Stress and airway resistance in children with asthma.

OBJECTIVE: The present study implements an experimental paradigm to examine airway reactivity to stress in children with asthma and controls. METHOD: 114 children with asthma and 30 controls (ages 9-15) participated. The protocol involved 5 min of baseline physiological measurements followed by a 5-min stressful task. Skin conductance (EDG), skin temperature, and heart rate were measured continuously. Airway resistance was measured at baseline and after the task. RESULTS: 110 children (76% of the sample) were significantly "stressed" as shown by physiological changes. Asthmatics and controls differed on overall airway resistance, F(1, 108)=12.3, P<.001. The entire sample demonstrated a trend toward increased airway resistance in response to stress, F(1,108)=3.1, P<. 08. A portion of asthmatics (22%) had increases of greater than 20% of baseline airway resistance. Changes in airway resistance in response to stress were unrelated to asthma severity, F(2,78)=2.0, ns. CONCLUSION: Children with asthma and controls demonstrate variation in airway function in response to stress, although increases are likely more meaningful for children with asthma. Further research is needed to examine the mechanisms underlying this response.

Repressive-defensive style and physiological reactivity among children and adolescents with asthma.

OBJECTIVE: This study evaluates the concordance of two self-report methods of operationalizing repressive-defensive style in children with asthma. It was hypothesized that, compared with low-anxious children, repressive-defensive children would exhibit increased physiological reactivity during a stressful laboratory task, despite comparable self-reports of state anxiety. METHODS: Ninety-one children and adolescents (mean age = 11.5 years) with asthma participated in the study. Repressive-defensiveness was operationalized as self-reported low distress coupled with high defensiveness or restraint. Self-report data reflecting trait anxiety, defensiveness, and personality style were used to classify children as repressive-defensive by two independent methods. Physiological reactivity was operationalized as standardized changes in peripheral temperature, heart rate, and/or skin conductance from baseline to a stressful task. For the stressful task, children spoke into a tape recorder about a stressful or embarrassing event. RESULTS: Each method classified 20% of children as repressive-defensive. However, of the children classified as repressive-defensive by either method (n = 26), only 38% (n = 10) were classified as repressive-defensive by both methods. In addition, regardless of the classification method, repressive-defensive children did not consistently differ from low-anxious children with respect to physiological reactivity under stress, one of the hallmarks of repressive-defensiveness in adults. CONCLUSION: These results cast doubt on our ability to measure repressive-defensiveness reliably using self-report measures. Future research should determine whether children and adolescents can be reliably classified as repressive-defensive, whether this classification is related to physiological reactivity as in adults, and whether repressive-defensiveness plays a role in emotionally triggered asthma symptoms.

Thresholds of resistive load detection in children with asthma.

Threshold detection of added resistive loads was studied in asthmatic children and compared to data previously obtained in a group of healthy children. The relationships between possible psychological predictors of perceptual ability, the perceptual threshold, and functional morbidity variables were also investigated. Our subjects were 103 children (mean age, 10.9 years) with asthma who completed two laboratory protocols in which they were asked to distinguish breaths with varying degrees of added resistance from unloaded breaths. Using two different computer-driven protocols, resistances were presented as percentages of each child's intrinsic respiratory system resistance (R(rs)). Cognitive ability was assessed through subtests of the Wechsler Intelligence Scale for Children, 3rd edition (WISC-III), and functional morbidity was quantified through a combination of school absences, emergency medical visits, and days hospitalized. Detection thresholds for both protocols were highly correlated with intrinsic resistance (r = 0.49 and 0.66; P < 0.001). Weber fraction thresholds were significantly lower for asthmatic children than healthy controls. Thresholds were not significantly related to either intelligence or pulmonary functional abnormalities due to asthma. Methodologic limitations require cautious interpretation of the results, but we conclude that psychophysical approaches may be useful in the study of symptom perception in pediatric asthma.

Pediatric residents' experiences with suicidal patients : implications for training.

The increased prevalence of attempted and completed suicide in childhood and adolescence, combined with recent emphasis on secondary prevention by primary care physicians, underscores the need for effective training of pediatricians and other primary care providers in assessment of suicidal risk. It is probable that psychiatrists will play a leading role in this training. This descriptive study uses interview data from a unique cohort of 19 graduating pediatric residents from 2 programs to document qualitative and quantitative aspects of their clinical experience with suicidal children and adolescents. The implications of these findings for those involved in resident training are discussed in light of pertinent literature.

The psychiatric consultant in professional team sports.

The role of the sport psychiatrist consulting to a professional sports team is complex, challenging, and varied. Sport psychiatrists enhance the psychosocial development of the athlete by removing obstacles to growth and by facilitating lines of communication that support exchange of information, sharing of feelings, and the development of solid winning relationships on the team and throughout the organization. The consultant psychiatrist often provides input both to players and to management, however; these dual responsibilities raise ethical concerns and often require the services of additional treating psychiatrists and other mental health professionals.

Somatoform disorders in children and adolescents: a review of the past 10 years.

OBJECTIVE: To review the literature on somatoform disorders in children and adolescents relevant to recertification by the American Board of Psychiatry and Neurology. METHOD: The psychiatric, pediatric, and psychological literatures were searched for clinical or research articles in the past 10 years dealing with somatization and somatoform disorders. RESULTS: Somatizing presentations are organized conceptually; somatization disorder, body dysmorphic disorder, hypochondriasis, conversion disorder, vocal cord dysfunction, pain disorder, and recurrent abdominal pain are described in children and adolescents; empirical evidence for treatment efficacy is scant, but clinically reasonable approaches are applied. CONCLUSION: More developmentally appropriate diagnostic schemas and better outcome studies are needed in all the somatoform disorders for children and adolescents.

Resistive-load detection in healthy school-aged children.

The ability to detect changes in respiratory resistance, which may be important in acute and chronic adaptations to airways obstruction, has not been measured previously in children. Two methods were used to measure the resistive-load detection thresholds (the added resistance that produced a "just noticeable difference" in perception) in a group of 38 healthy children and adolescents aged 7-16 years. Total respiratory system resistance (Rrs), as measured by forced oscillation, was used as an index of each child's intrinsic baseline (pre-test) resistance. To determine thresholds a computer program added various percentages of baseline resistance according to response (first method) and then in random order (second method). Thresholds by at least one of the two methods were detectable in 32 of the children (84%), and failure to detect a threshold was less common in older than in young children. Thresholds obtained by each method were significantly related to one another (r = 0.54, P < 0.05). Baseline resistance accounted for a marginally significant proportion of the variation in thresholds as assessed by the tracking method (R2 = 0.12, P < 0.10) and a large proportion of the variation in thresholds as assessed by the random method (R2 = 0.66, P < 0.0001). Thresholds expressed in terms of percent of baseline resistance were found to have mean values of 100.4-105.0%, regardless of gender or age. Results from a comparison group of adults (n = 10) indicated lower threshold by both procedures (mean values, 71.90-76.50%). We conclude that perceptual thresholds for added resistive loads are determined, in part, by growth-related changes in intrinsic resistance.

Symptom perception in pediatric asthma: relationship to functional morbidity and psychological factors.

OBJECTIVE: Perception of changes in respiratory symptoms is a critical element in the self-management of pediatric asthma. The purpose of this study was to quantify perceptual accuracy in childhood asthma, to investigate links between symptom perception and functional morbidity, and to examine relationships between psychological variables and perceptual accuracy. METHOD: Eighty-six children, aged 8 to 15 years, attending an asthma camp made subjective estimates of asthma severity immediately prior to spirometry an average of 31 times at camp. The correlation coefficient between these measures (the child's accuracy index) was analyzed in relation to morbidity data and to scores on instruments that assessed trait anxiety, repressive coping style, intelligence, behavior problems, and parental symptom-reporting patterns. RESULTS: A wide range of perceptual ability was found, as children's subjective-objective r ranged from-.39 to .88. Greater perceptual accuracy was significantly related to fewer days missed from school and fewer emergency medical visits. Of the psychological variables assessed, only intelligence was significantly related to accuracy. CONCLUSIONS: Symptom perceptual ability is an important psychosomatic factor affecting the course of asthma for some children. Further study is indicated to understand psychological variables in addition to intelligence that may determine a child's perceptual accuracy.

Conceptual and methodologic issues in quantifying perceptual accuracy in childhood asthma.

Delineated methodologic issues in the study of symptom perception in childhood asthma. A review of past and recent psychophysiological and clinical studies of both adults and children presents the methodologic and analytic approaches that have been applied to quantify perceptual accuracy. Peak expiratory flow rate, forced expiratory volume in the first second, and force expiratory flow can serve as objective measures of asthma. A visual analog scale, a numerical guess, and a categorical description as subjective measures all have clear strengths and weaknesses. Correlational analysis of subjective-objective data, arithmetic differences between subjective guess and objective value, and an error grid categorization can each be applied to calculate an accuracy index on an individual subject. Illustrative examples reveal that the same data lead to different indices depending on the method chosen. Empirical research is needed to standardize various methodologic approaches. Given the increasing prevalence, severity, and morbidity of pediatric asthma, the study of symptom perception may be a critical component in our understanding of asthma management, and will likely lead to useful clinical interventions.

Spirometric patterns in childhood asthma: peak flow compared with other indices.

The objective of this study was to determine patterns of pulmonary function abnormalities and to evaluate how adequately peak flow monitoring was correlated to other spirometric indices in childhood asthma. Ninety-one children, aged 8-15 years, with moderate-to-severe asthma were repeatedly tested in a summer camp. On-site medical staff permitted 24-hour-a-day supervision. Subjective and objective clinical evaluations of asthma status were made over 14 consecutive days. Detailed clinical history and clinical observations were made by an experienced staff, and a total of 2,663 pulmonary function tests were performed regularly three times daily and whenever a child sensed asthma symptoms. Patterns of obstruction were divided into large airway abnormalities and small airway abnormalities. There was a low concordance between standard large airway measures, such as the peak expiratory flow rate (PEFR) or the forced expiratory volume in 1 second (the FEV1), and measures of small airway obstruction, such as the forced expiratory flow rate 25-75% (FEF25-75). Normal PEFR measurements do not always indicate that all other pulmonary function measures are normal. In fact, 18% of children with a normal PEFR had abnormal FEF25-75 values. Results demonstrated that the FEF25-75 was the most specific and sensitive measure of airway obstruction. PEFR is widely used to monitor asthma symptoms objectively because it is technically simple to perform, relatively inexpensive, and helpful in most cases. It is, therefore, appropriate for asthma education programs to recommend PEFR as an objective measure to guide in making therapeutic decisions. Our data and clinical observations support the "Guidelines for the Diagnosis and Management of Asthma" of the NIH Health Asthma Education Program that suggest that children have more complete pulmonary function testing along with frequent PEFR measures. Many children may appear asymptomatic, while recording normal PEFR measures, and still having significant asthma. Repeated pulmonary function testing and evaluation of the pattern of respiratory obstruction aids in managing this challenging group. We recommend that efforts be made to develop a simple and inexpensive method of measuring FEF25-75 that will allow this measurement to be made even at home.

Symptom perception and self-management in childhood asthma.

Asthma self-management, an increasingly important component of the treatment of pediatric asthma, entails accurate perception of respiratory symptoms. This review summarizes what is known about symptom perception in both adults and children. The literature on visceral autonomic perception, laboratory studies of respiratory perception, and clinical work with asthmatic patients is reviewed.

Plasma levels and efficacy of imipramine treatment for enuresis.

OBJECTIVE: To determine the relationship between serum drug level and treatment efficacy in enuretic children treated with imipramine (IMI). METHOD: Eighteen children with primary nocturnal enuresis recruited from an ambulatory enuresis clinic population were the subjects of the study. After a baseline period of 2 weeks, children received placebo for 1 week followed by treatment with IMI in increasing dosages (1.0 mg/kg, 1.5 mg/kg, 2.0 mg/kg, and 2.5 mg/kg), each dosage being given for 2 weeks. Steady state IMI and desipramine levels were determined in each child for each dosage. Medication response ([drug % dryness-placebo % dryness] divided by [100%-placebo % dryness]) was determined for each dosing interval. RESULTS: Average dryness increased from 27.8% on placebo to 73% with 2.5 mg/kg of IMI. The overall correlation between medication response and combined serum level was .26 (p < .05). Side effects were monitored throughout the study and were found to be rare. CONCLUSIONS: The efficacy of IMI over placebo in reducing the frequency of nocturnal enuresis in children was confirmed. Efficacy was moderately but significantly related to increasing mg/kg dose. A higher serum level tended to be associated with a better response, but there was at least 700% variation in serum level between subjects at every dosage. Monitoring serum levels of imipramine in children with idiopathic functional nocturnal enuresis treated with that medication has a limited but real usefulness in clinical management.

Adolescent risk-takers: a trauma center study of suicide attempters and drivers.

Adolescence is a developmental stage characterized by excessive risk-taking behavior that produces adverse health effects, typically in the form of injury. At issue is whether adolescent suicide attempters and injured adolescent motor vehicle drivers constitute a common risk group and are differentiated by the response of the emergency medical care system and by case disposition. Data originated in the medical records of a Rhode Island (USA) trauma center. The two study groups were not distinguished by religious preference, socioeconomic status or timing of the injury incident, but differed significantly by gender, race, emergency vehicle use, hospital admission rates, and seasonal injury patterns. Alcohol and drug involvement was examined, but serious data deficiencies were noted.

AIDS education: the Rhode Island experience.

AIDS prevention, by public school education, is designed to change knowledge, attitudes, and future behavior. This study evaluated the impact of a state-mandated educational program on a sample of 2709 adolescents. Changes from pre to posttest were evaluated using standardized change scores and comparisons between the experimental and a delayed education control group were made. The experimental group, but not the control group, changed to a statistically significant degree (p less than .001). They became more knowledgeable, endorsed slightly more tolerant attitudes, and reported an increased intention to avoid intercourse as a means of AIDS prevention. The extent of change was substantially greater for knowledge than for attitudes. Age, gender, and AIDS-related anxiety were found to be significant variables in the AIDS education process. The modest changes observed emphasize that the dissemination of AIDS information by public schools is only the first step in changing adolescent behavior as a means to AIDS prevention and that other, additional approaches are needed.

The correlates of planning in adolescent suicide attempts.

Adolescent suicide attempts are often impulsive. It has been suggested that individuals who make nonimpulsive (premeditated) attempts have greater suicidal intent and are more hopeless than the impulsive attempters. Eighty-six adolescent suicide attempters were categorized according to the degree of premeditation of their attempt, as measured by two items of the Suicide Intent Scale. Sex, age, method of attempt, and the number of prior attempts were not useful discriminators between these groups. The nonimpulsive attempters were significantly more depressed and more hopeless than the impulsive attempters, as measured by several standardized scales. Measures of depression, hopelessness, and suicidal ideation were highly correlated in both groups. Anger turned inward and hopelessness were strongly correlated only in the premeditated group, suggesting that the nonimpulsive attempter's distress may bear a strong relationship to self anger.

Accuracy of symptom perception in childhood asthma.

Children's reports of their asthma symptoms are used as important data in the assessment and management of pediatric asthma, but little is known about the accuracy of such reports. Children's subjective perception of the level of asthma symptoms was correlated with peak expiratory flow rate measures on average of 34 observations for 37 children with asthma. Subjective/objective correlations for a given child varied from 0.86 to -0.16. The children's perceptual accuracy was not related to age or sex, or to duration or severity of asthma. Implications for clinical practice are discussed.

The impact of AIDS education on junior and senior high school students. A pilot study.

Prevention, through school-based education campaigns, has been suggested as a response to the AIDS crisis although the impact of such education is unproven. The seventh and tenth grade classes (n = 313) in one Rhode Island school district were surveyed regarding AIDS knowledge, attitudes, and coping skills before and after a two-session educational program. Following instruction, students reported more knowledge, greater tolerance of AIDS patients, and more hesitancy toward high-risk behaviors, but the changes were modest. Using residual change scores to control for baseline levels, two subgroups (seventh grade boys and tenth grade girls) changed the most in tolerance, and the correlations between variables were the strongest. In the general sample, change in knowledge was independent of change in tolerance, attitudes regarding high-risk behaviors, or coping strategies. These data lend support to the potential usefulness of school-based education programs, especially if behavior and coping skills are emphasized in the education. Evaluation of such programs should include assessment of change in subgroups to determine components of programs that can be tailored for more effective education.

Patterns of response to childhood asthma.

The present study was designed to evaluate the concordance between parental and child ratings of asthma symptoms, and to determine the relationship between symptom ratings and morbidity data. The sample consisted of 162 asthmatic children from various treatment settings and 105 parents. The symptom pattern assessment employed a modified-for-children version of the Asthma Symptom Checklist (CASCL), which was completed independently by the parent and by the child. The CASCL data were factor analyzed to replicate the findings of the earlier panic/fear work. Factor analysis of both versions of the Asthma Symptom Checklist yielded three interpretable factors, which we labeled General Physical Symptoms, Panic/Fear, and Hyperventilation/Irritability. Correlations between parent and child across individual items ranged from 0.00 to 0.35. Correlations between the parents and the children across factor scores resulted in modest agreement. Using medication level, emergency room visits, and hospitalizations as indices of functional morbidity, many of the parents' and none of the children's factor scores were significantly related to functional morbidity.