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  1. NEW DEVELOPMENTS IN THE PSYCHOBIOLOGY OF ASTHMA Gregory K. Fritz, M.D. Professor and Director of Child & Adolescent Psychiatry Brown Medical School Medical Director, E.P. Bradley Children’s Psychiatric Hospital Director of Psychiatry, Hasbro Children’s Hospital

  2. Childhood Asthma Research ProjectCOLLABORATORS Brown University School of Medicine: Gregory K. Fritz, M.D. Elizabeth McQuaid, Ph.D. Robert Klein, M.D. Jack Nassau, Ph.D. Anthony Mansell, M.D. Susan Penza-Clyve, Ph.D. Natalie Walders, Ph.D. Jonathan Feldman, Ph.D. Sheryl Kopel, M.S. University of Texas Health Center at Tyler: Rick Carter, Ph.D., M.B.A. National Jewish Center: Marianne Wamboldt, M.D. Mary Klinnert, Ph.D. University of Puerto Rico: Glorisa Canino, Ph.D. Jose Rodriguez-Santana, M.D.

  3. 7 psychosomatic diseases etiology: specific psychological conflicts or personality types Old Psychosomatic Medicine: New Psychosomatic Medicine: • mind-body interactions in disease • all illnesses may be psychosomatic • interest in psychophysiologic mechanisms

  4. Psychological Factors Affect Disease At Multiple Points • Vulnerability to Disease/Prevention • Precipitant or Trigger • Recognition/Perception of Symptoms • Acute Episode Interventions • Chronic Disease Management • Adaptation to Illness/Functional Morbidity

  5. TREATING AND STUDYING CHILDREN IS KEY Early treatment is most effective Children are more malleable than adults Lifelong patterns are established in childhood PROVISOS: Children are not short adults Developmental perspective is essential Cognitive development Physiological development, especial puberty Social roles, influence of family evolve

  6. Pediatric Asthma • Asthma is the most common chronic illness of childhood • Asthma is associated with significant pediatric morbidity  10% are hospitalized at least once yearly  2%-6% miss more than 30 days of school

  7. 5106 3154 1982 1992 Asthma Mortality1982 - 1992 Death rate up 40% to 18.8/1,000,000 (CDC data, 1995)

  8. Cost of Asthma • In 1990, cost of illness related to asthma: $6.2 Billion • 43% of cost is related to use of emergency services and hospitalization • Asthma is a major national health problem despite medical advances

  9. Multifactorial Etiology of Asthma • Infectious • Allergic • Mechanical • Psychosocial Plus: Genetic predisposition

  10. Psychological Factors Can Impact Pediatric Asthma At Multiple Points • Vulnerability to Disease/Prevention • Perinatal stress, psychoimmunology, parenting • Precipitant or Trigger • Suggestion, strong emotions, stress • Recognition/Perception of Symptoms • Accurate symptom perception, panic-fear response, denial • Acute Episode Interventions • Asthma knowledge, biofeedback/relaxation, family response • Chronic Disease Management • Medication adherence, depression, medication side effects • Adaptation to Illness/Functional Morbidity • Family adaptation, management responsibility, self image, • psychological interventions, factitious symptoms

  11. Psychological Factors Can Impact Pediatric Asthma At Multiple Points • Vulnerability to Disease/Prevention • Perinatal stress, psychoimmunology, parenting • Precipitant or Trigger • Suggestion, strong emotions, stress • Recognition/Perception of Symptoms • Accurate symptom perception, panic-fear response, denial • Acute Episode Interventions • Asthma knowledge, biofeedback/relaxation, family response • Chronic Disease Management • Medication adherence, depression, medication side effects • Adaptation to Illness/Functional Morbidity • Family adaptation, management responsibility, self image, • psychological interventions, factitious symptoms

  12. Experimental Separation of Children with Asthma from their Families Baseline PFT’s 4x/day 2 weeks Family Moves to Hotel PFT’s 4x/day 2 weeks Reunion PFT’s 4x/day 2 weeks 10/25 had significant positive PFT response to separation Purcell et al., 1969

  13. Suggestion can Trigger Acute Asthma • The case of the glass rose • Meta-analysis of 20 studies, 427 asthmatic subjects • Saline suggested as bronchoconstrictor; PFT’s pre and post-suggestion 35.6% “responded” to suggestion 20% is conservative estimate Isenberg et al., 1992

  14. Stress and Asthma Methods • 5 minute baseline • 5 minute stressful task • Measures: Airway resistance • Heart rate • Galvanic skin response (GSR) • Skin temperature

  15. Changes in Airway Resistance in Response to Stress • Controls • Changes in airway resistance ranged • from -32.0% to 65.5% • Children with Asthma • Changes in airway resistance ranged • from -51.8% to 219.4%

  16. Changes in Airway Resistance in Response to Stress • As a group, children with asthma did not have greater increases in resistance than controls • Approximately 20% of children with asthma demonstrate significant increases in resistance in response to stress

  17. STRESS AND ASTHMA: CLINICAL MANAGEMENT 1. Differentiate the 20% for whom stress is an important trigger from the 80% for whom it isn’t. -Clinical judgement -Direct questions about precipitants -Anxious response to symptoms 2. Psychological intervention often helpful to this 20%. -Relaxation techniques -Biofeedback, hypnosis -Family involvement in stress management

  18. Psychological Factors Can Impact Pediatric Asthma At Multiple Points • Vulnerability to Disease/Prevention • Perinatal stress, psychoimmunology, parenting • Precipitant or Trigger • Suggestion, strong emotions, stress • Recognition/Perception of Symptoms • Accurate symptom perception, panic-fear response, denial • Acute Episode Interventions • Asthma knowledge, biofeedback/relaxation, family response • Chronic Disease Management • Medication adherence, depression, medication side effects • Adaptation to Illness/Functional Morbidity • Family adaptation, management responsibility, self image, • psychological interventions, factitious symptoms

  19. HIGH RISK ASTHMATICS Global disregard of symptoms differentiated pediatric asthma patients who died from matched, living patients. (Strunk et al, 1985; Zach & Kainer, 1989) Survivors of near fatal asthma episodes showed blunted response to both load perception and chemosensitivity (Kikuchi et al, 1994)

  20. Asthma Perception Recognition of clinical symptoms Initiation of timely self-management Reduced functional morbidity

  21. Symptom Perception in the Clinical Setting: Does it Matter? • PEFR or FEF25-75 correlate with subjective estimates: r = -.54 to +.88 • Better perceptual accuracy  less functional morbidity (school days missed, ER visits) Fritz et al. JAACAP. 35:1033-41, 1996

  22. Clinical Assessment of Asthma Symptom Perception • Used at home, 1-2 months: naturalistic • Subjective estimate “locked in” before spirometry • Multiple pulmonary function indices • Easy data storage and downloading • Cost: $750 for each device AM-2 programmable, hand-held spirometer

  23. Psychological Variables • IQ (WISC Block Design and Vocabulary) • Attention 1. Auditory (WISC Arithmetic and Digit Span) 2. Visual (Continuous Performance Test) 3. Parent Ratings (Connor’s Parent Rating Scale) Subscales: Opposition, Inattention, Hyperactivity, ADHD • Depression (Children’s Depression Inventory Profile) • Anxiety (MASC)

  24. Perceptual Accuracy Assessments Per Child Mean = 53 (20-117) Child’s Percentage in Accurate Zone Mean = 54% (2-100%) Child’s Percentage in Danger Zone Mean = 12% (0-51%)

  25. What Factors Predict Perceptual Accuracy in Pediatric Asthma? • Better perceivers are older and have higher SES • Intelligence and attentional factors are related to perceptual accuracy • Depression and anxiety symptoms are not related to perceptual accuracy

  26. ASTHMA SYMPTOM PERCEPTION: CLINICAL MANAGEMENT 1. Identify the children with poor perception (not easy). 2. Insist that they use peak flow monitoring for management decisions. 3. Training in symptom perception skills?

  27. Psychological Factors Can Impact Pediatric Asthma At Multiple Points • Vulnerability to Disease/Prevention • Perinatal stress, psychoimmunology, parenting • Precipitant or Trigger • Suggestion, strong emotions, stress • Recognition/Perception of Symptoms • Accurate symptom perception, panic-fear response, denial • Acute Episode Interventions • Asthma knowledge, biofeedback/relaxation, family response • Chronic Disease Management • Medication adherence, depression, medication side effects • Adaptation to Illness/Functional Morbidity • Family adaptation, management responsibility, self image, • psychological interventions, factitious symptoms

  28. Asthma Education Programs Are Not a Panacea • Logic behind asthma education is indisputable • Meta-analysis of 29 clinical trials * 12/29 studies had to be excluded * No global reduction in: ~ school absenteeism ~ asthma attacks ~ hospitalizations ~ hospital delays ~ emergency visits

  29. Psychological Factors Can Impact Pediatric Asthma At Multiple Points • Vulnerability to Disease/Prevention • Perinatal stress, psychoimmunology, parenting • Precipitant or Trigger • Suggestion, strong emotions, stress • Recognition/Perception of Symptoms • Accurate symptom perception, panic-fear response, denial • Acute Episode Interventions • Asthma knowledge, biofeedback/relaxation, family response • Chronic Disease Management • Medication adherence, depression, medication side effects • Adaptation to Illness/Functional Morbidity • Family adaptation, management responsibility, self image, • psychological interventions, factitious symptoms

  30. Asthma Medication Adherence • Children, and adolescents in particular, have demonstrated poor adherence to complicated disease regimens • The standard of care in asthma treatment proposes that children and teens take medications that have no immediate effect on their symptoms multiple times a day • STUDY: 81 children monitored with medihaler (MDI-Logs) 1+ months

  31. Results: What are kids doing with those inhalers, anyway? • Children were taking less than half of their prescribed daily medications (mean daily adherence = .48, median = .45) • For all medications, the total of missed days ranged from 0-28; mean across medications ranged from 11-15 • Nine children “dumped” medication, 4 of these on last day of study

  32. MEDICATION ADHERENCE: CLINICAL MANAGEMENT 1. Adequate knowledge from a solid asthma education program does not guarantee adequate adherence. 2. Assume a significant degree of non adherence even when parent and child assures otherwise. 3. When a reasonable regimen does not lead to a good control, the child is probably not getting the medicine. 4. There are many paths to non adherence.

  33. Psychological Factors Can Impact Pediatric Asthma At Multiple Points • Vulnerability to Disease/Prevention • Perinatal stress, psychoimmunology, parenting • Precipitant or Trigger • Suggestion, strong emotions, stress • Recognition/Perception of Symptoms • Accurate symptom perception, panic-fear response, denial • Acute Episode Interventions • Asthma knowledge, biofeedback/relaxation, family response • Chronic Disease Management • Medication adherence, depression, medication side effects • Adaptation to Illness/Functional Morbidity • Family adaptation, management responsibility, self image, • psychological interventions, factitious symptoms

  34. Development of Children’s Asthma Responsibility: Sample • 209 children enrolled in a summer camp for children with asthma and their mothers  One year follow-up of 82 families • Ages 6-14 years (mean age = 9.9) • 43% female • Asthma severity ratings:  42% mild  27% moderate  31% severe

  35. Increase in Responsibility with AgeParent and Child Report

  36. Children’s Responsibility for Asthma Management • Increased with child age, by both parent report (r = .60, p < .001) and by child report (r = .47, p < .001) • By age 13, children are taking primary responsibility for a majority of asthma tasks

  37. Asthma Management Responsibility • Children with asthma take increasing responsibility for self-management with age • Parent and child reports of who performs management behaviors can be discrepant, particularly for preventive tasks • Adherence is a complex set of behaviors occurring within the family context. Assessments of adherence must identify family roles for the multiple components of disease management