Mental Health Conditions and Health Care Payments for Children with Chronic Medical Conditions.

OBJECTIVE: To estimate additional payments associated with co-existing mental health or substance use disorders (MH/SUDs) among commercially insured children and youth with chronic medical conditions (CMCs) and to determine whether children's MH/SUDs have similar associations with parental health care payments. METHODS: Cross-sectional analysis of a national database of paid commercial insurance claims for 2012-2013. Participants were children and youth ages 0 to 26 years covered as dependents on parents' health insurance and categorized by the presence or absence of any of 11 chronic medical conditions and MH/SUDs. We determined the numbers of children and youth with CMCs and paid health care claims categorized as hospital, professional, and pharmacy services and as medical or behavioral. We compared paid claims for children and youth with CMCs with and without co-occurring MH/SUDs and for their parents. RESULTS: The sample included almost 6.6 million children and youth and 5.8 million parents. Compared to children without CMCs, children with CMCs had higher costs, even higher for children with CMCs who also had MH/SUDs. Children with CMCs and co-occurring MH/SUDs had 2.4 times the annual payments of those with chronic conditions alone, especially for medical expenses. Estimated additional annual payments associated with MH/SUDs in children with CMCs were $8.8 billion. Parents of children with CMCs and associated MH/SUDs had payments 59% higher than those for parents of children with CMCs alone. CONCLUSIONS: MH/SUDs in children and youth with CMCs are associated with higher total health care payments for both patients and their parents, suggesting potential benefits from preventing or reducing the impact of MH/SUDs among children and youth with CMCs.

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.

Sleep Hygiene and Sleep Outcomes in a Sample of Urban Children With and Without Asthma.

Objective: To assess sleep hygiene and the sleep environment of urban children with and without asthma, and examine the associations among urban stressors, sleep hygiene, and sleep outcomes. Methods: Urban children, 7-9 years old, with (N = 216) and without (N = 130) asthma from African American, Latino, or non-Latino White backgrounds were included. Level of neighborhood risk was used to describe urban stress. Parent-reported sleep hygiene and daytime sleepiness data were collected using questionnaires. Sleep duration and efficiency were assessed via actigraphy. Results: Higher neighborhood risk, not asthma status, was associated with poorer sleep hygiene. Controlling for neighborhood risk, sleep hygiene was related to daytime sleepiness. Asthma status, not sleep hygiene, was related to sleep efficiency. In children with asthma, poorer sleep hygiene was associated with shorter sleep duration. Conclusion: Considering urban stressors when treating pediatric populations is important, as factors related to urban stress may influence sleep hygiene practices and sleep outcomes.

Good Sleep Health in Urban Children With Asthma: A Risk and Resilience Approach.

OBJECTIVES: To identify children demonstrating "good" sleep health in a sample of urban children with persistent asthma; to compare sociocontextual, asthma clinical characteristics, and sleep behaviors in children with "good" versus "poor" sleep health; and to examine protective effects of family-based health behaviors on sleep health. METHODS: Participants were 249 Black (33%), Latino (51%) and non-Latino White (16%) children with asthma, ages 7-9 years, and their primary caregivers. RESULTS: 32 percent of children had "good" sleep health. Well-controlled asthma and better lung function were more likely in this group. In the context of urban risks, sleep hygiene appeared to be a protective factor associated with better sleep quality. The protective effect of asthma management functioned differently by ethnic group. CONCLUSIONS: This study identifies protective processes that may guard against urban risks to optimize sleep health in children with asthma. Intervention programs can be tailored to consider specific supports that enhance sleep health in this high-risk group.

Stress and Bronchodilator Response in Children with Asthma.

RATIONALE: Stress is associated with asthma morbidity in Puerto Ricans (PRs), who have reduced bronchodilator response (BDR). OBJECTIVES: To examine whether stress and/or a gene regulating anxiety (ADCYAP1R1) is associated with BDR in PR and non-PR children with asthma. METHODS: This was a cross-sectional study of stress and BDR (percent change in FEV1 after BD) in 234 PRs ages 9-14 years with asthma. We assessed child stress using the Checklist of Children's Distress Symptoms, and maternal stress using the Perceived Stress Scale. Replication analyses were conducted in two cohorts. Polymorphisms in ADCYAP1R1 were genotyped in our study and six replication studies. Multivariable models of stress and BDR were adjusted for age, sex, income, environmental tobacco smoke, and use of inhaled corticosteroids. MEASUREMENTS AND MAIN RESULTS: High child stress was associated with reduced BDR in three cohorts. PR children who were highly stressed (upper quartile, Checklist of Children's Distress Symptoms) and whose mothers had high stress (upper quartile, Perceived Stress Scale) had a BDR that was 10.2% (95% confidence interval, 6.1-14.2%) lower than children who had neither high stress nor a highly stressed mother. A polymorphism in ADCYAP1R1 (rs34548976) was associated with reduced BDR. This single-nucleotide polymorphism is associated with reduced expression of the gene for the ß2-adrenergic receptor (ADRB2) in CD4(+) lymphocytes of subjects with asthma, and it affects brain connectivity of the amygdala and the insula (a biomarker of anxiety). CONCLUSIONS: High child stress and an ADCYAP1R1 single-nucleotide polymorphism are associated with reduced BDR in children with asthma. This is likely caused by down-regulation of ADRB2 in highly stressed children.

Asthma, allergic rhinitis, and sleep problems in urban children.

OBJECTIVES: In this study, we examine the association of asthma (asthma symptoms, asthma control, lung function) and sleep problems in a group of urban children. The role of allergic rhinitis (AR), a comorbid condition of asthma, on children's sleep problems is also examined. Finally, we investigate whether sleep hygiene moderates the association between asthma and sleep problems, and whether there are differences in these associations based on ethnic background. METHODS: Non-Latino White, Latino, and African American urban children with asthma (n = 195) ages 7-9 (47% female) and their primary caregivers participated in a baseline visit involving interview-based questionnaires on demographics, asthma and rhinitis control, and caregiver report of children's sleep problems and sleep hygiene. Children and their caregivers participated in a clinical evaluation of asthma and AR, followed by a month monitoring period of children's asthma using objective and subjective methods. RESULTS: Total sleep problem scores were higher in children of the sample who were from African American and Latino backgrounds, compared to non-Latino white children. Poor asthma control was predictive of higher levels of sleep problems in the entire sample. Poorer AR control also was related to more sleep problems, over and above children's asthma in the sample. This association was more robust in non-Latino white children. Poor sleep hygiene heightened the association between poor asthma control and sleep problems in the entire sample and in African American children. CONCLUSIONS: Multidisciplinary interventions integrating the co-management of asthma, AR, and the effects of both illnesses on children's sleep, need to be developed and tailored to children and their families' ethnic background.

Factors associated with recruitment and retention of diverse children with asthma.

This study examines factors associated with recruitment and retention of Latino, Dominican (DR) and mainland Puerto Rican (PR), and non-Latino white (NLW) families into a pediatric asthma study. Over eleven hundred (n=1185) families were screened, and 489 (n= 174 NLW, n= 160 DR, n= 155 PR) were enrolled. Rates of recruitment by source of recruitment and rates of retention differed by ethnic group. Families whose caregiver had never married had lower odds of completing the study. The findings highlight the need for further study to examine the effectiveness of specific recruitment and retention strategies with Latino and non-Latino white families.

Underdiagnosed and Undertreated Allergic Rhinitis in Urban School-Aged Children with Asthma.

Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.

Complementary and alternative medicine use and adherence to asthma medications among Latino and non-Latino white families.

OBJECTIVE: The current study sought to evaluate patterns of complementary and alternative medicine (CAM) use in a sample of Latino and non-Latino white (NLW) children with asthma to determine whether parental beliefs about conventional medications and barriers to obtaining these medications were related to CAM use and to assess whether CAM use was associated with decreased adherence to controller medications. METHODS: Participants included 574 families of children with asthma from NLW, Puerto Rican (PR), and Dominican backgrounds from Rhode Island (RI) and from Island PR. All parents completed a brief checklist of barriers to medication use and an assessment of CAM approaches. A subsample of 259 families had controller medication use monitored objectively for approximately 1 month by MDILog (fluticasone propionate), TrackCap (montelukast), or dosage counter (fluticasone/salmeterol combination). RESULTS: Prevalence of CAM use was high among Latino families. Perceived barriers to obtaining medication were related to increased CAM use in PR families from RI. Elevated medication concerns were positively associated with CAM use among NLW and Island PR families. CAM use was positively related to objective adherence within NLW families, and unrelated in other groups. CONCLUSIONS: CAM use is common among Latino families with asthma. Among some families, CAM use may be initiated as a way to cope with barriers to obtaining medication or when parents have concerns about conventional medications. Families who report CAM use do not appear to be substituting CAM for conventional asthma medication.

Perceptual accuracy of upper airway compromise in children: Clinical relevance and future directions for research.

Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12-18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251-256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms "guesses" by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.

The home environment and family asthma management among ethnically diverse urban youth with asthma.

Although the pediatric psychology literature underscores the importance of illness-related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to (a) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino White (NLW), and African American urban children with asthma; and (b) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management. Urban, low-income children (N = 131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multimodal assessment, including an in-home observation and semistructured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g., Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness-specific aspects of the home environment when addressing families' asthma management strategies.

Medication adherence among Latino and non-Latino white children with asthma.

OBJECTIVE: Latino children of Caribbean descent remain at high risk for poorly controlled asthma. Controller medications improve asthma control; however, medication adherence remains suboptimal, particularly among minorities. This study assessed socioeconomic, family-based, and parent factors in medication adherence among children with asthma from Rhode Island (RI; Latino and non-Latino white [NLW]) and Puerto Rico. METHODS: Data collection occurred as part of a multicenter study of asthma disparities. Our sample included children (ages 7-16) prescribed objectively monitored controller medications (n = 277; 80 island Puerto Rico, 114 RI Latino, 83 RI NLW). Parents completed questionnaires regarding family background and beliefs about medications. Families participated in an interview regarding asthma management. Multilevel analyses (maximum likelihood estimates) accounting for children being nested within site and ethnic group assessed the contribution of social context, family, and parent variables to medication adherence. RESULTS: Medication adherence differed by ethnic group (F(2, 271) = 7.46, P < .01), with NLW families demonstrating the highest levels of adherence. Multilevel models indicated that parental beliefs about medication necessity and family organization regarding medication use were significant predictors of adherence, even for families below the poverty threshold. With family factors in the model, a substantial improvement in model fit occurred (Akaike Information Criterion change of 103.45). CONCLUSIONS: Adherence to controller medications was lower among Latino children in our sample. Targeted interventions that capitalize on existing family resources, emphasize structure, and address parental beliefs about the importance of medications may be of benefit to families from different cultural backgrounds.

Identifying individual, cultural and asthma-related risk and protective factors associated with resilient asthma outcomes in urban children and families.

OBJECTIVE: The goal of this study is to identify individual, family/cultural, and illness-related protective factors that may minimize asthma morbidity in the context of multiple urban risks in a sample of inner-city children and families. METHODS: Participating families are from African-American (33), Latino (51) and non-Latino white (47) backgrounds. A total of 131 children with asthma (56% male), ages 6-13 years and their primary caregivers were included. RESULTS: Analyses supported the relationship between cumulative risks and asthma morbidity across children of the sample. Protective processes functioned differently by ethnic group. For example, Latino families exhibited higher levels of family connectedness, and this was associated with lower levels of functional limitation due to asthma, in the context of risks. CONCLUSIONS: This study demonstrates the utility of examining multilevel protective processes that may guard against urban risks factors to decrease morbidity. Intervention programs for families from specific ethnic groups can be tailored to consider individual, family-based/cultural and illness-related supports that decrease stress and enhance aspects of asthma treatment.

Psychological considerations of the child with asthma.

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Immigration and acculturation-related factors and asthma morbidity in Latino children.

OBJECTIVE: This article presents a summary of findings from asthma studies focusing on immigration and acculturation-related factors. A study examining associations between these processes, family cohesion and social support networks, and asthma morbidity in a sample of Dominican and Puerto Rican caregivers residing in the mainland U.S., is also described. METHODS: Latino children with asthma (n = 232), ages 7-16 (49% female) and their caregivers completed interview-based questionnaires on immigration and acculturation-related processes, family characteristics, and asthma morbidity. RESULTS: The frequency of ED use due to asthma may be higher for children of caregivers born in Puerto Rico. Acculturative stress levels were higher for Puerto Rican born caregivers residing in the mainland U.S. CONCLUSION: Asthma-related educational and intervention programs for Latino children and families should be tailored to consider the effects that the immigration and acculturation experience can have on asthma management. Specific family-based supports focused on decreasing stress related to the acculturation process, and increasing social and family support around the asthma treatment process may help to reduce asthma morbidity in Latino children.

Access to and use of asthma health services among Latino children: the Rhode Island-Puerto Rico asthma center study.

This study determines asthma-related health care access and utilization patterns for Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI) and Latino children residing in Puerto Rico (Island). Data included 804 families of children with persistent asthma recruited from clinics. Island children were less likely to receive regular asthma care and care from a consistent provider and more likely to have been to the emergency department and hospitalized for asthma than RI children. Island children were 2.33 times more likely to have used the emergency department for asthma compared with RI non-Latino White (NLW) children. Latino children residing in both Island and RI were less likely to have used specialty care and more likely to have had a physician visit for asthma in the past year than RI NLW children. The differences might reflect the effects of the different delivery systems on pediatric health care utilization and asthma management.