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

A Comprehensive Review of the Intersection Between Asthma and Depression

Objective To emphasize the necessity for increased research in this field, incorporating depression into the preventative, diagnostic, and therapeutic considerations for asthma. Additionally, we seek to highlight upcoming advancements that can be applied to simultaneously address these comorbidities, ultimately improving the overall well-being and quality of life for individuals coping with these conditions.Methods A rigorous search in PubMed using the MeSH terms "asthma" and "depression" was performed, and papers were screened by the authors in view of their eligibility to contribute to the study.Results There exists a correlation between these two conditions, with specific biological mechanisms and genetic factors playing a crucial role in their concurrent occurrence. In this review, we present preclinical and clinical research data, shed light on the possible mechanisms contributing to the co-occurrence of symptoms associated with both asthma and depression, and explore the intricate relationship between both conditions.Conclusion The evidence presented here supports the existence of a correlation between asthma and depression. By acknowledging these shared biological mechanisms, genetic factors, and epidemiological trends, we can formulate more efficacious strategies for addressing the dual impact of asthma and depression.

Neighborhood characteristics and ataque de nervios: the role of neighborhood violence

Ataque de nervios is a Latina/o idiom of distress that may occur as a culturally sanctioned response to acute stressful experiences, particularly relating to grief, threat, family conflict, and a breakdown in social networks. The contextual factors associated with ataque de nervios have received little attention in research. This study examined the association between neighborhood factors and the experience of ataque de nervios among a sample of Latinas/os participating in the Latino Health and Well-Being Project in the northeastern United States. We examined the association between neighborhood cohesion, safety, trust, and violence and ataque de nervios. In multivariate logistic regression models, neighborhood violence was associated with ataque de nervios (p = .02), with each unit increase in the neighborhood violence scale being associated with 1.36 times greater odds of experiencing ataque de nervios. None of the other neighborhood variables were significantly associated with ataque de nervios. The positive association between neighborhood violence and the experience of ataque de nervios makes a further case for policy efforts and other investments to reduce neighborhood violence.

Family Chaos and Asthma Control

OBJECTIVES

Asthma is a highly prevalent childhood chronic disease, with particularly high rates among poor and minority youth. Psychosocial factors have been linked to asthma severity but remain poorly understood. This study examined (1) relationships between parent and child depression and posttraumatic stress disorder (PTSD) symptoms, family functioning, and child asthma control in a sample of urban minority youth with uncontrolled asthma and (2) family functioning as a pathway linking parent depression and asthma outcomes.

METHODS

Data were drawn from the baseline cohort of a randomized trial testing community interventions for children aged 5 to 16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was defined by using the Asthma Control Test and Childhood Asthma Control Test, activity limitation, and previous-12-month asthma severity. Psychosocial measures included parent and child depression and PTSD symptoms, family chaos, and parent social support.

RESULTS

Parent and child depression symptoms, but not PTSD, were associated with worse asthma control (β = -.20 [SE = 0.06] and β = -.12 [SE = -.03]; P < .001). Family chaos corresponded to worse asthma control, even when controlling for parent and child depression (β = -.33; [SE = 0.15]; P < .05), and was a mediator of the parent depression-asthma path. Emotional triggers of asthma also mediated the parent depression-asthma relationship.

CONCLUSIONS

Findings highlight family chaos as a mechanism underlying the relationship between parent depression and child asthma control. Addressing parent and child depression, family routines, and predictability may optimize asthma outcomes.

Anxiety and Depression in Adolescents with Severe Asthma and in Their Parents: Preliminary Results after 1 Year of Treatment

Emotional problems, such as anxiety and depression, are a relevant co-morbidity in severe asthma. Anxiety and depression may also be common in the parents of asthmatic adolescents. The current study evaluated anxious and depressive symptoms in 40 adolescents suffering from severe asthma, and in their parents, before and after 1 year of treatment, tailored according to validated asthma guidelines. We used the HADS (Hospital Anxiety Depression Scale) questionnaire for the adolescents, and HADS, STAY (State-Trait Anxiety Inventory), and BDI (Beck Depression Inventory) questionnaires for their parents. We also considered the grade of asthma severity before and after 1 year of treatment. The current study demonstrated that anxiety and depression are common in both the adolescents suffering from severe asthma and their parents. Anxious and depressive symptoms were correlated between adolescents and their parents. Asthma treatment improved the asthma severity in almost all adolescents. However, the parental anxiety and depression remained unchanged at the end of the asthma treatment. Thus, a psychological assessment could be included in the adolescent severe asthma work-up, involving both the adolescents and their parents.

Living well with severe asthma

Living well with severe asthma can be challenging. People with severe asthma can be refractory to treatment, can experience poor symptom control and are at a heightened risk of death. Patients experience symptoms of shortness of breath, chest tightness, cough and wheeze. These symptoms influence many aspects of an individual's life, resulting in emotional, financial, functional and medication-related burdens that negatively impact quality of life. Quality of life is known to be influenced by individual levels of satisfaction that stem from real-life treatment experiences. This experience is portrayed through the lens of the patient, which is commonly referred to as the patient perspective. The patient perspective is only one element of the patient experience. It influences health status, which, in severe asthma, is commonly assessed using validated health-related quality of life measures. A positive patient perspective may be achieved with implementation of management strategies tailored to individual needs. Management strategies developed in partnership between the patient, the severe asthma multidisciplinary team and the general practitioner may minimise disease-related impairment, allowing patients to live well with severe asthma.

Key points

Despite advances in treatment over the past decade, the experience of living with severe asthma has not significantly improved, with high levels of burden influencing the patient perspective.The impact of severe disease is not only restricted to asthma symptoms and acute attacks. It causes significant emotional, financial, functional and medication-related burdens, leading to impaired health-related quality of life.Clinical outcomes should not be stand-alone measures in severe asthma. Nonclinical measures should also be considered when evaluating health-related quality of life.Disease burden may be minimised and quality of life improved via self-management strategies, including education sessions, written asthma action plans, symptom monitoring, breathing exercises, physical activity and psychotherapeutic interventions.

Educational aims

To demonstrate the importance of the patient perspective in severe asthma.To identify the significant levels of disease burden associated with severe asthma.To discuss quality of life in severe asthma.To outline strategies that increase well-being in severe asthma.

Routinely sleeping away from home and the association with child asthma readmission

The increased prevalence of transitions between households may have implications for child asthma morbidity. We, therefore, sought to enumerate the prevalence of regularly spending nights sleeping away from home among children admitted to the hospital for asthma and to examine the relationship of nights away to asthma-related readmission. This was a population-based, prospective cohort of 774 children, aged 1-16 years, who were admitted with asthma or bronchodilator-responsive wheezing and enrolled in the Greater Cincinnati Asthma Risks Study. The study took place at Cincinnati Children's Hospital Medical Center, an urban, academic children's hospital in the Midwest. The primary exposure was regularly spending nights away from home. Selected covariates included caregiver marital status, shift work, child's race, income, psychological distress, and running out of/not having medications on hand. The primary outcome was asthma-related readmission within 12 months. A total of 19 % were readmitted within 12 months. The 33 % of children that spent ≥1 night away from home per week were significantly more likely to be readmitted than those who spent no nights away (25 % vs. 16 %, p = 0.002). Spending nights away from home [adjusted relative risk (aRR) 1.5, 95 % confidence interval (CI) 1.2-2.0] and lower income (aRR 2.6, 95 % CI 1.1-6.4) were the strongest independent predictors of readmission after adjusting for child age, gender, and race, and caregiver marital status, shift work, risk of psychological distress, and running out of meds. Increased awareness of the multiple settings in which children with asthma live may help shape more comprehensive approaches to asthma care.

Systematic Review and Meta-Analysis of Anxious and Depressive Symptoms in Caregivers of Children With Asthma

OBJECTIVE

To provide a review of the literature comparing anxious and depressive symptoms in caregivers of children with asthma with caregivers of healthy children.

METHOD

A systematic search identified 25 studies from 17 articles, reporting outcomes on 4,300 caregivers of children with asthma and 25,064 caregivers of healthy children.

RESULTS

Overall, anxious (d = 0.50) and depressive symptoms (d = 0.44) were higher in caregivers of children with asthma compared with caregivers of healthy children. Age, site of recruitment, and whether the asthma diagnosis was medically confirmed were included as potential moderators. The relationship between parental psychopathology and asthma was stronger in those with medically confirmed asthma and participants recruited from clinical settings. Other moderators were not significant.

CONCLUSIONS

Caregivers of children with asthma appear to have greater anxious and depressive symptoms than caregivers of healthy children, but the reasons are unclear. More research that investigates modifiable factors that may moderate this association is urgently needed.

Structural and Functional Support in the Prediction of Smoking Cessation in Caregivers of Children with Asthma

Caregivers of children with asthma smoke at rates similar to the general population. Research on the relative importance of structural or functional social support in smoking cessation has been mixed. Participants were smokers (N = 154) who were caregivers of children with asthma. Both functional (Interpersonal Support Evaluation List) and structural social support (living with another smoker, partner status, and the proportion of smoking friends) were measured at baseline. Participants received an asthma-education and smoking cessation intervention based on Motivational Interviewing. Biochemically-verified abstinence was assessed at six months post treatment. Results indicated that functional support predicted smoking abstinence even when controlling for relevant covariates and structural support (OR = .896, p = .025). Exploratory analyses revealed that this effect was driven primarily by the self-esteem ISEL subscale. Smoking cessation that focuses on building general functional support, particularly self-esteem support, may be beneficial for smoking cessation in caregivers of children with asthma.

Health-related quality of life in paediatric asthma: Children's and parents' perspectives

This study aimed to describe the quality of life of a group of Portuguese children with asthma, to explore the association between health-related quality of life (HRQL), asthma severity, child's characteristics and parental psychopathology. Additionally, the concordance between the children's HRQL self-report and the parents' HRQL proxy was assessed. Fifty children with asthma (7-13 years) and their primary caregiver participated in the study by filling out the DISABKIDS-37 and other self-report questionnaires. Results for the DISABKIDS-37 supported a good internal consistency and associations between the facets and the global score, in the two versions of the questionnaire. Children and their caregivers scored the child's HRQL positively. Parents of children with an asthma diagnosis for a longer period reported better HRQL. The distribution of the HRQL scores in the child's version showed differences across categories of subjective severity rated by children and across categories of asthma control assessed by the physician. The group with uncontrolled asthma obtained lower HRQL scores than the other groups. There was a lack of convergence between self-report and parent's report of HRQL, with the exception of the physical limitation facet. Asthma severity assessed by the child and parental psychopathology explained 28% of the variance in the children's self-rated HRQL. Findings reinforce that children and caregivers' reports are complementary to each other and support the recommendation to use both information sources.

Naturalistically observed conflict and youth asthma symptoms

OBJECTIVE

To investigate the links between naturalistically observed conflict, self-reported caregiver-youth conflict, and youth asthma symptoms.

METHOD

Fifty-four youth with asthma (age range: 10-17 years) wore the Electronically Activated Recorder (EAR) for a 4-day period to assess interpersonal conflict and caregiver-youth conflict as they occur in daily life. Conflict also was assessed with baseline self-report questionnaires and daily diaries completed by youth participants and their caregivers. Asthma symptoms were assessed using daily diaries, baseline self-reports, and wheezing, as coded from the EAR.

RESULTS

EAR-observed measures of conflict were strongly associated with self-reported asthma symptoms (both baseline and daily diaries) and wheezing coded from the EAR. Further, when entered together in regression analyses, youth daily reports of negative caregiver-youth interactions and EAR-observed conflict uniquely predicted asthma symptoms; only EAR-observed conflict was associated with EAR-observed wheezing.

CONCLUSION

These findings demonstrate the potential impact of daily conflict on youth asthma symptoms and the importance of assessing conflict as it occurs in everyday life. More broadly, they point to the importance of formulating a clear picture of family interactions outside of the lab, which is essential for understanding how family relationships "get under the skin" to affect youth health.

Asthma knowledge, subjective assessment of severity and symptom perception in parents of children with asthma

OBJECTIVES

This study aimed to confirm the tendency for parents to underestimate the severity of symptoms and the poor consistency between parents' reports of symptoms and the physicians' evaluation of asthma control. Additionally, the relationship between parents' asthma knowledge and their report of symptoms and estimation of asthma severity was explored.

METHODS

Fifty children (M = 10.5 years) and their caregivers were recruited from two Portuguese hospitals. A measure of asthma symptoms report (Severity of Chronic Asthma, SCA) and a subjective evaluation of asthma severity were collected and compared with physicians' ratings of asthma control, as well as parents' knowledge about asthma (Asthma Knowledge Questionnaire, AKQ) and emotional disturbance (Brief Symptom Inventory, BSI).

RESULTS

Although parents' evaluation of perceived asthma severity was moderately correlated to symptoms reported, results confirm an inconsistency between parents' reports of symptoms, their subjective rating of asthma severity and the physician's rating of clinical control, revealing a tendency for parents to underestimate disease severity and to underreport asthma symptoms. Asthma knowledge was not significantly correlated to SCA or to parents' subjective evaluation of asthma severity. Parents with poorer knowledge reported fewer symptoms.

CONCLUSIONS

Portuguese parents revealed a tendency to overestimate their child's level of asthma control and a low level of asthma knowledge. Parents' education, psychological disturbance and time since diagnosis were associated with asthma knowledge. Parents' knowledge was not related to the child's asthma outcomes or to their subjective evaluation of asthma severity or symptoms reports. Parents' asthma knowledge deficits, underreporting of symptoms and underestimation of asthma severity, may affect parent-provider communication and impede asthma control.

Asthma and mental health among youth: etiology, current knowledge and future directions

Asthma and mental health problems, such as depression, anxiety and behavior disorders, are common among youth and are significant sources of morbidity. There is a consistent association between asthma and anxiety/depression and a less consistent association between asthma and behavior disorders. Possible biological and psychological mechanisms may include inflammatory processes as well as the stress of having to live with a life-threatening condition. Future studies are warranted with longitudinal designs to establish temporality as well as measures of potential confounds. Biological and psychological measures would complement the longitudinal design to further establish causality. In addition, more information on the degree to which asthma and mental health have reciprocal influences on each other over time - and the mechanisms of these relationships - are needed in order to develop more effective intervention strategies to improve asthma control and mental health among those with both.

Asthma Network of West Michigan: a model of home-based case management for asthma

Asthma remains a serious health risk in the United States, particularly among children from low-income families. This article presents an overview of the Asthma Network of West Michigan, the local asthma coalition serving West Michigan, and its intensive home-based case management model for individuals with uncontrolled asthma. The Asthma Network is believed to be the first grassroots asthma coalition in the nation to contract with health plans and obtain reimbursement for these services. The Asthma Network's program has had a positive impact on health care use as well as cost savings, and its model has been replicated in other communities.

Factors related to emotional responses in school-aged children who have asthma

A systematic review of the literature was performed to answer the following questions (a) What factors contribute to the emotional responses of school-age children who have asthma? (b) What are the potential gaps in the literature regarding the emotional responses of school-age children (ages 6-12) who have asthma? (c) Are children with a lower socioeconomic status (SES) and those who are minorities represented in the literature proportionate to their prevalence? Two main focus areas regarding emotional responses were identified: (a) factors related to children who have asthma and (b) factors related to caregivers of children who have asthma. Internalizing disorders were reported consistently for children and caregivers of children who have asthma. Negative consequences of asthma for children included panic and asthma attacks, missed school days, and behavioral problems. Issues for caregivers included higher levels of anxiety and depressive symptoms, asthma management deficits, and lower caregiver warmth and involvement. Gaps in the literature included separated studies for children ages 6-12, a lack of a standardized method to define SES, studies that were of a more experimental nature, and a disparate number of studies of minority children and caregivers relative to their asthma prevalence.

The health status of youth in Puerto Rico

BACKGROUND

Few population-based studies have assessed health outcomes and health care access and use among youth in the US Commonwealth of Puerto Rico.

METHODS

Data are from an island population-based sample of 337 youth, 10 to 17 years old, who participated in the Asthma, Depression, and Anxiety in Puerto Rican Youth Study. In-person interviews with youth and caregivers assessed self-rated physical and mental health, weight status, diagnosed health conditions, and health care access and use.

RESULTS

Island Puerto Rican youth report slightly worse physical and mental health than mainland youth. Puerto Rican youth have high rates of asthma, headaches, and stomachaches. Also, 6 in 10 island youth use public health insurance, and 1 in 3 regularly receive care at the emergency department.

CONCLUSIONS

Island Puerto Rican youth are at a health disadvantage compared with mainland youth. Public health research is needed to fully understand and combat health challenges among Puerto Rican youth.

Maternal mental health and social support: effect on childhood atopic and non-atopic asthma symptoms

BACKGROUND

Atopic and non-atopic asthma have distinct risk factors and immunological mechanisms, and few studies differentiate between the impacts of psychosocial factors on the prevalence of these disease phenotypes. The authors aimed to identify whether the effect of maternal mental health on prevalence of asthma symptoms differs between atopic and non-atopic children, taking into account family social support.

METHODS

This is a cross-sectional study of 1013 children participating in the Social Change Allergy and Asthma in Latin America project. Psychosocial data were collected through a household survey utilising Self-Reporting Questionnaire and Medical Outcome Study Social Support Scale. Socioeconomic and wheezing information was obtained through the questionnaire of the International Study of Allergy and Asthma in Childhood, and level of allergen-specific IgE was measured to identify atopy. Polytomous logistic regression was used to estimate the association between maternal mental health, social support and atopic and non-atopic wheezing. Effect modification was evaluated through stratified polytomous regression according to social support level.

RESULTS

Maternal mental disorder had the same impact on atopic and non-atopic wheezing, even after adjusting for confounding variables. Affective, material and informational supports had protective effects on non-atopic asthma, and there is some evidence that social supports may act as a buffer for the impact of maternal mental disorder on non-atopic wheezing.

CONCLUSION

Poor maternal mental health is positively associated with wheezing, independent of whether asthma is atopic or non-atopic, but perception of high levels of social support appears to buffer this relationship in non-atopic wheezers only.

Distressed fathers and their children: a review of the literature

BACKGROUND

Many men diagnosed with mental health problems are also fathers. This literature review addresses issues relating to both the fathering role taken on by men who have mental health problems as well as the impact of their mental health on their children.

MATERIAL

An integrative review of the literature was conducted from studies originating in four countries, resulting in an analysis of 31 journal articles.

DISCUSSION AND CONCLUSIONS

Most of the quantitative literature focuses on the many risks and negative outcomes for children. However, qualitative studies suggest positive outcomes such as strong parent-child relationships, which demand further attention both in research and in practice.

Genetic variations in the ADAMTS12 gene are associated with schizophrenia in Puerto Rican patients of Spanish descent

ADAMTS12 belongs to the family of metalloproteinases that mediate a communication between specific cell types and play a key role in the regulation of normal tissue development, remodeling, and degradation. Members of this family have been implicated in neurodegenerative and neuroinflammatory, as well as in muscular-skeletal, cardiovascular, respiratory and renal diseases, and cancer. Several metalloproteinases have been associated with schizophrenia. In our previous study of the pedigree from a genetic isolate of Spanish origin in Puerto Rico, we identified a schizophrenia susceptibility locus on chromosome 5p13 containing ADAMTS12. This gene, therefore, is not only a functional but also a positional candidate gene for susceptibility to the disorder. In order to examine possible involvement of ADAMTS12 in schizophrenia, we performed mutation analysis of the coding, 5'- and 3'-untranslated, and putative promoter regions of the gene in affected members of the pedigree and identified 18 sequence variants segregated with schizophrenia. We then tested these variants in 135 unrelated Puerto Rican schizophrenia patients of Spanish origin and 203 controls and identified the intronic variant rs256792 (P = 0.0035; OR = 1.59; 95% CI = 1.16-2.17) and the two-SNP haplotype rs256603-rs256792 (P = 0.0023; OR = 1.62; 95% CI = 1.19-2.21) associated with the disorder. The association remained significant after correction for multiple testing. Our data support the hypothesis that genetic variations in ADAMTS12 influence the risk of schizophrenia.

Do Puerto Rican youth with asthma and obesity have higher odds for mental health disorders?

BACKGROUND

Island Puerto Rican (PR) youth experience disproportionately high asthma and obesity rates compared with other racial/ethnic groups on the U.S. mainland. Previous research has demonstrated associations of chronic disease with psychiatric disorders.

OBJECTIVE

We examined the relationship among anxiety/depressive disorders, asthma, and obesity in an epidemiologic community sample of youth.

METHODS

The sample (n = 656) was derived from the second wave of an island-wide probabilistic representative household sample of PR youth stratified and based on whether or not they had a diagnosis of asthma and/or depressive/anxiety disorder. For this study, we used the subpopulation ages 10-19 years.

RESULTS

Asthma and obesity were significantly related to higher odds of depressive/anxiety disorders in youth. Obesity moderated the relationship between asthma attacks and depressive/anxiety disorders. The relationship between asthma attack and higher odds for depressive/anxiety disorders was only present in the non-obese group. Among the obese, females show a significant increase from 11% to 36% in the prevalence of anxiety/depressive disorders. Asthma and obesity were highly prevalent and a significant association was found between asthma attack and depressive/anxiety disorders. The effects of asthma and obesity were not additive; the prevalence for psychiatric disorder for those having both conditions did not increase above the prevalence associated having only one of the conditions.

CONCLUSIONS

Future studies should consider including longitudinal designs and examine the extent to which important variables not included in this study, such as body image dissatisfaction (particularly among females), teasing, and discrimination may moderate the relationship among obesity and depressive and anxiety disorders in youth.

Behavior problems and prevalence of asthma symptoms among Brazilian children

OBJECTIVE

Asthma is the most common chronic disease in childhood and has been designated a public health problem due to the increase in its prevalence in recent decades, the amount of health service expenditure it absorbs and an absence of consensus about its etiology. The relationships among psychosocial factors and the occurrence, symptomatology, and severity of asthma have recently been considered. There is still controversy about the association between asthma and a child's mental health, since the pathways through which this relationship is established are complex and not well researched. This study aims to investigate whether behavior problems are associated with the prevalence of asthma symptoms in a large urban center in Latin America.

METHODS

It is a cross-section study of 869 children between 6 and 12 years old, residents of Salvador, Brazil. The International Study of Allergy and Asthma in Childhood (ISAAC) instrument was used to evaluate prevalence of asthma symptoms. The Child Behavior Checklist (CBCL) was employed to evaluate behavioral problems.

RESULTS

19.26% (n=212) of the children presented symptoms of asthma. 35% were classified as having clinical behavioral problems. Poisson's robust regression model demonstrated a statistically significant association between the presence of behavioral problems and asthma symptoms occurrence (PR: 1.43; 95% CI: 1.10-1.85).

CONCLUSION

These results suggest an association between behavioral problems and pediatric asthma, and support the inclusion of mental health care in the provision of services for asthma morbidity.

The role of caregiver major depression in the relationship between anxiety disorders and asthma attacks in island Puerto Rican youth and young adults

The goal of this study was to assess whether the association between asthma attacks and anxiety disorders in youth/young adults is reduced after adjusting for the caregivers' psychiatric disorders. An island-wide probability sample of 641 households in Puerto Rico with youth/young adults between ages 10 and 25 years participated along with their caregivers. The Diagnostic Interview Schedule for Children and the Composite International Diagnostic Interview were conducted to assess anxiety and depressive disorders. Youth/young adults with an anxiety disorder were more likely to have a lifetime history of asthma attacks versus youth/young adults without an anxiety disorder. Caregivers of participants with asthma attacks were more likely to have major depression than did the caregivers of participants without asthma attacks. The association between asthma attacks and anxiety disorders in youth was no longer significant after adjustment for caregiver major depression. It is important to consider the role of caregiver depression in asthma-anxiety comorbidity in youth/young adults.

Disparities in asthma medication dispensing patterns: the case of pediatric asthma in Puerto Rico

BACKGROUND

Disparities exist in asthma medication dispensing between children with public insurance and those with private insurance under a Managed Care Medicaid system in Puerto Rico.

OBJECTIVES

Island-wide medical claims data were used to examine the extent to which differences between the private and public health care sectors affect medication dispensing and health care utilization among asthmatic children.

METHODS

Children 3-18 years old with at least one service claim [outpatient, hospitalization, or emergency department (ED) visit] for asthma or reactive airway disease from 2005 to 2006 were selected. Chi-square analyses compared medication dispensing and health care utilization between the public and private sectors. Negative binomial regression identified factors associated with the mean dispensing rate of prescriptions for anti-inflammatory controller medication (CM).

RESULTS

Private insurance families (n = 28,088) were dispensed significantly more CM (48.3% vs. 12.0%) and quick relief medication (47.4% vs. 44.6%) than public insurance families (n = 13,220). The dispensing of inhaled corticosteroids (24.4% vs. 6.7%) and leukotriene modifiers and cromolyn (31.4% vs. 5.7%) was dramatically higher in the private sector. In contrast, emergency room use was significantly higher among public insurance children (51.7% vs. 13.8%). Multivariate analysis showed that age, number of β-agonists, and type of insurance was associated with CM dispensing; private insurance showed the greatest effect.

CONCLUSION

Asthmatic Puerto Rican children enrolled in public insurance were significantly less likely to be dispensed CM than children with private insurance; suggesting that under-treatment of public insured children may substantially contribute to increased asthma morbidity in this population as evidenced by significantly higher rates of ED visits.

CAPSULE SUMMARY

A disparity exists in asthma medication dispensing between children with public insurance compared with those with private insurance under a Managed Care Medicaid system in Puerto Rico. If asthma disparities in medication dispensing are to be reduced, then a better understanding of the complex ways in which multiple variables related to the health care system policies, socioeconomic factors, family and provider interactions, as well as the relative weight that each one contributes to the observed inequalities is needed.

Depressive symptoms amongst asthmatic children's caregivers

We wanted to find out, whether the number of depressive symptoms is higher amongst asthmatic children's caregivers, compared to international data, to the Hungarian population average, and to parents of children with chronic renal disease. Are these depressive symptoms connected to the children's psychological status, asthma severity or current asthma symptoms? One-hundred and eight, 7- to 17-yr-old asthmatic children were enrolled, who have been treated at the Semmelweis University, First Department of Pediatrics. Children were suffering from asthma for at least 1 yr, with a median of 8 yr (1-16 yr), they started to develop asthmatic symptoms between the age of 0.5-14 yr (median: 3 yr). We also identified 27 children with chronic renal diseases and their caregivers, who functioned as a control group. Children were asked to complete the Hungarian-validated versions of the Child Depression Inventory, the Spielberger State Anxiety Inventory for Children and the Juniper Pediatric Asthma Quality of Life Questionnaire. Asthma severity and current symptoms were also documented, 56% had no symptoms on the preceding week. Caregivers were asked to complete the Hungarian versions of the Beck Depression Inventory (BDI) short form, the Spielberger Anxiety Inventory and the Juniper Pediatric Asthma Caregivers' Quality of Life Questionnaire. Caregivers of asthmatic children had significantly more depressive symptoms (7.73 +/- 6.69 s.d.) than the age-specific normal population (p < 0.01). Caregivers of renal patients also experience more depressive symptoms (9.61 +/- 7.43 s.d.) than their healthy peers, but difference between the two chronic diseases' group did not prove to be significant. Asthmatic children's caregivers who scored more points on the BDI than the population average suffer from more anxiety symptoms, but their quality of life is not worse than the caregivers' with less depressive points. Depressive symptoms were neither connected to the children's psychological and asthmatic symptoms nor quality of life. Amongst caregivers of asthmatic children, at least mild depressive symptoms were represented amongst 39% of men and 33% of women. Gender difference was not significant, despite observations in the normal Hungarian population. Amongst caregivers of renal patients, depressive symptoms were represented in 14% of men and 50% of women. Gender difference was significant. (p = 0.05). Significant difference was observed between male asthmatic and renal caregivers, albeit difference was not significant between the female groups. No difference was found in depressive symptoms according to caregivers' level of education. Caregivers of children with asthma have more depressive symptoms than the average Hungarian population, but their results do not differ from caregivers taking care of children with chronic renal diseases. Caregivers of asthmatic children having at least mild depressive symptoms tend to have higher anxiety symptoms as well. Up to date, childhood chronic disease management and long-term care should also focus on parental psychology, mainly on depression and anxiety, as prevalence is higher than in the average population.

Child and family psychiatric and psychological factors associated with child physical health problems: results from the Boricua youth study

To examine associations among Puerto Rican children's physical health problems and children's internalizing disorders, parental psychopathology and acculturative stress, and family factors. A population-based probability sample of 2491 Puerto Rican children, aged between 5 and 13 years, and caregivers from the South Bronx and the U.S. Commonwealth of Puerto Rico participated in this study. The parent version of the Diagnostic Interview Schedule for Children-IV was used to assess children's internalizing disorders. Children's anxiety disorders, parental psychopathology, and acculturative stress were associated with childhood asthma, abdominal pain, and headaches. Children's depressive disorders, maternal acceptance, and family functioning were associated with abdominal pain and headaches. Parents of children living in Puerto Rico were more likely to report physical health problems in their children than in the Bronx. Children's internalizing disorders, parental psychopathology, and acculturative stress may be important areas to target among Puerto Rican children with physical health problems.

Ataques de nervios and somatic complaints among island and mainland Puerto Rican children

Previous research has documented the association between the Latino cultural idiom of distress, ataques de nervios (i.e., "attacks of nerves"), and unexplained neurological symptoms among adults. However, the associations between ataques and somatic complaints in children have not been sufficiently explored.

AIMS

In this study, we assessed the relation between this anxiety-related experience, henceforth ataques, and somatic complaints in a probability sample of Puerto Rican youth, ages 5-13 years, living in San Juan, Puerto Rico (N = 1353) and in the South Bronx, New York (N = 1138). When both sites were combined, children with ataques were significantly more likely to have either a lifetime prevalence of asthma or headaches, and tended to have more stomach aches and a history of epilepsy or seizure than children without ataques. Further within site analyses showed a similar patterning of complaints for the South Bronx sample as for the combined sample. However, children in San Juan with ataques were only slightly more likely to experience headaches, and at risk for injury, than those without ataques. In addition, comparisons between ataque sufferers across sites indicated that children in San Juan with ataques were at elevated risk for serious illness or injury in comparison to those in the South Bronx with ataques. Ataques are significantly associated with a wide range of physical complaints in Puerto Rican youth. However, their pattern of associations differs by context.

Maternal mental health and childhood asthma among Puerto Rican youth: the role of prenatal smoking

RATIONALE

Childhood asthma is a major public health problem, with mainland and island Puerto Rican children having the highest asthma rates of any ethnic group in the United States.

OBJECTIVES

To examine the relationship between maternal mental health problems, prenatal smoking, and risk of asthma among children in Puerto Rico and the Bronx, New York.

METHODS

A cross-sectional community-based study was conducted in the South Bronx in New York City and the San Juan Standard Metropolitan Area in Puerto Rico. Participants were Puerto Rican children 5 to 13 years of age and their adult caretakers with probability samples of children 5 to 13 years of age and their caregivers drawn at two sites: the South Bronx in New York City (n = 1,135) and San Juan and Caguas, Puerto Rico (n = 1,351).

MEASUREMENTS

Self-reported maternal mental health, prenatal smoking, and rates of childhood asthma. Results. Maternal mental health problems were associated with significantly higher levels of prenatal smoking, compared with that among women without mental health problems (p < 0.0001). Both maternal mental health problems and prenatal smoking appear to make a contribution to increased odds of asthma among youth. After adjusting for prenatal smoking, the relationship between maternal mental health problems and childhood asthma was no longer statistically significant.

CONCLUSIONS

Previous research suggests children of Puerto Rican descent are especially vulnerable to asthma. Our results suggest that maternal mental health problems and prenatal smoking are both associated with increased odds of asthma among Puerto Rican youth and that prenatal smoking may partly explain the observed relationship between maternal psychopathology and childhood asthma. Future longitudinal and geographically diverse epidemiological studies may help to identify the role of both maternal mental health problems and prenatal smoking in the health disparities in childhood asthma.

High prevalence of depression amongst mothers of children with asthma

OBJECTIVE

To compare the prevalence of depression among mothers of children with asthma and mothers of children without asthma and to investigate the influence of severity and duration of childhood asthma on maternal depression.

METHOD

A cross-sectional study including 80 mothers of children with asthma and 160 mothers of children without asthma who attended the pediatric outpatient clinics of a teaching hospital in Southern Brazil. The main outcome measure was the presence of depression in these mothers, measured by the Beck Depression Inventory.

RESULTS

The prevalence of depression was higher among mothers of asthmatic children compared with mothers of non-asthmatic children (43.8% vs. 17.5%, p < 0.001), with an adjusted prevalence ratio of 2.74 (95% confidence interval [CI] 1.76-4.25). Mothers of children with persistent asthma had a higher prevalence of depression than mothers of children with intermittent asthma (62.8% vs. 21.6%, p < 0.001), with an adjusted prevalence ratio of 2.77 (95% CI: 1.46-5.27). No significant association was observed between duration of childhood asthma and maternal depression.

CONCLUSION

Mothers of children with asthma have a higher prevalence of depression than mothers of children without asthma. The severity but not duration of childhood asthma is associated with maternal depression.

Measuring outcomes in a longitudinal birth cohort

Longitudinal studies are often focussed on specific outcomes to address predetermined hypotheses. Nevertheless, many discoveries have been made with data collected that were not part of the original design. Measurement of a broad range of outcomes is therefore important. Here we describe examples of the types of outcome that a birth cohort should collect, with emphasis on accuracy. We emphasise the use of continuous traits as well as of dichotomous outcomes, using a variety of examples.

Minor psychiatric disorders in mothers and asthma in children

OBJECTIVE

Recent studies have shown that asthma represents a major health issue not only in children of developed countries but also in urban centers in some middle-income countries. Brazil has one of the highest prevalences of asthma worldwide. Recently, interest has grown in the relationship between psychosocial factors and asthma. This article examines the relationship between maternal mental disorders and the prevalence of asthma in low-income children from an inner city area of Salvador in the state of Bahia, Brazil, and is part of the SCAALA program (Social Change, Allergy and Asthma in Latin America).

PATIENTS AND METHODS

A total of 1,087 children between the ages of 5 and 12 were investigated, together with their mothers. The mothers' mental health was evaluated using the SRQ-20, an instrument for the psychiatric screening of minor psychiatric disorders (depression, anxiety and somatic complaints). The prevalence of asthma was investigated using the ISAAC survey, a standardized, validated questionnaire for asthma and other allergic diseases. Cases were defined as asthma if the patient reported having had wheezing in the previous 12 months in addition to at least one of the following: having asthma, wheezing while exercising, waking during the night because of wheezing, or having had at least four episodes of wheezing in the previous 12 months. Atopy was defined as a positive skin prick test to allergens.

RESULTS AND CONCLUSION

The presence of minor psychiatric disorders in the mothers was significantly associated with the presence of asthma in the children, and this association was consistent with all forms of asthma, irrespective of whether it was atopic or nonatopic. Future studies should be carried out to further investigate this association and the potential biological mechanisms involved. Programs for asthma control should include strategies for stress reduction and psychological support for the families of asthmatic children.

A review of candidate pathways underlying the association between asthma and major depressive disorder

OBJECTIVE

To consider the mechanisms that may link asthma and major depressive disorder (MDD). Asthma and MDD co-occur at higher rates than expected, but whether this reflects shared underlying pathophysiological mechanisms is not known.

METHODS

A review of the epidemiological data linking asthma and MDD was conducted and the possible biological mechanisms that could account for the high rate of this comorbidity were reviewed.

RESULTS

MDD occurs in almost half of patients with asthma assessed in tertiary care centers. Dysregulation of the hypothalamic pituitary adrenal axis may predispose people to both MDD and asthma, and similar alterations in the immune, autonomic nervous, and other key systems are apparent and may contribute to this increased risk of co-occurrence.

CONCLUSIONS

High rates of MDD in asthma may result from the stress of chronic illness, the medications used to treat it, or a combination of the two. The high level of co-occurrence may also reflect dysregulation of certain stress-sensitive biological processes that contribute to the pathophysiology of both conditions.

Estimating adjusted prevalence ratio in clustered cross-sectional epidemiological data

Background

Many epidemiologic studies report the odds ratio as a measure of association for cross-sectional studies with common outcomes. In such cases, the prevalence ratios may not be inferred from the estimated odds ratios. This paper overviews the most commonly used procedures to obtain adjusted prevalence ratios and extends the discussion to the analysis of clustered cross-sectional studies.

Methods

Prevalence ratios(PR) were estimated using logistic models with random effects. Their 95% confidence intervals were obtained using delta method and clustered bootstrap. The performance of these approaches was evaluated through simulation studies. Using data from two studies with health-related outcomes in children, we discuss the interpretation of the measures of association and their implications.

Results

The results from data analysis highlighted major differences between estimated OR and PR. Results from simulation studies indicate an improved performance of delta method compared to bootstrap when there are small number of clusters.

Conclusion

We recommend the use of logistic model with random effects for analysis of clustered data. The choice of method to estimate confidence intervals for PR (delta or bootstrap method) should be based on study design.

Parental mental and pain-related health and pediatric ambulatory care sensitive emergency department visits and hospitalizations

OBJECTIVE

To investigate the types of parental psychiatric and pain-related (PR) conditions that are associated with inadequate management of children's health and medical needs.

DATA SOURCES

The 1997-1998 Thomson/Medstat MarketScan claims and administrative dataset.

STUDY DESIGN

A cross-sectional study that assessed the associations between parents' claims for psychiatric and PR conditions, and their children's well-child care as well as emergency department (ED) visits and hospitalizations for conditions that can be treated effectively in outpatient settings (ambulatory care sensitive [ACS] conditions).

DATA EXTRACTION METHODS

Claims were extracted for 258,313 children of ages 0-17 years and their parents, who had insurance coverage for a full 2-year period.

PRINCIPLE FINDINGS

Multiple parental psychiatric and PR diagnoses were associated with child ACS emergency services/hospitalizations. Maternal depression was negatively associated with a child having the recommended well-child visits (odds ratio [OR]: 0.92, 95 percent confidence intervals [CI]: 0.84-0.99). The combined diagnoses of maternal depression and back pain was positively associated with a child having an ACS-ED visit (OR: 1.64, 95 percent CI: 1.33-2.03) and a child having an ACS hospitalization (OR: 2.04, 95 percent CI: 1.34-3.09).

CONCLUSIONS

Pediatricians' ability to manage child health may be enhanced with coordinated management of parental psychopathology and PR health conditions.

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.

[Depression, anxiety and quality of life in pediatric asthma]

AIMS

The study's objective was to examine depression, anxiety and quality of life according to age and asthma status in pediatric asthma in a pediatric university department.

METHODS

108 patients, age: 11.75 +/- 3.10 (mean +/- SD) years (boys 11.6 +/- 2.8 years and girls 12.1 +/- 3.7 years) completed the Child Depression Inventory, the State Trait Anxiety Inventory for Children, the Pediatric Asthma Quality of Life Questionnaire, and a symptom score. Forced expiratory volume in one second was also measured.

RESULTS

Mean forced expiratory volume in one second percent was 97.4 +/- 12.8. 23 patients (21%) had intermittent asthma, 40 patients (37%) had mild persistent, 43 patients (40%) had moderate persistent, 2 patients (2%) had severe persistent asthma. Pediatric asthma patients scored 9.36 +/- 5.57 points in the depression questionnaire. Patients showed as many depressive symptoms as the Hungarian average population, pre-adolescent boys with asthma showed even less. Children with asthma scored 31.16 +/- 4.61 points on the anxiety questionnaire; (boys 30.64 +/- 4.29, girls 32.67 +/- 5.27). Children with asthma have the same anxiety level as their healthy peers. On the quality of life questionnaire asthmatic children reached 6.18 +/- 1.00 (2.87-7.00); adolescent girls scored the worst (5.62 +/- 1.28). Adolescent asthmatic girls have the worst quality of life. Boys reach better quality of life scores as they grow older ( p = 0.02). Girls with adolescence have a tendency of decreasing quality of life, although the difference is not significant. In adolescence, asthmatic girls experience more quality of life deprivation than boys ( p = 0.013). Depression score, anxiety, or quality of life showed no difference between the intermittent and persistent asthmatic groups. Children in the symptomatic subgroup experienced poorer quality of life. Depression and anxiety were not affected by current asthma symptoms. There was no significant difference in depression, anxiety or quality of life scores according to age.

CONCLUSION

The psychological status of children with asthma is fairly good. One should concentrate more on the quality of life of girls in adolescence. The good pediatric care of childhood asthmatics helps to avoid the psychological consequences of the disease.

Comorbidity between asthma attacks and internalizing disorders among Puerto Rican children at one-year follow-up

Authors examined the association between internalizing disorders and asthma attacks at 1-year follow-up among a community sample of 1,789 children and adolescents ages 5-18 years living on the island of Puerto Rico. The Diagnostic Interview Schedule for Children was administered to assess DSM-IV internalizing disorders during the past year. Children with a lifetime history of asthma attacks at baseline had greater odds of having an internalizing disorder at 1-year follow-up, independent of socio-demographic measures. However, an association was not found between asthma attacks and persistence of internalizing disorders. These findings show that the association between internalizing disorders and asthma attacks was replicated 1 year later in the same sample.

Behavior problems among inner-city children with asthma: findings from a community-based sample

OBJECTIVE

Previous studies have suggested a relationship between childhood asthma and behavior problems. However, few studies have used community-based samples to assess the prevalence of behavior problems among urban children with asthma symptoms. The objective of this study was to evaluate the relationship between asthma symptoms and behavior among a population-based sample of inner-city children and to determine the prevalence of behavioral comorbidity among children with asthma symptoms.

METHODS

In 2003, parents of children who were entering kindergarten in the city of Rochester completed a detailed survey regarding the child's background, medical history (with specific questions about asthma symptoms), and behavior. We compared children with no asthma symptoms, intermittent symptoms, and persistent symptoms with regard to positive peer social skills (eg, makes friends easily), negative peer social skills (eg, fights with other children), task orientation (eg, concentrates well), and shy/anxious behavior (eg, is withdrawn) (validated scales; range: 1-4). We used multivariate regression to determine the independent association between symptom severity and behavioral outcomes.

RESULTS

A total of 1619 children were included (response rate: 80%; mean age: 5.1 year), and 15% had asthma symptoms (8% persistent, 7% intermittent). Average negative peer scores were worse for children with persistent asthma symptoms compared with children with intermittent and no symptoms (mean scores: 1.88, 1.70, and 1.65). Children with persistent symptoms also scored worse than children with no symptoms on the assessment of task orientation (2.85 vs 3.03) and shy/anxious behavior (2.11 vs 1.89). Among children with persistent asthma symptoms, >20% scored >1 SD below average on 2 or more scales, compared with 16% of children with intermittent symptoms and 10% with no symptoms.

CONCLUSIONS

Urban children with persistent asthma symptoms demonstrate more behavior problems across several domains compared with children with no symptoms. These findings suggest a clear need for an early biopsychosocial approach to care for vulnerable children with asthma.

The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey

Although depression has clearly been shown to be associated with physical disorders, few studies have examined whether anxiety disorders are independently associated with medical conditions after adjusting for comorbid mental disorders. We examined the relationship between anxiety disorders and a wide range of physical disorders in a nationally representative sample. Data came from the National Comorbidity Survey (N=5,877, range=age 15-54 years, response rate=82.4%). The Composite International Diagnostic Interview [Kessler et al., 1998] was used to make DSM-III-R [American Psychiatric Association, 1987] mental disorder diagnoses. Physical disorders were assessed based on a list of several conditions shown to respondents. All analyses utilized multiple logistic regression to examine the relationship between past-year anxiety disorder diagnosis and past-year chronic physical disorder. Anxiety disorders were positively associated with physical disorders even after adjusting for mood disorders, substance-use disorders, and sociodemographics. Among respondents with one or more physical disorders, a comorbid anxiety disorder diagnosis was associated with an increased likelihood of disability even after adjusting for severity of pain, comorbid mood, and substance use disorders. Among specific anxiety disorders, posttraumatic stress disorder, panic attacks, and agoraphobia were more likely to be associated with specific physical disorders than generalized anxiety disorder, social phobia, or simple phobia. There is a strong and unique association between anxiety disorders and physical disorders. Clinically, the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.