Journal of Pediatric Psychology, Vol. 25, No. 1, 2000, pp. 35-46
© 2000 Society of Pediatric Psychology
A Multimethod Assessment of Behavioral and Emotional Adjustment in Children With Asthma
1 National Jewish Medical and Research Center/University of Colorado Health Sciences Center, 2 Rhode Island Hospital/Brown University Medical School, 3 Colorado Allergy and Asthma Centers, 4 University of Florida
All correspondence should be sent to Mary D. Klinnert, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, Colorado 80206. E-mail: Klinnert M{at}njc.org .
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Abstract |
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Objective: Examine behavioral adjustment and emotion regulation among 6-year-old children with asthma and a group of healthy controls.
Method: Subjects were 81 children with asthma and 22 healthy controls. Asthma and allergy statuses were confirmed by objective measures. Emotional and behavioral functioning were assessed through parent report, child interview, and child participation in an emotional regulation paradigm.
Results: Maternal report revealed more internalizing and total behavior problems for children with asthma compared to controls. Child interview and behavioral observations of emotion regulation yielded no differences between groups. Severity of asthma was related to increased emotional difficulties by clinician interview and observation but not by maternal report.
Conclusions: Two groups of children with asthma who have psychological difficulties include those with increased anxiety and those with poor emotion regulation and more asthma symptoms. Different measures of child adjustment yield a complex picture of the behavioral difficulties associated with pediatric asthma.
Key words: pediatric; asthma; adjustment; emotion regulation; multimethod; illness severity; mother-child interaction.
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Introduction |
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Decades ago, pediatric asthma was perceived as a psychosomatic illness often characterized by difficulties in mother-child interaction. Advances in understanding the pathophysiology of asthma and documentation of the wide array of precipitating factors gradually tempered this view. However, the question of whether children with asthma have more difficulties in adjustment than other children has yet to be definitively answered. Empirical work investigating behavior problems in the pediatric asthma population has had methodological difficulties and has yielded inconsistent results. Studies that have considered the role of disease severity in relation to adjustment among individuals with asthma have also reported disparate findings. Further, few studies provide a model for explaining why children with asthma would have differing patterns of adjustment.
The goal of this study is to examine the behavioral and emotional adjustment of young children with asthma. We use a multimethod approach to elucidate the inconsistent results of prior research. We review data regarding children's emotion regulation and propose an alternate framework for explaining variation in behavioral adjustment in children with asthma.
Psychological Adjustment Among Children With Asthma
Early literature on psychological adjustment in children with asthma often
focused on emotional difficulties and disturbed parent-child relationships
(French & Alexander, 1941
).
Perhaps in response to these observations, two classic epidemiological studies
investigated the prevalence of psychiatric disorders in children with asthma
(Graham, Rutter, Yule, & Pless,
1967; McNicol, Williams,
Allan, & McAndrew, 1973). Both studies concluded that the
psychiatric disorder or behavioral disturbance found in children with asthma
did not exceed that found in children without asthma. However, more recent
research efforts have often reported increased levels of behavior problems
among children with asthma as compared to children without asthma
(Hamlett, Pelligrini, & Katz,
1992; Kashani, Konig,
Shepperd, Wilfley, & Morris, 1988;
MacLean, Perrin, Gortmaker, & Pierre,
1992). Different measurement approaches may account for these
varying estimates of the prevalence of psychological problems. Research
indicating higher levels of psychological problems in children with asthma
than in healthy children is derived primarily from parent report data
(Hamlett et al., 1992;
MacLean et al., 1992).
Furthermore, when differences are found, the difficulties reported are
generally minimal and fall in the range between normal behavior and
diagnosable disorder (Kashani et al.,
1988).
Studies that obtain information about child functioning from informants
other than the parents are less consistent regarding increased levels of
psychopathology in children with asthma. In the study by Graham and colleagues
(Graham et al., 1967),
teachers did not report higher levels of behavior problems among children with
asthma. In a more recent study including both parent and child structured
interviews, findings indicated children with asthma did not differ from
matched controls in number or type of psychiatric diagnoses
(Kashani et al., 1988).
However, parents of children with asthma reported higher levels of overanxious
symptoms for their children than parents of controls. No group differences
were found on levels of symptoms by child interview
(Kashani et al., 1988).
Hence, the finding that children with asthma have increased behavior
problems relative to their peers appears to derive specifically from parent
report measures. Parents tend to report higher levels of behavior problems for
children with asthma; other informants (teachers and the children themselves)
rarely report such differences. Recent research has emphasized the need for
utilizing multiple informants in any assessment of child behavior problems,
given that parents, children, and other adults may all provide unique
perspectives on child functioning
(Achenbach, McConaughy, & Howell,
1987; La Greca & Lamanek,
1996).
Illness Severity and Psychological Functioning Among Children With
Asthma
Findings have been contradictory as to whether increased asthma severity is
related to increased difficulties in emotional and behavioral adjustment.
Early research suggested that behavioral disturbances occurred at a
significant level only in the small group of children with severe and
continuing asthma (Graham et al.,
1967; McNicol et al.,
1973). Some recent studies have found greater asthma severity to
be associated with increased adjustment problems
(Bussing, Halfon, Binjamin, & Wells,
1995; MacLean et al.,
1992) and more difficulties in the mother-child relationship
(Hermanns, Florin, Dietrich, Rieger, &
Hahlweg, 1989). This pattern is consistent with reports of high
levels of psychiatric disorder among adolescents with very severe asthma
(Wamboldt, Weintraub, Krafchick, &
Wamboldt, 1996). However, others have found no relationship
between asthma severity and psychological functioning
(Kashani et al., 1988). Yet
others have found a curvilinear effect, with the greatest psychological
dysfunction occurring among children with both severe and mild asthma
(Perrin, MacLean, & Perrin,
1989).
Asthma severity is a complex construct defined by dimensions such as
symptom frequency and severity, response to treatment, and effect of the
illness on life activities. Inconsistent results regarding the relationship
between children's psychological functioning and asthma severity may be
caused, in part, by variations in assessment. Objective indices such as
measures of lung functions may be included, but most psychological studies
rely on reports of medications required to control asthma symptoms, frequency
and severity of symptoms, or functional indices such as school days missed.
Several studies that have used medication level as a measure of asthma
severity have found no relationship to psychological adjustment
(Kashani et al., 1988;
Norrish, Tooley, & Godfrey,
1977). In contrast, asthma severity measures that include
functional status items such as number of school days missed have more
frequently been related to psychological problems
(Graham et al., 1967;
MacLean et al., 1992). This
may be true because the management of asthma, including the extent to which it
negatively affects children's functioning, is associated with psychological
functioning (Stein & Jessop,
1984). Finally, number and severity of symptoms, in isolation from
medication levels required, might be expected to be related to psychological
functioning because the latter is related to compliance
(Milgrom, Sarlin, & Leung,
1994). In this study, we have distinguished between medication
level and symptom control to clarify the potentially differing relations
between these variables and child adjustment.
Emotion Regulation in Children With Asthma
We propose that difficulties in emotional regulation may provide a
useful heuristic for understanding the behavioral and interactional
difficulties reported in children with asthma. The process of emotional
regulation includes access to the range of emotions and the flexible
modulation of the intensity, duration, and transitions between emotions
(Cole, Michel, & O'Donnell Teti,
1994). Developmentally, emotion regulation is influenced not only
by intrinsic factors such as temperament but also by repeated interactions
with caretakers. The manner in which caretakers modulate emotions for their
young children and teach (e.g., through modeling or providing consequences)
the regulation of emotional behavior has been shown to play a major role in
children's emotion regulation (Thompson,
1991). Events that stress the child and caretakers, such as when
young children develop significant illness, may contribute to dysregulatory
aspects of emotional regulation that may impede adaptive coping; emotional and
behavioral difficulties may then result.
The examination of emotion regulation among children with asthma
complements the measures provided by behavioral ratings. Assessments of
emotion and emotion regulation focus on the key areas of behavior that often
have been described, through a variety of measures, as problematic for
individuals with asthma. Emotional symptoms such as anxiety or depression
(Kashani et al., 1988;
Wamboldt et al., 1996) and
parent-child interaction problems (Block,
Jennings, Harvey, & Simpson, 1964;
Hermanns et al., 1989;
Mrazek, Anderson, & Strunk,
1985; Schobinger, Florin,
Zimmer, Lindemann, & Winter, 1992) may be reinterpreted as
difficulties in emotion regulation. In this view, negative emotion may disrupt
the child's internal equilibrium as well as the relationship with the parent.
Such difficulties in the parent-child relationship can result in the negative
emotional climate noted in certain observational studies of children with
asthma (Block et al., 1964;
Mrazek et al., 1985) and may
also result in increased parental report of some child behavior problems
(Hamlett et al., 1992;
MacLean et al., 1992).
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Method |
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Sample
Eighty-one children with asthma and 22 healthy control children between the ages of 6 and 7 were enrolled in the study. Participants were recruited through physician referrals from the community, outpatient and inpatient services at the National Jewish Medical and Research Center, responses to community advertisements, and participation in a longitudinal study cohort (Mrazek, Klinnert, Mrazek, & Macey, 1991
). All of the healthy controls were recruited from the latter
cohort. Forty-three (42.6%) of the total sample were girls. The children's
ethnic background was 70% Caucasian, 14% Mexican American, 11% African
American, 3% American Indian, and 2% Asian. The groups of children with and
without asthma were comparable in terms of ethnic background,
2 (4) = 4.03, ns. The average socioeconomic level was middle
class, with 20% Level I, 33% Level II, 25% Level III, 12% Level IV, and 11%
Level V (Hollingshead, 1975).
There was no difference between the socioeconomic levels of the children with
asthma and those without, 2 (4) = 7.19, ns.
Asthma and Allergy Status
Children were recruited into the study on the basis of parent report of the
presence or absence of asthma symptoms. All children received methacholine
challenges to confirm the diagnosis of asthma. A positive response to inhaled
methacholine was defined as a decrease in lung function (FEV1) from baseline
of at least 20% and/or clinical signs and symptoms at 10 mg/ml administration
(Adinoff, Schlosberg, & Strunk,
1988). Children with asthma who did not demonstrate a positive
response to methacholine were excluded from the study, with the exception of
those who were currently taking inhaled corticosteroids
(Bel, Timmers, Zwinderman, Dijkman, &
Sterk, 1991) and had documentation of wheezing episodes by medical
record review. Children who presented with a history of bronchopulmonary
dysplasia in infancy (n = 2) or who presented with cough variant
asthma with no clinical evidence of wheezing (n = 8) were also
excluded.
Clinical classifications of asthma severity were made by an allergist who
reviewed the medical history and clinical presentation. Medical history review
included assessment of the frequency of asthma exacerbations and examination
of the medication regimen. Pulmonary function data and clinical observations
from the methacholine challenge were also reviewed. Classification of asthma
severity was made according to the levels provided by the National Asthma
Education Program: Expert Panel Report
(National Asthma Education Program,
1991). Of the 81 children with asthma, 27 (33%) were judged to be
in the mild range, 46 (57%) in the moderate range, and 8 (10%) in the severe
range.
We wanted a continuous measure of asthma severity so that we could use information contained within the broad categories of mild, moderate, and severe in our examination of psychological correlates. In addition, we wished to weight similarly the pattern of high medications/low symptom score (controlled, adequately treated) asthma and the pattern of low medication/high symptom score (out-of-control, inadequately treated) asthma. Children with high medications/high symptoms would receive scores reflecting the most severe asthma. Thus, we developed a continuous measure of asthma severity, which included information regarding medication level and symptom control. To derive a scale of severity of required medication, an allergist rank ordered the medication regimens of the children in the study along a dimension of medication severity. The same procedure was followed to derive a scale of symptom control, so that children with infrequent, milder symptoms received lower scores and children with severe symptoms requiring hospitalizations and/or emergency department visits received the highest scores. The two scales were correlated at r =.49 and were combined in order to achieve our goal for similar weight for the two patterns. An analysis of variance (ANOVA) was computed on the severity scores with three levels of asthma severity to determine whether children's scores on the continuous severity scale were consistent with the physician-rated severity level. The highly significant ANOVA, F(2, 78) = 20.16, p <.0001, indicated high agreement between the two dimensions of asthma severity. Analyses presented here of associations between psychological factors and asthma severity use the continuous scale.
We determined allergic status for both children with asthma and those without through a review of allergy symptom history and results of prick skin testing to a panel of 22 regional aeroallergens. Sixty-six (60%) of the children were judged as allergic and 37 (40%) as not allergic. For the children with asthma, a comparison between allergic and nonallergic groups on illness severity was not significant, t (78) = 1.21, ns.
Procedures
The study protocol was approved by the National Jewish Institutional Review
Board. Children came to the laboratory with their mothers on two occasions.
Mothers completed the Child Behavior Checklist (CBCL;
Achenbach, 1991) for their
children before the first visit. The purposes and procedures of the research
project were described to the mothers and children during the first laboratory
visit. Informed consent was obtained from the mothers, and informed assent was
obtained from the children. Mothers were then interviewed regarding their
child's asthma and allergy history while the child was interviewed by a child
clinician using the Semi-structured Clinical Interview for Children and
Adolescents (SCICA; McConaughy &
Achenbach, 1994). The clinician was unaware of the child's asthma
status and any extensive background or history of behavioral functioning.
Following the interviews, the child received prick skin testing.
Antihistamines were withheld prior to skin testing.
During the second laboratory visit, we assessed the child's emotion regulation by engaging him or her in a series of tasks designed to elicit a variety of emotional states (as described below). After the individual child tasks were completed, the mother joined the child for two final tasks. Following the laboratory assessment, the child was taken to the pulmonary function laboratory for a bronchial challenge to methacholine to determine airway reactivity.
Measures
Child Behavior Checklist. We used the Child Behavior Checklist
(CBCL; Achenbach, 1991) to
obtain parental report of the child's behavioral functioning. Parents read a
list of 113 behaviors (e.g., "has nightmares") and indicate on a
3-point scale the degree to which the behavior is typical of the child. Scores
result in several empirically derived scale scores, as well as broadband
Internalizing, Externalizing, and Total Behavior Problem scores. This measure
was recently revised to make it a more appropriate tool for use with a
chronically ill population and to provide more recent norms
(Achenbach, 1991).
Semistructured Clinical Interview for Children and Adolescents.
Children were interviewed by a child psychology doctoral candidate, trained by
the PI in the use of the Semistructured Clinical Interview for Children and
Adolescents (SCICA; McConaughy &
Achenbach, 1994). During this interview, developed for children
ages 6 to 18, the child is asked questions about the general areas of school,
friends, family, relatives, fantasies, and self-perceptions. Brief assessments
of academic achievement, fine motor skills, and gross motor skills are also
obtained. In addition, the interviewer receives a list of six behaviors that
the parent has identified as problematic while filling out the CBCL to use to
probe the child's perception of these difficulties. After the interview, the
clinician scores the child's behaviors and verbalizations using the SCICA
Observation and Self-Report forms. For 6- to 12-year-olds, this includes 235
items, each scored from 0 to 3, with 0 indicating "no occurrence"
and 3 indicating "severe intensity or > 3 minutes" (during the
interview). Sample items are "Defiant, talks back, or sarcastic"
(Observed and Externalizing scales) and "Reports feeling worthless or
inferior" (Self-Report and Internalizing scales). The SCICA yields
broadband Internalizing and Externalizing scores as well as several narrow
band subscale scores. Separate total Self-Report and Observed problem scores
are also derived based separately on the child's reported difficulties and
clinician observations during the interview. The SCICA has good psychometric
properties, with test-retest reliability (12 days) ranging from r
=.69 to r =.89 for broadband scores and interrater reliability
ranging from r =.52 to r =.72
(McConaughy & Achenbach,
1994). In this study, a subset of videotapes (n = 16) was
coded for reliability by another child psychologist. Correlations on broadband
scales (Internalizing, Externalizing, Self-Report, Observed) were at or above
r =.65.
System for Coding Affect Regulation in the Family. The System for
Coding Affect Regulation in the Family (SCARF;
Lindahl, Clements, & Markman,
1993) is an observational paradigm and rating system designed to
assess child behavior and parent-child interaction during a challenging or
frustrating experience. Originally developed for children approximately 5
years of age and their mothers, the SCARF was adapted for use with
6-year-olds. This behavioral observation strategy allows close scrutiny of the
quality of the child's emotion regulation, both individually and during an
interaction with the mother, and also allows examination of the manner in
which the mother helps the child to regulate his or her emotional
responses.
This study included a series of tasks in which the child was alone or interacting with the experimenter, as well as two parent-child interaction tasks. These included a cognitive task involving circling specified letters out of a random series, a positive affect task of playing a game with the experimenter, an anxiety task involving a brief interview regarding parent-child separations, and a frustration task consisting of an impossible timed game. Each 5-minute task was separated from the previous one by a 2-minute baseline period, during which the child was asked to sit quietly. In the first parent-child interaction task, the pair was instructed to complete an Etch-a-Sketch picture jointly, with the mother to give only verbal assistance. Last, the mother and child were instructed to discuss a problematic issue in the parent-child relationship.
Child and mother were videotaped during individual and joint tasks, and videotapes were later reviewed and rated by coders blind to family history and child asthma status. Coders rated a number of individual dimensions of child and parent behavior, which were then used to create summary scores of the child's regulation of his or her own negative emotion and the mother's regulation of the child's negative emotion. Child emotion regulation and behaviors were rated on 5-point Likert scales of Positive Affect, Negative Affect, Withdrawal, Engagement, and overall Negative Affect Regulation. These scales are combined to yield summary scores of the quality of the child's affect, Child Negativity, and the child's regulation of his or her own negative affect, Emotion Regulation. Maternal behaviors in relation to the child are rated on 5-point Likert scales including Emotional Support, Emotional Invalidation, Physical Nurturance, Affective Attunement, Control, and overall Negative Affect Regulation of Child. Summary scores derived from these scales reflect the quality of the mother's affect in the interaction with the child, Maternal Negativity, and the mother's regulation of the child's negative affect, Maternal Emotion Regulation.
Reliability for the SCARF scales has been found to be satisfactory. Lindahl
and colleagues (Lindahl et al.,
1993) reported average interrater Pearson correlation coefficients
of r =.82. For this study, coders were first trained to reliability
on the SCARF by the PI. Ratings were then completed by one coder, and a second
coder rated a subsample of videotapes for reliability (n = 23).
Intraclass correlations, computed for the summary scales to assess overall
agreement between coders, ranged from.68 to.84. Internal consistency estimates
for the summary scales ranged from.75 to.88.
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Results |
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We first report the relationships among the emotion regulation and adjustment scores for the entire sample. Then, we will compare the scores for the children with asthma with those of the healthy group. We will report the association between asthma severity and the emotion regulation and adjustment scores. Finally, we will present data demonstrating that difficulties in emotion regulation are related to higher levels of asthma symptoms.
Interrelationships Between Child Emotion Regulation and
Adjustment
The capacity to regulate emotion effectively is conceptualized as a skill
that emerges over the course of a child's development. As such, it is distinct
from a global assessment of child adjustment but should be positively
associated with child adjustment. Table
I presents the relationships among these variables for the entire
sample of children. Correlations between the parent report (CBCL), clinician
interview (SCICA), and observational tasks of emotion regulation are
presented.
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These data indicate little association between the CBCL broadband scores and the SCICA Observed or Self-Report scores. Mothers' reports of their children's externalizing behavior, completed before the laboratory visit, were significantly correlated with the child's ineffective emotion regulation during the dyadic interaction, r = -.28, p <.01, and with ratings of maternal negativity made during the same interactions, r = -.24, p <.05. In contrast, the Observed scores from the SCICA were strongly related to ratings of the child's emotion regulation when separated from mother, r = -.53, p <.0001, and during interaction with the mother, r = -.36, p <.001. They were also significantly related to the child's negativity when apart from the mother, r = -.28, p <.01. The SCICA Self-Report scores were unrelated to behavioral observations of the child's emotion regulation, either with mother or apart from her. Ratings of emotion regulation and negativity were most highly correlated when measured in the same context, r =.58, p <.0001. Emotion regulation measures from the different contexts, with and without mother, were also significantly correlated at r =.34, p <.001.
Adjustment and Emotion Regulation in Children With and Without
Asthma
We expected that the children with asthma would have more behavioral and
emotional problems than the healthy controls, but that these findings would
vary as a function of informant. We used ANOVAs to examine the relationships
between asthma status and the measures of child adjustment, including the CBCL
(parent report), the SCICA (clinician interview), and the SCARF (behavioral
observation of emotion regulation). Emphasis was given to the broadband scales
of the CBCL and the SCICA.
We conducted preliminary analyses for all variables with gender as a
factor. No significant findings were related to gender, so it was not included
in further analyses. Since some prior research has emphasized the role of
allergy in child behavior problems (Block
et al., 1964, Bussing et al.,
1995) we initially included allergic status as an independent
variable in all analyses. None of the variables of primary interest was
significantly related to allergic status, and it was therefore not controlled
in subsequent analyses.
Mothers of children with asthma reported higher Total Behavior Problem scores (Asthma M = 55.17, SD = 0.90; No Asthma M = 50.36, SD = 1.72), F(1, 101) = 6.16, p <.05, and higher scores on the Internalizing scale (Asthma M = 53.99, SD = 0.86; No Asthma M = 49.14, SD = 1.66), F(1, 101) = 6.75, p <.05, than did mothers of children who did not have asthma. No significant differences in maternal report of Externalizing behaviors were found between the two groups (Asthma M = 54.56, SD = 1.05; No Asthma M = 51.55, SD = 2.01), F(1, 101) = 1.76, ns.
The assessment for effects of asthma on child adjustment, measured by the SCICA, used a similar analytic strategy. The ANOVAs indicated no significant differences in child adjustment between the groups of children with and without asthma on the four broadband scales of Observed Problems, Self-Report, Internalizing, and Externalizing, all Fs (1, 101) < 0.58, ns.
We used multivariate ANOVAs (MANOVAs), with asthma status as a between-groups factor, to assess for group differences due to asthma status on multiple measures of child emotion regulation. For the first MANOVA, two measures of child Emotion Regulation, one assessed when the child was apart from the mother (Emotion Regulation-Apart) and the other when the two were together (Emotion Regulation-Dyadic), were grouped as dependent variables. Results indicated no significant differences in emotion regulation between the children with asthma and those without, F(1, 100) = 0.22, ns. Again using asthma status as the independent variable, we conducted a second MANOVA with Child Negativity measured apart from the mother (Negativity-Apart) and together with her (Negativity-Dyadic). Results showed no differences between the children with asthma and those without, F(1, 100) = 0.32, ns. A third MANOVA was used to assess whether Maternal Emotion Regulation and Maternal Negativity differed for children with and without asthma. There were no significant differences in the maternal behavior, F(1, 100) = 0.72, ns.
Adjustment in Relation to Asthma Severity
Among the children with asthma, behavioral and emotional problems were
expected to increase with increasing asthma severity. We used Pearson
correlation coefficients to examine the relationship between asthma severity
and child behavioral adjustment. Among the children with asthma, there was no
relationship between severity of illness and any of the CBCL broadband scales,
all rs <.07, ns.
We used similar analyses to examine relationships between asthma severity and child adjustment as assessed by the clinical interview (SCICA) ratings. In contrast with the parent report data, the clinical interviews with the children revealed significant relationships between asthma severity and problematic behavior. Increasing levels of asthma severity were related to higher scores on the broadband Observed scale, r =.23, p <.05. The relationship between the Self-Report scale and asthma severity approached significance, r = -.22, p =.06, with greater severity related to fewer reported problems. No significant relationships were found between asthma severity and either the Internalizing (r = -.18, ns) or Externalizing (r =.09, ns) scales of the SCICA.
Emotion Regulation and Asthma Severity
Difficulties with emotional regulation were also expected to increase with
greater illness severity among the children with asthma. Pearson correlation
coefficients were used to assess relationships between asthma severity and the
two ratings of emotion regulation. Greater asthma severity was related to
increased difficulty regulating emotion in a situation wherein the mother was
absent, Emotion Regulation-Apart, r = -.23, p <.05. The
relationship between asthma severity and poorer emotion regulation in the
presence of the mother, Emotion Regulation-Dyadic, approached statistical
significance, r = -.21, p =.06. The two Emotion Regulation
scores were combined into a composite score due to their moderate correlation
(r =.34). This composite Emotion Regulation score was significantly
correlated with asthma severity, r = -.27, p <.02.
Child Negativity-Apart was not significantly associated with asthma severity, r = -.07, ns. However, Child Negativity-Dyadic was significantly correlated with asthma severity, r = -.24, indicating that during interactions with mothers, the children with more severe asthma expressed greater negative affect. The two child negativity measures were also moderately correlated, r =.40, but when combined into a summary score they were not significantly correlated with asthma severity, r = -.18, ns. Neither Maternal Emotion Regulation of the child nor Maternal Negativity was significantly associated with asthma severity, r =.00 and r =.12, respectively.
Emotion Regulation and Asthma Symptoms
The literature regarding the relationship between asthma severity and
psychological adjustment has been inconclusive. We have suggested that such a
relationship appears when investigators use severity measures encompassing
symptoms and symptom control rather than measures of pulmonary functions or
medication requirements. In this study, we examined the relationship between
the emotion regulation and adjustment variables and the two components of the
severity scale.
We explored relationships between symptom and medication components of the severity scale and adjustment and emotion regulation measures. For simplicity, the composite scores for child Emotion Regulation and Negativity were employed. The Symptom scale was significantly correlated with the composite Emotion Regulation score, r = -.31, p <.01, and with the SCICA Self-Report score, r = -.32, p <.01, but not with the SCICA Observed scale, r =.10, ns. The correlation between the Medication scale and Emotion Regulation only approached significance, r = -.20, p <.10; it was unrelated to the SCICA Self-Report scale, r = -.09, ns; and it was significantly correlated with the SCICA Observed scale, r =.25, p <.05. Like the Total Severity score, the two component scores were unrelated to the CBCL broadband scales, and they were also unrelated to Child Negativity and Maternal Emotion Regulation and Negativity.
To further explore the relationship between the psychological variables and the children's asthma symptom levels, a hierarchical multiple regression was computed with the Symptom score as the response variable. We wished to test the contribution of the three informants regarding the child's psychological functioning, that is, the parent's report (CBCL Total Behavior Problem score), the child's own report (SCICA Self-Report), and the behavioral ratings of child emotion regulation. Because the Emotion Regulation and the SCICA Observed scores were highly correlated, we included the emotion regulation score because of greater theoretical interest. The Medication scale was entered prior to the psychological measures, to first account for that portion of symptoms due to asthma severity. As shown in Table II, after medication level was accounted for, emotion regulation accounted for almost 5% of the variance, with poorer emotion regulation related to higher symptom scores. The CBCL score did not add a significant increment in prediction. However, the SCICA Self-Report variable contributed almost another 7%, with lower self-report of problems related to more asthma symptoms. Thus, after we accounted for asthma severity measured by required medications, less effective emotion regulation and a lower level of self-reported psychological symptoms were associated with higher levels of asthma symptoms.
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Discussion |
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The emotional and behavioral adjustment of children with asthma has received a great deal of attention from investigators, yet clear conclusions have remained elusive. Our study focused on children's ability to regulate their emotions, a dimension of the behavior of children with asthma not previously described. The findings presented here help to clarify some of the pertinent issues and provide future directions for research.
We assessed the behavioral and emotional functioning of a group of children with asthma and a healthy comparison group utilizing a multimethod approach, including a commonly used parent report measure (CBCL), a standardized child interview measure (SCICA), and behavioral observation of the children's emotion regulation (SCARF). Data showing the relationship among these measures indicated that the parent report and the child interview broadband scales were unrelated. There were some associations between mothers' reports of behavior and the behavioral ratings of emotion regulation. The CBCL Externalizing scale was associated with observations of poor child emotion regulation in the laboratory as well as with observations of maternal negativity during interactions with the child.
Intercorrelations provided evidence for consistency in children's emotion regulation across contexts. The quality of mothers' attempts to regulate their children's emotions was associated with the children's emotion regulation when the two were interacting. The overall amount of negativity each of them displayed in the dyadic context was also correlated. However, maternal emotion regulation and negativity were unrelated to the child's emotion regulation when apart from the mother. Despite some context specificity of the child emotion regulation measures, the intercorrelations and the fact that patterns of associations with other variables were similar regardless of context suggest that a trait-like characteristic of the children was being measured.
There was a strong relationship between poor emotion regulation and higher
scores on the Observed scale of the SCICA. These two assessments were
completed on separate days during interactions with different adults, with
distinct scoring methods and different raters. High scores on the SCICA
Observed scale result when the clinician notes behavior that interferes with
the smooth conduct of the clinical interview, much of it in the interpersonal
realm, involving negative affect and disrupting the conduct of the task.
Ratings of poor emotion regulation indicate negative affect that is disruptive
to task completion or to interpersonal interactions. Thus, the similarity in
the behavioral bases of assessment may account for the strong correlations
between the emotion regulation and clinical interview measures. The fact that
the CBCL Externalizing score was associated with poor emotion regulation
provides further evidence that the interview and emotion regulation measures
were assessing disruptive behavior. These difficulties may indicate general
behavioral dysfunction, or they may represent subtle problems in emotional
modulation that do not reach threshold for disorder but result in
interpersonal difficulties, such as have been observed by prior researchers
(Mrazek et al., 1985).
When the children with asthma were compared with the healthy children,
there were no differences between them on either the child interview measures
or the emotion regulation measures. In contrast, this study provides a clear
replication of previous findings that mothers report higher levels of overall
and internalizing problems for their children with asthma than do mothers of
healthy controls (Hamlett et al.,
1992; Kashani et al.,
1988; MacLean et al.,
1992). This pattern of results parallels those of Kashani et al.,
who found that the parent report measure (CBCL) showed increased problems
among children with asthma, but the child interview diagnostic measure did not
reveal such increases.
Within the group of children with asthma, severity of asthma showed a mixed
relationship with the psychological measures. For the parent report of
problems, there was no relationship between asthma severity and behavior
problem scores. In contrast, significant relationships were demonstrated
between asthma severity and the emotion regulation and child interview
measures. Difficulties with emotion regulation were found to increase with
greater asthma severity. The child interview also showed increasing overall
observed child behavior problems, including more interpersonal difficulties,
with increasing asthma severity. These findings are particularly striking,
given that interviewers and raters were blind to the child's group status
(asthma or control), as well as the clinical severity of asthma. These results
are consistent with the findings of Mrazek et al.
(1985), who described negative
affect and emotional dysregulation among preschoolers with severe asthma.
We further explored psychosocial associations with asthma severity by
examining the correlates of the two components of the severity scale.
Medication level was found to have few significant relationships with
psychosocial variables. In contrast, more asthma symptoms were associated with
low SCICA Self-Report scores and poor emotion regulation. The relationship
between few reported psychological difficulties and a higher symptom level may
be accounted for by a repressive cognitive style, which has been reported
among asthmatics (Weinberger,
1991), or frank denial. The association between emotion
dysregulation and more frequent, poorly controlled asthma symptoms is
consistent with previous research showing a relationship between psychological
difficulties and greater asthma severity, when the latter is measured in terms
of functional status such as symptoms and health care utilization
(Stein & Jessop, 1984).
There is increasing evidence suggesting that poor symptom control is often
linked to poor adherence with medication
(Milgrom et al., 1994) and
poor asthma management in general
(Klinnert, McQuaid, & Gavin,
1997). Poor adherence and asthma management for childhood asthma
has been related to both child
(Christiannse, Lavigne, & Lerner,
1989) and family dysfunction
(Wamboldt, Wamboldt, Gavin, Roesler, &
Brugman, 1995). The role of overall family dysfunction in
contributing to poor child emotional regulation, poor adherence to medication
regimens, and greater asthma severity merits further investigation.
Longitudinal data are necessary to assess causal relations between asthma
symptoms, emotion regulation, and behavioral difficulties. One might view the
stresses associated with asthma as interfering with developmental processes in
such a way that emotions become dysregulated and behavioral symptoms occur.
Another intriguing possibility is that observable emotional dysregulation may
be related to aspects of physiologic dysregulation involved in asthma
(Lehrer, Isenberg, & Hochron,
1993). This physiological dysregulation could be an underlying
mechanism for both disease fluctuation and difficulties in emotion
regulation.
Findings from this study, utilizing multimethod behavioral assessment, provide a model for explaining previously contradictory study results. As a group, children with asthma probably have minimal increases in psychological problems compared to children without asthma. The exception is that parents of children with asthma report more internalizing disorders in their offspring, generally along the anxiety spectrum. Apparently anxiety is present at a low level for many children with asthma and is unrelated to disease characteristics. Parents may have a lower threshold than clinicians for detecting psychological distress among these children, a possibility that explains why clinicians have infrequently noted increased anxiety among children with asthma.
Within the population of children with asthma, a second group has generally
gone unrecognized: children with poor regulation of negative emotions and
higher levels of asthma symptoms. Emotion dysregulation, possibly more
apparent to outside observers than to parents, is characterized by difficulty
managing negative affect and interpersonal interactions marked by negativity
and conflict. Such behavior patterns, often too subtle to reach diagnostic
thresholds, appear to be more common among children with severe asthma,
particularly those with frequent, uncontrolled symptoms who find their way to
emergency rooms or require hospitalization. Although these children may deny
psychological problems, their difficulties may be observed in their
ineffective responses to interpersonal challenges. At high levels poor emotion
regulation will be manifested as disruptive negative affect, low frustration
tolerance resulting in inability to complete tasks, or conflict with
caregivers or staff. Children with unmanaged and disruptive negative affect
may appear to have more negative relationships with their parents. Although
the directionality of such relationship difficulties is unknown, conflicted
parent-child relationships have been reported in the literature, with greater
conflict associated with increased asthma severity
(Hermanns et al., 1989) and
even with asthma mortality (Strunk,
Mrazek, Wolfson Fuhrmann, & LaBrecque, 1985).
The contrasting patterns of functioning found in this study for the same
children, with parent reports providing one view and reports by external
observers providing another, illustrate the importance of utilizing different
measurement approaches for understanding the problems faced by children with
asthma. No one measure provides the true picture of children's psychological
adjustment, but rather different measures and different informants provide
information about separate facets of children's functioning. In fact, the
discrepancies themselves likely reflect different aspects of the children's
and their families' functioning. As noted by La Greca and Lamanek
(1996), future research is
needed to elucidate the factors contributing to such discrepancies. For
children with asthma, more specific information regarding difficulties in
parent-child interactions, or parental perception of illness burden in asthma,
may help to delineate the discrepancies noted between parents and others found
consistently in the literature.
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Acknowledgments |
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This study was supported by NIMH grant RO1HL53584, by the General Clinical Research Center grant M01 RR00051, by the Fetzer Foundation, and by the Developmental Psychobiology Research Group.
Received May 24, 1996; revision received February 13, 1997; revision received November 3, 1997; accepted December 9, 1997
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