Emotional distress is frequently encountered in pediatric patients with asthma. Children with asthma demonstrate more internalizing symptoms relative to normative and control groups (Bender and Zhang 2008; Goodwin and Eaton 2005; Klinnert et al. 2000; Wamboldt et al. 1998). A meta-analysis of behavioral adjustment in children with asthma confirmed that, in general, children with asthma do have more emotional difficulties than their peers and that these difficulties are more pronounced in the internalizing domain (McQuaid et al. 2001). Based on a controlled study of a large sample of children ages 11-17 years with asthma (n=781) and healthy controls (n=598), Katon et al. (2007) reported that 16.3% of youth with asthma, compared with 8.6% of youth without asthma, met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association 2000), criteria for one or more anxiety and depressive disorders. This finding demonstrates that the increases in emotional disturbance previously noted in children with asthma are severe enough to meet criteria for full clinical syndromes.
Furthermore, the degree of internalizing disorder has been shown to be associated with degree of disease activity (Klinnert et al. 2000; MacLean et al. 1992; McQuaid et al. 2001; Wamboldt et al. 1998; Waxmonsky et al. 2006). Severe disease likely contributes to emotional compromise, but compelling evidence also indicates that chronic stress and distress contribute to disease activity (Sandberg et al. 2000, 2004). Asthma also can impair developmental processes, including development of autonomy, individuation from parents, socialization outside the family, establishment of peer relationships, and development of a positive self-image. Academic achievement can be severely impaired by absences from school. The compromise in these domains likely is affected by the degree of disease severity, with those children who have the most severe and persistent symptoms suffering the most (Fritz and McQuaid 2000).
The impact of pediatric asthma on family function and emotional climate is notable. Asthma is an extremely disturbing disease that can wreak havoc with family patterns of function. It can contribute to economic hardship, demoralize caregivers, cause family conflict, and disrupt routines. The disruption in family routines not only can cause family dysfunction but also can contribute directly to impaired adherence and poor disease control (Fiese and Wam-boldt 2001). The literature has long implicated family function in childhood asthma (Klinnert et al. 1994; Minuchin et al. 1975; Mrazek et al. 1998; Purcell et al. 1969). In a review, Kaugars et al. (2004) reported family and parenting factors in asthma outcomes, positing asthma management as well as psy-chobiological (i.e., psychosomatic) pathways.
Maternal depressive symptoms are elevated in families in which a child has asthma (Bender and Zhang 2008; Waxmonsky et al. 2006). In a sample of 242 children with asthma, ages 7-17, family observation ratings and self-reports of depressive symptoms indicated that maternal depression was linked to child depressive symptoms by way of negative parenting and to asthma disease activity by way of child depressive symptoms (Lim et al. 2008a). Similar patterns of findings have been identified for paternal depression and marital conflict (Lim et al. 2008b). Thus, family distress and asthma disease activity influence one another in mutual effect. Regardless of where the cycle begins, the reverberating impact of asthma on family disruption/distress, and vice versa, constitutes a downward spiral that requires effective intervention to stem increasing asthma morbidity and mortality.
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