Psychological factors associated with medication nonadherence in asthmatic children

Asthma medication adherence, control, and psychological symptoms: a cross-sectional study

BACKGROUND

Nonadherence to therapies and psychological disorders are associated with poor asthma control. This study aims to assess the prevalence of anxiety and depressive symptoms, asthma control, and adherence to inhalers and to investigate whether there is an association of anxiety and depressive symptoms with adherence to inhalers and asthma control.

METHODS

We measured anxiety and depressive symptoms using the Hospital Anxiety and Depression Scale in patients with asthma. Asthma Control Test and the 10-Item Test of Adherence to Inhalers Scale were used to assess levels of asthma control adherence to inhalers, respectively. Univariate and multivariate regression models assessed the associations of anxiety and depressive symptoms with adherence to inhalers and asthma control.

RESULTS

A total of 287 patients completed the study, of whom 72% were female. The mean ± SD age and body mass index of our study population were 44 ± 13 years and 29 ± 7.2 kg/m2, respectively. Poor adherence to inhaler use was highly prevalent (49.8%; 95% CI: 43.8 to 55.7). The prevalence of anxiety, depression and poor asthma control was 27.2% (95% CI: 22.1 to 32.7), 20.9% (95% CI: 16.3 to 26.1), and 22.7% (95% CI: 17.9 to 27.9), respectively. We found a negative relationship between asthma control and anxiety, and depressive symptoms (adjusted β: -0.25; 95% CI: -0.36 to -0.14; p < 0.001 and adjusted β: -0.29; 95% CI: -0.40 to -0.18; p < 0.001, respectively). A negative relationship was also observed between adherence to inhalers and anxiety and depressive symptoms (adjusted β: -0.34; 95% CI: -0.46 to -0.22; p < 0.001 and adjusted β: -0.36; 95% CI: - 0.48 to - 0.24; p < 0.001, respectively).

CONCLUSIONS

The high prevalence of uncontrolled asthma symptoms and poor adherence to inhalers and their impact on anxiety and depression levels among patients with asthma point to the need for early screening for psychological symptoms and recognition of nonadherence as part of asthma assessment and management plan in primary care in Saudi Arabia to avoid further worsening of asthma symptoms. Further studies are needed to explore the effectiveness of specific psychoeducational interventions and investigate the long-term impact of early psychological symptom detection on asthma outcomes.

Basis of preventive and non-pharmacological interventions in asthma

Asthma is one of the most common atopic disorders in all stages of life. Its etiology is likely due to a complex interaction between genetic, environmental, and lifestyle factors. Due to this, different non-pharmacological interventions can be implemented to reduce or alleviate the symptoms caused by this disease. Thus, the present narrative review aimed to analyze the preventive and non-pharmacological interventions such as physical exercise, physiotherapy, nutritional, ergonutritional, and psychological strategies in asthma treatment. To reach these aims, an extensive narrative review was conducted. The databases used were MedLine (PubMed), Cochrane (Wiley), Embase, PsychINFO, and CinAhl. Asthma is an immune-mediated inflammatory condition characterized by increased responsiveness to bronchoconstrictor stimuli. Different factors have been shown to play an important role in the pathogenesis of asthma, however, the treatments used to reduce its incidence are more controversial. Physical activity is focused on the benefits that aerobic training can provide, while physiotherapy interventions recommend breathing exercises to improve the quality of life of patients. Nutritional interventions are targeted on implement diets that prioritize the consumption of fruits and vegetables and supplementation with antioxidants. Psychological interventions have been proposed as an essential non-pharmacological tool to reduce the emotional problems associated with asthma.

How older adults’ health beliefs affect intention to perform COVID-19 self-examination: A reasoned action approach

BACKGROUND: COVID-19 self-examination is a significant part of the national recovery plan against the virus. Although it is easier to perform COVID-19 self-examination (CSE), only a small percentage of people prefer it. There are no precise statistics on CSE in Malaysia, but informal data from news agencies imply low CSE. Lack of awareness and conflicting information about the reliability of CSE results may have raised concerns about CSE’s efficacy and effectiveness. OBJECTIVE: This study investigates how Malaysian older adults’ health beliefs influence their intention to perform CSE. The study developed a framework combining illness threats (ITH), perceived barriers (PBA), medical motivations (MMO), and control over illness (COI) from the Health Belief Model (HBM) with the Reasoned-Action Approach’s attitude (ATT), perceived control (PCO), and intention (INT). METHODS: Structural Equation Modelling (SEM) analyses were conducted with AMOS 26 software to determine the influence of HBM on older adults’ attitude, perceived control, and intention. The study collected 200 data for the pilot study and 400 data for hypotheses testing. RESULTS: ITH, MMO, and COI have positive effects, whilst PBA affects ATT negatively. ITH and COI positively impact PCO, and PCO has a greater significant effect on INT than ATT. CONCLUSION: Given the HBM’s role in influencing older adults’ intention to perform COVID-19 self-examination, providing different levels of care and emphasising the perception of knowledge of illness are especially beneficial. Several recommendations are made to ensure that CSE remains relevant for older adults’ well-being, although COVID-19’s impact has become more stabilised.

Determining factors associated with inhaled therapy adherence on asthma and COPD: A systematic review and meta-analysis of the global literature

BACKGROUND

Adherence to therapy has been reported worldwide as a major problem, and that is particularly relevant on inhaled therapy for Asthma and Chronic Obstructive Pulmonary Disease (COPD), considering its barriers and features. We reviewed the global literature reporting the main determinants for adherence on these patients.

METHODS

Searches were made using the Cochrane Library, MEDLINE, EMBASE and ISI Web of Science databases. Analytical, observational and epidemiological studies (cohort, case-control and cross-sectional studies) were included, reporting association between any type of determinant and the adherence for inhaler therapy on Asthma or COPD. Random-effects meta-analysis were used to summarise the numerical effect estimates.

RESULTS

47 studies were included, including a total of 54.765 participants. In meta-analyses, the significant determinants of adherence to inhaled therapy were: older age [RR = 1.07 (1.03-1.10); I² = 94; p < 0.0001] good disease knowledge/literacy [RR = 1.37 (1.28-1.47); I² = 14; p = 0.33]; obesity [RR = 1.30 (1.12-1.50); I² = 0; p = 0.37]; good cognitive performance [RR = 1.28 (1.17-1.40); I² = 0; p = 0.62]; higher income [RR = 1.63 (1.05-2.56); I² = 0; p = 0.52]; being employed [RR = 0.87 (0.83-0.90); I² = 0; p = 0.76] and using multiple drugs/inhalers [RR = 0.81 (0.79-0.84); I² = 0; p = 0.80]. Overall, the strength of the underlying evidence was only low to moderate.

CONCLUSIONS

Many determinants may be associated to patient's adherence, and personalised interventions should be taken in clinical practice to address it by gaining an understanding of their individual features.

Asthma Management Responsibility, Control, and Quality of Life Among Emerging Adolescents

OBJECTIVE

To examine how asthma control is related to the association between the division of responsibility for asthma management and asthma-related quality of life among early adolescents.

METHODS

Forty-nine youth aged 10-15 years (Mage = 12.25, 57.1% female) with a physician-verified asthma diagnosis completed the Standardized Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and Asthma Control Test (ACT). Youth and their caregivers also completed the Asthma Responsibility Questionnaire (ARQ). Higher ACT scores indicate better asthma control.

RESULTS

There was a significant difference in ARQ scores between youth and caregivers (p < .001, d = .94). Youth reported sharing equal responsibility for asthma management with caregivers, while caregivers reported having more responsibility relative to youth. Greater youth-reported ARQ (p = .004) and greater ACT scores (p < .001) were associated with higher PAQLQ scores. ACT scores moderated the effect of youth-reported ARQ on PAQLQ scores (p = .043). For youth with lower ACT scores, higher youth-reported responsibility was associated with higher PAQLQ scores; while for youth with higher ACT scores, PAQLQ scores were high regardless of perceived responsibility. The interaction between caregiver ARQ scores and ACT scores was not significant.

CONCLUSION

This study suggests youth and caregivers report discrepant ARQ for asthma management tasks. Responsibility and level of asthma control are important factors for PAQLQ, with results indicating that fostering responsibility is an important factor, even among youth with poorly controlled asthma. Findings suggest that healthcare providers should assess family responsibility and help caregivers support adolescents in developing asthma management skills.

Systematic Review of Digital Interventions for Pediatric Asthma Management

BACKGROUND

Pediatric patients with asthma take only approximately half of their prescribed medication. Digital interventions to improve adherence for youth with asthma exist and have the potential to improve accessibility, cost-effectiveness, and customizability.

OBJECTIVE

To systematically review published research examining digital interventions to promote adherence to the treatment of pediatric asthma.

METHODS

A systematic search of the PubMed, Scopus, CINAHL, PsycINFO, and reference review databases was conducted. Articles were included if adherence was an outcome in a randomized controlled trial of a digital intervention for children with asthma. We compared samples, intervention characteristics, adherence measurement and outcomes, as well as additional health outcomes across studies.

RESULTS

Of the 264 articles reviewed, 15 studies met inclusion criteria and were included in the review. Overall, 87% of the digital interventions demonstrated improved adherence and 53% demonstrated improved health outcomes. All the promising interventions included a behavioral component and most were 3 to 6 months in length, delivered through a digital stand-alone medium (eg, automated personalized texts, mobile health apps, and website), and assessed adherence to controller medication.

CONCLUSIONS

Overall, digital interventions aimed at improving adherence are promising and also improve health outcomes in addition to medication adherence. Although future studies using evidence-based adherence assessment and multifactorial design should be conducted, the current literature suggests that both digital stand-alone interventions and interventions combining digital technology with support from a health care team member result in improved adherence and asthma outcomes. Recommendations for digital interventions for pediatric patients with asthma with adherence concerns are provided.

Decision-Making Involvement and Prediction of Adherence in Youth With Type 1 Diabetes: A Cohort Sequential Study

Objective

To assess developmental trajectories of decision-making involvement (DMI), defined as the ways in which parents and children engage each other in decision-making about illness management, in youth with type 1 diabetes (T1D) and examine the effects of DMI on levels of and changes in adherence with age.

Methods

Participants included 117 youth with T1D, enrolled at ages 8-16 years and assessed five times over 2 years. The cohort sequential design allowed for the approximation of the longitudinal curve from age 8 to 19 from overlapping cohort segments. Children and parents completed the Decision-Making Involvement Scale, which yields subscales for different aspects of DMI, and a self-report adherence questionnaire. Mixed-effects growth curve modeling was used for analysis, with longitudinal measures nested within participant and participants nested within cohort.

Results

Most aspects of DMI (Parent Express, Parent Seek, Child Express, and Joint) increased with child age; scores on some child report subscales (Parent Express, Child Seek, and Joint) decreased after age 12-14 years. After accounting for age, Child Seek, Child Express, and Joint were associated with overall higher levels of adherence in both child (estimates = 0.08-0.13, p < .001) and parent (estimates = 0.07- 0.13, p < .01) report models, but they did not predict changes in adherence with age.

Conclusion

These data suggest that helping children to be more proactive in T1D discussions, by encouraging them to express their opinions, share information, and solicit guidance from parents, is a potential target for interventions to enhance effective self-management.

Do parents implement pediatric neuropsychological report recommendations?

OBJECTIVE

We explored parent-reported implementation rates of medical, home/community, and school recommendations following a pediatric neuropsychological evaluation, as well as demographic group differences in, and potential barriers to, recommendation implementation.

METHOD

Participants were 55 parents of children and adolescents who completed an outpatient neuropsychological evaluation in a university-based hospital neuropsychology clinic within 4 to 6 months prior to study participation. Participants were contacted by phone to complete a short interview regarding implementation of report recommendations.

RESULTS

Slightly over half (52%) of all recommendations were implemented, with higher implementation rates of school (62%) and home/community recommendations (53%) than medical recommendations (40%). Results indicated significantly lower recommendation implementation for households with low income (particularly for medical recommendations). Reported reasons for not implementing recommendations included lack of time, lack of resources (geographical and financial), ambivalence about the need to implement the recommendation, not remembering the recommendation, confusion about how to implement the recommendation, and resistance from schools and teachers.

CONCLUSIONS

The results for this study provide information for pediatric neuropsychologists regarding rates of recommendation implementation, with differences identified based on type of recommendation and demographic factors. Further empirical investigation is indicated in order to determine practical, concrete steps to improve recommendation implementation.

Improving shared health decision making for children and adolescents with chronic illness: A narrative literature review

OBJECTIVE

This review aims to increase understanding of health decision-making by children and adolescents with chronic illnesses and offer suggestions for improving shared decision-making with healthcare professionals.

METHODS

Using cross-disciplinary publication databases, we surveyed literature on children's and adolescents' health decision-making from psychology, health sciences, and neuroscience.

RESULTS

Several factors influencing health decision-making were identified. Considering neurobiological aspects, children lack functionality in the frontal lobe resulting in lesser cognitive control and higher risk-taking compared to adults. Additionally, adolescents' generally higher arousal of socioemotional systems demonstrates neurological underpinnings for reward-seeking behaviours. Psychological investigations of children's health decision-making indicate important age-dependent differences in risk-taking, locus of control, affect and cognitive biases. Furthermore, social influences, particularly from peers, have a large, often negative, effect on individual decision-making due to desire for peer acceptance.

CONCLUSION

Acknowledging these factors is necessary for optimising the process of shared decision-making to support minors with chronic illnesses during healthcare consultations.

PRACTICE IMPLICATIONS

Doctors and other healthcare professionals may need to counteract some adolescents' risk-taking behaviours which are often spurred by peer pressure. This can be achieved by highlighting the patient's control over health outcomes, emphasising short-term benefits and long-term consequences of risky behaviours, and recommending peer support networks.

Associations between self-harm and chronic disease among adolescents: Cohort study using statewide emergency department data

INTRODUCTION

We sought to understand the association between youthful self-harm and subsequent chronic disease-related healthcare utilization and whether self-harm reflects unique vulnerability in comparison with severe psychiatric disorders.

METHODS

We used a retrospective matched cohort design with statewide, all-payer, individually linked emergency department (ED) data from California, USA. Risk of future ED visits for common chronic conditions in adolescence (headaches, asthma, epilepsy, diabetes, and gastrointestinal disorders, assessed using ICD-9 diagnoses) were compared between three adolescent study groups presenting to an ED in 2010: self-harm patients (n = 5,484), patients with psychiatric complaints but no self-harm (n = 14,235), and patients with other complaints (n = 16,452). Cohort follow-up ended on Sept. 30, 2015. Analyses were adjusted for patients' prior histories of ED utilization for chronic conditions as well as patient- and area-level sociodemographic characteristics.

RESULTS

Risk of subsequent ED visits was higher among self-harm patients compared to non-psychiatric control patients for subsequent epilepsy- (aRR = 1.77, 95% CI [1.42, 2.21]). Risk of subsequent ED visits was higher among psychiatric patients compared to non-psychiatric control patients for subsequent headache- (aRR = 1.31, 95% CI [1.21, 1.42]), and epilepsy-related problems (aRR = 1.85, 95% CI [1.55, 2.21]). Self-harm patients were at higher risk than psychiatric patients for subsequent gastrointestinal disorder (aRR = 1.76, 95% CI [1.03, 3.01]).

CONCLUSIONS

Findings suggest that self-harm behavior and psychiatric disorders are associated with increased ED utilization for subsequent chronic disease-related ED utilization. Chronic disease among adolescent psychiatric patients should be attended to, potentially involving new models of clinical follow-up care.

Involving Youth With a Chronic Illness in Decision-making: Highlighting the Role of Providers

Decision-making is important in the context of pediatric chronic illness because children and families need to make decisions about burdensome and complex treatments on a regular basis, and children must eventually learn how to make such decisions independently. Research related to children's decision-making in medical settings has been focused primarily on cognitive aspects of decision-making, such as understanding and capacity. The concept of decision-making involvement (DMI) recognizes that children can be involved in decision-making in multiple ways, regardless of capacity, and that parents and health care providers play a critical role in supporting children as they learn to make decisions on their own. Providers can facilitate DMI during medical encounters by asking for the children's opinions and concerns, encouraging turn-taking, soliciting questions, asking for information directly from the children, and checking that the children understand what has been said. Efforts to involve children send the message that the youth perspective is important and set the expectation for increased participation over time. Providers can also support parent-child decision-making about illness management at home by guiding parents as to how best to involve children in decisions about illness management, identifying areas in which more or less parental guidance and support are needed, and assisting youth in planning ahead for decision-making about illness management in high-risk situations. Additional research is needed to identify why children's DMI in medical settings remains low, develop and evaluate strategies to enhance DMI, and test the effects of DMI on health-related behaviors and outcomes over time.

Medication adherence in pediatric asthma: A systematic review of the literature

OBJECTIVE

To provide a systematic review of correlates of adherence to inhaled corticosteroids (ICS) in pediatric asthma across the individual, family, community, and healthcare system domains.

METHODS

Articles assessing medication adherence in pediatric asthma published from 1997 to 2016 were identified using PsychINFO, Medline, and CINAHL. Search terms included asthma, compliance, self-management, adherence, child, and youth. Search results were limited to articles: 1) published in the US; 2) using a pediatric population (0-25 years old); and 3) presenting original data related to ICS adherence. Correlates of adherence were categorized according to the domains of the Pediatric Self-Management Model. Each article was evaluated for study quality.

RESULTS

Seventy-nine articles were included in the review. Family-level correlates were most commonly reported (N = 51) and included socioeconomic status, race/ethnicity, health behaviors, and asthma knowledge. Individual-level correlates were second-most common (N = 37), with age being the most frequently identified negative correlate of adherence. Health care system correlates (N = 24) included enhanced asthma care and patient-provider communication. Few studies (N = 10) examined community correlates of adherence. Overall study quality was moderate, with few quantitative articles (26.38%) and qualitative articles (21.4%) referencing a theoretical basis for their studies.

CONCLUSIONS

All Pediatric Self-Management Model domains were correlated with youth adherence, which suggests medication adherence is influenced across multiple systems; however, most studies assessed adherence correlates within a single domain. Future research is needed that cuts across multiple domains to advance understanding of determinants of adherence.

Psychosocial Factors in Severe Pediatric Asthma

Asthma is the most common chronic illness among children in the United States and can impact nearly all aspects of functioning. Most research suggests that children with severe asthma display more emotional and behavioral problems than their healthy peers. These psychological difficulties are associated with increased risk for functional impairments and problematic disease course. Multidisciplinary teams that assess and treat these psychosocial factors using psychoeducational and behavioral interventions are important for children whose asthma is poorly controlled. Future research should examine the ways in which stress, emotions, and immune functions interact, so as to develop more preventative interventions.

Patient adherence and effective communication

BACKGROUND

Poor adherence to inhaled corticosteroid medication is a critical problem for asthma because it contributes to morbidity and mortality through poor asthma control, frequent asthma exacerbations, acute care visits, and oral corticosteroid use.

OBJECTIVE

To discuss evidence-based, time-efficient strategies that can be adopted by most practitioners to try to increase patient adherence.

METHODS

Asthma management guidelines and other key publications are used to enhance discussion.

RESULTS

Establishing patient-centered, collaborative care that permits effective patient-practitioner communication can improve adherence, thus leading to improved asthma outcomes. One critical strategy is shared decision making, in which the patient and the practitioner share relevant information, discuss risks vs benefits of various treatment options, express treatment preferences, deliberate the options, and agree on treatment. Asthma self-management education, which emphasizes self-efficacy, is also essential. The education necessary to provide those skills depends in part on consideration of the patient's health literacy. Practitioners also have at their disposal a variety of tips and techniques to improve communication and gather information not only at the patient-practitioner level but also at the practitioner-practitioner level, such as within a group practice or within a health care system.

CONCLUSION

To improve patient adherence, clinicians need to consider a variety of factors and implement strategies that directly target underlying issues. Strategies may include customizing and simplifying learning and intervention regimens, identifying barriers to adherence and addressing them, ensuring patient support structures are in place, and improving self-efficacy and health literacy.

Caregiver's depressive symptoms and asthma control in children from an underserved community

Caregiver's or maternal depression has been associated with increased asthma morbidity in children from prosperous nations, but little is known about this link in low and middle-income countries.

OBJECTIVE

To examine if caregiver's depressive symptoms are associated with poor asthma control and abnormal immune responses in school-aged children.

METHODS

Case-control study of 87 asthmatic children (aged 4-11 years) attending a primary care clinic in an underserved area of Santiago (Chile). Cases were children with poor asthma control (Child Asthma Control Test [cACT] <20 points) and controls were children with adequate asthma control (cACT ≥20 points). The Beck Depression Inventory-II (BDI) and a locally validated family health vulnerability test (SALUFAM) were used to assess caregivers' depression and family health vulnerability. Serum from participating children was assayed for IFN-γ, IL-4, IL-13, TGF-β, cortisol, and total IgE.

RESULTS

The mean (SD) age of study participants was 8.23 (2.15 years), and 55.2% were females. Use of inhaled corticosteroids (ICS), family health vulnerability, and caregiver's depressive symptoms were significantly more common in cases than in controls (65.4% vs. 34.6%, p = 0.003; 41.3% vs. 24.8%, p = 0.07; and 39.1% vs. 19.5%, p = 0.04, respectively). There was no significant difference in the level of any serum biomarkers between groups. In a multivariate analysis, only ICS use was significantly associated with better asthma control (OR = 3.56 [1.34-9.48], p = 0.01).

CONCLUSIONS

Presence of caregiver's depressive symptoms is associated with poor asthma control among children from an underserved community, but this association was no longer significant after accounting for ICS use.

Routines and Rituals: Opportunities for Participation in Family Health

Family routines and rituals offer the opportunity to fully participate in family health. “Family health” is defined as the ways in which the household, as a whole, engages in daily activities to promote the well-being of its members and is emotionally invested in the maintenance of health over time. Routines and rituals provide the settings for family health. Empirical support for the importance of routines and rituals is provided from studies aimed at examining medical adherence, mealtime interactions, and nighttime waking in children with chronic health conditions. Implications for practice and policy are provided.

Child maltreatment and pediatric asthma: a review of the literature

BACKGROUND

Child maltreatment is a common problem with known adverse consequences, yet its contributions to the development and course of pediatric asthma are only poorly understood.

MAIN

This review first describes possible pathways connecting child maltreatment to pediatric asthma, including aspects of the physical home environment, health behaviors and disease management, and psychological consequences of child maltreatment. We subsequently review existing studies, which generally report an association between maltreatment experiences and asthma outcomes in childhood. However, this literature is in its early stages; there are only a handful studies, most of them rely on self-reports of both child maltreatment and asthma history, and none have investigated the physiological underpinnings of this association. Taken together, however, the studies are suggestive of child maltreatment playing a role in pediatric asthma incidence and expression that should be explored further.

CONCLUSION

Existing data are sparse and do not allow for specific conclusions. However, the data are suggestive of child maltreatment influencing asthma risk and morbidity long before the adult years. Future research should focus on understanding how child maltreatment contributes to asthma disease risk and progression in this highly vulnerable population.

Factors associated with medication adherence in school-aged children with asthma

Adherence to preventive asthma treatment is poor, particularly in children, yet the factors associated with adherence in this age group are not well understood.

Adherence was monitored electronically over 6 months in school-aged children who attended a regional emergency department in New Zealand for an asthma exacerbation and were prescribed twice-daily inhaled corticosteroids. Participants completed questionnaires including assessment of family demographics, asthma responsibility and learning style. Multivariable analysis of factors associated with adherence was conducted.

101 children (mean (range) age 8.9 (6–15) years, 51% male) participated. Median (interquartile range) preventer adherence was 30% (17–48%) of prescribed. Four explanatory factors were identified: female sex (+12% adherence), Asian ethnicity (+19% adherence), living in a smaller household (−3.0% adherence per person in the household), and younger age at diagnosis (+2.7% for every younger year of diagnosis) (all p<0.02).

In school-aged children attending the emergency department for asthma, males and non-Asian ethnic groups were at high risk for poor inhaled corticosteroid adherence and may benefit most from intervention. Four factors explained a small proportion of adherence behaviour indicating the difficulty in identifying adherence barriers. Further research is recommended in other similar populations.

Girls, children of Asian ethnicity, small household size and younger diagnosis age have better adherence to asthmahttp://ow.ly/Z1y6Q

Patterns and predictors of medication adherence to lipid-lowering therapy in children aged 8 to 20 years

BACKGROUND

The American Academy of Pediatrics recommends lipid-lowering therapy (LLT) for children at high risk of cardiovascular disease. However, the use of LLT in children is rare, and rates of nonadherence are unknown.

OBJECTIVE

To identify patterns of use and predictors of nonadherence to LLT in children aged 8 to 20 years and the subgroup with dyslipidemia.

METHODS

Commercially insured patients with a new dispensing for an LLT were included. Nonadherence was defined as a gap of >90 days between the last dispensing plus the medication days supply and the next dispensing or censoring. Descriptive statistics characterize the patterns of LLT adherence and class-specific drug switching. Kaplan-Meier curves and multivariable Cox proportional hazard models identified time to, and predictors of, nonadherence for the cohort and the dyslipidemia subgroup.

RESULTS

Of the 8710 patients meeting inclusion criteria, 87% were nonadherent. Statins were the most common index prescription, and patients with an index statin dispensing were more likely to have multiple comorbidities and other prescription drug use. In multivariable analyses, nonadherence was inversely associated with dyslipidemia (hazard ratio [HR] = 0.61, 95% confidence interval [CI] = 0.57-0.65), chronic kidney disease (HR = 0.69, 95% CI = 0.54-0.88), higher outpatient (HR = 0.87, 95% CI = 0.77-0.98), and inpatient (HR = 0.83, 95% CI = 0.70-0.97) use. When limited to patients with dyslipidemia, nonadherence was related to age (HR = 1.21, 95% CI = 1.07-1.38) and obesity (HR = 1.23, 95% CI = 1.02-1.49).

CONCLUSIONS

Despite recommendations to begin continuous treatment early for high-risk children, nonadherence to LLT is frequent in this population, with modestly higher adherence in children with dyslipidemia.

The Digital Asthma Patient: The History and Future of Inhaler Based Health Monitoring Devices

The wave of digital health is continuously growing and promises to transform healthcare and optimize the patients' experience. Asthma is in the center of these digital developments, as it is a chronic disease that requires the continuous attention of both health care professionals and patients themselves. The accurate and timely assessment of the state of asthma is the fundamental basis of digital health approaches and is also the most significant factor toward the preventive and efficient management of the disease. Furthermore, the necessity of inhaled medication offers a basic platform upon which modern technologies can be integrated, namely the inhaler device itself. Inhaler-based monitoring devices were introduced in the beginning of the 1980s and have been evolving but mainly for the assessment of medication adherence. As technology progresses and novel sensing components are becoming available, the enhancement of inhalers with a wider range of monitoring capabilities holds the promise to further support and optimize asthma self-management. The current article aims to take a step for the mapping of this territory and start the discussion among healthcare professionals and engineers for the identification and the development of technologies that can offer personalized asthma self-management with clinical significance. In this direction, a technical review of inhaler based monitoring devices is presented, together with an overview of their use in clinical research. The aggregated results are then summarized and discussed for the identification of key drivers that can lead the future of inhalers.

Review of family relational stress and pediatric asthma: the value of biopsychosocial systemic models

Asthma is the most common chronic disease in children. Despite dramatic advances in pharmacological treatments, asthma remains a leading public health problem, especially in socially disadvantaged minority populations. Some experts believe that this health gap is due to the failure to address the impact of stress on the disease. Asthma is a complex disease that is influenced by multilevel factors, but the nature of these factors and their interrelations are not well understood. This paper aims to integrate social, psychological, and biological literatures on relations between family/parental stress and pediatric asthma, and to illustrate the utility of multilevel systemic models for guiding treatment and stimulating future research. We used electronic database searches and conducted an integrated analysis of selected epidemiological, longitudinal, and empirical studies. Evidence is substantial for the effects of family/parental stress on asthma mediated by both disease management and psychobiological stress pathways. However, integrative models containing specific pathways are scarce. We present two multilevel models, with supporting data, as potential prototypes for other such models. We conclude that these multilevel systems models may be of substantial heuristic value in organizing investigations of, and clinical approaches to, the complex social-biological aspects of family stress in pediatric asthma. However, additional systemic models are needed, and the models presented herein could serve as prototypes for model development.

Adherence in childhood asthma: the elephant in the room

Adherence to inhaled steroids is suboptimal in many children with asthma and can lead to poor disease control. Many previous studies in paediatric populations have used subjective and inaccurate adherence measurements, reducing their validity. Adherence studies now often use objective electronic monitoring, which can give us an accurate indication of the extent of non-adherence in children with asthma. A review of the studies using electronic adherence monitoring shows that half of them report mean adherence rates of 50% or below, and the majority report rates below 75%. Reasons for non-adherence are both intentional and non-intentional, incorporating illness perceptions, medication beliefs and practical adherence barriers. Interventions to improve adherence in the paediatric population have had limited success, with the most effective containing both educational and behavioural aspects.

A review of the effects of medication delivery systems on treatment adherence in children with asthma

BACKGROUND

A patient's adherence to an appropriate treatment regimen is necessary to minimize morbidity and mortality associated with childhood asthma. Many factors influence the success of treatment adherence.

OBJECTIVE

The goal of this article was to examine the effect of the mode of medication delivery on the success of treatment adherence in children with asthma.

METHODS

Relevant clinical studies were identified through a MEDLINE search of articles published from 1966 to 2002, using the search terms adherence, aerosol, asthma, children, compliance, dry powder inhaler, metered-dose inhaler, nebulizer, and pediatric.

RESULTS

A relationship seems to exist between treatment adherence and the type of medication delivery system used in childhood asthma. The highest rates of adherence appear to be associated with oral medications.

CONCLUSIONS

Clinicians should consider the mode of medication delivery as 1 factor that can influence the success of treatment adherence.

Preventive asthma medication discontinuation among children enrolled in fee-for-service Medicaid

OBJECTIVE

Local-area studies demonstrate that preventive asthma medication discontinuation among Medicaid and Children's-Health-Insurance-Program (CHIP) enrolled children leads to adverse outcomes. We assessed time-to-discontinuation for preventive asthma medication and its risk factors among fee-for-service Medicaid/CHIP child beneficiaries.

METHODS

National-Health-Interview-Survey participants (1997-2005) with ≥1 Medicaid- or CHIP-paid claims when 2-17 years old (n = 4262) were linked to Medicaid-Analytic-eXtract claims (1999-2008). Multivariate Cox proportional-hazards models to assess time-to-discontinuation (i.e. failing to refill prescriptions <30 d after previous supplies ran out) included demographic factors and medication regimen (inhaled corticosteroids [ICS], long-acting β2-agonists, leukotriene modifiers, mast cell stabilizers, and monoclonal antibodies).

RESULTS

Sixty-three percent discontinued preventive asthma medications by 90 d after the first prescription. Adolescents and toddlers had slightly higher hazards of discontinuation (adjusted hazard ratios [aHR], 1.13; 95% CI, 1.05-1.23; and 1.12; 1.03-1.21, respectively) versus 5-11-year-olds, as did Hispanics (aHR, 1.24; 1.13-1.35) and non-Hispanic blacks (aHR, 1.17; 1.07-1.28) versus non-Hispanic whites, children in households with one adult and ≥3 children (aHR, 1.17; 1.05-1.30) versus multiple adults and ≤2 children, and children with caregivers' educational-attainment ≤12th grade (aHR, 1.11; 1.02-1.20) versus caregivers with some college. Compared to regimens including both ICS and leukotriene modifiers, discontinuation was greater for those on ICS without leukotriene modifiers or on other preventive asthma medications (aHR, 1.67; 1.56-1.80; and 2.23; 1.78-2.80, respectively).

CONCLUSION

More than 60% of children enrolled in fee-for-service Medicaid/CHIP discontinued preventive asthma medications by 90 d. Risk was increased for minorities and children from disadvantaged households. Understanding these factors may inform future pediatric asthma guidelines.

Factors associated with levels of adherence to inhaled corticosteroids in minority adolescents with asthma

BACKGROUND

Nonadherence to inhaled corticosteroids (ICS) is a significant risk factor for poor asthma outcomes in minority adolescents with persistent asthma.

OBJECTIVE

To identify factors associated with nonadherence to daily ICS in this target population.

METHODS

Adolescents 11 to 16 years old, self-identified as African American or Hispanic, diagnosed with persistent asthma and with an active prescription for daily ICS were invited to participate. Participant adherence to ICS was electronically measured during 14 days. Concurrently, participants completed the following assessments: demographic information, asthma history, asthma control, asthma exacerbations, media use, depression, asthma knowledge, ICS knowledge, and ICS self-efficacy. Of the 93 subjects, 68 had low (<48%) adherence and 25 had high (>48%) adherence.

RESULTS

Older age and low ICS knowledge each were associated with low (≤48%) adherence (P < .01 for the 2 variables).

CONCLUSION

Older age and low ICS knowledge each may be associated with poor adherence to ICS in minority adolescents with persistent asthma. Although older age often is associated with the assignment of increased responsibility for medication-taking behavior, it may not be associated with increased adherence. Continued and expanded efforts at promoting asthma education and specifically knowledge of ICS may increase adherence to ICS.

Investigating reasons for CPAP adherence in adolescents: a qualitative approach

STUDY OBJECTIVES

Adolescents with obstructive sleep apnea syndrome (OSAS) represent an important but understudied subgroup of long-term continuous positive airway pressure (CPAP) users. The purpose of this qualitative study was to identify factors related to adherence from the perspective of adolescents and their caregivers.

METHODS

Individual open-ended, semi-structured interviews were conducted with adolescents (n = 21) and caregivers (n = 20). Objective adherence data from the adolescents' CPAP machines during the previous month was obtained. Adolescents with different adherence levels and their caregivers were asked their views on CPAP. Using a modified grounded theory approach, we identified themes and developed theories that explained the adolescents' adherence patterns.

RESULTS

Adolescent participants (n = 21) were aged 12-18 years, predominantly male (n = 15), African American (n = 16), users of CPAP for at least one month. Caregivers were mainly mothers (n = 17). Seven adolescents had high use (mean use 381 ± 80 min per night), 7 had low use (mean use 30 ± 24 min per night), and 7 had no use during the month prior to being interviewed. Degree of structure in the home, social reactions, mode of communication among family members, and perception of benefits were issues that played a role in CPAP adherence.

CONCLUSIONS

Understanding the adolescent and family experience of using CPAP may be key to increasing adolescent CPAP adherence. As a result of our findings, we speculate that health education, peer support groups, and developmentally appropriate individualized support strategies may be important in promoting adherence. Future studies should examine these theories of CPAP adherence.

Using communication skills to improve adherence in children with chronic disease: the adherence equation

Nonadherence to maintenance medication is common in paediatric chronic conditions. Despite the common belief that nonadherence is therapy-resistant, and the apparent lack of evidence for successful interventions to improve adherence, there is, in fact, a considerable body of evidence suggesting that adherence can be improved by applying specific communicative consultation skills. These can be summarized as the adherence equation: adherence=follow-up+dialogue+barriers and beliefs+empathy and education => concordance. Close follow-up of children with a chronic condition is needed to establish a therapeutic partnership with the family. Teaching self management skills is not a unidirectional process of providing information, but requires a constructive and collaborative dialogue between the medical team and the family. Identifying barriers to adherence can be achieved in a non-confrontational manner, by showing a genuine interest what the patient's views and preferences are. In particular, parental illness perceptions and medication beliefs should be identified, because they are strong drivers of nonadherence. Through empathic evidence-based education, such perceptions and beliefs can be modified. By applying these strategies, concordance between the child's family and the medical team can be achieved, resulting in optimal adherence to the jointly created treatment plan.

Outpatient management of asthma in children

The principal aims of asthma management in childhood are to obtain symptom control that allows individuals to engage in unrestricted physical activities and to normalize lung function. These aims should be achieved using the fewest possible medications. Ensuring a correct diagnosis is the first priority. The mainstay of asthma management remains pharmacotherapy. Various treatment options are discussed. Asthma monitoring includes the regular assessment of asthma severity and asthma control, which then informs decisions regarding the stepping up or stepping down of therapy. Delivery systems and devices for inhaled therapy are discussed, as are the factors influencing adherence to prescribed treatment. The role of the pediatric health care provider is to establish a functional partnership with the child and their family in order to minimize the impact of asthma symptoms and exacerbations during childhood.

Efficacy of a parent-youth teamwork intervention to promote adherence in pediatric asthma

OBJECTIVE

To determine whether a parent-youth teamwork intervention improved medication adherence and related outcomes among youth with asthma.

METHODS

We used a randomized clinical trial with 48 youth (aged 9-15 years) assigned to 1 of 3 groups: Teamwork Intervention (TI), Asthma Education (AE), or Standard Care (SC). Treatment occurred across 2 months, with a 3-month follow-up assessment. Adherence to inhaled corticosteroids was assessed via the MDILog-II. Parent-adolescent conflict, asthma functional severity, and spirometry assessments were obtained pre-treatment, post-treatment, and on follow-up. Mixed linear model analysis was used to evaluate group and time effects for outcome measures.

RESULTS

TI group had significantly higher adherence and lower functional severity scores than AE or SC conditions, and lower parent-reported conflict and a trend for higher spirometry values compared with the SC group.

CONCLUSIONS

Results suggest support for the efficacy of TI for improving medication adherence as youth acquire more responsibility for their asthma management.

The French version of the Family Assessment Device

OBJECTIVE

To validate a French version of the Family Assessment Device (FAD), a well-known self-report questionnaire assessing family functioning in clinical and research settings.

METHODS

A French adaptation of the FAD was administered to 3 groups of subjects: a nonclinical group (n = 115), relatives of psychiatric patients (n = 102), and medical patients and their relatives (n = 106). Temporal stability was assessed by test-retest intraclass correlations. Internal consistency was measured by Cronbach alpha reliability coefficients. Discriminant validity was explored, comparing the scores of the 3 groups, using a covariance analysis (ANCOVA). The dimensional structure of the instrument was explored using a principal component analysis, with promax oblique rotation, on the entire sample.

RESULTS

The French FAD showed good temporal stability and good discriminant validity across groups. Internal consistency was satisfactory only for the General Functioning (GF) subscale. Factor analysis yielded a 3-factor model. The GF subscale was highly correlated with all of the other subscales.

CONCLUSIONS

The French version of the FAD provides a valuable tool for assessing family functioning. However, our study failed to identify the theoretical structure of the FAD and suggests that the GF subscale could be used as a better overall indicator of family functioning.

Socioeconomic status and the health of youth: a multilevel, multidomain approach to conceptualizing pathways

Previous research has clearly established associations between low socioeconomic status (SES) and poor youth physical health outcomes. This article provides an overview of the main pathways through which low SES environments come to influence youth health. We focus on 2 prevalent chronic health problems in youth today, asthma and obesity. We review and propose a model that encompasses (a) multiple levels of influence, including the neighborhood, family and person level; (b) both social and physical domains in the environment; and finally (c) dynamic relationships between these factors. A synthesis of existing research and our proposed model draw attention to the notion of adverse physical and social exposures in youth's neighborhood environments altering family characteristics and youth psychosocial and behavioral profiles, thereby increasing youth's risk for health problems. We also note the importance of acknowledging reciprocal influences across levels and domains (e.g., between family and child) that create self-perpetuating patterns of influence that further accentuate the impact of these factors on youth health. Finally, we document that factors across levels can interact (e.g., environmental pollution levels with child stress) to create unique, synergistic effects on youth health. Our model stresses the importance of evaluating influences on youth's physical health not in isolation but in the context of the broader social and physical environments in which youth live. Understanding the complex relationships between the factors that link low SES to youth's long-term health trajectories is necessary for the creation and implementation of successful interventions and policies to ultimately reduce health disparities.

Beyond the guidelines: fatal and near-fatal asthma

While asthma is extremely common, fatal and near fatal asthma is rare and often preventable if there is early recognition of symptom progression and appropriate intervention. In the past decade, asthma mortality has progressively declined in association with the widespread use of inhaled corticosteroids and asthma care plans. Management of life threatening asthma requires patient education to ensure the proper use of medications and to enable the patient to recognize when additional therapy for poorly controlled asthma is required. There is some evidence that suggests that the overly aggressive use of asthma medications when treating a severe exacerbation may contribute to morbidity. Because of the risks of air trapping and barotrauma associated with partial airway obstruction, it is best to avoid mechanical ventilation if possible but when this is used, low tidal volumes, longer exhalation times, and permissive hypercarbia can minimize these risks. There is the promise that a better understanding of asthma immunology and severe asthma "phenotypes" will lead to better prevention and therapy.

Measurement of inhaled corticosteroid adherence in inner-city, minority children with persistent asthma by parental report and integrated dose counter

Parents often overreport adherence to asthma treatment regimens making accurate assessment of medication adherence in clinical practice difficult. This study was conducted to compare two adherence assessment methods clinicians may choose from when assessing patient inhaled corticosteroid (ICS) adherence: parental report and dose counter measurements of metered-dose inhaler (MDI) actuation. Participants included children (N = 50) with persistent asthma and their parents (N = 50). At enrollment, children received a new, marked ICS at the dose prescribed by their physician. Thirty days following enrollment, we measured ICS adherence by parental report and objectively, with a dose counter. Parental report overestimated ICS adherence when compared to dose counter. We found a statistically significant overall difference between parental report and objectively measured adherence. A dose counter that most ICS inhalers are equipped with may be a more reliable alternative measure of ICS adherence in a clinical practice setting.

Translational behavioral research in respiratory medicine

Human behavior can prevent or invite disease and is a major determinant of treatment success. Consequently, many efforts have been directed toward developing interventions to promote behaviors essential to managing or preventing respiratory disease. The process of developing, testing, and disseminating health behavior interventions should closely follow the translational research paradigm. However, most behavioral investigators have failed to adequately apply the translational research paradigm to behavioral research. The final stage of translation, consisting of testing the effectiveness of interventions in broad clinical settings after efficacy has been demonstrated in randomized controlled trials, is too often omitted. Additionally, the important task of understanding why any given health behavior intervention succeeds with some people but fails to change behavior in others is inconsistently pursued and seldom used to develop the robust theories of behavior change needed to improve respiratory health. Bringing health behavior research through the full translational process has the potential to significantly enhance respiratory health with specific behavioral targets, including smoking cessation, obesity prevention, TB control, and adherence to a multitude of respiratory treatments.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Adherence with preventive medication in childhood asthma

Suboptimal adherence with preventive medication is common and often unrecognised as a cause of poor asthma control. A number of risk factors for nonadherence have emerged from well-conducted studies. Unfortunately, patient report a physician's estimation of adherence and knowledge of these risk factors may not assist in determining whether non-adherence is a significant factor. Electronic monitoring devices are likely to be more frequently used to remind patients to take medication, as a strategy to motivate patients to maintain adherence, and a tool to evaluate adherence in subjects with poor disease control. The aim of this paper is to review non-adherence with preventive medication in childhood asthma, its impact on asthma control, methods of evaluating non-adherence, risk factors for suboptimal adherence, and strategies to enhance adherence.

The Role of Parents' Medication Beliefs, Religious Problem-Solving, and Risks for Treatment Nonadherence in Urban Families with Asthma

Childhood asthma is highly prevalent, affecting approximately nine million children in the United States. Negative effects of pediatric asthma are disproportionately experienced by ethnic minorities living in low-income, urban settings. Given the great diversity in families' ways of addressing children's asthma symptoms, sociocultural factors underlying asthma disparities must be examined. The current study investigated associations among parents' beliefs about conventional and holistic/alternative medications, parents' religious problem-solving strategies and childrens' risks for asthma treatment nonadherence. The sample included 66 parents of ethnically diverse children with asthma living in urban settings. Factor analysis of the Religious Problem Solving Questionnaire yielded two factors, self-directed (ie, solving problems independently of God) and God-involved problem solving. Parents' strong positive beliefs about conventional and alternative medications were associated with greater self-directed problem solving and with more risks for nonadherence. Higher levels of self-directed problem solving also were associated with more risks for nonadherence. Self-directed problem solving mediated the associations of conventional and alternative medication beliefs with risks for nonadherence. Possible explanations for these findings are discussed.

The parenting attitudes and the stress of mothers predict the asthmatic severity of their children: a prospective study

Objective

To examine relationships between a mother's stress-related conditions and parenting attitudes and their children's asthmatic status.

Methods

274 mothers of an asthmatic child 2 to 12 years old completed a questionnaire including questions about their chronic stress/coping behaviors (the "Stress Inventory"), parenting attitudes (the "Ta-ken Diagnostic Test for Parent-Child Relationship, Parent Form"), and their children's disease status. One year later, a follow-up questionnaire was mailed to the mothers that included questions on the child's disease status.

Results

223 mothers (81%) responded to the follow-up survey. After controlling for non-psychosocial factors including disease severity at baseline, multiple linear regression analysis followed by multiple logistic regression analysis found chronic irritation/anger and emotional suppression to be aggravating factors for children aged < 7 years; for children aged 7 and over, the mothers' egocentric behavior was a mitigating factor while interference was an aggravating factor.

Conclusions

Different types of parental stress/coping behaviors and parenting styles may differently predict their children's asthmatic status, and such associations may change as children grow.

Treatment adherence among low-income, African American children with persistent asthma

OBJECTIVE

The study aims to assess medication adherence and asthma management behaviors and their modifiable predictors in low-income children with persistent asthma.

METHODS

The authors conducted a cohort study of 143 children ages 6 to 11 prescribed a daily inhaled controller medicine that could be electronically monitored. Children were recruited from clinics or the emergency department of an urban children's hospital. Data were collected at baseline (T1) and 1 year later (T2). Outcome measures were adherence to controller medications as measured by electronic monitoring devices, observed metered-dose inhaler and spacer technique, exposure to environmental tobacco smoke, and attendance at appointments with primary health care provider.

RESULTS

Medication adherence rates varied across medications, with higher rates for montelukast than for fluticasone. Eleven percent to 15% of children demonstrated metered dose inhaler and spacer technique suggesting no drug delivery, and few (5% to 6%) evidenced significant exposure to environmental tobacco smoke. Less than half of recommended health care visits were attended over the study interval. Few psychosocial variables were associated with adherence at T1 or in the longitudinal analyses. Fluticasone adherence at T2 was predicted by caregiver asthma knowledge.

CONCLUSIONS

A substantial number of low-income children with persistent asthma receive less than half of their prescribed inhaled controller agent. Patients without Medicaid, with low levels of caregiver asthma knowledge, or with caregivers who began childrearing at a young age may be at highest risk for poor medication adherence.

Patient attitudinal and behavioral factors associated with warfarin non-adherence at outpatient anticoagulation clinics

BACKGROUND

Warfarin is an anticoagulant effective in preventing stroke, but it has a narrow therapeutic range requiring optimal adherence to achieve the most favorable effects.

PURPOSE

The goal of this study was to examine specific patient factors that might help explain warfarin non-adherence at outpatient anticoagulation clinics.

METHOD

In a prospective cohort study of 156 adults, we utilized logistic regression analyses to examine the relationship between the five Treatment Prognostics scales from the Millon Behavioral Medicine Diagnostic (MBMD), as well as three additional MBMD scales (Depression, Future Pessimism, and Social Isolation), and daily warfarin non-adherence assessed using electronic medication event monitoring systems caps over a median of 139 days.

RESULTS

Four of the five Treatment Prognostic scales and greater social isolation were associated with warfarin non-adherence. When controlling for pertinent demographic and medical variables, the Information Discomfort scale remained significantly associated with warfarin non-adherence over time.

CONCLUSION

Although several factors were related to warfarin non-adherence, patients reporting a lack of receptivity to details regarding their medical illness seemed most at risk for warfarin non-adherence. This information might aid in the development of interventions to enhance warfarin adherence and perhaps reduce adverse medical events.

Adherence to pediatric asthma treatment in economically disadvantaged African-American children and adolescents: an application of growth curve analysis

OBJECTIVES

The primary aims of the study were to: (a) describe the trajectories of adherence to daily inhaled corticosteroid (ICS) medication for a year in economically disadvantaged, African-American youth with asthma based on growth curve modeling; and (b) test the relationship of treatment adherence to symptom control, quick-relief medication, and healthcare utilization.

METHODS

This prospective study measured adherence to daily ICS treatment using electronic monitoring in 92 children and adolescents with moderate to severe asthma for 9-12 months and assessed clinical outcomes, including asthma-related symptoms, quick-relief medication, and healthcare utilization.

RESULTS

Youth showed a decrement in treatment adherence to less than half of prescribed corticosteroid treatment over the course of the study, which related to increased healthcare utilization (p < .04), but not to asthma symptoms or albuterol use.

CONCLUSION

Economically disadvantaged youth with asthma demonstrate high rates of chronic nonadherence that warrant identification and intervention to reduce asthma-related healthcare utilization.

[Asthma treatment adherence]

Asthma is a very prevalent chronic disease in the general population, characterized by reversible obstruction of respiratory airways. Multiple studies demonstrate an improper control of the disease, and one of the main reasons for that is reduced adherence to treatment. Non -adherence can be classified as nonintentional or intentional, and the causes can be related to the motivations, beliefs and knowledge of the patient or due to the therapeutic regimen. The reasons for non -adherence are non -comprehension of the treatment goals; non -comprehension of disease severity; fears related to drugs; psychological conditions such as depression; complexity of treatment regimen; difficulties with administration route, mainly inhaler. After recognizing these issues as cause of non- -adherence, different approaches should be considered: set up a good physician -patient communication; promote asthma education; schedule regular appointments; simplify therapeutic regimen. It is important to promote adherence to achieve a good asthma control, and consequently a better quality of life and reduction of asthma associated costs.

Providing feedback on adherence increases use of preventive medication by asthmatic children

This study investigates the impact of measuring adherence and providing feedback on medication usage by children with unstable asthma. Adherence was measured using an electronic monitoring device. Subjects were randomized to either being told of their adherence during review consultations or for their adherence to remain undisclosed to their parents and treating physician. Subjects were reviewed monthly for 4 months. Twenty-six children aged between 6 and 14 years were recruited. Adherence was significantly higher in the intervention group (79% versus 58%, p <.01). There were significant improvements in clinical measures of disease control compared with baseline in both groups. The change in forced expiratory volume in 1 s (FEV(1)) (% predicted) was greater in those subjects receiving feedback (13.8% versus 9.8%). However, lung function values were lower in the intervention group at baseline and the relative improvement failed to reach statistical significance. Measuring adherence and providing feedback increases the use of preventive medication. A larger study is required to explore implications for disease control.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Do family mealtime interactions mediate the association between asthma symptoms and separation anxiety?

BACKGROUND

Respiratory problems have been shown to be associated with the development of panic anxiety. Family members play an essential role for children to emotionally manage their symptoms. This study aimed to examine the relation between severity of respiratory symptoms in children with asthma and separation anxiety. Relying on direct observation of family interactions during a mealtime, a model is tested whereby family interactions mediate the relation between asthma severity and separation anxiety symptoms.

METHODS

Sixty-three children (ages 9-12 years) with persistent asthma were interviewed via the Diagnostic Interview Schedule for Children IV; family interactions were assessed via direct observation of a mealtime; primary caregivers completed the Childhood Asthma Severity Scale; youth pulmonary function was ascertained with pre- and post-bronchodilator spirometry; adherence to asthma medications was objectively tracked for six weeks.

RESULTS

Poorer pulmonary function and higher functional asthma severity were related to higher numbers of separation anxiety symptoms. Controlling for medication adherence, family interaction patterns mediated the relationship between poorer pulmonary function and child separation anxiety symptoms.

CONCLUSIONS

Family mealtime interactions may be a mechanism by which respiratory disorders are associated with separation anxiety symptoms in children, potentially through increasing the child's capacity to cognitively frame asthma symptoms as less threatening, or through increasing the child's sense of security within their family relationships.