The Chronicity of Depressive Symptoms in Mothers of Children With Asthma

Study of the emotional adjustment of the caregiver-patient dyad to bronchial asthma in adolescence

AIM

This study aimed to investigate the impact of bronchial asthma-related factors on the emotional well-being of adolescents with bronchial asthma and their primary caregivers.

BACKGROUND

Bronchial asthma is a common chronic disease in childhood and adolescence that can have a psychological impact on both patients and their primary caregivers.

METHODS

The study used a cross-sectional design and included 150 patient-caregiver dyads diagnosed with bronchial asthma, aged between 12 and 16 years and collected between 2018 and 2020. It assessed the emotional adjustment of both patients and caregivers and recorded variables related to the disease. Qualitative and quantitative analyses were conducted to perform statistical analyses.

RESULTS

Caregivers had higher anxiety and depression scores than patients. Good adherence to treatment was necessary for the emotional adjustment of the dyad. Controlled asthma, good adherence to treatment and a reduction in medical treatment were the primary predictors of emotional adjustment.

CONCLUSIONS

The study highlights the importance of assessing anxiety and depression levels in both patients and caregivers because the presence of these symptoms can lead to the misuse of medication, inadequate inhalation techniques, the omission of medication and reduced confidence in controlling asthma symptoms.

Changes in caregiver mental health and pediatric asthma control during COVID-19

OBJECTIVE

This study evaluated caregivers' stress and depressive symptoms, and children's asthma control, before COVID-19 began and after its onset among families in the RVA Breathes program.

METHODS

The RVA Breathes intervention, which took place in an urban city in the United States, includes asthma education delivered by a community health worker (CHW), a home assessment, and school nurse components. Participants included 125 children (5-11 years) with asthma and their caregivers (48% household income <$25,000) enrolled prior to the pandemic. Families were randomized to an active intervention arm (full intervention or intervention without school nurse component) or the control group. Caregivers completed the Center for Epidemiological Studies Depression Scale (CES-D) and the Perceived Stress Scale (PSS); children and caregivers completed the Childhood Asthma Control Test (cACT). Assessments pre-COVID-19 were compared to those completed after the pandemic's onset.

RESULTS

Children in both intervention groups had better cACT scores after the start of COVID-19 compared to before (t(55) = -2.131, p = .019; t(28) = -2.893, p = .004). Caregivers in the intervention groups had lower PSS scores after the start of COVID-19 compared to pre-COVID-19 (t(53) = 3.928, p < .001; t(28) = 2.568, p = .008). Furthermore, CES-D scores improved among caregivers in the full intervention (t(48) = 1.789, p = .040). Caregivers in the control condition did not report significant changes in stress or depressive symptoms.

CONCLUSIONS

Findings suggest that support from interventionists, including CHWs, might have alleviated stress and depressive symptoms during COVID-19, as well as improved asthma control during the pandemic.

Stressful life events, caregiver depressive symptoms, and child asthma symptom-free days: a longitudinal analysis

OBJECTIVE

To examine relationships among stressful life events (SLE), caregiver depression, and asthma symptom free days (SFDs) in publicly insured Black children aged 4-12 years with persistent asthma.

METHODS

Secondary analysis of longitudinal data from a clinical trial assessing the efficacy of a six-month parental stress management intervention. Using repeated measures Poisson regression, we constructed four models of SLE (Rochester Youth Development Stressful Life Events scale-Parent Items), caregiver depression (Center for Epidemiologic Studies Depression scale ≥ 11), and child asthma symptom-free days (SFDs) in the prior 14 days.

RESULTS

There was no association between SLE and child SFDs, but there was for caregiver depression (Incidence Rate Ratio [IRR]: 0.904; 95% CI 0.86-0.95). The interaction between SLE and caregiver depression was not significant. A specific SLE (recent serious family accident or illness) predicted fewer child SFDs (IRR: 0.91, 95% CI: 0.85-0.98). In the interaction model between caregiver depression and recent accident/illness, caregiver depression was associated with fewer child SFDs (IRR: 0.95, 95% CI: 0.91-0.99) as was the interaction between caregiver depression and recent accident/illness (IRR: 0.77, 95% CI 0.66-0.91); but the relationship between recent accident/illness and child SFDs was not (IRR: 1.00, 95% CI, 0.92-1.09), meaning accident/illness was only associated with fewer child SFDs among depressed caregivers.

CONCLUSIONS

In a sample of publicly insured Black children with persistent asthma, caregiver depression was negatively associated with child SFDs while overall SLE were not. A recent family accident or illness was negatively associated with child SFDs only when the caregiver was depressed.

Caregiver Depressive Symptoms and Primary Medication Nonadherence in Children With Asthma

INTRODUCTION

The purpose of this study was to identify risk factors for primary medication nonadherence among low-income minority children with persistent asthma.

METHOD

Data were from an environmental control and educational intervention for children with uncontrolled asthma who were treated in the emergency department for an asthma exacerbation. Presence or absence of pharmacy records for child asthma medications was the outcome of interest. A range of sociodemographic, health, and psychosocial measures were included in the binary logistic regression.

RESULTS

Of the 222 youths (mean age = 6.3 years; 93.7% Black), 25 (11.3%) lacked pharmacy records of asthma medications. For every 1-point increase in caregiver depressive symptoms, the odds of the child having a pharmacy record declined by 5% (odds ratio = 0.95; p = .012).

DISCUSSION

Providers should systematically assess and monitor caregiver depressive symptoms as a potential contributing factor for primary medication nonadherence in low-income minority children with persistent, uncontrolled asthma.

Predictors of Depressive Symptoms in Caregivers of Children With Poorly Controlled Asthma: Is the Neighborhood Context Important?

Children residing in low-income neighborhoods are disproportionately affected by asthma morbidity and mortality. Neighborhood violence has been explored in relationship to child morbidity and health and developmental outcomes, but less is known about the relationship of violence to caregiver mental health. The purpose of this study was to examine the relationship of neighborhood violent crime victimization (objective and subjective measures), perceptions of community well-being and support, and depressive symptoms among a sample of primarily single female caregivers of children with uncontrolled asthma. This is a secondary analysis of baseline data obtained from a randomized controlled trial of a home-based environmental control intervention for children aged 3 to 12 years, who were primarily African American, and diagnosed with persistent, uncontrolled asthma. Results showed that both objective and subjective measures of crime, particularly in those with relatively low life stress (P < .001), limited education of the caregiver (P < .001), and fewer children (P < .01) in the household had direct associations with depressive symptoms in caregivers of children with uncontrolled asthma. Neighborhood perceptions of satisfaction and a sense of community, as well as perceptions of social support, were not associated with depressive symptoms. Our findings emphasize the need to screen for depressive symptoms, life stress, as well as both objective and subjective perceptions of neighborhood violence among caregivers of children with poorly controlled asthma. Furthermore, when providing holistic care to these caregivers, stress reduction and the provision of mental health resources are paramount.

The Effects of Caregiver Social Support and Depressive Symptoms on Child Medication Adherence and Asthma Control

The purpose of this study was to examine relationships among caregiver social support, caregiver depressive symptoms, medication adherence, and asthma control in a sample of low-income, urban, Black children aged 3–12 years with uncontrolled asthma and their caregivers. Using longitudinal data from a randomized controlled trial (RCT) assessing the efficacy of an environmental control educational intervention, we used generalized estimating equations and ordered logistic regression models to evaluate the relationship between caregiver social support (Medical Outcomes Study Social Support Survey), depressive symptoms (Center for Epidemiologic Studies Depression scale), and two child asthma outcomes: (a) medication adherence (Asthma Medication Ratio) and (b) asthma control. At baseline, 45.7% of the 208 children had very poorly controlled asthma. Nearly a third of caregivers (97% female) had clinically significant depressive symptoms at each data collection point. Social support was not associated with either asthma outcome nor did it moderate the relationship between depressive symptoms and child asthma outcomes. Higher caregiver depressive symptoms predicted decreased medication adherence (b=−0.003, SE 0.002). Moderate asthma at baseline (OR: 0.305, SE: 0.251), severe asthma at baseline (OR: 0.142, SE: 0.299), household income < $20,000 per year (OR: 0.505, SE: 0.333), and fall season (OR: 0.643, SE: 0.215) were associated with poorer asthma control. Attending to the social context of low-income, urban, Black children with asthma is critical to reduce asthma morbidity. Maternal depressive symptoms are modifiable and should be targeted in interventions to improve child asthma outcomes in this vulnerable population. The RCT was registered with ClinicalTrials.gov (NCT01981564) in October 2013.

Participant-level characteristics differ by recruitment setting when evaluating a behavioral intervention targeting adolescents with asthma

OBJECTIVE

The recruitment setting plays a key role in the evaluation of behavioral interventions. We evaluated a behavioral intervention for urban adolescents with asthma in three randomized trials conducted separately in three different settings over the course of 8 years. We hypothesized that characteristics of trial participants recruited from the ED and clinic settings would be significantly different from that of youth participating in the school-based trials. The intervention evaluated was Puff City, a web-based program that uses tailoring to improve asthma management behaviors.

METHODS

The present analysis includes youth aged 13-19 years who reported a physician diagnosis of asthma and symptoms at trial baseline. In the three trials, all participants were randomized post-baseline to a web-based, tailored intervention (treatment) or generic web-based asthma education (control).

RESULTS

Compared to school-based trial participants, ED participants had significantly more acute-care visits for asthma (p < 0.001) and more caregiver depression (p < 0.001). Clinic-based participants were more likely to have computer/ internet access than participants from the school-based trial (p < 0.001). Both ED and clinic participants were more likely to report controller medication (p's < 0.001) and higher teen emotional support (p's < 0.01) when compared to the schools, but were less likely to report Medicaid (p's < 0.014) and exposure to environmental tobacco smoke (p < 0.001).

CONCLUSION

Compared to participants in the school-based trials, participants recruited from ED and clinic settings differed significantly in terms of healthcare use, as well as psychosocial and sociodemographic factors. These factors can inform intervention content, and may impact external validity of behavioral interventions for asthma.

Exploring a broader context of the home environment and its relationship with asthma control in American Indian children

In this cross-sectional study of 60 American Indian mother-child dyads from Southeastern North Carolina, we examined whether childhood asthma control was related to household-level factors, such as environmental tobacco smoke and family management behaviors. We also examined the relationships among family management behaviors and maternal depressive symptoms. We used logistic regression to assess the relationships among childhood asthma control, the presence of environmental tobacco smoke, and family management behaviors, specifically condition management ability (CMA) and condition management effort (CME). We used linear regression to evaluate the relationships between both CMA and CME and maternal depressive symptoms. Better asthma control in children was associated with the absence of environmental tobacco smoke in the home and the maternal perception of asthma as a manageable condition. Mothers perceived an increase in effort to manage their child's asthma as their depressive symptoms increased. These findings emphasize the importance of environmental triggers, perceptions of condition management, and maternal mental health in controlling asthma in American Indian children. Interventions to reduce environmental triggers, treat maternal depressive symptoms, and support mothers in their ability to manage childhood asthma may yield better asthma control and help to reduce existing racial disparities in this population.

Fostering Effective Asthma Self-Management Transfer in High-Risk Children: Gaps and Opportunities for Family Engagement

INTRODUCTION

The process of self-management knowledge, behavior, and skill development in children with asthma from families with low income is understudied.

METHOD

Fifteen mothers of children with uncontrolled asthma participated in semistructured interviews exploring the transfer of asthma self-management responsibilities from parent to child. Team members performed thematic analysis of written transcripts.

RESULTS

All participants were all the biological mothers and were impoverished, with most (73%) reporting an annual family income of less than $30,000. Their children ranged from 5 to 15 years old, were African American (100%), and had uncontrolled asthma based on national guidelines. Themes showed that child asthma self-management is difficult to achieve, that the transfer of asthma responsibility from mother to child is variable, and that mothers overestimate their child's developmental capacities for independent asthma self-management and have poor understanding of what well-controlled asthma means.

DISCUSSION

Ongoing assessment and tailored guidance from health care providers are critical to support the pivotal role of mothers in their child's self-management development process.

Randomized clinical trial of parental psychosocial stress management to improve asthma outcomes

OBJECTIVE

Because higher parental psychosocial stress is associated with worsened asthma outcomes in children, we sought to determine if a parent-focused stress management intervention would improve outcomes among their at-risk African American children.

METHODS

We enrolled self-identified African American parent-child dyads (children aged 4-12 years old with persistent asthma, no co-morbidities, on Medicaid) in a prospective, single-blind, randomized clinical trial with follow-up at 3, 6, and 12 months. All children received care based on the guidelines of the National Institutes of Health. Developed with extensive local stakeholder engagement, the intervention consisted of four individual sessions with a community wellness coach (delivered over 3 months) supplemented with weekly text messaging and twice monthly group sessions (both delivered for 6 months). The main outcome was asthma symptom-free days in the prior 14 days by repeated measures at 3 and 6 months follow-up.

RESULTS

We randomized 217 parent-child dyads and followed 196 (90.3%) for 12 months. Coaches completed 338/428 (79%) of all individual sessions. Symptom-free days increased significantly from baseline in both groups at 3, 6, and 12 months, but there were no significant differences between groups over the first 6 months. At 12 months, the intervention group sustained a significantly greater increase in symptom-free days from baseline [adjusted difference = 0.92 days, 95% confidence interval (0.04, 1.8)].

CONCLUSION

The intervention did not achieve its primary outcome. The efficacy of providing psychosocial stress management training to parents of at-risk African American children with persistent asthma in order to improve the children's outcomes may be limited.

CLINICALTRIALS.GOV

NCT02374138.

Evaluation of MOS social support in low-income caregivers of African American children with poorly controlled asthma

Objective: The purpose of this study was to examine the factor structure of the Medical Outcomes Study Social Support Survey (MOS-SSS) in a sample of low-income, urban caregivers of African American children with poorly controlled asthma. Although the MOS-SSS is a commonly used measure of social support, its psychometric properties have not been studied in this population. Methods: Confirmatory factor analysis was conducted to determine the most appropriate factor structure for the MOS-SSS in caregivers of African American children with frequent Emergency Department visits for uncontrolled asthma. The following models were tested and compared using established fit statistics: an 18-item second-order four factor model, an 18-item four factor model, a bifactor model and an 18-item one factor model with nested models. Results: Participating caregivers were single (75.6%) and female (97%). An 18-item one factor version of the scale had the best fit statistics compared to the other models tested: χ 2 (142) = 308.319, p > 0.001; Root mean square error of approximation (RMSEA) = 0.077; CFI (Comparative Fit Index) = 0.990; and Tucker-Lewis Index (TLI) = 0.988. Construct validity was supported by a statistically significant negative relationship between our final MOS-SSS model and caregiver depressive symptoms ( β = -0.374, p < 0.001). Conclusions: The 18-item one factor MOS-SSS may be appropriate for use in research and clinical practice with caregivers of African American children with poorly controlled asthma. It appears promising as a mechanism to advance understanding of relationships between social support and asthma outcomes in this vulnerable population.

Improving Care of Inner-City Children with Poorly Controlled Asthma: What Mothers Want You to Know

INTRODUCTION

Low-income caregiver perspectives on asthma management are understudied but may illuminate strategies to improve care delivery and child outcomes.

METHOD

Purposive sampling methods were used to recruit 15 caregivers of children with frequent asthma emergency department visits. Interviews explored how poverty and stress affect asthma management. Grounded theory coding techniques were used to analyze the data.

RESULTS

Participants were the biological mother (100%) and were poor (75% had mean annual income ≤ $30,000). Their children (mean age = 6.9 years) were African American (100%), enrolled in Medicaid (100%), and averaged 1.5 emergency department visits over the prior 3 months. Four themes emerged: (a) Deplorable Housing Conditions, (b) Allies and Adversaries in School-Based Asthma Management, (c) Satisfaction With Asthma Health Care Delivery, and (d) Prevalent Psychological Distress.

DISCUSSION

Impoverished caregivers of children with frequent asthma emergency department visits describe stress that is multifaceted, overwhelming, and difficult to eradicate. Their experiences underscore the need for improved school-based asthma management and family-centered approaches to health care delivery.