Sleep Hygiene and Sleep Outcomes in a Sample of Urban Children With and Without Asthma

Objective

To assess sleep hygiene and the sleep environment of urban children with and without asthma, and examine the associations among urban stressors, sleep hygiene, and sleep outcomes.

Methods

Urban children, 7-9 years old, with (N = 216) and without (N = 130) asthma from African American, Latino, or non-Latino White backgrounds were included. Level of neighborhood risk was used to describe urban stress. Parent-reported sleep hygiene and daytime sleepiness data were collected using questionnaires. Sleep duration and efficiency were assessed via actigraphy.

Results

Higher neighborhood risk, not asthma status, was associated with poorer sleep hygiene. Controlling for neighborhood risk, sleep hygiene was related to daytime sleepiness. Asthma status, not sleep hygiene, was related to sleep efficiency. In children with asthma, poorer sleep hygiene was associated with shorter sleep duration.

Conclusion

Considering urban stressors when treating pediatric populations is important, as factors related to urban stress may influence sleep hygiene practices and sleep outcomes.

Asthma-related lung function, sleep quality, and sleep duration in urban children

OBJECTIVES

Examine (1) the extent to which changes in objectively measured asthma-related lung function (forced expiratory volume in 1 second) within a sleep period are associated with sleep quality and sleep duration during that sleep period in a group of urban children with persistent asthma, (2) associations between morning and evening asthma-related lung function and sleep quality and duration on the adjacent night, and (3) whether these associations differ by ethnic group.

DESIGN

Cross-sectional, multimethod approach. Children completed a clinic assessment of asthma and allergy status and used home-based objective measurements of asthma-related lung function and sleep.

SETTING

Children and their caregivers participated in a clinic assessment at an asthma and allergy clinic and completed additional assessments at home.

PARTICIPANTS

Two hundred and sixteen African American, Latino, and non-Latino white urban children, ages 7-9 years, and their primary caregivers.

MEASUREMENTS

Participants took part in a clinic assessment of asthma and allergy status, completed interview-based questionnaires including a diary to track asthma symptoms and sleep patterns, and used actigraphy and home-based spirometry daily across a 4-week period to assess sleep and lung function.

RESULTS AND CONCLUSIONS

Results from analyses using structural equation modeling revealed an association between worsening asthma-related lung function and poor sleep quality in the full sample, as well as better asthma-related lung function at night and more optimal sleep efficiency that night. Ethnic group differences emerged in the association with morning or nighttime lung function measurements and sleep quality. Urban minority children with asthma may be at heightened risk for poorer quality sleep. Timing of lung function worsening may be important when considering when and how to improve both asthma health outcomes and sleep quality within specific groups.

Stress and Bronchodilator Response in Children with Asthma

RATIONALE

Stress is associated with asthma morbidity in Puerto Ricans (PRs), who have reduced bronchodilator response (BDR).

OBJECTIVES

To examine whether stress and/or a gene regulating anxiety (ADCYAP1R1) is associated with BDR in PR and non-PR children with asthma.

METHODS

This was a cross-sectional study of stress and BDR (percent change in FEV1 after BD) in 234 PRs ages 9-14 years with asthma. We assessed child stress using the Checklist of Children's Distress Symptoms, and maternal stress using the Perceived Stress Scale. Replication analyses were conducted in two cohorts. Polymorphisms in ADCYAP1R1 were genotyped in our study and six replication studies. Multivariable models of stress and BDR were adjusted for age, sex, income, environmental tobacco smoke, and use of inhaled corticosteroids.

MEASUREMENTS AND MAIN RESULTS

High child stress was associated with reduced BDR in three cohorts. PR children who were highly stressed (upper quartile, Checklist of Children's Distress Symptoms) and whose mothers had high stress (upper quartile, Perceived Stress Scale) had a BDR that was 10.2% (95% confidence interval, 6.1-14.2%) lower than children who had neither high stress nor a highly stressed mother. A polymorphism in ADCYAP1R1 (rs34548976) was associated with reduced BDR. This single-nucleotide polymorphism is associated with reduced expression of the gene for the β2-adrenergic receptor (ADRB2) in CD4(+) lymphocytes of subjects with asthma, and it affects brain connectivity of the amygdala and the insula (a biomarker of anxiety).

CONCLUSIONS

High child stress and an ADCYAP1R1 single-nucleotide polymorphism are associated with reduced BDR in children with asthma. This is likely caused by down-regulation of ADRB2 in highly stressed children.

Good Sleep Health in Urban Children With Asthma: A Risk and Resilience Approach

OBJECTIVES

To identify children demonstrating "good" sleep health in a sample of urban children with persistent asthma; to compare sociocontextual, asthma clinical characteristics, and sleep behaviors in children with "good" versus "poor" sleep health; and to examine protective effects of family-based health behaviors on sleep health.

METHODS

Participants were 249 Black (33%), Latino (51%) and non-Latino White (16%) children with asthma, ages 7-9 years, and their primary caregivers. 

RESULTS

32 percent of children had "good" sleep health. Well-controlled asthma and better lung function were more likely in this group. In the context of urban risks, sleep hygiene appeared to be a protective factor associated with better sleep quality. The protective effect of asthma management functioned differently by ethnic group.

CONCLUSIONS

This study identifies protective processes that may guard against urban risks to optimize sleep health in children with asthma. Intervention programs can be tailored to consider specific supports that enhance sleep health in this high-risk group.

Asthma, allergic rhinitis, and sleep problems in urban children

OBJECTIVES

In this study, we examine the association of asthma (asthma symptoms, asthma control, lung function) and sleep problems in a group of urban children. The role of allergic rhinitis (AR), a comorbid condition of asthma, on children's sleep problems is also examined. Finally, we investigate whether sleep hygiene moderates the association between asthma and sleep problems, and whether there are differences in these associations based on ethnic background.

METHODS

Non-Latino White, Latino, and African American urban children with asthma (n = 195) ages 7-9 (47% female) and their primary caregivers participated in a baseline visit involving interview-based questionnaires on demographics, asthma and rhinitis control, and caregiver report of children's sleep problems and sleep hygiene. Children and their caregivers participated in a clinical evaluation of asthma and AR, followed by a month monitoring period of children's asthma using objective and subjective methods.

RESULTS

Total sleep problem scores were higher in children of the sample who were from African American and Latino backgrounds, compared to non-Latino white children. Poor asthma control was predictive of higher levels of sleep problems in the entire sample. Poorer AR control also was related to more sleep problems, over and above children's asthma in the sample. This association was more robust in non-Latino white children. Poor sleep hygiene heightened the association between poor asthma control and sleep problems in the entire sample and in African American children.

CONCLUSIONS

Multidisciplinary interventions integrating the co-management of asthma, AR, and the effects of both illnesses on children's sleep, need to be developed and tailored to children and their families' ethnic background.

Underdiagnosed and Undertreated Allergic Rhinitis in Urban School-Aged Children with Asthma

Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.

Complementary and alternative medicine use and adherence to asthma medications among Latino and non-Latino white families

OBJECTIVE

The current study sought to evaluate patterns of complementary and alternative medicine (CAM) use in a sample of Latino and non-Latino white (NLW) children with asthma to determine whether parental beliefs about conventional medications and barriers to obtaining these medications were related to CAM use and to assess whether CAM use was associated with decreased adherence to controller medications.

METHODS

Participants included 574 families of children with asthma from NLW, Puerto Rican (PR), and Dominican backgrounds from Rhode Island (RI) and from Island PR. All parents completed a brief checklist of barriers to medication use and an assessment of CAM approaches. A subsample of 259 families had controller medication use monitored objectively for approximately 1 month by MDILog (fluticasone propionate), TrackCap (montelukast), or dosage counter (fluticasone/salmeterol combination).

RESULTS

Prevalence of CAM use was high among Latino families. Perceived barriers to obtaining medication were related to increased CAM use in PR families from RI. Elevated medication concerns were positively associated with CAM use among NLW and Island PR families. CAM use was positively related to objective adherence within NLW families, and unrelated in other groups.

CONCLUSIONS

CAM use is common among Latino families with asthma. Among some families, CAM use may be initiated as a way to cope with barriers to obtaining medication or when parents have concerns about conventional medications. Families who report CAM use do not appear to be substituting CAM for conventional asthma medication.

Factors associated with recruitment and retention of diverse children with asthma

This study examines factors associated with recruitment and retention of Latino, Dominican (DR) and mainland Puerto Rican (PR), and non-Latino white (NLW) families into a pediatric asthma study. Over eleven hundred (n=1185) families were screened, and 489 (n= 174 NLW, n= 160 DR, n= 155 PR) were enrolled. Rates of recruitment by source of recruitment and rates of retention differed by ethnic group. Families whose caregiver had never married had lower odds of completing the study. The findings highlight the need for further study to examine the effectiveness of specific recruitment and retention strategies with Latino and non-Latino white families.

Perceptual accuracy of upper airway compromise in children: Clinical relevance and future directions for research

Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12-18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251-256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms "guesses" by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.

The home environment and family asthma management among ethnically diverse urban youth with asthma

Although the pediatric psychology literature underscores the importance of illness-related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to (a) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino White (NLW), and African American urban children with asthma; and (b) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management. Urban, low-income children (N = 131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multimodal assessment, including an in-home observation and semistructured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g., Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness-specific aspects of the home environment when addressing families' asthma management strategies.

Medication adherence among Latino and non-Latino white children with asthma

OBJECTIVE

Latino children of Caribbean descent remain at high risk for poorly controlled asthma. Controller medications improve asthma control; however, medication adherence remains suboptimal, particularly among minorities. This study assessed socioeconomic, family-based, and parent factors in medication adherence among children with asthma from Rhode Island (RI; Latino and non-Latino white [NLW]) and Puerto Rico.

METHODS

Data collection occurred as part of a multicenter study of asthma disparities. Our sample included children (ages 7-16) prescribed objectively monitored controller medications (n = 277; 80 island Puerto Rico, 114 RI Latino, 83 RI NLW). Parents completed questionnaires regarding family background and beliefs about medications. Families participated in an interview regarding asthma management. Multilevel analyses (maximum likelihood estimates) accounting for children being nested within site and ethnic group assessed the contribution of social context, family, and parent variables to medication adherence.

RESULTS

Medication adherence differed by ethnic group (F(2, 271) = 7.46, P < .01), with NLW families demonstrating the highest levels of adherence. Multilevel models indicated that parental beliefs about medication necessity and family organization regarding medication use were significant predictors of adherence, even for families below the poverty threshold. With family factors in the model, a substantial improvement in model fit occurred (Akaike Information Criterion change of 103.45).

CONCLUSIONS

Adherence to controller medications was lower among Latino children in our sample. Targeted interventions that capitalize on existing family resources, emphasize structure, and address parental beliefs about the importance of medications may be of benefit to families from different cultural backgrounds.

Identifying individual, cultural and asthma-related risk and protective factors associated with resilient asthma outcomes in urban children and families

OBJECTIVE

The goal of this study is to identify individual, family/cultural, and illness-related protective factors that may minimize asthma morbidity in the context of multiple urban risks in a sample of inner-city children and families.

METHODS

Participating families are from African-American (33), Latino (51) and non-Latino white (47) backgrounds. A total of 131 children with asthma (56% male), ages 6-13 years and their primary caregivers were included.

RESULTS

Analyses supported the relationship between cumulative risks and asthma morbidity across children of the sample. Protective processes functioned differently by ethnic group. For example, Latino families exhibited higher levels of family connectedness, and this was associated with lower levels of functional limitation due to asthma, in the context of risks.

CONCLUSIONS

This study demonstrates the utility of examining multilevel protective processes that may guard against urban risks factors to decrease morbidity. Intervention programs for families from specific ethnic groups can be tailored to consider individual, family-based/cultural and illness-related supports that decrease stress and enhance aspects of asthma treatment.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Immigration and acculturation-related factors and asthma morbidity in Latino children

OBJECTIVE

This article presents a summary of findings from asthma studies focusing on immigration and acculturation-related factors. A study examining associations between these processes, family cohesion and social support networks, and asthma morbidity in a sample of Dominican and Puerto Rican caregivers residing in the mainland U.S., is also described.

METHODS

Latino children with asthma (n = 232), ages 7-16 (49% female) and their caregivers completed interview-based questionnaires on immigration and acculturation-related processes, family characteristics, and asthma morbidity.

RESULTS

The frequency of ED use due to asthma may be higher for children of caregivers born in Puerto Rico. Acculturative stress levels were higher for Puerto Rican born caregivers residing in the mainland U.S.

CONCLUSION

Asthma-related educational and intervention programs for Latino children and families should be tailored to consider the effects that the immigration and acculturation experience can have on asthma management. Specific family-based supports focused on decreasing stress related to the acculturation process, and increasing social and family support around the asthma treatment process may help to reduce asthma morbidity in Latino children.

Access to and use of asthma health services among Latino children: the Rhode Island-Puerto Rico asthma center study

This study determines asthma-related health care access and utilization patterns for Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI) and Latino children residing in Puerto Rico (Island). Data included 804 families of children with persistent asthma recruited from clinics. Island children were less likely to receive regular asthma care and care from a consistent provider and more likely to have been to the emergency department and hospitalized for asthma than RI children. Island children were 2.33 times more likely to have used the emergency department for asthma compared with RI non-Latino White (NLW) children. Latino children residing in both Island and RI were less likely to have used specialty care and more likely to have had a physician visit for asthma in the past year than RI NLW children. The differences might reflect the effects of the different delivery systems on pediatric health care utilization and asthma management.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Ethnic differences in perception of lung function: a factor in pediatric asthma disparities?

RATIONALE

Disparities in pediatric asthma exist in that Latino children have higher prevalence and greater morbidity from asthma than non-Latino white children. The factors behind these disparities are poorly understood, but ethnic-related variations in children's ability to accurately recognize and report their pulmonary functioning may be a contributing process.

OBJECTIVES

To determine (1) if differences exist between Latino and non-Latino white children's perceptual accuracy and (2) whether these differences are related to asthma outcomes.

METHODS

Five hundred and twelve children, aged 7-16 years (290 island Puerto Ricans, 115 Rhode Island Latinos, and 107 Rhode Island non-Latino white children) participated in a 5-week home-based protocol in which twice daily they entered subjective estimates of their peak expiratory flow rate into a hand-held, programmable spirometer and then performed spirometry. Their accuracy was summarized as three perceptual accuracy scores. Demographic data, asthma severity, intelligence, emotional expression, and general symptom-reporting tendencies were assessed and covaried in analyses of the relationship of perceptual accuracy to asthma morbidity and health care use.

MEASUREMENTS AND MAIN RESULTS

Younger age, female sex, lower intelligence, and poverty were associated with lower pulmonary function perception scores. Island Puerto Rican children had the lowest accuracy and highest magnification scores, followed by Rhode Island Latinos; both differed significantly from non-Latino white children. Perceptual accuracy scores were associated with most indices of asthma morbidity.

CONCLUSIONS

Controlling for other predictive variables, ethnicity was related to pulmonary function perception ability, as Latino children were less accurate than non-Latino white children. This difference in perceptual ability may contribute to recognized asthma disparities.

Cultural-related, contextual, and asthma-specific risks associated with asthma morbidity in urban children

The objective of this study was to examine associations between specific dimensions of the multi-dimensional cumulative risk index (CRI) and asthma morbidity in urban, school-aged children from African American, Latino and Non-Latino White backgrounds. An additional goal of the study was to identify the proportion of families that qualify for high-risk status on each dimension of the CRI by ethnic group. A total of 264 children with asthma, ages 7-15 (40% female; 76% ethnic minority) and their primary caregivers completed interview-based questionnaires assessing cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Higher levels of asthma-related risks were associated with more functional morbidity for all groups of children, despite ethnic group background. Contextual and cultural risk dimensions contributed to more morbidity for African-American and Latino children. Analyses by Latino ethnic subgroup revealed that contextual and cultural risks are significantly related to more functional morbidity for Puerto Rican children compared to Dominican children. Findings suggest which type of risks may more meaningfully contribute to variations in asthma morbidity for children from specific ethnic groups. These results can inform culturally sensitive clinical interventions for urban children with asthma whose health outcomes lag far behind their non-Latino White counterparts.

Asthma symptom perception and obesity in children

This study examined the relationship between obesity and asthma symptom perception in 200 youth with asthma. Repeated subjective and objective peak flow measurements were summarized using the Asthma Risk Grid (Klein et al., 2004), resulting in Accurate, Symptom Magnification and Danger Zone scores. Analyses were stratified by age and included ethnicity. For younger children, obesity was not significantly related to perception scores. For older children, a significant obesity-by-ethnicity interaction for Accurate Symptom Perception scores indicated that obese white children had lower accuracy than white nonobese children, while there was no difference for obese versus nonobese minority children. Obesity was also related to higher Symptom Magnification scores regardless of ethnicity for older children. These findings suggest that obesity may complicate asthma management by interfering with the ability to accurately perceive symptoms for some patients. More remains to be learned about the role of sociodemographic factors underlying this relationship.

Beliefs and barriers to medication use in parents of Latino children with asthma

OBJECTIVE

Disparities in asthma outcomes exist between Latino and non-Latino white (NLW) children. We examined rates of medication use, medication beliefs, and perceived barriers to obtaining medication in US and island Puerto Rican parents of children with asthma.

HYPOTHESES

Island PR parents would report the lowest rates of controller medication use, followed by RI Latino and RI NLW parents; Latino parents would report more medication concerns than NLW parents; and Island PR parents would report the most barriers to medication use.

STUDY DESIGN

Five hundred thirty families of children with persistent asthma participated, including 231 Island PR, 111 RI NLW, and 188 RI Latino. Parents completed survey measures.

RESULTS

Group differences were found on reported use of ICS (X(2) = 50.96, P < 0.001), any controller medication (X(2) = 56.49, P < 0.001), and oral steroids (X(2) = 10.87, P < 0.01). Island PR parents reported a greater frequency of barriers to medication use than the other two groups (X(2) = 61.13, P < 0.001). Latino parents in both sites expressed more medication concerns than NLW parents (F = 20.18, P < 0.001). Medication necessity was associated with ICS use in all three groups (all P's < 0.01). Medication concerns were positively associated with ICS use in PR only (OR = 1.64, P < 0.05).

CONCLUSIONS

Differences in medication beliefs and the ability to obtain medications may explain the reported disparity in controller medication use. Further studies are needed to evaluate these obstacles to medication use.

Issues and methods in disparities research: the Rhode Island-Puerto Rico asthma center

BACKGROUND

Epidemiologic studies have documented higher rates of asthma prevalence and morbidity in minority children compared to non-Latino white (NLW) children. Few studies focus on the mechanisms involved in explaining this disparity, and fewer still on the methodological challenges involved in rigorous disparities research.

OBJECTIVES AND METHODS

This article provides an overview of challenges and potential solutions to research design for studies of health disparities. The methodological issues described in this article were framed on an empirical model of asthma health disparities that views disparities as resulting from several factors related to the healthcare system and the individual/community system. The methods used in the Rhode Island-Puerto Rico Asthma Center are provided as examples, illustrating the challenges in executing disparities research.

RESULTS

Several methods are described: distinguishing ethnic/racial differences from methodological artifacts, identifying and adapting culturally sensitive measures to explain disparities, and addressing the challenges involved in determining asthma and its severity in Latino and other minority children. The measures employed are framed within each of the components of the conceptual model presented.

CONCLUSIONS

Understanding ethnic and/or cultural disparities in asthma morbidity is a complicated process. Methodologic approaches to studying the problem must reflect this complexity, allowing us to move from documenting disparities to understanding them, and ultimately to reducing them.

Conundrums in childhood asthma severity, control, and health care use: Puerto Rico versus Rhode Island

BACKGROUND

The lifetime prevalence of self-reported asthma among Puerto Ricans is very high, with increased asthma hospitalizations, emergency department visits, and mortality rates. Differences in asthma severity between the mainland and island, however, remain largely unknown.

OBJECTIVE

We sought to characterize differences in asthma severity and control among 4 groups: (1) Island Puerto Ricans, (2) Rhode Island (RI) Puerto Ricans, (3) RI Dominicans, and (4) RI whites.

METHODS

Eight hundred five children aged 7 to 15 years completed a diagnostic clinic session, including a formal interview, physical examination, spirometry, and allergy testing. Using a visual grid adapted from the Global Initiative for Asthma, asthma specialists practicing in each site determined an asthma severity rating. A corresponding level of asthma control was determined by using a computer algorithm.

RESULTS

Island Puerto Ricans had significantly milder asthma severity compared with RI Puerto Ricans, Dominicans, and whites (P < .001). Island Puerto Ricans were not significantly different from RI whites in asthma control. RI Puerto Ricans showed a trend toward less control compared with island Puerto Ricans (P = .061). RI Dominicans had the lowest rate of controlled asthma. Paradoxically, island Puerto Ricans had more emergency department visits in the past 12 months (P < .001) compared with the 3 RI groups.

CONCLUSIONS

Potential explanations for the paradoxic finding of milder asthma in island Puerto Ricans in the face of high health care use are discussed. Difficulties in determining guideline-based composite ratings for severity versus control are explored in the context of disparate groups.

Innovative training in pediatrics, general psychiatry, and child psychiatry: background, outcomes, and experiences

OBJECTIVES

The authors describe the history, rationale, and outcomes of combined training programs in pediatrics, psychiatry, and child psychiatry ("triple board"), including narrative feedback from graduates and reflections upon the important components of the program.

METHODS

This article reviews the background and experiences of triple board graduates and programs using published data regarding triple board history and outcomes, reflections and follow-up information collected from triple board graduates as part of a national triple board network development, and direct experiences with triple board training programs.

RESULTS

The triple board training program provides a unique training background for physicians who serve children and their families. The programs train physicians who seek out additional training opportunities, succeed in passing board certification examinations, and earn national recognition. Additionally, feedback from graduates reflects satisfaction with training experiences.

CONCLUSION

The outcomes from this experiment in integrated training in child psychiatry support the consideration of expanding triple board training programs and introducing new innovations in training.

Symptom perception in children with asthma: cognitive and psychological factors

OBJECTIVE

This study tested the differential effects of several cognitive and psychological variables on children's perception of asthma symptoms by use of an Asthma Risk Grid. Children's subjective and objective assessments of PEFR (peak expiratory flow rate) were characterized as representing perceptual accuracy, symptom magnification, and/or underestimation of asthma symptoms.

DESIGN

The study included 270 children with asthma (ages 7-17) and their primary caregivers who completed measures assessing cognitive and psychological factors and a 5 to 6 week symptom perception assessment.

MAIN OUTCOME MEASURES

Children's symptom perception scores by use of the Asthma Risk Grid.

RESULTS

Children's attentional abilities had more of a bearing on their symptom monitoring abilities than their IQ estimates and psychological symptoms. The more time children took on Trails and Cancellation Tasks and the fewer errors they made on these tasks, the more likely they were to perceive their asthma symptoms accurately. More time on these tasks was associated with more symptom magnification scores, and fewer errors were related to fewer symptom magnification scores. More errors and higher total scores on the Continuous Performance Task were associated with a greater proportion of scores in the danger zone.

CONCLUSION

Statistical support was provided for the utility of attentional-based instruments for identifying children who may have problems with perceptual accuracy, and who are at risk for asthma morbidity.

The asthma/mental health nexus in a population-based sample of the United States

BACKGROUND

Asthma is one of the most prevalent chronic medical conditions in the United States. The relationship of asthma with psychological factors has been known for centuries, and recently there has been a resurgence of interest in this topic. This study investigates the relationship between current asthma and poor mental health in a nationally representative sample of the US population.

METHODS

This study utilizes data from the 2006 Behavioral Risk Factor Surveillance System survey (n = 355,710). A multinomial logistic regression model was constructed to assess the relationship between current asthma and poor mental health. The relationship between formerly having asthma and poor mental health was also investigated.

RESULTS

Persons reporting poor mental health have increased risk of currently having asthma compared to persons reporting good mental health. Additionally, this asthma/mental health relationship has a "dose-response" relationship. For every incremental increase in days of poor mental health, there is a corresponding increase in risk of currently having asthma. Previously reported risk factors for asthma (ie, age, gender, race, marital, smoking, overall health, exercise, obesity, and socioeconomic status) were all found to be important covariates of asthma. The relationship between former asthma and poor mental health is less clear.

CONCLUSIONS

This large, nationally representative sample confirms the relationship between asthma and mental health symptoms. Any degree of poor mental health appears to increase one's risk for asthma. Future research is needed to determine the causal and/or physiologic relationship between asthma and mental health symptoms.

Latino caregivers' beliefs about asthma: causes, symptoms, and practices

BACKGROUND AND OBJECTIVE

This study examined belief systems of Latino caregivers who have children with asthma from Puerto Rican and Dominican backgrounds who resided on the Island of PR and the Mainland. The goal of this study was to document similarities and differences in beliefs about the causes, symptoms, and treatments of asthma across two sites and two Latino ethnic sub-groups of children who remain the most at risk for asthma morbidity.

METHODS

Participants included 100 primary caregivers of a child with asthma; 50 caregivers from Island PR and 50 caregivers from mainland RI were interviewed (at each site; 25 caregivers were from Puerto Rican backgrounds and 25 caregivers were from Dominican backgrounds). The interview included an assessment of demographic information and beliefs about the causes and symptoms of asthma and asthma practices.

RESULTS

Results indicated more similarities in beliefs about the causes and symptoms of asthma across site and ethnic group. The majority of differences were among beliefs about asthma practices by site and ethnic group. For example, a higher proportion of caregivers from Island PR, particularly those of Dominican descent, endorsed that a range of home and botanical remedies are effective for treating asthma.

CONCLUSIONS

Results from this study point to several interesting directions for future research including larger samples of Latino caregivers with children who have asthma. A discussion of the importance of understanding cultural beliefs about asthma and asthma practices is also reviewed.

Review of the literature: integrating psychoneuroimmunology into pediatric chronic illness interventions

OBJECTIVE

Provide an orientation to psychoneuroimmunology, a rationale for including assessments of immune function in intervention studies of pediatric chronic illness, review the current literature, and provide recommendations for future research.

METHODS

Using electronic searches and previous reviews, selected and reviewed published studies in which immunological changes related to psychological interventions were assessed in pediatric samples.

RESULTS

Eight studies were identified and included in the review. These utilized a range of interventions (e.g., disclosure and hypnosis) and included a variety of pediatric samples (e.g., those with asthma, HIV infection, or lupus).

CONCLUSIONS

Results suggest that psychological intervention can influence immune function in pediatric samples. Recommendations for advancing our knowledge by studying populations for whom the immune system plays an active role in disease pathophysiology, measuring disease-relevant immune mediators, studying pediatric patients under times of stress, and focusing on interventions aimed at altering the stress system are provided.

Pediatric Asthma and Problems in Attention, Concentration, and Impulsivity: Disruption of the Family Management System

RATIONALE: This study assesses the relationships between ADHD symptoms, specific family asthma management domains, and pediatric asthma morbidity. METHODS: Participants were 110 children with asthma and a respective parent (ages 7-17, X = 11.6 years, 25% ethnic/racial minority). Parents completed measures of asthma morbidity and report of child ADHD symptoms. Children completed measures of attention, concentration, and impulsivity. Families participated in the Family Asthma Management System Scale (FAMSS) interview to assess the effectiveness of eight features of asthma management. RESULTS: Parent report of ADHD symptoms and poor child performance on a computerized task of sustained visual attention were associated with asthma morbidity. Paper and pencil tasks of visual attention, and an index of auditory attention, were not related to asthma morbidity. Modest associations were found between parent report of ADHD symptoms, child performance-based indicators of attention and concentration, and features of family asthma management, although not across all measures. The family response to asthma partially mediated the relationship between ADHD symptoms and morbidity. CONCLUSIONS: ADHD symptoms are modestly associated with difficulties in family asthma management.

Symptom perception in pediatric asthma: resistive loading and in vivo assessment compared

BACKGROUND

Inaccurate symptom perception contributes to asthma morbidity and mortality in children and adults. Various methods have been used to quantify perceptual accuracy, including psychophysical (resistive loading) approaches, ratings of dyspnea during induced bronchoconstriction, and in vivo monitoring, but it is unclear whether the different methods identify the same individuals as good or poor perceivers. The objectives of the study were as follows: (1) to compare in the same asthmatic children two methods of quantifying perceptual ability: threshold detection of added resistive loads and in vivo symptom perception; and (2) to determine which method best predicts asthma morbidity.

METHODS

Seventy-eight asthmatic children 7 to 16 years of age completed two threshold detection protocols in the laboratory and recorded their subjective estimates of lung function prior to spirometry at home twice daily for 5 to 6 weeks. Summary measures from both methods were compared to each other and to asthma morbidity (as measured with the Rosier asthma functional severity scale).

RESULTS

Symptom perception ability, as summarized by either method, varied greatly from child to child. Neither of the resistive load detection thresholds were significantly related to any of the three in vivo perception scores, nor were they related to asthma morbidity. The three in vivo scores did show a significant or marginal relationship with morbidity (p < 0.01, p < 0.06, and p < 0.07, respectively).

CONCLUSIONS

Resistive loading techniques may not be useful in assessing symptom perception ability in children. Measuring estimates of symptoms in relation to naturally occurring asthma can identify children at risk for greater asthma morbidity.

Multiple urban and asthma-related risks and their association with asthma morbidity in children

OBJECTIVE

To determine whether a multi-dimensional cumulative risk index (CRI) is a stronger predictor of asthma morbidity in urban, school-aged children with asthma, than poverty or severity alone.

METHODS

A total of 163 children with asthma, ages 7-15 years (42% female; 69% ethnic minority) and their primary caregivers completed interview-based questionnaires, focusing on potential cultural, contextual, and asthma-specific risks that can impact asthma morbidity.

RESULTS

Higher levels of cumulative risks were associated with more asthma morbidity, after controlling for poverty level or asthma severity. Analyses by ethnic group and subgroup also supported the relationship between the CRI and specific indices of asthma morbidity.

CONCLUSIONS

This study demonstrates the utility of multiple-dimensional risk models for predicting variations in asthma morbidity in urban children. Research efforts with urban families who have children with asthma need to consider the context of urban poverty as it relates to children's cultural backgrounds and specific asthma outcomes.

Symptom perception and functional morbidity across a 1-year follow-up in pediatric asthma

The purpose of this study was to examine the association between asthma symptom perception measured during a 5-6 week baseline and functional morbidity measured prospectively across a 1-year follow-up. Symptom perception was measured by comparing subjective ratings with peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV(1)). We hypothesized that accurate symptom perception (ASP) would be associated with less functional morbidity. Participants consisted of 198 children with asthma ages 7-17 recruited from three sites. The children used a programmable electronic spirometer in the home setting to guess their PEFR prior to exhalation. Each "subjective" guess was classified as being in an ASP, dangerous symptom perception (DSP; underestimation of symptoms), or symptom magnification (SM; overestimation) zone based upon the corresponding measurement of PEFR or FEV(1). An index of functional morbidity was collected by parent report at baseline and across 1-year follow-up. A greater proportion of ASP blows and a lower proportion of DSP blows based on PEFR predicted less functional morbidity reported at baseline, independent of asthma severity and race/ethnicity. A greater proportion of ASP blows (using PEFR and FEV(1)) and a lower proportion of SM blows (using FEV(1)) predicted less functional morbidity across 1-year follow-up. Symptom perception was not associated with emergency department visits for asthma at baseline or across follow-up. In comparison to PEFR, FEV(1) more frequently detected a decline in pulmonary function that children did not report. Symptom perception measured in naturalistic settings was associated with functional morbidity at baseline and prospectively across 1-year follow-up. Support was found for including multiple measures of pulmonary function in the assessment of asthma symptom perception.

Asthma disparities in the prevalence, morbidity, and treatment of Latino children

The paper reviews the existing research related to asthma disparities and frames the results of this research within a conceptual model modified from the Institute of Medicine model in order to explain asthma health disparities in Latino children in the USA. The model of pediatric asthma disparity presented is based on the conceptualization of health disparities as the result of a complex interaction of factors related to four main domains: the individual and family, the environment or context in which the child lives, the health-care system, and provider characteristics. Asthma disparities are discussed as they are reflected in the process of care (access and quality of treatment) and outcome (prevalence, morbidity, severity) experienced by Latino children. The potential mechanisms that may account for the asthma disparities documented as reflected by the conceptual model proposed are discussed. Finally, several suggestions for future research examining determinants that account for asthma disparities are examined.

Pediatric asthma morbidity: the importance of symptom perception and family response to symptoms

OBJECTIVE

To determine whether family response to asthma symptoms mediates the relationship between child symptom perception and morbidity.

METHODS

A total of 122 children with asthma, aged between 7 and 17 years (47% females; 25% ethnic minorities), were recruited from three sites. Participants completed a family asthma management interview and 5-6 weeks of symptom perception assessment.

RESULTS

Family response to symptoms mediated the relationship between child underestimation of symptoms and asthma morbidity and partially mediated the relationship between accurate symptom perception and morbidity. In contrast, although child overestimation of symptoms and family response to symptoms were independently related to asthma morbidity, a mediational model was not supported.

CONCLUSIONS

Our study found support for the role of family response to symptoms in mediating the relationship between child symptom perception and morbidity, particularly with regard to underestimation of symptoms, underscoring the need for behavioral tools to accurately recognize and optimally respond to exacerbations.

Pediatric asthma management in the family context: the family asthma management system scale

OBJECTIVE

To examine psychometric properties of a revised version of the Family Asthma Management System Scale (FAMSS), a clinical interview to assess asthma management.

METHODS

The FAMSS was administered to 115 children with asthma and their primary caregivers, along with a measure of asthma morbidity. A subset of families (n = 53) participated also in objective-adherence monitoring and completed measures of asthma knowledge and self-efficacy.

RESULTS

The FAMSS demonstrated good internal consistency (alpha = .84). The FAMSS summary score was unrelated to age, gender, race, or minority status, but was related to socioeconomic status (SES) and to functional morbidity at baseline and prospectively. Convergent validity of the FAMSS was documented. The FAMSS explained additional variance in concurrent-asthma morbidity beyond self-reports or objective adherence monitoring.

CONCLUSION

The FAMSS is a valuable tool to assess family-based asthma management that addresses gaps in available assessment methodologies and holds promise for research and clinical applications.

Comorbidity of asthma and anxiety and depression in Puerto Rican children

Studies have reported that childhood asthma is associated with internalizing disorders, but most of these studies have used global measures of depressive and anxiety symptoms. The Diagnostic Interview Schedule for Children was administered to a group of 1891 youth ages 4 to 17 and their caregivers in Puerto Rico to determine DSM-IV symptoms and diagnoses. Asthma diagnosis and having had an asthma attack were assessed by parental report. A diagnosis of asthma was associated with having any depressive disorder and one symptom of separation anxiety. An asthma attack was associated with any depressive disorder and any anxiety disorder and, more specifically, with separation anxiety disorder, major depressive disorder, and symptoms of depression, separation anxiety, and generalized anxiety. Possible explanations for the findings are discussed.

The Asthma Risk Grid: clinical interpretation of symptom perception

The ability to perceive accurately the onset and intensity of asthma symptoms is a cornerstone of effective asthma management. Research in pediatric and adult asthma patients has shown the important role of symptom perception in asthma management, morbidity, and mortality. Assessment of symptom perception ability has largely remained an empiric methodology rather than an applied clinical tool. The Asthma Risk Grid represents a clinical application of symptom perception measurement, and pediatric cases are described as clinical examples. Clinical and research applications of the Asthma Risk Grid are presented.

Suicide attempts and self-mutilative behavior in a juvenile correctional facility

OBJECTIVE

To determine the lifetime history of suicide attempts in incarcerated youths and psychological factors related to suicidal and self-mutilative behaviors during incarceration.

METHOD

A 25% systematic random sample chart review of adolescents admitted to a juvenile correctional facility yielded a sample of 289 adolescents. Seventy-eight of these adolescents were clinically referred for psychiatric assessment. Suicidal behavior was assessed with the Spectrum of Suicidal Behavior Scale and self-mutilation with the Functional Assessment of Self-Mutilation.

RESULTS

Of the 289 adolescents, 12.4% reported a prior suicide attempt. Almost 60% of these attempts were made using violent methods (e.g., cutting). Of the 78 clinically referred subjects, 30% reported suicidal ideation/behavior and 30% reported self-mutilative behavior while incarcerated. Suicidal clinically referred adolescents reported more depression, anxiety, and anger than nonsuicidal youths. Adolescents who reported self-mutilative behavior had higher anxiety, anger, and substance use than non-self-mutilative adolescents.

CONCLUSIONS

Results suggest that incarcerated adolescents have higher rates of suicide attempts and use more violent methods of attempt than adolescents in the general population. Furthermore, incarcerated clinically referred suicidal and self-mutilative youths report more severe affective symptoms than their nonsuicidal and non-self-mutilative counterparts, suggesting a need for mental health treatment.

Medication adherence in pediatric asthma: reasoning, responsibility, and behavior

OBJECTIVE

To assess child adherence to preventive asthma medications; to investigate relations between knowledge, reasoning about asthma, and responsibility for management and adherence; and to determine the association between adherence and morbidity.

METHODS

Participants were 106 children with asthma and their parents. Medication adherence was electronically monitored for 1 month. Participants completed self-report measures. Children were interviewed to assess reasoning about asthma.

RESULTS

Children's adherence was approximately 48% of prescribed doses. Adherence was negatively related to age (r = -.21, p <.05); minority status, F(1, 98) = 7.55, p <.01; and morbidity (r = -.26, p <.01). Age was associated with increased child knowledge (r =.47, p <.001), reasoning about asthma (tau =.23, p <.01), and responsibility for asthma management (r =.44, p <.01). These variables were not associated with adherence.

CONCLUSIONS

Although older children know more about asthma and assume more responsibility for disease management, their adherence is lower than that of younger children. No association was found between adherence and child knowledge, reasoning about asthma, or responsibility for asthma management.

Association of psychiatric disorders and different indicators of asthma in island Puerto Rican children

BACKGROUND

We examined the relationship between three different indicators of childhood asthma (asthma diagnosis, ever had an asthma attack, and asthma hospitalization) and having any psychiatric disorder, comorbid disorders, or specific disorders. Three study hypotheses were examined: 1) there will be subject variability in responses to the asthma indicators; 2) there will be different observed associations between the three asthma indicators and psychiatric disorders; and 3) maternal mental health, family income, and maternal education will confound the associations between childhood asthma and psychiatric disorders.

METHOD

Data were drawn from a community-based, random sample of 1,891 island Puerto Rican children aged 4-17 years. Information was collected through direct interview with children and adolescents and their primary caretakers. The Diagnostic Interview Schedule for Children (DISC) was used to determine DSM-IV diagnoses.

RESULTS

Thirty-two percent of the children had been diagnosed with asthma but only 22 % had ever experienced an asthma attack. Seventeen percent of the children had been hospitalized for asthma. Having been hospitalized for asthma was not associated with any of the psychiatric disorders, having a diagnosis was associated with some of the disorders, and having experienced an asthma attack was associated with almost all the disorders, after controlling for family income and maternal education and mental health.

CONCLUSIONS

Determining and measuring asthma may be difficult because of confusion and differing perceptions of what constitutes asthma or an asthma attack. Future studies should consider the problems in capturing perceptions of asthma and severity in Puerto Rican children and should continue to explore the relationship between asthma and mental illness.

Guidelines for mechanical lung function measurements in psychophysiology

Studies in psychophysiology and behavioral medicine have uncovered associations among psychological processes, behavior, and lung function. However, methodological issues specific to the measurement of mechanical lung function have rarely been discussed. This report presents an overview of the physiology, techniques, and experimental methods of mechanical lung function measurements relevant to this research context. Techniques to measure lung volumes, airflow, airway resistance, respiratory resistance, and airflow perception are introduced and discussed. Confounding factors such as ventilation, medication, environmental factors, physical activity, and instructional and experimenter effects are outlined, and issues specific to children and clinical groups are discussed. Recommendations are presented to increase the degree of standardization in the research application and publication of mechanical lung function measurements in psychophysiology.