Jack H. Nassau

Behavioral adjustment in children with asthma: a meta-analysis.

This study is a meta-analytic review of the behavioral adjustment of children and adolescents with asthma. Of 78 studies initially reviewed, 26 studies (encompassing 28 data sets), reflecting data on nearly 5000 children with asthma (mean age = 8.4 years; 40% female), met criteria for inclusion. Effect size estimates were calculated across studies using standard methods. Separate effect sizes were calculated for internalizing and externalizing behavioral problems, degrees of asthma severity, and differences in control group used (i.e., sample controls or normative data). Results indicate that children with asthma have more behavioral difficulties than do healthy children, with the effect for internalizing behaviors being greater than that for externalizing behaviors (dmn = .73 vs .40). Increased asthma severity was associated with greater behavioral difficulties. Results did not differ by comparison group (healthy controls vs normative data). The findings suggest that patients with asthma, particularly children with severe asthma, should be considered at higher risk for behavioral difficulties that may necessitate psychosocial intervention.

The Asthma Responsibility Questionnaire: Patterns of Family Responsibility for Asthma Management

This study provided preliminary validation of the Asthma Responsibility Questionnaire (ARQ), a brief measure that assesses the division of family responsibility for 10 asthma management tasks. Data were collected from 2 samples of children (ages 7 to 15 years) and their mothers, recruited from an asthma camp (Sample 1) and various community sources (Sample 2). The ARQ demonstrated good internal consistency and convergent validity. Child and mother reports of child responsibility were modestly correlated and increased with child age by mother and child report. Four-year longitudinal data demonstrated significant increases in child responsibility for asthma management. Overall, children reported a higher degree of responsibility for themselves than mothers did for them. CHILDREN’S HEALTH CARE, 30(3), 183–199 Copyright

AIDS Education: The Rhode Island Experience

AIDS prevention, by public school education, is designed to change knowledge, attitudes, and future behavior. This study evaluated the impact of a state-mandated educational program on a sample of 2709 adolescents. Changes from pre to posttest were evaluated using standardized change scores and comparisons between the experimental and a delayed education control group were made. The experimental group, but not the control group, changed to a statistically significant degree (p < .001). They became more knowledgeable, endorsed slightly more tolerant attitudes, and reported an increased intention to avoid intercourse as a means of AIDS prevention. The extent of change was substantially greater for knowledge than for attitudes. Age, gender, and AIDS-related anxiety were found to be significant variables in the AIDS education process. The modest changes observed emphasize that the dissemination of AIDS information by public schools is only the first step in changing adolescent behavior as a means to AIDS prevention and that other, additional approaches are needed.

Symptom Perception in Children with Asthma: Cognitive and Psychological Factors

OBJECTIVE This study tested the differential effects of several cognitive and psychological variables on childrens perception of asthma symptoms by use of an Asthma Risk Grid. Childrens subjective and objective assessments of PEFR (peak expiratory flow rate) were characterized as representing perceptual accuracy, symptom magnification, and/or underestimation of asthma symptoms. DESIGN The study included 270 children with asthma (ages 7-17) and their primary caregivers who completed measures assessing cognitive and psychological factors and a 5 to 6 week symptom perception assessment. MAIN OUTCOME MEASURES Childrens symptom perception scores by use of the Asthma Risk Grid. RESULTS Childrens attentional abilities had more of a bearing on their symptom monitoring abilities than their IQ estimates and psychological symptoms. The more time children took on Trails and Cancellation Tasks and the fewer errors they made on these tasks, the more likely they were to perceive their asthma symptoms accurately. More time on these tasks was associated with more symptom magnification scores, and fewer errors were related to fewer symptom magnification scores. More errors and higher total scores on the Continuous Performance Task were associated with a greater proportion of scores in the danger zone. CONCLUSION Statistical support was provided for the utility of attentional-based instruments for identifying children who may have problems with perceptual accuracy, and who are at risk for asthma morbidity.

Rates and Predictors of Oral Medication Adherence in Pediatric Patients with IBD

Background:Symptoms of inflammatory bowel disease (IBD) include bloody diarrhea, fatigue, abdominal pain, and weight loss. Long-term management of remission for most patients requires adherence to taking 1 or more oral medications daily, in the absence of symptoms. We investigated whether disease characteristics and behavioral characteristics predict adherence to prescribed medical regimens. Methods:Patients aged 8 to 17.5 years, newly diagnosed with IBD, and a matched cohort previously diagnosed were studied over a 6-month period. Adherence was assessed using medication electronic monitoring devices (Medication Event Monitoring Systems); participants and parents completed questionnaires regarding emotional and behavioral functioning, and biological parameters were monitored. Results:Adherence was monitored for 45 newly and 34 previously diagnosed patients. In total, 16,478 patient-days (including 12,066 discrete days) were electronically monitored. Overall, 70.6% of 5-aminosalicylic acid and 65.4% of 6-mercaptopurine doses were taken. Only 25% and 15% of older adolescents took at least 80% of their 5-aminosalicylic acid and 6-mercaptopurine, respectively, compared with about 83% and 64% of 8-year-olds to 11-year-olds. Only age and behavioral issues were statistically linked to rates of adherence. Conclusions:Adherence to commonly prescribed oral medications for IBD is challenging for patients. Screening for emotional and behavioral problems, especially among older adolescents, would be important in identifying patients at risk of poor adherence, who might benefit from interventions. Biological solutions, although critical, when applied without attention to behavioral issues, are not likely to provide the level of therapeutic benefit that can be provided in a combined biobehavioral approach.

Depressive symptoms in youth with inflammatory bowel disease compared with a community sample.

Background:Previous investigations have produced mixed findings on whether youth with inflammatory bowel disease (IBD) experience elevated rates of depressive symptoms. Our first aim was to compare self-report of depressive symptoms by youth with IBD with a community sample. The second aim was to examine the relationship between symptoms of depression and measures of disease activity. Methods:Item-level responses on the Childrens Depression Inventory among a sample of 78 youth diagnosed with IBD were compared with responses from a community sample using 1-sample t-tests. Particular attention was given to items assessing somatic symptoms of depression given the potential overlap with IBD disease symptoms. The relationship between depressive symptoms and IBD disease activity was evaluated using Spearmans rank correlation coefficients and linear regression. Results:Youth with IBD reported lower levels of depressive symptoms compared with the community sample on the Childrens Depression Inventory Total Score, and similar or lower levels of difficulty on items assessing somatic symptoms. Most of the sample had inactive or mild disease activity at the time of participation, with 14% experiencing moderate/severe disease activity. Higher ratings of disease activity were related to greater depressive symptoms. Responses on somatic items from the Childrens Depression Inventory were not differentially related to disease activity. Conclusions:As a group, pediatric patients with IBD did not experience the clinical levels of depressive symptoms or elevations in depressive symptoms when compared with a community sample. Somatic symptoms of depression do not differentiate youth with IBD experiencing elevations in disease activity from youth experiencing nonsomatic symptoms of depression.

Thresholds of resistive load detection in children with asthma

Threshold detection of added resistive loads was studied in asthmatic children and compared to data previously obtained in a group of healthy children. The relationships between possible psychological predictors of perceptual ability, the perceptual threshold, and functional morbidity variables were also investigated. Our subjects were 103 children (mean age, 10.9 years) with asthma who completed two laboratory protocols in which they were asked to distinguish breaths with varying degrees of added resistance from unloaded breaths. Using two different computer‐driven protocols, resistances were presented as percentages of each childs intrinsic respiratory system resistance (Rrs). Cognitive ability was assessed through subtests of the Wechsler Intelligence Scale for Children, 3rd edition (WISC‐III), and functional morbidity was quantified through a combination of school absences, emergency medical visits, and days hospitalized.

Pediatric Asthma and Problems in Attention, Concentration, and Impulsivity: Disruption of the Family Management System.

RATIONALE: This study assesses the relationships between 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.

Repressive-defensive style and physiological reactivity among children and adolescents with asthma

OBJECTIVE This study evaluates the concordance of two self-report methods of operationalizing repressive-defensive style in children with asthma. It was hypothesized that, compared with low-anxious children, repressive-defensive children would exhibit increased physiological reactivity during a stressful laboratory task, despite comparable self-reports of state anxiety. METHODS Ninety-one children and adolescents (mean age = 11.5 years) with asthma participated in the study. Repressive-defensiveness was operationalized as self-reported low distress coupled with high defensiveness or restraint. Self-report data reflecting trait anxiety, defensiveness, and personality style were used to classify children as repressive-defensive by two independent methods. Physiological reactivity was operationalized as standardized changes in peripheral temperature, heart rate, and/or skin conductance from baseline to a stressful task. For the stressful task, children spoke into a tape recorder about a stressful or embarrassing event. RESULTS Each method classified 20% of children as repressive-defensive. However, of the children classified as repressive-defensive by either method (n = 26), only 38% (n = 10) were classified as repressive-defensive by both methods. In addition, regardless of the classification method, repressive-defensive children did not consistently differ from low-anxious children with respect to physiological reactivity under stress, one of the hallmarks of repressive-defensiveness in adults. CONCLUSION These results cast doubt on our ability to measure repressive-defensiveness reliably using self-report measures. Future research should determine whether children and adolescents can be reliably classified as repressive-defensive, whether this classification is related to physiological reactivity as in adults, and whether repressive-defensiveness plays a role in emotionally triggered asthma symptoms.

6-Thioguanine levels in pediatric IBD patients: adherence is more important than dose.

Background:Thiopurine immunosuppressants such as 6-mercaptopurine (6-MP) are widely used to maintain remission in children with both Crohns disease and ulcerative colitis. Therapeutic efficacy is associated with higher red blood cell levels of the thiopurine metabolite 6-thioguanine (6-TGN). Studies in both children and adults have inexplicably failed to demonstrate a significant correlation between prescribed dose and level of 6-TGN. We aimed to quantify the relationship between 6-TGN levels and adherence. Methods:We used electronic monitoring devices to assess adherence in children and adolescents with inflammatory bowel diseases who were prescribed 6-MP. Results:During 3230 days of monitoring in 19 subjects, adherence to 6-MP was 74.2%. Due to the generally low adherence to the prescribed dose of 6-MP, the 6-TGN level was not correlated with the prescribed dose. The 6-TGN level was significantly correlated with the adherence-adjusted dose (R2 = 0.395). It was also significantly correlated to adherence alone (R2 = 0.478). Adherence to 5-aminosalicylic acid and 6-MP were significantly positively correlated (rs (9) = 0.82, P = 0.00), and a significant relationship was found between 5-aminosalicylic acid adherence and 6-TGN levels independent of 6-MP adherence. Furthermore, low adherence to 6-MP was associated with increased likelihood of escalation of medical therapy. Conclusions:Red blood cell 6-TGN levels are strongly correlated with the dose, when the dose is actually taken. Lack of efficacy of thiopurines may often be the result of poor adherence. Novel ways of assessing and improving adherence are necessary. Future trials should assess adherence in study participants. Intake of 5-aminosalicylic acid positively influences 6-TGN levels.