psychosocial components of asthma management in children

Psychosocial Components ofAsthma Management in ChildrenShari L. WadeChildren’s Hospital Medical Center, Cincinnati, Ohio, USA

ContentsAbstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171. Risk and Protective Factors in the Social Environment . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.1 Caregiver and Child Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.2 Family Functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.3 Other Environmental Risk and Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . 20

2. Self-Management Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202.1 Asthma Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212.2 Attitudes and Beliefs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212.3 Problem-Solving Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212.4 Role of Shared Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3. Relationship of Risk and Protective Factors to Self-Management Skills . . . . . . . . . . . . . . . . 224. Implications for Working with Children with Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

4.1 Different Families Have Different Psychosocial Issues . . . . . . . . . . . . . . . . . . . . . . . 234.2 Family Barriers and Risk Factors Change Over Time . . . . . . . . . . . . . . . . . . . . . . . . 244.3 Mental Health Issues are Important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244.4 Importance of Patient-Physician Communications . . . . . . . . . . . . . . . . . . . . . . . . 244.5 Role of an Interdisciplinary Treatment Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Abstract Asthma is a growing health problem that affects 4.8 million children in theUS alone. This paper considers empirical studies from the past 20 years examin-ing the relationship between psychosocial factors and asthma management andmorbidity. Research indicates that psychosocial factors, including risk and pro-tective factors in the social environment, and knowledge, attitudes and skillspertaining to asthma management, can play an important role in asthma manage-ment, adherence and morbidity. Caregiver and child mental health problems havebeen linked to increased asthma symptoms and poorer functional status. Familyfunctioning, chronic stresses and social support have also been identified as po-tential risks and/or protective factors in the social environment.Of the asthma self-management skills, practical problem-solving skills have

received increasing attention as an important, and potentiallymodifiable, psycho-social component. Families may also fail to adhere to medical recommendationsbecause of concerns regarding their utility. Results from a recent individualisedasthma intervention protocol provide a strategy for successfully addressing bothenvironmental risk factors and asthma self-management skills to reduce asthmamorbidity. Recommendations for healthcare providers include: (i) screening fam-

REVIEW ARTICLE Dis Manage Health Outcomes 2000 Jul; 8 (1): 17-271173-8790/00/0007-0017/$20.00/0

© Adis International Limited. All rights reserved.

ilies for psychosocial risk and protective factors on an ongoing basis, includingmental health concerns; (ii) engaging family members in dialogue to identifypotential areas of confusion or disagreement with the treatment plan; and (iii)including non-medical specialists such as health educators and mental healthpractitioners as part of the treatment team.

Asthma is a serious and growing health prob-lem. In the US, it affects 4.8 million children andis the leading cause of school absences.[1,2] TheNa-tional Health and Examination Survey reportedthat the prevalence of asthma in children aged 6 to11 years increased from 4.8 to 7.6% between 1971and 1980.[3] Moreover, the hospitalisation rate forasthma among individuals between the ages of 0and 24 years increased by 28% during the 1980s.[4]These increases in prevalence and morbidity havebeen greatest among urban children from ethnicminority groups.[5]Although paediatric asthma is a chronic medical

condition, psychosocial factors can play a criticalrole in symptom expression andmanagement. There-fore, it is essential for healthcare providers to un-derstand and address psychosocial factors and theassociated barriers to effective asthma manage-ment. Psychosocial factors can be conceptualisedin 2 broad domains: (i) risk and protective factorsin the social environment that influence asthmamanagement and morbidity; and (ii) self-manage-ment skills including asthma-related knowledge,beliefs and management behaviour.[6,7] Althoughthe latter have been the focus of numerous asthmamanagement interventions, the former may play animportant role in limiting the ability of familymembers to translate knowledge and attitudes intobehaviour change as well as directly impacting ad-herence, symptoms and healthcare utilisation (seefig. 1).As depicted in figure 1, potential risk factors

include maternal psychological difficulties, childbehaviour problems, family dysfunction, life stressesand the lack of adequate social support. However,these same factors may serve a protective role andfacilitate adherence when family members are welladjusted and provide support for one another. Thisarticle examines the theoretical and research evi-

dence for the importance of both types of factors(social environmental risk and protective factors,and asthma self-management skills) that has beenpublished in the psychological and medical litera-ture during the past 20 years.

1. Risk and Protective Factors in theSocial Environment

1.1 Caregiver and Child Adjustment

The primary caregiver’s level of psychologicaladjustment may serve as both a risk and a protec-tive factor with regard to the child’s asthma mor-bidity.[8] Psychological distress in the parent orcaregiver may contribute to increased asthmamor-bidity through impaired problem solving skills, in-appropriate utilisation of healthcare services andreduced adherence tomedical recommendations.[9-11]Previous investigations have documented a rela-tionship between parental psychological symptomsand asthma severity and manageability.[12]The National Cooperative Inner-City Asthma

Study (NCICAS), a recent investigation of 1528inner-city children with asthma, found that rates ofhospitalisation for asthma during the 9 months fol-lowing the baseline assessment were nearly dou-bled among children of caregivers with clinicallysignificant levels of psychological symptoms, evenafter controlling for pre-baseline rates of hospital-isation.[11] Caregiver psychological symptoms werealso predictive of asthma symptoms within thissample, although this relationship was attenuatedwhen child behaviour problems were taken intoaccount.Positive child adjustment may serve as a protec-

tive factor, with well-adjusted children demon-strating better self-management skills and adher-ence. Conversely, child behavioural problems mayreduce the child’s capacity to successfully partici-

18 Wade

© Adis International Limited. All rights reserved. Dis Manage Health Outcomes 2000 Jul; 8 (1)

pate in his or her own asthma management, includ-ing medication adherence, and may directly con-tribute to asthma morbidity via emotionally-in-duced asthma attacks.[13] The NCICAS study ofasthma among inner-city children described abovefound a significant relationship between childbehavioural problems and increased asthma symp-toms (greater wheezing and poorer functional sta-tus) across the 9-month follow-up period.[11] Spe-cifically, children with clinically significant levelsof behavioural problems experienced an additional18 days of wheezing per year compared with theircounterparts with better behavioural adjustment.Other investigations have also documented a rela-tionship between child psychological problems,especially depression, and asthma morbidity andmortality.[13,14]In the case of both caregiver and child adjust-

ment, there is evidence that the illness itself maycontribute to increased psychological distress.[15,16]In a nationwide sample of 10 244 children, Bussinget al.[17] found that children with severe asthma werenearly 3 timesmore likely to have severe behaviou-ral problems than were children with no chronichealth-impairing conditions. Elevated levels ofbehavioural problems among children with asthmawere also documented in inner-city samples.[6,18]For children with asthma, functional limitations may

contribute to increased emotional distress.[19] Forcaregivers, parenting a child with asthmamay con-tribute to increased parenting stress and more crit-ical parent-child interactions.[20-23] Thus, the pres-ence of a chronic illness may result in increasingcaregiver or child distress that in turn contributesto poorer adherence and increased morbidity. Al-though not characteristic of all families, this recip-rocal relationship between family distress andasthma morbidity has the potential to lead to anescalating spiral of psychological symptoms andasthma morbidity.

1.2 Family Functioning

The relationship between family functioningand asthma management and morbidity has re-ceived less empirical attention. However, there issome evidence that a supportive family environ-ment may serve as a protective factor facilitatingadherence and reducing morbidity in children withchronic illness.[24,25] In studies of asthma, familyconflict has been documented in children with se-vere, life-threatening asthma[26] and has beenlinked to asthma severity and manageability.[12]Thus, existing data suggest that the family mayserve as either a resource facilitating asthma man-agement or as an additional risk factor for nonad-herence.

Adherence

Wheezing

Utilisation

Self-management skills

· Knowledge

· Attitudes and beliefs

· Problem-solving skills

Risk and protective factorsin the social environment

· Maternal mental health

· Child adjustment

· Family functioning

· Chronic stresses

· Social supports

Fig. 1. Framework for understanding the psychosocial components of asthma management.

Psychosocial Components of Asthma Management 19


1.3 Other Environmental Risk andProtective Factors

In addition to the quality of relationships withmembers of the immediate family, the primary car-egiver and child may be confronted by a range ofother stresses and resources that influence theirability to manage the child’s asthma. Stress maydirectly affect physical functioning by altering im-mune responses and the threshold for infection.[27,28]Stress may also have indirect effects on the physi-cal health of the child through a series of pathways.First, caretakers of a child with asthma are thedecision-makers concerning behaviours relating toasthmamorbidity. They influence, for example, ad-herence to recommendations from health provid-ers, utilisation of health services, evaluation of theseverity of symptoms and whether they should betreated, and restrictions on activity.[29] Factors suchas mental illness that affect caretakers’ capacity toperform this role may, in turn, influence asthmamorbidity. Secondly, stress influences problemsolving in caretakers of chronically ill children[9]and reduces caretakers’ adherence to medicationregimens. Stress also appears to increase caretak-ers’ sensitivity to children’s symptoms, thereby al-tering the threshold for care. High levels of lifestress may also be associated with abuse and ne-glect, which have in turn been linked to mortalityfrom asthma.[30] Although the relationship betweenstress and asthma morbidity in children has notbeen well documented, a host of studies have dem-onstrated an association between stress and physi-cal illness in children.[31,32]Supportive relationships with family members

and friends may buffer the relationship betweenlife stress and physical and psychiatric morbidity,including asthma symptoms in children. Socialsupport may facilitate appropriate coping therebyreducing the likelihood of life stressors (includinghaving a child with asthma) resulting in significantpsychological distress. Social support may alsohave more direct effects on asthma managementand morbidity. Family members and friends mayassist the primary caregiver in managing the child’sasthma and facilitating adherence. Data from the

NCICAS study indicated that inner-city childrenwith asthma had 3.4 caregivers on average, withsome children having 6 or more individuals in-volved in their care.[33] Support may also improvethe child’s resistance to infection, thereby reducingasthma morbidity.In addition to supportive social relationships,

asthma management may be enhanced by other re-sources such as the family’s financial assets, accessto high quality healthcare and the caregiver’s cog-nitive competence. These and other resources mayserve to lessen the impact of adverse social envi-ronmental characteristics on asthma morbidity andmanagement. The family’s ethnic and culturalbackground may also contribute to its under-standing of the illness and approach toward man-agement.[34]

2. Self-Management Skills

The vast majority of research and treatment pro-grammes on paediatric asthma during the past 2decades have emphasised cognitive-behaviouralmodels of disease management, in large part be-cause these models have clear implications for in-tervention with children and families. The specificfocus of these models has varied, with some plac-ing greater emphasis on factual knowledge regard-ing the illness, while others stress the importanceof the caregiver’s (or child’s) attitudes and beliefsregarding the illness and his or her confidence inthe ability to successfully manage it.[35,36] Withinthese models, knowledge and beliefs are hypothes-ised to shape the strategies employed tomanage thechild’s asthma and influence adherence to physi-cian’s recommendations. However, more recently,psychological models have been developed to ad-dress the often profound gap observed betweenknowledge and professed attitudes toward recom-mended actions and actual management behav-iours.[37] These newer models, such as SocialAction Theory,[38] highlight the importance ofbehavioural skills, including being able to imple-ment effective problem solutions in difficult man-agement situations. A critique of the literature per-

20 Wade


taining to each of these frameworks is presentedbelow.

2.1 Asthma Knowledge

Much research on asthma management has fo-cused on the caregiver’s factual knowledge aboutasthma.[39,40] Asthma knowledge has been docu-mented to have a modest association with asthmasymptoms, and consequently the level and accuracyof knowledge about asthma have been a primaryfocus of intervention in nearly all of the paediatricasthma self-management programmes.[41,42] Al-though these programmes have documented suc-cess in improving knowledge about asthma, theyhave been considerably less effective in control-ling asthma symptoms or reducing healthcareutilisation for acute episodes.[41-44] Thus, althoughinadequate information regarding asthmamay leadto inappropriate asthma management practices,high levels of knowledge may be insufficient toeffect substantial changes in asthma morbidity.

2.2 Attitudes and Beliefs

Beliefs regarding the efficacy of recommendedtreatments, the ability to carry them out success-fully and the perceived difficulty of doing so (e.g.expense, inconvenience), have been predicted toinfluence adherence to medical recommenda-tions.[45-49] Of these, self-efficacy, or the individu-al’s assessment of his or her capacity to success-fully follow through with recommendations, hasemerged as an important predictor of subsequenthealth-related behaviours.[49] Children’s percep-tions of self-efficacy have also been linked toasthma management practices.[35] However, chil-dren’s health beliefs have been shown to differfrom those of their parents and from their parents’report of the child’s beliefs.[50,51] These findingssuggest that it may be necessary to understand thecontribution of both the parent’s and child’s atti-tudes and beliefs to asthma management practices,particularly among pre-teens and teens.Health belief and self-efficacy models have re-

ceived criticism because positive attitudes and highlevels of self-efficacy have not consistently re-

sulted in desired changes in observed managementbehaviours. This discontinuity between asthmaknowledge and beliefs on one hand and problem-solving skills on the other is supported in the de-scriptive analyses of theNCICAS data. These anal-yses revealed high levels of asthma knowledge andrelatively positive expectations regarding theirability to prevent and manage asthma symptomseffectively among the adult caregivers inter-viewed.[6] However, these inner-city caregiversgenerated surprisingly few problem-solving strat-egies in response to typical asthma problem sce-narios, revealing a substantial gap between asthmaknowledge and the ability to generate effectivemanagement strategies.[6] These findings suggestthat improving self-efficacy among caregiversmay be a necessary but not sufficient step in estab-lishing effective asthma management practices.

2.3 Problem-Solving Skills

Given the apparent limitations of models em-phasising knowledge and beliefs, psychological re-search on adherence to health regimens in chronicdiseases has shifted in recent years from knowl-edge-focused interventions to a conceptual frame-work focusing on personal capabilities such asresourcefulness, flexibility and creativity in con-fronting the daily challenges of illness manage-ment. Interventions based on this framework stresspractical problem-solving skills, such as the abilityto anticipate problematic illness management situ-ations, manage emotions during these situationsand come up with effective responses. These newerapproaches to facilitating effective health manage-ment behaviours, such as Social Action Theory andSelf Regulation Theory,[38,52] contend that inter-ventions will only be successful in producing longterm change if they stress the development of prac-tical problem-solving skills and personal confi-dence in the ability to use these skills effectively.Thus, healthcare providers and health educatorsmust incorporate training in how to confront day-to-day management problems together with know-ledge about asthma if their efforts are to be success-ful. The Childhood Asthma Management Program



has adapted this approach for asthma managementby developing an educational program that empha-sises anticipating problems before they arise, de-vising appropriate responses and practicing behav-iours that are effective solutions.[53] Although noefficacy data have been published, thematerials fromthis programme provide a useful framework for ad-dressing these issues with children and caregivers.

2.4 Role of Shared Responsibility

The development of programmes to improveknowledge, attitudes and skills in the managementof paediatric asthma is further complicated by thefact that both the parent and the child are likely tohave a role in managing the child’s asthma. Addi-tionally, there is often poor correspondence be-tween the parent’s and child’s perceptions of howmuch responsibility the child is taking for manag-ing his or her own illness.[33] Perhaps, not surpris-ingly, the discrepancy between the parent’s andchild’s perceptions is greatest with regard to pre-ventive strategies, many of which are likely to oc-cur outside of the home. Adult and child percep-tions of symptoms and the need for medication arealso likely to differ.[54] As the child ages, the burdenof responsibility for asthma care shifts from parentto child, increasing the importance of the child’sattitudes and skills. However, existing data suggestthat children may not assume responsibility as an-ticipated when responsibility is transferred.[55] Thus,parents and healthcare providers may need to pro-vide additional structure and support to childrenand adolescents as they begin to assume responsi-bility for self-care.There is also evidence, at least among inner-city

families, that management responsibilities may beshared with other adult caregivers.[33] Although theinvolvement of other adults in the child’s asthmamanagement may provide a valuable source of sup-port, it may also serve to dilute the importance ofthe primary caregiver’s management skills. Theremay also be differences in opinion among care-givers regarding the value of specific treatment rec-ommendations, thereby increasing the risk of non-adherence. For example, the child’s mother may be

convinced of the importance of daily preventivemedication, whereas the child’s grandmother, whocares for him/her during the day, may view dailymedications as unnecessary and potentially addic-tive. Thus, efforts to improve asthma managementskills need to take into account which individual orindividuals are involved in performing those skills.

3. Relationship of Risk and ProtectiveFactors to Self-Management Skills

Risk and protective factors in the social environ-ment may directly influence caregiver and childattitudes regarding asthma management by reduc-ing self-confidence in the ability to carry out pre-scribed treatment recommendations and effectivelymanage symptoms. More significantly, parent orchild adjustment difficulties, family dysfunction orchronic stresses may impede the family’s ability toeffectively translate knowledge and attitudes intosuccessful asthma management strategies. Thus,any programme to improve asthma managementskills needs to take into account both the individu-als involved in caring for the illness and the envi-ronmental barriers and supports to effective man-agement.The nature of paediatric asthma and current rec-

ommendations for disease management contributeto further barriers to effective symptom manage-ment. Asthma is a chronic respiratory illness re-quiring ongoing anti-inflammatory medication tominimise or eliminate symptoms.[56] However, formost childrenwith mild tomoderate asthma, symp-tom flareups occur only a few times a year duringthe cold and flu season or when exposed to seasonalallergens. Thus, parents (and children) may perce-ive (at times appropriately) that the prescribeddaily treatment regimen is not necessary to controlsymptoms.[57] Moreover, in a culture sensitised toinappropriate drug use, daily medications may beviewed as potentially addictive or as creating asense of dependence.[58]Because of the episodic nature of symptoms,

less medication than prescribed is likely to be givenduring asymptomatic periods, and more medicationthan prescribed is likely to be given during symp-

22 Wade


tom flareups. In fact, studies of adherence to pre-scribed medication regimens have revealed adher-ence rates ranging from 3 to 80%, with an averageof approximately 50% adherence.[59,60] Adherenceto recommendations for preventive actions, suchas trigger avoidance, may be even lower.[58] Eventhe most effective medication regimen is unlikelyto reduce asthma symptoms if the child does notreceive the medications as prescribed. Therefore,it is incumbent upon physicians and other health-care providers to assess family members’ feelingsabout the medication(s) and be realistic about theirability to follow treatment recommendations.[61]For example, although it may be optimal for thechild’s sheets, bed clothes and floor to be cleanedthoroughly on a weekly basis, this recommendationmay be unrealistically time consuming for manyfamilies at greatest risk (i.e. ethnic minorities liv-ing in the inner city). To successfully work with suchfamilies, it may be necessary to jointly negotiatemore realistic treatment goals.The second phase of NCICAS involved the

evaluation of a treatment protocol that sought toreduce asthma morbidity among inner-city chil-dren by providing asthma education and trainingin problem-solving skills while addressing extantpsychosocial risk factors and caregiver attitudestoward asthma management and medications.[62]As part of this intervention for families of childrenwith asthma aged from 5 to 11 years, 515 familieswere provided with education in state-of-the-artasthma management together with training inproblem-solving skills and communicating withtheir physicians. Prior to receiving this core inter-vention, families were also screened for risk fac-tors in the social and physical environment (e.g.cockroaches) and barriers to effective asthmaman-agement (e.g. concerns about over-medication). Fam-ilies who identified specific risks or barriers duringthis screening received additional individualisedsessions with an asthma counsellor (a trained so-cial worker) targeted to address these issues.Across the first 12 months of follow-up, results re-vealed an average of approximately 0.5 days fewersymptoms per 2-week period in the intervention

group compared with a nontreatment control group.The intervention led to an even greater reductionin symptoms among children with severe asthma(1.54 days per 2 weeks). Observed group differ-ences persisted over the second year of the 24-month follow-up. These findings suggest that it ispossible to develop and implement successful in-terventions that address both environmental riskfactors and asthma-related knowledge, attitudesand beliefs. They further support the value of in-dividualised interventions designed to target theunique strengths and weaknesses of individualfamilies.[63,64]

4. Implications for Working withChildren with Asthma

Before considering the specific implications forworking with families of children with asthma, itis important to keep in mind that all of these rec-ommendations are predicated upon the availabilityof high quality, state-of-the-art medical care.[56]Clearly, addressing psychosocial issues will be oflittle value if the child is receiving inadequate orinappropriate asthma medication.[65] The variabil-ity in asthma symptoms over time also necessitatesongoing access to the healthcare provider to ad-dress questions, concerns and emerging problems.Finally, the clinical recommendations outlined inthis section are derived from the empirical litera-ture outlined in sections 1 and 2 documenting therelationship between aspects of the psychosocialenvironment and asthma morbidity. However, fur-ther research must be conducted to identify empir-ically validated strategies for addressing thesepsychosocial risks.

4.1 Different Families Have DifferentPsychosocial Issues

The framework presented in figure 1 depicts thekey psychosocial issues to be considered when treat-ing a child with asthma. However, it is unlikely thatany given child or family will have concerns in allof the areas indicated. In the NCICAS study, cor-relations between individual psychosocial risk fac-tors and asthma knowledge, beliefs and problem-



solving skills were quite low (r < 0.10), suggestingthat a family with problems in one area does notnecessarily have problems in another. For manywell-functioning families, asthma education at thetime of diagnosis may be sufficient to address thefamily’s need for psychosocial intervention. How-ever, for families at greatest risk (e.g. those in whichthe mother is unmarried and depressed and thereare few extra-familial resources), outside referralsmay be required in addition to more extensive train-ing in problem-solving and asthma managementskills. Therefore, it is useful to screen for potentialrisk factors in all families to identify areas warrant-ing further assessment or intervention.

4.2 Family Barriers and Risk Factors ChangeOver Time

Not only are psychosocial risk factors likely tovary substantially from family to family, but indi-vidual risks, protective factors and barriers arelikely to change over time with the developmentalstage of the family (e.g. birth of a new child), thechild’s age and degree of responsibility for self-care and the status of the illness.[66] For example, afamily who was managing the child’s asthma wellmay begin experiencing difficulties with adher-ence when the child is asked to take charge ofhis/her ownmedication following the birth of a sib-ling. Since changes in family status are inevitable,it is critical to periodically reassess psychosocialrisk and protective factors and the family’s abilityto effectively manage the child’s asthma, particu-larly if the child has begun experiencing moresymptoms.

4.3 Mental Health Issues are Important

The most recent research reviewed in section1.1 suggests that caregiver and child mental healthare important considerations in paediatric asthma.Children with asthma appear to be at greater riskfor behavioural problems and these problems, inturn, contribute to increased asthma morbid-ity.[11,13,14] A similar pattern has been observed forcaregivers of children with asthma. These findingsdo not suggest that asthma is fundamentally a psy-

chological disorder or that most children withasthma have psychological problems; however,given the elevated risk, current findings supportscreening for mental health concerns among chil-dren with asthma and their caregivers. Again, at-tention to mental health issues may be particularlysalient for children with poor symptom control.

4.4 Importance of Patient-PhysicianCommunications

Asthma knowledge, attitudes and managementskills may be difficult to assess in the paediatricoffice setting, particularly given the reluctance ofmost caregivers to question the recommendationsof the physician.[67] As a result, family membersmay express agreement with the physician’s rec-ommendation despite serious concerns regardingthe appropriateness of the treatment or their abilityto carry it out. To better assess family attitudes, itmay be necessary to engage family members in adialogue about problems they currently encounterin managing the child’s asthma and how the treat-ment recommendations fit with these barriers, thefamily’s lifestyle and other demands. Some asthmamanagement skills, such as using a metered-doseinhaler, can be directly observed in the office set-ting; others, such as getting a resistant child to takehis or her asthma medications, may require discus-sion and troubleshooting. The bottom line is thatsome level of discussion and problem-solving isrequired with all families to ensure that they under-stand and are prepared to carry out the healthcareprovider’s plan.

4.5 Role of an InterdisciplinaryTreatment Team

An interdisciplinary team that incorporates phy-sicians, nurses, health educators and mental healthpractitioners can be an invaluable resource in treat-ing paediatric asthma. Healthcare providers oftenlack the time and expertise to assess psychosocialrisk and protective factors and identify families atrisk. Moreover, family members may be reluctantto share problems with the physician. Health edu-cators can assume the role of assessing and reme-

24 Wade


dying knowledge or skill deficits. They can facili-tate adherence by identifying who is responsiblefor specific aspects of asthmamanagement (parent,child or other adult) and ensuring that the individ-ual understands why a particular recommendationis important (e.g. taking preventive medications ona daily basis). Mental health practitioners can pro-vide more in-depth screening of caregivers or chil-dren who have been identified as having potentialmental health problems, and link them to appropri-ate resources. Although this model is most com-monly employed in allergy and pulmonology sub-speciality clinics, it can also provide a usefulframework for facilitating asthma managementamong those at greatest risk, namely children fromethnic minority groups living in the city.

5. Conclusions

Table I summarises the key points of this re-view. Asthma is a life-threatening chronic healthcondition that has been on the rise among childrenin the US and other industrialised countries for thepast 2 decades. Although the underlying causes ofasthma relate to the pathophysiology of airway re-sponse, psychosocial factors play an important rolein determining symptom recognition and manage-ment, problem-solving in asthma management sit-uations, adherence to medical recommendationsand decisions regarding healthcare utilisation.Among the psychosocial factors identified, care-giver and child mental health and asthma attitudes

and problem-solving skills may be among themostimportant determinants of adherence and subse-quent asthma morbidity. Fortunately, these psycho-social risks can be identified and addressed throughroutine screening, troubleshooting and referral foradditional services, such as psychotherapy, whenappropriate. Future treatment-outcomes researchis necessary to identify the most successful strate-gies for ameliorating psychosocial risks. However,addressing the psychosocial component of asthmamanagement, when combined with state-of-the-artmedical care, holds the promise for reducingasthma morbidity for a wide range of children.

Acknowledgements

This work was supported in part by a grant from theNational Institute of Disability and Rehabilitation Research.The author also wishes to acknowledge the contributions ofthe following members of the National Cooperative Inner-City Asthma Study to the earlier conceptualisation of mate-rial presented in this manuscript: Laurie Bauman Ph.D.,Craig Ewart Ph.D., Gary Holden Ph.D., Fredrick LeicklyM.D., Herman Mitchell Ph.D. and Connie Weil Ph.D.

References1. Adams PF, Marano MA. Current estimates from the National

Health Interview Survey. Vital Health Stat 1995; 10: 942. Taylor WR, Newacheck P. Impact of childhood asthma on

health. Pediatrics 1992; 90: 657-623. Gergen PJ,MullallyDI, Evans R. National survey of prevalence

of asthma among children in the United States, 1976-1980.Pediatrics 1988 Jan; 81: 1-7

4. Gergen PJ, Weiss KB. Changing patterns of asthma hospitaliza-tion among children: 1979-1987. JAMA 1990 Oct; 264:1688-92

5. Crain EK, Weiss K, Bijur P, et al. An estimate of the prevalenceof wheezing among inner city children. Pediatrics 1994; 94:356-62

6. Wade S, Weil C, Holden G, et al. Psychosocial characteristicsof inner-city children with asthma: a description of theNCICAS psychosocial protocol. Pediatr Pulmonol 1997; 24:263-76

7. Creer TL. The application of behavioral procedures to child-hood asthma: current and future perspectives. Patient EducCouns 1991; 17: 9-22

8. Wallander JL, Varni JW, Babani L, et al. Family resources asresistance factors for psychological maladjustment in chron-ically ill and handicapped children. J Pediatr Psychol 1989;14: 157-73

9. Fehrenbach AMB, Peterson L. Parental problem solving skillsand dietary compliance in phenylketonuria. J Consult ClinPsychol 1989; 57: 238-41

10. Riley AW, Finney JW, Mellins ED, et al. Determinants of chil-dren’s health care use: an investigation of psychosocial fac-tors. Med Care 1993; 31: 767-83

Table I. Key points in the psychosocial aspects of asthma manage-ment in children

Risk and protective factors in the social environment, includingmaternal and child mental health, can influence paediatricasthma outcomes

Asthma education will only be successful if it addresses personalconfidence and practical problem-solving skills

Screening for psychosocial risk factors can identify vulnerablechildren and facilitate individualised treatment

An ongoing dialogue between the patient/family and physician iscritical for understanding changes in risk and protective factorsand self-management skills

Involvement of health educators and mental health practitionerscan facilitate effective asthma management



11. Weil CM,Wade SL, Bauman LJ, et al. The relationship betweenpsychosocial factors and asthma morbidity in inner-city chil-dren with asthma. Pediatrics 1999; 104: 1274-80

12. Christiaanse ME, Lavigne JV, Lerner CV. Psychosocial aspectsof compliance in children and adolescents with asthma. J DevBehav Pediatr 1989; 10: 75-80

13. Creer TL. Self-management in the treatment of childhoodasthma. J Allergy Clin Immunol 1987; 80: 500-5

14. Miller BD, Strunk RC. Circumstances surrounding the deathsof children due to asthma. Am J Dis Child 1989; 143: 1294-9

15. Jessop DJ, Riessman CX, Stein REK. Chronic childhood illnessand maternal mental health. J Dev Behav Pediatr 1988; 9:147-56

16. Kashani JH, Konig P, Shepperd JA, et al. Psychopathology andself-concept in asthmatic children. J Pediatr Psychol 1988; 13:509-20

17. Bussing R, HalfonN, Benjamin, B, et al. Prevalence of behaviorproblems in US children with asthma. Arch Pediatr AdolescMed 1995 May; 149: 565-72

18. Butz AM, Malveaux FJ, Eggleston P, et al. Social factors asso-ciated with behavioral problems in children with asthma. ClinPediatr 1995 Nov; 34: 581-90

19. Padur JS, Rapoff MA, Houston BK, et al. Psychosocial adjust-ment and the role of functional status for children withasthma. J Asthma 1995; 32: 345-53

20. Carson DK, Schauer RW. Mothers of children with asthma:perceptions of parenting stress and the mother-child relation-ship. Psychol Rep 1992; 71: 1139-48

21. Gartland HJ, Day HD. Family predictors of the incidence ofchildren’s asthma symptoms: expressed emotions, medica-tion, parent contact and life events. J Clin Psychol 1999; 55:573-84

22. Schoebinger R, Florin I, Zimmer C, et al. Childhood asthma:paternal critical attitude and father-child interaction. J Psy-chosomatic Res 1992; 36: 743-50

23. Schoebinger R, Florin I, Reichbauer M, et al. Childhoodasthma: mother’s affective attitude, mother-child interactionand children’s compliance with medical requirements. J Psy-chosomatic Res 1993 Oct; 37: 697-707

24. Anderson BJ, Miller JP, Auslander WF, et al. Family charac-teristics of diabetic adolescents: relationship to metaboliccontrol. Diabetes Care 1981 4: 586-94

25. Hanson CL, Henggeler SW, Burghen GA. Social competenceand parental support as mediators of the link between stressand metabolic control in adolescents with insulin-dependentdiabetes mellitus. J Consult Clin Psychol 1989; 55: 529-33

26. Strunk RC, Mrazek DA, Fuhrmann W, et al. Physiological andpsychological characteristics associated with deaths due toasthma in childhood. JAMA 1985; 254: 1193-8

27. Cohen S, Tyrrell DA, Smith AP. Negative life events, perceivedstress, negative affect, and susceptibility to the common cold.J Pers Soc Psychol 1993 Jan; 64: 131-40

28. Cohen S, Tyrrell DA, Smith AP. Psychological stress and sus-ceptibility to the common cold. N Engl J Med 1991 Aug; 325:606-12

29. Gortmacher SL, Eckenrode J, Gore S. Stress and the utilizationof health services: a time series and crossectional analysis. JHealth Soc Behav 1982; 23: 25-38

30. Boxer GH, Carson J, Miller BD. Neglect contributing to tertiaryhospitalization in childhood asthma. Child Abuse Negl 1988;12: 491-501

31. Beautrais AL, Fegussen DM, Shannon FT. Life events andchildhoodmorbidity: a prospective study. Pediatrics 1982; 70:935-40

32. Boyce WT, Jensen EW, Cassel JC, et al. Influence of life eventsand family routines on childhood respiratory tract illness. Pe-diatrics 1977; 60: 609-15

33. Wade SL, Islam S, Holden G, et al. Division of responsibilityfor asthma management tasks between caregivers and chil-dren in the inner-city. J Dev Behav Pediatr 1999 April; 20:93-8

34. Clark NM, Gotsch A, Rosenstock IR. Patient, professional, andpublic education on behavioral aspects of asthma: a review ofstrategies for change and needed research. J Asthma 1993; 30:241-55

35. Clark NM, Rosenstock IM, Hassan H, et al. The effect of healthbeliefs and feelings of self-efficacy on self-management be-havior of children with chronic disease. Patient Educ Couns1988; 11: 131-9

36. Rosenstock IM. The Health Belief Model: explaining healthbehavior through expectancies. In: Glanz K, Rimer B, LewisF, editors. Health behavior and health education: theory, re-search and practice. San Francisco (CA): Jossey Bass, 1990

37. Kolbe J, Vamos M, Fergusson W, et al. Differential influenceson asthma self-management knowledge and self-managementbehavior in acute severe asthma. Chest 1996; 100: 1463-8

38. Ewart CK. Social action theory for a public health psychology.Am Psychol 1991; 46: 931-46

39. Rubin D, Bauman L, LaubyD. The relationship between knowl-edge and reported behavior in childhood asthma. J Dev BehavPediatr 1989; 10: 307-12

40. Wilson-Paesano SR,McNabbWL. The role of patient educationin the management of childhood asthma. Prev Med 1985; 75:670-87

41. Howland J, Bauchner H, Adair R. The impact of pediatricasthma education on morbidity. Chest 1988; 94: 964-9

42. Rachelefsky GA. Review of asthma self-management pro-grams. J Allergy Clin Immunol 1987; 80: 506-11

43. Bernard-Bonnin AC, Stachenko S, Bonin D, et al. Self-manage-ment teaching programs and morbidity of pediatric asthma: ameta-analysis. J Allergy Clin Immunol 1995; Jan 95: 34-41

44. Klingeholfer EL, Gershwin ME. Asthma self-management pro-grams: premises not promises. J Asthma 1988; 25: 89-101

45. Holden G. The relationship of self-efficacy appraisals to sub-sequent health related outcomes: a meta-analysis. PsycholRep 1991; 66: 1044-6

46. Janz NK, Becker MH. The health belief model: a decade later.Health Educ Q 1984; 11: 1-47

47. Strecher VJ, DeVellis BM, Becker MH, et al. The role of self-efficacy in achieving health behavior change. Health Educ Q1986; 13: 73-91

48. Maddux JE, Brawley L, Boykin A. Self-efficacy and healthybehavior: prevention, promotion and detection. In: MadduxJE, editor. Self-efficacy, adaptation, and adjustment: theory,research, and application. New York (NY): Plenum Press,1995

49. Bandura A. Self-efficacy: the exercise of control. New York(NY): WH Freeman, 1997

50. Campbell JD. The child in the sick role: contributions of age,sex, parental status, and parental values. J Health Soc Behav1978; 19: 35-51

51. Campbell JD. Illness a point of view: the development of chil-dren’s concepts of illness. Child Dev 1975; 46: 92-100

52. Clark NM, Zimmerman BJ. A social cognitive view of self-reg-ulated earning about health. Health Educ Res 1990; 5: 371-9

53. Childhood AsthmaManagement ProgramResearch Group. De-sign and implementation of a patient education center for the

26 Wade


Childhood Asthma Management Program. Ann AllergyAsthma Immunol 1998 Dec; 81: 571-81

54. Guyatt GH, Juniper EF, Griffith LE, et al. Children and adultperceptions of childhood asthma. Pediatrics 1997 Feb; 99:165-8

55. Ingersoll G, Orr D, Herrold A, et al. Cognitive maturity andself-management among adolescents with insulin-dependentdiabetes. J Pediatr 1986; 108: 620-3

56. National Heart, Lung, and Blood Institute. Guidelines for thediagnosis and management of asthma. Bethesda (MD): Na-tional Institutes of Health, 1991. Publication no.: 91-3042

57. Deaton AV. Adaptive noncompliance in pediatric asthma: theparent as expert. J Pediatr Psychol 1985 Dec; 10: 1-14

58. Leickly FE, Wade SL, Crain E, et al. Self-reported adherence,management behavior, and barriers to care after an emer-gency department visit by inner city children with asthma.Pediatrics 1998 May; 101 (5): E8

59. Creer TL. Medication compliance and childhood asthma. In:Krasneger NA, Epstein L, Johnson SB, et al. editors. Devel-opmental aspects of health compliance behavior. Hillsdale(NJ): Lawrence Erlbaum Associates, 1993: 303-33

60. Lemanek KL. Adherence issues in the medical management ofasthma. J Pediatr Psychol 1990 Aug; 15: 437-58

61. Becker MH. Improving patient compliance to prescribed ther-apy. Cardiovasc Rev Rep 1987; 8: 57-9

62. Evans R, Gergen P,Mitchell H, et al. A randomized clinical trialto reduce asthmamorbidity among inner-city children: resultsof the National Cooperative Inner-City Asthma Study(NCICAS). J Pediatr 1999; 135: 332-8

63. Kotses H, Stout C, Wigal JK, et al. Individualized asthma self-management: a beginning. J Asthma 1991; 28: 287-9

64. Kotses H, Stout C, McConnaughy K, et al. Evaluation of indi-vidualized asthma self-management programs. J Asthma1996; 33: 113-8

65. Evans D, Mellins R, Lobach K, et al. Improving care for minor-ity children with asthma: professional education in publichealth clinics. Pediatrics 1997 Feb; 99: 157-64

66. Rolland JS. Chronic illness and the life cycle: a conceptualframework. Fam Process 1987; 26: 203-21

67. Korsch BM. What do patients and parents want to know?Whatdo they need to know? Pediatrics 1984 Nov; 74: 917-9

About the Author: Shari L. Wade, Ph.D. is an adjunct asso-ciate professor of clinical paediatrics in the Division ofPediatric Rehabilitation at the Children’s Hospital MedicalCenter, Cincinnati, Ohio, USA. Her research interests in-volve examining the impact of psychosocial factors on thecourse of childhood illness and recovery and translatingthis knowledge into empirically based treatment pro-grammes. Dr Wade is currently developing interventionsto reduce the medical and psychological morbidity arisingfrom asthma and traumatic brain injury in children.Correspondence and offprints: Dr Shari L. Wade, Divisionof Paediatric Rehabilitation, Children’s Hospital MedicalCenter, 2310 Pavillion, 3333 Burnet Avenue, Cincinnati, OH45229-3039, USA.E-mail: [email protected]



psychosocial components of asthma management in children

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