Transcript Childhood Asthma Research Project STAFF

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
Childhood Asthma Research Project
COLLABORATORS
Brown University School of Medicine:
Gregory K. Fritz, M.D.
Robert Klein, M.D.
Anthony Mansell, M.D.
Natalie Walders, Ph.D.
Sheryl Kopel, M.S.
Elizabeth McQuaid, Ph.D.
Jack Nassau, Ph.D.
Susan Penza-Clyve, Ph.D.
Jonathan Feldman, Ph.D.
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.
Old Psychosomatic Medicine:
• 7 psychosomatic diseases
• etiology: specific psychological
conflicts or personality types
New Psychosomatic Medicine:
• mind-body interactions in disease
• all illnesses may be psychosomatic
• interest in psychophysiologic mechanisms
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
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
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
Asthma Mortality
1982 - 1992
5106
Death rate up 40%
to 18.8/1,000,000
3154
(CDC data, 1995)
1982
1992
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
Multifactorial Etiology of Asthma
•
•
•
•
Infectious
Allergic
Mechanical
Psychosocial
Plus: Genetic predisposition
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
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
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
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
Stress and Asthma Methods
• 5 minute baseline
• 5 minute stressful task
• Measures: Airway resistance
Heart rate
Galvanic skin response (GSR)
Skin temperature
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%
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
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
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
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)
Asthma Perception
Recognition of clinical symptoms
Initiation of timely self-management
Reduced functional morbidity
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
Clinical Assessment of Asthma
Symptom Perception
AM-2 programmable, hand-held spirometer
•
•
•
•
•
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
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)
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%)
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
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?
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
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
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
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 (MDILogs) 1+ months
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
Children's adherence to preventive
asthma medications
Ideal %
adherence
100
% of prescribed doses taken
90
80
70
range = 52-59%
60
range = 0-94%
50
40
range = 5-129%
range = 0-96%
30
range = 0-102%
20
10
0
Beclomethasone
(Vanceril,
Beclovent)
Auticasone
(Flovent)
Cromolyn (Intal)
Medications
Neocromil
(Tilade) N=2
Salometrol
(Serevent)
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.
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
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
Increase in Responsibility with Age
Parent and Child Report
r = .29, p < .001 (child)
r = .38, p < .001 (parent)
Responsibility
4
3
Parent
Child
2
1
6
7
8
9
10
Child Age
11
12
13
14
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
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