Childhood asthma complicated by anxiety: an application of cognitive behavioural therapy

Asthma and anxiety in children and adolescents: characteristics and treatment outcomes

OBJECTIVE

This study (a) examined anxious youth with and without asthma on measures of negative self-talk, parental psychopathology, worry content, physical symptoms, panic symptoms, generalized symptoms, and separation anxiety symptoms, and (b) tested if outpatient CBT or medication were differentially effective in reducing anxiety for youth with asthma and anxiety.

METHODS

This secondary analysis separated youth with an anxiety disorder into asthma and non-asthma groups. Youth were also compared on response to treatments (i.e. CBT, sertraline, combined, and placebo).

RESULTS

A total of 488 participants participated in the original study, with an average age of 10 years (SD 2.87). Youth with comorbid asthma and anxiety demonstrated higher rates of negative self-talk. Youth with comorbid asthma and anxiety did not differ from the non-asthma group on measures of physical symptoms, anxiety disorder specific symptoms, parental psychopathology, or worry content. Youth with asthma and anxiety responded similarly to the non-asthma group to treatment across treatment conditions.

CONCLUSIONS

Treatment was comparably effective for youth with comorbid asthma and anxiety and youth with anxiety. Future research could examine the effects of psychopharmaceuticals on asthma and anxiety comorbidity.

Parental Feeding, Child Eating and Physical Activity: Differences in Children Living with and without Asthma

This study aimed to establish the differences in parental attitudes toward feeding and activity, as well as child eating and activity levels, between families of children living with and without asthma. Parents of children and young people aged between 10 and 16 years living both with asthma (n = 310) and without asthma (n = 311) completed measures for parental feeding, parental attitudes toward child exercise, child eating, child activity level and asthma control. Children living with asthma had a significantly higher BMIz (BMI standardised for weight and age) score, were significantly more likely to emotionally overeat and desired to drink more than their peers without asthma. Parents of children with asthma reported greater use of food to regulate emotions, restriction of food for weight control, monitoring of child activity, pressure to exercise and control over child activity. When asthma symptoms were controlled, parental restriction of food for weight management predicted greater child BMIz scores, and higher child activity predicted lower child BMIz scores. These relationships were not found to be significant for children with inadequately controlled asthma. Differences in parental attitudes toward feeding and exercise, and child eating and exercise behaviors, between families may help to explain the increased obesity risk for children with asthma.

Weight-management in children living with asthma: a qualitative study of the experiences of paediatric healthcare professionals

Objective: Weight loss has been found to improve the symptoms of asthma in children who are overweight. However, many paediatric weight management programmes do not address the challenges associated with living with asthma. The aim of this study was to explore the views and experiences of paediatric healthcare professionals concerning weight management advice and support offered to families of children living with asthma. Methods: In-depth individual interviews with 10 healthcare professionals who work with a paediatric asthma population (n = 4 Respiratory Consultants, 3 Respiratory Nurses, 3 General Paediatricians). Data were analysed using a Framework approach. Results: Healthcare professionals highlighted that families' perceptions of weight, their approach to physical activity and nutrition, the family's social context and perceptions of asthma and asthma treatment all influence weight management in children living with asthma. Initiating weight management conversations and referring to weight management support were perceived as challenging. It was thought that tailoring weight management to the needs of children living with asthma and locating support within the community were important to the success of a family-centred intervention. Conclusions: The results highlight the added complexity of responding to excessive weight in a paediatric population with asthma. Training and referral guidance for healthcare professionals may help overcome weight management support challenges. Addressing family beliefs about the factors influencing paediatric asthma and exploring families' motivations for behaviour change may enhance engagement with weight management.

Attentional Bias in Children with Asthma with and without Anxiety Disorders

Children with asthma have a high prevalence of anxiety disorders, however, very little is known about the mechanisms that confer vulnerability for anxiety in this population. This study investigated whether children with asthma and anxiety disorders display attentional biases towards threatening stimuli, similar to what has been seen in children with anxiety disorders more generally. We also examined the relationships between attentional biases and anxiety symptomatology and asthma control for children with asthma. Ninety-three children, aged 8-13, took part in the study and were recruited into one of four conditions (asthma/anxiety, asthma, anxiety, control). Asthma was medically confirmed and anxiety was assessed through clinical interview. We used self- and parent-report questionnaires to measure child asthma (ATAQ) and anxiety (SCAS, CASI) variables. Participants completed a visual dot-probe task designed to measure attentional bias towards two types of stimuli: asthma related words and general threat words, as well as tasks to assess reading ability and attentional control. Results showed that attentional biases did not differ between the groups, although children with anxiety disorders displayed poorer attentional control. A significant correlation was found between poor asthma control and an attentional bias of asthma stimuli. While we found no evidence that anxiety disorders in children with asthma were associated with threat- or asthma-related attentional biases, preliminary evidence suggested that children with poor asthma control displayed biases towards asthma-specific stimuli. Future research is needed to explore whether these attentional biases are adaptive.

Anxiety in youth with asthma: A meta-analysis

OBJECTIVES

Anxiety often presents comorbidly with asthma in youth under 18; however, prevalence rates are unclear. The aim of this review was to provide an up-to-date analysis of the literature investigating the prevalence of anxiety disorders, and comparisons of anxiety disorders and symptomatology in youth with asthma, compared to those without.

METHODS

A systematic search was conducted using the databases PsycINFO, MEDLINE, EMBASE, and CINAHL.

RESULTS

The search process produced 15 studies (n = 7443) reporting data on youth with asthma and anxiety disorders, 11 studies (n = 10 332) reporting data on youth with and without asthma and anxiety disorders, and 28 studies (n = 5848) reporting data on youth with and without asthma and anxiety symptomatology. Youth with asthma had an anxiety disorder prevalence rate of 22.7%. Youth with asthma also had a greater number of anxiety disorders, compared to those without asthma (d = 0.37, 95%CI: 0.24-0.50, P < 0.001), and higher levels of anxiety symptomatology than youth without asthma (d = 0.29, 95%CI: 0.19-0.39, P < 0.001).

CONCLUSIONS

Youth with asthma display a prevalence rate for anxiety disorders that is more than three times higher than the prevalence in healthy youth. For the specific anxiety disorders investigated, elevated prevalence rates for youth with asthma were also found. Future research needs to focus on the factors that mediate or predict the development and maintenance of anxiety in youth with asthma and the development of clinically efficacious treatments.

Parent-child interactions in children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the parenting factors that may underlie this relationship. The aim of the current study was to examine observed parenting behaviours - involvement and negativity - associated with asthma and anxiety in children using the tangram task and the Five Minute Speech Sample (FMSS). Eighty-nine parent-child dyads were included across four groups of children (8-13 years old): asthma and anxiety, anxiety only, asthma only and healthy controls. Overall, results from both tasks showed that parenting behaviours of children with and without asthma did not differ significantly. Results from a subcomponent of the FMSS indicated that parents of children with asthma were more overprotective, or self-sacrificing, or non-objective than parents of children without asthma, and this difference was greater in the non-anxious groups. The results suggest that some parenting strategies developed for parents of children with anxiety may be useful for parents of children with asthma and anxiety (e.g. strategies targeting involvement), however, others may not be necessary (e.g. those targeting negativity).

A Case Series Evaluation of a Pilot Group Cognitive Behavioural Treatment for Children With Asthma and Anxiety

Anxiety disorders occur at an increased rate in children with asthma; however, there is only a small evidence base to support specific psychological treatments for these children. The current study evaluated the efficacy of a pilot cognitive behavioural treatment (CBT) group intervention for children with asthma and a comorbid anxiety disorder in a case series design. Five children (aged 8–11 years old) with asthma and a comorbid anxiety disorder and their mothers took part in eight 1-hour group treatment sessions. Primary outcomes measures were anxiety diagnosis and asthma-related quality of life. Secondary outcome measures were asthma symptom control and parent quality of life associated with caring for a child with asthma. Three of the participants no longer met diagnostic criteria for an anxiety disorder following treatment and three different participants reported a reliable improvement in asthma-related quality of life. Two participants reported a reliable improvement in asthma symptom control. Three mothers reported an improvement in caregiver quality of life. The findings provide preliminary proof of concept evidence for the efficacy of a CBT intervention for children with asthma and clinical anxiety.

Threat interpretation and parental influences for children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the cognitive and parent factors that may underpin this relationship. The present study investigated interpretation biases in children with asthma and anxiety and their parents, and whether parent-child discussions influenced children's interpretations. Eighty-nine parent-child dyads were included across four groups: children with asthma and anxiety, children with anxiety only, children with asthma only and healthy children (aged between 8 and 13 years old). Interpretation bias was assessed using ambiguous scenarios. Children with anxiety showed an interpretation bias in the general threat scenarios, whereas children with asthma showed an interpretation bias in the asthma threat scenarios. Parental predictions of their child's responses showed similar results. Parent-child discussions increased avoidance for children with anxiety and no asthma across all scenarios, but only for children with asthma and anxiety in the asthma threat scenarios. The results provide partial support for a cognitive theory of asthma and anxiety in children and suggest that parents play a role in influencing children's thinking styles. Treatment programs could thus aim to target and modify interpretation biases in children with anxiety, and include parents as part of treatment.

Cognitive-behavioural Interventions in Pediatric Chronic Illness

This paper provides an overview of cognitive-behavioural interventions in pediatric behavioural medicine. Although the literature so far is sparse, the contribution of cognitive-behavioural therapy is reviewed in the areas of pediatric cancer, asthma, and diabetes mellitus. The future potential of cognitive-behavioural therapy for the management of other chronic conditions, including cystic fibrosis and rheumatoid arthritis, is recommended.

Diagnosis and management of asthma in adolescents

OBJECTIVES

In this review we explore some of the issues surrounding the diagnosis and misdiagnosis of asthma in adolescents and suggest a management approach which might facilitate the provision of optimal treatment in order to minimise morbidity from asthma in this vulnerable and often difficult-to-manage age group.

RESULTS

We highlight important diagnostic traps which occur in the adolescent age group, including the misdiagnosis of asthma in young people presenting with exercise-related symptoms or cough, and stress the importance of considering alternative diagnoses, including vocal cord dysfunction. We explore how adolescence impacts on asthma management and emphasise the importance of an understanding of normal adolescent development and an awareness of high-risk indicators in developing a strategy to optimally manage a young person with asthma. We also illustrate how psychosocial functioning may impact on both perceived asthma severity and quality of life as well as interfere with optimal asthma control both directly and by increasing non-adherence. A suggested management strategy for adolescents is provided which emphasises a supportive approach to help facilitate optimal control of asthma by involving the young person in management decisions about their asthma. Specific mention is made about smoking cessation assistance and the interrelationship between physical activity, obesity and asthma. Finally we discuss the importance of an appropriate transition process to prepare the young person for transfer from child-centred care to adult-centred care.

CONCLUSION

Many different factors is of outmost importance when diagnosing adolescents with shortness of breath; furthermore, management of asthma need a supportive approach in both paediatric and adult setting.

Fears and anxiety in children with long-QT syndrome compared to children with asthma

OBJECTIVE

To compare children with asthma to children with long-QT syndrome (LQTS) in terms of anxiety and medical fears.

METHOD

Forty children (25 males/15 females) with asthma and their mothers participated, along with seven children with LQTS (four males/three females) and their mothers.

RESULTS

Children with asthma had significantly more medical fears, fear of danger/death, and fear of minor injury and small animals compared to children with LQTS. Children with LQTS tended to have more fear of failure and criticism, and tended to keep their feelings to themselves and minimize their real feelings of anxiety. Children with LQTS had significantly more internalizing problems, and their mothers had significantly higher anxiety.

CONCLUSION

Fear and uncertainty can be overwhelming in LQTS. Children with LQTS do not seem to be able to share their feelings openly. Examining the psychosocial adjustment of affected children may assist professionals to help families to cope more effectively.

Characterization and treatment response of anxious children with asthma

OBJECTIVES

To compare children with Axis I anxiety disorders and asthma with a matched group of anxious children without asthma on questionnaire measures and response to cognitive-behavioural treatment (CBT) for anxiety.

METHOD

A sample of 36 children with comorbid anxiety and asthma, aged 8 to 12 years, were matched for age, sex, and specific anxiety disorder with 36 children with an Axis I anxiety disorder but no asthma. Parents and children completed standardized questionnaires.

RESULTS

Children with comorbid anxiety and asthma had significantly more perinatal complications (P = 0.001), and higher total (P = 0.000) and psychological stressors (P = 0.02), especially parent-child problems (P = 0.01), but lower levels of depression (P = 0.03) and anxiety (P = 0.05), compared with anxious, nonasthmatic children. All children reported decreased anxiety (P = 0.001) and depression (P = 0.000) posttreatment, with a trend toward less improvement in anxiety in anxious children with asthma.

CONCLUSIONS

Although replication is needed, addressing psychosocial stress and parent-child problems may increase CBT efficacy in children with comorbid anxiety and asthma.

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.

Psychological aspects of asthma

Asthma can be affected by stress, anxiety, sadness, and suggestion, as well as by environmental irritants or allergens, exercise, and infection. It also is associated with an elevated prevalence of anxiety and depressive disorders. Asthma and these psychological states and traits may mutually potentiate each other through direct psychophysiological mediation, nonadherence to medical regimen, exposure to asthma triggers, and inaccuracy of asthma symptom perception. Defensiveness is associated with inaccurate perception of airway resistance and stress-related bronchoconstriction. Asthma education programs that teach about the nature of the disease, medications, and trigger avoidance tend to reduce asthma morbidity. Other promising psychological interventions as adjuncts to medical treatment include training in symptom perception, stress management, hypnosis, yoga, and several biofeedback procedures.

Perception of induced bronchoconstriction in a community sample of adolescents

BACKGROUND

Poor perception of asthma symptoms has been cited as a risk factor for asthma death, yet there is no consensus as to the best way to characterize perception, and little is known about perception in normative samples. Hypoperceivers are of clinical interest because of risks of undertreatment; hyperperceivers are at risk for adverse iatrogenic effects caused by overtreatment.

OBJECTIVE

This study investigates perception of methacholine-induced bronchoconstriction in 175 adolescents.

METHODS

Breathlessness was rated after each inhalation by using the Borg scale. Perception groups were calculated on the basis of change from placebo Borg to high Borg scores (perception score at the highest methacholine dose). Subjects were called hypoperceivers if their Borg change score was greater than 1 SD below the mean for their FEV(1) group, hyperperceivers if their Borg change score was greater than 1 SD above the mean for their FEV(1) group, and accurate perceivers otherwise.

RESULTS

For subjects with an FEV(1) drop of less than 10%, accurate perceivers had a change in Borg score of 1.4 or less, and hyperperceivers had a change of greater than 1.4. For a drop in FEV(1) between 10% and 19%, hypoperceivers had a change in Borg score of less than 0.2, accurate perceivers had a change between 0.2 and 2.1, and hyperperceivers had a change of greater than 2.1. For those with an FEV(1) drop of 20% or greater, hypoperceivers had a Borg change of less than 0.2, accurate perceivers had a change between 0.2 and 2.6, and hyperperceivers had a change of greater than 2.6. No differences in age, sex, placebo Borg ratings, baseline pulmonary functions, PC(20) values, or psychologic variables were found among perception groups.

CONCLUSION

This study provides reference Borg values during methacholine challenge for 175 community adolescents.