Family dysfunction in asthma: a prospective study of illness development

Allergic Diseases and Internalizing Behaviors in Early Childhood

BACKGROUND AND OBJECTIVES

The relationship between allergic diseases and internalizing disorders has not been well characterized with regard to multiple allergic diseases or longitudinal study. The objective of this study was to examine the association between multiple allergic diseases in early childhood with validated measures of internalizing disorders in the school-age years.

METHODS

Children enrolled in the Cincinnati Childhood Allergy and Air Pollution Study underwent skin testing and examinations at ages 1, 2, 3, 4, and 7 years. At age 7, parents completed the Behavior Assessment System for Children, Second Edition (BASC-2), a validated measure of childhood behavior and emotion. The association between allergic diseases at age 4, including allergic rhinitis, allergic persistent wheezing, atopic dermatitis, and allergic sensitization, and BASC-2 internalizing, anxiety, and depression T scores at age 7 was examined by logistic and linear regression, adjusting for covariates.

RESULTS

The cohort included 546 children with complete information on allergic disease and BASC-2 outcomes. Allergic rhinitis at age 4 was significantly associated with elevated internalizing (adjusted odds ratio [aOR]: 3.2; 95% confidence interval [CI]: 1.8-5.8), anxiety (aOR: 2.0; 95% CI: 1.2-3.6), and depressive scores (aOR: 3.2; 95% CI: 1.7-6.5) at age 7. Allergic persistent wheezing was significantly associated with elevated internalizing scores (aOR: 2.7; 95% CI: 1.2-6.3). The presence of >1 allergic disease (aOR: 3.6; 95% CI: 1.7-7.6) and allergic rhinitis with comorbid allergic disease(s) (aOR: 4.3; 95% CI: 2.0-9.2) at age 4 had dose-dependent associations with internalizing scores.

CONCLUSIONS

Children with allergic rhinitis and allergic persistent wheezing at age 4 are at increased risk of internalizing behaviors at age 7. Furthermore, multiple allergic diseases had a dose-dependent association with elevated internalizing scores.

Experiences, Functioning and Needs of Low-Income African American Mothers of Children With Asthma

The purpose of this proposed study was to explore experiences, needs and functioning of low-income, African American caregivers of children with asthma in order to better understand symptom management.

METHOD

A qualitative, descriptive design was used. A purposive sampling technique was used to screen 32 caregivers of children with asthma, and 15 caregivers agreed to participate.

RESULTS

Three main themes were identified: managing the symptoms; cultural beliefs and values; and culturally competent health care provider.

CONCLUSION

For the caregivers culture disparity is not just about access to health services but instead the healthcare providers' understanding of the complexity of symptoms management.

Maternal depression related to infant's wheezing

OBJECTIVE

To assess whether maternal psychological status is related to infant's wheezing.

STUDY DESIGN

In a case-control study conducted in Paris in cases aged less than 36 months suffering from wheezing and matched healthy controls, mothers filled a standardized questionnaire on child's health and the State Trait Anxiety Inventory form Y-B and the Beck Depression Inventory short form. Cases underwent also routine clinical and biological assessments. The statistical analysis used the propensity score analysis to control for selection bias.

RESULTS

Hundred and thirty-eight wheezers and hundred and nine controls participated in the study. After adjustment for confounders, maternal depressive symptoms at the period of the survey according to the Beck Inventory were more significantly found in the cases than in others (p < 0.01). A trend was found for maternal depression during pregnancy. Among the cases, 10.6% suffered from severe asthma, 84.8% took inhaled corticosteroids (ICs), 17.4% had positive specific immunoglobulin E (IgE) to allergens and 11.5% hypereosinophilia. The more the mother was depressed according to the Beck Inventory, the more the infant's asthma was severe (OR = 4.25, 95% CI: 1.14, 15.9 between severe infant's wheezing and severe maternal depression). No relationship was observed between mother's depressive symptoms and ICs taken by the infant, allergic sensitization or eosinophilia.

CONCLUSION

Our findings support the hypothesis of a link between maternal depression and infant's wheezing and its severity early in life independent of allergic status. Consequences of our study include the need to assess depressive symptoms in mothers of infants with asthma.

Correlation of Tourette syndrome and allergic disease: nationwide population-based case-control study

OBJECTIVE

Linkage between allergy and increased immune response activation in Tourette syndrome (TS) has been reported. We performed a matched case-control study to evaluate correlation between allergic diseases and TS.

METHODS

Data in this case-control study were from the Taiwan National Health Insurance Research Database. The sample comprised 845 2- to 18-year-old patients with newly diagnosed TS in 2003–2007 and 3378 controls frequency matched with cases on age, sex, and urbanization level. Unconditional logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) of the association between allergic disease (e.g., allergic rhinitis, atopic dermatitis, asthma, and allergic conjunctivitis), the number of allergic comorbidities, and TS.

RESULTS

The majority (76.0%) of incident TS cases were boys; the 4 allergic diseases strongly correlated with higher risk of TS. In a model simultaneously considering all 4 allergic diseases, subjects with allergic rhinitis showed double the risk of TS (adjusted OR = 2.18, 95%CI 1.83–2.59; p < 0.0001); adjusted ORs were 1.82, 1.61, and 1.33, respectively, for asthma (95% CI 1.47–2.24; p < 0.0001), dermatitis (95%CI 1.32–1.95; p < 0.0001), and allergic conjunctivitis (95% CI 1.13–1.57; p < 0.001). Risk increased with number of comorbidities (p < 0.0001); this association was positively modified by age (p < 0.0001).

CONCLUSIONS

Our data showed significant correlation between allergic diseases and TS. Risk also increased with number of allergic comorbidities and with age. Further studies on the mechanism of neuroimmunology of TS are required.

Treatment of ADHD with amphetamine: short-term effects on family interaction

OBJECTIVE

This research seeks to study the impact on family function after 3 months of treatment with amphetamine.

METHOD

A total of 43 children, 6 to 11 years of age, with ADHD were treated with amphetamine for 3 months. Family function was studied before and after treatment by parent self-rating and independent observer ratings of videotaped parent-child interactions.

RESULTS

The families with a child with ADHD were found to be more dysfunctional than control families. Families with children with severe ADHD behavior showed evidence of more family dysfunction compared to families with children with less severe ADHD behavior. After 3 months of treatment with amphetamine, the children's behavior and the mother's well-being and some aspects of parent-reported and observer-rated family functioning improved.

CONCLUSION

This study gives support to the notion that some aspects of family dysfunction may be related to the child's ADHD behavior.

Stressful life events and asthma in adolescents

Recent studies suggest that psychosocial factors may contribute to asthma. We examined associations of stressful life events with asthma prevalence and morbidity among Chicago adolescents. Self-reported asthma, measures of asthma morbidity, and 15 life events were collected from 2026 seventh to ninth grade students from 34 Chicago Catholic schools as part of the International Study of Allergies and Asthma in Childhood in 1994-95. Life events were reported by 77% of adolescents and overall asthma prevalence was 15.5%. Stressful life events in adolescents were significantly related to both asthma and asthma morbidity. Odds of asthma was 1.44 (95% confidence interval [CI] = 1.07, 1.95) for those reporting two to three stressful events and 1.92 (95% CI = 1.41, 2.62) for subjects endorsing more than three stressful events. In adolescents with asthma, number of asthma symptoms (odds ratio [OR] for increase in one event = 1.16, 95% CI = 1.07, 1.27), asthma-related school absenteeism (OR = 1.17, 95% CI = 1.04, 1.32), physician visits for asthma (OR = 1.16, 95% CI = 1.04, 1.29), and hospitalization for asthma (OR = 1.20, 95% CI = 1.001, 1.44) were significantly associated with the number of stressful events, independent of home exposure to cigarette smoke and dampness, use of inhaled substances, and sociodemographic factors. While these results are not sufficient to assign causality in the relationship between stress and asthma, they are supported by a number of other studies and by plausible biologic mechanisms. Assessing and addressing the effects of stressful life events may be helpful in managing asthma in inner city adolescents.

Psychological factors in asthma

Asthma has long been considered a condition in which psychological factors have a role. As in many illnesses, psychological variables may affect outcome in asthma via their effects on treatment adherence and symptom reporting. Emerging evidence suggests that the relation between asthma and psychological factors may be more complex than that, however. Central cognitive processes may influence not only the interpretation of asthma symptoms but also the manifestation of measurable changes in immune and physiologic markers of asthma. Furthermore, asthma and major depressive disorder share several risk factors and have similar patterns of dysregulation in key biologic systems, including the neuroendocrine stress response, cytokines, and neuropeptides. Despite the evidence that depression is common in people with asthma and exerts a negative impact on outcome, few treatment studies have examined whether improving symptoms of depression do, in fact, result in better control of asthma symptoms or improved quality of life in patients with asthma.

Family climate of routine asthma care: associating perceived burden and mother-child interaction patterns to child well-being

This preliminary report links the literatures on family asthma management practices and on the characteristics of family interaction patterns thought to influence children's adjustment to a chronic physical illness. Specifically, this study of 60 families with a child with asthma examined the extent to which perceived burden of routine asthma care affected child mental health via its influence on parent-child interaction patterns. Mothers completed a measure of asthma management routine burden, mother and child were observed in a 15-minute interaction task, and children completed measures of child anxiety and asthma quality of life (QOL). Perceived routine burden significantly predicted child anxiety and QOL through its effect on mother-child rejection/criticism. The same pattern did not hold for mother intrusiveness/control. The results are discussed in terms of how overall family climate and regulation of routines affects child well-being. Implications for clinical practice and limitations of the study are provided.

Incorporating family therapy into asthma group intervention: a randomized waitlist-controlled trial

Asthma psychoeducational programs have been found to be effective in terms of symptom-related outcome. They are mostly illness-focused, and pay minimal attention to systemic/familial factors. This study evaluated a novel asthma psychoeducation program that adopted a parallel group design and incorporated family therapy. A randomized waitlist-controlled crossover clinical trial design was adopted. Children with stable asthma and their parents were recruited from a pediatric chest clinic. Outcome measures included, for the patients: exhaled nitric oxide (eNO), spirometry, and adjustment to asthma; and for the parents: perceived efficacy in asthma management, Hospital Anxiety and Depression Scale anxiety subscale, Body Mind Spirit Well-being Inventory emotion subscale, and Short Form 12 health-related quality of life scale. Forty-six patients participated in the study. Attrition rates were 13.0% and 26.0% for the active and control groups, respectively. Repeated-measures ANOVA revealed a significant decrease in airway inflammation, as indicated by eNO levels, and an increase in patient's adjustment to asthma and parents' perceived efficacy in asthma management. Serial trend analysis revealed that most psychosocial measures continued to progress steadily after intervention. Significant improvements in both symptom-related measures and mental health and relationship measures were observed. The findings supported the value of incorporating family therapy into asthma psychoeducation programs.

Early-life psychological stress exacerbates adult mouse asthma via the hypothalamus-pituitary-adrenal axis

RATIONALE

Despite accumulating evidence that psychological stress has a short-lasting detrimental effect on asthma, little is known about the way stress in childhood predisposes to adult asthma.

OBJECTIVES

Using a communication box, we investigated the long-lasting effect of early psychological and physical stress on adult asthma in mice.

METHODS

Male BALB/c mice were exposed to either psychological stress or physical stress three times (every other day) during their fourth week of life. The mice were sensitized to ovalbumin at 8 and 10 weeks, and an ovalbumin airway challenge was conducted at the age of 11 weeks.

RESULTS

Twenty-four hours after ovalbumin challenge, both psychological and physical stress-exposed mice exhibited a significant acceleration in the number of total mononuclear cells and eosinophils and airway hyperresponsiveness compared with control mice. No differences in serum anti-OVA-specific immunoglobulin E levels were found between stress-exposed and control animals after antigen sensitization. In the psychological stress group, but not in the physical stress group, an elevation of the serum corticosterone levels during ovalbumin challenge was significantly attenuated in comparison with the control group. Moreover, pretreatment with RU-486, a glucocorticoid receptor antagonist, before ovalbumin challenge completely inhibited a psychological stress-induced exacerbation of asthma. However, pretreatment with GR-82334, a neurokinin-1 receptor antagonist, failed to affect physical stress-induced augmentation of airway inflammation.

CONCLUSION

Early psychological and physical stresses aggravated adult asthma via hyporesponsiveness of the hypothalamic-pituitary-adrenal axis during antigen challenge and via a pathway(s) distinct from the hypothalamic-pituitary-adrenal axis or neurokinin-1 receptors.

Describing relationship problems in DSM-V: toward better guidance for research and clinical practice

The authors provide a description of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) and its limitations, as well as empirical connections between relational processes and mental health. Four types of relational processes are identified, with each type clearly distinguished in terms of its pattern of association with psychopathology. For illustrative purposes, examples are provided along with suggestions of how each might be accommodated in the DSM-V. In view of the importance and complexity of the connections between relational processes and mental health, the authors argue that reliable and standardized assessments of relational processes are needed and suggest 6 possible approaches for providing better coverage of relational processes and relational disorders in the DSM-V. The article concludes with a discussion of potential concerns about expansion of attention to relational processes in the DSM-V.

Psychological interventions for children with asthma

BACKGROUND

Asthma is a chronic disease of inflammation and smooth muscle dysfunction, including bronchoconstriction. These symptoms are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. Psychological factors may influence the symptoms and management of asthma in children in many ways, for example, evidence suggests that emotional stress can either precipitate or exacerbate both acute and chronic asthma.

OBJECTIVES

To assess the efficacy of psychological interventions in improving health and behavioural outcomes for children with asthma.

SEARCH STRATEGY

The Cochrane Airways Group Specialised Register and PsycINFO were searched with pre-defined terms up until March 2005.

SELECTION CRITERIA

Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a control intervention in children and adolescents with asthma were included in the review. Cross-over trials were considered inappropriate for studies using psychological interventions and were therefore excluded from this systematic review.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted.

MAIN RESULTS

Twelve studies (588 children) were included in the review. Study quality was poor and sample sizes were frequently small. A meta-analysis was possible on two studies only examining the effects of relaxation therapy on PEFR which favoured the treatment group (32 L/min, 95% CI 13 to 50 L/min). No other meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. In addition, many studies reported insufficient data.

AUTHORS' CONCLUSIONS

This review was unable to draw firm conclusions for the role of psychological interventions for children with asthma. This review demonstrates the absence of an adequate evidence base and highlights the need for well-conducted and reported randomised trials in this area.

Predictors of adaptation in Icelandic and American families of young children with chronic asthma

The purposes of this international study were to determine the predictors of adaptation and to assess potential moderating effects of parents' sense of coherence and family hardiness on the relationship of severity of illness of a child with asthma and family and caregiving demands as predictors of family adaptation. For both parents, sense of coherence and family hardiness predicted family adaptation. Icelandic mothers perceived their family's adaptation more favorably than did their American counterparts. For the fathers, family demands predicted adaptation. Sense of coherence moderated the effect of family demands on adaptation for both parents. These findings underscore the importance of strengthening individual and family resiliency as a mechanism for improving family adaptation.

Parental psychopathology and childhood atopic disorders in the community

OBJECTIVE

To examine the association of parental psychopathology and childhood atopic disorders in the general population.

METHODS

In a sample of 9,240 parent-child dyads drawn from the 1999 US National Health Interview Survey, the association of childhood atopic disorders with parental major depression, generalized anxiety disorder, and panic attacks was examined. Parental DSM-IV psychiatric diagnoses were ascertained by the Composite International Diagnostic Interview, Short-Form (CIDI-SF).

RESULTS

Parental major depression and panic attacks were associated with childhood atopic disorders only in biological parent-child dyads (adjusted odds ratios = 1.67 for major depression and 1.46 for panic attacks), and among these more strongly in mother-child dyads. Parental atopic disorders and parental psychopathology had an additive effect on the risk of atopic disorders in the offspring.

CONCLUSION

Findings from this study lend support to the "shared genetic liability" hypothesis for the association of childhood atopic disorders and parental major depression and panic attacks.

The relationship of psychologic stress with childhood asthma

The psychologic influence on childhood asthma has long been a subject of investigation and controversy. This article illustrates the evidence that psychologic stress is related to children with asthma. Individual experience, the impact of family and neighborhood, the effect of caregiver mental status, and the presence of negative psychologic events affect symptoms and management. The pathways through which these factors influence asthma are mediated through cognitive and biologic mechanisms, with evidence indicating changes in behavior and alteration in immune response as underlying mechanisms. Psychologic issues are important in the patient with severe asthma. The mind-body paradigm that links psychologic stress to disease is necessary when considering the global evaluation of childhood asthma.

Parental mental health, childhood psychiatric disorders, and asthma attacks in island Puerto Rican youth

OBJECTIVE

Previous research documents an association of poor parental mental health with asthma in children. This study aims to determine whether the associations between parental mental health problems and childhood asthma attacks persist after controlling for childhood anxiety and depression and other confounding factors.

DESIGN/METHODS

A community household sample of youth ages 4 to 17 years and their primary caregivers from the US Commonwealth of Puerto Rico was studied to determine the associations between parental mental health and childhood asthma attacks. Regression models that predicted asthma attacks in youth controlled for parental mental health problems, childhood anxiety and depression, zone of residence, and parents' age, education, and perception of poverty.

RESULTS

After adjusting for children's depressive and anxiety disorders as well as other important confounders, associations between parental depression, suicide attempts, ataque de nervios, and history of mental health treatment and asthma attacks in offspring, by parental report, persisted. Additionally, the frequency of parental mental health problems was associated with children's asthma attacks.

CONCLUSION

Parents with mental health problems were more likely to report histories of asthma attacks in their children compared with parents without mental health problems in Puerto Rico. These associations were not attributable to internalizing disorders in youth but persisted independent of childhood psychopathology and other confounding factors. Clinicians and researchers should recognize the relations between poor parental mental health and childhood asthma and explore the potential role of family psychosocial and behavioral factors related to the manifestation of the disease.

Parents' experiences of asthma: process from chaos to coping

The aim of the present qualitative study was to describe nine parents' everyday experiences of living with a child suffering from asthma. Data were collected by means of in-depth interviews and phenomenological content analysis. Four main themes emerged: feelings of uncertainty, helplessness and guilt; the need for support and help from healthcare professionals; adaptation to everyday life; and the development of coping strategies. In addition, two subthemes; trying out and seeking information, emerged. Trying out was found to be an important strategy for parents in managing the illness. In encounters with healthcare professionals, parents felt that they were not respected and that their competence was questioned. In conclusion, this study emphasizes the importance of a mutual dialogue between healthcare professionals and parents to enable the parents to develop the competence necessary to care for their child.

Relations governed by uncertainty: part of life of families of a child with asthma

This study identifies what influences and characterizes family relations in families of a child with asthma. Seventeen mothers of children aged between 6 and 16 years participated in audio-taped in-depth interviews. The researchers were inspired by grounded theory in data collection and data analysis. The core category that developed was being governed by disease-engendered uncertainty. The category mothers' availability was seen in two dimensions. The first dimension, mothers' being available for the child with asthma, created two subcategories: 1. control and 2. tight bonds. The second dimension, mothers' being less available for other family members, also created two subcategories: 3. being forsaken and 4. lack of understanding. Nursing implications are discussed in relation to the findings.

A new methodological approach in nursing research: an actor, partner, and interaction effect model for family outcomes

Methodological and statistical challenges have been identified in family research when the parental dyad is under study. The purposes of this article are to review the literature on methodological and statistical procedures in research on families, and to introduce an analysis technique that is new to the nursing literature, the actor-partner interdependence model (APIM). The use and interpretation of the APIM method is illustrated through an example of families of young children with asthma. In the APIM an actor effect is the impact a person has on his or her own outcome, whereas a partner effect is the impact a member of a dyad has on his or her partner's outcome. The main findings from the data example indicate that family adaptation is influenced by the actor effect of resiliency factors (sense of coherence and family hardiness), the partner effect of caregiving demands, as well as by both the actor and partner effects of family demands. The APIM method gives new insight into how parental data can be analyzed by taking both the individual and the partner contribution into account when studying family phenomena. Knowing how outcomes may be influenced not only by individuals (via an actor effect) but also by their partners (through a partner effect) enriches our understanding of how families function.

The Experience of Parenting an Adolescent with Spina Bifida

Parents of adolescents with spina bifida (SB) face unique challenges of which they may not be aware. The purpose of this study was to heighten awareness of the challenge of parenting such adolescents. This enhanced understanding can help rehabilitation professionals optimize their interventions with families. In this qualitative study, which was part of a larger mixed-method descriptive investigation exploring adaptation by adolescents with SB, we used content analysis to evaluate 20 parent interviews for common domain, themes, and subthemes. The analysis yielded four major domains: (a) daily life experiences, (b) the dance of individuation, (c) reflections on parenting, and (d) practice suggestions for healthcare professionals. Overall, experiences of the parents were positive. Parents described meeting daily demands and balancing independence-dependence needs with the adolescent as major challenges. Rehabilitation professionals must provide guidance to foster autonomy, decision making, cognitive skill building, and coping skills to help parents and adolescents manage independence-dependence issues and multiple life demands.

Relationship between behavior and asthma in children with atopic dermatitis

OBJECTIVE

The significance of psychological factors in asthma is a subject of considerable dispute. This study addressed the little investigated question of the potential role of psychological factors in the initial onset of asthma.

MATERIALS AND METHODS

Data on the validated, standardized Behavior Screening Questionnaire were obtained prospectively from 35 to 53 months for 150 atopic children who had asthma by age 53 months and for 115 who did not.

RESULTS

At each age, the children who had asthma by 53 months had more behavior problems. There was no evidence that the subsequent behavior of those children who had asthma became more problematic. However, for those children without asthma by 35 months, an elevated behavior problem score at that age was related to the subsequent onset of asthma by age 53 months. The behavior problem score added significantly to the prediction of asthma onset (OR adjusted: 1.15; 95% CI: 1.02-1.29) when known risk factors of asthma and IgE levels for grass pollen and house dust mite at age 17 months were taken into account.

CONCLUSIONS

Behavior problems may precede asthma onset in young atopic children. In this age group, behavior problems are not secondary psychological reactions to asthma onset. They may act as a marker for stress in the child's life. The presence of behavior problems should alert clinicians that the child may be at increased risk for transition from atopic dermatitis to asthma.

Predictors of repeat hospitalizations in children with asthma: the role of psychosocial and socioenvironmental factors

This study examined relationships between psychosocial factors and asthma rehospitalization patterns in 115 children (ages 4-15) who had > or = 1 hospitalization during the study period. Lifetime history of hospitalizations and new hospitalizations during a 1-year follow-up period were measured, controlling for baseline asthma symptoms and medications. Prospectively, caretaker characteristics (lower sense of mastery, being less emotionally bothered by asthma) predicted greater likelihood of future asthma hospitalizations. Lifetime history of hospitalizations was associated with family impacts (greater family strain and family conflict greater financial strain) as well as caretaker characteristics (greater personal strain, beliefs about not being able to manage one's child's asthma). These findings could help guide future interventions targeted at the subgroup of children who represent a high proportion of asthma hospitalizations.

Patterns of family adaptation to childhood asthma

This study examined patterns in adaptation among parents with a child who had moderate to severe persistent asthma. Specifically, we were interested in examining the differences in adaptation between mothers and fathers in which it was hypothesized that gender effects would be obtained in patterns of coping. Eighty-four parents participated in the study, representing 37 intact families in which both parents were present and 13 single-parent families. Within intact families, mothers exhibited greater efforts than fathers in coping patterns including strategies to acquire social support outside the family, enhance self-worth, and decrease psychological tensions. When compared to mothers in single-parent families, mothers within intact families had a greater tendency to use coping patterns related to family integration and cooperation. Such findings demonstrate a need for additional support for mothers in their role in caring for the chronically ill child. The implications of these findings for clinical practice are discussed.

Family interaction and a supportive social network as salutogenic factors in childhood atopic illness

The role of psycho-social factors in the development of allergy was studied prospectively in 82 infants with a family history of atopy. The family participated in a standardized family test when the children were 18 months old. The ability to adjust to demands of the situation ('adaptability'), and the balance between emotional closeness and distance ('cohesion'), were assessed from videotapes by independent raters. Families rated as functional in both of these aspects were classified as 'functional', otherwise as 'dysfunctional'. The social network, life events, atopic symptoms (based on postal inquiries regarding symptoms answered by the parents, and on physical examinations), psychiatric symptoms, and socio-economic circumstances of the families were evaluated when the children were 18 months and 3 years of age. The children were classified as atopic (asthmatic symptoms or eczema) or as non-atopic. All but two children with atopic disease at 3 years of age had atopic disease before 18 months of age, while 32 of 60 children with atopic disease at 18 months of age had no problems by 3 years of age. An unbalanced family interplay at 18 months was associated with a relative risk (RR) of 1.99 for continuing atopic illness at 3 years of age (1.18 < RR < 3.37, p = 0.01). There was a weak positive confounding effect for smoking (RR reduced by 7%), eczema on three or more localizations (RR reduced by 4.5%), and the amount of cat allergen in household dust (RR reduced by 3%). Recovery from atopic illness between 18 months and 3 years of age was four times as probable in families with functional interaction and a good social supportive network when children were 18 months of age, than in dysfunctional families with a poor social network (74% versus 20% p < 0.01). Children with asthmatic symptoms showed more signs of emotional distress than did healthy children (p = 0.02). Dysfunctional family interaction patterns were more commonly observed in families of children who at 3 years of age still had atopic symptoms, than in children who had recovered. The patterns included expression of emotion and reaction to the needs of others, alternating between total disinterest and over-involvement (p = 0.02), lack of support and rejection of offered support (p = 0.01), a greater number of individual decisions without regard to the other family members (p = 0.04), and indistinct 'generational boundaries' (p = 0.04). We conclude that psychosocial factors, such as family interaction and a supportive social network, play a significant role in the course of atopic illness in early childhood and that measures which enhance family interaction and the social network could influence the course of the disease favorably.

Parental stress as a predictor of wheezing in infancy: a prospective birth-cohort study

The role of stress in the pathogenesis of childhood wheeze remains controversial. Caretaker stress might influence wheeze through stress-induced behavioral changes in caregivers (e.g., smoking, breast-feeding) or biologic processes impacting infant development (e.g., immune response, susceptibility to lower respiratory infections). The influence of caregiver stress on wheeze in infancy was studied in a genetically predisposed prospective birth-cohort (n = 496). Caregiver-perceived stress and wheeze in the children were ascertained bimonthly from the first 2 to 3 mo of life. Greater levels of caregiver-perceived stress at 2 to 3 mo was associated with increased risk of subsequent repeated wheeze among the children during the first 14 mo of life (RR, 1.6; 95% CI, 1.3 to 1.9). Caregiver-perceived stress remained significant (RR, 1.4; 95% CI, 1.1 to 1.9) when controlling for factors potentially associated with both stress and wheeze (parental asthma, socioeconomic status, birth weight, and race/ethnicity) as well as mediators through which stress might influence wheeze (maternal smoking, breast-feeding, indoor allergen exposures, and lower respiratory infections). Furthermore, caregiver stress prospectively predicted wheeze in the infants, whereas wheeze in the children did not predict subsequent caregiver stress. The effect of caregiver stress on early childhood wheeze was independent of caregiver smoking and breast-feeding behaviors, as well as allergen exposure, birth weight, and lower respiratory infections. These findings suggest a more direct mechanism may be operating between stress and wheeze in early childhood. Stress may contribute significantly to the population burden of preventable childhood respiratory illness.

Psychological interventions in cystic fibrosis and asthma

Cystic fibrosis and asthma have many psychosocial implications for patients and their relatives. These can stem from parental adaptational problems following diagnosis, negative illness perceptions, feeling 'different' and other associated developmental intrusions. In asthma, psychological factors arising from a variety of sources are known to 'trigger' attacks. For adolescents, psychological problems are hallmarked by loss (e.g. of identity, independence and peers) which results in re-appraisals of self-worth, depression and anxiety. Early intervention strategies and screening are crucial in ameliorating unsuccessful emotional adaptation and preventing chronic psychological morbidity. Behavioural and cognitive-behavioural interventions are particularly effective for both treatment-related behavioural problems (e.g. procedural distress, and poor feeding behaviour) and some psychological disorders (e.g. anxiety and depression). However, outcome depends on patients' motivation to change and willingness to collaborate. Where this is absent, less directive, but nonetheless effective, psychotherapies are utilised. Family therapy is also considered useful in addressing family dysfunction when thought to be intrinsic to the emotional problems.

Role of the family in the onset and outcome of childhood disorders: selected research findings

OBJECTIVE

Three areas of basic family research were selected for review as being of special importance to the clinically oriented child and adolescent psychiatrist: behavioral genetics, expressed emotion, and the interaction of family dynamics and childhood illness.

METHOD

Medline and PSYCINFO searches using appropriate keywords were obtained for each of the 3 major areas. All English-language articles published after 1989 that included empirical research pertaining to children or adolescents were reviewed.

RESULTS

Behavioral genetics research indicates that the shared environment, including issues of parental monitoring and discipline, is important in the development and outcome of externalizing disorders. Differential parental treatments of one sibling are critical in internalizing disorders. Criticism (as measured by expressed emotion) is associated with poor outcome of many childhood medical and psychiatric disorders. Chronic illness in a child changes the family dynamics toward being more structured and less emotionally warm and communicative. The family's role in adherence to treatment is critical, and families with high levels of criticism have more difficulty.

CONCLUSIONS

Families can cause problems, but many times the problems families have are in response to a child's problems. There is a continued need to empirically assess which family processes are important for specific childhood disorders.

Psychological reaction by children of various ages to hospital care and invasive procedures

Hospital care and treatment by invasive procedures produce significant psychological effects on children. Urogenital surgery deserves particular study. The developmental aspects of different ages are highly relevant. A proposed multidimensional model of contributing factors includes type of medical treatment, any previous surgery, the child's temperament, coping strategies of both child and parents and their psychological health, support from parents and staff, information and psychological preparation and age of the child. Up to now, there have been no clear recommendations as to the best age for elective surgical procedures in children according to psychological risk. In general, older children adapt better psychologically after hospital care. The literature, however, tends to advise elective surgery before 12 mo of age, based on apparent psychological adjustment in the very young after surgery and from a desire to shorten the period of living with the malformation/disorder. However, increased follow-up surgery from early interventions gives a higher risk of psychological problems. More well-controlled studies are needed before final evaluation of the impact of surgical interventions on psycho-social symptoms according to age group. In this analysis a multidimensional model is preferred.

The environmental influence on childhood asthma

The pathogenesis of allergy depends on the interaction between the time and amount of allergen exposure and the presence of nonspecific "adjuvant" factors in genetically susceptible individuals. There seems to be a period in early life during which the individual is particularly susceptible to sensitization, and there are variations in susceptibility over time. Allergens are almost ubiquitous, but the relative importance of the individual allergens varies between regions. In many temperate regions, house-dust mites used to be absent but are now more common. This may be due to modern methods of building houses. Differences in the prevalence of a particular allergy cannot explain variations in the prevalence of allergy in general. Various environmental factors that may enhance sensitization include tobacco smoke, NO2, SO2, ozone, and diesel particles. Passive smoking is by far the best established risk factor, particularly in early childhood. The indoor environment probably plays a larger role than outdoor air pollution in the development of allergic disease. The mother is not only a source of genetic information, but also an "environmental factor", as there is a close immunologic interaction between the mother and her offspring, mediated through the placenta and the breast milk, which may affect the likelihood of allergic disease. The concepts of "lifestyle" and "environment" should be expanded to include, for example, dietary changes, the microbial environment, and extensive traveling, as all the currently suspected risk factors taken together can only explain a small proportion of the geographic differences in and increasing prevalence of allergy. The future search for significant environmental factors should be interdisciplinary and be directed toward areas that have not yet been explored, thus giving "lifestyle" a broader interpretation.

Joint consultation for high-risk asthmatic children and their families, with pediatrician and child psychiatrist as co-therapists: model and evaluation

Although a very common disease, childhood asthma can be a life-threatening condition. Psychosocial determinants have been acknowledged to trigger severe asthma. The authors review current knowledge about how psychosocial factors influence childhood asthma, with a special focus on compliance with treatment and family interaction. The authors describe their experience of joint treatment of high-risk asthmatic children and their families. The pediatrician and child psychiatrist work as co-therapists, and the results of this intervention are investigated. Forty-one high-risk asthmatics and their families were followed in the joint-consultation program. Two years after the onset of joint consultation, a significant improvement was found in symptom score, treatment score, and compliance score. The number of hospital admissions and of days spent in hospital decreased significantly. The cost of care was subsequently cut by two-thirds, despite the added cost of psychiatric care. The authors conclude that it is possible for doctors of the body and of the mind to share consultation work, with a positive impact on both the patient's health and the cost of treatment.

The patient and family adjustment to chronic disease in the home

The increase in chronic disease with shortened hospitalizations has led to an increase in home care, with added adjustment problems for patients and their families. The majority of families cope satisfactorily, although most have periods of instability or difficulties which require appropriate support. In considering the impact of chronic illness, cognizance must be taken of the patient, the illness, the caregiving system, the medical care system, the interrelationship between them and the effect of the environment on all of them. The adjustment to chronic illness depends on the complementary meshing of the life and time cycles of the above factors during the alternating periods of crises and chronic maintenance. It is apparent that, in a pluralistic multicultural society, a broad range of diverse family forms and functioning is compatible with adjustment to a member with chronic disease. Finally, a scheme for the medical team's assessment and care is presented.

Caring for the severely asthmatic child and family. I. The rationale for family systems integrated medical/psychological treatment

Comprehensive care for the severely asthmatic child includes psychological as well as medical treatment. Family therapy is a recognized modality of therapy. Investigations have examined the role of emotion and asthma as well as psychosomatic asthma. Pharmacological treatment of beta 2-agonist and cromolyn prior to disciplining the child prevents psychosomatic asthma secondary to crying or shouting. Adherence to multiple asthma therapeutic modalities is imperative, and a psychological and medical team can address these important clinical issues in a high-risk population.

Decreasing admissions for childhood asthma to a Swedish county hospital

Hospital admission rates for childhood asthma have increased in many countries. To study if this is also true for Norrköping Hospital, paediatric admission rates for asthma every fifth year were examined for the period 1973 to 1993. Admission rates were found to have fallen over the last 10 years, especially in children of school age. Among the younger age groups (below 5 years of age) a fall in admission rates was also observed over the last 5 years. This fall occurred in spite of reported increases in the prevalence of childhood asthma. The relative risk for admission due to asthma thus decreased from 1 in 1973 to 0.09 in 1993. The readmission rate has been stable. The mean length of stay in hospital for asthma decreased significantly. The observed decreasing trend in hospital admissions for childhood asthma is contrary to that found in many other countries. Possible explanations are discussed.