1. Psychological Impact of Asthma in Children Kristin A. Kullgren, Ph.D.

2. Presentation Outline Psychological adjustment in children with asthma and their families Family correlates of non-adherence Time for discussion and questions

3. Protective Factors That Promote Adjustment in Childhood Chronic Illness Temperament Social support Peer relationships Motivation Problem-solving skills Self-efficacy Parent adjustment Family resources Family cohesion Low family conflict

4. Risk Factors for Poor Adjustment in Childhood Chronic Illness Low socioeconomic status (SES) Major life events Poor family functioning Longer duration of illness Greater functional impairment Greater illness severity

5. Psychological Adjustment in Children With Asthma Psychological factors are not initiating causes of asthma Asthma is a risk factor for maladjustment Maladjustment not more common with asthma vs. other chronic illnesses –10-35% children with adjustment problems

6. Psychological Adjustment in Children With Asthma Greater risk for internalizing vs. externalizing problems –More symptoms of anxiety than other chronic illnesses 35% with DSM-IV anxiety disorders –Simple phobia –Separation anxiety –Generalized anxiety disorder

7. Psychological Adjustment in Children With Asthma Other issues in kids with asthma & anxiety –Poorer self-esteem –More activity restrictions –Lower social competence

8. Why Anxiety? Similar physiological experience When you can’t breathe, its scary!

9. Psychological Adjustment in Teens With Asthma 39% report fearing death from asthma 63% report feeling anxious –Social anxiety –Dating anxiety Less likely to date

10. Psychological Adjustment in Teens With Asthma: Importance of Peers 39% disclose to friends 29% embarrassed to have attack in front of peers 38% bring inhaler when leave house –More likely if feel can control asthma –Less likely if embarrassed by asthma

11. Relationship Between Psychological Adjustment and Asthma Symptoms More severe asthma –Higher levels anxiety –More behavior problems More behavior problems –More days of wheezing –Poorer functional status But it’s a two-way street!

12. Parenting the Child With Asthma Higher levels of criticism with their children Mothers –Involved more physically and emotionally Fathers –Involved less physically –More critical regarding school absences –More face-to-face contact associated with better asthma outcomes 5 hours/day

13. Psychological Adjustment in Moms of Children With Asthma Half report significant depression –Unemployed –Lowest income category –Lower quality of life Those w/high depressive symptoms are 40% more likely to take child to ED

14. Psychological Adjustment in Moms of Children With Asthma Caregivers w/clinically significant mental health problems –Children twice as likely to be hospitalized Children with greater asthma morbidity –Moms with depressive symptoms –More negative life stressors Report >8 undesirable events last year Chaotic family life –More hospital admissions asthma

15. Prevalence of Non-Adherence Acute Disease - 30% Chronic Disease - 50% Childhood Asthma –Rates of adherence average around 50% –28.6% children using meds as prescribed –41% teens cannot name their medications –Poor adherence related to asthma exacerbations

16. Adherence: Patient & Family Correlates Demographics Knowledge Adjustment & coping Parental monitoring Division of responsibility Previous adherence Beliefs & expectancies

17. Adherence: Who’s Doing What? Asthma self-management is occurring by ages 4-6 School or home circumstances vs. developmental readiness –Parent employment status –Independence in other areas Children’s inhaler use skills –60% parents rate child’s skill as excellent –7% observed to be effective

18. Adherence: Who’s Doing What? Allocation of family responsibilities for asthma –Disagreement between children and caregivers Children report more responsibility for themselves than mothers report Caregivers overestimate adolescent responsibility –Leads to non-adherence and functional morbidity

19. Adherence: Who’s Doing What? Average # of asthma caregivers is > 3 –1/3 with > 4 caregivers Responsibility for medication monitoring is often confused –Daycare provider, parent, grandparent, siblings, child, school Need to clarify who does what!

20. Adherence: Parent Beliefs Belief that child is vulnerable –More likely to use regular preventive meds –Take child to doctor –Keep home from school Belief that child is not vulnerable –May discontinue medication

21. Adherence: Parent Beliefs Caregivers with negative expectations of their ability to manage asthma –Increased asthma morbidity Belief that asthma is episodic vs. chronic Negative perceptions of medications

22. Adherence: Family Functioning Poorer asthma adherence –Families with high conflict –High levels of child behavior difficulties

23. Summary Children with asthma are at risk for maladjustment, primarily anxiety Parent/family factors can impact asthma morbidity and adherence