Asthma and academic performance in urban children.

BACKGROUND: Urban minority children experience high levels of asthma morbidity. Poor school performance can be an indicator that asthma is in poor control. Little attention has been paid to examining real-time links between asthma and academic performance, particularly in high-risk groups. OBJECTIVE: Examine 1) academic performance across a range of indicators in a group of urban children with asthma and urban children without chronic illness and ethnic differences in these associations, and 2) associations between asthma and academic performance in the group of urban children with asthma and ethnic differences in these associations. METHODS: Two hundred sixteen black/African American (33%), Latino (46%), and non-Latino white (21%) urban children, ages 7 to 9 years completed a clinic- and home-based protocol that assessed asthma and allergy status, objective measurements of lung function, and academic functioning. RESULTS: Analyses revealed that children with asthma experienced a higher number of school absences when compared with healthy controls. Greater disparities in academic outcomes emerged when examining ethnic differences within the groups of children with and without asthma. Poor academic outcomes were observed in Latino children with asthma. Furthermore, a strong correspondence of poor asthma outcomes and decrements in academic performance were seen in the full sample, and these associations emerged across ethnic groups. CONCLUSION: Asthma activity contributes to poorer academic outcomes across a range of indicators, and urban minority children with asthma, particularly Latino children, may be at heightened risk for poorer academic performance. School management guidelines for asthma need to be consistently implemented and tailored for school staff, caregivers, and students with asthma to address challenges of managing asthma within the urban school setting.

Integrated, Family-based, Partial Hospital Treatment for Complex Pediatric Illness.

This paper describes a unique treatment program for complex pediatric illness. The Hasbro Children's Partial Hospital Program uses a family systems orientation, integrated care, and a partial hospital setting to treat children with a wide range of pediatric illnesses that have failed outpatient and inpatient treatments. We have treated more than 2000 children with at least 80 different ICD-9 diagnoses. The multidisciplinary treatment team functions as a meta-family for children and their families who present with illness and family beliefs that impede successful outcomes with standard care. The three features: family systems orientation, integrated care, and partial hospital setting, hopefully interact to create an environment that helps families expand and modify their explanatory models regarding participating in effective medical care. The goal of treatment is for both children and their parents to feel empowered to take control of the illness. Parents completing standardized measures at intake describe their children and families as experiencing significant emotional distress, low levels of general family functioning, and poor quality of life. Although the children are described as having distinct behavioral differences, the families are described as responding to the experience of a seriously ill child in similar ways. A treatment program that addresses the noncategorical aspects of how families respond to illness while addressing the specific diseases of the children can allow children and their families to respond favorably to treatment.

En este artículo se describe un programa de tratamiento único para las enfermedades pediátricas complejas. El programa hospitalario parcial de Hasbro Children's Hospital utiliza una orientación de sistemas familiares, atención integrada y un formato de hospital parcial para tratar a niños con una amplia variedad de enfermedades pediátricas a quienes los tratamientos ambulatorios y con internación no les han dado resultado. Hemos tratado a más de 2000 niños con, por lo menos, 80 diagnósticos diferentes de ICD-9. El equipo de tratamiento multidiscplinario funciona como una metafamilia para los niños y sus familiares que presentan una enfermedad y creencias familiares que impiden resultados favorables con la atención convencional. Las tres características: orientación de sistemas familiares, atención integrada y formato de hospital parcial interactuarían para crear un entorno que ayude a las familias a ampliar y modificar sus modelos explicativos con respecto a participar en una atención médica eficaz. El objetivo del tratamiento es que tanto los niños como sus padres se sientan facultados para tomar las riendas de la enfermedad. Los padres que se someten a evaluaciones estandarizadas en el ingreso explican que sus hijos y familias sufren distrés emocional considerable, niveles bajos de funcionamiento familiar general y una mala calidad de vida. Si bien se describe a los niños como personas con diferencias conductuales definidas, las familias se describen como personas que responden a la experiencia de un niño gravemente enfermo de formas similares. Un programa de tratamiento que aborde los aspectos no categóricos de las formas en las que las familias responden a la enfermedad y que, al mismo tiempo, aborde las enfermedades específicas de los niños puede permitir a los niños y a sus familias responder favorablemente al tratamiento.

Family-Based Integrated Care (FBIC) in a Partial Hospital Program for Complex Pediatric Illness: Fostering Shifts in Family Illness Beliefs and Relationships.

The heuristic model of family-based integrated care (FBIC) was developed from 1998 to 2016 in the context of the development of the Hasbro Children's Partial Hospital Program (HCPHP) along with the development of a family therapy training program for Brown University child psychiatry and triple board residents. The clinical experience of the HCPHP team in treating more than 2000 patients and families in combination with the authors' experience in training residents for diverse practice settings highlights the usefulness of the FBIC paradigm for interdisciplinary family-based treatment for a broad range of illnesses and levels of care.

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.

Depressive symptoms in youth with inflammatory bowel disease compared with a community sample.

BACKGROUND: Previous investigations have produced mixed findings on whether youth with inflammatory bowel disease (IBD) experience elevated rates of depressive symptoms. Our first aim was to compare self-report of depressive symptoms by youth with IBD with a community sample. The second aim was to examine the relationship between symptoms of depression and measures of disease activity. METHODS: Item-level responses on the Children's Depression Inventory among a sample of 78 youth diagnosed with IBD were compared with responses from a community sample using 1-sample t-tests. Particular attention was given to items assessing somatic symptoms of depression given the potential overlap with IBD disease symptoms. The relationship between depressive symptoms and IBD disease activity was evaluated using Spearman's rank correlation coefficients and linear regression. RESULTS: Youth with IBD reported lower levels of depressive symptoms compared with the community sample on the Children's Depression Inventory Total Score, and similar or lower levels of difficulty on items assessing somatic symptoms. Most of the sample had inactive or mild disease activity at the time of participation, with 14% experiencing moderate/severe disease activity. Higher ratings of disease activity were related to greater depressive symptoms. Responses on somatic items from the Children's Depression Inventory were not differentially related to disease activity. CONCLUSIONS: As a group, pediatric patients with IBD did not experience the clinical levels of depressive symptoms or elevations in depressive symptoms when compared with a community sample. Somatic symptoms of depression do not differentiate youth with IBD experiencing elevations in disease activity from youth experiencing nonsomatic symptoms of depression.

Stability of Emotional and Behavioral Functioning in Youth with Inflammatory Bowel Disease.

This study prospectively examined stability of psychological and behavioral functioning in two matched cohorts of youth with inflammatory bowel disease (IBD): (1) newly-diagnosed and (2) previously-diagnosed patients. Youth and their parents completed measures of emotional and behavioral functioning at Time 1 and 6-months later. Mean-level analyses indicated that scores at Time 1 and Time 2 were within the nonclinical range. A significant decrease occurred in Internalizing symptoms for previously-diagnosed patients. Both groups demonstrated high levels of profile stability, with no significant differences across groups. Results suggest that emotional and behavioral functioning is generally stable without targeted intervention.

6-Thioguanine levels in pediatric IBD patients: adherence is more important than dose.

BACKGROUND: Thiopurine immunosuppressants such as 6-mercaptopurine (6-MP) are widely used to maintain remission in children with both Crohn's disease and ulcerative colitis. Therapeutic efficacy is associated with higher red blood cell levels of the thiopurine metabolite 6-thioguanine (6-TGN). Studies in both children and adults have inexplicably failed to demonstrate a significant correlation between prescribed dose and level of 6-TGN. We aimed to quantify the relationship between 6-TGN levels and adherence. METHODS: We used electronic monitoring devices to assess adherence in children and adolescents with inflammatory bowel diseases who were prescribed 6-MP. RESULTS: During 3230 days of monitoring in 19 subjects, adherence to 6-MP was 74.2%. Due to the generally low adherence to the prescribed dose of 6-MP, the 6-TGN level was not correlated with the prescribed dose. The 6-TGN level was significantly correlated with the adherence-adjusted dose (R(2) = 0.395). It was also significantly correlated to adherence alone (R(2) = 0.478). Adherence to 5-aminosalicylic acid and 6-MP were significantly positively correlated (r(s)(9) = 0.82, P = 0.00), and a significant relationship was found between 5-aminosalicylic acid adherence and 6-TGN levels independent of 6-MP adherence. Furthermore, low adherence to 6-MP was associated with increased likelihood of escalation of medical therapy. CONCLUSIONS: Red blood cell 6-TGN levels are strongly correlated with the dose, when the dose is actually taken. Lack of efficacy of thiopurines may often be the result of poor adherence. Novel ways of assessing and improving adherence are necessary. Future trials should assess adherence in study participants. Intake of 5-aminosalicylic acid positively influences 6-TGN levels.

Rates and predictors of oral medication adherence in pediatric patients with IBD.

BACKGROUND: Symptoms of inflammatory bowel disease (IBD) include bloody diarrhea, fatigue, abdominal pain, and weight loss. Long-term management of remission for most patients requires adherence to taking 1 or more oral medications daily, in the absence of symptoms. We investigated whether disease characteristics and behavioral characteristics predict adherence to prescribed medical regimens. METHODS: : Patients aged 8 to 17.5 years, newly diagnosed with IBD, and a matched cohort previously diagnosed were studied over a 6-month period. Adherence was assessed using medication electronic monitoring devices (Medication Event Monitoring Systems); participants and parents completed questionnaires regarding emotional and behavioral functioning, and biological parameters were monitored. RESULTS: : Adherence was monitored for 45 newly and 34 previously diagnosed patients. In total, 16,478 patient-days (including 12,066 discrete days) were electronically monitored. Overall, 70.6% of 5-aminosalicylic acid and 65.4% of 6-mercaptopurine doses were taken. Only 25% and 15% of older adolescents took at least 80% of their 5-aminosalicylic acid and 6-mercaptopurine, respectively, compared with about 83% and 64% of 8-year-olds to 11-year-olds. Only age and behavioral issues were statistically linked to rates of adherence. CONCLUSIONS: Adherence to commonly prescribed oral medications for IBD is challenging for patients. Screening for emotional and behavioral problems, especially among older adolescents, would be important in identifying patients at risk of poor adherence, who might benefit from interventions. Biological solutions, although critical, when applied without attention to behavioral issues, are not likely to provide the level of therapeutic benefit that can be provided in a combined biobehavioral approach.

Mentoring reviewers: the Journal of Pediatric Psychology experience.

OBJECTIVES: To describe a program designed to meet the need to mentor trainees in manuscript reviewing. METHODS: Mentors (n = 25) and mentees (n = 32) participating in the Journal of Pediatric Psychology's Manuscript Review Mentoring Program completed an online survey assessing their experiences and satisfaction with the program, perceptions of benefits and challenges to participating, and desirable characteristics of mentors and mentees. RESULTS: Participants reported using several methods to create mentored reviews. Satisfaction was generally high, and participants reported benefits related to manuscript review training and professional development. Challenges to participating in the program were primarily logistical. Participants noted personal characteristics and behaviors that were desirable for mentors and mentees. CONCLUSIONS: Providing mentored manuscript review experiences through a structured program appears to be feasible and well received by mentors and mentees. Future programs might provide guidance on how participants can discuss their expectations, benchmarks for review quality, and evaluations of the quality of reviews.

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.

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.

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.

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.

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.

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.