The family of the asthmatic child

Psychiatric Factors in Asthma

Emotional factors are an obstacle in the diagnosis and management of asthma. This review discusses three problem patterns: negative emotions in relatively normal patients with asthma; patients presenting possible functional symptoms and; patients presenting asthma in conjunction with psychiatric deviations. Negative emotions influence the symptoms and management of asthma, even in relatively normal patients. Psychogenic symptoms appear normal, but culminate in functional symptoms in a minority of patients. Diagnosing and treating asthma in patients with comorbid asthma and psychiatric symptoms is very difficult. On the one hand, treating asthma may often be just treating the emotions. On the other hand, negative emotions make the treatment of asthma guesswork. Physicians should estimate emotional influences in their patients' symptoms for an optimal evaluation of medication efficacy. Assessment and analysis of emotional factors surrounding exacerbations seems essential, e.g. emotional precipitants of asthma and asthma-evoked negative emotions. Moreover, patients should be informed about stress-induced breathlessness and the consequences of overuse of bronchodilators. When patients present with atypical symptoms, or do not properly respond to asthma medication, functional symptoms should be suspected. Psychiatric analysis may often lead to the conclusion that symptoms have a functional basis. In patients with comorbid asthma and anxiety disorders, asthma should be the focus for treatment since difficult-to-control asthma often causes anxiety problems in the first place. Moreover, panic-like symptoms in asthma are often related to sudden onset asthma exacerbations. However, in patients with comorbid asthma and depression, depression should become the focus of treatment. The reason is that optimal treatment of depressive asthmatics is probably impossible. Special issues include specific problems with children, compliance problems, and physicians' dilemmas regarding the simultaneous treatment of asthma and psychiatric symptoms.

Weight gain in bipolar disorder: pharmacological treatment as a contributing factor

OBJECTIVE

The aim of this paper was to review the association of most commonly used psychopharmacological drugs with weight gain in bipolar disorder.

METHOD

Information was retrieved from a PubMed/Medline literature search reviewing weight gain in pharmacological studies in bipolar disorder.

RESULTS

Obesity and overweight in bipolar disorder are partly related to prescribed drugs with a strong effect of clozapine and olanzapine. Lesser but still relevant weight gain is caused by quetiapine, risperidone, lithium, valproate, gabapentin and by some antidepressants. Ziprasidone, aripiprazole, carbamazepine and lamotrigine do not seem to cause significant overweight.

CONCLUSION

Careful monitoring of weight changes in patients before and after drug prescription should be implemented in the clinical routine and drugs which potentially cause weight gain should be avoided in overweight patients with bipolar disorder. Furthermore, eating habits and daily activities should be targeted as they may also have a significant impact on overall health and weight-related issues.

Feasibility and impact of a school-based intervention for families of urban adolescents with asthma: results from a randomized pilot trial

The purpose of this study was to test the feasibility and short-term outcomes of Asthma: It's a Family Affair!, a school-based intervention for adolescents with asthma and their caregivers. Twenty-four ethnic minority families with a middle school student with asthma were randomized to immediate intervention or no-treatment control. Intervention students received six group sessions on prevention and management of asthma. Caregivers received five group sessions teaching child-rearing skills to support the youth's autonomy and asthma self-management. All students attended all sessions; caregivers attended an average of three. Two months post-intervention, relative to controls, intervention caregivers reported better problem-solving with children. Intervention students were more responsible for carrying medication, took more prevention steps, and woke fewer nights from asthma. The intervention resulted in positive short-term changes in family relations, asthma management by students, and health status.

Helping children with asthma by repairing maternal-infant bonding problems

Studies about the psychology of childhood asthma have revealed that parenting difficulties are related to the development of asthma in some children. Disruptions in maternal-infant bonding are highly correlated with pediatric asthma and are presented as a cause for these parenting problems. Bonding problems are known to be caused most often by physical separation at birth or by some recent trauma in the mother's life. By using hypnosis to remove the pain of the separation or trauma in the mother, and by creating a new birth history in her imagination, some children's asthmatic symptoms have been shown to remit or greatly improve. The hypnotic method for this treatment is described.

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.

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.

Meta-Analysis of Placebo Rates in Major Depressive Disorder Trials

BACKGROUND

Placebo effects in major depressive disorder (MDD) have received much interest in the medical literature. However, few quantitative analyses have been done in homogeneous populations.

OBJECTIVE

To determine efficacy rates for placebo in patients with MDD; to quantify the correlation between efficacy and publication year, as well as between placebo and drug response rates.

DESIGN

Searching MEDLINE (1966-December 2000), EMBASE (1998-February 2001), HealthSTAR (1975-December 2000), and Cochrane (1980-December 2000) databases, randomized, placebo-controlled trials were retrieved including patients with MDD as defined by Diagnostic and Statistical Manual of Mental Disorders, 3rd and 4th editions criteria, Hamilton Rating Scale for Depression score >/=18 or Montgomery-Asberg Depression Rating Scale score >/=16, reporting successes as 50% decreases in scores after 6-8 weeks of treatment. Response rates were summarized using a random effects meta-analysis for per protocol (PP) and intent-to-treat (ITT) results.

RESULTS

We included 24 of 134 potential studies examining 4459 patients, 1786 on placebo and 2673 on an antidepressant. Placebo response rates were 45.5% (PP) and 26.9% (ITT). Correlations were significant between year and rates (PP rho 0.448, p = 0.042; ITT rho 0.557; p = 0.006), but not for active drugs. Placebo and drug rates were correlated (PP r 0.397, p = 0.020; ITT r 0.539; p = 0.002).

CONCLUSIONS

These placebo rates confirm those reported previously, but were from a homogeneous population. Although statistically significant, the correlation between drug and placebo rates was lower than others reported. During the study period, placebo rates increased linearly; active drugs did not. Correlations between placebo and drug response rates reflected moderate to strong effect sizes. We suggest that current methodology has been unsuccessful in achieving unbiased double-blind conditions not influenced by extra-trial factors, including time.

Effect of asthma in childhood on psycho-social problems in the family

OBJECTIVE

The responsibility for treating children with asthma has gradually shifted from the medical health service to the family and parents, which may cause new psycho-social problems in the family. This study aimed at describing the psycho-social effects on families having a child with asthma, and at determining whether a relation exists between the medical severity of disease and psycho-social problems.

METHODS

The findings are based on a questionnaire with the following domains: economy, work, free time, health, environment, and family, as well as a health-related medical questionnaire. They are built on psycho-social problems and on medical records.

RESULTS

The frequency of psycho-social problems was high regarding single questions in the evaluated psycho-social domains. A relation was found between high drug consumption and severe psycho-social problems. However, no positive correlation was detected among visits at the hospital's emergency department, absence from school due to asthma or disturbed sleep, and psycho-social problems. On the contrary, a negative correlation was found between absence from school due to asthma and psycho-social problems.

CONCLUSION

We conclude that for single questions in each psycho-social domain, the problem rate is high, but when taking into account the mean value of different psycho-social problems in each domain, the reported problem rate is fairly low. This method permits selection of the psycho-social domains with the most severe problems in each family. It can, therefore, be used to direct help from the medical service. We also found a relation between the medical severity of asthma and the extent of the psycho-social problems caused by the disease.

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.

Managing it: a mother's perspective of managing a pre-school child's acute asthma episode

Over the last decade asthma management strategies have required families to take increased responsibility for the assessment and treatment of their child's asthma. This exploratory descriptive study informed by grounded theory examines the experience of mothers in managing their pre-school child's acute asthma attack at home. The study reveals that mothers perceive that they are responsible for the management of their pre-school child during an acute asthma episode, a process they described as 'managing it'. This process involves mother in 'working on treatment', 'making the call', 'watching' and 'calming', while the husband/partner, family, friends and health professionals are 'supporting treatment'. This study suggests that nurses and doctors need to move away from the current paternalistic view of health care delivery in acute settings and embrace the concepts of support and partnership in the care of the pre-school child with asthma and their family.

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.

Family rituals as a protective factor for children with asthma

OBJECTIVE

To examine how one aspect of family life, notably family rituals and routines, may protect children with asthma from anxiety-related symptoms.

METHODS

Eighty-six families (43 children with asthma, 43 healthy comparison children) participated in the study. Children completed measures of anxiety (Revised Child Manifest Anxiety Scale) and health. Parents completed measures of stress (Parenting Stress Index), family rituals (Family Routines Questionnaire), and family health.

RESULTS

Families that reported more meaning in their family routines had children who reported lower levels of anxiety. Mother endorsement of family ritual meaning and father endorsement of family ritual routine were most strongly related to lower levels of anxiety. Support for the protective function of meaningful family rituals was stronger when a general health stress model was used rather than the presence or absence of asthma alone.

CONCLUSIONS

Family rituals may serve a protective function for children with asthma under conditions of heightened parenting stress.

Factors associated with self-concept in children with asthma

PURPOSE

To investigate the relationship of demographic asthma, family, and child factors with self-concept in children with asthma.

METHODS

Data were collected twice approximately 4 years apart from both the affected children and their mothers (N = 134) via interviews and self-report questionnaire.

FINDINGS

Children who demonstrated more negative attitudes toward their illness, had less satisfaction with family relationships, and used more negative coping behaviors had the poorest self-concepts. Over time, the greatest improvement in self-concept occurred in children whose attitudes and satisfaction with family relationships improved and whose use of negative coping behaviors decreased.

CONCLUSIONS

Results suggest that some children with asthma, especially girls with severe asthma, appear to be at risk for poor self-concept.

Influence of specific emotional states on autonomic reactivity and pulmonary function in asthmatic children

OBJECTIVE

Research relating depression/hopelessness to cholinergic activation suggests the hypothesis that sad emotional states evoke patterns of autonomic reactivity that predispose to cholinergically mediated airway constriction in asthma. A corollary hypothesis is that positive (e.g., happy) emotional states evoke opposing effects. The purpose of the current study is to assess whether specific emotional states (sadness and happiness) can be reliably induced, physiologically differentiated, and related to asthma-relevant physiologic (autonomic) reactivity and pulmonary function in asthmatic children.

METHOD

Twenty-four children, aged 8 to 17 years, with moderate to severe asthma, viewed the movie E.T., The Extra-Terrestrial while having their heart and respiration rate and oxygen saturation continuously recorded. Specific scenes were identified and preselected to evoke sadness, happiness, and a mixture of happiness and sadness. Self-report of emotion and indices of physiologic response were analyzed for these targeted scenes.

RESULTS

Sadness was associated with greater heart rate variability and instability of oxygen saturation compared with happiness, with mixed results for mixed happiness and sadness.

CONCLUSION

Results support sadness as evoking patterns of autonomic influence consistent with cholinergically mediated airway constriction. Happiness appears to effect autonomic patterns that would tend to relieve airway constriction.

Antidepressant treatment of depression: a metaanalysis

OBJECTIVE

To carry out a metaanalysis of antidepressant studies to calculate the effect sizes for antidepressant effect in depressive disorder.

METHOD

A metaanalysis of all antidepressant studies that included an active comparison drug as well as placebo was used to calculate the effect size. Articles were selected from a MEDLINE search for the period January 1966 to June 1995. Forty-nine studies were included in the metaanalysis.

RESULTS

The effect sizes for antidepressant treatment are moderately larger than for placebo. A larger effect size was observed in studies where objective diagnostic criteria for depression were used.

CONCLUSIONS

We conclude that the superior efficacy of antidepressants over placebo can be demonstrated.

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

OBJECTIVE

To identify characteristics within the patient and the environment that might be instrumental in triggering and maintaining an episode of asthma in children whose objective lung function tests suggested a less severe exacerbation than the subjective report and behaviour indicated, and also to investigate the efficacy of a cognitive behavioural intervention, using the paradigm of a panic anxiety disorder.

METHODOLOGY

A retrospective investigation of 23 case records and psychosocial histories, focusing on the characteristics of the sample and the number of presentations and admissions before and after the intervention, which is described.

RESULTS

Children aged 10-12 years predominated. A precipitating event triggered a fear that their condition had deteriorated in the context of a growing understanding that asthma in a child could be fatal. A reduction in presentations and admissions post-intervention is shown.

CONCLUSIONS

The paradigm of panic disorder is useful to understand the sudden onset of apparent deterioration in the severity of asthma when objective lung function tests do not support the subjective experience.

Intractable or uncontrolled asthma: psychosocial factors

The purpose of this study was to address the question of why, when there is a comparable severity of asthma, medical facilities, and treatments, some children develop controlled asthma whereas other children do not and are frequently ill. The major research questions pertained to whether families with a child with uncontrolled asthma differ from families with a child with controlled asthma as regards family characteristics and child-rearing attitudes, whether particular psychosocial variables relate to the severity of the asthma, and whether the interaction between the severity of the asthma and its controllability may clarify the role of psychosocial variables. Two studies were conducted, in which 70 asthmatic children (age range 9-15 years) and their families participated. The children and their caregivers were presented with measures assessing parental child-rearing attitudes, the problem-solving abilities of the caregivers, family functioning, and emotional disorders in the asthmatic children. Contrary to the assumptions derived from the psychosomatic family model, the findings of these studies suggest, among other things, that cohesion of family members and rigid manner of function of caregivers may have a positive rather than a negative influence on the welfare of the asthmatic child. In addition, controlled asthma was found to relate to the correct use of medication, which was predominantly evident in more structured and interdependent family environments. Of major importance is the conclusion that a distinction between controlled and uncontrolled asthma leads to a better insight into the role of psychosomatic variables than a distinction on the basis of the severity of the asthma.

Antidepressant efficacy and quality of life in depression: a double-blind study with moclobemide and fluoxetine

The efficacy of moclobemide (300-450 mg/day) was compared with fluoxetine (20-40 mg/day) in a double-blind, multicentre study in 209 patients with new episodes of depression selected from 612 consecutive depressed patients representative of those consulting psychiatric services in Finland. Antidepressant efficacy was assessed with the Hamilton Depression Rating Scale (HDRS), Montgomery-Asberg Depression Rating Scale and Clinical Global Impression (CGI). The Medical Outcome Study Short-form General Health Survey (SF-20) and 15D Measure of Quality of Life were used to measure effectiveness in terms of health-related quality of life. Efficacy was evident with both drug treatments, with 67% in the moclobemide group and 57% in the fluoxetine group having a reduction in HDRS of more than 50%. Similarly, 77% of the patients in the moclobemide group and 67% in the fluoxetine group were assessed on the CGI as much better or very much better after 6 weeks of treatment. The most commonly reported adverse events were nausea, other gastrointestinal symptoms, nervousness, dizziness and sleep disorders. Nausea was significantly more common in the fluoxetine group and was found especially in women. Premature terminations of treatment were 18% in the moclobemide and 21% in the fluoxetine group. A significant change for the better in quality of life was found in both treatment groups, even at week 2 but especially after 6 weeks of treatment. Improvement was not only seen in dimensions measuring depression or mental health but also in other dimensions.