Overweight, race, and psychological distress in children in the Childhood Asthma Management Program.

OBJECTIVE: The purpose of this work was to determine whether overweight in youth with mild-to-moderate asthma occurs with increased frequency and is accompanied by impaired psychological functioning. PATIENTS AND METHODS: The interrelationships among BMI and demographic and psychological characteristics were examined in 1005 children (aged 5-12 years) enrolled in the Childhood Asthma Management Program and seen for repeated visits over 4 1/2 years. RESULTS: Baseline rates of overweight (BMI for age: > or = 95th percentile) were comparable, but rates of overweight risk (BMI for age: 85th to < 95th percentile) among children in the Childhood Asthma Management Program were elevated in comparison with the general population of children in the United States. Rates of overweight and overweight risk did not increase over the course of the longitudinal study. Overweight and overweight risk were more frequent among black and Hispanic than white children, although they were not higher relative to same-race groups in the general population. Overweight at baseline was associated with lower IQ, more social withdrawal, and greater internalized psychological distress. As the children became older, the overweight group demonstrated increased evidence of behavior problems and decreased physical activity. CONCLUSIONS: This study identifies an increase in overweight risk but not overweight in children with mild-to-moderate asthma. Comorbidity between asthma and overweight may be underestimated, because children with severe asthma and those from impoverished backgrounds were not represented in this sample. For the 14% of children who were overweight, some associated psychological difficulties were present in childhood, and additional problems were seen during adolescence. These results suggest a need for programs that encourage greater vigilance and intervention for overweight children with asthma.

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.

An interdisciplinary intervention for undertreated pediatric asthma.

STUDY OBJECTIVES: To examine the effectiveness of an interdisciplinary intervention for pediatric asthma. DESIGN: Randomized, controlled study. SETTING: Urban tertiary-referral pediatric hospital. PARTICIPANTS: One hundred seventy-five patients with asthma lacking written treatment plans and presenting with asthma-related emergency department visits (two or more) and/or hospitalizations (one or more) in the past year were randomized to a comparison group receiving medical care alone (n = 86) or to an interdisciplinary intervention group receiving medical care, asthma education, and problem-solving therapy (n = 89) INTERVENTION: All participants received written asthma management plans, peak flow meters, and spacer devices. The intervention group also received asthma education, an asthma risk profile assessment, brief problem-solving therapy, and access to a 24-h nurse advice line. The primary outcome measure was change in asthma symptoms, and secondary outcomes included health-care utilization and asthma-related quality of life. RESULTS: Both groups demonstrated significant reductions in asthma symptoms and improvements in quality of life without any between-group differences identified over the course of follow-up. In contrast, the intervention group demonstrated less frequent health-care utilization than the comparison group, with 28% of the intervention group requiring emergency department or inpatient services for asthma compared to 41% of the comparison group (adjusted odds ratio, 1.92; 95% confidence interval, 1.00 to 3.69) over the 12-month follow-up period. CONCLUSIONS: This study examined the effectiveness of an interdisciplinary intervention for undertreated asthma. The intervention did not result in improvements in asthma symptoms, but accomplished modest reductions in the utilization of acute medical care.

Effect of body mass index on response to methacholine bronchial provocation in healthy and asthmatic adolescents.

A linkage between airway hyperreactivity and obesity could partly explain the prevalence of obesity in asthmatics. To test for such a linkage, we analyzed body mass index (BMI), pulmonary function, methacholine bronchial provocation, and asthma severity scores in 216 adolescents (aged 12-18 years), of whom 82 were healthy and 134 were asthmatic. Methacholine provocations in a subgroup of 36 subjects (healthy and asthmatic) enabled us to examine the effects of BMI on dynamic hyperinflation and ventilatory indices during induced bronchospasm. Age- and gender-specific BMI was higher in asthmatics (74 +/- 24%) compared to healthy subjects (61 +/- 28%, P < 0.002). General linear model analysis, in which baseline spirometric results were adjusted for gender, age, race, and height, showed opposing effects of BMI on expiratory flow in controls and asthmatics (P < 0.05), i.e., forced expired volume in 1 sec increased with BMI in controls (P < 0.02), but forced expiratory flow (FEF)(25-75%) decreased with BMI in asthmatics (P < 0.05). However, linear regression analysis showed no effect of BMI on the provocation dose for methacholine (PD(20)) in either controls or asthmatics, and there was no effect of BMI on asthma severity scores. Overweight (BMI >85th percentile) and nonoverweight subjects had similar degrees of dynamic hyperinflation during positive provocations, but overweight subjects had greater decreases in mean inspiratory flow (mean, 28% vs. 9%, P < 0.05). We conclude that our measurements support a relationship between overweight and baseline flow limitation, rather than a relationship between overweight and airways hyperreactivity, in the linkage between overweight and asthma during adolescence.

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.

Patterns of quick-relief and long-term controller medication use in pediatric asthma.

OBJECTIVES: To simultaneously examine adherence to long-term controller and quick-relief medications and to contrast patterns of medication use in children with asthma. STUDY DESIGN: Cross-sectional, 1-month follow-up study conducted with 75 children ages 8 to 16 years diagnosed with persistent asthma and prescribed quick-relief and long-term controller medications by metered dose inhaler. Participants were a subsample of a larger adherence study. The primary outcome measure was adherence to both medications as measured by electronic monitoring devices. A classification framework for contrasting adherence patterns between medication classes was developed to identify cases for individual analysis. RESULTS: High levels of nonadherence to long-term controller medications (median = 46% of prescribed doses taken) and variable patterns of quick-relief medication use (range = 0 to 251 doses over the month) were documented, whereas consistent relationships between patterns of medication use across both classes were not found. Individual cases identified by the classification scheme illustrated the complexity and clinical utility of contrasting adherence patterns. CONCLUSIONS: Monitoring long-term controller medication adherence may be more predictive of morbidity than quick-relief medication use, except in outlier cases in which monitoring both medication types may be valuable for clinical and empirical purposes.

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.

Predicting attrition in a pediatric asthma intervention study.

OBJECTIVES: To operationalize a comprehensive description of attrition, including pre-inclusion, dropout, and attrition due to intermittent missing data, and to test a predictive model of attrition using a data set from a randomized controlled intervention in pediatric asthma. METHODS: Participants included children, ages 4-12, diagnosed with asthma and their caregivers. Demographic variables and outcome measures of asthma morbidity were examined in 327 families to determine their association with attrition. RESULTS: Families who did not complete randomization and the intervention tended to have younger caregivers than did completers. Caregiver age emerged as the most consistent predictor of pre-inclusion and dropout attrition. There were no significant predictors of attrition due to intermittent missing data. CONCLUSION: Younger caregivers may be at particular risk for attrition in pediatric asthma intervention studies and warrant special attention by investigators.

Barriers to mental health referral from pediatric primary care settings.

OBJECTIVE: To examine the frequency of barriers to mental health referral according to pediatric primary care physician (PCP) report and to identify factors related to perceptions of referral barriers for patients with managed care coverage. DESIGN AND METHODS: Data from a national sample of 319 PCPs were examined. Comparisons were made concerning the frequency of PCP-reported barriers to mental health referrals for patients with fee-for-service versus managed care coverage. The relationship between relevant factors (eg, practice structure, interdisciplinary office staff, availability of community mental health resources) and perceived barriers was examined for managed care coverage. RESULTS: Barriers to mental heath referrals were more commonly reported for those with managed care versus fee-for-service coverage for 11 of the 12 barriers assessed (P < .0001). For patients with managed care coverage a high availability of community mental health resources was associated with fewer perceived barriers among physicians (P < .0001). CONCLUSIONS: Our findings suggest that PCPs perceive barriers to mental health referrals as common challenges when addressing psychosocial concerns. Referral barriers were more commonly reported for patients with managed care coverage. Increasing the availability of community mental health resources was identified as an important variable in facilitating appropriate referrals.

The experience of schizophrenia: what's gender got to do with it? A critical review of the current status of research on schizophrenia.

The role of gender in schizophrenia is explored, and literature on gender and schizophrenia is critically reviewed. The importance of investigating gender differences in schizophrenia is underscored by the lack of sufficient research in this area to date and the comparative neglect of sociocultural issues during the "decade of the brain." The importance of incorporating gender factors into research analysis is demonstrated via an interdisciplinary discussion that involves psychiatric, anthropological, and sociological theory. Methodological and measurement issues in gender-based research are considered. Selected directions for future research initiatives that expand beyond a dichotomous comparison of "male" and "female" sex differences to examine the role of gender along a continuum as a sociocultural influence on schizophrenia onset, illness presentation, and treatment are presented.