Indian Pediatrics 2001; 38: 524-530
Screening for Psychosocial Problems in Children and Adolescents with Asthma
Initial review completed: September 22, 2000;
Asthma is one of the most common chronic childhood illness(1). Children with chronic physical disorders have been found to have higher incidence of psychosocial adaption problems than do children in the general population(2,3). Studies have reported increased adaptation problems in children with asthma(4-6) and these have been attributed to occur due to adverse developmental impact of having a chronic illness, psychosocial stress on the family, and repeated encounters with medical personnel(7,8). There is, however, wide variability observed in the adaptation in children with chronic physical conditions thereby suggesting the need to identify accurately those children who are functioning in the maladjustment range. According to Drotar and Bush (9) systematic documentation of the psychosocial adjustment difficulties experienced by children with chronic physical disorders is of immense importance if programs to meet their needs for mental health services are to be developed.
The present study aimed at: (i) syste-matically describing the psychosocial adapta-tion problems of children with asthma and contrasting it with a matched group of healthy children, and (ii) examining the relationship between demographic and illness related variables and psychosocial adaptation of children with asthma.
One hundred and thirty eight children and their mothers participated as subjects. The children were between the ages of 8 to 16 years and were from one of the two following groups: (i) Children with asthma (n = 70) consecutively selected from the population of children being treated for asthma on an Out Patient basis in the Allergy Clinic, at the Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, and (iii) Healthy children with no history of chronic illness (n = 68). These children were also selected from the OPD of the same hospital and were either being treated for minor self limiting illnesses or were healthy siblings of children with acute illness who were being treated at the same hospital. These two groups were matched on age, sex and socio-economic status.
For the 70 children with asthma (53 boys and 17 girls) the mean age was 10.8 years (SD = 1.92). The mother’s mean age was 35 years and they had completed on an average 10.56 years of schooling. The age at onset of symptoms of asthma ranged from less than one year to 12 years and mean age at onset was 5.16 years. The duration of illness ranged from 6 months to 13.5 years with a mean of 5.59 years. All children were on regular oral and/or inhaled medication. The symptoms of asthma were fairly diverse with 44% children having had no coughing or wheezing episodes in the month before the interview and 44% had 1 to 10 episodes, and 12% had more than 10 episodes in the past one month.
Children with asthma were compared to a matched group of healthy children at one point of time on three measures of psychosocial adaptation: Self-concept, adjustment and emo-tional and behavioral problems at home. The first two measures were child reported and the third measure was reported by the mothers.
(i) Self Concept: The self concept of the child was measured by the Piers Harris Children’s Self Concept Scale (CSCS)–Hindi adaptation(10). The CSCS consists of 80 first person declarative statement to which the child responds with "yes" or "no". Responses are coded in a manner that a higher score indicates a more positive self concept. The total score and the six sub scale scores (behavior, intellec-tual and school status, physical appearance, anxiety, popularity, and happiness-satisfac-tion) were used as dependent measures. The CSCS is a widely used scale and test- retest reliability is 0.88 and the concurrent and factorial validity has also been established(10).
(ii) Psychosocial Adjustment: The psycho-social adjustment of the child was assessed by the Pre Adolescent Adjustment Scale (PAAS)(11). The scale consists of 40 state-ments to which the child has to respond with "yes" or "no". The scale measures the child’s adjustment towards home, school, teachers, peers and general issues. Scores on each sub-scale are attained by additing the scale values on the items checked in the affirmative by the respondent. High positive scores indicate good adjustment while high negative scores indicate poor adjustment. The PAAS has been validated by the authors against the rating of the teachers from four schools. For all areas, the calculated Mann-Whiteny U values were significant. Test-retest reliability values for different areas, are, however, moderate and range from 0.28 to 0.54(11). In the present study, the total scores and all the 5 sub-scale scores were used as dependant measures.
(iii) Emotional and Behavioral Functioning: The child’s emotional and behavioral functioning at home was measured by the mothers rating of the child’s behavior on the Childhood Psychopathology Measure-ment Schedule (CPMS)(12). The scale consists of 75 items and is a Hindi adaptation of the Child Behavior Checklist(13), one of the most extensively used instrument to assess child’s psychosocial functioning. The CPMS has eight sub scales including low intelligence and behavioral problems, conduct problems, depression, anxiety, psychotic symptoms, somatization, special symptoms, and physical illnesses and emotional problems(12). The authors also recommend a cut off score of 10 and children scoring above the cut off score are considered as exhibiting clinically significant level of maladjustment.
Independent t test were used to determine if there were differences in the psychosocial adaptation of children with asthma and controls. It was anticipated that children with asthma would have lower psychosocial adaptation than controls. Data from the asthma sample were further analyzed and Pearson’s correlation coefficients were computed to determine if illness related variables (i.e., age at onset, duration of illness, frequency of episodes) and demographic variables (i.e., age, sex of the child and socio-economic status of the household) were related to any of the 3 measures of psychosocial adaptation.
Analysis of socio-demographic data for the asthma and control groups of children indi-cated that they were similar in age, sex and socio-economic status. The two groups were also matched on the educational level of parents.
Comparison of asthma and control group on the three psychosocial adjustment measures is presented in Table I. There were no significant differences in the overall self concept scores of the two groups although children with asthma were significantly less happy and satisfied than the control group.
Moreover, there was no difference in the overall adjustment scores or on any one of the sub scale scores on the PAAS thereby indicating that children with asthma were not experiencing any adjustment difficulties.
Children with asthma were, however, found to have significantly (p <0.01) higher childhood psychopathology scores than control subjects. Some of the common behavioral and emotional problems reported were argumenta-tive (31%), labile mood (31%), attention seek-ing (29%), irritability (27%), destructiveness (26%), temper tantrums (24%), fearfulness (24%), dependency (24%), and nervousness (22%). In addition, 20% of the children with asthma had scores above the recommended cut off score on the CPMS and were functioning in the clinically significant maladjustment range. In contrast, only 2.9% of the control subjects had CPMS scores above the cut off score.
Pearson’s correlation coefficient were computed to assess the relationship between demographic variables, illness related variables and psychological adaptation measures (Table II). Correlations ranged from –0.01 to –0.29. Generally these results indicate very weak or no relationship between demographic, illness related variables and psychosocial adaptation measures of children with asthma. The only correlation which was significant was between frequency of episodes and adjustment (r = –0.29, p <0.05). Greater the frequency of episodes of wheezing or coughing, poorer the adjustment.
Table I__ Comparison of asthma and control groups on psychosocial adjustment measures
Childhood Psychopathology** 6.5 3.8 * – p <0.05; ** – p <0.01.
Children with asthma were found to be more at risk for emotional and behavioral problems than healthy controls. Externalizing behavioral problems such as argumentative, irritability, destructiveness, temper tantrums, and internalizing problems such as labile mood, fearfulness, dependency and nervous-ness were widespread in children with asthma. These results are consistent with previous research indicating chronic illnesses including asthma, have a higher incidence of emotional and behavioral problems(4,5,14-16). For example, Kashani et al.(4) reported that 63% of 56 children with asthma met the diagnostic criteria for a psychiatric disorder. Bussing et al.(5) found that children with severe asthma as compared to children without chronic conditions were 3 times more likely to have severe behavioral problems.
Several studies suggest that pediatricians are not very accurate in their identification of emotional and behavioral difficulties in children(17,18). For instance, Costello et al. (17) found that only 17% of the children with psychosocial problems were identified by pediatricians resulting in 83% of children at risk being missed. The authors termed this continued under identification of mental health problems in pediatric practice as the "new hidden morbidity".
It seems then that the CPMS may be a useful screening instrument in identifying psychosocial problems in children with asthma. Accurate identification of children at risk for psychosocial adaptation difficulties in a timely manner can help in designing of mental health services that may serve to prevent further psychosocial morbidity and remediate existing maladaptation(17).
Contrary to expectation, no significant differences in the overall self concept and adjustment were found among children with asthma and matched healthy controls, but the asthmatics reported that they were less happy and satisfied than the controls. These results suggest that children with asthma have good overall self concept and were not experiencing any adjustment difficulties at home, school or with their teachers and peers. These findings are also consistent with previous research wherein children with asthma have been found to have a good overall self esteem(16,19,20). It is possible that children with asthma are more prone to developing behavioral and emotional problems which do not necessarily affect the way they adjust with others and the way they perceive themselves.
Demographic and illness related variables were generally not found to be significantly correlated with psychosocial adaptation measures. The only significant correlation was between frequency of episodes of wheezing and/or coughing and adjustment. Greater the frequency, poorer the adjustment. This implies that poor control of the disease is an important factor in predicting the overall adjustment of the child. Possibly, the use of adequate prophylactic therapy is likely to be helpful in promoting better overall adjustment in children with asthma. Further research should identify the potentially modifiable correlates of the psychological and social functioning of children with asthma.
Our findings, highlight the need to evaluate the adaptation of children with asthma. By recognizing that children with asthma are at a risk for developing adjustment problems, health care providers can through routine systematic screening assessment identify children at risk. It is concluded that there is a need for planning for the mental health needs of children with asthma as part of their overall medical management.
Contributors: PM co-ordinated the study, designed it, collected the data and drafted the paper; she will act as the guarantor for the manuscript. LK and MS helped in designing the study and drafting the paper.
Funding: Post Graduate Institute of Medical Education and Research, Chandigarh.
Competing interests: None stated.
Table II__ Intercorrelations among demographic, disease related and psychosocial adaptation variables (asthma group)