEV1 less than 60% predicted, FEV1/FVC less than 70%, and post bronchodilator FEV1 less than 70%.

INTERVENTIONS

Patients received either theophylline or ipratropium for 2 weeks, followed by a 1-week placebo control period, then a 2-week treatment period of the alternative drug therapy. A standard therapy of albuterol MDI, 2 puffs (180 microg) qid was given throughout the study.

MEASUREMENTS

The main response level was an 11-part battery of psychometric tests. Tests were administered at the end of each treatment period and at the end of the washout period. Covariates were sequence of treatment, pulmonary function tests, age, and baseline psychometric test scores.

RESULTS

There was no difference in performance scores on the cognitive tests among the three treatment periods.

CONCLUSIONS

We were unable to detect a harmful effect of treatment with either theophylline or ipratropium on the performance of elderly patients with chronic obstructive pulmonary disease on a battery of psychometric tests, suggesting that significant cognitive impairment in the elderly is not commonly associated with treatment with either theophylline or ipratropium.

Psychosocial characteristics of asthma

The objective of this study was to compare psychosocial characteristics of children with asthma and children with bronchial hyperreactivity with those of normal children. A population-based study of 2634 children (mean age, 10 years) was carried out. Pulmonary function tests of children were performed in children before and after cold air hyperventilation challenge to determine bronchial hyperreactivity. Parental assessment of children's behavior was evaluated with 15 questions about school/learning habits, level of activity, communication/affection, and sleeping patterns. A factor analysis was performed and the factor loading adjusted for confounders compared in the different groups. Asthmatic children sleep less well than normal and hyperreactive children (p < 0.001). Unexpectedly, however, all other single items did not differ significantly. As a result of the factorial analysis we obtained two factors. On the first factor, measuring school behavior and learning, there was a small difference between asthmatic and normal children, which could not be found on the second factor indicating activity and communication. We conclude that psychosocial differences of asthmatic children are less remarkable than expected. As a result of the examination of the hyperreactive children it is likely that asthmatic children are influenced more by secondary psychosocial factors than by any primary effect of asthmatic disease.

Associations between childhood asthma and ADHD: issues of psychiatric comorbidity and familiality

OBJECTIVE

In this paper we evaluate the association between asthma and attention-deficit hyperactivity disorder (ADHD), addressing issues of comorbidity and familiality by formulating and testing competing hypotheses.

METHOD

Subjects were 6- to 17-year-old boys with DSM-III-R ADHD (N = 140) and normal controls (N = 120) and their first-degree relatives. Information on asthma was obtained from the mothers in a standardized manner blind to the proband's clinical status.

RESULTS

The risk for asthma did not meaningfully differ between ADHD and control children. Relatives of ADHD probands with and without asthma were at significantly greater risk for ADHD than relatives of normal controls. In contrast, the risk for asthma was significantly elevated only among relatives of children with ADHD plus asthma.

CONCLUSIONS

These findings argue against a substantial etiological or pathophysiological relationship between the two conditions but suggest that ADHD and asthma are independently transmitted in families. Thus, the observation of ADHD symptoms in an asthmatic child should not be dismissed out of hand as being a consequence of asthma since many asthmatic ADHD children may actually have ADHD.

Therapeutic drug monitoring in pediatrics: a need for improvement

Therapeutic drug monitoring (TDM) is practiced for a number of frequently used drugs in infants and children. It is believed that monitoring drug levels will increase the probability of a therapeutic response and minimize the probability of adverse drug sequelae. Dose adjustments are based on measured drug levels interpreted relative to published therapeutic ranges which may or may not reflect the true relationship with either therapeutic or adverse effects. Potential errors derive from many sources, some amenable to solutions based on current knowledge, others awaiting improved understanding of the causes and consequences of unreliable therapeutic ranges.

Childhood asthma: diagnosis and treatment

This discussion of asthma management should be regarded as providing guidelines, not dogma. The underlying principles of asthma management include recognition of the variability of the disease and the importance of the underlying inflammatory condition. Clinical assessment is not enough and objective monitoring with PEFR or spirometry provides important data. The treatment protocols require individualization. It is important that the patient and family are team members working together with the medical staff toward a goal of good asthma management. In the discussion of the management of asthma, much emphasis was placed on spirometry and home measurement of PEFR. Office use of spirometry is now the norm for asthma management. Providing asthmatic patients with peak flow meters and instructions in their use is part of the routine care of asthma. Instruction of the patient and family in the proper use of medications is paramount. The MDI devices need to be prescribed with careful instructions regarding their use. When the patient comes in for follow-up, part of the examination should include the patient's demonstration of how he uses this device. Discussion of the proper and safe use of bronchodilators is important. Overuse of inhaled bronchodilators may be a reflection of increasing asthma or, at the very least, evidence that the patient does not understand appropriate treatment of asthma. If a patient is dependent on regular use of an inhaled beta agent, it is likely that he would benefit from therapy directed at the underlying inflammation of asthma. The patient and the family should understand the purpose of each medication, the side effects, and the risks and benefits of their use. In particular, if steroid medications are necessary, the reasons for their use should be explained. Carefully matching the severity of the asthma with the therapeutic protocols provides an organized approach to asthma treatment. Avoiding triggers of asthma and controlling the environmental exposure to potential triggers leads to lower medication requirements and less lability. Offering the family written instructions to cope with changes in the child's condition, based on assessment of clinical and PEFR observations, allows them more autonomy and comfort in the day-to-day care of the asthmatic child.

Theophylline. Current thoughts on the risks and benefits of its use in asthma

Theophylline and its derivatives have been used in the treatment of asthma for over 50 years, but since the advent of more potent bronchodilators their use has become cloaked in controversy. Their continued existence results from their undoubted usefulness in severe acute asthma, nocturnal asthma, childhood asthma and moderate to severe chronic airflow limitation, and because of habitual use by physicians in other situations. The precise mechanism of action of theophylline remains uncertain. The role of phosphodiesterase inhibition and adenosine antagonism has been reviewed and the clinical significance of the anti-inflammatory action of theophylline discussed. Theophylline has unpredictable metabolism when first administered, and continued monitoring of drug concentrations is essential. Commonly encountered adverse effects may occur at therapeutic serum concentrations, frequently necessitating drug withdrawal. The overlapping therapeutic and toxic theophylline serum ranges can lead to life-threatening adverse effects at the upper end of the therapeutic range, especially in the elderly in whom special precaution is required.