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Article Excerpt
Rationale: This study assesses the relationships between attention-deficit/hyperactivity disorder (ADHD) symptoms, specific family asthma management domains and pediatric asthma morbidity. Methods: Participants were 110 children with asthma and a respective parent (ages 7-17, X = 11.6 years, 25% ethnic/racial minority). Parents completed measures of asthma morbidity and report of child ADHD symptoms. Children completed measures of attention, concentration, and impulsivity. Families participated in the Family Asthma Management System Scale (FAMSS) interview to assess the effectiveness of eight features of asthma management. Results: Parent report of ADHD symptoms and poor child performance on a computerized task of sustained visual attention were associated with asthma morbidity. Paper-and-pencil tasks of visual attention, and an index of auditory attention, were not related to asthma morbidity. Modest associations were found between parent report of ADHD symptoms, child performance-based indicators of attention and concentration, and features of family asthma management, although not across all measures. The family response to asthma partially mediated the relationship between ADHD symptoms and morbidity. Conclusions: ADHD symptoms are modestly associated with difficulties in family asthma management.
Keywords: asthma, ADHD, adherence
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Asthma is the most common childhood chronic illness, with current prevalence estimates at approximately 8% of the United States population (National Center for Health Statistics, 2002). Effective asthma management is necessary to control symptoms, maintain appropriate activity levels, and attain educational goals through consistent school attendance. Current guidelines for asthma management place considerable responsibility on the patient and family for monitoring symptoms, taking medications consistently, and avoiding triggers that initiate episodes (National Heart, Lung, & Blood Institute, 1997, 2002). Reviews of the literature, however, reveal that children with asthma and their families often have difficulty implementing treatment recommendations. For example, many children with asthma do not take preventive medications as regularly as prescribed (Bender et al., 2000; McQuaid, Kopel, Klein, & Fritz, 2003), and numerous families fail to follow environmental recommendations regarding issues, such as pet ownership (Wamboldt et al., 2002) or exposure to environmental tobacco smoke (Kattan et al., 1997).
Because disease management is central to asthma outcomes, researchers have sought to identify factors that place families at risk for difficulties in asthma management. Broad factors, such as lower socioeconomic status (SES), may impede effective disease management through multiple channels, including exposure to significant environmental triggers because of poor housing (Gruchalla et al., 2005), and limited access to quality health care (Valerio et al., 2006). Caregiver factors, such as stress (Wade et al., 1997) and maternal depression (Bartlett et al., 2001; Shalowitz, Berry, Quinn, & Wolf, 2001), have also been studied, but the mechanisms through which parental psychopathology affect disease management are not well understood.
Interesting to note, despite the fact that children with asthma are at increased risk for behavioral difficulties (Goodwin, Fergusson, & Horwood, 2004; McQuaid, Kopel, & Nassau, 2001), little research has assessed whether and how child behavior problems disrupt asthma disease management processes. Children with asthma are at increased risk for internalizing problems such as anxiety and depression (e.g., Good win et al., 2004) and, to a lesser degree, externalizing problems (e.g., more disruptive behavioral issues such as oppositional defiant behavior or impulsivity; McQuaid et al., 2001). Furthermore, children with more severe or persistent asthma symptoms are at greater risk for behavioral difficulties, as indexed by global ratings of behavioral and emotional problems (such as oppositional behavior and depressive symptoms; Halterman et al., 2006; McQuaid et al., 2001; Wamboldt, Fritz, Mansell, McQuaid, & Klein, 1998).
Psychiatric comorbidity, or even behavioral symptoms that are below threshold for psychiatric diagnosis, may be important factors in disrupting family asthma management.
The presence of comorbid behavior problems and/or reported depressive symptoms in children with asthma is associated with more frequent and prolonged hospital admissions (Kaptien, 1982) and more functional impairment due to asthma (Gustadt et al., 1989). Indeed, most of the research that has been conducted on the interface between psychiatric symptoms and asthma symptom management has emphasized depression (e.g., Bender, 2006; DiMatteo, 2000). Research in other childhood chronic diseases, however, suggests that externalizing problems may also be related to poor treatment adherence and impaired disease control. Specifically, research in diabetes has indicated that the presence of global externalizing problems in children may be a key factor that challenges effective and coordinated disease management. For example, Cohen and colleagues (2004) found that the presence of externalizing symptoms was related to poor glycemic control in a sample of economically disadvantaged children with Type 1 diabetes. Similarly, in a study of gender differences in adherence and metabolic control in low-income children with Type 1 diabetes, externalizing behavior problems were associated with poor adherence and worse metabolic control, particularly for boys (Naar-King et al., 2006).
We propose that features of a specific externalizing disorder, attention-deficit/ hyperactivity disorder (ADHD), may challenge effective pediatric asthma management in the family context. Children with ADHD have difficulties with attention, concentration, impulsivity, and self-regulation (American Psychiatric Association, 2000). In addition, parents of children with behavior problems such as ADHD typically report elevated levels of child rearing stresses (Mash & Johnston, 1990).
Effective asthma management relies on timely recognition and monitoring of symptoms, consistent implementation of medication routines and strategies for trigger control, and a coordinated plan of care between family and health care provider. Family routines may serve to support consistent management behaviors (Fiese, Wamboldt, & Anbar, 2005). We propose that the difficulties in attention, concentration, and impulsivity that typically characterize ADHD pose particular problems for asthma management and, consequently, lead to increased asthma morbidity. For example, recent research indicates that children who have problems with attention and concentration may have more difficulty identifying symptoms to family members (Koinis Mitchell et al., 2004). As a result, family members may not respond to increasing symptoms of asthma in a coordinated manner, leading to treatment delays and increased risk of significant exacerbation.
The purpose of the present article is to evaluate the associations among symptoms of ADHD and asthma morbidity, and to assess whether these associations are mediated through specific dimensions of family asthma management. We chose to study symptoms of ADHD, as opposed...
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